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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6000
} | Medical Text: Admission Date: [**2179-11-8**] Discharge Date: [**2179-11-18**]
Date of Birth: [**2154-11-12**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motor Vehicle Crash
Major Surgical or Invasive Procedure:
[**11-7**] IM nail Left Femur
[**11-8**] IVC filter placement
Exploration/repair of rectal tear
History of Present Illness:
24 yo female retrained driver s/p MVC hydroplane and rollover;
prolonged extrication (~1 hour). Tachycardic at scene, no
hypotension, transferred to [**Hospital1 18**] from referring facility for
continued trauma care.
Past Medical History:
None
Social History:
Denies tobacco, occas ETOH
Teaches Spanish to high school students
Lives with roomate
Family History:
Noncontributory
Physical Exam:
afebrile hr120 bp148/75 rr18 sats 97
Awake, responsive, gcs 15
op clear
ctab
rrr
soft, ttp b lower quadrants no rebound
no midline back tenderness
B femorl splinting with good B distal pulses
gross blood from vaginal area, known perineal tears, no
hematuria
Pertinent Results:
[**2179-11-8**] 10:40PM HCT-32.7*
[**2179-11-8**] 07:53PM TYPE-ART TEMP-37.2 PO2-368* PCO2-39 PH-7.30*
TOTAL CO2-20* BASE XS--6 INTUBATED-INTUBATED
[**2179-11-8**] 07:37PM GLUCOSE-140* UREA N-10 CREAT-0.7 SODIUM-141
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-18* ANION GAP-19
[**2179-11-8**] 07:37PM CALCIUM-9.7 PHOSPHATE-3.7 MAGNESIUM-1.0*
[**2179-11-8**] 07:37PM WBC-14.9* RBC-3.86*# HGB-12.5# HCT-34.2*#
MCV-89 MCH-32.3* MCHC-36.5* RDW-13.1
[**2179-11-8**] 07:37PM PLT COUNT-117*
[**2179-11-8**] 07:37PM PT-13.2 PTT-31.0 INR(PT)-1.2
[**2179-11-8**] 01:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
Ms [**Known lastname 64708**] was admitted to the trauma/SICU at [**Hospital1 18**] for further
assessment and management of her injuries. Prior to arrival, she
was intubated. FAST exam in the ED negative. CTA of carotids,
CT head and CT C-spine negative in ED. In [**Name (NI) **], pt received ancef,
flagyl, clindamycin and levofloxacin. After multiple plain films
and CT imaging, the following injuries were discovered:
.
1. L femoral fracture
2. R subtrochanteric fracture
3. B inferior pelvic rami fx
4. L superior pelvic ramus fx
5. diastasis of pubic symphasis with presacral hematoma
6. L first rib fracture
7. multiple vaginal and perianal lacerations with associated
perianal hematoma. Eventual exam under anesthesia revealed
intact rectum, posterior vaginal wall and
normal cervix.
.
Over the subsequent 3 days, pt underwent several orthopedic
procedures to repair her femurs, pelvis and perineal injuries.
An IVC filter was also placed to prevent migration of any
possible clot. Pt did not develop any thrombus during her
hospitalization. These procedures are detailed in operative
notes on [**11-7**] through [**11-9**], [**2178**].
.
Pt was transferred to regular hospital floor on [**2179-11-10**] where
she remained hemodynamicaly stable and had stable serial
hematocrits. PT and OT were consulted to assist in this
patient's recovery. Upon discharge, she will remain NWB LLE,
WBAT RLE. Pt completed a 6 day course of the antibiotics started
in the ED.
.
Pain control was an issue throughout this hospitalization, and
several different regimens were tried after the patient's PCA
was discontinued. Eventually, the acute pain service was
consulted for guidance in pain management. Final recommendations
were to use a 100 mcg fentanyl patch q 72 hours with 2-6 mg
dilaudid q 3-4. At time of discharge, this regimen appeared to
control patient's pain. While her injuries are severe, it was
explained to her that these medications were being administered
at high doses and that she would have to help guide the care
team in slow weaning of these medications.
.
Ms [**Known lastname 64708**] was discharged to rehab in stable condition on
Jaunary 5, [**2179**].
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for pruritis.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for anxiety.
8. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous
once a day: Continue for 4 weeks.
9. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) patch Transdermal
every seventy-two (72) hours.
10. Dilaudid 2 mg Tablet Sig: 1-3 Tablets PO q3-4 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 24402**], ME
Discharge Diagnosis:
s/p Motor Vehicle Crash
Inferior/Superior Pubic Rami Fracture
Bilateral Femoral Fractures (Right Proximal/Left Distal)
Perirectal laceration
Vaginal laceration
Discharge Condition:
Stable
Discharge Instructions:
1.Follow up with Orthopedic Surgery and OB/GYN after discharge.
2.Take all of your medications as prescribed.
3. Do not bear any weight on your left lower extremity.
Followup Instructions:
1.Call [**Telephone/Fax (1) 1228**] for a follow up appointment with Orthopedic
Surgery in [**11-15**] weeks.
2.Followup with your primary OB/GYN for reevaluation/pelvic
exam; you will need to call for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6001
} | Medical Text: Admission Date: [**2170-11-1**] Discharge Date: [**2170-11-3**]
Date of Birth: [**2096-8-3**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
CODE STROKE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 yo M PMH hemorrhagic stroke [**2167**] presents as CODE STROKE.
Called at 11:30pm at bedside within seconds. Last seen well @
6:30pm. Onset of symptoms unknown.
History provided by ED resident as wife not present. Wife last
saw patient well @6:30pm this evening when he went upstairs to
go to the bathroom. She became concerned when he seemed to take
longer than usual so went upstairs to find him lying on the
floor in BR blocking the door. He was unresponsive but
breathing on his own. She called 911, EMS found him without
respiratory
distress but comatose and took him to OSH. At OSH, noted not to
be moving R side of body. Wet read of Head CT showed old R PCA
infarct, no change from prior [**2170-3-30**] and no acute process and of
CT C-spine showed no fx, extensive
degenerative changes. Found to be in atrial fibrillation HR 105
with signs acute ischemia which was thought to be new. He was
intubated due to altered mental status (w/etomidate 10mg and
succinylcholine 100mg), given propofol after intubation and
transferred to [**Hospital1 18**] for neuro eval. (Also, OSH ED note
mentioned Versed 2mg IV and Dopamine for pressor support). No
IV TPA given h/o hemorrhagic stroke.
At [**Hospital1 18**] ED, 99.5 128/74 74 18 100 vent. Head CT performed
at showed dense left MCA sign with early loss of insular
ribboning, loss of [**Doctor Last Name 352**]-white differentiation and
hypoattentuation of the basal ganglia. [**Name (NI) **] PT 10, Cr 3.1 and
FS 166.
ROS: unable
Past Medical History:
- CAD, h/o MI, prior CABG multivessel
- HTN
- Hyperlipid
- Gout
- Partial nephrectomy for benign renal CA (BUN 37 Cr 1.8 in
[**4-4**])
- Prior strokes
Social History:
Lives with wife
Family History:
non-contributory
Physical Exam:
99.5 128/74 74 18 100 vent
Gen: Lying in bed, mildly agitated off propofol
HEENT: NC/AT, moist oral mucosa, intubated
Neck: supple, no carotid or vertebral bruit
CV: irreg irreg, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Spontaneously opening eyes and grimacing. Not
cooperative with exam, does not regard or follow commands.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Resists passive eye opening with conjugate left
eye deviation but able to cross midline with oculocephalic
movements. Grimaces to nasal tickle without obvious asymmetry
but difficult to assess with ETT tube in place. Positive yawn.
Motor/Sensory:
Normal bulk bilaterally. Mildly increased tone on the right.
No observed myoclonus or tremor. Localizes and very purposeful
with left hand, withdraws in legs symmetrically. Right arm
extends to noxious stim.
Reflexes:
+2 brisk symmetric throughout. Right toe upgoing, left down.
Coordination/Gait/Romberg: deferred
Pertinent Results:
[**2170-10-31**] 11:25PM BLOOD WBC-13.1* RBC-4.09* Hgb-13.5* Hct-40.6
MCV-99* MCH-33.0* MCHC-33.2 RDW-13.4 Plt Ct-345
[**2170-11-1**] 03:00AM BLOOD WBC-11.5* RBC-3.67* Hgb-12.1* Hct-36.6*
MCV-100* MCH-33.0* MCHC-33.1 RDW-13.5 Plt Ct-302
[**2170-11-2**] 03:05AM BLOOD WBC-9.4 RBC-3.41* Hgb-11.5* Hct-33.3*
MCV-98 MCH-33.6* MCHC-34.4 RDW-13.6 Plt Ct-276
[**2170-10-31**] 11:25PM BLOOD PT-11.9 PTT-24.5 INR(PT)-1.0
[**2170-10-31**] 11:25PM BLOOD Glucose-122* UreaN-46* Creat-2.4* Na-143
K-4.0 Cl-105 HCO3-26 AnGap-16
[**2170-11-1**] 03:00AM BLOOD Glucose-129* UreaN-46* Creat-2.2* Na-144
K-4.0 Cl-109* HCO3-24 AnGap-15
[**2170-11-2**] 03:05AM BLOOD Glucose-95 UreaN-30* Creat-1.7* Na-140
K-5.0 Cl-110* HCO3-23 AnGap-12
[**2170-10-31**] 11:25PM BLOOD ALT-16 AST-17 CK(CPK)-85 TotBili-0.6
[**2170-10-31**] 11:25PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2170-11-1**] 08:57AM BLOOD CK-MB-5 cTropnT-<0.01
[**2170-11-1**] 04:54PM BLOOD CK-MB-4 cTropnT-<0.01
[**2170-11-2**] 03:05AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.3
[**2170-10-31**] 11:25PM BLOOD TSH-2.7
[**2170-10-31**] 11:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Head CT ([**10-31**]): Dense left MCA and loss of [**Doctor Last Name 352**]-white matter
differentiation in the left MCA territory consistent with acute
stroke of the left MCA territory.
MRA [**11-1**]: Partial occlusion of the supraclinoid left internal
carotid artery with slow flow in the left middle cerebral
artery. Non-visualization of distal right vertebral artery.
Carotid Dopplers [**11-1**]:
There is a less than 40% right ICA stenosis and less than 40%
left ICA stenosis with nonvisualized right vertebral artery and
antegrade flow in the left vertebral artery.
Renal US: No hydronephrosis
Brief Hospital Course:
Mr. [**Known lastname 74524**] was admitted to the ICU for closer monitoring and
evaluation. His hospital course by problem is as follows:
Neuro: L MCA infarct
Given the finding on OSH EKG of new atrial fibrillation,
cardiac source of emboli more likely than artery-artery emboli.
Patient has a history of intracranial hemorrhage and presented
in ARF. As a result, he was considered not a candidate for IV/IA
TPA or clot retrieval. The following day, his PCP was [**Name (NI) 653**]
and his history was reviewed. Per these records he had prior
infarcts but no history of hemorrhage. He had no history of afib
in the past, however had been work-up and found to have an
elevated anticardiolipin antibody. When this had been found, he
was evaluated for anticoagulation but the decision was made not
to start coumadin.
In the ICU, he remained unresponsive. He was continued on ASA
325mg QD and his Lipitor was increased from 10 to 40. His LDL
was 99. He remained in afib but given the size of the infarct he
was not a candidate for anticoagulation given the high risk for
spontaneous bleeding. He remained in afib but without
tachycardia. His BP was allowed to autoregulate and lopressor
was used PRN for SBP>200. He was rulled out for MI with CE. He
was gradually restarted on his home regimen of felodine 10 QD
and atenolol 25 QD. His Cr improved with gentle IVF
resuscitation. A renal US was negative.
Given his poor prognosis, his family decided to make him CMO. He
was extubated and died shortly there after.
Medications on Admission:
Home meds:
Lyrica 25mg PO TID (not taking it)
allopurinol 100mg PO QD
Avapro 300mg PO QD
HCTZ/triamterene 25/37.5 QD
ASA 81
Trental 100mg PO QD
Atenolol 25mg PO QD
Lipitor 10mg PO QD
NG SL
Felodipine 10mg PO QD
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Cerebral Infarction
Atrial Fibrillation
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 5859, 2749, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6002
} | Medical Text: Admission Date: [**2103-10-1**] Discharge Date: [**2103-10-21**]
Date of Birth: [**2069-7-31**] Sex:
Service: Neurosurgery
DATE OF DEATH: [**2103-10-21**]
HISTORY OF PRESENT ILLNESS: This is a 34-year-old woman who
had sudden onset of severe headache accompanied by slurred
speech and confusion. She was brought to [**Hospital6 50324**] with a diagnosis of a subarachnoid hemorrhage. She
had several episodes of vomiting in [**Hospital1 498**] and was then
transferred to [**Hospital1 69**].
PAST MEDICAL HISTORY: Remarkable for diabetes.
Hypertension.
Breast cancer.
CURRENT MEDICATION ON ADMISSION: Meridia 30 mg q.d.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: She is legally separated, has 2 children,
and was not working. She does not have a history of smoking
or drug use. She does drink alcohol occasionally.
PHYSICAL EXAMINATION: Vital signs at the time of admission
were 195/101, 86, 22, and 10. Head, eyes, ears, nose, and
throat, her pupils to be equal, round, and reactive to light
and accommodation, 3 mm to 2.5 mm. EOMs were full. Lungs
were clear. Heart showed regular rate and rhythm, normal S1
and S2. Abdomen was obese, soft, and nondistended.
Extremities showed no edema. Neuro exam, she was awake,
alert, and oriented times 3. Did complain of headache.
Moving all extremities. Closes eyes at times, but opens to
voice. No drift. Cranial nerves II through XII are intact.
Strength was [**4-30**] bilaterally in biceps, triceps, iliopsoas,
anterior tibialis, and [**Last Name (un) 938**]. Pupils were equal, round, and
reactive to light and accommodation. Extraocular movements
were full. She had no meningeal signs. Deep tendon reflexes
were 1 plus bilaterally at biceps, 2 plus bilaterally at
knees.
LABORATORY DATA: On admission her sodium was 142, potassium
3.4, chloride 104, bicarb 25, BUN 12, creatinine 0.9, glucose
175, PT was 12, PTT 23.5, and INR 1.0. Her white blood cells
were 10.9, hematocrit 40.5, and platelets were 268,000. She
did have a CT of the head, which did show a subarachnoid
hemorrhage on the left with multiple clot in the suprasellar
cistern and Sylvian cistern, left greater than right. She
was admitted to the Neurointensive Care Unit with q.1h. neuro
checks. She obtained an A-line and the goal was to keep her
blood pressure less than 120 with Nipride as needed. She was
started on nimodipine 60 mg q.4 h., normal saline,
famotidine. She was to have her glucoses checked q.i.d. She
was preop for an angiogram in the morning. She was started
on Dilantin at 100 mg t.i.d.
HOSPITAL COURSE: She did undergo the angiogram and
postprocedure she was sleepy, but was easily awakened and
followed commands, and moved all extremities; however, was unable
to perform complex tasks. Pupils were 3 to 2 bilaterally.
She underwent an angiogram, which did show a left internal
carotid artery aneurysm and was then brought to the operating
room for clipping of her aneurysm. Then early in the morning
on [**2103-10-4**], the patient did have an increase in her
intracranial pressure. She had a stat head CT
at that time, which did show left frontal intraparenchymal
hemorrhage at the surgical site. She then underwent an
emergency craniectomy with bone flap placement in the
abdomen. Postoperatively, she returned to the intensive care
unit and was monitored closely. She was kept sedated and was
followed with CAT scans of the head. Her serum osmolality
was checked every 4 hours. Her INR was followed with the
goal of keeping less than 1.3 at all times. She was able to
move her left side spontaneously, but moved and localized in
the right upper extremity to deep pain only. Her brain flap
was tense. She did spike fevers and was pancultured. On
[**2103-10-14**], a repeat head CT did show an acute new hemorrhage
in the left frontal lobe with surrounding edema and
herniation. Ventricles were increased in size slightly.
ICPs had been reported as high as 33. A repeat CAT scan
again on [**2103-10-15**] showed a large left hemorrhage. Due to the
repeat hemorrhage, discussion was held with the patient's
cousin and significant other and she was made do not
resuscitate. On [**2103-10-21**], she did expire.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 50325**]
MEDQUIST36
D: [**2104-6-16**] 10:41:55
T: [**2104-6-16**] 15:07:29
Job#: [**Job Number 50326**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6003
} | Medical Text: Admission Date: [**2168-1-31**] Discharge Date: [**2168-2-8**]
Date of Birth: [**2108-6-28**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Mechanical fall at nursing home on [**2168-1-30**], transferred from OSH
to [**Hospital1 18**] for orthopedic hemiarthroplasty of displaced left
femoral neck fracture, acute on chronic subdural hematoma
Major Surgical or Invasive Procedure:
Left hemiarthroplasty
IVC filter placement
Left IJ central venous line placement
Hemodialysis
History of Present Illness:
59 [**Hospital **] [**Hospital **] nursing home resident with ESRD/HD, seizure
disorder, CVA w/ left-sided weakness, recent MRSA endocarditis
s/p 6 week course of Vancomycin, SLE, Atrial Fibrillation and
antiphospholipid syndrome on coumadin. She was admitted on
[**2168-1-31**] (transfer from OSH, where she presented on [**2168-1-30**])
after a mechanical fall resulting in a left femoral neck
fracture and acute on chronic SDH in setting of INR 3.4. She is
s/p left hemiarthroplasty on [**2168-2-1**], which was uncomplicated.
Geriatrics is following the patient and Dr. [**Last Name (STitle) **] will be
attending upon transfer.
.
Overnight from [**2-1**] --> [**2-2**], she had two witnessed tonic-clonic
seizures that both self-resolved after 1-3 minutes (note is made
in the neurology consult note that she missed her home
lamotrigine that morning). After these seizures, she was
transferred to the SICU for further monitoring. Neurology
following the patient was concerned for lupus cerebritis; they
requested a hypercoagulability workup, as well as a TTE given
recent endocarditis. She has had continuous EEG to evaluate for
non-convulsive status epilepticus given her lethargy and recent
seizures. She is currently on keppra and lamotrigine.
.
Patient was also found to have a right upper extremity DVT and
is s/p IVC filter placement on [**2168-2-1**]. As her platelets
continued to decrease, patient was found to be HIT antibody
positive.
Past Medical History:
-- IVC filter placed [**2168-2-1**]
-- s/p left hemiarthroplasty
-- MV MRSA endocarditis [**11-5**]; on vanco from [**11-5**] - [**12-17**] (6
wks)
--h/o R CVA w. residual L sided weakness, ESRD on HD M/W/F
[**University/College **], hx seizures, lupus, atrial fibrillation,
hypercoagulability, anemia
-hx of R CVA with residual L sided weakness
-Stats she had possibly more than one CVA but unsure, states one
in her late 20's and then in her early to mid 30's per her
report
-ESRD on HD M/W/F
-Lupus
-Hx of seizures on lamotrigine
-Atrial fibrillation
-Hypercoagulability
-Anemia
-Left UE AVG [**12-5**]
-[**10-6**]: Fistulogram and balloon angioplasty venous anastomosis
and outflow vein stenosis.
Social History:
Has been living at [**Hospital 599**] Nursing Home in [**Location (un) 55**] since
2/[**2167**]. Denies alcohol and tobacco use. Healthcare proxy is
sister, [**Last Name (NamePattern1) 73364**] [**Telephone/Fax (1) 73365**]; guardian [**Name (NI) **] [**Telephone/Fax (1) 73366**]
.
Functional Baseline:
ADLS: mostly dependent
IADLS: dependent
Services at home: lives at [**Location **]
Assistive Device: walker
Family History:
Father had Parkinson's
Physical Exam:
VS prior to transfer to floor: T 97.4 (Tmax 99.6); P 94 (70-90);
BP 181/74 via right calf (MAP 95); 97% RA
GENERAL: frail woman, appears older than stated age, sitting in
chair; follows commands but slowed with high speech latency
HEENT: PERRL, oral mucosa dry
NECK: no LAD, no JVD, right IJ CVL line
CV: irregular, II/VI SEM at USB w/o radiation to neck
LUNGS: CTA, no wheezes, no crackles
ABD: + BS, soft, non-distended, non-tender
GU: Foley catheter in place
EXT: 2+ RUE edema, no no cyanosis, no clubbing
NEURO: AA, Oriented to person & place as hospital (though wrong
one); slow somewhat slurred speech though appropriate; slight
ptosis of left eye & baseline medial deviation of left eye, also
noted in prior neurology note; strength 3/5 in b/l UE, [**5-2**] in
lower; no tremor, no rigidity; gait deferred.
Able to ambulate to bathroom with 2 assist
CAM - A/F: N Inat: Y Disorg: N Consc: N total: [**2-1**]
Pertinent Results:
MB: 2 Trop-T: 0.02
.
PT: 33.3 PTT: 50.1 INR: 3.4
.
CBC
13.7 > 13.1 < 193
40.4
N:90.9 L:4.0 M:3.1 E:1.8 Bas:0.2
.
Chem 10
135 95 51 97 AGap=20
5.2 25 8.4 ∆
.
Urinalysis: neg leuks, neg nitrites
.
Imaging:
[**1-31**] Left Tib/Fib Xray: No acute fracture to the tibia or fibula
[**1-31**] Bil hip Xray: Impacted transcervical fracture of the left
hip with medial rotation of the distal femur.
[**1-31**] CT head: mixed density L subdural collection consistent w/
acute on chronic hemorrhage
[**1-31**] C-spine XRay: 1. No evidence for traumatic injury involving
the cervical spine. Significant degenerative change is noted,
most severe from C4 through C7; Right thyroid nodule
1/3 L-spine: Mildly limited study of the lumbar spine with no
compression fractures identified.
.
ECHO: Mild symmetric left ventricular hypertrophy with normal
global and regional biventricular systolic function. Thickened
mitral valve, but no discrete vegetation seen. At least moderate
mitral regurgitation.
Compared with the prior study (images reviewed) of [**2167-11-9**],
mitral valve morphology is similar, but severity of
regurgitation has increased. The other findings are similar.
.
EEG: This is an abnormal noncontinuous extended routine EEG due
to slowing and disorganization of the background and
intermittent focal
left frontotemporal theta/detla slowing. These findings suggest
a mild
to moderate diffuse encephalopathy, and with a potentially
epileptogenic
focal structual lesion in the left frontotemporal region. No
electrographic seizures were seen during this recording.
[**2-1**] Heac Ct : Stable
Brief Hospital Course:
59 yoF with multiple medical problems including SLE, ESRD/HD,
recent endocarditis, problems with left AV fistula, seizure
disorder, CVA with left sided weakness, AFib, hypercoagulopathy
who p/w falls resulting in left hip fracture and acute on
chronic SDH. Patient is s/p left hip hemiarthoplasty and IVC
filter placement. During this hospitalization, had two seizures
overnight on POD#1, was transferred to the ICU and also found to
have HIT+ antibody.
.
#. HYPERCOAGULABLE STATE vs. BLEEDING RISK: Very complicated
risk-benefit analysis in terms of restarting anticogaulation in
patient. She has been on long-term anticoagulation with Coumadin
which had to be reversed in the setting of her acute on chronic
subdural hematoma and left hip fracture. Reasons to start
anticoagulation: HIT +, new right basilic vein DVT, AFib, recent
endocarditis, antiphospholipid syndrome in setting of SLE,
multiple CVAs with therapeutic INR, recent ortho trauma with
relative immobilization. [**Name2 (NI) 73367**] to not anticoagulate: s/p
acute on chronic SDH after a fall on [**2167-1-31**], IVC filter.
Neurosurgery preferred that patient not be anticoagulated but
felt that if absolutely necessary, patient should be
anticoagulated with a lower PTT goal of 40-60. In the setting of
heparin-induced thrombocytopenia, Hematology recommended
anticoagulation with Argatroban. The Primary Geriatric team and
patient's primary care doctor, Dr. [**Last Name (STitle) **] also favored
anticoagulation. Patient was started on Argatroban gtt and was
intially supratherapeutic in the high 60s-70s. Ultimately,
patient's PTT was therapeutic at ~60 mcg/kg/minute. Patient had
neurological checks every 4 hours without concerns for rebleed
into her SDH in setting of resumed anticoagulation. Hematology
contact[**Name (NI) **] patient's previous rheumatologist at [**Hospital1 **] who confirmed patient has antiphospholipid,
anticardiolipin antibodies since [**2147**], lupus anticoagulant in
[**2152**]. Of note, Neurology had wished to start antiplatelet
therapy on patient, as well, given her coagulopathies but given
patient's low platelet counts during this admission and the fact
that she was not on Coumadin during this admission, they held
off. This will need to be discussed at her outpatient Neurology
appointment.
- Continue Argatroban gtt at rate of 0.171 mcg/kg/min given PTT
of 45.1 (decreasing) on day of discharge. Patient will get PTT
checks at hemodialysis three times weekly. Please titrate
Argatroban infusion rate accordingly, for goal PTT of 40-60.
When changing rate, should increase/decrease by
0.125-0.25mcg/kg/min.
- Start Coumadin once platelets >100 with 5 days of overlap with
Argatroban
- Please have patient follow-up in [**Hospital 878**] Clinic with Drs.
[**First Name4 (NamePattern1) 73368**] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**]. She has an appointment for
Thursday, [**2-25**] at 10:30am.
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) 858**], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 1694**]
.
# THROMBOCYTOPENIA: Patient was noted to have dropping platelet
counts and was diagnosed with HIT antibody positive serology on
[**2168-2-3**]. Hematology contact[**Name (NI) **] patient's outpatient
nephrologist, Dr. [**Last Name (STitle) 15172**], who confirmed patient has known HIT
antibody positive history. She had initially been diagnosed at
[**Hospital 794**] Hospital in [**Hospital1 789**], RI and had been evaluated by
hematology there. Once care was transferred to Dr. [**Last Name (STitle) 15172**],
patient has been receiving altepase instead of heparin during
outpatient hemodialysis sessions. Hematology reviewed patient's
peripheral smear and felt that microangiopathic hemolytic anemia
is unlikely. They felt that the recent decline in platelet count
could be attributed to appropriate consumption, given recent
hemorrhage and clotting. Drug effect was also considered
although which medication causing it could not be pin-pointed.
Keppra has not been known to cause thrombocytopenia, nor
Argatroban. Lamictal is reported to cause thrombocytopenia but
patient has been on that medication long-term. Hematology
recommended platelet goal >50 with plans to start Prednisone
1mg/kg daily for ?autoimmune thrombocytopenia (in association
with APLAS) should platelet count continue to drop. Patient's
platelet count was relatively stable at 65 on day of discharge
- Continue to avoid heparin in patient; altepase can be used as
an alternative for flushes
- Please resume Coumadin once patient's platelet count is above
100. She will need 5 days overlap of Coumadin with Argatroban
- Please follow-up in [**Hospital **] Clinic. You have an appointment
to see Dr. [**First Name4 (NamePattern1) 3065**] [**Last Name (NamePattern1) 4762**] on [**2-19**] at 10:30am. You can
reach his office at: [**Telephone/Fax (1) 22**]
.
#. SEIZURE DISORDER: Has prior seizure disorder and acute on
chronic subdural hematoma. Neurology monitored patient for 24
hours with EEG and she was not having status epilepticus.
Immediately after her two seizures, patient was noted to have
altered mental status which gradually resolved. By day of
discharge, patient was alert and oriented X3.
- Continue Lamictal 50mg twice daily with uptitration as
follows:
Week [**1-30**] 50mg [**Hospital1 **]
Week [**3-31**] 50/75mg
Week [**6-2**] 75mg [**Hospital1 **]
Week [**8-4**] 75/100mg
Week [**10-7**] 100mg [**Hospital1 **]
Week [**12-9**] 100/125mg
Week 13-14 125mg [**Hospital1 **]
- Continue Keppra 750mg daily, dosed AFTER hemodialysis on HD
days
- Please have patient follow-up in [**Hospital 878**] Clinic with Drs.
[**First Name4 (NamePattern1) 73368**] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**]. She has an appointment for
Thursday, [**2-25**] at 10:30am.
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) 858**], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 1694**]
.
#. s/p LEFT HEMIARTHROPLASTY: Patient was briefly on Cefazolin
post-operatively. She continued to work with physical therapy
and pain was controlled with tylenol 1 gram every 8 hours
standing
- Continue to have patient work with physical therapy (weight
bearing as tolerated)
- Continue pain control with Tylenol 1 gram every 8 hours
standing --> can decrease and make PRN as needed
- Patient needs to follow-up in the [**Hospital **] Clinic within 2
weeks. Please have her call [**Telephone/Fax (1) 1228**] to set up a
"Post-Operative Appointment" with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the Nurse
Practitioner.
.
#. s/p ACUTE ON CHRONIC SDH: Stable. Neurosurgery felt no
surgical intervention was needed. Of note, patient did sustain
another unwitnessed fall the day prior to discharge. CT head was
negative for any new hemorrhage and the old acute on chronic
subdural hematoma was stable. Patient demonstrated no acute
mental status changes concerning for worsening of her subdural
hematoma.
- Patient will need follow-up head CT once anticoagulation is
therapeutic
- Patient will need head CT if mental status changes (for
possible bleeding into subdural hematoma)
.
#. HYPERTENSION: It was difficult to obtain consistent blood
pressure measurements on patient given her left AV fistula and
difficulties measuring in right arm. Per neurosurgery, goal was
for patient's mean arterial pressures to be <110 to manage her
subdural hematoma and subsequent bleeding risk. Patient was
continued on home nifedipine 30mg daily and home metoprolol; the
latter was increased from 75mg to 125mg twice daily to maintain
MAP <110.
- Continue Metoprolol 125mg twice daily
- DISCONTINUE Nifedipine 30mg daily
- START Lisinopril 5mg daily
.
#. RECENT ENDOCARDITIS: Patient completed 6 week course of
Vancomycin in mid-[**Month (only) **] for MRSA endocarditis. Repeat ECHO
(TTE) during this admission confirmed residual thickening and
fibrous quality to mitral valve that can make patient at
increased risk for future embolic events.
.
#. NONFUNCTIONAL LEFT AV FISTULA: See Letter to Dr. [**Last Name (STitle) **] by
Transplant Surgery (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]) from [**2168-1-3**] in OMR.
Patient's left AV fistula is non-salvageable and patient prefers
not to have AV fistula placed in right arm. Plan was for leg
graft to be placed.
- Please have patient follow-up in Transplant Surgery with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] regarding left arm AV fistula, which is no longer
working. She can discuss plans for the leg graft. She has an
appointment for Thursday, [**2-18**] at 8:00am.
Location: [**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] Bldg [**Location (un) **], [**Location (un) 86**], MA
Phone number: ([**Telephone/Fax (1) 3618**]
.
#. ESRD/HD: Likely secondary to lupus and/or hypertension.
Patient has some residual urine output
- Continue routine hemodialysis schedule,
Monday/Wednesday/Friday
- Continue neprhocaps and sevelamer
.
#. ANEMIA: Unclear baseline but stable during this
hospitalization
- Consider Epo at outpatient dialysis
.
#. THYROID NODULE: Incidentally noted on admission CT spine.
- Patient will need outpatient follow-up with her primary care
provider
.
#. NUTRITION: Speech and Swallow evaluated patient and felt she
was appropriate for diet as follows - PO diet of soft solids,
pills crushed in applesauce, one-on-one supervision, every 4
hours oral care.
.
#. ACCESS: Patient has right IJ placed [**2167-2-3**]; right tunneled HD
cath. Patient's left IJ entral venous line stopped drawing back
blood and could not be flushed. Patient has left AV graft and
right upper extremity DVT, making PICC lines in either arm
impossible. Left subclavian and repeat left IJ were ultimately
not attempted given significant ecchymosis in that region. Labs
can be drawn from patient's right tunneled HD catheter. Nothing
can be drawn back from the right IJ line.
.
#. CODE: DNR/DNI
Medications on Admission:
metoprolol 75 mg po bid,
nifedipine 30 mg po every other day,
sevelamer 2400 mg po four times daily,
wafarin,
lamotrigine 25 mg poqam and 50 mg po qhs,
omeprazole 20 mg daily,
nephrocaps 1 tab daily,
percocet prn,
trazodone 12.5 mg po bid,
docusate prn
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Simvastatin 10 mg 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. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain: This can be changed to PRN (as
needed) once left hip heals more. .
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Weekly uptitration as outpatient.
Week [**1-30**] 50mg [**Hospital1 **]
Week [**3-31**] 50/75mg
Week [**6-2**] 75mg [**Hospital1 **]
Week [**8-4**] 75/100mg
Week [**10-7**] 100mg [**Hospital1 **]
Week [**12-9**] 100/125mg
Week 13-14 125mg [**Hospital1 **] .
13. Argatroban 100 mg/mL Solution Sig: 0.171 mcg/kg/min
Intravenous INFUSION (continuous infusion): Patient will have
PTT labs checked during dialysis. Please titrate Argatroban
infusion rate accordingly, for goal PTT of 40-60. When changing
rate, should increase/decrease by 0.125-0.25mcg/kg/min.
14. Insulin Regular Human 100 unit/mL Solution Sig: Per insulin
sliding scale, which is included Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Left trochanteric femur fracture, acute on chronic
subdural hematoma, heparin-induced thrombocytopenia
Secondary: Antiphospholipid syndrome, atrial fibrillation,
seizure disorder, anemia, lupus, ESRD on HD, CVA with residual
left sided weakness
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
-You were admitted after falling at your nursing home. You were
found to have a left hip fracture which was repaired by the
Orthopedic Surgeons. You also sustained bleeding into the lining
of your brain during the fall. You were followed by Neurosurgery
for this and watched closely. You had two seizures shortly after
your surgery so your seizure medications have been revised by
Neurology. You were also found to have a clot in your right arm
and an allergy to heparin (a blood thinner) that depleted your
platelets. You were treated with anticoagulation using a
medication called Argatroban with plans to eventually resume
Coumadin.
.
-It is important that you continue to take your medications as
directed. We made a number of changes to your medications during
this admission. Please start taking the medications listed as
follows.
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please follow-up in the [**Hospital **] Clinic within 2 weeks. You
can call [**Telephone/Fax (1) 1228**] to set up a 'Post-Operative Appointment'
with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the Nurse Practitioner.
.
Please follow-up in Transplant Surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]
regarding your left arm AV fistula, which is no longer working.
You can discuss plans for the leg graft. You have an appointment
for Thursday, [**2-18**] at 8:00am.
Location: [**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] Bldg [**Location (un) **], [**Location (un) 86**], MA
Phone number: ([**Telephone/Fax (1) 3618**]
.
Please follow-up in [**Hospital **] Clinic. You have an appointment
to see Dr. [**First Name4 (NamePattern1) 3065**] [**Last Name (NamePattern1) 4762**] on [**2-19**] at 10:30am. You can
reach his office at: [**Telephone/Fax (1) 22**]
.
Please follow-up in [**Hospital 878**] Clinic with Drs. [**First Name4 (NamePattern1) 73368**] [**Last Name (NamePattern1) **] and
[**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**]. You have an appointment for Thursday, [**2-25**]
at 10:30am.
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) 858**], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 1694**]
.
Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 622**]
[**Last Name (NamePattern1) **] within 2-3 weeks. You can reach her office at: ([**Telephone/Fax (1) 15260**]
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6004
} | Medical Text: Admission Date: [**2116-2-19**] Discharge Date: [**2116-2-27**]
Date of Birth: [**2055-5-29**] Sex: F
Service: MEDICINE ICU
HISTORY OF PRESENT ILLNESS: This is a 60 year old woman with
a history of end stage renal disease secondary to polycystic
kidney disease on hemodialysis, also with chronic obstructive
pulmonary disease, coronary artery disease, pneumonia,
congestive heart failure, atrial fibrillation, and recurrent
line sepsis, who was transferred from [**Hospital3 10377**]
Hospital to [**Hospital1 69**] for
percutaneous endoscopic gastrostomy tube placement.
On arrival to the surgery floor, she was found to have a
blood pressure of around 60 to 80 over 30 to 50 with an
altered mental status. She was then transferred to the
Medical Intensive Care Unit for further monitoring and
treatment.
The patient was initially admitted to [**Hospital3 10377**]
Hospital on [**2116-1-24**], from [**Hospital3 **] [**Hospital **]
Hospital with suspicion of line sepsis. She had been febrile
and had her permacath removed that same day. The catheter was
placed in her right groin and then her left groin
temporarily. She then had a permacath placed in her left
subclavian on [**2116-2-7**].
Culture data showed coagulase negative Staphylococcus in
blood cultures from [**2116-1-11**], gram positive cocci in clusters
from [**2116-1-21**], in a blood culture, and Serratia marcescens
sensitive to Amikacin, Imipenem, Bactrim, and Levofloxacin
from a right femoral line on [**2116-2-1**], and finally coagulase
negative Staphylococcus on blood cultures from [**2116-2-6**]. She
was treated with Amikacin and Linezolid between [**2116-2-2**], and
[**2116-2-16**].
She was also seen by neurology for an altered mental status.
It was believed that her altered mental status was due to a
metabolic encephalopathy. This was determined by an
electroencephalogram on [**2116-12-19**], and [**2116-1-24**], as well as a
magnetic resonance scan which was reportedly negative.
Because she was somnolent and had difficulty eating, it was
believed that she may be at serious risk for aspiration.
Gastroenterology consultation was obtained for percutaneous
endoscopic gastrostomy tube placement as her nutritional
status was poor as evidenced by an albumin of 1.8. The
outside records document that she is DNI.
After being transferred to the [**Hospital1 188**] Medial Intensive Care Unit, a left femoral arterial
line and right femoral central venous catheter were placed.
She was given approximately three liters of normal saline
which did not improve her hypotension or mental status. She
was then started on Levophed, which subsequently improved the
above.
An arterial blood gas was obtained while on ten liters face
mask and that revealed the following values: 7.26/56/109.
Because she was DNI, a trial of BiPAP was performed and she
was not intubated. However, this was discontinued because
she could not tolerate BiPAP secondary to discomfort while
wearing the mask.
PAST MEDICAL HISTORY:
1. End stage renal disease on hemodialysis three times a
week secondary to polycystic kidney disease.
2. Chronic obstructive pulmonary disease.
3. Cerebrovascular accident.
4. Pneumonia.
5. Intractable diarrhea history.
6. Status post cholecystectomy.
7. Status post appendectomy.
8. Hypertension.
9. Recurrent sepsis secondary to line infections.
10. Compression fracture of the lumbar spine.
11. Atrial fibrillation with rapid ventricular rate, on
Coumadin.
12. Congestive heart failure.
13. Oxacillin resistant Staphylococcus aureus.
14. Coronary artery disease.
15. Anemia.
ALLERGIES:
1. Vancomycin causes redman syndrome.
2. Hycodone, unknown allergy.
3. Levofloxacin, unknown allergy.
4. Penicillin causes anaphylaxis.
5. Quinidine, unknown reaction.
6. Sulfa drugs cause anaphylactic reaction.
7. Opiates, unknown reaction.
MEDICATIONS AT OUTSIDE HOSPITAL:
1. Digoxin 0.125 mg q.Monday, Wednesday and Friday.
2. Advair Discus 250/50 one puff twice a day.
3. Prevacid.
4. Lactulose.
5. Linezolid.
6. Nephrocaps.
7. Pericolace.
8. Digoxin.
9. Dicacodyl.
10. Epoetin.
11. Amikacin.
12. Coumadin.
FAMILY HISTORY: Not obtained.
SOCIAL HISTORY: The patient is married and lives with her
husband and two daughters. She also has another daughter.
She has no alcohol history. She smoked thirty-five plus
years but stopped smoking three years ago.
PHYSICAL EXAMINATION: Vital signs revealed a temperature
97.0, pulse 89, blood pressure 82/42, oxygen saturation 96%
on ten liters cool nebulizer. In general, the patient is
oriented times two in moderate respiratory distress. Head,
eyes, ears, nose and throat examination - Mucous membranes
are dry. No jugular venous distention. Cardiovascular is
regular rate and rhythm, no murmurs, rubs or gallops.
Distant heart sounds. Respiratory - Decreased breath sounds
throughout, crackles at the left lung base greater than
right, scattered wheezes. Abdomen reveals mild epigastric
tenderness and no rebound, positive bowel sounds.
Extremities - no cyanosis, clubbing or edema.
LABORATORY DATA AND DIAGNOSTICS: On admission,
electrocardiogram showed an atrial fibrillation at a rate of
66 beats per minute and normal axis, Q wave in V1, diffuse T
wave flattening and inversions in V4 and V5, but no change
compared to that done at outside hospital.
Chest x-ray revealed a right lower lobe opacity and a
retrocardiac density.
White blood cell count was 7.5, hematocrit 29.7, platelet
count 162,000. INR 1.6, partial thromboplastin time 36.4.
Normal chemistries with the exception of a potassium of 3.5,
blood urea nitrogen 8 and creatinine of 3.0. Normal liver
function tests. Cardiac enzymes revealed a CPK of 19, CK MB
of 3.0 and a troponin of 0.5. The patient's magnesium level
was low at 1.5. Her calcium was 7.9, phosphate was 3.5. The
patient's blood gases on 100% nonrebreather mask were
7.29/57/113.
ASSESSMENT AND PLAN: This is a 60 year old female with a
history of end stage renal disease on hemodialysis, also with
chronic obstructive pulmonary disease, and recurrent line
infections, admitted to the outside hospital for treatment of
permacath line infection. She was transferred to [**Hospital1 346**] for percutaneous endoscopic
gastrostomy tube. On arrival, the patient was found to be
hypertensive along with an arterial blood gas consistent with
hypercarbic respiratory failure. She was admitted to the
Medical Intensive Care Unit for aggressive treatment of her
hypotension with pressor support, management of possible
pulmonary edema, management of overwhelming sepsis, and
monitoring of her electrolytes and mental status.
HOSPITAL COURSE: The following is a summary of the [**Hospital 228**]
hospital course by systems:
1. Respiratory - The patient was diagnosed with acute
hypercarbic respiratory failure likely triggered by
pneumonia, all this on top of a setting of chronic
obstructive pulmonary disease. BiPAP was attempted at the
time of hospitalization, however, the patient could not
tolerate the mask. The patient was maintained on ten liters
face mask during which her saturation was satisfactory. The
patient remained tachypneic throughout her hospital stay.
Serial chest x-rays continued to reveal bilateral pleural
effusions and congestive heart failure. The patient
continued to receive nebulizer treatments throughout her
hospital stay for her chronic obstructive pulmonary disease.
She was continued on her face mask for noninvasive
ventilation, and towards the end of her hospital stay, she
was switched to BiPAP which she, unlike during the beginning
of her hospital stay, began to tolerate. She was treated for
possible pneumonia, the treatment of which is further
delineated under the infectious disease section. She
received respiratory therapy in the form of nebulizer
treatments and chest physical therapy and suctioning
throughout her hospital stay. The patient's wish to remain
DNI was honored throughout her hospital stay. When the
patient was made comfort measures only, she was taken off her
BiPAP and once again placed on a comfortable Venturi mask.
Respiratory cultures were obtained in the form of sputum
samples and these ended up growing 4+ gram negative rods,
which lead to a change in her antibiotic regimen as described
in the infectious disease section.
2. Infectious disease - The patient was diagnosed with
presumed sepsis, the most likely cause being one of her
lines, although a chest x-ray suggesting pneumonia could also
point to a culprit. The patient underwent a sepsis workup
which included CT and magnetic resonance scan of the lumbar
spine to rule out osteomyelitis, CT of the brain to rule out
an abscess, serial chest x-rays which showed continued
pulmonary processes which may be suggestive of pneumonia,
multiple blood cultures including blood cultures positive for
gram positive cocci later identified as coagulase negative
Staphylococcus, CT of the abdomen to rule out abdominal
abscess or colitis. The patient's antibiotic regimen was
carefully chosen in light of the patient's multiple drug
allergies. At first, she was started on broad spectrum
antibiotics consisting of Linezolid, Imipenem, and Flagyl.
This was then changed to Amikacin, Vancomycin, and Flagyl.
When no gram negative culture data had been obtained after a
few days, her Amikacin and Flagyl were discontinued and she
was continued on Vancomycin. She had levels of Vancomycin
that were therapeutic throughout her hospital stay. When
gram negative rods were discovered in her sputum culture
towards the end of her hospital stay, the Amikacin was
restarted. When the patient was made comfort measures only,
the patient was taken off all antibiotics.
3. Cardiovascular - The patient had hypotension for which
she required pressor support consisting of Vasopressin and
Levophed throughout her hospital stay. With these, we were
able to maintain her MAP greater than 70 throughout her
hospital stay. The patient was initially started on Digoxin,
but this medication was discontinued after an echocardiogram
was performed which showed no signs of heart failure. She
did, however, have multiple x-rays which revealed pulmonary
edema. The patient's Coumadin was held in light of possible
need for percutaneous endoscopic gastrostomy in the near
future, and she was prophylaxed for deep vein thrombosis with
pneumatic boots. However, given concern for her atrial
fibrillation and the need for anticoagulation, she was
eventually restarted on a Heparin drip in addition to having
had subcutaneous Heparin before that. The patient underwent
another echocardiogram towards the end of her hospital stay
to rule out pulmonary embolism after her tachypnea did not
resolve. This echocardiogram did not reveal any new right
heart disease, but, as on earlier studies, did indicate that
there was mild pulmonary hypertension and right ventricular
volume and pressure overload.
4. Renal - The patient had end stage renal disease secondary
to polycystic kidney disease. She was continued on her
dialysis regimen of three times a week. In addition, the
patient required extra dialysis during her hospital stay to
either remove volume or provide ultrafiltration. The
patient's dialysis catheter which had been placed on
[**2116-2-7**], did grow positive blood cultures, but given her
poor access issues, this catheter was left in place. An
attempt was made to provide the patient with another source
of access, but ultrasound of the right neck area revealed a
clotted superior vena cava which would preclude any chance
for a right IJ or permacath site. The patient was continued
on her Nephrocaps. Her electrolyte balance was maintained
within normal limits throughout her hospital stay. She
remained anuric throughout her hospital stay.
5. Neurology - The patient was admitted with altered mental
status most likely secondary to toxic metabolic changes and
hypotension. She did improve with respect to her mental
status when her pressures were increased by pressors, but her
mental status remained subpar throughout her hospital stay.
She had had a negative magnetic resonance scan at the outside
hospital, and she had a negative CT scan for acute processes
such as bleeds or abscesses at this hospital. Her TSH,
folate and B12 levels were normal. Towards the end of her
hospital stay, the patient developed new mental status
changes that were more profound and her neurologic
examination revealed left sided weakness and decreased
reflexes as well as left sided hemineglect. It was thought
that the patient would require new brain imaging, but, given
her persisting tachypnea, she was deemed unstable to leave
the Medical Intensive Care Unit. When she was made comfort
measures only, the patient's mental status worsened to the
point that she was no longer responsive.
6. Endocrine - The patient ruled in for adrenal
insufficiency with an ACTH stimulation test. It was thought
that this could be a potential contributing factors to her
hypotension. She was started on Dexamethasone empirically
before this test was positive, and afterwards was started on
Florinef and Hydrocortisone. However, her pressures did not
increase substantially with these alone, and she continued to
need pressors. Her TSH was negative which ruled out any
potential hypothyroidism. She was placed on a regular
insulin sliding scale throughout her hospital stay for
coverage since the patient was on steroids.
7. FEN, gastrointestinal - The patient was diagnosed with
functional dysphagia secondary to either her mental status
changes or a real neuromuscular defect at the outside
hospital. A speech and swallow consultation was requested
for the purpose of evaluating dysfunctional dysphagia, but
give the patient's poor mental status, a video swallowing
study was never performed. The patient was made NPO
throughout her hospital stay, and a nasogastric tube was
placed so that the patient could receive nutrition in the
form of tube feeds. The patient tolerated these tube feeds,
except for the fact that towards the middle of her hospital
stay, she was found to have blood in her residual. As a
result, nasogastric tube feeds were discontinued and the tube
was used only for medication delivery. The patient then
received TPN for the rest of her hospital stay, which she
tolerated without any problem. The patient was maintained on
aspiration precautions during her hospital stay. She
received no extra fluids given chest x-rays revealing
pulmonary edema and her end stage renal disease status. It
was thought that dialysis would help her volume status, but
her hypotension and pulmonary edema persisted regardless. The
patient's electrolyte levels were maintained within normal
limits throughout her hospital stay.
8. Pain - The patient was admitted with a complaint of pain
secondary to compression fractures in her lumbar spine. She
was continued on Tylenol PR which she was on at the outside
hospital. Given her renal failure, there was concern about
giving narcotics, and more so, the patient had a history of
opioid allergies as well as hypotension. The decision was
made not to treat the patient with narcotics. Instead, the
patient was treated at first with Toradol, and then with
Tramadol. Her pain was maintained under control throughout
her hospital stay.
9. Access - The patient received a femoral arterial line on
her left leg, a femoral venous line on her right leg and a
nasogastric tube. Arterial lines were attempted in her upper
extremities, but these attempts were not successful
throughout her hospital stay. The femoral arterial line was
discontinued after it grew positive blood cultures. The
patient had a permacath on her left upper thorax throughout
her hospital stay, but this was not discontinued despite gram
positive blood cultures as dialysis access was desperately
needed.
10. Prophylaxis - The patient was placed on a H2 blocker at
the time of admission and that was later changed to a PPI
after blood was found in her residual. The patient was also
started on Heparin subcutaneous on her admission. When the
blood was found, this was taken off and she was placed on
pneumatic boots. When she developed neurological deficit, she
was started on a Heparin drip.
11. Code Status - The patient came into the hospital with a
DNI status. This status was honored throughout her hospital
stay. Towards the end of her hospital stay, numerous family
meetings were held, including with the help of the palliative
care team and Dr. [**Last Name (STitle) 22926**] [**Name (STitle) **], and the decision was made to
change the patient's status to comfort measures only.
Previous to this, the family had decided to make her DNR/DNI.
When she was made comfort measures only, the patient was
discontinued of all her medications. Her nasogastric tube
was pulled. She was discontinued of all her medications and
she was started on a Morphine drip. She passed away on
[**2116-2-27**], at 10:22 a.m. when her breathing stopped.
Permission was obtained from the family for an autopsy.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36
D: [**2116-2-27**] 13:48
T: [**2116-3-1**] 12:07
JOB#: [**Job Number 4719**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6005
} | Medical Text: Admission Date: [**2174-4-4**] Discharge Date: [**2174-4-19**]
Date of Birth: [**2096-6-1**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
CHF/Sarcoma
Major Surgical or Invasive Procedure:
Excision of right groin soft tissue sarcoma, gracilis muscle
flap coverage: [**4-13**].
History of Present Illness:
The patient is a 77 year old female with history of
hypertension, hyperlipidemia, and moderate-severe aortic valve
stenosis who was recently diagnosed in [**2174-1-6**] with a
soft-tissue sarcoma in her right groin after developing right
groin pain. She presented on this admission for surgical
excision of the right groin mass.
Past Medical History:
#. Soft tissue right thigh sarcoma - identified [**1-7**] right groin
pain [**2174-1-6**]
- s/p gamma knife
- admitted this admission for wide excisional therapy
#. Aortic Stenosis
- moderate to severe aortic stenosis, [**Location (un) 109**] 0.8cm2; peak 64mmHg,
mean 39mmHg) with mild aortic regurgitation
- echocardiogram at OSH revealed mild concentric LVH with
normal biventricular function
- moderate tricuspid regurgitation and moderate pulmonary
artery systolic hypertension (46mmHg
#. Post-polio syndrome with fusion of right ankle.
#. Hypertension
#. Hyperlipidemia
#. Chronic backpain spinal stenosis
Social History:
The patient is married (first husband died at age 28 [**1-7**]
Hodgkin's lymphoma). The patient lives in a single family home
and was previously a singer.
Tobacco: 1-2ppd x 48 years,
ETOH: None
Illicts: None
Family History:
Mother - passed in the 80's from "old age,"
Father - unknown
5 children
Physical Exam:
Vitals: Afebrile, vital signs stable.
General: Alert and oriented.
Abdomen: Obese, soft. Non-tender, non-distended.
Right Lower Extremity: Incision site clean/dry/intact with some
swelling over incision site. She has a drain intact. She is
neurovascularly intact distally.
Pertinent Results:
[**2174-4-4**] 11:30PM WBC-8.3 RBC-4.03* HGB-10.8* HCT-33.4* MCV-83
MCH-26.7* MCHC-32.2 RDW-17.1*
CPK: 74, 91, Troponin x 2 sets [**Date range (1) 22743**]: <0.01.
[**4-19**]: HCT: 28.9, WBC: 5.6 PLT: 359
Brief Hospital Course:
The patient was admitted to the vascular surgery service on
[**2174-4-4**] for pre-operative planning. In anticipation of the
surgery, the patient underwent diagnostic abdominal aortogram
with pelvic arteriogram with pre and post hydration with
discontinuation of patient's home lasix. The following morning,
on the day of planned surgical resection, the patient was noted
to be tachypnic, hypertensive, hypoxic and agitated with rales
[**12-7**] way up her lung fields, consistent with pulmonary edema. The
surgery was cancelled given decompensated CHF requiring a
non-rebreather. The patient received 20mg IV lasix x 2, was
transferred to the PACU with improvement in O2 requirements to >
95% on 2L NC. The patient was then transferred to the medical
service for management of CHF and medical optimization prior to
possible repeat attempt for surgery. Pain service was consulted
and a tunneled epidural catheter was placed for pain control.
She was optimized medically for one week and on [**4-13**], she
underwent resection of her right groin sarcoma without
complications. Vascular surgery was not needed as the tumor was
resected off the femoral vessels without the need for bypass.
Plastic surgery applied a gracilis flap over the femoral
vessels. Post-operatively, internal medicine was consulted to
help manage her fluid status. She did extremely well
post-operatively. Her epidural was discontinued a few days
after the procedure and she had good pain control on oral pain
medications. Her foley catheter was removed on post-operative
day number five. She worked with physical and occupational
therapy. She was discharged in stable condition to rehab on
post-operative day number six.
Due to the drain output of 20 cc over 24 hours, plastic surgery
service decided to keep the drain in place at the time of
discharge for plan to record drain amounts at rehab then return
to plastic surgery (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) in 1 week for removal of
the drain. It was also decided by them to keep her on oral
keflex to prevent infection while the drain is in place.
Medications on Admission:
Medications on transfer:
ISS
Lidocaine 5% Patch 2 PTCH TD Q 24 HRS
Atenolol 25 mg PO DAILY
Nifedipine CR 30 mg PO DAILY
Lorazepam 0.5-1 mg PO Q4-6H:PRN
Citalopram Hydrobromide 40 mg PO DAILY
Nicotine Patch 14 mg TD DAILY
Furosemide 40 mg PO DAILY (holding)
OxycoDONE (Immediate Release) 5 mg PO Q4-6H:PRN
Oxycodone SR (OxyconTIN) 20 mg PO Q12H
Gabapentin 600 mg PO TID
Simvastatin 10 mg PO DAILY
Haloperidol 2.5 mg IV Q4H:PRN
Lasix 20mg IV x 2
.
Medications, outpatient
Atenolol 25mg daily
Nifedipine XL 30mg qd
Simvastatin 20mg qd
Lasix 40mg qd
Neurontin 300mg [**Hospital1 **]
Celexa 40mg qd
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q 24 HRS ().
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6-8H
(every 6 to 8 hours) as needed.
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-7**] Sprays Nasal
TID (3 times a day) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
12. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
14. Insulin Regular Human Subcutaneous
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed. Tablet(s)
17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
19. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] center
Discharge Diagnosis:
Primary:
1. Congestive heart failure secondary to aortic stenosis and
fluid overload
2. Sarcoma, right thigh
3. Delirium secondary to hypoxia and oversedation with
underlying dementia.
4. Anxiety
5. Elevated blood sugar
6. Moderate-Severe aortic stenosis
7. Hypertension
.
Secondary:
1. Hyperlipidemia
2. Post Polio Syndrome
Discharge Condition:
Good: No shortness of breath, no supplemental oxygen
requirement, good pain control.
Discharge Instructions:
You were admitted for the surgical removal of the soft tissue
sarcoma in your right groin. Pre-operatively, you experienced
an episode of CHF secondary to fluid overload in the setting of
aortic stenosis. You underwent surgical excision of the mass.
.
Please call your doctor or return to the emergency room if you
develop fevers/chills, chest pain, lightheadedness/dizziness,
faiting, shortness of breath, worsening back/leg pain, inability
to tolerate food/fluid or any other symptoms that concern you.
Please record the daily drain output. Continue with oral keflex
while the drain is in place. Return in 1 week to see Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of plastic surgery for removal of the drain.
Followup Instructions:
Please follow up with your primary care provider within one week
of your discharge from rehab. Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 71433**].
.
Follow-up with Dr. [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**] in 3
weeks.
.
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in plastic surgery in 1 week
for removal of your drain.
Completed by:[**2174-4-19**]
ICD9 Codes: 4280, 4241, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6006
} | Medical Text: Admission Date: [**2124-10-24**] Discharge Date: [**2124-10-30**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
.
cc: fatigue and SOB
Major Surgical or Invasive Procedure:
right IJ central line
History of Present Illness:
History obtained from patient, wife and family.
.
80 yo male w/ recent hospitalizfation for diverticular bleed,
h/o stroke, h/o CAD and MI, CRI who p/w few days of malaise and
SOB. Pt was feeling reasonably well since his last admission
when his wife brought him to [**Name (NI) 2025**] for increasing SOB over last
few days. Per pt and family, he has been having progressive
fatigue over last months with decrreased interest in activity.
He has been feeling lethargic and wife reports increased
somnolence. He reports an increase in his thirst but denies
polyuria or polydypsia and has no h/o diabetes. He has been
feeling light headed and his appetite as been low over past few
days. Pt endorses some increase in LE swelling, +orthopnea and
occasional PND. He denies chest pain or palipations. He denies
any fevers or chills, weight loss or weight gain, abdominal
pain, dysuria or hematuria. He has chronic black stools and is
on iron but denies any BRBPR. He uses a walker to get around
[**1-21**] residual right-sided weakness after sroke. Pt is not on
home oxygen and has 25-30 pack year smoking hx, quit 20 years
ago. He takes tiotropium daily but denies h/o asthma or COPD.
Pt had nml Echo [**2122**] w/ EF >55%. He denies any changes in his
medications and denies any new weakness. Wife does report
increase in slurred speech over past few weeks.
.
Pt was transferred from [**Hospital1 2025**] ED where he was noted to be in
a-flutter. He received lasix 20mg IV, Metop 25mg PO, atrovent
nebs. Head Ct was ordered but results not reported.
Past Medical History:
- h/o GI bleed, diverticulitis and recent hospitalization
- C. Diff colitis
- h/o stroke 12 years ago w/ right-sided weakness
- h/o nephrolithiasis w/ stent and nephrostomy tube
- CAD s/p MI
- sleep apnea
- h/o supplemental oxygen
- thrombocytopenia
- h/o klebsiella urosepsis
- CRI BL Cr 1.2-1.7, 2.5 last admission w/ GI bleed
- sleep apnea
- depression
.
MEDS:
metoprolol 25mg [**Hospital1 **]
Iron 325mg TID
Tiotropium 18mcg daily
Social History:
Lives with wife [**Name (NI) **], h/o smoking [**12-21**] PPD for 50 years, quit
20 years ago, does not drink alcohol, no drugs.
Family History:
non-contributory
Physical Exam:
VS: 96.3 112/68 68 24 97% on 2L
Gen'l: obese, sleepy, NAD
HEENT: NC/AT, EOMI, MMM, OP clear
NECK: IJ in place, site c/d/i, unable to assess JVD
CVS: NR/RR, +s1/s2 but distant heart sounds, no murmur
appreciated
PUL: ([**Last Name (un) **]) ronchorous breathing, difficult to assess, pt too
lethargic to sit up
[**Last Name (un) **]: obese, +BS, soft, NT/ND, no masses
Extrems: no c/c/e
Pulses: 2+ radial, 2+ DP
Neuro/Psyche: oriented to name, place, year, season, current
events; unable to recite days of week backwards
Pertinent Results:
12:45pm: Trop-T: 0.04
CK: 33 MB: Notdone
.
u/a:
mod leuks, large bld, neg nit, tr prot, neg glu, neg ket, >50
RBCs, 21-50 WBC, mod bacteria
.
03:55am
.
140 106 113
--------------< 110
4.6 18 4.3
.
CK: 36 MB: Notdone Trop-T: 0.05
.
ALT: 34 AP: 194 Tbili: 0.4
AST: 20 LDH: 182
[**Doctor First Name **]: 59
proBNP: 9866
.
T4: 7.5
.
Lactate:1.0
.
9.0 > 29.5 < 330 D
N:85.3 Band:0 L:11.8 M:1.7 E:0.9 Bas:0.2
.
PT: 15.1 PTT: 28.3 INR: 1.4
.
RENAL U/S:
The study is limited by body habitus. The kidneys demonstrate a
homogenous echotexture, although are slightly hyperechoic to the
liver which may indicate underlying medical renal disease. There
is no evidence of hydronephrosis, mass or stone. No definite
stent is seen. IMPRESSION: No evidence of hydronephrosis.
.
CXR:
IMPRESSION: Right IJ terminates at the cavoatrial junction. No
acute cardiopulmonary disease is identified. Stable
cardiomegaly, suggestive of possible cardiomyopathy.
.
EKG: 4:1<-->2:1 flutter; EKG#2 4:1 flutter w/ LAD and LAFB, no
ST segment changes; flutter not noted on prior EKGs
.
ECHO [**2123-6-16**]
The left atrium is mildly dilated. 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%). The right
ventricle may be mildly dilated. Right ventricular systolic
function is normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The tricuspid valve leaflets are mildly thickened.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2122-3-24**], estimated pulmonary artery
systolic pressure is now higher.
.
p-mibi [**2121**] negative
Brief Hospital Course:
80 yo male w/ h/o diastolic CHF, CAD s/p MI, chronic renal
insufficiency (Cr 1.3-1.7), h/o lower GI bleed, diverticulosis,
CVA, C.diff, urosepsis who presents to the ED at [**Hospital1 18**] with
several days of shortness of breath, gradually worseing fatigue,
acute on chronic renal failure and newly diagnosed atrial
flutter.
.
1. Dyspnea
The most likely etiology was CHF exacerbation secondary to new
atrial flutter. BNP was elevated to 9866 on admission. Chest
x-ray on admission showed possible pleural effusion on left side
and stable cardiomegaly. EKG showed new atrial flutter with no
evidence of acute myocardial ischemia. Cardiac enzymes x 3 were
negative. The patient received Lasix 20 mg IV x 2. He had good
urine output and denied any dyspnea during his hospital stay. He
was on oxygen 2L nc which was d/c'd on HOD3.
.
2. Fatigue
His fatigue had started 1-2 months PTA and was most likely
secondary to his CHF and recent lower GI bleed/anemia. Other
contributing causes were uremia (BUN 113) and atrial flutter.
His Hct on admission was 29.3. His Hct in the past have been
between 26-35. His guaiac tests were all negative. Another
contributing was an UTI and bacteremia. His urine culture and
blood culture were positive for E.coli.
On HOD3 he felt much better and was not exhausted any mor.
.
3. Atrial flutter
Possible etilogy was the UTI and bacteremia and CHF
exacerbation. Thyrotoxicosis was unlikely as T4 was normal.
Electrophysiology was consulted and did not change his
metoprolol. He was started on aspirin but no anticoagulation due
to his risk for GI bleed. He got an ECHO which showed LVEF >
55%, and minor changes from last ECHO.
.
4. Acute renal failure
The patient's Cr was 4.3 on admission with baseline Cr 1.3-1.7.
The most likely cause was pre-renal, cardiogenic acute renal
failure resulting from hypoperfusion of kidneys secondary to CHF
and decreased stroke volume. Post-renal cause was unlikely since
renal US was negative for any hydronephrosis. Renal cause was
unlikely since there are no urine casts, no RBC, no protein.
His Cr improved daily and he had good urine output.
.
5. UTI
Patient had positive UA with urine cx E.coli, sensitive to
ceftriaxone and ciprofloxacin. He had no c/o dysuria, hematuria
while in the hospital. He was treated with Ceftriaxone 1 grm IV
q24h while in the hospital and he will be discharged on cipro to
complete a 14 day course.
.
6. Bacteremia
Blood culture was positive for E.coli, sensitive to ceftriaxone
and ciprofloxacin. He had no signs of sepsis. No tachycardia, no
fever or hypothermia. WBC decreasing. He was treated with
Ceftriaxone 1 grm IV q24h while in the hospital and he will be
discharged on cipro to complete a 14 day course.
.
7. Hyperkalemia
The patient's potassium increased to 5.2 on [**10-26**]. This was most
likely related to acute renal insufficiency. EKG showed no
peaked T waves. He received Kayexalate and his potssium
decreased to 4.7. He was placed on a renal/low K diet.
.
8. Gastrointestinal bleed:
Patient has history of recurrent bleeds in the past. During
this admission, he was noted to have several large bloody bowel
movements with blood clots. He was monitored in the intensive
care unit where his bleeding resolved and his hematocrit
remained stable. He denied any abdominal pain, chest pain, new
dyspnea, fevers, chills, night sweats, lightheadedness. GI was
consulted while the patient was in the ICU and colonoscopy was
not performed during this admission as his bleeding had resolved
and his bleed was thought most likely secondary to
diverticulosis. He was recommended to follow-up with GI . . .
.
Of note, he was recently admitted to [**Hospital1 18**] at the end of [**Month (only) 359**]
for a GI bleed. He was not scoped during that admission b/c the
bleed stopped on its own and his hct was stable. He was
scheduled to follow up with GI as an outpatient.
This was likely related to his severe diverticulosis, though AVM
or other etiology cannot be excluded. He appeared stable and
asymptomatic at that time.
Medications on Admission:
Metoprolol 25mg PO BID
Iron 325mg TID
Tiotropium 18mcg daily
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 8 days: Take 1 pill TWICE a day till finished. .
Disp:*16 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12874**] [**Hospital **] Nursing Home
Discharge Diagnosis:
Primary Diagnoses:
- E. coli bacteremia with sepsis
- Urinary tract infection
- Gastrointestinal bleeding
- Atrial flutter
- Acute renal failure
- Congestive heart failure exacerbation
.
Secondary Diagnoses:
- history of gastrointestinal bleed, diverticulitis
- history of stroke 12 years ago with right-sided weakness
- history of nephrolithiasis with stent and nephrostomy tube
- coronary artery disease
- sleep apnea
- chronic renal insufficiency
Discharge Condition:
Stable. Ambulating, talking, returned to baseline.
Discharge Instructions:
You were admitted with a change in your mental status and
shortness of breath and were found to have bacteria (E. coli) in
your urine and your blood. You were started on intravenous
antibiotics and improved. You also had acute renal failure
likely secondary to this infection, in addition to your chronic
kidney disease, and were seen by the Kidney Consult service.
Your kidney function improved over your stay. You will need to
follow-up with the Kidney service.
.
You will finish a 14-day total course of antibiotics on [**11-5**].
Please take as directed.
.
You also had a newly diagnosed abnormal heart rhythm called
atrial flutter. No medications were started and you will
continue to take metoprolol. You will need to follow-up with
the electrophysiology clinic to monitor your rhythm. This
rhythm may have been caused by your infection.
.
You had transient increases in your potassium levels and were
treated with a bowel medicine and your potassium normalized.
You will need to have your blood drawn to monitor this.
.
You were started on an aspirin daily for the heart and brain
protective-effect. You do have a recent history of bleeding
from your gastrointestinal tract.
.
You had gastrointestinal bleeding and you were transferred to
the Intensive care unit for close monitoring. You received IV
fluids and your hematocrit was stable.
.
You need to drink a lot of fluids in the next couple days.
.
If you develop any concerning symptoms such as frequent or
prolonged palpitations, chest pain, swelling in your legs,
shortness of breath, fevers, dizzyness or notice large blood in
your stool, or other concerning symptoms, please call your
primary care physician or proceed to the emergency room.
Followup Instructions:
Renal appointment: Dr. [**Last Name (STitle) 4883**], Monday, [**11-13**], at 3PM. If
you have questions, please call [**Telephone/Fax (1) 60**].
Primay care physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], Wednesday, [**11-8**],
at 11:50AM. If you have any questions, please call [**Telephone/Fax (1) 1579**].
Electrophysiology: Dr. [**Last Name (STitle) 73**], Monday, [**11-28**], at
11:20AM. If you have questions, please call [**Telephone/Fax (1) 902**].
.
Provider [**Name9 (PRE) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2125-1-15**] 1:30
.
Please also follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 9890**] on
Friday [**12-8**] at 11am. Her office is located in the [**Hospital Unit Name 1824**] [**Location (un) **]. If you need to reschedule, please call her
office at [**Telephone/Fax (1) 463**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2124-10-30**]
ICD9 Codes: 5849, 5990, 4280, 5859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6007
} | Medical Text: Admission Date: [**2177-8-16**] Discharge Date: [**2177-8-16**]
Date of Birth: [**2097-3-17**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
man with a long history of coronary artery disease who for
the past several weeks has experienced increasing chest pain
which in retrospect was angina and
has taken increased nitroglycerine. He
was taking care of his ill wife and therefore did not want to
come to the hospital. The patient has a history of chronic
obstructive pulmonary disease, peripheral vascular disease,
and shortness of breath. He presented to the hospital and was
felt initially to have pneumonia. He was admitted to the
medical intensive care unit, however review of the EKG showed
severe EKG changes. He was taken for emergent catheterization
that showed 90% left main, 90% ostial LAD stenosis,
circumflex disease and moderate right coronary artery
disease. The patient was hypotensive and hemodynamically
unstable. Surgery was consulted because the patient developed
cardiogenic shock acidosis and hypotension and intraaortic
balloon pump was placed which stabilized his hemodynamics
although he continued to be somewhat hypotensive and acidotic.
On physical examination, his BP was 90/50 on the intraaortic
ballon pump with elevated filling pressures, HR was 90 BPM. He
was not intubated. Lung exam
showed bilateral rales. Abdomen was soft and nontender.
Cardiac exam showed distant heart sounds. The patient had
non-papable distal extremity pulses, suggesting peripheral
vascular disease. Neurologic exam was grossly normal.
He was taken for emergency bypass surgery where coronary
artery bypass grafting x3 was performed. The conduits were
extremely poor. The LIMA was placed to the OM, veins were
placed to the LAD and RCA. Ejection fraction initially was
20-30% with pulmonary hypertension and 1+ mitral
regurgitation. His mixed venous oxygen saturation
was approximately 48%, suggesting poor peripheral perfusion
and shock. His filling pressures were elevated with a CVP of
about 25 mmHg. He has rather severe pulmonary
hypertension prior to surgery (55/27 mmHg). After surgery
initially he did feel well with moderate inotropic support and
intraaortic balloon pump support. However his condition
gradually and progressively deteriorated.
He developed severe episode of ventricular tachycardia prior
to chest closure. His chest was reopened but his hemodynamics
did not significantly change. The sternum was left open but
the skin was closed. His poor hemodynamic condition was felt
most likely to be due to poor underlying cardiac function,
poor bypass targets and poor vein
conduit. His acidosis may be in part been due to the IABP and
peripheral vascular disease.
He was transported to the cardiac surgical recovery unit. He
continues to have low cardiac output syndrome and acidosis
despite maximal inotropic support and intraaortic balloon
pump support. Consideration for left ventricular assist
device was given however because of his advanced age and poor
chances for recovery this was not placed. The situation was
discussed with the family. The patient's family were at his
bedside when he died.
FINAL DIAGNOSIS:
1. Acute myocardial infarction.
2. Cardiogenic shock, treated with IABP and emergency CABG x
3. Congestive heart failure, pulmonary edema.
4. Mild renal insufficiency, peripheral vascular disease.
5. Moderate chronic obstructive pulmonary disease.
6. Status post coronary artery bypass grafting.
7. Death following emergent CABG.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 5297**]
MEDQUIST36
D: [**2177-8-16**] 22:35:21
T: [**2177-8-17**] 04:35:09
Job#: [**Job Number 74285**]
ICD9 Codes: 496, 4280, 2762, 5119, 486, 4240, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6008
} | Medical Text: Admission Date: [**2140-7-29**] Discharge Date: [**2140-8-3**]
Date of Birth: [**2100-11-24**] Sex: M
Service: MEDICINE
Allergies:
Propoxyphene / Methadone / pseudoephedrine / Peanut / Adhesive
Bandage / Banana
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
IR guided HD line placement
History of Present Illness:
Mr. [**Known lastname 15532**] is a 39 y.o incarcerated male w/ HIV, ESRD M/W/F HD,
last got it Weds, presenting with fevers. On Monday had erythema
around his catheter site (in the groin) at HD. He finished HD
and got a dose of vanc. On Wed he continued to feel fatigue and
had more fevers so go dialyzed completely, got a dose of vanc
and then had his catheter pulled. They packed the wound and he
went home. He came back today and the site looked much worse
after the packing was taken out and the cath site was indurated
with concern for an abscess. In addition he was complaining of
SOB and couldn't lay flat in HD which they called "respiratory
distress".
In the ED, VS: 9 98.4 85 173/102 18 87%. he triggered for
hypoxia to 87% RA. Responded to upright position and
supplemental O2. Also given morphine and 80mg IV lasix. Now sat
94-95 4 L NC
In addition he was hypertensive to the 200's and got 10mg IV
hydral which dropped the BP to 170s (pt reports this is his
baseline).
On labs he was noted to have a mild troponin leak. EKG with
peaked T waves concerning for hyperkalemia although K 4.7. Got
calcium gluconate prior to seeing Ca which was wnl.
CXR with diffuse infiltrate suggestive of fluid overload. Exam
correlated.
Patient had no HD access and a 16 gauge EJ placed and IR was
called so patient could get an HD line. Only access site is
right groin. Called renal who will evaluate.
Also on exam groin site: Erythemaotous, warm, cellulitic, had
U/S looks like small ? complex collection--> got IV vanc and
pipercillin tazobactam
Attempting to obtain more records from federal prison. Contact
[**Name (NI) **] at number in RN comments.
.
On the floor, patient was breathing comfortably. He re-iterated
the above story including feeling unwell for the last few days
starting Monday.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
HIV (CD4 308 in [**Month (only) 958**] with undetectable VL)
End Stage Renal Disease
H/O ESBL sepsis last year
AV graft failure complicated by amputation of right forearm and
hand
HTN
DMII
Asthma
GERD
Chronic phantom limb pain
Social History:
Incarcerated
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Endorses marijuana approximately 7 years ago
Family History:
Father with ESRD and CAD w/ death of MI at 56.
Physical Exam:
Vitals: T: 96.9 BP:175/98 P:86 R: 24 O2: 93 on 3L NC
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,
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge exam:
GEN: Lying in bed in NAD
HEENT: NCAT, EOMI.
COR: +S1S2, no m/g/r.
PULM: Diminished breath sounds bilaterally secondar to habitus &
posture, however CTAB, no c/w/r .
[**Last Name (un) **]: +NABS in 4Q. Slight transient tenderness is right lower
quadrant, no tenderness to percussion or rebound tenderness.
EXT: Left groin site markedly improved, without any surrounding
erythema. Area is still firm/scarred. Right tunneled groin
catheter tender to palpation over tunneled aspet, but without
erythema.
NEURO: Awake & alert, MAEE.
Pertinent Results:
[**2140-7-29**] 09:35PM VANCO-22.5*
[**2140-7-29**] 11:54AM COMMENTS-GREEN TOP
[**2140-7-29**] 11:54AM LACTATE-0.8 K+-4.7
[**2140-7-29**] 11:50AM GLUCOSE-123* UREA N-89* CREAT-11.2*
SODIUM-135 POTASSIUM-4.9 CHLORIDE-91* TOTAL CO2-24 ANION GAP-25*
[**2140-7-29**] 11:50AM CK(CPK)-98
[**2140-7-29**] 11:50AM cTropnT-0.09*
[**2140-7-29**] 11:50AM CK-MB-2
[**2140-7-29**] 11:50AM CALCIUM-9.8 PHOSPHATE-6.8* MAGNESIUM-2.5
[**2140-7-29**] 11:50AM VANCO-9.0*
[**2140-7-29**] 11:50AM WBC-11.6* RBC-4.56* HGB-9.8* HCT-30.7*
MCV-67* MCH-21.4* MCHC-31.8 RDW-19.2*
[**2140-7-29**] 11:50AM NEUTS-84.0* LYMPHS-9.4* MONOS-3.5 EOS-2.5
BASOS-0.7
[**2140-7-29**] 11:50AM PLT COUNT-310
[**2140-7-29**] 11:50AM PT-13.9* PTT-32.9 INR(PT)-1.2*
Micro:
Blood Cultures 6/25 NGTD; MRSA Nasal Screen positive
.
EKG: NSR. Nl Axis, intervals. Peaked Twaves in V2-V4 and TW
inversions I, II. LVH. Probably [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6192**].
.
RADIOLOGY:
LENI:
1. No left lower extremity deep venous thrombosis.
2. 1.3 cm complex fluid collection reflects hematoma with or
without
superinfection or abscess with reactive lymphadenopathy.
.
CXR: Moderate pulmonary edema with probable small bilateral
pleural
effusions. No pneumothorax.
Brief Hospital Course:
Mr. [**Name13 (STitle) **] is a 39 year old gentleman with End Stage Renal
Disease on Dialysis admitted with a catheter site infection,
transferred to the MICU for volume overload/hypoxia.
Dyspnea: The patient was dyspneic and hypoxic on presentation
to the MICU. He was treated with several hours of
Ultrafiltration and Hemodialysis and his symptoms resolved.
Groin/catheter site infection: The patient developed an area of
induration and erythema at his groin catheter site. Surgery was
consulted and did not intervene. He was started on Vancomycin
and Meropenem given a history of Resistant organisms and MRSA.
The patient's dialysis catheter was moved under interventional
radiology guidance. A PICC was also placed for antibiotic
administration.
ESRD: The patient was dialyzed while admitted through his newly
placed catheter. He did develop asymptomatic hyperkalemia while
admitted. He will continue a Monday, Wednesday, Friday scheduled
for Dialysis.
# HIV: continued home regimen.
# Communication: Patient and [**First Name8 (NamePattern2) 8254**] [**Known lastname 15532**] [**Telephone/Fax (1) 87718**] (we
cannot contact her she needs to be called by the policemen)
# Code: Full (discussed with patient)
Transitional issues:
Complete Vancomycin/Ertapenem (switched for availability of
pharmaceutical [**Doctor Last Name 360**]) until [**2140-8-7**].
Medications on Admission:
Nifedipine CR 60 mg PO daily
Emtricitabine 200 mg PO 2*/wk (MO, FR)
Insulin SC PRN for BG>200
Sevelamer Carbonate 3200 mg PO TID
Sertraline 200 mg PO daily
Omeprazole 20 mg PO daily
Mom[**Name (NI) 6474**] inhaled [**Hospital1 **]
Minoxidil 10 mg PO BID
Metoprolol Succinate 200 mg PO daily
Ferrous gluconate 324 mg PO BID
Lisinopril 40 mg PO daily
Efavirenz 600 mg PO QHS
Docusate 100 mg PO BID
Diphenhydramine 25 mg PO Q8hr: PRN itching
Amitriptyline 100 mg PO HS
Albuterol inhalers Q4hrs
Abacavir 600 mg PO daily
Discharge Medications:
1. nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
2. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO 2X/WEEK
(MO,FR).
3. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. mom[**Name (NI) 6474**] 110 mcg (30 doses) Aerosol Powdr Breath Activated
Sig: One (1) puff Inhalation twice a day.
7. minoxidil 10 mg Tablet Sig: One (1) Tablet PO twice a day.
8. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
9. ferrous gluconate 324 mg (36 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. insulin lispro 100 unit/mL Solution Sig: As directed
Subcutaneous three times a day: As directed per attached sliding
scale.
14. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
every eight (8) hours as needed for itching.
15. amitriptyline 100 mg Tablet Sig: One (1) Tablet PO at
bedtime.
16. ertapenem 1 gram Recon Soln Sig: Five Hundred (500) mg
Intravenous every twenty-four(24) hours for 5 days: To be given
after dialysis on dialysis days. Last dose [**8-7**].
Disp:*5 doses* Refills:*0*
17. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
18. abacavir 300 mg Tablet Sig: Two (2) Tablet PO once a day.
19. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
Daily after dialysis for 5 days: To be given on dialysis days
only, last dose [**8-9**].
Disp:*3 grams* Refills:*0*
20. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 3 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
- Left groin Cellulitis catheter infection
- ESRD
Secondary Diagnoses:
- HIV infection
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 15532**],
You have been admitted to the hospital with an infection around
your dialysis line. While you were here we replaced a new
dialysis line, and treated you with ultrafiltration and
hemodialysis to allievate your shortness of breath. You have
been evaluated by Surgery and your Kidney team and you are now
safe for discharge.
New Medications:
We have added the following Antibiotics: Ertapenem & Vancomycin
for 5 more days.
Followup Instructions:
Please follow up with your primary care doctor: [**Last Name (LF) **],[**First Name8 (NamePattern2) 3679**]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 87719**] within 1-2 weeks.
ICD9 Codes: 5856, 7907, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6009
} | Medical Text: Admission Date: [**2150-2-23**] Discharge Date: [**2150-2-27**]
Date of Birth: [**2083-10-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion and positive exercise tolerance test
Major Surgical or Invasive Procedure:
[**2150-2-23**] - CABGx4 (Lima->Lad, SVG->Diagonal, SVG->Obtuse marginal,
SVG->Right coronary artery)
History of Present Illness:
Mr. [**Name13 (STitle) 34062**] is a 66 year-old male with worsening anginal symptoms.
A cardiac catheterization showed severe three-vessel disease. He
now presents for
revascularization.
Past Medical History:
Coronary artery disease
Hypercholesterolemia
HTN
BPH
Colonic polyps
Left inguinal hernia
Social History:
Quit smoking 30 years ago. No alcohol or drug use. He is single
and lives in [**Location 86**].
Family History:
Brother with CABG at age 74.
Physical Exam:
Vitals: BP 162/86, HR 46, RR 14, SAT 98% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD
Heart: regular rate, normal s1s2
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2150-2-25**] 08:45AM BLOOD WBC-8.8 RBC-2.97* Hgb-9.6* Hct-26.8*
MCV-91 MCH-32.5* MCHC-35.9* RDW-13.1 Plt Ct-132*
[**2150-2-25**] 08:45AM BLOOD Plt Ct-132*
[**2150-1-24**] CXR
1. No evidence of pneumothorax.
2. Worsening left lower lobe atelectasis
[**2150-2-23**] ECHO
PREBYPASS- A left-to-right shunt across the interatrial septum
is seen at
rest. A small secundum atrial septal defect is present. Left
ventricular wall thicknesses and cavity size are normal. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The descending thoracic aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen.
POST BYPASS-Biventricular systolci function remains normal.
Remaining study is otherwise unchanged compared to pre-bypass
[**2150-2-27**] 06:20AM BLOOD Hct-26.3*
[**2150-2-25**] 08:45AM BLOOD Plt Ct-132*
[**2150-2-27**] 06:20AM BLOOD UreaN-13 Creat-0.8 Na-143 K-4.6
[**2150-2-26**] CXR
There has been interval removal of a right internal jugular
vascular catheter. No pneumothorax. Cardiac and mediastinal
contours are stable in the postoperative period. There is
improving atelectasis in the left lower lobe, and there are
small bilateral pleural effusions, left greater than right,
which have increased on the left in the interval.
Brief Hospital Course:
Mr. [**Known lastname 43313**] was admitted to the [**Hospital1 18**] on [**2150-2-23**] for elective
surgical management of his coronary artery disease. He was taken
directly to the operating room where he underwent coronary
artery bypass grafting to four vessels. Postoperatively he was
taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Mr. [**Known lastname 43313**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Aspirin and beta
blockade were started. He was then transferred to the step down
unit for further recovery. Mr. [**Known lastname 43313**] was gently diuresed towards
his preoperative weight. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. Vitamin C and folic acid were started for
postoperative anemia. His wires and drains were removed without
complication. Mr. [**Known lastname 43313**] continued to make steady progress and
was discharged home on postoperative day four. He will follow-up
with Dr. [**Last Name (STitle) **], his cardiologist and his primary care
physician as an outpatient.
Medications on Admission:
Aspirin 81mg QD
Atenolol 12.5mg QD
Lipitor 20mg QD
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease
Hypercholesterolemia
HTN
BPH
Colonic polyps
Left inguinal hernia
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These included
redness, drainage or increased pain.
2) Report any fever greater then 100.5
3) Report any weight gain of greater then 2 pounds in 24 hours
or 5 pounds in 1 week.
4) No lifting greater then 10 pounds for 10 weeks
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month.
Follow-up with your cardiologist Dr. [**Last Name (STitle) **] in [**1-19**] weeks
Follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-19**]
weeks.
Call all providers for appointments.
Completed by:[**2150-2-27**]
ICD9 Codes: 2859, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6010
} | Medical Text: Unit No: [**Numeric Identifier 75913**]
Admission Date: [**2158-12-24**]
Discharge Date: [**2159-1-3**]
Date of Birth: [**2158-12-24**]
Sex: F
Service: NB
SERVICE: Neonatology.
PATIENT IDENTIFICATION: Baby girl [**Known lastname 75914**] [**Known lastname 75915**] is a former
34 week gestation infant, now 10-days-old, corrected to 35
3/7th week gestation.
HISTORY OF PRESENT ILLNESS: This the former 1.915 kilogram
product of a 34 week gestation pregnancy, born to 24-year-old
G2, P0, now 1 woman. Prenatal screens: Blood type B
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group beta strep status
unknown. The pregnancy was notable for fevers of unknown
origin. The mother was initially evaluated on [**2158-12-21**], as a transfer from [**Hospital3 **]. She was given
beta Methasone at that time. She was subsequently discharged,
but re-admitted on [**2158-12-24**] with a fever of 101.7 and
a severe headache. At this time the fetal heart tracing was
noted to be 180 to 200 beats per minute and decision was made
to proceed with a Cesarean section, due to the non-reassuring
fetal heart rate tracing and fetal tachycardia. The infant
emerged vigorous, required only crying and bulb suction and
brief blow by oxygen. Apgars were 8 at 1 minute and 9 at 5
minutes. She was admitted to the neonatal intensive care unit
for treatment of prematurity. Anthropometric measurements at
the time of admission, weight 1.915 kg, 25th percentile,
length 44.5 cm, 25th percentile, head circumference 32 cm,
50th percentile.
PHYSICAL EXAMINATION AT DISCHARGE: Weight 1.875 kg, head
circumference 31 cm, length 45 cm. General: Nondysmorphic,
nondistressed preterm infant in room air. Skin: Warm and dry,
color pink, well-perfused. Head, ears, eyes, nose and throat:
Nondysmorphic facies, mucous membranes moist, neck supple,
clavicles intact, palate intact. Chest: Lungs clear and equal
bilaterally. Cardiovascular: No murmur, normal S1, S2,
femoral pulses +2. Abdomen: Soft, nontender, nondistended, no
masses. GU: Normal female, patent anus. Musculoskeletal:
Moving all extremities equally. Hips stable. Neurologic:
Appropriate tone and reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA SYSTEM:
1. Respiratory: This infant has been in room air since
admission to the neonatal intensive care unit. She has
not had any episodes of apnea or bradycardia. At the
time of discharge she is breathing comfortably with a
respiratory rate of 50 to 60 breaths per minute.
2. Cardiovascular: A murmur was noted on day of life #1.
This infant has maintained normal heart rates and blood
pressures. The murmur resolved by day of life 4. At the
time of discharge her baseline heart rate is 141-160
beats per minute with a recent blood pressure of 68 over
41 mmHg, mean arterial pressure 51 mmHg. A recurrent murmur
was noted at the time of discharge. A chest xray was normal as
was an EKG. 4 ext Bps were normal. RA sats were up to 100%.
3. Fluids, electrolytes, nutrition: This infant was
initially NPO and maintained on intravenous fluids.
Enteral feeds were started on day of life #1 and
gradually advanced to full volume. At the time of
discharge she is taking po feeds well with
Enfamil 24 calorie per ounce by bottle . Weight on the day of
discharge is 2.435 kg.
4. Infectious disease: Due to the mother's history with the
fevers, and fetal tachycardia, this event was evaluated
for sepsis upon admission to the neonatal intensive care
unit. A white blood cell count and differential were
within normal limits. A blood culture was obtained prior
to starting intravenous ampicillin and gentamicin. The
blood culture was no growth at 48 hours and the
antibiotics were discontinued.
5. Hematological: Hematocrit at birth was 47.7%. This
infant did not receive any transfusions or blood
products.
6. Gastrointestinal: This infant required treatment for
unconjugated hyperbilirubinemia, with phototherapy. Peak
serum bilirubin occurred on day of life #8, with a total
of 8.7 mg per dL. The phototherapy had been discontinued
on day of life #4 as the infant is feeding and otherwise
well. No further treatment was thought indicated.
7. Neurological: This infant has maintained the normal
neurological exam during admission and there are no
neurological concerns at the time of discharge.
8. Sensory: Audiology, hearing screening was referred
bilaterally. Arrangements for post-discharge audiologic testing
were made. parents aware of testing results and need for
follow-up
9. Psychosocial: This mother moved to the United States
from [**Country 11150**] in [**2157-5-16**]. While she was visiting her
infant she was noted to have a clonic seizure. She was
readmitted to [**Hospital1 69**] and
evaluated for her seizure disorder and then started on
medication. [**Hospital1 **] Center social work has
been involved with this family in the contact social
worker is [**Name (NI) 46381**] [**Name (NI) 36527**], and she can be reached
at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home with parents.The primary
pediatrician is Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73225**], [**Country 75916**], [**Location (un) **], [**Numeric Identifier 75917**], phone number [**Telephone/Fax (1) 73227**].
CARE AND RECOMMENDATIONS AT TIME OF DISCHARGE:
1. Feeding: Ad lib Enfamil 24
calorie per ounce formula, either p.o. by gavage.
2. No medications.
3. Iron and vitamin D supplementation:
Iron supplementation is recommendation for preterm and low
birth weight infants until 12 months correct age.
All infants centered on early breast milk should receive
vitamin D supplementation at 200 international units,
(provided as a multivitamin preparation) daily until 12
months corrected age.
1. Car seat position screening is recommended prior to
discharge.
2. Newborn Screen was sent on [**2158-12-27**] and there
has been no notification of abnormal results to date.
3. Immunizations: No immunization administered thus far.
4. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet and use the following 4
criteria:
First born at less than 32 weeks; second born between 32 and
35 and 0/7th weeks with 2 of the following: Daycare during
RSV season, a smoker in the household, neuromuscular disease,
airway abnormalities, or school age siblings; thirdly chronic
lung disease; fourth, hemodynamically significant congenital
heart disease.
Influenza immunization is recommended for all infants once
they reach 6 months of age. Before this age and for the first
24 months of the child's life, immunization against influenza
is recommended for household contacts and out of home
caregivers.
This infant has not received rotavirus vaccine. The American
Academy of Pediatrics recommend initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable and at least 6 weeks, but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks gestation.
2. Suspicion for sepsis ruled out.
3. Unconjugated hyperbilirubinemia.
4. Referred hearing screen bilaetrally.
[**Doctor Last Name **],[**Doctor Last Name **] 50.470
Dictated By:[**Name8 (MD) 75740**]
MEDQUIST36
D: [**2159-1-3**] 02:23:35
T: [**2159-1-3**] 05:46:42
Job#: [**Job Number 75918**]
ICD9 Codes: V053, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6011
} | Medical Text: Admission Date: [**2102-2-7**] Discharge Date: [**2102-2-14**]
Date of Birth: [**2041-3-4**] Sex: M
Service: Cardiothoracic Surgery Service
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
gentleman with progressively increasing dyspnea on exertion.
His primary care physician recommended an echocardiogram
which revealed severe aortic stenosis. The patient was
ultimately referred for cardiac catheterization. The cardiac
catheterization revealed 50% proximal left anterior
descending artery occlusion as well as 20% to 40% other
coronary artery disease. He also had an left ventricular
ejection fraction of 56% at that time.
The patient has subsequently been referred for a coronary
artery bypass graft and aortic valve replacement. His aortic
valve gradient was 50 mmHg, and his aortic valve area was
0.94 cm2.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Insulin-dependent diabetes mellitus.
2. Obesity.
3. Hypertension.
4. Parkinson disease.
5. Hypercholesterolemia.
6. Depression.
MEDICATIONS ON ADMISSION: (Preoperative medications
included)
1. Humalog 75/25 insulin 64 units in the morning and 22
units in the evening.
2. Aspirin 325 mg by mouth once per day.
3. Multivitamin.
4. Lipitor 20 mg by mouth once per day.
5. Atenolol 25 mg by mouth twice per day.
6. Tricor 160 mg by mouth once per day.
7. Prozac 20 mg by mouth once per day.
8. Metformin 500 mg by mouth twice per day.
9. Isosorbide 30 mg by mouth twice per day.
10. Requip 0.5 mg by mouth three times per day.
ALLERGIES: The patient states no known drug allergies.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) **] quit smoking 40 years ago and does not drink
alcohol.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
on the day of surgery; which was [**2102-2-7**]. The patient
was taken directly to the operating room where he underwent
coronary artery bypass graft times one with a left internal
mammary artery to the left anterior descending artery as well
as an aortic valve replacement 23-mm St. [**Male First Name (un) 923**] mechanical
valve.
Postoperatively, he was transported in stable condition from
the operating room to the Cardiothoracic Surgery Recovery
Unit. On the night of surgery, he was weaned from mechanical
ventilation and successfully extubated. He remained on
amiodarone intravenous drip for some atrial fibrillation
intraoperatively as well as Levophed for some hypotension.
On postoperative day two, the patient had been weaned off of
his Levophed drip. His chest tubes drainage had decreased,
and he remained hemodynamically stable. He was transfused
for a hematocrit of 23.5 at that time and was transferred
from the Cardiothoracic Surgery Recovery Unit to the
postoperative telemetry floor in hemodynamically stable
condition.
On postoperative day three, the patient's chest tubes and
epicardial pacing wires were removed. He was started on
heparin at 800 units per hour because of his mechanical
valve. He was slow to progress with Physical Therapy on
ambulation, but this was also initiated at that time.
Over the next couple of days, the patient progressed from an
ambulation standpoint. The patient was started on Coumadin
on postoperative day four. His INR, however, was slow to
become therapeutic, and he remained on an intravenous heparin
drip over the next few days awaiting his INR to become
therapeutic.
During this time, he progressed from a cardiac rehabilitation
standpoint with Physical Therapy and nurses increasing his
level of activity. The patient also had been complaining of
insomnia. He had no significant complaints of discomfort.
He had remained hemodynamically stable throughout and in a
normal sinus rhythm.
Today, the patient had an INR of 2. His heparin was
discontinued, and he was able to be discharged home today.
PHYSICAL EXAMINATION ON DISCHARGE: The patient remained
afebrile. Neurologically, he was grossly intact. His
pulmonary examination revealed his lungs were clear to
auscultation bilaterally; although somewhat diminished at the
bilateral bases. Cardiovascular examination revealed a
regular rate and rhythm. His abdomen was obese, soft,
nontender, and nondistended. There were positive bowel
sounds. The patient had trace pedal edema bilaterally.
MEDICATIONS ON DISCHARGE:
1. Coumadin 5 mg today ([**2-14**]) and tomorrow ([**2-25**]);
then he was to have an INR drawn by the visiting nurses which
was to be called to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office (telephone
number [**Telephone/Fax (1) 3183**]). I have spoken with [**Doctor First Name **] at his office
who confirmed that they will dose his Coumadin subsequently,
and the visiting nurse was to call with the INR results to
get subsequent dosing for Coumadin.
2. Humalog 75/25 insulin 64 units in the morning and 22
units in the evening.
3. Aspirin 325 mg by mouth once per day.
4. Multivitamin.
5. Lipitor 20 mg by mouth once per day.
6. Amiodarone 400 mg p.o. once per day.
7. Dilaudid 2 mg by mouth q.4h. as needed (for pain).
8. Zantac 150 mg by mouth twice per day.
9. Tricor 160 mg by mouth once per day.
10. Requip 0.5 mg by mouth three times per day.
11. Prozac 20 mg by mouth once per day.
12. Metformin 500 mg by mouth twice per day.
13. Lopressor 25 mg by mouth twice per day.
14. Potassium chloride 20 mEq by mouth twice per day (times
seven days).
15. Lasix 20 mg by mouth twice per day (times seven days).
DISCHARGE DISPOSITION: Of note, the patient had a marginally
elevated white blood cell count today ([**2-14**]) of 14.2; up
from 11.3 yesterday. The patient had no obvious signs of
infection. He had no erythema. His incisions were clean and
healing well. The patient had no fevers.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient has been instructed to call for any
temperature of greater than 101, any change in his wound
status; to include any drainage or erythema of any of his
wounds or any questions concerning his incisions whatsoever.
2. The patient was to be sent home with visiting nurses as
well as physical therapist.
3. The patient was instructed to follow up with his primary
care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) in two to three weeks.
4. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 7047**] (his cardiologist) in two to three weeks.
5. The patient was instructed to follow up with Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **] (Cardiac Surgery) in four weeks for a
postoperative check.
DISCHARGE DIAGNOSES:
1. Aortic stenosis.
2. Coronary artery disease.
3. Insulin-dependent diabetes mellitus.
4. Hypertension.
5. Obesity.
6. Parkinson disease.
7. Depression.
8. Intraoperative atrial fibrillation.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2102-2-14**] 13:36
T: [**2102-2-14**] 13:38
JOB#: [**Job Number 33054**]
ICD9 Codes: 4241, 9971, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6012
} | Medical Text: Admission Date: [**2114-6-13**] Discharge Date: [**2114-6-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
HPI: Briefly, this is an 84yo man with h/o DVT, PAF, gastric
ulcer, CAD s/p MI admitted to the [**Hospital Unit Name 153**] with melena. He was
residing in a care facility (Coolige House) after total hip
arthroplasty.
.
The patient has a history of DVT and PAF three years ago after
right THA and was previously on coumadin but stopped in setting
of gastric ulcer bleed (switched to ASA 81mg qday). The patient
underwent a THR on [**2114-5-16**] at NEBH and was restarted on Coumadin
for DVT prophylaxis. After his THR, he developed an ileus and
"small heart attack," likely started on Plavix and was
discharged to [**Hospital3 2558**] for rehabilitation. There, he was
noted to have brown/black guaiac positive stools for
approximately 5 days and on the morning of admission had 4
episodes of melena, became dizzy and presyncopal while shaving.
.
In the ED, his vitals were: T 98.9, BP 132/63, HR 82, RR 17, Sat
98% on RA. On exam, he was found to be pale with guaiac positive
brown stool. His initial labs were notable for a Hct of 23
(unclear baseline) and INR 3.9. He had a NGL that revealed
bright red blood, not cleared with 700 cc of sterile water. GI
was consulted, recommended ICU admission for close monitoring,
FFP for INR reversal, PRBC transfusion, IV Protonix. He received
FFP and Protonix in the ED before transfer. He has an 18 Ga PIV
and a midline (is on rocephin for possibly infected sacral
decubitus ulceration post op). ECG was performed, with no
evidence of ischemia.
Social History:
SH: lived at home alone before recent hospitalizations; widowed
1.5y ago; has a son and dtr who live nearby. Denies tobacco now
or in past. Reports rare etoh intake.
.
Family History:
FH: father with MI
Physical Exam:
Afebrile, vital signs stable on room air.
Gen -- pleasant, cooperative
HEENT -- sclera anicteric, conjuctiva clear, op without erythema
or exudate, neck supple
Heart -- regular, no murmur
Lungs -- clear
Abd -- soft, benign
Ext -- no edema rash or lesion
Pertinent Results:
[**2114-6-13**] 10:25PM WBC-8.2 RBC-2.71* HGB-8.5* HCT-23.6* MCV-87
MCH-31.5 MCHC-36.1* RDW-14.9
Discharge HCT stable >30 for greater than 72 hours.
Brief Hospital Course:
Mr. [**Known lastname 74188**] was admitted [**2114-6-13**] from his rehab center with
melena, lightheadedness and fatigue. His hematocrit was 23%,
and INR was supratheraputic. He was taking warfarin post
operatively for total hip arthroplasty. He was also taking
Aspirin and Plavix because of coronary artery disease. He had
been recently treated with antibiotics for Stage II decubitus
ulcers as well.
He was admitted to the [**Hospital Unit Name 153**] for fluid resucitation, blood
products, and gastroenterology consultation. Initial endoscopy
showed mild gastritis and several small AVMs. He had a troponin
leak and ST depressions with associated shortness of breath
during his initial presentation, which resolved with
transfusion. Cardiology was consulted and followed during this
episode, but recommended against intervention given the acute
blood loss anemia as the precursor for NSTEMI. A second
endoscopy with small bowel push reveal a large duodenal AVM with
evidence of fresh bleeding, and several clips were placed at the
site. GI recommended avoiding aspirin, plavix for at least one
week, and to reevaluate need for warfarin.
On [**2114-6-15**], Mr. [**Known lastname 74188**] was transferred to the general medicine
hospitalist team for further evaluation and management. He
remained stable, had resolution of melena, and resumed physical
therapy. Wound care for his sacral decubiti remained as
follows:
Commercial wound cleanser to irrigate/cleanse gluteal open
wounds.
Pat the tissue dry with dry gauze.
Apply moisture barrier ointment to the periwound tissue with
each drg change.
Apply a thin layer of wound gel to the wound bed.
Cover with dry gauze, Sofsorb sponge
Change dressing daily.
Given high risk of venous thromboembolism in a post operative
lower extremity joint replacement patient, subcutaneous heparin
was initiated after Hct was stable >48 hours. Compression boots
were used during his acute bleeding episode.
Metoprolol was added in light of his cardiac disease, and
aspirin and Plavix will be added back per GI recommendations at
one week post bleeding episode ([**2114-6-21**]). Given his previous
DVT/PE was provoked (in setting of right total hip
arthroplasty), warfarin is not indicated for chronic
anticoagulation. However, with his history of paroxysmal atrial
fibrillation, warfarin is indicated for stroke prevention.
Given his life threatening gastrointestinal bleed, the risks and
benefits of anticoagulation for stroke prevention versus
recurrent gastrointestinal bleeding were explained to the
patient. We will defer the decision making to his primary
physician on discharge. He should, however, continue post
operative THA DVT prophylaxis for the intended period.
Medications on Admission:
Ambien 5mg qhs
ASA 81mg qday***
Reglan 10mg q4h
Coumadin 4mg qhs
Rocephin 2gm IV q24h
Nifedipine ER 90mg qday***
Zocor 20mg qhs
Allopurinol 100mg [**Hospital1 **]***
Senna 2 tabs qhs
Tylenol 650mg q4h prn pain
Oxycodone 5-15mg q3h prn pain
Flomax 0.4mg [**Hospital1 **]***
Lopressor 50mg qday
Miralax powder 17gm qday***
MVI qday
Nexium 40mg qday
Plavix 75mg qday
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day). Tablet(s)
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO BID (2 times a day).
4. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. 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*
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
1. acute blood loss anemia
2. gastrointestinal bleed, duodenal arteriovenous malformation
3. non ST elevation myocardial infarction in the setting of
anemia
4. stage II bilateral sacral decubiti
Discharge Condition:
stable
Discharge Instructions:
You have been hospitalized for a gastrointestinal bleed with
severe anemia. Please return to the hospital or call your
doctor with any lightheadedness, blood in your stool, black or
tarry stools, chest pain, or any other concerns.
You should restart your baby aspirin on [**6-21**] (one week from
latest bleeding episode).
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 74189**] on Monday, [**6-25**] at 1:45 pm
evaluation of Hematocrit, and discussion of further
anticoagulation and care.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6013
} | Medical Text: Admission Date: [**2194-4-18**] Discharge Date: [**2194-4-26**]
Date of Birth: [**2139-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2194-4-20**] Urgent Coronary Artery Bypass Graft x 3 (Left internal
mammary artery to left anterior descending artery, Saphenous
vein graft to right coronary artery, Saphenous vein graft to
posterior lateral branch)
History of Present Illness:
54 year old male with history of coronary artery disease with
prior stents complaing of increased chest pain on exertion. Had
a positive stress test and then underwent a cardiac cath. Cath
revealed three vessel coronary disease. Patient was experiencing
chest pain during cath and was transferred to [**Hospital3 **] for
surgery.
Past Medical History:
Coronary Artery Disease status post Percutaneous Coronary
intervention and stents to left anterior descending and left
circumflex
Metbolic Syndrome
Diabetes Mellitus
Obesity
Sleep Apnea
Social History:
Lives alone. Rare alcohol use. Quit smoking in [**2172**] after 2-3ppd
x 17 yrs.
Family History:
non-contributory
Physical Exam:
Vitals: 69 10 140/75 6' 124kg
Skin: Warm, dry and intact
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear to auscultation bilaterally
Heart: Regular rate and rhythm with no murmurs
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused
Neuro: Grossly intact
Pertinent Results:
[**4-20**] Echo: PRE-BYPASS: 1. No atrial septal defect is seen by 2D
or color Doppler. 2. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. 3. Right
ventricular chamber size and free wall motion are normal. 4.
There are simple atheroma in the descending thoracic aorta. 5.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen. 6. Mild (1+) mitral
regurgitation is seen. Dr. [**First Name (STitle) **] was notified in person of the
results. POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine. 1.
Biventricular function is unchanged 2. Aorta is intact post
decannulation. 3. Other findings are unchanged
[**2194-4-26**] 07:15AM BLOOD WBC-9.6 RBC-3.39* Hgb-9.6* Hct-29.1*
MCV-86 MCH-28.4 MCHC-33.0 RDW-14.7 Plt Ct-408#
[**2194-4-18**] 01:40PM BLOOD WBC-8.2 RBC-4.68 Hgb-13.4* Hct-38.7*
MCV-83 MCH-28.6 MCHC-34.6 RDW-14.6 Plt Ct-276
[**2194-4-26**] 07:15AM BLOOD Glucose-96 UreaN-35* Creat-1.9* Na-135
K-4.0 Cl-96 HCO3-27 AnGap-16
[**2194-4-25**] 05:50AM BLOOD Glucose-123* UreaN-33* Creat-1.7* Na-135
K-4.3 Cl-99 HCO3-23 AnGap-17
[**2194-4-18**] 01:40PM BLOOD Glucose-238* UreaN-39* Creat-1.5* Na-138
K-3.5 Cl-102 HCO3-26 AnGap-14
[**2194-4-18**] 01:40PM BLOOD %HbA1c-8.2*
Brief Hospital Course:
As mentioned in the history of present illness, Mr. [**Known lastname **] was
transferred from outside hospital after his cardiac cath
revealed severe coronary disease. Patient was complaining of
chest pain upon admission and was given IV Nitroglycerin until
he was pain free. He underwent usual pre-operative cardiac
work-up and was planned to have surgery on [**4-22**]. Patient
continued to have chest pain on and off despite receiving IV
Nitroglycerin and was brought to the operating room on [**4-20**]
where he underwent a coronary artery bypass graft x 3. Please
see operative report for surgical details. Following surgery he
was transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. Chest tubes and epicardial
pacing wires were removed per protocol. [**Last Name (un) **] was consulted on
post-op day one for improved management of diabetes. On post-op
day two he was transferred to the telemetry floor for further
care.
Patient began to experience some leg pain with movement and at
rest. A uric acid was drawn per rheumatology and it was found to
be elevated. They suggested 3 days of therapy with colchicine
and motrin.
He continued to progress and was ready for discharge to home on
post-operative day 6.
Medications on Admission:
At home: Metformin 500mg [**Hospital1 **], Lopressor 100mg TID, Diovan 320mg
daily, HCTZ 50mg daily, Isordil 10mg TID, Pravachol 40mg daily,
Aspirin 325mg daily, Plavix 75mg daily (last dose 4/17)
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
[**Hospital1 **]:*7 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Hospital1 **]:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 100 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
[**Hospital1 **]:*135 Tablet(s)* Refills:*0*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime) for 1 months.
[**Hospital1 **]:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 days.
[**Hospital1 **]:*2 Tablet(s)* Refills:*0*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for sternal drainage for 3 days.
[**Hospital1 **]:*6 Capsule(s)* Refills:*0*
10. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for 1 days.
[**Hospital1 **]:*8 Tablet(s)* Refills:*0*
11. Insulin Glargine 100 unit/mL Solution Sig: as directed
Subcutaneous twice a day: 50 units in the morning, 20 units in
the evening.
[**Hospital1 **]:*qs qs* Refills:*0*
12. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
with breakfast, lunch, and dinner: Blood sugar:
0-75: 4oz juice
76-110: no action
111-150: 4 units
151-190: 6 units
191-230: 8 units
231-270: 10 units
271-310: 12 units
311-350: 14 units
> 350: [**Name8 (MD) 138**] MD.
[**Last Name (Titles) **]:*qs qs* Refills:*2*
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
14. Insulin Syringe MicroFine 0.3 mL 28 x [**1-3**] Syringe Sig: as
directed Miscellaneous 4-6 times/day.
[**Month/Day (2) **]:*qs qs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Coronary Artery Disease
Metbolic Syndrome
Diabetes Mellitus
Obesity
Sleep Apnea
status post Percutaneous Coronary intervention and stents to
left anterior descending and left circumflex
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:
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 14522**] in [**2-4**] weeks
Dr. [**Last Name (STitle) **] in [**1-3**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2194-4-26**]
ICD9 Codes: 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6014
} | Medical Text: Admission Date: [**2183-8-4**] Discharge Date: [**2183-8-20**]
Date of Birth: [**2152-7-2**] Sex: M
Service: SURGERY
Allergies:
peanut / latex
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
1. [**2183-8-7**] left above-the-knee amputation
2. [**2183-8-7**] Debridement of left lower extremity wound and
placement of a wound VAC
3. [**2183-8-10**] Revision of left AKA with partial closure and
placement of VAC 100 cm2 and debridement of upper sacral
wound and back decubitus with placement of wet-to-dry
dressings
4. Debridement of presacral ulcer, placement of V.A.C. on left
amputation below-knee amputation stump, tracheostomy
History of Present Illness:
31 year old male with spina bifida, s/p spinal fusion,
hydrocephalus s/p shunt, bilaterally dislocated hips and clubbed
feet presented to OSH with chills/night sweats and a known
likely infected left foot (has a history of many lower extremity
infections in the past). At the OSH, noted to be septic with HR
in the 120s, hypotensive to the 70s responsive to IVF, afebrile
with source likely cellulitis in his left leg; UA and CXR
negative, blood cultures NGTD. Initially was put on vanc/clinda
however pt continued to be septic with WBC count trending
upwards (17 on [**8-2**] to 33 on [**8-4**], day of transfer) and with
spreading of his cellulitis, so his abx were changed to
vanc/zosyn. He was seen by surgery at the OSH who felt that he
likely did not have nec fasc and recommended adding IV diflucan.
Skin/wound cultures reportedly growing group G strep, blood
cultures negative. He was transferred for further
multidisciplinary workup; normally he is seen at [**Hospital1 2025**] for his
lower extremity infections, it is unclear why he was not
transferred there.
His custom wheelchair recently broke and he has since been in
one
that is not well fitted to him. He developed lower extremity
abrasions and sacral skin breakdown complicated by lower
extremity and sacral cellulitis for the past few weeks.
On the floor he appears tired and ill but not toxic,
intermittently falling asleep. He is oriented to person and time
but not place, and exhibits [**Doctor Last Name 688**] concentration. Endorses
chills, night sweats, mild shortness of breath. States that he
can feel his lower extremities but does not feel pain in them
currently. Endorses dysuria.
Pt was initially admitted to HMED service. He became
increasingly toxic overnight and was transferred to the MICU for
dropping pressures in the setting of afib with RVR.
On arrival to the MICU, pt was hypotensive to 70s systolic,
still in RVR.
Past Medical History:
PMH: Spina bifida, chronic lymphedema, hydrocephalus s/p shunt,
lower extremity paralysis with bilateral clubbed foot
deformities
PSH: s/p VP shunt placement, s/p spinal fusion
Social History:
Lives with parents who are caregivers. Worked in the past at
kiosk in the mall, but not currently employed. Not married, no
children. No tobacco, ethanol, drugs.
Family History:
Mother with chronic fatigue syndrome and allergies, Dad unknown
Physical Exam:
97.2 108/42 110 26 94%2L
Admission Exam:
GEN Alert, oriented to person/time, states he is at [**Hospital1 2025**], no
acute distress
HEENT NCAT dry MM, EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Only able to auscultate anteriorly due to habitus, good
aeration, CTAB no wheezes, rales, ronchi
CV regular tachycardia normal S1/S2, no mrg
ABD obese soft NT ND normoactive bowel sounds
EXT
L: massive lymphedema with club foot deformity, capillary refill
<2sec distally, over medial thigh and lateral club foot area of
skin with cellulitic appearance with skin sloughing and weeping
of serous fluid, dermis underneath appears beefy red, nontender
to palpation, no area of fluctuance noted. No crepitus. Some
areas with dark purple discoloration. Fungal appearing coat over
some areas of skin.
R: mild lymphedema with club foot deformity, no areas of skin
breakdown noted.
Sacrum: erythematous non-necrotic ulcer noted without
penetration to bone/muscle. Non purulent.
NEURO CNs2-12 intact, upper motor function grossly normal
GU fungal appearing discharge from meatus
Pertinent Results:
Admission labs:
[**2183-8-5**] 01:55AM BLOOD WBC-41.7* RBC-4.42* Hgb-11.8* Hct-38.2*
MCV-86 MCH-26.7* MCHC-30.9* RDW-18.5* Plt Ct-270
[**2183-8-5**] 01:55AM BLOOD Neuts-85* Bands-1 Lymphs-11* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2*
[**2183-8-5**] 01:55AM BLOOD PT-12.4 PTT-25.2 INR(PT)-1.1
[**2183-8-5**] 01:55AM BLOOD Glucose-118* UreaN-52* Creat-1.6* Na-130*
K-4.3 Cl-97 HCO3-22 AnGap-15
[**2183-8-5**] 01:55AM BLOOD ALT-13 AST-37 AlkPhos-207* TotBili-0.8
[**2183-8-5**] 01:55AM BLOOD Albumin-2.0* Calcium-8.4 Phos-4.2 Mg-2.7*
[**2183-8-5**] 07:01AM BLOOD Lactate-1.7
[**2183-8-5**] 09:58AM BLOOD Lactate-1.3
[**2183-8-5**] 07:01AM BLOOD Type-ART O2 Flow-4 pO2-137* pCO2-73*
pH-7.15* calTCO2-27 Base XS--5 Intubat-NOT INTUBA
[**2183-8-5**] 11:04AM BLOOD Type-ART Temp-36.2 Rates-21/ PEEP-5
FiO2-100 pO2-165* pCO2-60* pH-7.14* calTCO2-22 Base XS--9
AADO2-490 REQ O2-83 Intubat-INTUBATED
Abscess culture/wound swab [**2183-8-6**] Staph [**Last Name (LF) 61227**], [**First Name3 (LF) **],
bacteroides
[**2183-8-20**] 12:39AM BLOOD WBC-4.6 RBC-2.78* Hgb-8.2* Hct-27.2*
MCV-98 MCH-29.4 MCHC-30.1* RDW-19.5* Plt Ct-212
[**2183-8-20**] 12:39AM BLOOD Plt Ct-212
[**2183-8-20**] 12:39AM BLOOD Glucose-89 UreaN-30* Creat-1.4* Na-141
K-4.4 Cl-112* HCO3-25 AnGap-8
[**2183-8-13**] 01:00AM BLOOD ALT-15 AST-18 AlkPhos-121 TotBili-0.6
[**2183-8-20**] 12:39AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.5
[**2183-8-18**] 04:10AM BLOOD Vanco-15.9
Brief Hospital Course:
Mr. [**Name13 (STitle) **] is a 31 yo M w/ PMH of spina bifida with paraplegia and
is wheelchair bound at baseline who was transferred from an OSH
for concern re: his left leg cellulitis. Upon admission, he was
found to be hypotensive despite aggressive fluid resuscitation.
He was transferred to the MICU initially, and surgery was
consulted for concern regarding necrotizing fasciitis in the
face of elevated WBC and signs of sepsis. He was taken urgently
to the OR and did require AKA for necrotizing fasciitis; he was
transferred to the surgical service postoperatively. His course
is summarized by systems below:
N: He was initially mentating well. He was sedated while
intubated, but remained responsive when sedation was weaned.
After sedation was d/c'd, he was A&Ox3. He worked with PT and
was out of bed to chair and interacting appropriately.
CV: At admission, his pressures did drop and upon transfer to
the MICU on [**8-5**] he required three pressors to maintain his BP.
His rhythm at this point was afib; he was started on an
amiodarone drip. It was at this point that the patient was taken
urgently to the OR. He remained on pressors post-operatively,
but they were able to be significantly weaned. After the initial
operation, he was weaned down to a small dose of levophed, which
he continued to require. He was weaned off the amiodarone drip
on POD 1 and remained in sinus rhythm. He was weaned off
pressors and remained in sinus rhythm. Patient was stable from a
cardiovascular standpoint at time of discharge
Pulm: He was initially intubated on [**8-5**] after transfer to the
MICU due to worsening ventilation and combined respiratory and
metabolic acidosis on ABG. He was kept intubated postoperatively
initially due to the need to return to the OR for washout.
However he did continue to require high PEEP, and attempts to
wean off the ventilator were unsuccessful. He was taken to the
OR on [**8-13**] for trach placement. At time of discharge patient
with stable 02 saturations on trach collar at 40% FiO2
GI: The patient was initially kept NPO with IVF. On [**2183-8-9**] he
was started on tube feeds via NGT. These were held as needed for
a return trip to the OR on [**8-10**] for washout and partial closure,
and then restarted postoperatively. They were titrated up to
goal and he tolerated them with low residuals. Patient was
tolerating tube feeds at goal at time of discharge and was
advanced to a soft solid diet with trach cuff inflated while
taking po intake.
GU: Urine output was monitored with a foley catheter. His UOP
remained good however his creatinine did increase during the
course of his ICU stay. This was monitored daily.
ID: At initial presentation he was septic [**1-23**] necrotizing
fasciitis in his left lower extremity. His preop WBC was 59. He
was started on vanc/zosyn/clinda/flagyl for broad spectrum
coverage and ID was consulted. ID continued to follow throughout
his course. After the initial operation his WBC dropped to 26 on
POD1; his hemodynamic status stabilized. His antibiotics were
narrowed to vanc/zosyn/clinda. The cultures of his leg returned
MRSA. Patient was continued on antibiotics until time of
discharge and was discharged without antibiotics, afebrile with
stable WBC.
Patient was discharged to Rehabilitation facility with trach
collar, tolerating tube feeds at goal with a soft diet and vac
in place. Vac will be changed every 3 days tube feeds will be
managed by the rehab facility pending po intake requirements.
Abx were discontinued at time of discharge and patient will call
to arrange a follow up appointement with [**Hospital 2536**] clinic in 2 weeks
time.
Medications on Admission:
Medication on transfer from Medical service:
metrogel q12h to face
tylenol prn
albuterol nebs prn
oxycodone 5-10mg q3h prn pain
zosyn 3.375g q6
vancomycin 2g q12
diflucan 200 qd
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever/pain
2. Artificial Tear Ointment 1 Appl BOTH EYES PRN redness/dry
eyes
3. Bisacodyl 10 mg PO/PR DAILY
4. BusPIRone 10 mg PO BID anxiety
5. Collagenase Ointment 1 Appl TP DAILY
apply to sacral decubitus ulcer daily
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Gabapentin 300 mg PO DAILY
8. Heparin 7500 UNIT SC TID
9. HydrOXYzine 25-50 mg PO Q6H:PRN anxiety/puritus
10. Lactulose 30 mL PO BID
11. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg [**12-23**] tablet(s) by mouth every four
(4) hours Disp #*30 Tablet Refills:*0
12. Sarna Lotion 1 Appl TP TID:PRN itching
13. Senna 1 TAB PO BID *AST Approval Required*
14. Zolpidem Tartrate 10 mg PO HS
15. MetronidAZOLE Topical 1 % Gel 1 Appl TP [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
RLE necrotizing fasciitis
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the General surgery service for Necrotizing
fasciitis of the Right lower extremity.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
The rehabilitation facility will be caring for your wound vac
and your wound will be reevaluated at your follow up visit with
ACS General Surgery
Followup Instructions:
Please call the [**Hospital 2536**] clinic to make a follow up appointment in 2
weeks.
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6015
} | Medical Text: Admission Date: [**2201-1-23**] Discharge Date: [**2201-1-28**]
Date of Birth: [**2117-11-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
transferred from OSH for continued care
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 25788**] is an 83-year-old woman with a history of peripheral
vascular disease, hypertension, osteoporosis, and alcohol abuse
with a history of alcohol withdrawal who presented to [**Hospital1 18**]
[**Location (un) 620**] on [**2201-1-17**] with 2 days of shortness of breath, malaise,
dry cough, chest pain, and myalgia. She had been feeling poorly
and had been taking ibuprofen around the clock for 2 days. Per
her daughter, the patient was confused the morning of admission
and this resolved after oxygen supplementation in the ED. In the
ED, she received levofloxacin and then started on ceftriaxone
for CAP.
.
Ms. [**Known lastname 25788**] was Dr. [**Last Name (STitle) **] at [**Hospital1 **]-N and ruled out for MI but
was seen by cardiology in consult for atrial tachycardia. She
was placed on amiodarone which did not control the pulse
initially, so she was placed on digoxin as well. Dig was
evenutally held for bradycardia. She also had elevated calcium
to 11.4 once corrected for albumin thought [**2-23**] to dehydration.
Therefore, calcium and vitamin D were held. Urine electrolytes
were monitored, and she had a low FENa of 0.4%, and IV hydration
continued and they felt she was clinically dry. Spiked temp to
100.2, blood cultures obtained, repeated CXR.
Echocardiogram showed an EF of 30%-35% and, therefore, Zestril
was restarted. However, the patient's creatinine bumped up to
2.0 on [**2201-1-23**]. Therefore, the Zestril was held.
Patient's daughter requested on [**1-23**] in the am to have patient
transferred to [**Hospital1 18**].
.
Upon transfer VS: BP 148/67 HR 65 T 97.9 96%on 3L R 20.
.
Currently, patient feels well. She denied shortness of breath,
fever or chills. She denied chest pain but said she had some in
a band like pattern when she was first admitted to the hospital
that has resolved. She also said she had a cough earlier in
admission productive of yellow sputum. Upon further questioning,
she had some epigastric abdominal pain and endorsed
constipation, not recalling last bowel movement.
.
ROS:: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Peripheral vascular disease with bilateral claudication
(refusing surgery)
Hypertension
Depression
Osteoporosis with compression fractures
Left hip ORIF
Polymyalgia rheumatica
alcohol abuse with a history of alcohol withdrawal
Social History:
Lives at home; smokes [**1-23**] pack per day for 15 years; 1 bottle of
wine daily; uses a cane to walk.
Family History:
NC
Physical Exam:
Vitals - T:96.7 BP:132/66 HR: 103 RR:24 02 sat:94%2L
GENERAL: Pleasant but lethargic, increased work of breathing
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. dryMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: tachy, irreg, irreg. Normal S1, S2. No murmurs, rubs or
[**Last Name (un) 549**]. JVP=8cm
LUNGS: decreased b/l BS, good air movement biaterally, LLL fine
crackles, no accessory muscle use
ABDOMEN: Soft, ND, +BS, tender to deep palpation in epigastrium
and RLG, No HSM
EXTREMITIES: No edema, 1+ dorsalis pedis/ posterior tibial
pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox1(only to name, close on year [**2200**] but no orientation
to place). Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 4-/5 strength throughout. [**1-23**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
.
Pertinent Results:
[**2201-1-23**] 05:10PM GLUCOSE-104 UREA N-37* CREAT-2.1* SODIUM-141
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-17
[**2201-1-23**] 05:10PM estGFR-Using this
[**2201-1-23**] 05:10PM ALT(SGPT)-150* AST(SGOT)-127* LD(LDH)-1426*
CK(CPK)-98 ALK PHOS-113 AMYLASE-74 TOT BILI-0.6
[**2201-1-23**] 05:10PM LIPASE-25
[**2201-1-23**] 05:10PM CK-MB-NotDone cTropnT-0.08*
[**2201-1-23**] 05:10PM CALCIUM-10.4* PHOSPHATE-3.8 MAGNESIUM-2.0
[**2201-1-23**] 05:10PM WBC-21.0* RBC-4.25 HGB-13.9 HCT-41.3 MCV-97
MCH-32.8* MCHC-33.8 RDW-14.4
[**2201-1-23**] 05:10PM NEUTS-90.3* LYMPHS-5.9* MONOS-3.1 EOS-0.6
BASOS-0.1
[**2201-1-23**] 05:10PM PLT COUNT-318
.
[**2201-1-23**] CXR:Evidence of failure and effusions.
[**2201-1-23**] LENIs neg for DVT
[**2201-1-23**] RUQ US . Normal liver. No evidence of intra- or
extra-hepatic biliary dilatation. 2. Right kidney is small with
cortical thinning consistent with chronic medical renal disease.
3. Patent main portal and hepatic veins.
[**2201-1-24**] CT chest/abd/pelvis1. Bilateral pleural effusions with
bilateral lower lobe atelectasis. 2. Mild enlargement of the
left kidney with perinephric stranding. Study is limited
secondary to lack of IV contrast, however, findings may be
secondary to pyelonephritis and correlation with UA is
suggested. 3. Bilateral adnexal cysts as described. When patient
has improved a pelvic ultrasound can be performed for further
evaluation.
[**2201-1-26**] Renal U/S Right renal atrophy with prominent cortical
thinning and lack of Doppler flow, renal artery stenosis cannot
be excluded. Patient could not tolerate Doppler examination.
Normal left kidney.
[**2201-1-26**] CT head No evidence of hemorrhage or recent infarction.
However, MRI with diffusion-weighted imaging is more sensitive
in the evaluation for acute infarct.
[**2201-1-27**] Echo: The left atrium is mildly dilated. The right atrium
is markedly dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
severe global left ventricular hypokinesis (LVEF = 20-30 %); the
anterior septum appears akinetic and somewhat fibrotic. There is
no ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. There is
abnormal diastolic septal motion/position consistent with right
ventricular volume overload. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
[**2201-1-27**] CXR: There is stable moderate sized bilateral pleural
effusions with mild atelectasis at the left lung base. Overall,
there is no change.
Brief Hospital Course:
83 yo F with PVD and [**Hospital 4747**] transferred from OSH for continue
management of pneumonia.
.
#Leukocytosis: Patient admitted with cough, SOB, malaise and WBC
to 18. WBC initially trended down on ceftriaxone. CXR with B/L
pleural effusions. Currently afebrile without cough but
tachypnic, but with rise in white count which may represent HAP.
Blood cultures, urine cultures negative to date. Urine
legionella neg. Started levaquin 500mg PO qday for 5days, white
count only trended up with LDH>1000. Never febrile. No source of
infx identified. ?pyelo seen on CT. ?Cancer but no clear sight.
Trended fever curve, WBCs. BCx negative to date.
.
#Rhythm: New onset Afib with RVR, pressures stable. Not
anticoagulated. Cardiac Enzymes slightly elevated at OSH, was
started on amiodarone. Continue to work on rate control
metoprolol. Started hep gtt for anticoagulation. Monitored on
tele.
.
#Pump: systolic dysfunction with EF of 35-40% seen on recent
echo seemed to be new, BNP elevated to [**Numeric Identifier **] with B/L pleural
effusions seen at OSH. No known ischemic disease but focal
hypokinesis on echo may suggest it vs. myocarditis in setting of
troponin spill. No PND, orthopnea, DOE. No chest pain.
Clinically she seem hypovolemic. Held amiodarone started at OSH,
started metoprolol 25mg PO BID and titrated up to 50mg [**Hospital1 **].
Cards was consulted and felt she had an AMI about 1 month ago
and suggested starting hydralazine, imdur, continue aspirin.
.
#ARF: Admitted at 2.0. Baseline Cr appears ~0.9-1.1. Patient
appears dry. Said she had been eating and drinking prior to
admission but her history is not reliable and she seems
deconditioned. [**Month (only) 116**] have been taking a lot of NSAIDs prior to
admission in combination with ACEI. Continued to hydrated her
given 5L of NS overlength of stay, her Cr worsened, renal was
consulted and felt she was prerenal. Despite fluids, her Cr
bumped to 2.7. No casts were seen in urine, AceI was held.
.
#Decompensation: on the morning of [**2201-1-27**] patient converted from
Afib to bradycardia and then normal sinus brady(betablocker on
board), her respiratory status worsened with tachypnea, and
hypotension however he oxygen requirement did not change. CXR
showed worsening of pleural effusions. ABG performed. ICU was
consulted.
.
#Patient was transferred to the ICU and started on a Dopamine
drip for pressure support this was later changed to Dobutamine.
Cardiology was consulted but had no further recommendations.
Repeat echo showed worsen EF with global hypokinesis. After
discussion with the family, the decision was made to make the
patient comfortable and withdraw other support. The patient
then passed away on the morning of [**2200-1-27**].
Medications on Admission:
Ceftriaxone 1 gram IV q24 hours
CIWA - no longer needs
Wellbutrin SR 150 mg [**Hospital1 **]
Amiodarone 400 mg po day
Heparin SQ 5000 Units TID
Nicotine Patch 21 mg apply Qday
Atrovent 1 neb q6 hours prn
Toprol XL 12.5 mg/day
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2201-2-1**]
ICD9 Codes: 486, 5849, 4280, 4019, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6016
} | Medical Text: Admission Date: [**2147-2-2**] Discharge Date: [**2147-2-15**]
Date of Birth: [**2091-11-15**] Sex: F
Service: SURGERY
Allergies:
Amoxicillin / [**Last Name (un) **]-Dur / Lipitor / ketorolac / Sporanox / Latex
/ Lasix / Amitriptyline / Benadryl / Sulfa (Sulfonamide
Antibiotics) / Erythromycin Base / Haldol
Attending:[**First Name3 (LF) 17197**]
Chief Complaint:
acute onset back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55M with chronic abdominal and back pain for over 15 yrs from
previous surgeries p/w acute onset of back pain while resting.
Pain radiating to abdomen. This was associated with profuse
vomiting. She was seen at [**Hospital3 68**] ED where imaging CT
showed a Type B aortic dissection.
On arrival to ED, SBP > 200 and after nitroprusside and esmolol,
her BP did respond. She was still complaining of abdominal and
back pain but decreased in severity with narcotics.
Past Medical History:
PMH: MI, COPD, CVA, [**Doctor Last Name **] disease, prolonged QT, rectocele,
HTN, conversion disorder presenting with signs/sx of CVA
PSH: CCY, TAH/BSO, appy
Social History:
Lives at home, continues to smoke. Does not work. Son with
schizoaffective disorder, daughter with bipolar disorder.
Physical Exam:
Gen: Mild distress, in bed, sleepy
Lungs: clear
Cardio: RRR
Abd: soft, dist, obese, tender diffusely but to epigastric
region, no palpable masses
Ext: scabs t/o lower extremities, no edema or cyanosis
Pulses fem [**Doctor Last Name **] DP PT
L p/d d p p/d
R p/d d p p/d
Pertinent Results:
139 103 8
-------------< 150
3.7 25 0.7 estGFR: >75
Ca: 8.1 Mg: 1.8 P: 4.5
15.3> 11.9/34.9< 413 N:86.9 L:9.5 M:2.6 E:0.4 Bas:0.6
PT: 11.8 PTT: 20.0 INR: 1.0
CTA (OSH) - type B dissection starting just past takeoff of L
subclavian artery and extending down to above iliac bifurcation.
There is some R renal artery as discrepancy in perfusion of
kidneys (R<L).
CTA ([**2-6**]): Redemonstration of known type B aortic dissection,
which extends from the proximal descending thoracic aorta to
just above the aortoiliac bifurcation. The compressed true lumen
supplies the celiac axis, the SMA, and the left renal artery.
The false lumen supplies the right renal artery. Evolution of
infarct involving the right kidney, with increasing edematous
appearance of the largely nonperfusing kidney. Residual thin
cortical perfusion is identified, along with some segmental
perfusion of the right lower pole.
CTA ([**2-13**]): Redemonstration of type B aortic dissection. No
evidence of dissection extension into the proximal ascending
thoracic aorta or the aortic arch branch vessels. Stable
extension of the dissection into the infrarenal portion of the
abdominal aorta. Celiac axis, SMA, left renal artery and
inferior mesenteric artery arise from the true lumen. Two right
renal arteries are present, with one artery arising from the
false and true lumen each. The right renal artery arising from
the true lumen is compressed as it passes through the false
lumen. Evolving right renal infarct.
Brief Hospital Course:
Patient was admitted to the Vascular Surgery service with a type
B aortic dissection. She was initially admitted to the ICU for
monitoring and strict blood pressure control. She was seen by
cardiology for recommendations regarding a anti-hypertensive
medication regimen that would keep her systolic BP less than
130. She underwent serial exams and demonstrated no signs of
mesenteric or peripheral limb ischemia. On hospital day 3 she
underwent a repeat CTA abdomen due to continued abdominal and
back pain, which showed unchanged aortic dissection. Abdominal
pain and back pain improved over the course of her ICU stay and
her diet was advanced to regular diet, which she tolerated well.
On hospital day 3 she was found to have a UTI and she was
started on a 3 days course of ciprofloxacin. On hospital day 5
she was transferred to the VICU. She was evaluated by PT who
recommended eventual dispo home. She had been intermittently
confused in the ICU and her confusion recurred while in the
VICU. She underwent an extensive delerium workup, which was
negative and her delerium subsequently resolved. She had one
recurrence of abdominal pain and underwent another CTA abdomen
which showed unchanged aortic dissection.
Her creatinine remained stable throughout her hospital stay
despite infarcted right kidney. Her blood pressure was well
controlled on the regimen recommended by cardiology. At time of
discharge she had no pain, was tolerating a regular diet, was
alert and oriented, was able to ambulate independently and was
voiding spontaneously. She will be discharged with close
follow-up with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 32366**], for blood pressure control.
Medications on Admission:
Lactulose [**1-29**] tsp tid prn, Fosamax qweekly, Caltrat 600, Bentyl
20 QID prn GI spasms, Albuterol prn, Ativan 1''' prn, ASA 81',
HCTZ 25', Cyclobenzaprine 10''', prn back spasms, Vicodin
5/500''' prn pain, Cymbalta 60', FioriCET 352/50/40 [**Hospital1 **] prn
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back spasms .
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) puff Inhalation Q4H (every 4 hours) as
needed for SOB/wheezing. puff
5. dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day) as needed for GI spasms .
Disp:*60 Capsule(s)* Refills:*0*
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
7. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Disp:*60 Capsule(s)* Refills:*6*
8. losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*6*
9. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*6*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
type B aortic dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
*You were admitted for an aortic dissection which was managed
conservatively with tight blood pressure control and no surgery.
*It is extremely important that you continue to take your blood
pressure medications as prescribed!
What is aortic dissection?
Aortic dissection is a tear or partial tear in the lining of the
largest blood vessel in the body, the aorta. This tear allows
blood (and the pressure of the blood flow) to penetrate the
arterial wall. Over time, this continuous flow can cause the
aorta to rupture - a condition that most people do not survive.
There are two types of aortic dissections, although sometimes
both are required:
Type A: A dissection to the ascending aorta is classified as a
Type A dissection. These dissections can be treated medically
(usually only briefly) or with interventional catheterization or
open surgical techniques.
Type B: A dissection of the descending aorta is classified as a
Type B dissection. These dissections are most often treated
medically with routine monitoring and prescribed medications.
There is a surgical option, but it carries substantially
increased risk of paralysis.
What are the warning signs and symptoms of aortic dissection?
Aortic dissections are commonly found in people with high blood
pressure, arteriosclerotic vascular disease, in individuals with
a family history of aortic (or thoracic) dissection and more
rarely associated with congenital cardiovascular disorders
(Marfan??????s syndrome, Ehlers-Danlos syndrome, and congenital
valvular disorders).
"Stabbing" pain in the back is a common symptom of an aortic
dissection. In some cases, people present with pain in the
chest. This pain may be confused with angina (commonly referred
to as "chest pain" and a warning sign of a possible heart
attack). The main difference between pain resulting from
dissection of the aorta, and angina due to lack of blood supply
to the heart muscle, is its sudden and intense onset. The pain
is characterized as a "ripping" or "tearing" sensation. This
sudden pain can be felt in the back, chest, neck, or jaw.
These are important differences to understand. Why? Because a
common recommendation to those with angina or "chest pain" (that
may result in a heart attack) is to chew an aspirin to thin the
blood. This is NOT the case if you are experiencing an aortic
dissection. Thinning the blood for a person with aortic
dissection may cause more blood to leak out of the aorta. This
internal bleeding can lead to death.
In some cases, people do not experience any pain. Instead, you
may experience any of the following symptoms:
Distorted mental capacity (due to lack of blood supply to the
brain)
Numbness or tingling sensation in the arms or legs (due to lack
of blood supply to the spinal cord)
If you or someone you know is experiencing any of the above
symptoms, call 9-1-1 immediately to get to a hospital. The
survival rate increases dramatically the sooner a person is
treated for an aortic dissection.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 32366**],
Monday [**2-27**] at 1230 hrs, Please call ([**Telephone/Fax (1) 32367**], if there
is a change
You have an appoitment with Dr. [**Last Name (STitle) **], MD on [**2147-4-4**] at
1:00pm. Phone:[**Telephone/Fax (1) 170**], Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2147-4-4**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20205**], MD Phone:[**Telephone/Fax (1) 20206**]
Date/Time:[**2147-3-24**] 12:30, lowey building, [**Location (un) 442**], [**Doctor First Name **]
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2147-3-24**] 11:30
XCT [**Apartment Address(1) 9394**] [**Hospital Ward Name **]
CC CLINICAL CENTER, [**Location (un) **]
RADIOLOGY
ICD9 Codes: 2930, 5990, 4019, 2768, 412, 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6017
} | Medical Text: Admission Date: [**2189-11-18**] Discharge Date: [**2189-12-3**]
Date of Birth: [**2112-1-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
-Central Line placement (Right internal jugular) in ICU-removed
at discharge
-[**2189-11-30**] Uncomplicated placement of a percutaneous GJ tube with
tip in jejunum. The T-fasteners will fall out on their own in
approximately six weeks. The tube should be changed
approximately every 3 months.
History of Present Illness:
Mr. [**Known lastname 42086**] is a 77M with a PMH s/f ogilvies syndrome with
frequent admissions for abdominal pain/distention, who was sent
to the emergency department when he complained of lower
abdominal pain at an outpatient ophthalmology appointment.
.
The patient is a difficult historian secondary to expressive
aphasia, but he is able to tell me that he has right upper
quadrant pain with associated nausea, and no vomiting. His last
bowel movement was in the emergency department. He also reports
three weeks of cough, denies sore throat, but does report
chills. Otherwise his review of systems is negative.
.
In the emergency department presenting vital signs were T=99.4,
BP=167/72, HR=93, RR=20, O2sat=99%RA. Per ED resident, his
abdominal examination was benign. Laboratory data was wnl,
though a lactate was not drawn. A CT of the abdomen showed
unchanged sigmoid dilation, consistent with his known Ogilvies
syndrome, with moderate fecal loading. A Surgical consultation
was obtained, and they assessed him to have no signs of ischemia
at this time. They recommended admission to medicine for serial
abdominal exams, rectal tube decompression, and GI consultation
for possible colonoscopic decompression. Of note, his CT showed
"concern for aspiration vs. pneumonia at lung bases". He was
given 750mg of levofloxacin.
Past Medical History:
#. Ogilvies Syndrome- Has frequent admissions for abdominal
distention, with dilated colon on imaging, which resolves with
rectal tube decompression.
#. Chronic aspiration (Per PCP)
#. CVA complicated by expressive aphagia, dysphagia
#. Coronary artery disease, s/p CABG in [**2154**], mild systolic
regional hypokinesis with EF 55%
#. HTN
#. Hyperlipidemia
#. GERD
#. History of pancreatitis
#. Type 2 diabetes c/b gastroparesis
#. Anemia
#. Atrial fibrillation on coumadin
Social History:
Living at [**Hospital3 1186**] nursing home since stroke in [**2183**], wife
passed away 5 years ago, no tobacco or ETOH use. Is on
aspiration precautions with honey thick liquids.
Family History:
Non-contributory
Physical Exam:
Exam on admission [**2189-11-18**]:
T=97.6, BP=138/65, HR=89, RR=20, O2=93%RA
GENERAL: Elderly male in NAD, non-toxic appearing
HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.
Neck Supple
CARDIAC: Irregular rhythm, normal rate, no murmurs
LUNGS: Crackles at the right base, overall, good air movement
ABDOMEN: On inspection, his abdomen is distended. High pitched
bowel sounds. Soft, tympanitic. Tenderness to deep palpation
diffusely, no rebound or guarding.
EXTREMITIES: No edema or calf pain
SKIN: No rashes/lesions, ecchymoses.
Exam on discharge [**2189-12-3**]:
T 98.5 BP 145/72 HR 78 O2 95-97%RA
GENERAL: Elderly male in NAD, lying in bed, alert
HEENT: MMM. OP clear. Neck Supple
CARDIAC: Irregular rhythm, normal rate, unable to appreciate
murmurs due to upper airway sounds
LUNGS: Poor effort, difficult to assess given upper airway
sounds, clear at apices, coarse breath sounds at bases laterally
ABDOMEN: soft, mildly distended, non-tender, +BS, no rebound or
guarding.
EXTREMITIES: warm, R hand with 1+ edema, R foot with 2+ edema, L
foot with trace edema
SKIN: Well healed coccyx sore without signs of infection
Pertinent Results:
Labs on admission [**2189-11-18**]:
WBC-7.1 RBC-3.59* Hgb-10.4*# Hct-32.1* MCV-89 MCH-28.8 MCHC-32.3
RDW-16.6* Plt Ct-283
Neuts-77.2* Lymphs-13.9* Monos-5.7 Eos-2.9 Baso-0.3
PT-28.2* INR(PT)-2.8*
Glucose-118* UreaN-32* Creat-1.0 Na-142 K-6.5* Cl-115* HCO3-21*
AnGap-13
Labs on discharge [**2189-12-3**]:
WBC-5.5 RBC-3.23* Hgb-9.2* Hct-28.8* MCV-89 MCH-28.3 MCHC-31.8
RDW-16.9* Plt Ct-254
PT-26.8* PTT-42.2* INR(PT)-2.6*
Glucose-92 UreaN-9 Creat-0.6 Na-140 K-3.7 Cl-112* HCO3-26
AnGap-6*
Calcium-7.9* Phos-2.3* Mg-1.8
Iron studies:
calTIBC-134* VitB12-1305* Folate-16.7 Ferritn-248 TRF-103*
Thyroid studies:
TSH 6.3
Free T4 0.98
.
MICRO:
[**2189-11-18**], [**2189-11-22**] Urine culture: negative
[**2189-11-19**], [**2189-11-22**] Blood cultures: negative
[**11-20**] MRSA screen: negative
[**11-20**] and [**11-22**] c diff: negative
[**2189-11-22**] sputum culture:
STAPH AUREUS COAG +.- MODERATE GROWTH.
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
IMAGING:
[**11-18**] CXR: No acute pneumonia.
[**11-18**] CT Abd/pelvis:
1. Unchanged, massively dilated sigmoid colon, with smooth taper
and a
fluid-filled rectum, compatible with pseudoobstruction ([**Last Name (un) **]
syndrome).
2. Unchanged marked fecal loading in the proximal colon.
3. Interval resolution of bilateral pleural effusions. Chronic
bibasilar
consolidations, suggestive of chronic aspiration.
[**11-20**] TTE:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with mild hypokinesis of the mid to distal anterior
septum and distal anterior wall. There is abnormal septal
motion/position. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion. Compared with the
prior study (images reviewed) of [**2189-8-17**], the findings are
similar.
[**11-20**] CT abd/pelvis:
1. Mildly dilated sigmoid and rectum without evidence of
obstructions; findings consistent with pseudoobstruction.
2. Stable bilateral consolidation at the lung bases, may
represent chronic aspirations
[**11-21**] Right UE ultrasound:
Right axillary vein could not be assessed due to arm
contracture. Right internal jugular, subclavian and brachial
veins patent, without evidence of thrombus.
[**11-22**] KUB:
Interval improvement in gaseous distention of bowel.
[**11-22**] CXR:
Limited study demonstrating streaky density at the right base
most consistent with subsegmental atelectasis.
[**2189-11-29**] KUB: In comparison with the study of [**11-22**], there is
some increase in the generalized dilatation of the colon with a
substantial amount of fecal material within it. The findings are
consistent with the clinical impression of colonic ileus.
Nasogastric tube extends to the upper stomach. Total hip
arthroplasties are again seen.
Brief Hospital Course:
Mr. [**Known lastname 42086**] is a 77M with a PMH s/f Ogilvies Syndrome, who
presents with abdominal pain
.
#. Abdominal pain/Ogilvies Syndrome: Distention and abdominal
pain were consistent with prior episodes of Ogilvies. Initial
exam and CT were not concerning for an acute intra-abdominal
catastrophe. Rectal tube was placed, and bowel regimen given.
He continued to have profuse watery stools. Shortly after
admission he had two episodes of vomitting guaic-positive
material. He also developed a fever to 100.8. In the context
of these changes, abdominal pain worsened over the first
hospital day, although abdominal exam remained benign. Repeat
KUB demonstrated increased distention and possible volvulus.
Immediately after this was discovered he was briefly
hypotensive, as below. He was given levofloxacin and
metronidazole empirically. Surgery was consulted and
recommended serial exams and noncontrast CT abdomen when stable
to evaluate further volvulus which was negative. Antibiotics
were discontinued, and pt's obstruction improved with rectal
tube, which was stopped. Tube feeds were given via NGT until
[**2189-11-29**], when he had more distention again attributed to mild
obstruction with KUB results as above. His fibersource tube
feeds were held. His abdominal distention again improved and
no-fiber tube feeds were initiated to decrease work for colon.
TSH slightly elevated but Free T4 normal suggesting
hypothyroidism not a major etiology in his Ogilvies.
.
# Hypotension: After blood pressures ranging 130-160 all day
morning of admission, patient was found on routine vital signs
check to have blood pressure 58/40 several hours after he had
complained of worsening abdominal pain. His mental status
remained at baseline during the episode, and telemetry
demonstrated sinus tachycardia. He was bolused with IVNS, and
pressure rebounded to systolic 100 within 30 minutes. This was
thought to be secondary to an intra-abdominal process vs a
primary cardiac event, as below.
.
# Demand ischemia: During and immediately after hypotensive
episode, Mr. [**Known lastname 42086**] complained of new [**10-3**] substernal chest
pain. EKG demonstrated new precordial TWI similar to EKG during
recent NSTEMI [**8-2**]. Chest pain responded partially to SL nitro
and morphine. Troponin was elevated above recent values, but CK
was normal. EKG changes partially normalized with return of
blood pressure, and the changes were thought to be most likely
representative of demand ischemia. However, he continued to
complain of chest pain. He was transferred to the intensive care
unit for futher management and improved with sublingual
nitroglycerin. As he was therapeutic on Coumadin, a heparin
drip was not started. Home CAD regimen including ACEI, beta
[**Last Name (LF) 7005**], [**First Name3 (LF) **], Imdur, simvastatin were continued. Chest pain
resolved without recurrence during remainder of hospitalization.
Echo [**2189-11-20**] unchanged from [**2189-8-17**].
.
# Chronic aspiration / nutrition: Pt was evaluated by speech and
swallow multiple times. At times, he was able to tolerate some
PO and at others, he demonstrated frequent aspiration. With poor
nutrition, NGT was placed for tube feeds. After discussion with
family, pt had G-J tube placed by IR on [**2189-11-30**] as above.
No-fiber tube feeds were initiated, which pt tolerated well. He
refused final speech and swallow evaluation prior to discharge
and remained NPO at discharge. He should be evaluated by speech
and swallow at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] if he would like to eat for
pleasure. If he remains NPO, oral care should be performed every
4 hours.
.
# Anemia - pt had continued low hematocrit. Iron studies as
above. Guaiac negative. He required 2 blood transfusions during
his hospitalizations. Hct 28.8 at discharge. continue workup as
outpatient.
.
# Pneumonia: Sputum grew Staph aureus coag positive. Pt started
on vancomycin changed to bactrim after sensitivities returned
for total 7 day course.
.
#. Hypertension: For his chronic hypertension, ACEI and BB were
initially continued but stopped after episode of hypotension.
.
#. GERD: Omeprazole changed to lansoprazole after placement of
PEG.
.
#. Type 2 diabetes c/b gastroparesis: Pt developed hypoglycemia
on NPH while NPO. His NPH was stopped and he was continued on
Humalog ISS. He was discharged on humalog insulin sliding scale.
He will need outpatient adjustment of his insulin regimen as
nutrition improves with tube feeds.
.
#. Atrial fibrillation: The patient was in NSR or sinus
tachycardia throughout his stay. INR became supratherapeutic
with poor nutrition, likely secondary to vitamin K deficiency.
His warfarin was held and he was maintained on heparin drip once
INR decreased until PEG placement. Home beta [**Last Name (NamePattern1) 7005**] was
continued. He was re-initiated on coumadin titrated to INR goal
[**1-27**].
.
# Communication:
[**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] SW ([**Doctor First Name **]): [**Telephone/Fax (1) 94608**]
Son [**Name (NI) **] (HCP): [**Telephone/Fax (1) 94609**] (work/attorney for Ride);
[**Telephone/Fax (1) 94610**] (cell); [**Company 94611**]
Medications on Admission:
-Aspiration precautions
-Honey thick liquids
-Prednisolone 1% eye drops 1gtt right eye [**Hospital1 **]
-Neomycin/polymyxin ointment to right eye daily
-Aspirin 325 mg daily
-Multivitamin
-Lisinopril 20 mg daily
-Omeprazole 20 mg daily
-Metoprolol Tartrate 25 mg [**Hospital1 **]
-Isosorbide Dinitrate 10 mg TID
-Mirtazapine 30 mg qhs
-Warfarin 2 mg daily
-Furosemide 20 mg daily
-KCl 40MEQ daily
-Simvastatin 40mg daily
-Novolin N 5 Subcutaneous QAM/QHS.
-Polyethylene Glycol 3350 17 gram Powder one packet daily
-Fleet enema, daily prn if ducolax does not produce bm
-Bisacodyl suppository daily as needed for BM/24hrs
-MOM, if no BM in 3 days
-Calcium/ Vitamin D
-Nitro prn
Discharge Medications:
1. Aspiration Precautions
2. Prednisolone Acetate 1 % Drops, Suspension [**Hospital1 **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Neomycin-Bacitracin-Polymyxin Ointment [**Hospital1 **]: One (1) Appl
Ophthalmic DAILY (Daily).
4. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
6. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily):
Hold for SBP<100.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day): Hold for SPB<100 or HR<60.
9. Isosorbide Dinitrate 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day): Hold for SBP<120.
10. Mirtazapine 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
11. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: Hold
for SBP<100.
12. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: Two (2) PO once a
day.
13. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Miralax 17 gram/dose Powder [**Last Name (STitle) **]: One (1) packet PO once a
day.
15. Fleet Enema 19-7 gram/118 mL Enema [**Last Name (STitle) **]: One (1) enema Rectal
once a day as needed for If Dulcolax does not produce bowel
movement: Please give if dulcolax does not produce bowel
movement.
16. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) suppository Rectal
once a day as needed for for 1 BM / 24 hours: Please give as
needed for 1 BM / 24 hours.
17. Milk of Magnesia 400 mg/5 mL Suspension [**Last Name (STitle) **]: [**5-3**] mL PO As
directed as needed for if not BM in 3 days: Please give if pt
has not had Bowel movement in 3 days.
18. Nitroglycerin 0.3 mg Tablet, Sublingual [**Month/Year (2) **]: One (1) tablet
Sublingual as directed as needed for chest pain: 1 tablet every
5 minutes x3 tablets as needed for chest pain.
19. Calcium 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO three times a
day.
20. Vitamin D 400 unit Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
21. Warfarin 2 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
22. Humalog 100 unit/mL Solution [**Month/Year (2) **]: as directed as directed
Subcutaneous As directed: Per Humalog Insulin Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1188**] house
Discharge Diagnosis:
PRIMARY:
Ogilvies Syndrome
Chronic aspiration
Staph aureus pneumonia
SECONDARY:
Hypertension
Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Sometimes alert and interactive vs
somtimes lethargic but arousable
Activity Status:Bedbound vs Out of Bed with assistance to chair
or wheelchair
SaO2 97% RA, tolerating tube feeds, having bowel movements, PEG
site without erythema or induration
Discharge Instructions:
You were admitted to the hospital with abdominal pain and
distention. Your blood pressure dropped and you developed chest
pain, which was concerning for a heart attack. You were closely
monitored in the intensive care unit, and your pain resolved.
Your abdominal fullness improved with decompression. A PEG tube
was placed for feeding given your chronic aspiration. You were
treated for a pneumonia.
The following changes were made to your medications:
1. STOP Omeprazole
2. START Lansoprazole 30mg daily as it can go through the PEG
3. CONTINUE your home bowel regimen
4. CONTINUE Warfarin 2mg daily and it will be titrated to INR
goal [**1-27**]
5. STOP Novolin (NPH) 5 units in the morning and at night
6. START finger sticks QID (4 times a day) and use the Humalog
sliding scale for insulin. Once you reach a steady state on your
tube feeds, your doctor can adjust your insulin regimen.
Avoid lactulose or high fiber foods in your diet.
Followup Instructions:
Please call Dr.[**Name (NI) 51133**] office at [**Telephone/Fax (1) 608**] to be seen
within 2 weeks of discharge.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5070, 5119, 2760, 4019, 2724, 2859, 4589, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6018
} | Medical Text: Admission Date: [**2104-8-7**] Discharge Date: [**2104-8-20**]
Date of Birth: [**2032-3-24**] Sex: M
Service: Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 363**] is a
72-year-old male with a past medical history significant for
pancreatic cancer, ulcerative colitis, hypertension, status
post endoscopic retrograde cholangiopancreatography, and
status post total abdominal colectomy 20 years ago with an
end-ileostomy.
The patient underwent an endoscopic retrograde
cholangiopancreatography recently, but a stent was unable to
be placed. A computed tomography was performed which
demonstrated a head of the pancreas mass with dilated
intrahepatic duct along with vascular involvement of the
gastroduodenal artery and superior mesenteric vein. He
presented for exploratory laparotomy with possible pancreatic
mass resection.
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Hypertension.
3. Benign prostatic hypertrophy.
PAST SURGICAL HISTORY:
1. Total abdominal colectomy with end-ileostomy.
2. Status post transurethral resection of prostate.
MEDICATIONS ON ADMISSION:
1. Moexipril 15 mg by mouth once per day.
2. Aspirin 81 mg by mouth once per day.
3. Atenolol 25 mg by mouth once per day.
4. Allopurinol 300 mg by mouth once per day.
5. Multivitamin.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: The patient is a thin,
cachectic Caucasian male who was alert and oriented times
three. In no apparent distress. The sclerae were anicteric.
The patient was jaundiced. The oropharynx was clear with
moist mucous membranes. The neck was supple and without
lymphadenopathy. The heart was regular in rate and rhythm.
The lungs were clear to auscultation bilaterally. The
abdomen was soft, nontender, and nondistended. There was a
well-healed midline scar and ileostomy present. The
extremities were warm without cyanosis, clubbing, or edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: His hematocrit
was 43.2. His INR was 1.2. Creatinine was 1.6. Aspartate
aminotransferase was 51, his alanine-aminotransferase was 89,
his alkaline phosphatase was 395, and his total bilirubin was
12.5.
BRIEF SUMMARY OF HOSPITAL COURSE: On the day of admission,
the patient was taken to the operating room where an
exploratory laparotomy was performed. The patient had
evidence of unresectable pancreatic cancer with biliary
obstruction seen intraoperatively. Adhesiolysis was
therefore performed along with a Roux-en-Y
hepaticojejunostomy, and open cholecystectomy, an open
pancreatic biopsy, and a gastrojejunostomy. The estimated
blood loss for the procedure was 250 cc.
The patient was discharged to the regular hospital floor
after being extubated in the Postanesthesia Care Unit in good
condition.
In the evening on postoperative day one, the patient was
taken back to the operating room emergently for likely
mesenteric bleeding. This was controlled with suture
ligation, and the patient was admitted to the Surgical
Intensive Care Unit postoperatively for close monitoring.
The patient remained intubated in the Intensive Care Unit on
pressor support and received total parenteral nutrition until
postoperative day seven. At this time, the patient's mental
status was extremely labile requiring Haldol for agitation.
The patient's hematocrit was stable at 35.8 at this time.
Tube feeds were initiated on postoperative day eight. On
postoperative day nine, the patient was transferred to the
regular hospital floor. At this time, tube feeds were held
for elevated residuals and nausea. He was still receiving
total parenteral nutrition at this time. The patient's
mental status was still not completely improved. A computed
tomography scan was performed on postoperative day ten which
did not demonstrate any intra-abdominal pathology.
The patient was started on sips on postoperative day eleven
and was started on his home medications. At this time, he
was seen by the Physical Therapy Service and was being
screened for rehabilitation placement.
However, on the evening on postoperative day twelve the
patient spiked a temperature to 101.5 degrees Fahrenheit. A
fever workup was done including a chest x-ray and blood
cultures.
Early the next morning, the patient was found unresponsive
without a pulse at approximately 2:45 a.m. At this time, a
code blue was called and advanced cardiac life support
protocol was initiated. However, the patient was asystolic
without any respiratory effort at this time. He did receive
multiple rounds of epinephrine along with attempts at
ventilation. However, the patient never regained electrical
activity and was pronounced deceased at 2:57 a.m. The
patient's wife was notified at this time. However, a
postmortem examination was declined.
CONDITION AT DISCHARGE: The patient expired on [**2105-8-21**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2105-3-16**] 16:05
T: [**2105-3-16**] 18:33
JOB#: [**Job Number 105917**]
ICD9 Codes: 9971, 4275, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6019
} | Medical Text: Admission Date: [**2150-3-4**] [**Month/Day/Year **] Date: [**2150-3-9**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F with multiple recent admissions to [**Hospital1 18**] following fall on
[**2150-1-19**] with C1 fracture after a mechanical fall down stairs.
She was evaluated for surgery but was found to be nonoperable,
and was placed in a C-collar at least through [**4-19**] to be
followed up with Dr. [**First Name (STitle) 23161**]. She was also noted to have an
associated vertebral artery dissection and was treated
conservatively with aspirin, and a large retropharyngeal
hematoma. She was discharged to [**Hospital1 1501**] on [**1-27**].
.
On [**1-29**] she was seen in the ED after sliding out of a chair, but
the C1 fracture was stable. She was sent back to rehab, but was
noted to not be eating well and have a WBC count of 34k. She was
sent to [**Hospital3 **], then transferred to [**Hospital1 18**] on [**2150-2-4**] for
white count of 34K, significant dehydration, intraventricular
hemorrhage and question of colitis. Her hospital course was
complicated by C dif sepsis with hypotension requiring pressors,
acute renal failure, subdural hematoma (stable). She was
discharged to [**Hospital6 **] on [**2150-2-17**].
.
Today she was noted to have fevers to 101-102 and loose slightly
bloody stools. She was started on flagyl, then received empiric
vancomycin and imipenem and was transferred to the ED. In the
ED, she was noted to be tachycardic and febrile, and received
about 2 liters of fluids without improvement in her HR. She was
never hypotensive. They also gave her some ativan and haldol for
agitation. Cultures were drawn and she got additional 500 mg IV
flagyl and was admitted to the MICU service.
.
ROS: denies pain. Other ROS limited by hearing loss and mental
status.
.
Past Medical History:
Hypertension
Hypothyroidism
Osteoarthritis
Depression
Obesity
Urinary Incontinence
GERD
s/p Total TAH
C1 fracture [**12-28**]
subdural hematoma
ventricular hemorrhage
C.difficile colitis ([**1-28**])
Social History:
Pt has been widowed for 6 yrs and currently lives alone in her
home of 36 yrs. She has one daughter and four sons. Patient's
daughter visits daily, and she has two sons near by. Family is
close and supportive. Prior to recent trauma, patient was very
independent. - EtOH - denies
- Tob - denies
- IVDU - denies
Family History:
Noncontributory
Physical Exam:
V: T99.7 BP 135/35 P108 R26 90% 5L NC
Gen: lying in bed, moaning, opens eyes to voice
HEENT: pupils 1 mm, min reactive, MM dry
Neck: C collar in place, limits JVD assessment
Resp: crackles bilateral bases, no wheezes
CV: RRR nl s1s2 no MGR
Abd: soft NTND +BS
Ext: 2+ edema bilaterally
Neuro: responds to voice
Pertinent Results:
Imaging:
PORTABLE ABDOMEN [**2150-3-3**] 10:25 PM
IMPRESSION: Nonspecific but non-obstructive bowel gas pattern.
.
CHEST (PORTABLE AP) [**2150-3-3**] 10:21 PM
IMPRESSION: Bibasilar atelectasis with left pleural effusion.
Retrocardiac opacity likely represents combination of these two
processes, although underlying consolidation cannot be excluded.
.
CHEST (PORTABLE AP) [**2150-3-4**] 5:09 PM
IMPRESSION:
1. Moderate sized layering left pleural effusion, and small
right pleural effusion, both increased from [**2150-3-3**].
2. Increase in size and density of retrocardiac opacity, which
may be related to technical differences, but this area remains
suspicious for underlying consolidation or atelectasis.
.
CHEST (PORTABLE AP) [**2150-3-5**] 5:50 AM
IMPRESSION: Moderate bibasilar pleural effusions with increasing
size of the right effusion. Retrocardiac opacity suggests
atelectasis or consolidation.
.
CHEST (PORTABLE AP) [**2150-3-6**] 5:55 PM
IMPRESSION:
1. Unsatisfactory placement of Dobbhoff tube which is coiled in
the upper mediastinum. Recommend immediate removal.
2. Appearance of cardiomediastinal silhouette and lung fields
are not significantly changed compared to an hour prior.
These findings were discussed with the SICU nurse at the time of
this dictation.
.
CHEST (PORTABLE AP) [**2150-3-6**] 5:04 PM
IMPRESSION:
1. Intrabronchial placement of Dobbhoff tube. These results were
immediately called to the SICU.
2. Moderate bibasilar pleural effusions and persistent
retrocardiac opacity suggesting atelectasis versus
consolidation.
.
CHEST (PORTABLE AP) [**2150-3-7**] 10:41 AM
FINDINGS:
The tip of the NGT is well below the diaphragm and seen just to
the left of midline by the L4 vertebral body. Perhaps the chest
is obscured from view and the lower portions demonstrate some
atelectatic features.
.
CT HEAD W/O CONTRAST [**2150-3-8**] 3:56 PM
IMPRESSION: No significant interval change of left frontal
cerebral convexity subdural hematoma. Decrease in lateral
ventricle hemorrhage and frontal subgaleal hematomas.
.
PORTABLE ABDOMEN [**2150-3-8**] 11:17 AM
Supine views of the abdomen and pelvis demonstrate no evidence
of intestinal obstruction. Previously reported distended
air-filled loops of bowel have decreased in caliber since the
previous study.
.
CHEST (PORTABLE AP) [**2150-3-8**] 8:28 AM
Nasogastric tube remains in place terminating below the
diaphragm. Cardiac silhouette is enlarged but stable in size.
Bilateral pleural effusions have worsened, moderate on the right
and small-to-moderate on the left, with adjacent basilar
opacities that likely represent atelectasis.
.
Micro:
*[**2150-3-3**]*
Blood Culture: PENDING
Stool: C Diff positive
*[**2150-3-4**]*
Urine Culture: P. aeruginosa & VRE
MRSA Screen: negative
Stool: C diff positive
*[**2150-3-5**]*
Stool: C diff positive
Blood Culture: NGTD
PICC line tip culture: No growth
.
Labs:
[**2150-3-3**] 09:50PM BLOOD WBC-15.0* RBC-3.20* Hgb-9.8* Hct-29.6*
MCV-93 MCH-30.8 MCHC-33.3 RDW-18.8* Plt Ct-240#
[**2150-3-6**] 03:29AM BLOOD WBC-17.9* RBC-2.81* Hgb-8.6* Hct-26.3*
MCV-94 MCH-30.7 MCHC-32.8 RDW-17.5* Plt Ct-264
[**2150-3-9**] 06:10AM BLOOD WBC-20.4* RBC-3.08* Hgb-9.4* Hct-29.4*
MCV-95 MCH-30.5 MCHC-32.0 RDW-17.0* Plt Ct-380
[**2150-3-3**] 09:50PM BLOOD PT-12.2 PTT-26.6 INR(PT)-1.0
[**2150-3-6**] 03:29AM BLOOD PT-12.9 PTT-25.6 INR(PT)-1.1
[**2150-3-8**] 07:25AM BLOOD PT-13.2* PTT-24.5 INR(PT)-1.1
[**2150-3-3**] 09:50PM BLOOD Glucose-99 UreaN-28* Creat-0.8 Na-141
K-4.3 Cl-103 HCO3-30 AnGap-12
[**2150-3-5**] 03:27AM BLOOD Glucose-141* UreaN-27* Creat-0.9 Na-141
K-4.1 Cl-103 HCO3-30 AnGap-12
[**2150-3-9**] 06:10AM BLOOD Glucose-106* UreaN-37* Creat-1.2* Na-147*
K-4.2 Cl-109* HCO3-31 AnGap-11
[**2150-3-7**] 02:32AM BLOOD CK(CPK)-23*
[**2150-3-8**] 07:25AM BLOOD ALT-11 AST-14 LD(LDH)-306* AlkPhos-117
Amylase-32 TotBili-0.3
[**2150-3-8**] 07:25AM BLOOD Lipase-20
[**2150-3-3**] 09:50PM BLOOD Calcium-7.4* Phos-3.2 Mg-2.2
[**2150-3-6**] 03:29AM BLOOD Calcium-7.3* Phos-3.1# Mg-2.3
[**2150-3-9**] 06:10AM BLOOD Calcium-7.7* Phos-3.7 Mg-2.4
[**2150-3-5**] 03:27AM BLOOD Triglyc-157*
[**2150-3-8**] 07:25AM BLOOD Osmolal-303
[**2150-3-7**] 02:32AM BLOOD TSH-11*
[**2150-3-7**] 02:32AM BLOOD Free T4-0.68*
Brief Hospital Course:
[**Age over 90 **]F with MMP including C difficle infection, UTI, PICC line
infection, PNA.
.
#) fever, elevated WBC - Patient was on multiple antibiotics to
treat C. diff, Pseudomonas/VRE UTI, Coag - staph PICC line
associated bacteremia, PNA and these were likely the causes of
her fevers and leuckocytosis. After discussion the family,
these measures were to be discontinued prior to [**Age over 90 **].
.
#) Respiratory distress: Patient with hypercarbic respiratory
distress. Patient is DNI and CPAP contraindicated at this time
as patient has some respiratory secretions. After discussion
with the family, it was determined that the patient definitively
not be intubated and she was not transferred to the MICU for
respiratory ventilation. RA saturations are 86-88%.
.
#) Mental status - AAOx3 intermittently in the MICU, although
while on the floor the patinet has been slightly responsive to
noxious stimulus. Family has been by the bedside and have
reassured us that this is not her baseline..
.
#) Paroxysmal atrial fibrillation - Likely in setting of
numerous infections. Patient was started on IV Lopressor for
rate control. This medication was held in the setting of
hypotension.
.
#) h/o C1 fracture - no new trauma since 1/[**2149**]. Patient has
been in hard collar and recommendations were to keep patient in
hard collar until [**2150-4-19**]. Given goals of comfort, patient will
be able to remove the collar. Patient does have scheduled
appointments with Neurosurgery in the upcoming months.
.
#) Hearing loss - appears at baseline. Patient with headphones
and microphone for communication.
.
#) hypothyroid - Synthroid was continued although TFTs were not
suggestive of such. This was likely due to decreased PO
absorption in the setting of C diff infection.
.
# Anemia - stable, acute GI bleed resolved at this point, will
continue to monitor.
.
# Depression - on Remeron 15 mg prior to admission but unable to
take po's.
.
# FEN - Family have decided not to undergo PEG placement as
this contradicts patient's wishes. Patient initially had an NGT
placed although this was removed by the patient on the day of
[**Month/Day/Year **].
.
.
After discussion with the patient's family, HCP, and medical
staff, all were in agreement that [**Known firstname **] [**Known lastname 23162**] was a suitable
candidate to [**Known lastname **] to hospice.
Medications on Admission:
imipenem 500 mg x1
vanco 1000 mg x 1
flagyl 500 mg po tid (start [**3-3**] for diarrhea)
lorazepam 0.5 mg po qhs, [**Hospital1 **] prn agitiation
TPN at 75/hour
heparin SQ TID
tylenol 1000 mg po q6h
calcium carbonate 500 mg po tid
hemorrhoidal ointment/hydrocort rectally
lansoprazole 30 mg po qd
levothyroxine 150 mcg po qd
miconazole topically [**Hospital1 **]
remeron 30 mg po qhs
vitamin d 800 units po qd
atrovent nebs Q6H prn
[**Hospital1 **] Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
4. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours).
5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q2H (every 2 hours) as needed.
6. Levothyroxine 50 mcg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
7. Nystatin 100,000 unit/g Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Lorazepam 0.5 mg IV Q6H:PRN agitation
10. Pantoprazole 40 mg IV Q24H
11. Morphine Sulfate 1 mg IV Q4H:PRN pain
12. Metoprolol 5 mg IV Q6H
please hold for SBP<100, HR<60
[**Hospital1 **] Disposition:
Extended Care
[**Hospital1 **] Diagnosis:
Primary Diagnosis: C. diff, Complicated Urinary tract infection,
Hypercarbic respiratory failure
.
Secondary Diagnoses:
Hypertension
Hypothyroidism
Osteoarthritis
Depression
Obesity
Urinary Incontinence
GERD
s/p Total TAH
C1 fracture [**12-28**]
subdural hematoma
ventricular hemorrhage
C.difficile colitis ([**1-28**])
[**Month/Year (2) **] Condition:
Afebrile, normotensive, tachycardic, nonambulatory, not
tolerating POs, nonresponsive
[**Month/Year (2) **] Instructions:
You were admitted with an infection and have been treated with
antibiotics.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. NEUROSURGERY WEST
Date/Time:[**2150-4-21**] 2:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-4-21**] 1:00
Completed by:[**2150-3-10**]
ICD9 Codes: 5849, 5990, 486, 2449, 4019, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6020
} | Medical Text: Admission Date: [**2186-3-24**] Discharge Date: [**2186-6-1**]
Date of Birth: [**2145-4-18**] Sex: M
Service: SURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 14255**]
Chief Complaint:
cholangiocarcinoma
Major Surgical or Invasive Procedure:
1. R hepatic lobectomy and pancreaticoduodenectomy
([**2186-3-24**]-[**Location (un) **]),
2. ex-lap, drainage of RUQ abscess, and redo
pancreaticojejunostomy ([**2186-4-8**]-[**Location (un) **]),
3. ex-lap, washout for bleeding ([**2186-4-14**]-[**Location (un) **]),
4. abd washout, temporary closure ([**2186-4-16**]-[**Location (un) **]),
5. ex-lap, washout, attempted closure ([**2186-4-19**]-[**Location (un) **]),
6. abd washout and closure ([**2186-4-25**]-[**Location (un) **])
Thoracentesis [**2186-4-21**], [**2186-4-28**]
Picc placed [**2186-4-4**], removed [**2186-5-30**]
History of Present Illness:
40-year-old Italian male who presents with a segment VIII
hepatic lesion. [**Known firstname 91899**] was initially diagnosed with his bile
duct stricture in [**2183**]. He has undergone multiple brushings and
biopsies of this lesion, which were all consistent with a benign
stricture. He has had a number of stents placed in
the bile duct and eventually these were removed. He was doing
well until he was seen at the [**Hospital 8**] Hospital by Dr. [**Last Name (STitle) 2161**]
and [**Last Name (STitle) 1834**] a CT scan, which demonstrated what appeared to be
metastasis in the right lobe of the liver. He has no
significant past medical history.
Past Medical History:
None
Social History:
He is currently employed as a construction worker working full
time. He divides his time between [**State 108**]
and [**Location (un) 86**]. He notes that he has a glass of wine or beer a
couple of times a week, approximately 10 cigarettes per day and
he has quit approximately three years ago. No drugs, no
marijuana.
Family History:
Non-contributory
Physical Exam:
discharge PE
98.5 92 100/64 18
A&O, anicteric
decreased breath sounds R lower half
rrr
abd soft/non-tender, capped Roux tube, 2 JP drains with greenish
fluid, L side of incision with 2x2 damp to dry NS dressing
ext trace edema right ankle
roux capped
JP #1 15ml/day
JP #2 20ml/day
BM x2 [**5-31**]
Pertinent Results:
[**2186-6-1**] 05:55AM BLOOD WBC-9.8 RBC-2.96* Hgb-8.9* Hct-27.4*
MCV-92 MCH-30.1 MCHC-32.5 RDW-14.6 Plt Ct-365
[**2186-5-29**] 03:46AM BLOOD PT-13.8* PTT-28.9 INR(PT)-1.3*
[**2186-5-29**] 03:46AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-132*
K-3.9 Cl-98 HCO3-28 AnGap-10
[**2186-6-1**] 05:55AM BLOOD Glucose-116* UreaN-10 Creat-0.6 Na-130*
K-4.0 Cl-96 HCO3-29 AnGap-9
[**2186-5-22**] 05:50AM BLOOD ALT-37 AST-36 AlkPhos-215* TotBili-1.1
[**2186-5-29**] 03:46AM BLOOD ALT-30 AST-35 AlkPhos-242* TotBili-0.6
[**2186-6-1**] 05:55AM BLOOD ALT-33 AST-41* AlkPhos-270* TotBili-0.6
[**2186-4-28**] 01:13AM BLOOD Lipase-36
[**2186-6-1**] 05:55AM BLOOD Albumin-2.7* Calcium-8.3* Phos-4.6*
Mg-1.8
[**2186-5-9**] 05:32AM BLOOD calTIBC-213* TRF-164*
[**2186-5-8**] 05:08AM BLOOD Triglyc-111
[**2186-5-21**] 5:46 pm PLEURAL FLUID PLEURAL FLUID .
**FINAL REPORT [**2186-5-27**]**
GRAM STAIN (Final [**2186-5-22**]):
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 (Final [**2186-5-24**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2186-5-27**]): NO GROWTH.
[**2186-4-7**] 4:20 am BLOOD CULTURE
**FINAL REPORT [**2186-4-15**]**
Blood Culture, Routine (Final [**2186-4-14**]):
PREVOTELLA SPECIES. BETA LACTAMASE NEGATIVE.
Anaerobic Bottle Gram Stain (Final [**2186-4-9**]):
Reported to and read back by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1650,
[**2186-4-9**].
GRAM NEGATIVE ROD(S).
Brief Hospital Course:
On [**2186-3-24**], Mr. [**Known lastname 91900**] [**Last Name (Titles) 1834**] right hepatic lobectomy and
Whipple procedure for distal cholangiocarcinoma with metastasis
to the right lobe of the liver. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
co-surgeon Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **].
He was intubated and sedated postoperatively for a prolonged
period due to revision of pancreaticojejunostomy, drainage of
right upper quadrant abscess and redo of pancreaticojejunostomy
on [**4-8**] for pancreaticojejunostomy dehiscence. He had open
abdomen and need for repeated abdominal washouts. SICU course
was prolonged.
He was successfully extubated after repeated operations on [**4-22**].
Despite his prolonged intubation, he was oriented to time and
place post extubation. Following repeated surgeries, he was
persistently tachycardic. CTA was performed on [**2186-3-27**] and was
negative for pulmonary embolus, but did show a subdiaphragmatic
fluid collection. He remained on pressor support
(neo,vasopressin from [**Date range (1) 89937**]). Octreotide was also started
due to continued bleeding after initial OR on [**4-8**]. Cardiac echo
was performed [**2186-4-10**] which revealed normal biventricular cavity
sizes with preserved regional and hyperdynamic global
biventricular systolic function. No valvular pathology or
pathologic flow identified.
On [**4-8**], (postop day 15), he continued to drain bile from his JP
drains. He was taken back to the OR for concern of anastomotic
leak from his pancreaticojejunostomy. He continued to have a
dropping hematocrit on [**4-14**] and returned to to OR on [**4-14**] for
abdominal washout, however no source of bleeding was determined.
Despite this the patient continued to have a transfusion
requirement. had a persistent transfusion requirement and
returned again to the OR for abdominal washout later that day.
In total, between [**4-8**] and [**4-16**] he received 23 Units of PRBC,
16U of FFP. He again returned to the OR on [**4-14**] for abdominal
washout. Abdomen was left open. Following diuresis with a Lasix
drip the patient subsequently returned to the OR [**4-25**] for
closure. Please refer to operative reports for details.
Thoracentesis was done on [**4-21**] and [**4-28**] for 1200 cc and 1000 cc
respectively. Respiratory status subsequently improved and
patient had decreased oxygen requirement. Thoracentesis was
again performed on [**5-16**] for large pleural effusion. Pleural
fluid culture isolated pan sensitive E.coli. IV Ciprofloxacin
was administered for 15 days. CXR demonstrated apical
pneumothorax. Reaccumulation of the pleural effusion occurred
necessitating repeat thoracentesis with pigtail drain placement
was done on [**5-21**] yielding one liter of exudate. TPA instillation
was attempted, however, pigtail catheter became dislodge.
Culture of this fluid demonstrated 4+PMN, but was negative for
microorganisms.
Given concern for empyema, a thoracic consult was obtained on
[**5-25**]. After review of CXRs , no further intervention was
recommended as the thoracic surgery service thought the effusion
was most likely reactive from the subdiaphragmatic collection.
Notation of an 8-mm right upper lobe nodule was made and
attention on followup scans
for surveillance for metastasis was recommended.
He was weaned off oxygen and O2 saturations were greater than
93%. CXR on [**5-29**] showed slightly decreased loculated right
pleural effusion since the prior study still involving the major
fissure and still with multiple air-fluid levels consistent with
air loculations. No pneumothorax was noted. There was a small
left pleural effusion.
He was maintained on total parenteral nutrition throughout most
of his hospital course. On postop day 32, a post-pyloric feeding
tube was placed and tube feedings were started and successfully
advanced to goal rate. Throughout hospital stay, regular
insulin was given per sliding scale. From [**Date range (1) 91901**] while
critically ill he remained on an insulin gtt which was
subsequently weaned off. He passed a bedside swallow and was
subsequently advance to clears and then regular diet.
Otolaryngology was consulted for weak, hoarse voice. It was felt
that prolonged and repeated intubations were likely the cause
and that granulomatous changes would resolve over time. PPI
therapy was recommended and administered (Protonix [**Hospital1 **]).
Hoarseness and projection improved.
Creatinine remained stable at ~1.0. He tolerated diuresis with
a Lasix drip until successful closure of abdomen on [**4-25**]. While
on Lasix drip, urine output remained excellent 100-400 cc/hr
with urine output of >4-6L/day.
Following abdominal washout on [**2186-4-8**] he was placed on broad
spectrum antibiotics including vanc/zosyn and fluconazole.
Blood cultures returned on [**4-7**] positive for Prevotella species,
but surveillance cultures remained negative since this blood
culture. On [**2186-4-20**] his PICC line was removed and his CVL was
replaced for concern of rising leukocytosis to 14. PICC line
culture was negative. Central line was eventually removed and
another PICC line was placed ([**5-6**]/)into left upper arm. This
line was used for TPN/antibiotics/blood draws. On [**5-30**], this
line was removed as IV antibiotic course (Ciprofloxacin)was
stopped on [**5-31**].
Give protracted hospital course, he was very depressed. Social
work and pastoral care supported. Remeron was started on [**5-11**] at
7.5mg then increased to 15mg on [**5-25**]. Mood, energy level and
sleep pattern improved.
LFTs slowly improved with values approaching normal limits with
the exception of alk phos which remained in the low to mid 200s.
Ursodiol was continued. He continued to have anemia with stable
hematocrit of 25.
Physical therapy worked with him throughout this hospital stay.
He became more independent with ambulation and ADLs as his
condition improved. He had been very debilitated, tachycardic
and with O2 requirement. Rehab was recommended. Rehab screen was
done per case management and [**Hospital3 **] in [**Hospital1 8**]
offered a bed on [**6-1**]. He will transfer there today.
Medications on Admission:
none
Discharge Medications:
1. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain
4. Mirtazapine 15 mg PO HS
5. Octreotide Acetate 100 mcg SC Q8H
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Pantoprazole 40 mg PO Q12H
8. Ursodiol 300 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Cholangiocarcinoma
pancreaticojejeunostomy dehiscence
right pleural effusion
prevotella bacteremia [**2186-4-7**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You will be transferring to [**Hospital3 **] in [**Hospital1 8**].
Please call Drs.[**First Name (STitle) **] and [**Doctor Last Name **] office if you have any of
the following: temperature of 101 or greater, chills, nausea,
vomiting, jaundice, increased abdominal pain, drain output stops
or increases significantly or changes in color/odor,
constipation or diarrhea or if feeding tube clogs.
You may shower.
Followup Instructions:
Follow up will be with Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] on [**2186-6-15**] at 1:15 PM
at [**Hospital **] Medical Office Building, [**Location (un) **], [**Last Name (NamePattern1) **].
[**Location (un) 86**], [**Numeric Identifier **]
Completed by:[**2186-6-1**]
ICD9 Codes: 0389, 7907, 5119, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6021
} | Medical Text: Admission Date: [**2186-1-25**] Discharge Date: [**2186-2-6**]
Date of Birth: [**2142-4-6**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Ampicillin / Levofloxacin
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
RLE: significant worsening of pain and swelling
Major Surgical or Invasive Procedure:
[**2186-1-26**] Extensive debridement of right lower extremity.
[**2186-1-27**] Exploration, washout and debridement of right lower
extremity.
History of Present Illness:
This 43-year-old male patient with a history of ESLD, cirrhosis
secondary to hepatitis C, genotype I, He had been followed in
the [**Hospital 1326**] clinic (last visit [**2185-9-21**]). Presented with
mildly encephalopathic status and has significantly worsened
synthetic function of his liver with low albumin, high INR, and
low glucose, MELD 38. Acute on chronic renal failure with uremia
in setting of GNR bacteremia. Pt has significant h/o unilateral
RLE lymphedema, with progressively worsening pain and tenderness
and uncompromised perfusion.
Past Medical History:
PMH:
-Hep C, genotype 1
-Cirrhosis.
-MELD 38
-Hx IVDU
-Chronic unilateral right leg lymphedema
-Chronic renal failure
Social History:
lives with girlfriend and 3 cats at home
+ tobacco - [**12-10**] ppd
denies etoh
+ IVDU - He has a history of IV drug use with heroin and
cocaine between [**2164**] and [**2174**] but denies any use since then.
He repairs computers part time.
He was incarcerated between [**2173**] to [**2177**] for possession of drugs
with intent, and he does smoke an occasional marijuana, but he
reports it is prescribed by doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
Family History:
Non-contributory
Physical Exam:
VS: 98.2 92/34 106 18 92%RA
General: awake orientated, inappropriate responses, anxious.
HEENT: Sclera anicteric, dry MM.
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, mildly hypogastric tender , non-distended, BS+ no
rebound tenderness or guarding, no fluid shift,no visceromegaly,
no herniation.
Ext: Significant RLE 2+, non pitting,very tender tense
compartments, with cellulitis, no crepitus. Pain on passive
flexion/extension. Uncompromised perfusion, pulses preserved. R
inguinal region lymphovarux palpable.
L with mild baseline Lymphedema.
Neuro: A&O x 3, no focal or global deficits.
Pertinent Results:
wbc- 3.6, hct 32.1, plt 16.9, plt 19
diff- n- 82, l- 5.7, e-6
Na 135, Cl 96, K 5.6, CO2 24, BUN 47, Cr 3.9, Glucose 59, Ca
8.2,
Pr 5.4, Albumin 2.3, T bili 4.2, d bili 2.4, AST 131, Alk Phs
57,
ALT 61, CK 115, Mag 1.8
ESR 34
Ammonia 55
INR 2.97 PT 30.5 PTT 47.4
UA- 1.030, ph 5, neg for pro, glu, ketones, RBC [**5-18**], WBC 0-2,
granular casts 0-1, hyaline cast [**1-13**]
Brief Hospital Course:
Patient was admitted with worsening liver disease, acute on
chronic renal failure, with encephalopathy/ uremia in the
setting of GNR bacteremia/sepsis and worsening swelling/
cellulitis of the RLE. He was admitted to the SICU on [**2186-1-25**].
Comparment syndrome was ruled-out, but he was noted to have
increasing erythema, pain and tenderness over the right lower
extremity up into the thigh. He became hypotensive requiring
volume resuscitation and intermittent vasopressors.
Broad-spectrum antibiotics were started. Plans were made to
explore the right lower extremity for concern for a deep
infection and underwent an extensive debridement of the RLE on
[**2186-1-26**]. The patient tolerated the procedure well. He
intermittently required Neo-Synephrine for hypotension in the
OR. He was transferred back to the ICU. On [**2186-1-27**], he was taken
to the OR again for re-exploration of the RLE and to assess the
need for further debridement. A washout and further debridement,
specially of the anterior incision of the lower leg was made. He
was taken intubated on low-dose Neo- Synephrine to the SICU in
guarded condition. He was kept intubated, on neo and on CVVHD
for his renal failure 2ry to ATN. He was initially treated with
Vanc, Cefe, Clinda, flagyl for his GNR on OSH. These actually
grew Pasturella, and additionally, his tissue cx grew staph
coagulase negative (thought to be likely contaminant). He was
continued on Vanco, and started on high dose Cipro, Meropenem
and Clinda, following ID recs. From a nutritional standpoint he
was started on tube feeds on [**1-27**] via dobhoff catheter. The
surgical wounds were managed initially with wet to dry dressing
changes but ultimately with VAC dressings applied at the bedside
and changed every 3 days. The T.Bili progressively increased
from 5.7 preop to 24.6 on [**2-2**]. His transaminases then started
to worsen dramatically to [**Telephone/Fax (1) 78539**] (ALT/AST) on [**2-5**] and up to
3640/[**Numeric Identifier 78540**] on [**2-6**]. His renal function also started to get worse
on [**2-5**] with serum creatinine higher than 2.0 and up to 3.4 on
[**2-6**]. He was evidently coagulopathic due to his liver failure and
his INR was notably high during his stay in the ICU, but
significantly raisen from 2.1 to 3.6 on [**2-4**] and 7.6 on [**2-5**].
His platelets were also notably low, between 20,000-40,000 and
getting down to 12,000 on [**2-2**]. On [**2-3**] his clinical status
changed, started again with hypotension requiring pressors, not
following commands. Additionally, HIT antibody was found to be
positive, thus heparin products were d/c'd and argatroban gtt
was started on [**2-4**]. On [**2-5**] patient was complicated with melena
- ?GI bleed. Argatroban gtt was held and pRBC/FFP/plt were
transfused. NGT lavage was negative. CT head was negative.
Patient had progressive deterioration with significant worsening
LFTs, liver failure, coagulopathy and renal failure. A duplex
U/S of the liver ruled out PVT or HVT. Due to his multiorgan
failure and his progressive clinical deterioration despite
maximal treatment, poor prognosis was discussed with the family
on [**2-6**] and patient was made CMO. Patient expired on [**2186-2-6**] at
7:10 pm.
Medications on Admission:
Dilaudid 15mg PO PRN, Methadone 64 mg liquid qday, Advil PRN,
Lasix 120", aldactone 100', Rifaximin 200mg Q48hours,
Testosterone gel unsure dose
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis by Pasteurella Multocida
Multiorgan failure
Liver Failure, Encephalopathy, Renal Failure, Coagulopathy
HCV cirrhosis
RLE cellulits s/p I&D and debridement [**1-26**] and [**1-27**]
Heparin Induced Thrombocytopenia
Cardiopulmonary Arrest
Discharge Condition:
Expired
Completed by:[**2186-2-24**]
ICD9 Codes: 5856, 5849, 2762, 5715, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6022
} | Medical Text: Admission Date: [**2158-8-7**] Discharge Date: [**2158-8-30**]
Date of Birth: [**2096-4-23**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
Fevers and decreased O2 sats
Major Surgical or Invasive Procedure:
Bronchoscopy
Tracheostomy [**5-22**]
History of Present Illness:
62M w/ h/o OLT [**2158-5-22**] c/b wound infection for which a wound VAC
was placed was tranferred from his rehabilitation facility for
decreased oxygen saturation. he was seen in clinic that day and
had his T-tube clamped. Noted to have lower extremity edema
with lethargy. Oxygen saturation was 60-70% on RA with fever to
101.0. In ED was tachycardic to 130 with O2 sats of 91% on 4L
nasal canula. Was alert and oriented, but reported upper
respiratory congestion and cough. ABG showed hypoxia and
hypercarbia: 7.34/67/65, CXR showed LLL consolidation. He
recieved levaquin and vancomycin and was admitted to the SICU.
Past Medical History:
OLT [**2158-5-22**] c/b wound infection
HCV
DM II
Esophageal varices
BPH
Bipolar d/o
Heart Failure
Social History:
Quit ETOH 17yrs ago
Quit tobacco 8yrs ago
No illicit drug use
Divorced, lives alone
Family History:
Noncontributory
Physical Exam:
Admission:
T101.2 HR 117 BP128/61 RR22 SAT95/5L
GEN:Obese gentleman, NAD
HEENT: NCAT, PERRLA, EOMI
Neck: supple, no LAD
Lungs: diminished BS L base w/ rhonchi
CV: tachy, reg rythm
ABD: soft NT, distended, VAC in place
EXT: LE w/ 2+ edema, warmth, no erythema, cyanosis
Pertinent Results:
Admission Labs:
[**2158-8-7**] WBC-7.1 Hgb-9.6* Hct-29.5* Plt-191
[**2158-8-7**] Glucose-53* UreaN-23* Creat-1.2 Na-142 K-3.7 Cl-101
HCO3-31* AnGap-14
[**2158-8-7**] ALT-11 AST-18 AlkPhos-86 Amylase-50 TotBili-0.3
Albumin-2.9* Calcium-8.6 Phos-3.4 Mg-1.7
Discharge Labs:
[**2158-8-29**] WBC-9.9 RBC-3.45* Hgb-9.4* Hct-29.4* MCV-85 MCH-27.4
MCHC-32.1 RDW-16.4* Plt Ct-199
[**2158-8-29**] Glucose-115* UreaN-51* Creat-1.2 Na-145 K-5.0 Cl-105
HCO3-35* AnGap-10
[**2158-8-28**] ALT-9 AST-11 LD(LDH)-203 AlkPhos-93 Amylase-28
TotBili-0.5
[**2158-8-29**] 08:07AM Type-ART pO2-80* pCO2-72* pH-7.33* calHCO3-40*
Base XS-8
Cultures:
[**8-7**] BCX- neg
[**8-7**] UCX- neg
[**8-9**] sputum- klebsiella (multi-resistant, [**Last Name (un) 36**] to meropenem)
LEGIONELLA CULTURE (Final [**2158-8-19**]): NO LEGIONELLA ISOLATED.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2158-8-10**]): PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Final [**2158-8-22**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2158-8-11**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
This is only a PRELIMINARY result. If ruling out
tuberculosis, you
must wait for confirmation by concentrated smear.
DUE TO QUANTITY NOT SUFFICIENT CONCENTRATED SMEAR RESULT
NOT
AVAILABLE.
[**2158-8-24**] L SCV CVL- No significant growth.
Brief Hospital Course:
Mr [**Known lastname 1182**] was admitted to the SICU and placed on BIPAP/mask
ventilation to manage his hypoxia/hypercarbia. Zosyn was
started, and he was tranfused 1u pRBCs. A CTA of the chest,
abdomen and pelvis was obtained that did not show a PE, but a
LLL pneumonia and a R posterior perihepatic fluid collection
were visualized. He defervesced on HD#4. By systems:
Neuro: He was admitted on his outpatient regimen of resperidal
for his bipolar disorder. Psychiatry was consulted and had no
specific recommendations. They did not think the resperidal was
diminishing his respiratory drive. Neurology consult did not
think there was a central inhibition of his respiratory drive.
Cardiovascular: Given the reported history of CHF, and findings
on his CXR an echo was obtained on [**2158-8-15**]. This showed that LV
and RV systolic function were normal(LVEF>55%). There were no
major valvular abnormalities and moderate pulmonary artery
systolic hypertension that had increased from the last study.
He was diuresed with lasix, for diastolic dysfunction. PA
catheter was placed [**2158-8-19**] with PA 64/32 and PCWP 24-26 and
lasix drip was started. His PA numbers improved and his swan
was subsequently removed.
Pulmonary: Treatment was started for LLL pneumonia with zosyn.
He was maintained on BIPAP, however he continued to be somnolent
and tachypneic with elevated pCO2. He was electively intubated
[**2158-8-11**] and bronchoscopy was performed. This showed mild LMSB
deviation c/w LLL collapse and minimal secretions. BAL was
performed and subsequently grew multi-resistant klebsiella. He
remained a difficult wean with hypercarbia thought to be driven
by lasix diuresis with metabolic alkalosis. Pulmonary consult
was obtained: thought that pt had pickwickian syndrome with
hypoventilation with diastolic dysfunction/CHF and needed more
agressive diuresis. His pleural effusions continued to worsen
so more lasix and diamox were admininstered. His effusions
eventually improved and his oxygenation improved, but he
continued to have a poor respiratory drive, requiring high
pressure support. Tracheostomy was performed [**2158-8-25**]. Trach
collar trials were unsuccessful due to hypercarbia w/ pCO2 in
the 70s.
GI: He was started on liquids initially. After intubation he
was started on tube-feeds. A post-pyloric dobhoff was placed,
and TF were advanced to goal of 120cc/h of [**2-9**] strength 1cc/kg
formula (currently on impact w/ fibre).
Liver Transplant: LFT's and coags were normal on admission. His
[**Last Name (un) **] was held because of persistently high levels. He was
switched to cyclosporin (neoral) with good levels. His current
regimen includes: MMF 1gram [**Hospital1 **], prednisone 10mg qd, and neoral
200mg [**Hospital1 **]. His valcyte and fluconazole were discontinued. He
continues on bactrim. He will need full labs, including
cyclosporin level twice weekly. The t-tube remained clamped.
GU: Given his respiratory failure and CHF, he was diuresed with
lasix, with intermittent diamox to manage metabolic alkalosis.
His creatinine peaked at 1.8, and subsequently came down to 1.2
and stabilized.
HEME: Required blood transfusions initially for a
borderline/low HCT of 28. He otherwise stabilized with no major
issues.
ID: He was started on zosyn emperically, however his BAL grew
multiresistant klebsiella, sensitive only to meropenem. He
completed a 14 day course on [**2158-8-28**], and remained afebrile with
a normal WBC count.
END: His insulin regimen was adjusted, and his glargine was
incresed to 80u at HS.
Wound: His abdominal wound was managed with a VAC dressing,
changed every 3 days. The wound was clean and granulating well.
Medications on Admission:
Lopressor 75 [**Hospital1 **]
Bactrim 1 qd
fluconazole 200qd
valcyte 450 qd
cellcept 1gm [**Hospital1 **]
hydralazine 75 qid
protonix 40qd
lantus 58qam
riss
cardura 2qpm
rapamycin 7qd
risperidal 4qd
lasix 60 [**Hospital1 **]
colace 100 [**Hospital1 **]
prednisone 10 qd
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
2. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
Sig: 1000 (1000) mg PO BID (2 times a day).
3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
6. Doxazosin Mesylate 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
9. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Hydralazine HCl 50 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection [**Hospital1 **] (2 times a day): subcutaneous.
13. Cyclosporine Modified 100 mg/mL Solution Sig: Two Hundred
(200) mg PO 6PM AND 6AM (): [**Hospital1 **]. dose may change depending on
results of [**Hospital1 **]-weekly levels. MUST CALL TRANSPLANT CENTER AFTER
LEVEL SENT.
14. Insulin Glargine 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous at bedtime.
15. Insulin Regular Human 300 unit/3 mL Syringe Sig: sliding
scale Subcutaneous four times a day.
16. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
End-stage liver disease
Orthotopic liver transplant [**5-22**]
Respiratory failure
Left lower lobe Pneumonia
Hepatitis C
Esophageal varices
history of encephalopathy
diabetes mellitus
heart failure
benign prostatic hypertrophy
Bipolar disorder
Discharge Condition:
Good
Discharge Instructions:
[**Hospital1 **]-weekly labs (Monday/Thursday): CBC, chem10, AST, ALT, alk
phos, albuimin, T. bili, cyclosporin level 2hours after am dose
on the given day. [**Last Name (un) **] lab results to: [**Telephone/Fax (1) 697**]
Trach care/vent wean
Tubefeeding via dobhoff
VAC dressing to abdominal wound, change every 3 days.
Followup Instructions:
Transplant Center [**Last Name (NamePattern1) 439**], [**Location (un) 436**] [**Telephone/Fax (1) 673**]/ Dr
[**Last Name (STitle) **]. Follow-up in [**6-17**] days
Completed by:[**0-0-0**]
ICD9 Codes: 4280, 2875, 5180, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6023
} | Medical Text: Admission Date: [**2156-6-21**] Discharge Date: [**2156-6-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 398**]
Chief Complaint:
UTI/sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82M with metastatic esophageal CA managed by watchful waiting,
diabetes p/w confusion at [**Hospital 27838**] rehab. He was noted by the
staff at the rehab to develop difficulty breathing, decreased
oxygen sats requiring supplemental oxygen, and bp to the 80s
systolic. Of note, at the rehab he had just completeted a course
of levofloxacin for a RLL PNA for which he was treated at [**Hospital **]. He was sent to the ED at [**Hospital1 18**] for further evaluation where
he was found to have initial vitals T 99.4 bp 146/72 satting 95
on 3L. He afebrile though found to have a lactate of 5.3 with a
wbc of 18.4 from 16.9 a couple of days prior. While his bp and
pulse were stable, sepsis protocol was initiated given the
elevated lactate and central line was placed in the ED. He was
given 3L NS in smaller boluses. CXR showed no infiltrates. UA
was positive. Vanc/zosyn were started empirically in the ED. He
was admitted to ICU.
Past Medical History:
1. Esophageal CA
2. HTN
3. gastric ulcers
4. diabetes, has been diet controlled.
Status post left knee replacement x3.
Status post right knee replacement x2.
Social History:
The patient is married and lives with his wife in [**Name (NI) 1474**]. He
drives and keeps track of the bills. He is a retired deli store
owner, and reports a remote tobacco history, rare alcohol use,
and no intravenous drug use.
Family History:
brother with prostate CA.
Physical Exam:
VS: Temp: 98.2 BP: 127/56 HR: 71 RR: 25 O2sat: 93% 3L
GEN: awake, oriented to self, occasional bursts of agitation
HEENT: PERRL, eomi, MM dry
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: bibasilar crackles
CV: RR, S1 and S2 wnl, IV/VI early systolic murmur
ABD: soft, moderately distended, no caput medusae
EXT: 1+ edema b/l
SKIN: no rashes/no jaundice
NEURO: MAEW, CN grossly intact,
Pertinent Results:
[**2156-6-21**] 09:26PM LACTATE-2.1*
[**2156-6-21**] 09:26PM O2 SAT-66
[**2156-6-21**] 09:13PM CORTISOL-27.8*
[**2156-6-21**] 08:09PM TYPE-ART O2 FLOW-5 PO2-67* PCO2-42 PH-7.34*
TOTAL CO2-24 BASE XS--2 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2156-6-21**] 07:20PM GLUCOSE-58* UREA N-54* CREAT-1.5* SODIUM-138
POTASSIUM-5.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-13
[**2156-6-21**] 07:20PM WBC-17.0* RBC-3.09* HGB-9.5* HCT-27.6* MCV-90
MCH-30.6 MCHC-34.2 RDW-13.8
[**2156-6-21**] 07:20PM NEUTS-80* BANDS-11* LYMPHS-7* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2156-6-21**] 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-MOD
[**2156-6-21**] 04:20PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2156-6-21**] 03:42PM LACTATE-5.3* K+-5.3
[**2156-6-21**] 03:40PM ALT(SGPT)-35 AST(SGOT)-54* LD(LDH)-350*
CK(CPK)-60 ALK PHOS-303* AMYLASE-22 TOT BILI-0.7
[**2156-6-21**] 03:40PM CK-MB-NotDone cTropnT-0.05* proBNP-2755*
[**2156-6-21**] 03:40PM CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-2.3
[**2156-6-21**] 03:40PM HAPTOGLOB-301*
[**2156-6-21**] 03:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2156-6-21**] 02:37PM GLUCOSE-83 UREA N-57* CREAT-1.6* SODIUM-137
POTASSIUM-5.7* CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
[**2156-6-21**] 02:37PM PLT COUNT-316
[**2156-6-24**] 03:25AM BLOOD WBC-19.9* RBC-3.24* Hgb-9.8* Hct-28.9*
MCV-89 MCH-30.3 MCHC-34.0 RDW-14.2 Plt Ct-307
[**2156-6-21**] 07:20PM BLOOD Neuts-80* Bands-11* Lymphs-7* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-6-24**] 03:25AM BLOOD Plt Ct-307
[**2156-6-21**] 03:40PM BLOOD PT-15.3* PTT-34.3 INR(PT)-1.4*
[**2156-6-23**] 04:31AM BLOOD Glucose-90 UreaN-42* Creat-1.1 Na-142
K-4.5 Cl-111* HCO3-25 AnGap-11
[**2156-6-22**] 03:20PM BLOOD Glucose-80 UreaN-44* Creat-1.2 Na-141
K-4.4 Cl-109* HCO3-24 AnGap-12
[**2156-6-21**] 03:40PM BLOOD ALT-35 AST-54* LD(LDH)-350* CK(CPK)-60
AlkPhos-303* Amylase-22 TotBili-0.7
[**2156-6-22**] 04:02AM BLOOD Albumin-2.0* Calcium-7.8* Phos-4.0 Mg-2.0
[**2156-6-21**] 09:13PM BLOOD Cortsol-27.8*
[**2156-6-21**] 03:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
.
Abd US
IMPRESSION:
1. Multiple nodules throughout the liver consistent with
widespread metastases.
2. Small amount of perihepatic ascites.
.
KUB:
IMPRESSION: No evidence of bowel obstruction or free
intra-abdominal air is identified.
.
CXR:
IMPRESSION:
Suboptimal study due to markedly reduced lung volumes with no
acute consolidation. Right hemidiaphragm elevation. Probable
cardiomegaly. This will be better evaluated with PA and lateral
views of the chest when the patient could tolerate this.
.
URINE CULTURE (Final [**2156-6-23**]):
ESCHERICHIA COLI. >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------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
A/P:
82M with metastatic esophageal CA, diabetes p/w sepsis.
.
1. Sepsis/UTI:
Pt had lactate to 5.3 on admission, with elevated WBC. The ource
was found to be UTI. He was treated initially with vanc and
zosyn. he was admitted under sepsis protocol with SvO2 central
venous line placed and received multiple fluid boluses in the
ED. His pulse and BP remained stable in the ED, although the
lactate was indicative of early sepsis. This resolved with
treatment. Urine Cx showed E Coli sensitive to bactrim. At
rehab, pyridium can be considered for pain if needed, patient's
daughter specifically requested this.
.
2. Hypoxia:
He was noted to have a new oxygen requirement. This was thought
to be [**2-6**] hypoventilation and abdominal distension. BNP was 2755
in the ED, although there was no other evidence of CHF.
.
3. Metastatic esophageal CA:
Liver US showed worsening metastatic disease with minimal
ascites, patent portal vein with hepatopetal flow. DNR/DNI
discussion was held with the patient and his son and daughter.
The patient expressed a clear desire to be DNR/DNI and also a
general preference to avoid further tests or procedures. His
goals are palliative.
.
4. ARF:
Cr was elevated 1.5 and had been 1.5 range at rehab for the past
week. His baseline was 1.0 on [**2156-4-1**]. This resolved to 1.1 with
IV fluids. His ACE inhibitor was held.
.
# hyperkalemia:
potassium was elevated to 5.7 on [**6-20**] at rehab, and was 5.7
again in ED. Pt is now s/p insulin and kayexalate, with k to
4.9. The potassium remained stable during the rest of the
admission.
.
# confusion:
This resolved by hospital day #2. It was likely mutlifactorial,
[**2-6**] acute illness, infection, oxycodone at rehab. This resolved
by the second hospital day.
.
# dm2:
Oral agents were held and he was covered with RISS.
.
# htn:
Lisinopril was held given the ARF.
.
FEN: cardiac, diabetic diet
.
Access: RSC central line
PPx: Hep SQ, ppi
DISPO: ICU care
Contact: [**Name (NI) **] [**Name (NI) **] [**Name (NI) 44908**] [**Telephone/Fax (1) 101480**]
Medications on Admission:
glyburide 1.25 mg p.o. daily
metformin 500 mg p.o. daily
lisinopril 40 mg p.o. daily,
Detrol LA 4 mg p.o. daily,
finasteride 5 mg p.o. daily
Prevacid 30 mg p.o.daily.
megace 400'
percocets
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days: please continue for
14 day course for UTI, day 1=[**6-21**].
6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
7. insulin
standard regular insulin slliding scale
8. Outpatient Lab Work
CBC and chem-7 within 1-2 days of arrival at rehab
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
UTI
ARF
metastatic esophageal CA
Discharge Condition:
fair, requiring 2L nasal cannula.
Discharge Instructions:
You were admitted for a urinary infection. You were also found
to have worsening metastatic cancer and we had important
discussions regarding the goals of your care.
.
2. please have lab work drawn at rehab for CBC and electrolytes
within 1-2 days.
Followup Instructions:
Please call your primary oncologist, Dr. [**Last Name (STitle) **] to update him
this week. We have been in contact with him as well. Provider
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**] Date/Time:[**2156-7-1**]
2:00
.
Provider [**Name9 (PRE) **] [**Name9 (PRE) 10341**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2156-7-1**]
2:00
ICD9 Codes: 0389, 5990, 5849, 2767, 496, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6024
} | Medical Text: Admission Date: [**2187-12-17**] Discharge Date: [**2187-12-24**]
Date of Birth: [**2112-12-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2187-12-18**]
1. Mitral valve repair with a 3-D [**Company 1543**] annuloplasty
ring, 28 mm and a cleft repair of A2.
2. Tricuspid valve repair with 30 mm MC3 annuloplasty ring.
History of Present Illness:
75 year old female c/o dyspnea on
exertion since summer [**2186**]. Developed congestive heart failure
which required diuresis and multiple thoracentesis for recurrent
pleural effusions. Most recent right thoracentesis at [**Hospital3 418**] [**2187-12-14**] for 1 liter.
Work-up revealed severe mitral regurgitation and she is admitted
for heparinization for MV surgery [**2187-12-18**].
Past Medical History:
Mitral Regurgitation
Congestive heart failure, recurrent effusions s/p thoracentesis
x
4 (most recent was last week, also had PTX after thoracentesis)
Moderate pulmonary hypertension
Atrial Fibrillation (on Coumadin)
Diabetes Mellitus
Hypertension
Hyperlipidemia
Hypothyroidism
?COPD
Colon Cancer s/p resection
Social History:
Race: Caucasian
Last Dental Exam: [**2187-11-27**], cleared
Lives: alone
Occupation: Secretary
Tobacco: Quit 50 yrs ago
ETOH: Occ.
Family History:
non-contributory
Physical Exam:
Physical Exam
Pulse: 107- irreg Resp: 20 O2 sat: 88% on RA
B/P Right: 107/59 Left: 105/63
Height: 170cm Weight: 72kg
General: well-developed female in no acute distress
Skin: Dry [X] - dime sized area of blanching erythema on right
buttock.
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Bilateral rales at the bases with right>left
Heart: RRR [] Irregular [X] Murmur [**1-19**] holosystolic heard
loudest
at the apex
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: +2 Varicosities:
None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 2+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: none
Pertinent Results:
[**2187-12-24**] 05:30AM BLOOD WBC-6.1 RBC-3.13* Hgb-8.8* Hct-28.1*
MCV-90 MCH-28.1 MCHC-31.2 RDW-15.6* Plt Ct-301#
[**2187-12-21**] 06:05AM BLOOD WBC-9.6 RBC-3.04* Hgb-8.7* Hct-27.2*
MCV-89 MCH-28.7 MCHC-32.1 RDW-15.7* Plt Ct-168
[**2187-12-20**] 03:57AM BLOOD WBC-11.1* RBC-3.27* Hgb-9.3* Hct-28.5*
MCV-87 MCH-28.5 MCHC-32.8 RDW-15.6* Plt Ct-157
[**2187-12-24**] 05:30AM BLOOD PT-14.1* INR(PT)-1.2*
[**2187-12-23**] 06:10AM BLOOD PT-13.4 INR(PT)-1.1
[**2187-12-22**] 07:50AM BLOOD PT-12.8 INR(PT)-1.1
[**2187-12-24**] 05:30AM BLOOD Glucose-103* UreaN-12 Creat-0.6 Na-140
K-4.5 Cl-104 HCO3-33* AnGap-8
[**2187-12-23**] 06:10AM BLOOD Glucose-99 UreaN-12 Creat-0.5 Na-141
K-4.6 Cl-104 HCO3-32 AnGap-10
PREBYPASS
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is moderately dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. The mitral valve leaflets do not fully
coapt. An eccentric, posteriorly directed jet of Severe (4+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen.
POSTBYPASS
LV systolic function is preserved. The is a ring prosthesis in
the mitral position . MR is now mild. RV systolic function
remains mildly depressed. There is a ring prosthesis in the
tricuspid position. TR is mild. The remaining study is unchanged
from the prebypass period.
Brief Hospital Course:
The patient was admitted one day prior to surgery for
pre-admission testing and heparin bridge. She was brought to
the operating room on [**2187-12-18**] where she underwent mitral valve
repair and tricuspid valve repair with Dr. [**Last Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition on neo and propofol
for recovery and invasive monitoring. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. She
was neurologically intact and hemodynamically stable on no
inotropic or vasopressor support. Chest tubes and pacing wires
were discontinued without complication. Coumadin was resumed
for atrial fibrillation. She was diuresed toward her
preoperative weight and beta-blockade was initiated. She does
have a history of chronic pleural effusions, and this was
closely followed by CXR following removal of chest tubes.
Diuresis was adjusted accordingly for pleural effusions and
significant lower extremity edema. She will follow up in one
week with a chest x-ray. The patient progressed without
complication, and was cleared by Dr. [**Last Name (STitle) **] for discharge to
**** on POD ******.
Medications on Admission:
Cardizem CD 120mg QD
Lasix 40mg 5x/day
Synthroid 75mcg QD
Metformin 500mg qd
Metoprolol XL 100mg QD
KCl 10mEq QD
Simvastatin 20mg qd
Diovan 80mg QD
Coumadin 2.5mg QD- last dose [**2187-12-12**]
levaquin 750mg daily- started at [**Hospital3 **] [**2187-12-14**]- unknown
infectious process
Discharge Medications:
1. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
dose will change daily for goal INR 2-2.5, Dr. [**Last Name (STitle) **] to
manage.
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*2*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Mitral Regurgitation
Congestive heart failure,
recurrent effusions s/p thoracentesis x 4
Moderate pulmonary hypertension
Atrial Fibrillation (on Coumadin)
Diabetes Mellitus
Hypertension
Hyperlipidemia
Hypothyroidism
?COPD
Colon Cancer s/p resection
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] Thursday, [**2188-1-17**] 1:15pm [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 19470**] in [**11-17**] weeks
Cardiologist Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8725**] in [**11-17**] weeks
CXR [**2187-12-31**] to follow up on pleural effusions, with film emailed
to [**University/College 86751**], for Dr. [**Last Name (STitle) **]
Completed by:[**2187-12-24**]
ICD9 Codes: 4240, 4280, 4168, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6025
} | Medical Text: Admission Date: [**2175-6-10**] Discharge Date: [**2175-6-20**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Ceftriaxone
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo female with hx of HTN, afib, ? PE, multiinfarct dementia
and recurrent UTI who presents with lethargy, hypoxia, and LE
erythema. Pt is aphasic at baseline. Per notes from ED and PCP
coverage, the patient was being treated for recurrent UTI with a
course of levofloxacin started on [**6-7**] but was otherwise doing
well. Last night she was noted to be more lethargic than normal
with increasing SOB. She was noted to be hypoxic with O2 Sats of
80% so was transferred to the ED.
In the ED she had a fever to 101.8 with intermittent hypoxia
that improved to 98% with 4LNS oxygen . She was given
Clindamycin 600mg IV x1 for LE cellulitis and a dose of
Levofloxacin 500mg IV for possible UTI. For her hypoxia, she was
given 20mg IV Lasix and a combivent neb with significant
improvement with CTA neg for PE and LENI neg for DVT. She
continued to have intermittent hypoxia of unclear etiology so
was transferred to the [**Hospital Unit Name 153**] for closer monitoring.
.
In the MICU, the patient was treated with CTX and Vanc for
UTI/cellulitis. Also diuresed. Patient improved and sent to
floor [**6-11**] on 2L NC. Patient noted to have increased Eos in
blood and urine so CTX stopped and placed on levo/macrodantin.
.
[**6-13**] Patient decompenstated on the floor. Patient desatted to
80's on 6L NC. ABG 7.46/52/63 on 6L NC. Patient initially with
HR in 80's. Patient given lasix 20mg IV x 1 and an alb neb. Then
went into afib with RVR into the 140's maintaining her pressure.
Patient given 5mg IV lopressor x 3 with out response in HR.
Transferred back unit for further mgt of HR and hypoxia, where
she was started on a diltiazem drip; CTA was without evidence of
PE. Course complicated by persistent hypotension requiring
multiple fluid boluses; this resolved after the discontinuation
of the diltiazem drip. She was started on an amiodarone load
with conversion into NSR. Her O2 sat improved with diuresis. A
picc line was placed and she was started on aztreonam (instead
of macrobid) for UTI. She was transferred back to the general
medical floor on [**2175-6-16**]. Currently, she has a new rash over her
trunk and arms bilaterally--thought to be from Ceftriaxone.
Past Medical History:
CVA-with multiinfarct dementia-aphasic at baseline
Afib
UTI
Zoster-L thorax
Syncope
PE
Hypothyroidism
DJD
Social History:
Divorced, lived alone in [**Location (un) 7349**] until fall at home with hip fx then
moved to NH here in [**Location (un) 86**] because son lives in [**Name (NI) 392**], had CVA
at [**Name (NI) **], never smoker, no ETOH, no illicits.
Family History:
NC
Physical Exam:
T 98 HR 93 BP 100/37 RR 24 O2Sat 99 (3LNC)
Gen: chronically ill, in bed listing to left side, NAD
HEENT: R nasolabial flattening, Edentulous, Dry MM,
Neck: JVP to mandible
Heart: regular with occasional premature beats, no MRG, no
heave, not parvus et tardus
Lungs: Marked kyphosis, Bilateral crackles throughout, decreased
breath sounds at R base- not dull to percussion.
Abd: soft, NT, ND, BS+
Extrem: 2+ LLE with erthema to midshin, 1+ RLE, 1+ DP pulses
bilaterally.
Neuro: expressive aphasia- unintelligable speech, follows verbal
commands "close your eyes" "wiggle your toes" Pupils 2-->1cm
bilaterally, arcus senilis, moving all 4 extremities.
Skin: Large 3x4cm SK's over thorax, crusted raised lesions in T4
distribution on Left back and chest.
Pertinent Results:
[**2175-6-10**] CT CHEST: 1. No evidence of acute pulmonary embolism,
aortic aneurysm, or dissection.
2. No evidence of pneumonia.
3. Midthoracic vertebral body compression fracture likely
chronic.
4. Calcified left lung granuloma and mediastinal lymph node
consistent with old granulomatous disease, such as tuberculosis.
5. Moderate-sized hiatal hernia.
.
[**2175-6-10**] BILAT LOWER EXT VEINS: No evidence of DVT.
.
[**2175-6-10**] CT HEAD: Slightly limited study by patient motion, but
no intracranial hemorrhage is identified.
.
[**2175-6-10**] CXR: No evidence of pneumonia or CHF.
.
[**2175-6-10**] ECG: Technically difficult study
Sinus tachycardia
Left ventricular hypertrophy
Early R wave progression
Lateral ST-T changes are probably due to ventricular hypertrophy
Clinical correlation is suggested
No previous tracing available for comparison
.
[**2175-6-13**] CTA CHEST: 1. No pulmonary embolism.
2. Right lower lobe atelectasis/consolidation with tiny
bilateral pleural effusions.
3. Moderate hiatal hernia.
4. Unchanged calcified mediastinal lymph node.
.
[**2175-6-13**] CXR: Small bilateral pleural effusions without overt
CHF/pulmonary edema and no evidence for new pneumonia. Calcified
granuloma and node on left. Osteoporosis of spine with
compression fractures.
.
[**2175-6-13**] ECG: Sinus rhythm @ 78 with atrial premature beats. Left
ventricular hypertrophy. Since the previous tracing of [**2175-6-10**]
probably no significant change, although baseline artifact on
both tracings makes comparison difficult. TRACING #1
.
[**2175-6-13**] ECG: Atrial fibrillation with a rapid ventricular
response. Left ventricular hypertrophy. Non-specific ST-T wave
changes. Since the previous tracing of [**2175-6-13**] atrial
fibrillation and ST-T wave changes are present. TRACING #2
.
[**2175-6-14**] FLUORO: Successful repositioning of the right-sided PICC
which now terminates in the distal SVC. Line is ready for use.
.
[**2175-6-14**] ECHO: The left atrium is mildly dilated. The estimated
right atrial pressure is 16-20 mmHg. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF 70-80%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Impression: hypertrophic, hyperdynamic left ventricle
.
[**2175-6-16**] CXR: Lung volumes have improved, borderline interstitial
edema decreased, heart size normal, but left atrium likely
enlarged. Stable pulmonary vascular congestion. Small right
pleural effusion may also have decreased. Leftward tracheal
deviation just above the thoracic inlet is due to tortuous head
and neck vessels.
.
[**2175-6-11**] 8:35 am URINE Source: Catheter.
URINE CULTURE (Final [**2175-6-12**]): NO GROWTH.
.
[**2175-6-10**] 03:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2175-6-10**] 03:15AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2175-6-10**] 03:15AM URINE RBC-[**7-23**]* WBC->50 Bacteri-RARE Yeast-NONE
Epi-[**4-17**]
[**2175-6-12**] 06:31PM URINE Eos-POSITIVE
[**2175-6-11**] 08:35AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2175-6-11**] 08:35AM URINE Blood-LGE Nitrite-NEG Protein-100
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2175-6-11**] 08:35AM URINE RBC-88* WBC-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2175-6-10**] 03:15AM BLOOD WBC-17.6* RBC-3.73* Hgb-11.3* Hct-34.2*
MCV-92 MCH-30.4 MCHC-33.1 RDW-13.8 Plt Ct-229
[**2175-6-10**] 03:15AM BLOOD Neuts-84* Bands-9* Lymphs-2* Monos-2
Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2175-6-10**] 03:15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Stipple-OCCASIONAL
[**2175-6-10**] 03:15AM BLOOD Plt Ct-229
[**2175-6-10**] 03:15AM BLOOD Glucose-144* UreaN-19 Creat-0.8 Na-138
K-4.5 Cl-99 HCO3-30 AnGap-14
[**2175-6-10**] 03:15AM BLOOD ALT-11 AST-21 AlkPhos-101 Amylase-23
TotBili-0.4
[**2175-6-10**] 03:15AM BLOOD Lipase-17
[**2175-6-10**] 03:15AM BLOOD CK-MB-2 cTropnT-0.03*
[**2175-6-10**] 10:30AM BLOOD CK-MB-NotDone proBNP-1148*
[**2175-6-10**] 10:30AM BLOOD cTropnT-0.03*
[**2175-6-10**] 04:41PM BLOOD CK-MB-2 cTropnT-0.03* proBNP-1259*
[**2175-6-10**] 03:15AM BLOOD Albumin-3.6 Phos-3.4 Mg-2.1
[**2175-6-10**] 11:55AM BLOOD Type-ART pO2-101 pCO2-49* pH-7.43
calTCO2-34* Base XS-6 Intubat-NOT INTUBA
[**2175-6-10**] 03:34AM BLOOD Lactate-1.9
.
[**2175-6-11**] 10:15AM BLOOD WBC-10.2 RBC-3.35* Hgb-10.5* Hct-31.9*
MCV-95 MCH-31.2 MCHC-32.8 RDW-13.1 Plt Ct-211
[**2175-6-11**] 10:15AM BLOOD Neuts-73.5* Lymphs-12.2* Monos-1.0*
Eos-12.2* Baso-0 Atyps-1.0*
[**2175-6-11**] 10:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2175-6-11**] 10:15AM BLOOD PT-14.3* PTT-32.3 INR(PT)-1.3*
[**2175-6-11**] 10:15AM BLOOD Plt Smr-NORMAL Plt Ct-211
[**2175-6-11**] 05:54AM BLOOD Glucose-95 UreaN-15 Creat-0.6 Na-140
K-3.6 Cl-101 HCO3-31 AnGap-12
[**2175-6-11**] 05:54AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.2
.
CT Head
FINDINGS: There is no intracranial hemorrhage, mass effect,
hydrocephalus, or shift of normally midline structures.
Ventricular prominence is unchanged, consistent with moderate
cortical atrophy. Focal hypodensities in the left parietal lobe,
coronal radiata, and frontal lobe are unchanged, representing
chronic infarction. More diffuse hypodensities in the
periventricular white matter are unchanged, and most consistent
with chronic small vessel ischemic disease. Surrounding osseous
and soft tissue structures are unremarkable.
.
IMPRESSION: No significant change since [**2175-6-10**]. Unchanged
appearance of several left-sided chronic infarcts, and small
vessel ischemic disease. No intracranial hemorrhage.
.
[**2175-6-20**] 06:10AM 98 13 1.3* 141 4.0 100 36* 9
.
CXR [**6-19**]: IMPRESSION: Slight interval improvement in pulmonary
vascular congestion, otherwise no significant interval change.
Brief Hospital Course:
A/P: [**Age over 90 **] yo female with hx of HTN, afib, PE, multinfarct dementia
admitted with UTI, left leg cellulitis, and diastolic CHF;
course c/b AF with RVR.
.
#Diastolic CHF: initially due to infection, worsened by AF with
RVR and fluid resuscitation, was continued on Lasix with good
diuresis. Needs serial assesments of volume status/weights at
her nursing home with her lasix titrated accordingly.
Low dose ACE was added. No evidence of ACS. Lasix held on day
of d/c secondary to bump in Cr (.8-->1.3). Needs serial Chem 7
at her nursing home. Currently has minimal oxygen requirements.
.
#AF: Now in NSR on amiodarone and Lopressor 12.5 TID. Needs one
more week of Amio 200 [**Hospital1 **] then 200 mg daily. Poor
anticoagulation candidate given fall risk and advanced age.
.
#UTI: Pt has received 7 days of treatment (CTX, macrodantin,
aztreonam) for E. coli UTI; d/c'd aztreonam/ctx given rash.
.
#LLE Cellulitis: resolved with 10 days of vancomycin.
.
#Rash: suspect secondary to ceftriaxone or aztreonam. Resolving.
.
#Dementia: pt noted to be more somnolent on [**6-19**]; CT
head/ABG/toxic-metabolic w/u unrevealing. ?secondary to
benadryl (from rash) along with neurontin. Would avoid sedating
meds until MS completely back to baseline. No evidence of
recurrent infection.
Medications on Admission:
Ciprofloxacin 250mg [**Hospital1 **]
Amoxicillin 500mg PO tid ? d/c'ed
Lopressor 25mg tid
Lasix 40mg alt 20mg qd held
Neurontin 100mg [**Hospital1 **]
Levofloxacin 250mg qd-started on
Tylenol prn
Erythromycin eye ointment
Levalbuterol Nebs q6h prn
Nortryptilline 25mg qhs
MVI
Digoxin 0.125mg qd
KCl 10 meq qd
Celexa 10mg qd
Colace
Levothyroxine 50mcg qd
Macrodantin 50mg qid-completed
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 100 mg Tablet Sig: One (1) Tablet PO twice a day:
Pleaes hold for somnolence.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO every
eight (8) hours: hold for SBP <110 or HR <55 .
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Please
alternate with 20 mg daily
to start [**6-21**].
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
to begin after one week of [**Hospital1 **].
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing Facility
Discharge Diagnosis:
Left Lower Extremity Cellulitis
Urinary Tract Infection
Diastolic Dysfunction/Congestive Heart Failure
Atrial Fibrillation
Drug Rash
Secondary Diagnoses:
CVA-with multiinfarct dementia-aphasic at baseline
h/o Zoster-L thorax
Hypothyroidism
DJD
Discharge Condition:
Stable
Discharge Instructions:
Please come back to the emergency room should you develop any
fevers, chills, chest pain, shortness of breath, difficulty
thinking, or any other complaints.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] within the next two weeks.
ICD9 Codes: 5119, 5990, 4280, 4589, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6026
} | Medical Text: Admission Date: [**2117-6-18**] Discharge Date: [**2117-6-24**]
Date of Birth: [**2051-3-8**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Ace Inhibitors / Penicillins / Benzodiazepines
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Somnolence
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy x 2
Transthoracic Echocardiography
PICC Line Placement
Arterial line placement
Tracheal Intubation with eventual extubation
History of Present Illness:
66 yo F with history of DM2, portal HTN from EtOh cirrhosis,
prior right hepatectomy for HCC, and hx of encephalopathy who
was admitted to OSH this AM after being more somnolent this AM.
On arrival to OSH her vitals were 97.4, HR 68, BP 116/45, RR 12,
100% on RA, GCS 6. She was found to be "gurgling" with breathing
and was given etomidate, versed, propofol and intubated for
airway protection. Also received IV flagyl and levofloxacin, and
lactulose, and 2L NS. Her HCT was 20.3, Na 133, BUN/Cr 45/2.0.
Trop was elevated at 2.55 and ECG showing new lateral TWI.
Patient was transferred to [**Hospital1 18**] via [**Location (un) **] for management of
upper GIB.
.
Yesterday, per sister patient seemed more tired but went outside
in wheelchair and was interactive and oriented. She did not seem
confused. She has been unresponsive with encephalopathy in the
past in the setting of UTIs. Per the sister she has had chronic
"blood in stool" and has been getting "almost weekly"
transfusions for past 1 year.
.
In the emergency department, vitals were: HR 59, BP 104/57, RR
14, O2 100% on vent (AC 500x14+5). She received lactulose, ASA.
She got 5L NS, 50mcg fentanyl IV, 1g ceftriaxone and 1U RBCs.
HCT was 18.5 and Cr 1.8. NG tube initially did not show any
blood or coffee grounds but subsequently returned frank blood.
CXR was obtained and showed mild pulmonary edema without
consolidations. U/A was positive with 180 WBCs, many bacteria,
and large leuk.
.
Vitals prior to transfer to the floor were: HR 57, BP 105/51, RR
13, O2Sat 100% on PEEP 5 and FiO2 of 40%.
.
REVIEW OF SYSTEMS:
(+)ve:
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, palpitations, rhinorrhea, nasal congestion, cough,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
1. Cirrhosis c/b encephalopathy
2. Hepatocellular CA s/p resection
3. Diabetes
4. Hypertension
5. Congestive heart failure, EF 55% TTE [**2108**]
6. Coronary artery disease
7. Chronic kidney disease stage III baseline creatinine 1.4
8. s/p ORIF L hip
9. History of gluteal muscle bleed secondary to coagulopathy
10.Gastropathy
Social History:
The patient does not smoke. She did drink alcohol but has not
since developing liver disease. According to prior discharge
summaries she has not had any illicit drug use. She is a
resident of [**Location 582**] [**Location (un) 620**].
Family History:
Non-contributory.
Physical Exam:
On Admission:
VS: T 96, HR 65, BP 108/60, RR 8, 99%
GEN: intubated, does not open eyes or respond to verbal
commands, in no distress
HEENT: lateral eye movements, R pupil 4mm and reactive, L pupil
3mm and reactive, dry mucosa
NECK: supple, no cervical LAD, R IJ in place
PULM: anterior breath sounds symmetrical and clear, no rhonchi
or rales
CARD: nl S1/S2, no m/r/g
ABD: tense, non-distended, obese, no fluid wave appreciated,
sluggish BS, no grimace to deep palpation
EXT: 2+ pitting edema in upper and lower extremities, 1+ distal
pulses
SKIN: no rashes
NEURO: pupils anisicoric and reactive, patient withdraws to pain
On Discharge:
VS: T 98.3 HR 62, BP 116/56, RR 18, 99% RA
GEN: Anasarcous. Opens eyes spontaneously. No acute distress.
HEENT: Dry lips but wet mucuous membranes. PERRLA. No cervical
lymphadenopathy.
NECK: supple, no cervical LAD
PULM: Bilateral crackles up to midlung fields. No wheezes or
rhonchi appreciated.
CARD: Distant heart sounds. Normal S1/S2. No MRG apprecaited.
ABD: Large, soft obese abdomen. No shifting dullness
appreciated. NBS. Nontender to palpation
EXT: 3+ pitting edema in upper and lower extremities
bilaterally. Right PICC line in place. Right UE slightly more
swollen than left UE, with tenderness to pressure. No evidence
of erythema. 1+ radial/posterior tibial pulses.
GU: Foley in place (since admission- discharged on 6 days of
foley)
SKIN: no rashes noted.
NEURO: Alert and oriented to person and time. Confused to
place/hospital setting. Cannot do serial sevens or days of the
week backwards. No asterixis. Moving all extremities.
Pertinent Results:
Laboratory Data:
Trop/CK/MB:
[**2117-6-18**] 01:00PM BLOOD CK-MB-6 cTropnT-2.45*
[**2117-6-19**] 11:30AM BLOOD CK-MB-8 cTropnT-1.97*
[**2117-6-19**] 06:35PM BLOOD CK-MB-7 cTropnT-2.07*
[**2117-6-20**] 05:36AM BLOOD CK-MB-6 cTropnT-1.83*
CBC
[**2117-6-18**] 01:00PM BLOOD WBC-3.4* RBC-1.83* Hgb-6.3* Hct-18.5*
MCV-102* MCH-34.6* MCHC-34.1 RDW-21.8* Plt Ct-100*
[**2117-6-24**] 06:08AM BLOOD WBC-4.5 RBC-2.77* Hgb-9.5* Hct-26.7*
MCV-97 MCH-34.5* MCHC-35.7* RDW-21.3* Plt Ct-89*
COAGS
[**2117-6-18**] 01:00PM BLOOD PT-16.0* PTT-32.2 INR(PT)-1.4*
[**2117-6-24**] 06:08AM BLOOD PT-17.8* INR(PT)-1.6*
METABOLIC PANEL
[**2117-6-19**] 11:30AM BLOOD Glucose-256* UreaN-54* Creat-2.0* Na-137
K-5.0 Cl-112* HCO3-14* AnGap-16
[**2117-6-24**] 06:08AM BLOOD UreaN-32* Creat-1.4* Na-134 K-4.3 Cl-109*
HCO3-18* AnGap-11
[**2117-6-19**] 11:30AM BLOOD Calcium-7.8* Phos-4.3# Mg-1.9
[**2117-6-24**] 06:08AM BLOOD Phos-3.4 Mg-1.7
[**2117-6-20**] 06:59PM BLOOD freeCa-1.16
LIVER FUNCTION TESTS
[**2117-6-19**] 11:30AM BLOOD ALT-26 AST-32 CK(CPK)-108 AlkPhos-104
TotBili-1.8*
[**2117-6-24**] 06:08AM BLOOD ALT-22 AST-35 TotBili-1.6*
ABG'S
[**2117-6-18**] 02:36PM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5
FiO2-100 pO2-580* pCO2-19* pH-7.50* calTCO2-15* Base XS--5
AADO2-129 REQ O2-31 -ASSIST/CON Intubat-INTUBATED
[**2117-6-21**] 04:39PM BLOOD Type-[**Last Name (un) **] pO2-208* pCO2-34* pH-7.26*
calTCO2-16* Base XS--10
URINE TESTS
[**2117-6-18**] 01:00PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2117-6-21**] 10:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2117-6-18**] 01:00PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2117-6-21**] 10:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2117-6-18**] 01:00PM URINE RBC-3* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
[**2117-6-18**] 01:00PM URINE CastHy-6*
[**2117-6-18**] 01:00PM URINE WBC Clm-MANY
[**2117-6-21**] 10:00AM URINE Hours-RANDOM UreaN-665 Creat-56 Na-51
K-15 Cl-36 HCO3-LESS THAN
[**2117-6-21**] 10:00AM URINE Osmolal-451
MICROBIOLOGY
URINE ADDED TO 64689E [**2117-6-18**].
**FINAL REPORT [**2117-6-22**]**
URINE CULTURE (Final [**2117-6-22**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I 8 S
CEFAZOLIN------------- 8 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- 2 I <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- 8 R <=1 S
RADIOGRAPHIC/IMAGING DATA
Chest X-Ray [**2117-6-18**]
IMPRESSION: Mild pulmonary edema with small bilateral pleural
effusions.
Endotracheal tube and nasogastric tube are in standard
positions.
Chest X-Ray [**2117-6-20**]
Endotracheal tube and nasogastric tube have been removed. Heart
is mildly
enlarged, and is accompanied by mild pulmonary vascular
congestion. Small
right pleural effusion is present and has likely decreased in
size compared to
prior study, although positional differences limit comparisons.
Minor areas
of atelectasis are present at the lung bases, right greater than
left.
RUQ ULTRASOUND [**2117-6-19**]
RIGHT UPPER QUADRANT ULTRASOUND: Changes of right hepatectomy
are present.
The liver is coarsened and nodular, consistent with cirrhosis.
Again seen is
a 2.3 x 1.9 x 1.6 cm hypoechoic mass in segment III, with mild
peripheral
vascularity.
Normal flow and Doppler waveforms are seen in the main and left
portal veins,
with wall-to-wall hepatopetal flow. Color flow is also noted in
the hepatic
arteries, hepatic veins, and IVC. There is no intrahepatic or
common biliary
ductal dilation.
The pancreatic head and body are normal, and the tail is not
well visualized
due to shadowing bowel gas. The spleen is stably enlarged at
14.7 cm. There
is mild ascites, concentrated in the right lower quadrant.
IMPRESSION:
1. Cirrhosis post right hepatectomy, with patent main and left
portal veins.
2. 2.3-cm mass in segment III, concerning for HCC.
3. Splenomegaly.
4. Mild ascites.
EKG [**2117-6-21**]
Sinus bradycardia. QTc interval prolongation. Loss of R waves in
leads I, aVL and V3-V6 consistent with extensive anterolateral
myocardial
infarction, age undetermined but possibly acute. Compared to the
previous
tracing of [**2116-6-9**] these changes are present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
59 158 84 504/502 4 -138 165
EKG [**2117-6-22**]
Sinus bradycardia. Marked right superior axis. Consider a
lateral myocardial infarction. Q-T interval prolongation. T wave
abnormalities. Since the previous tracing of [**2117-6-21**] probably no
significant change from previously noted findings.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
55 164 84 518/509 50 -157 162
PICC LINE PLACEMENT
TECHNIQUE: Using sterile technique and local anesthesia, the
right basilic
vein was punctured under direct ultrasound guidance using a
micropuncture set. Hard copies of ultrasound images were
obtained before and immediately after establishing intravenous
access are on file. A peel-away sheath was then placed over a
guide wire and a double lumen PICC line measuring 43 cm in
length was then placed through the peel-away sheath with its tip
positioned in the SVC under fluoroscopic guidance. Position of
the catheter was confirmed by a fluoroscopic spot film of the
chest.
The peel-away sheath and guide wire were then removed. The
catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no
immediate
complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French
double lumen PICC line placement via the right basilic venous
approach. Final internal length is 43 cm, with the tip
positioned in SVC. The line is ready
to use.
ECHOCARDIOGRAPHY [**2117-6-22**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.3 m/s
Left Atrium - Peak Pulm Vein D: 0.6 m/s
Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *18 < 15
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.57
Mitral Valve - E Wave deceleration time: 140 ms 140-250 ms
Mitral Valve - [**Last Name (un) **]: 0.20 cm2
Mitral Valve - Regurgitation Volume: 29 ml
TR Gradient (+ RA = PASP): *43 mm Hg <= 25 mm Hg
Findings
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Severe regional LV systolic dysfunction. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate (2+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is severe regional left ventricular systolic
dysfunction with akinesis of the mid- and distal LV segments.
This most compatible with either LAD-territory myocardial
infarction or Takotsubo cardiomyopathy. The remaining segments
contract normally (LVEF = 25-30%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w LAD-territory infarction or Takotsubo
cardiomyopathy. Moderate mitral and tricuspid regurgitation.
Mild pulmonary hypertension.
Findings discussed with Dr. [**First Name8 (NamePattern2) 7306**] [**Last Name (NamePattern1) 805**] at 1550 hours on the
day of the study.
EGD [**2117-6-15**]
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Friability, erythema, congestion and mosaic appearance
of the mucosa with contact bleeding were noted in the stomach
body and antrum. These findings are compatible with hypertensive
gastropathy.
Duodenum:
Mucosa: Erythema and congestion of the mucosa were noted in the
second part of the duodenum.
Other
findings: No varices noted.
Impression: Gastritis, Duodenitis (Portal hypertensive
gastropathy)
No varices noted.
Otherwise normal EGD to third part of the duodenum
egd [**2117-6-18**]
Findings: Esophagus:
Contents: Clotted blood was seen in the lower third of the
esophagus.
Mucosa: Normal mucosa was noted in the whole esophagus.
Stomach:
Contents: Coffee ground heme was seen in the fundus.
Mucosa: Diffuse continuous congestion, erythema and mosaic
appearance of the mucosa with spontaneous bleeding were noted in
the antrum, stomach body and fundus. These findings are
compatible with severe portal hypertensive gastropathy.
Duodenum:
Mucosa: Normal mucosa was noted in the whole duodenum.
Impression: Normal mucosa in the whole esophagus
Blood clot in the lower third of the esophagus
Old blood in the fundus
Congestion, erythema and mosaic appearance in the antrum,
stomach body and fundus compatible with severe portal
hypertensive gastropathy
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
Additional notes: specimens: none
blood loss: none
final diagnosis: severe portal hypertensive gastropathy causing
GI bleed
The attending was present for the entire procedure
Brief Hospital Course:
# Upper GI bleed - Presented from OSH with HCT of 18. Required
a total of 6 red blood cell transfusion during her stay. EGD
was negative for varices, but did show Diffuse continuous
congestion, erythema and mosaic appearance of the mucosa with
spontaneous bleeding noted in the antrum, stomach body and
fundus compatible with severe portal hypertensive gastropathy.
Initially maintained on PPI on Octreotide drip. Allergic to
cephalosporins, so given ciprofloxacin for SBP prophylaxis in
presence of GIB. Outside of hospital, she has been on near
weekly blood transfusions for chronic slow GIB. Her baseline HCT
is around 30, and is around 26 prior to discharge. Colonoscopy
not perfromed in house. No melena, hematachezia, or hematemesis
in house.
*Follow daily CBC's, decrease frequency if stable
*Sufferred NSTEMI (see below). Should keep HCT greater than 25
to optimize coronary oxygen delivery.
*Please set up follow up with her [**Hospital1 882**] gastroenterologist,
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 75046**], within 1-2 weeks.
Encephalopathy - patient has many previous admissions for
hepatic encephalopathy which typically presents as
unresponsiveness. Likely precipitated by GI bleed and urinary
tract infection (see below). She was intubated for airway
protection at OSH prior to arrival at [**Hospital1 18**]. At home patient is
on lactulose and rifaximin. Became more alert/oriented after
lactulose administration and blood transfusions.
Patient was treated with lactulose 30 mg q3h, which was titrated
to 3 - 4 bowel movements daily. Continued home dose of
rifaximin. Her UTI was treated (see below). RUQ US showed
cirrhosis post right hepatectomy, with patent main and left
portal veins. Incidenetally, 2.3-cm mass in segment III was
seen concerning for HCC (see below). Splenomegaly and mild
ascites was also identified.
*Continue lactulose administration to titrate to [**4-16**] bowel
movements per day.
*Continue Rifaxamin dosing
*Note, patient had Non-Gap metabolic acidosis after leaving the
ICU, probably from fluid boluses with NS and diarrhea from
lactulose. Consider non-saline IVF repletion if necessary and
having diarrhea.
Urinary tract infection- Patient has history of UTIs, no
previous culture date available in online medical record. U/A
positive on admission. Started on IV ciprofloxacin for SBP ppx
as well as UTI treatment. Cultures grew out P.Mirabilis
with intermediate sensitivity to ciprofloxacin, and K.Pneumoniae
sensitivity to cipro. Please note, has documented cephalosproin
allergy.
*Please perform UA and UCx prior to cessation of ciprofloxacin
(last day [**2117-7-3**])
NSTEMI - Trop elevated to 2.55 at OSH with CK 58, new lateral
TWI in V3-6 and AvL with no ST-T changes. Likely in setting of
demand from acute GI bleed as well as documented history of
coronary artery disease. Troponin trended 2.45 to 1.97 to 2.07,
CK and MB remained flat. Patient was not started on
antithrombotic therapy due to GI bleed. TTE showed anterior
wall akinesis as well as worsening depression in EF to 25-30%.
Restarted propanolol for beta blockade/portal hypertension, and
started losartan 12.5 mg as well as pravastatin 40 mg qhs. Also
on spironolactone for diuresis.
*Please continue above medications. Please note patient has a
documented allergy history to ACE-I.
*Patient has severe anasarca from fluid boluses. Will need
daily diuresis and monitoring of Ins/Outs until achieves
euvolemia. Also need to monitor renal function and
electrolytes. Currently on Furosemide 40 mg po daily as well as
spironolactone 25 mg daily. [**Month (only) 116**] want to increase if patient
requiring additional diuretic boluses. Was on 50 mg of
spironolactone prior to admission.
EtOH cirrhosis - history of right hepatectomy for HCC, hepatic
encephalopathy and portal hypertension with portal gastropathy.
No fluid wave appreciated on exam and encephalopathy as above
likely due to acute GI bleed and UTI. Continued thiamine and
folic acid. Continued lactulose and rifaxamin for hepatic
encephalopathy. Baseline mental status is mild to moderately
confused, with occassional visual hallucinations
(puppies/putting away jewlry)
*Regarding US liver lesion, patient is aware and says it has
been biopsied at [**Hospital1 2025**] in [**Location (un) 86**] [**State 350**] and is non
cancerous. Please reference [**Hospital1 2025**] hepatologists for further
details.
*Monitor LFTs
Diabetes Mellitus II: Discontinued original NPH insulin and
transitioned to Glargine Insulin while in house. Glucoses
marginally controlled. Increased Glargine to 20 U qhs and also
increased sliding scale (please reference medication list)
*Check for appropriate glucose control and increase long
acting/SSI prn
T12/L1 compression fracture: Seen on radiographic imaging from
prior hospitalization. Should wear TLSO brace while ambulating.
Goals of care- patient has had progressive decline in function
and is not a transplant or TIPS candidate. She has recurrent
severe encephalopathy with multiple prior admissions. Per sister
they have discussed with patient goals of care. Family meeting
occurred prior to discharge resulted in patient requesting to be
full code. Should continue to have ongoing discussion as most
likely will continue to need frequent hospital readmissions
given patient's multiple comorbidities.
Given overall poor prognosis and poor functional status, need to
discuss limitations of treatments without transplant.
*Should attempt to have repeated goals of care discussions with
the patient and family as will most likely require frequent
repeated hospitalizations based on morbidity of current illness.
TRANSITIONAL ISSUES: Please see asterisks with individual
issues.
PENDING LABS: None
Medications on Admission:
lactulose 10 gram/15 mL Syrup 30ml QID
rifaximin 550 mg [**Hospital1 **]
thiamine HCl 100 mg daily
folic acid 1 mg daily
propranolol 40 mg [**Hospital1 **]
venlafaxine 37.5 mg [**Hospital1 **]
aripiprazole 5 mg daily
omeprazole 40 mg [**Hospital1 **]
Lasix 40 mg daily
spironolactone 50 mg daily
Klonopin 0.5 mg qhs
NPH insulin human recomb 100 unit/mL 35 units [**Hospital1 **]
insulin lispro 100 unit/mL per sliding scale
Iron (ferrous sulfate) 325 mg daily
multivitamin
ergocalciferol (vitamin D2) 50,000 unit weekly
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
7. insulin glargine 100 unit/mL Solution Sig: Twenty (20)
Subcutaneous at bedtime.
8. insulin lispro 100 unit/mL Solution Sig: Per sliding scale
Subcutaneous qachs: BRKFAST,LNCH,DNER SSI
101-150 3 Units
151-200 5 Units
201-250 7 Units
251-300 9 Units
301-350 11 Units
351-400 13 Units
BEDTIME SSI
101-150 0 Units
151-200 2 Units
201-250 3 Units
251-300 4 Units
301-350 5 Units
351-400 6 Units
.
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP<100.
10. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold
for SBP<100.
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Please continue up to and including [**2117-7-3**]
for total 2 week treatment of complicated UTI. Please renally
dose with changes in renal function.
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. multivitamin Tablet Sig: One (1) 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. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
17. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Hepatic Encephalopathy
Non-ST Elevation Myocardial Infarction
Urinary Tract Infection
Gastrointestinal Bleed
.
Secondary:
1. Cirrhosis
2. Hepatocellular cancer status post resection
3. Diabetes
4. Hypertension
5. Coronary artery disease
6. Chronic kidney disease stage III baseline creatinine 1.4
7. Gastropathy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 40860**],
You presented to the hospital due to being more somnolent.
You were found to have multiple issues, including a
gastrointestinal bleed, a urinary tract infection, and you also
sufferred a heart attack. You were evaluated in the cardiac ICU
then transferred to the Liver service.
You had an endoscopy performed which did not show any evidence
of acute bleeding, but rather slow oozing bleeds in your
stomach.
Your heart attack was medically managed as best possible, but
given your risk for bleeding we do not suggest you take a daily
aspirin. Your urinary tract infection was treated with
antibiotics.
You had imaging of your heart after your heart attack which
showed compromised function, giving you a diagnosis of systolic
heart failure. You will need to take some new medications to
help your heart.
You were also found to have compound fractures in your back
requiring a brace for you to wear when you walk around. Please
work with physical therapy to help gain your strength.
Lastly, you were given lots of fluids when you came to the
hospital to keep your blood pressure up. You will require
medication to help urinate off the extra fluid that has
accumulated in your body over the last several days.
Some of your medications have changed.
1) We have DECREASED your dosing of Omeprazole 40 mg [**Hospital1 **] to 20
mg [**Hospital1 **].
2) We have DECREASED you dose of spironolactone from 50 mg daily
to 25 mg daily.
3) Please STOP taking your Klonopin 0.5 mg at night
4) We have changed your Insulin. Please STOP taking NPH insulin
human recomb 100 unit/mL 35 units twice a day. Please START
taking Glargine Insulin 20 U at night with Insulin lispro 100
unit/mL per sliding scale
5) Please DECREASE your propanolol from 40 mg twice a day to 10
mg twice a day
6) Please START taking pravastatin 40 mg at night
7) Please START taking losartan 12.5 mg daily.
8) Please CONTINUE to take your antibiotic ciprofloxacin up to
an including [**2117-7-3**]
9) Please STOP taking your venlafaxine 37.5 mg twice a day
10) Please STOP taking aripiprazole 5 mg daily.
Please continue to take the rest of your medications as
prescribed.
.
While in the hospital, you had a family meeting with your
medical team and your sister. [**Name (NI) **] understand that you are not a
surgical candidate for liver transplant. You determined that
you would like to continue with medical therapy and physical
rehab, and rehospitalizations if necessary. You will be going
to physical therapy for strengthening.
.
It has been a pleasure taking care of you Ms. [**Known lastname 40860**]!
this AM. On arrival to OSH her vitals were 97.4, HR 68, BP
116/45, RR 12, 100% on RA, GCS 6. She was found to be "gurgling"
with breathing and was given etomidate, versed, propofol and
intubated for airway protection. Also received IV flagyl and
levofloxacin, and lactulose, and 2L NS. Her HCT was 20.3, Na
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You have the following follow up appointments:
Department: ORTHOPEDICS
When: FRIDAY [**2117-7-9**] at 9:05 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: FRIDAY [**2117-7-9**] at 9:25 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5990, 2762, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6027
} | Medical Text: Admission Date: [**2151-3-26**] Discharge Date: [**2151-4-13**]
Date of Birth: [**2082-11-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Keflex / Diovan /
Ciprofloxacin / Ace Inhibitors / Quinine / Levaquin / Novocain /
Lidocaine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dsypnea and fatigue
Major Surgical or Invasive Procedure:
[**2151-4-2**] - 1. Redo sternotomy with aortic valve replacement with
a 19-mm St. [**Hospital 923**] Medical Biocor Epic Supra tissue heart valve.
2. Mitral valve replacement, 27-mm St. [**Hospital 923**] Medical Biocor Epic
tissue valve.
[**2151-3-26**] - Cardiac catheterization
History of Present Illness:
68F w/CAD s/p CABG '[**39**](LIMA/LAD, SVG/OM1, SVG/RCA) c/b occlusion
of LIMA/LAD graft s/p DES to LAD '[**46**], NSTEMI due to LAD in-stent
stenosis [**2-22**] s/p repeat DES, recurrrent NSTEMI during HD run
[**2-23**] in context of LGIB & cath demonstrating patent vein grafts
&
LAD stent and an echo indicating moderate to severe aortic
stenosis ([**Location (un) 109**] 0.8-1.0) at that time who is seen today as an
inpatient consultation to evaluate her appropriateness for
AVR/MVR. Had recent episode of sub-sternal chest pain after HD;
responsive to SLNTG. Sent to ED for eval and subsequently to
cath
lab.
Past Medical History:
IDDM
CAD, s/p CABG
CHF
ESRD on hemodialysis Tues, Thurs and Sat
Anemia
PVD, s/p right BKA
Irritable bowel syndrome
Diverticulitis
Social History:
Patient lives iwth her daughter and son-in-law as well as
granddaughter. She does not work. She reports recent significant
stressors as 2 family members have died in the last month and a
great-grandaughter was born.
Tobacco: smoked as a teenager
EtOH: rare glass of wine
Drugs: denies
Family History:
Mother died of colon ca; she also had diabetes. Father died of
heart disease.
Physical Exam:
Pulse: 68 BP: 100/46 Resp: 16 O2 sat: 97/2L
Height: Weight:
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [] Full ROM [x]
Chest: Lungs clear bilaterally [ ] bibasilar crackles
Heart: RRR [] Irregular [] Murmur [x] III/VI at base > neck
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [] R BKA
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: palp
DP Right: na Left: -
PT [**Name (NI) 167**]: na Left: -
Radial Right: na Left: palp
Carotid Bruit obscured by murmur
Pertinent Results:
[**2151-3-26**] Cardiac Catheterization
1. Two vessel coronary artery disease.
2. Patent native LAD, SVG-OM, and SVG-RCA unchanged from prior.
3. Severe aortic stenosis.
4. Severe mitral regurgitation.
5. Mild systolic ventricular dysfunction.
6. Elevated biventricular filling pressures.
7. Severe pulmonary hypertension.
[**2151-4-2**] ECHO
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. The left ventricular cavity size is
normal. There is mild global left ventricular hypokinesis (LVEF
= 45 %). The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. There are simple atheroma in the
ascending aorta. 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. The mitral valve leaflets are moderately thickened. There
is severe mitral annular calcification. There is severe
thickening of the mitral valve chordae. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is no pericardial effusion.
[**2151-3-30**] Carotid duplex ultrasound
Impression: Right ICA stenosis <40%. Left ICA stenosis <40%.
Pre-op:
[**2151-3-26**] 09:49PM GLUCOSE-196* UREA N-55* CREAT-5.7*#
SODIUM-135 POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-22 ANION GAP-23*
[**2151-3-26**] 09:49PM CK(CPK)-28*
[**2151-3-27**] 06:50AM BLOOD WBC-9.0 RBC-3.25* Hgb-11.0* Hct-33.0*
MCV-102* MCH-33.9* MCHC-33.4 RDW-14.5 Plt Ct-213
[**2151-3-27**] 06:50AM BLOOD Plt Ct-213
[**2151-3-26**] 09:49PM BLOOD Glucose-196* UreaN-55* Creat-5.7*# Na-135
K-5.0 Cl-95* HCO3-22 AnGap-23*
[**2151-3-27**] 06:50AM BLOOD ALT-5 AST-15 CK(CPK)-22* AlkPhos-99
[**2151-3-27**] 06:50AM BLOOD CK-MB-NotDone cTropnT-0.28*
[**2151-3-27**] 06:50AM BLOOD %HbA1c-6.0* eAG-126*
[**2151-3-29**] 06:25AM BLOOD PTH-559*
Post-op:
[**2151-4-13**] 03:51AM BLOOD WBC-11.8* RBC-2.91* Hgb-9.7* Hct-31.0*
MCV-107* MCH-33.2* MCHC-31.1 RDW-21.8* Plt Ct-335
[**2151-4-13**] 03:51AM BLOOD Plt Ct-335
[**2151-4-13**] 03:51AM BLOOD Glucose-181* UreaN-43* Creat-5.0* Na-132*
K-4.7 Cl-90* HCO3-30 AnGap-17
Radiology Report CHEST (PORTABLE AP) Study Date of [**2151-4-7**] 5:22
PM
Final Report
CHEST RADIOGRAPH
INDICATION: Triple lumen change over wire, evaluation of line
placement.
COMPARISON: [**2151-4-5**].
FINDINGS: As compared to the previous examination, the right
central venous introduction sheath has been removed and
exchanged against a central venous access line. The tip of this
access line projects over the leads of the pacemaker and is
difficult to visualize but appears to be positioned at the
inflow tract of the right atrium.
No evidence of complications, notably no pneumothorax.
Subtle increase of bilateral basal opacities. Unchanged size of
the cardiac silhouette.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION
EVALUATION:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with Radiology. Thin liquid,
Nectar-thick
liquid, and pureed consistency barium were administered. Results
follow:
RECOMMENDATIONS:
1. PO diet: soft solids, thin liquids
2. PO meds whole with thin liquids as tolerated
3. TID oral care
4. Strict aspiration precautions including:
a) sit fully upright for all PO intake
b) alternate between bites and sips to clear oropharynx
c) swallow twice per bite as needed to clear oropharynx
d) swallow-cough-swallow with ALL liquids including when
taking meds
5. ENT eval in if vocal quality does not continue to improve
6. Swallow follow up in rehab setting to ensure tolerating diet,
re-assess need for swallow-cough-swallow maneuver.
These recommendations were shared with the patient, the nurse
and
the medical team.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 77062**] M.S., CCC-SLP
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2151-3-26**] for work up of
her chest pain during hemodialysis. She underwent a cardiac
catheterization which revealed two vessel coronary artery
disease with patent grafts froom her previous bypass syrgery.
Severe aortic stenosis and mitral regurgitation were also noted.
Given the severity of her valvular disease, the cardiac surgical
service was consulted for evaluation for redo surgery. She was
accepted for AVR/MVR and on [**4-2**] she was brought to the
operating room for aortic and mitral valve replacement. Please
see OR report for details, in summmary she had: 1. Redo
sternotomy with aortic valve replacement with a 19-mm St. [**Hospital 923**]
Medical Biocor Epic Supra tissue heart valve.
2. Mitral valve replacement, 27-mm St. [**Hospital 923**] Medical Biocor Epic
tissue valve.
She tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
She was sedated through the night on the surgical day, the
following day see awoke and followed commands but remained
intubated as she was somewhat lethargic and she needed to have
hemodialysis prior to extubation to support her pulmonary
status. She was dialyzed on a daily basis and was ultimately
extubated on POD3. She remained hemodynamically stable
throughout this period. On POD4 she was transferred from the ICU
to the stepdown floor for further recovery.
She made slow progress in her physical activity and was
transferred to rehabilitation at [**Hospital1 2670**] Care and Rehab in
[**Location (un) 5871**],MA on POD 11
Medications on Admission:
Plavix 375mg today,
aspirin 324mg today
lopressor 25mg,
TUMS,
NTP (held),
Insulin sliding scale,
celexa,
Lantus at hs,
prilosec,
renagel,
vitamin C,
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAC&HS.
11. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
SunbridgeCare and Rehab for [**Location (un) 5871**]
Discharge Diagnosis:
Aortic valve stenosis s/p AVR
Mitral valve regurgitation s/p MVR
s/p CABG '[**39**](LIMA/LAD, SVG/OM1, SVG/RCA) c/b occlusion
of LIMA/LAD graft s/p DES to LAD '[**46**], NSTEMI due to LAD in-stent
stenosis [**2-22**] s/p repeat DES,
CHF(EF50% 2/09)
HTN
hyperlipidemia,
IDDM2
ESRD on HD(Tu-Th-Sa)
Anemia
Irritable bowel syndrome
Diverticulitis
PAD s/p R BKA
Discharge Condition:
Alert and oriented x3 nonfocal
s/p BKA: prostetic device not yet fitting stump, unable to
ambulate
Sternal pain managed with percocet prn
Sternal wound healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) **] [**2151-5-13**] @ 1PM [**Telephone/Fax (1) 170**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Please call to schedule appointments:
Primary Care Dr. [**Last Name (STitle) 77063**]([**Telephone/Fax (1) 8539**]) in [**1-16**] weeks
OUTPATIENT CARDIOLOGIST: [**Location (un) 24344**] [**Telephone/Fax (1) 77064**] in [**2-17**] weeks
Completed by:[**2151-4-13**]
ICD9 Codes: 5856, 2762, 4280, 4168, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6028
} | Medical Text: Admission Date: [**2164-5-23**] Discharge Date: [**2164-6-20**]
Date of Birth: [**2092-5-28**] Sex: F
Service: VASCULAR SURGERY
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-old
white female with diabetes, hypertension, chronic low back
pain, who was evaluated by her PCP in [**Name9 (PRE) 958**] for her back
pain. Plain films showed degenerative arthritis and an
abdominal aortic aneurysm. CT scan of the abdomen done at
[**Hospital1 **] confirmed a 4.9 cm AAA. The patient was
referred to Dr. [**Last Name (STitle) 1391**] for further treatment.
The patient's back pain has been controlled with Vicodin but
has worsened her preexisting constipation. The patient
complained of bilateral band-like upper abdominal pain, worse
with movement of her arms. She has also decreased her oral
intake due to abdominal discomfort. She was admitted for
further treatment.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Chronic low back pain.
PAST SURGICAL HISTORY:
1. Bilateral carpal tunnel release.
2. Cataract extraction O.U.
ALLERGIES: Sulfa causes swelling.
ADMISSION MEDICATIONS:
1. Glyburide.
2. Verapamil.
3. Prilosec.
4. Zocor.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives alone. She quit smoking
tobacco about 15 years ago. She has approximately six
glasses of wine per week.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.2, pulse 74, respirations 18, blood pressure 174/75 on the
right, 171/75 on the left, 02 saturation equals 97% on room
air. General: Alert, cooperative white female in no acute
distress. HEENT: Sclerae anicteric. Neck: Supple. No
lymphadenopathy or thyromegaly. Carotids palpable. No
bruits. Chest: Heart revealed a regular rate and rhythm
without murmur. Lungs: Clear bilaterally. Abdomen: Soft,
distended, mild diffuse tenderness. Palpable aortic
aneurysm. Extremities: Feet equally warm. No edema. Pulse
examination: Carotid, radial, femoral pulses 2+ bilaterally.
Popliteal and dorsalis pedis pulses were 1+ bilaterally. PT
pulses have biphasic Doppler signals bilaterally.
Neurologic: Nonfocal.
LABORATORY/RADIOLOGIC DATA: Admission laboratories revealed
a WBC of 7.5, hematocrit 33.8, platelets 318,000, PT 12.6,
PTT 23.5, INR 1.0. Sodium 142, potassium 4.2, chloride 106,
C02 22, BUN 22, creatinine 1.1, glucose 68.
Chest x-ray showed no acute pulmonary disease, compression
deformities of the lower thoracic vertebra present.
EKG on [**2164-5-22**] showed a normal sinus rhythm at a rate of 77.
CT of the abdomen showed a 5 by 5 cm infrarenal AAA with
extension into both iliacs, left greater than right. No
leaking, no dissection.
HOSPITAL COURSE: The patient was initially evaluated in the
Emergency Room on [**2164-5-22**]. She was admitted to the Vascular
Surgical Service on [**2164-5-23**]. The Cardiology Service was
consulted for preoperative clearance. They ordered a
Persantine MIBI study which showed a moderate, reversible
anterior wall perfusion defect. They cleared the patient for
urgent surgery with careful hemodynamic perioperative
monitoring.
On [**2164-5-26**], the patient underwent abdominal aortic aneurysm
repair with Dacron graft. Postoperatively, the patient had
equally warm feet with pedal Doppler signals. In the early
afternoon of [**2164-5-26**], the patient developed a cold,
pulseless right leg with no palpable femoral pulse and no
Dopplerable pedal pulses.
The patient was taken to the Operating Room several hours
later where she underwent thrombectomy of the right
aortoiliac limb of her graft and had a right common iliac
artery to right common femoral artery bypass graft with
Dacron. Postoperatively, the patient had equally warm feet
and Doppler signals of the right DP and left DP/PT. The
patient was transferred to the SICU. The patient developed
significant oozing at her incision site and had required 8
units of packed red blood cells, 4 units of fresh frozen
plasma, 2 units of platelets and IV vitamin K for
coagulopathy. She received several doses of Kefzol
perioperatively. An epidural for pain control was removed on
postoperative day number two.
The patient was unable to be weaned and extubated.
The patient developed a low-grade fever. Blood cultures were
drawn. Sputum culture was sent. Stool for Clostridium
difficile was negative times three. On [**2164-6-4**], the patient
spiked to 103. She was jaundiced. A gallbladder ultrasound
was negative. Blood cultures showed gram-negative rods which
were later identified as Enterobacter cloacae. Initial
sputum culture grew Hemophilus and a repeat sputum culture
grew Enterobacter. Urine culture also grew Enterobacter.
Zosyn had been started and vancomycin had been added shortly
afterwards.
The patient completed a two week course of IV vancomycin and
subsequently will finish two weeks of oral levofloxacin.
Diuresis with Lasix was started in the hopes of removing 1-2
liters of fluid per day. The patient's preoperative weight
was 73 kilograms and postoperatively was 90 plus kilograms.
The patient responded well to Lasix. She was finally able to
be extubated on [**2164-6-15**], postoperative day number 20.
The patient was started on TPN during her prolonged
intubation. She was then started on Trophik tube feedings
via postpyloric Dobbhoff catheter. The patient was started
on clear liquids on [**2164-6-17**]. She did extremely well and her
feeding catheter was removed the following day. She was able
to tolerate a house diet over the next 24 hours without
difficulty and was ready for discharge.
Staples from surgical incision were removed on [**2164-6-16**].
Physical Therapy evaluated the patient and recommended
[**Hospital 3058**] rehabilitation initially. However, the patient
was anxious to be discharged to the home of her sister
in-law. Physical Therapy reassessed the patient and felt
that she would be safe to go home but recommended physical
therapy at home.
At the time of discharge, the patient's surgical incisions
were clean, dry, and intact. She had palpable dorsalis pedis
pulses bilaterally.
While on tube feedings, the patient had been started on 10
units of NPH insulin b.i.d. in addition to her Glyburide 5 mg
p.o. q.d. After resuming a normal diet, the patient had low
blood sugars and the NPH insulin was discontinued. The
patient was instructed to continue taking her Glyburide 5 mg
p.o. q.d. and following up with her primary care physician
within [**Name Initial (PRE) **] week after discharge from the hospital to reassess
her blood sugar control.
The patient was instructed to follow-up with Dr. [**Last Name (STitle) 1391**] in
the office in two weeks by calling the office for an
appointment.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg p.o. q.d. for 11 days to finish a two
week course.
2. Glyburide 5 mg p.o. q.d.
3. Lopressor 50 mg p.o. t.i.d.
4. Simvastatin 10 mg p.o. q.d.
5. Timolol 0.25% ophthalmic solution one drop O.U. b.i.d.
6. Tylenol 325-650 mg p.o. q. four to six hours p.r.n.
DISPOSITION: Home with home physical therapy.
CONDITION ON DISCHARGE: Satisfactory.
PRIMARY DIAGNOSIS:
1. Abdominal aortic aneurysm.
2. Abdominal aortic aneurysm resection with aortobi-iliac
Dacron graft on [**2164-5-26**].
3. Thrombectomy, right limb of bypass graft and right
iliofemoral Dacron bypass graft on [**2164-5-26**].
SECONDARY DIAGNOSIS:
1. Blood loss anemia, status post transfusion.
2. Postoperative coagulopathy, treated.
3. Respiratory failure with prolonged intubation until
postoperative day number 20.
4. Enterobacter urosepsis.
5. Enterobacter pneumonia.
6. Postoperative malnutrition, treated with total parenteral
nutrition and tube feedings.
7. Jaundice, resolved.
8. Anasarca, treated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2164-6-22**] 07:24
T: [**2164-6-22**] 18:28
JOB#: [**Job Number 52144**]
ICD9 Codes: 5185, 5990, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6029
} | Medical Text: Admission Date: [**2145-7-30**] Discharge Date:
Date of Birth: [**2145-7-30**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 953**], twin number 2,
is a newborn, born at 31 and 2/7 weeks, admitted to the NICU
with respiratory distress and prematurity. He was born at
5:57 a.m. on [**2145-7-30**]. He was a 1520 gram product of a
31 and [**2-16**] week twin gestation. He was born to a 37 year-old,
Gravida III, Para 0, now II mother, with estimated date of
confinement of [**2145-9-29**]. Prenatal labs included blood type 0
positive, antibody negative, RPR non reactive, Rubella
immune, hepatitis B surface antigen negative and GBS unknown.
Pregnancy was Clomid induced. It was uncomplicated until
early in the morning of [**2145-7-30**] when mother presented
with abdominal pain, contractions and bleeding. Variable
decelerations were noted and due to persistent abdominal
pain, mother was taken for Cesarean section delivery for
concern for abruption. She received one dose of betamethasone
shortly before delivery. She did not receive intrapartum
antibiotics and membranes were intact at delivery. Twin 2
was in breech presentation and emerged with good tone and
spontaneous cry. He was resuscitated with stimulation and
blow-by oxygen and was brought to the NICU. Apgars were 9 and
9. In the NICU, moderate respiratory distress was noted and
he was begun on C-pap.
PHYSICAL EXAMINATION: Weight 1520 grams, 50th percentile.
Head circumference 29.5 cm, 50th to 75th percentile. Length
41 cm, 50th percentile. Vital signs: Temperature 97.3; heart
rate 180; respiratory rate 50; blood pressure 55/27 with a
mean of 37. Oxygen saturations 92 to 98% on C-Pap of 6 and
FI02 of 25 to 35%. In general, active, vigorous, premature
infant, responsive to exam, moderate respiratory distress.
Skin: Warm, pale, pink, bruises over right leg and feet, no
rash. HEENT: Fontanel soft and flat. Ears: Nares patent.
Palate intact. Positive red light reflex bilaterally. Neck
supple. Chest: Coarse, moderately aerated, moderate
retractions. Cardiac: Regular rate and rhythm, no murmur.
Femoral pulses 2+ bilaterally. Abdomen soft, no
hepatosplenomegaly, no masses, quiet bowel sounds. Three
vessel cord. Genitourinary: Normal male. Testes palpable in
inguinal canals bilaterally. Anus patent. Extremities:
Hips, back normal. Neuro: Appropriate tone and activity.
Intact Moro grasp.
HOSPITAL COURSE BY SYSTEMS: Baby [**Name (NI) **] [**Known lastname 953**] was initially
admitted to the NICU and placed on C-Pap. He remained on C-
Pap for several hours and then was transitioned to
conventional ventilator, SIMV where he received Surfactant x2
and was quickly extubated to C-Pap. He remained on C-Pap for
another 3 days and then was transitioned to nasal cannula.
Nasal cannula was discontinued on day of life #5 at which
point the patient was transitioned to room air. He has since
been in room air and has been doing well. He has completed a
5 day spell count of no apnea, bradycardia or desaturation.
At the time of discharge, his respiratory rate is anywhere
from the 30's to the 60's and his oxygen saturation is above
96%.
Cardiovascular: This infant does have a history of good
blood pressures and good heart rates throughout his hospital
stay. His heart rate has ranged anywhere from the 130s to
160s and blood pressure means have been anywhere from 45 to
55. He has not had a murmur and there has been no indication
for cardiac evaluation.
Fluids, electrolytes and nutrition: Initially, Baby [**Name (NI) **]
[**Known lastname 953**] was started on intravenous fluids. He has since
transitioned to gavage feeds and now he has full p.o. feeds
of breast milk and/or Similac 24 with a minimum of 150 cc per
kg per day. He averages anywhere between 160 and 190 cc per
kg per day. His discharge weight is 2570 grams. Discharge
height is 44.5 cm. Discharge head circumference is 33 cm.
Gastrointestinal: This infant was treated for
hyperbilirubinemia. His peak bilirubin was noted on day of
life #2 and was 6.9 over 0.3. phototherapy was discontinued
on day of life #5 with a rebound bilirubin of 5.5 over 0.3.
Hyperbilirubinemia now resolved.
Hematology: Admission hematocrit was 47.8. Most recent
hematocrit was performed on [**8-30**] and was 35.3 with a
reticulocyte count of 3.4%. he was not transfused throughout
this admission.
Infectious disease: Baby [**Known lastname 953**] is status post a sepsis
rule out on hospital day number #[**Serial Number **]. He did receive Ampicillin
and Gentamycin x 48 hours with all blood cultures negative to
date.
Neurology: Initial head ultrasound was performed on [**8-5**]
on day of life #7. This exam was normal. A subsequent head
ultrasound was performed on [**8-31**] and revealed two very
small choroid plexus cysts. Neurologic exam is appropriate
for gestational age. No further work-up deemed necessary by
the NICU team.
Sensory:
Audiology: Hearing screening was performed with automated
auditory brain stem responses. Baby [**Name (NI) **] [**Known lastname 953**] passed his
hearing screen on [**2145-9-5**].
Ophthalmology: Mature. Eyes were examined most recently on
[**2145-9-7**] revealing mature retinal vessels. A follow-
up exam is recommended in 9 months. Infant is recommended to
follow-up with Dr. [**Last Name (STitle) 36137**] of [**Hospital3 1810**] in 9
months time. Mother to schedule this appointment.
Psychosocial: [**Hospital1 18**] social work is involved with the family.
The contact social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
telephone number [**Telephone/Fax (1) 69395**].
CARE RECOMMENDATIONS: Baby [**Name (NI) **] [**Known lastname 953**] should continue on
his ad lib p.o. feeds of breast milk and/or Similac 24 with a
minimum of 150 cc/kg/day.
MEDICATIONS: The patient should continue on his Ferrous
sulfate 0.4 ml once daily.
CAR SEAT POSITION SCREENING: Passed on [**2145-9-7**].
STATE NEWBORN SCREEN STATUS: [**2145-8-5**], normal.
[**2145-8-20**], normal.
IMMUNIZATIONS RECEIVED: Hepatitis B #1 received on [**2145-8-27**].
IMMUNIZATIONS RECOMMENDED: 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 weeks and 35 weeks with two of
the following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP:
1. Infant is to follow-up with the primary care physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2145-9-9**] at 1:30 p.m.
Telephone number [**Telephone/Fax (1) 69395**].
2. VNA scheduled via Maximum Health Care, 1-[**Telephone/Fax (1) 69396**].
They should be meeting with the family on Friday,
[**9-10**] or Saturday, [**9-11**].
3. Early intervention should be arranged through Minuteman
Early Intervention Program of [**Location (un) 14753**]. Telephone number
[**Telephone/Fax (1) 43117**].
4. Ophthalmology: Follow-up is scheduled in 9 months due to
the last eye exam on [**2145-9-7**] revealing mature
retinal vessels bilaterally.
5. Breech presentation. Should have hip ultrasound at outpt.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Respiratory distress syndrome.
3. Rule out sepsis.
4. Hyperbilirubinemia.
5. Follow-up hip ultrasound due to breech presentation.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) 62404**]
MEDQUIST36
D: [**2145-9-7**] 12:36:49
T: [**2145-9-7**] 13:52:54
Job#: [**Job Number 69397**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6030
} | Medical Text: Admission Date: [**2162-10-26**] Discharge Date: [**2162-11-22**]
Date of Birth: [**2122-1-24**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
Central line placement x2, Intubation x3, Arterial line
placement x3, Removal of percutaneous gall bladder drain
History of Present Illness:
Patient is a 40 year old female with history of alcohol use,
pancreatitis, and hyperlipidemia who presented to [**Hospital1 3325**] on [**2162-10-25**] with abdominal pain. She reports that she
was feeling relatively well until the day prior to presentation,
when she developed nausea, vomiting, abdominal pain, and chills.
Her last meal prior to onset of the symptoms was spaghetti and
meatballs.
At [**Hospital3 3583**], she underwent a CT of her abdomen and
pelvis, which per report demonstrated findings consistent with
mild pancreatitis and a distended gallbladder with mild
"prominence" of the extrahepatic duct system. She then underwent
a RUQ ultrasound which demonstrated gallbladder wall thickening
and edema, with minimally dilated common bile duct, as well as
diffuse fatty infiltration of the liver. Per report, no stones
were noted, and no intrahepatic ductal dilatation was noted.
MRCP demonstrated dilated common duct without obstruction or
stone within the common duct.
She was hydrated aggressively, but the morning of [**10-26**], several
laboratory abnormalities were noted. Her creatinine bumped from
0.2 to 2.1 and her HCT also rose from 40 to 52, and she was
noted to be increasingly acidotic. She also had increased amount
of pain. She was noted to be mildly hypotensive, and there was
concern for cholangitis. A percutaneous gall bladder drain was
placed, with drainage of non-purulent bile.
Of note, her triglycerides came back at over 6300. Gram stain
and culture of the bile drained from the percutaneous tube are
pending.
Request for transfer was made for further management and
evaluation. Patient was Med Flighted over to [**Hospital1 18**].
Upon arrival to the floor, patient states she would like more
pain medication, but denied any concerns or complaints.
Past Medical History:
- Previous episode of pancreatitis, hospitalized at [**Hospital3 **]
- GERD
- Seasonal allergies
- Alcohol use
- Developmental disorder of her bones requiring multiple
surgeries on her lower extremities to remove bone fragments
- Status post Cesarian section
- Arthritis
Social History:
Patient is a single mother, has an 11 year old son who she is
very close with. She cites her mother, [**Name (NI) **], as her
preferred contact. She reports she enjoys drinking wine and
White Russians, and drinks several a week. According to the
chart from the outside hospital, it was noted that she drinks
daily. She could not further elaborate on the amount she drinks.
Her last drinks were the night prior to admission to the OSH (PM
of [**10-24**]).
She smokes "a few" cigarettes a week (less than a half pack
weekly). She was formerly employed at Linen's 'N Things, but
lost her job when the branch closed. She is looking for work at
present. No illicit drug use.
Family History:
Her mother has Lupus.
Physical Exam:
Temperature 98, Heart rate 110, Blood pressure 113/76, Oxygen
saturation 95% on 4L nasal cannula
General: Slightly diaphoretic and flushed, slightly lethargic
but fully arousable and appropriately converses.
HEENT: NC/AT. Dry MM, clear oropharynx. No scleral icterus or
conjunctival pallor. PERRL, EOMI.
Neck: Supple, flat JVP.
Cardiac: Tachycardic, regular, no rubs, murmurs, gallops
appreciated.
Lungs: Slightly decreased BS at bases, otherwise CTAB no w/r/r
Abdomen: Distended, tender to palpation without guarding or
rebound tenderness. +BS.
Extremities: Warm, good capillary refill, no c/c/e
Neurologic: A&Ox3, CN symmetric, moving all extremities without
difficulty.
Skin: No rashes or lesions, slightly flushed.
Pertinent Results:
LABS ON ADMISSION:
[**2162-10-26**] 10:18PM TYPE-ART PO2-84* PCO2-30* PH-7.38 TOTAL
CO2-18* BASE XS--5
[**2162-10-26**] 10:18PM GLUCOSE-141* LACTATE-1.5 NA+-137 K+-4.0
CL--111
[**2162-10-26**] 10:18PM freeCa-0.83*
[**2162-10-27**] 01:45AM BLOOD WBC-10.1 RBC-4.07* Hgb-14.3 Hct-41.6
MCV-102* MCH-35.0* MCHC-34.3 RDW-14.1 Plt Ct-197
[**2162-10-27**] 01:45AM BLOOD Neuts-88.6* Lymphs-8.0* Monos-2.1 Eos-1.0
Baso-0.2
[**2162-10-27**] 01:45AM BLOOD PT-14.3* PTT-47.6* INR(PT)-1.2*
[**2162-10-27**] 01:45AM BLOOD Glucose-124* UreaN-20 Creat-2.0* Na-137
K-4.1 Cl-113* HCO3-19* AnGap-9
[**2162-10-27**] 01:45AM BLOOD ALT-138* AST-219* LD(LDH)-638*
AlkPhos-172* Amylase-77 TotBili-1.1
[**2162-10-27**] 01:45AM BLOOD Lipase-112*
[**2162-10-27**] 01:45AM BLOOD Albumin-2.4* Calcium-6.6* Phos-2.1*
Mg-1.5*
[**2162-10-29**] 05:42AM BLOOD calTIBC-114* VitB12-GREATER TH Hapto-380*
Ferritn-763* TRF-88*
[**2162-10-27**] 01:45AM BLOOD Triglyc-2335*
LABS ON DISCHARGE:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
10.4 2.84* 9.0* 26.4* 93 31.7 34.1 14.3 590*
Glucose UreaN Creat Na K Cl HCO3 AnGap
81 7 0.8 133 3.6 97 27 13
Calcium Phos Mg
9.7 5.1* 2.1
MICROBIOLOGY:
Blood Culture, Routine (Final [**2162-11-2**]):
ENTEROCOCCUS FAECALIS. BETA LACTAMASE NEGATIVE.
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
gentamicin. Screen predicts NO synergy with penicillins
or
vancomycin. Consult ID for treatment options.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2162-10-27**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 247**] [**Last Name (NamePattern1) **] @ 2040 ON [**10-27**] - CC7D.
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
-----------
FROM PERCUTANEOUS TUBE BILE TEST.
**FINAL REPORT [**2162-10-30**]**
GRAM STAIN (Final [**2162-10-27**]):
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..
FLUID CULTURE (Final [**2162-10-30**]): NO GROWTH.
----------
Source: Endotracheal.
**FINAL REPORT [**2162-11-7**]**
GRAM STAIN (Final [**2162-11-4**]):
[**11-27**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2162-11-7**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. RARE GROWTH.
----------
[**2162-11-7**] 11:49 pm SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2162-11-10**]**
GRAM STAIN (Final [**2162-11-8**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2162-11-10**]):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
----------
Log-In Date/Time: [**2162-11-8**] 7:51 pm
BLOOD CULTURE
**FINAL REPORT [**2162-11-19**]**
Blood Culture, Routine (Final [**2162-11-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES REQUESTED BY [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Numeric Identifier 80005**] [**2162-11-17**]
09:00AM.
FINAL SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 2 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final [**2162-11-10**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2162-11-10**] 232PM.
GRAM POSITIVE COCCI IN CLUSTERS.
-----------
Log-In Date/Time: [**2162-11-9**] 5:58 am
BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
-----------
[**2162-11-11**] 2:50 pm CATHETER TIP-IV Source: picc.
**FINAL REPORT [**2162-11-13**]**
WOUND CULTURE (Final [**2162-11-13**]): No significant growth.
IMAGING STUDIES:
[**2162-10-26**] Chest X-ray:
IMPRESSION:
1. Right IJ central line ending in the right atrium. No
pneumothorax.
2. Low lung volumes and bibasilar atelectasis with bilateral
small pleural
effusions
[**2162-10-27**] Abdominal X-ray:
IMPRESSION: NG tube with tip in the stomach.
[**2162-10-29**]: CT Abdomen and Pelvis:
IMPRESSION:
1. New large bilateral pleural effusions with compressive
atelectasis.
2. New significant ascites.
3. Peristent pericholecystic fluid and port and cholecystostomy
tube with
patent appearing CBD. No calcified gall stones.
4. Homogenously enhancing pancreas with fluid and fat stranding
about it,
consistent with persistent pancreatitis.
[**2162-11-2**] Abdominal Ultrasound:
INDICATION FOR STUDY: Suspected bile leak in a patient with
cholecystostomy tube and pancreatitis.
A portable ultrasound examination was performed and compared
with the recent CT scan, which demonstrated fluid around the
liver. The portable study demonstrates no fluid around the liver
or in the right upper quadrant or right lower quadrant. For that
reason, a paracentesis was not performed.
IMPRESSION: No fluid identified. Therefore, paracentesis not
performed
[**2162-11-3**]: MRCP
IMPRESSION:
1. Markedly thickened gallbladder wall and heterogeneity of the
gallbladder wall likely due to inflammation from the patient's
acute pancreatitis. There is also pericholecystic blood and
blood in the region of the porta hepatis likely due to
pancreatitis.
2. Findings of acute pancreatitis without pancreatic necrosis or
acute fluid collection.
3. Mildly dilated common bile duct without evidence of stone or
stricture.
4. Small amount of ascites increased. New moderate bilateral
pleural
effusions.
[**2162-11-3**]: Transthoracic Echocardiogram
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: No echo evidence of vegetation or abscess. Normal
global and regional biventricular systolic function. No
diastolic dysfunction, pulmonary hypertension or significant
valvular disease seen.
[**2162-11-8**] CTA and CT Abdomen and Pelvis:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Moderate-sized bilateral pleural effusions, with associated
atelectasis of the adjacent lung. However, superimposed
pneumonia cannot be excluded.
3. Patchy airspace consolidation within the right lung apex,
concerning for a focal area of pneumonia.
4. Continued inflammatory changes surrounding the pancreas, with
peripancreatic fluid and phlegmon. However, no drainable fluid
collection
identified.
5. Markedly abnormal gallbladder, with gallbladder wall
irregularity,
pericholecystic fluid, and a pigtail catheter in place. These
findings likely reflect inflammatory changes secondary to the
adjacent pancreatitis.
6. Tiny amount of perihepatic free fluid, with a small amount of
free fluid tracking inferiorly into the pelvis.
[**2162-11-8**] CT Sinus:
IMPRESSION:
1. Fluid in the paranasal sinuses, which may be related to
intubation.
However, acute sinusitis cannot be excluded.
2. Left middle ear cavity and mastoid air cell opacification
without evidence of osseous erosion. Please correlate clinically
to exclude mastoiditis.
[**2162-11-11**]: CT Abdomen and Pelvis:
IMPRESSION:
1. Continued pancreatitis and cholecystitis. The overall
appearance of the
gallbladder is grossly similar from [**2162-11-8**], with
slightly improved
stranding surrounding the pancreas.
2. No drainable fluid collection identified.
3. Small amount of ascites, with fluid tracking into the pelvis.
4. Moderate-sized bilateral pleural effusions, with associated
atelectasis of the adjacent lung.
[**2162-11-17**]: KUB
PORTABLE SUPINE ABDOMEN, ONE VIEW: NG tube tip terminates in the
stomach.
There are no dilated loops of small or large bowel, without
evidence of
obstruction or ileus. Retained contrast is seen throughout the
colon. There
is no supine evidence of free intraperitoneal air or
pneumatosis.
IMPRESSION: No evidence of obstruction or ileus. No supine
evidence of free
intraperitoneal air.
[**2162-11-17**]: CXR
INDINGS: There are low lung volumes. There is opacification in
the lung
bases, likely consistent with minimal basilar atelectasis,
unchanged. There
is no change in the hilar, mediastinal, and cardiac silhouette.
There is no
evidence of pneumonia or pleural effusion.
IMPRESSION: Low lung volumes. Minimal basilar atelectasis. No
obvious
evidence of pneumonia. No obvious evidence of pleural effusion.
Brief Hospital Course:
This is a 40 year old female with history of pancreatitis,
alcohol abuse, and hyperlipidemia who was transferred from an
outside hospital for further management.
#) Pancreatitis: Patient had pancreatitis based on elevated
amylase, lipase, high triglycerides, exam, and imaging studies.
It was felt that her pancreatitis was secondary to high
triglycerides, also possibly related to alcohol use. She may
have had a stone as well that passed, given dilated common bile
duct noted.
Upon arrival to the intensive care unit, a central line was
placed for administration of fluids. Patient was aggressively
fluid resuscitated with lactated ringers, titrated to improved
urine output, heart rate, and normalization of her acute renal
failure, hemoconcentrated state, acid-base status, and
hypocalcemia. Surgery was consulted and followed along during
her stay. During her stay, she had numerous imaging studies done
to evaluate for transition of her pancreatitis into a
hemorrhagic or infectious process, however none were noted.
Initially tube feeds were held and a nasogastric tube was placed
for decompression, but after her pancreatitis was stable, they
were initiated. She was given TPN while kept NPO. Patient was
eventually started on tube feeds which she tolerated well. Her
nausea and vomiting significantly improved. Prior to discharge
she was started on clears thickened with nectars and her NG tube
was removed. Abdominal pain controlled with Fentanyl patches
which should continue to be weaned down as pain continues to
improve.
#) Respiratory failure: On morning of [**2162-10-28**], patient was
intubated for increased work of breathing, likely secondary to
abdominal distension and pleural effusions. During her stay, it
was difficult to wean her from the ventilator due to large
amounts of sedation required and agitation when sedation was
lifted. During her stay, she managed to self extubate herself
twice, both times necessitating immediate re-intubation as she
was hypoxic and apneic. She did not tolerate spontaneous
breathing trials, as she would become hypoxic and have markedly
increased work of breathing.
Imaging and culture data suggested that the patient developed a
ventilator associated pneumonia, and she received an eight day
course of meropenem for klebseilla in her sputum. Thoracentesis
was considered a number of times, however she did not have
enough fluid to make the procedure possible.
Given her slow weaning process from the ventilator, a family
meeting was held, and her family decided to pursue tracheostomy,
which she underwent on [**2162-11-11**]. Patient's respiratory status
has remained very stable on a tracheostomy collar Fi02 of 40%.
Would suggest that trach weaning be continued and eventually
trach should be removed.
#) Fevers, bacteremia: Patient developed fevers on [**9-26**].
She initially had been started on Zosyn at the outside hospital
empirically given concern over cholangitis, however repeated
imaging of her abdomen was not consistent with an infection.
During her stay, given an initial positive blood culture for
enterococcous, her work up included a transthoracic
echocardiogram which was negative for abscess or vegetation. All
of her central lines, arterial lines, and PICC line were
removed. Abdominal ultrasound revealed there was not enough
fluid for a paracentesis, as did repeated CT scans. There was
not enough fluid for a paracentesis either. A CTA was completed
to evaluate for a pulmonary embolus, which was negative. A CT of
her sinuses was also completed to evaluate for sinus disease.
Culture data ultimately revealed Klebseilla in sputum, and gram
positive cocci in blood along with bacillus in blood.
Drug-related fevers were also a consideration.
She was treated with an empiric course of flagyl given
improvement in her leukocytosis and bandemia with initiation of
that therapy. She completed 14 day course of zosyn ([**Date range (1) 80006**])
to empirically cover potential gastrointestinal pathogens as
well as the entercoccous in one blood culture.
Blood cultures from [**11-9**] grew coag negative staph and bacillus
species (not anthracis) sensitive to Vancomycin. She was started
on a 14 day course of Vancomycin that will be completed
[**2162-11-24**].
#) Alcohol Use: Patient's last known drink was in the evening of
[**10-24**]. Initially she had significant transaminitis (AST much
greater than ALT), which was felt to likely be related to
alcohol consumption, as her transaminases have returned to
[**Location 213**]. She was initially maintained on a CIWA scale prior to
intubation. It was felt that her alcohol use was likely
contributing to her need for large doses of sedation. She was
initially placed on standing diazepam, which was weaned down to
2mg twice daily at the time of discharge. We recommend weaning
this to off within two days --> first down to 2mg daily, then
off. In addition, she received folate and thiamine
supplementation. Social work has followed patient during
hospitalization and has provided coping support to patient and
her family. Would suggest that patient be connected with social
work/substance abuse counseling resources at rehab and in her
community.
#) Distended, thickened, gallbladder: Initially there was
concern for cholangitis at the outside hospital, and a
percutaneous drain was placed. Culture data from the outside
hospital, as well as repeated cultures here did not demonstrate
any growth from her bile. Ultimately, it was felt that her
cholecystitis was related to edema from her pancreatitis, as no
stones were seen on repeated imaging. During her stay, patient
pulled out the percutaneous cholecystostomy tube. Surgery was
again consulted, and imaging was completed to ensure that no
part of the tube had been retained. Suture material that
remained was removed by the surgery team.
Surgery has recommended that patient should undergo
cholecystectomy in [**5-9**] weeks after she recovers from her acute
illness. She has a follow up appointment with Dr. [**Last Name (STitle) 468**] in the
department of General Surgery on [**2162-12-18**].
#) Anemia: Patient's hematocrit has trended down during her
admission and remained in the mid 20's. This initially was felt
to be secondary to fluid resuscitation. Repeated imaging did not
reveal any evidence of bleeding. Iron studies, B12, folate,
hemolysis, DIC labs all checked, iron studies consistent with
anemia of chronic disease. B12 and folate were within normal
limits.
#) Elevated INR: Patient's INR was initially trending upward,
which was felt to be likely secondary to nutritional
deficiencies. INR has since normalized likely due to improved
nutrition.
#) Eosinophilia: Patient developed eosinophilia at the same time
she began antibiotoc therapy for her ventilator associated
pneumonia and bacteremia. Likely this lab finding is secondary
to these medications. Since antibiotic course will be finished
by [**11-24**] would suggest continuing to follow this lab value.
#) Swallow Evaluation: An oral and pharyngeal swallowing
videofluoroscopy was performed. Based on test results it is
recommended that patient have nectar thick liquids and regular
solids. Pills should be crushed with puree. Patient most
comfortable with small bites and sips.
#) GERD: Patient has a history of gastric reflux. She was
changed from her home medication prilosec to lansoparazole
during this hospitalization. Would recommend that she is
restarted on prilosec when discharged home.
Patient was a FULL code during this admission.
Medications on Admission:
- Lortadine for allergies
- Prilosec daily
- Sudaphed PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1)
Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol [**Month/Year (2) **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Year (2) **]: [**2-3**]
Drops Ophthalmic PRN (as needed).
4. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
7. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical PRN
(as needed).
8. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. Prochlorperazine Maleate 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
11. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal
Q72H (every 72 hours).
12. Fentanyl 25 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal
every seventy-two (72) hours.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed.
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
16. Ondansetron 8 mg IV Q8H:PRN
17. 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.
18. Diazepam 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q 12H (Every 12
Hours).
19. Metoclopramide 5 mg/mL Solution [**Last Name (STitle) **]: One (1) Injection Q6H
(every 6 hours) as needed for nausea.
20. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 12H (Every 12 Hours): last doses on [**11-24**] to
complete 14 day course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] hospital at [**Hospital6 10353**]
Discharge Diagnosis:
Primary: Pancreatitis, Ventilator Associated Pneumonia confirmed
by sputum as Klebsiella, Bacteremia with Staphylococcus
coagulase negative, bacillus and enterococcus
Secondary: Anemia, Gastroesophageal reflux disease
Discharge Condition:
good
Discharge Instructions:
You were transferred to this hospital for further management of
you pancreatitis and inflamed gallbladder. You spent three weeks
in the intensive care unit where you received intravenous fluid
hydration and your pancreas and gallbladder were monitored
closely with multiple imaging studies. You were also followed by
our general surgery service. Your pancreatitis has improved
clinically. You continue to have abdominal pain that we are
managing with pain control medications. The surgeons recommend
that you have your gallbladder removed within the next [**5-9**]
weeks.
During your stay in the ICU you had to be intubated because you
were having difficulty breathing on your own. It was very
difficulty to get you off the ventilator so you had to have a
tracheostomy put in place. Your breathing is now very stable and
we feel that you will likely be able to wean from your trach.
While on the ventilator you developed a pneumonia that we
treated you with antibiotics for. You have completed your
antibiotics for this condition.
You also developed multiple infections in your blood that we
also treated you with antibiotics for. You are nearly done with
these antibiotics.
You have been continued on your hospital medications. The
medications that you will discharged home on are dependent on
your course at rehab.
If you develop fevers, chills, worsening abdominal pain, chest
pain or shortness of breath please contact your primary care
physician or go to the emergency department for further
evaluation.
Followup Instructions:
You should follow up with your primary care physician [**Name Initial (PRE) 176**] 1
week of discharge from rehab.
You should follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] in the department of
general surgery to plan your cholecystecomy. Your appointment
has been scheduled for [**2162-12-13**] 11:15pm. The office phone number
is [**Telephone/Fax (1) 476**].
Completed by:[**2162-11-23**]
ICD9 Codes: 5849, 2762, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6031
} | Medical Text: Admission Date: [**2119-9-6**] Discharge Date: [**2119-9-10**]
Date of Birth: [**2080-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
activity intolerance
Major Surgical or Invasive Procedure:
[**2119-9-7**] Mini-thoracotomy, atrial septal defect
History of Present Illness:
This 38 year old male with congential sensorineural hearing loss
and a secundum ASD who has been experiencing worsening dyspnea
on exertion over the last 6 months. His activity level is quite
low. He has been followed by Dr. [**Last Name (STitle) 171**] and has had both an
echo and cardiac MRI demonstrating secundum atrial septal
defect. The cardiac MRI done [**1-29**] reveals the atrial septal
defect's maximal diameter to 2.3cm with a QP/QS to 1.56 and
right ventricular enlargement. The patient was then referred for
TEE and possibly a percutaneous atrial septal defect closure.
Past Medical History:
Chronic kidney disease
Congenital deafness; uses American sign language (even though
understands Spanish; does not speak)
Gynecomastia
Nephrolithiasis
Hypertension
Secundum ASD
Obesity
Asthma as a child
Leg surgery as a child for "bowed legs"
Social History:
Mr. [**Known lastname **] lives with his father and does not work. He denies
smoking or drinking alcohol.
Family History:
Mr. [**Known lastname **] has a sister with an atrial septal defect which was
surgically repaired in [**Male First Name (un) 1056**].
Physical Exam:
Pulse: 100 Resp: 16 O2 sat: 100% RA
B/P Right: 128/86 Left: 119/82
Height: 64 in Weight: 214 lbs
General:
Skin: Warm [x] Dry [x] intact [x]
HEENT: NCAT [] PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact []
Discharge Exam:
VS: T:98.9 HR: 70-80's SR BP: 125-139/70's Sats: 97% RA
Wt: 102.3 kg
General: 39 year-old male in no apparent distress
HEENT: normocephalic mucus membranes moist
Card: RRR normal S1,S2 no murmur
Resp: clear breath sounds
GI: benign
Extr: warm no edema
Incision: right anterior chest below right breast clean dry
intact, no erythema
Neuro: awake alert. Sign language intrepreter present
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **] JR, [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81079**] (Complete)
Done [**2119-9-6**] at 11:30:42 AM FINAL
Conclusions
PRE-BYPASS:
The left atrium is normal in size. No thrombus is seen in the
left atrial appendage. A secundum type atrial septal defect is
present measuring 2.2 cm x 1.7cm with left to right flow. No
other ASDs or VSDs visualized. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
No clot in LAA. Normal appearing coronary sinus. Dr.
[**Last Name (STitle) **] was notified in person of the results on[**2119-9-6**] at
1030.
POST-BYPASS:
There is preserved left ventricular function. There is a patch
occluding the ASD with no residual defect. There is no evidence
of Aortic dissection. Valvular function is unchanged from
prebypass.
.
CXR [**2119-9-9**]
Right internal jugular line tip is at the level of mid SVC.
Heart size and mediastinum are unremarkable. Bibasilar
atelectasis are present. Small amount of pleural effusion is
seen. No overt pneumothorax is demonstrated.
[**2119-9-8**] WBC-14.3* RBC-3.64* Hgb-11.2* Hct-32.2* MCV-88 MCH-30.7
MCHC-34.8 RDW-13.0 Plt Ct-207
[**2119-9-7**] WBC-19.8* RBC-4.41* Hgb-13.5* Hct-39.5* MCV-90 MCH-30.7
MCHC-34.3 RDW-13.0 Plt Ct-293
[**2119-9-6**] WBC-22.3*# RBC-4.49* Hgb-13.7* Hct-39.0* MCV-87
MCH-30.5 MCHC-35.1* RDW-12.6 Plt Ct-261
[**2119-9-9**] Glucose-202* UreaN-12 Creat-0.9 Na-135 K-3.9 Cl-101
HCO3-26
[**2119-9-9**] Mg-2.3
[**2119-9-6**] MRSA SCREEN (Final [**2119-9-9**]): No MRSA isolated.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2119-9-6**] where
the patient underwent an atrial septal defect repair via a
mini-thoracotomy. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD **** the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to home with Multicultural VNA in
good condition with appropriate follow up instructions.
Medications on Admission:
AMLODIPINE 10 mg tablet daily
HYDROCHLOROTHIAZIDE 25 mg tablet daily
LISINOPRIL 20 mg tablet daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Aspirin EC 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ibuprofen 600 mg PO Q8H Duration: 2 Weeks
Take with food and water
RX *ibuprofen 600 mg 1 tablet(s) by mouth three times a day Disp
#*45 Tablet Refills:*0
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Hydrochlorothiazide 25 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**12-19**] tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
atrial septal defect
PMH:
Chronic kidney disease
Congenital deafness; uses American sign language (even though
understands Spanish; does not speak)
Gynecomastia
Nephrolithiasis
Hypertension
Secundum ASD
Obesity
Asthma as a child
Past Surgical History:
Leg surgery as a child for "bowed legs"
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming, and look at your incisions
NO lotions, cream, powder, or ointments to incisions
Daily weights. Keep a log
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2119-9-19**]
12:30 in the [**Hospital **] Medical Building [**Hospital Unit Name **]
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**], [**2119-10-10**] 1:15
in the [**Hospital **] Medical Building [**Hospital Unit Name **]
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2119-10-18**] 10:20
Please call to schedule the following:
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 3581**] in [**3-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2119-9-10**]
ICD9 Codes: 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6032
} | Medical Text: Admission Date: [**2101-10-1**] Discharge Date: [**2101-10-5**]
Date of Birth: [**2046-11-20**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
male, who was admitted to [**Hospital **] Hospital on [**9-29**] after being
found unresponsive by his girlfriend. [**Name (NI) **] had a five minute
long generalized tonoclonic seizure followed by two more
generalized tonoclonic seizures in the ED at [**Hospital1 **] lasting
approximately 2-5 minutes each. Patient was loaded with
Dilantin. Head CT at that time showed diffuse subarachnoid
hemorrhage with a large amount of interventricular clot.
At [**Hospital **] Hospital, an externalized ventriculostomy drain was
placed with good return of CSF. Patient had reflexes in the
ED all which were brain stem reflexes only, and an EEG which
demonstrated diffuse slowing without focal epileptiform
discharges. Initially ICPs were approximately 38-43 cm of
water, which decreased to 20-23, 25 grams of mannitol post
EVD placement.
MRI at [**Hospital **] Hospital demonstrated a 3 mm aneurysm of the
ACOM and left A2 segment, as well as dilation of the left
lateral ventricle.
While at [**Hospital1 **], patient had ICPs rising to approximately 8 cm
of water at one point. Because of the inability to treat the
aneurysm, the patient was transferred to [**Hospital1 346**] on [**2101-10-1**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hepatitis C and B.
3. Oxygenous imperfecta.
4. Depression.
5. Gastritis.
MEDICATIONS ON ADMISSION:
1. Cardizem.
2. Protonix.
3. Hydrochlorothiazide.
4. Diovan.
5. Paxil.
PAST SURGICAL HISTORY: Patient has no past surgical history.
Remote history of trauma.
SOCIAL HISTORY: The patient was an IV drug abuser prior to
[**2095**].
MEDICATIONS ON TRANSFER:
1. Dilantin 100 mg q.8h.
2. Amlodipine.
3. Vancomycin.
4. Rocephin.
5. Mannitol.
6. Morphine prn.
PHYSICAL EXAM ON ADMISSION: Pulse 81, blood pressure 165/89,
ICP is 24, CPP 96, respiratory rate 23, sating 98% ventilated
and sedated. Patient had EVD in place with straining of
bloody fluid. Pupils are 1.5 to 1 mm. There is no eye
opening spontaneously. There were brief torsional eye
movements as well as some rhythmic oscillations and
dysconjugate gaze. There was no doll's eyes. There is a
positive gag, and positive corneal reflexes. There is
minimal left hand flexion to deep painful stimuli. There is
no other movement of the extremities.
HOSPITAL COURSE: The patient was admitted to the
Neurosurgery service of Dr. [**Last Name (STitle) 1132**] on [**2101-10-1**]. After
discussion with the family about the patient's poor prognosis
and discussion of possible options, the patient was taken to the
Angiography Suite. Prior to the onset of the procedure, the
patient's ICP was found to be again elevated to 40 cmH2O.
Accordingly a contralateral second ventricular drain was inserted
prior to the beginning of the angiogram. The patient's ICP
then stabilized to the around 20 cmH2O. The patient then
underwent a diagnostic cerebral angiogram as well as
coiling of a left pericallosal aneurysm. A small contrast leak
was experienced during the deployment of the last coil which was
treated with immediate coagulation reversal with protamine. The
transient extravasation subsided spontaneously. There was no
evidence of intracranial flow decrease and the ICP was noted to
increase back to the low 40's. This was then followed by
irrigation of the drains with saline and with one dose of tPA
which improved CSF flow significantly.
Postoperatively, the patient was returned to the Medical
Intensive Care Unit. Overnight, both externalized ventriculostomy
drains continued to work putting out a moderate amount of CSF
overnight from postoperative day 0 to postoperative day one. The
patient's intracranial pressures declined from mid-20's into the
low teen's progressing further from postoperative day one to
postoperative day two into the values of approximately
[**5-14**].
Neurologically postprocedure the patient demonstrated minimal
improvement compared to his admission. He progressed to a point
where he was able to open his eyes, but was not able to attend to
examiner, follow commands, or be responsive to deep painful
stimuli. Serial CAT scans demonstrated persistent
interventricular clot despite multiple attempts to place
intrathecal TPA. On [**2101-10-5**] with the patient demonstrating
minimal neurologic improvement and after prolonged discussions
with the family and Dr. [**Last Name (STitle) 1132**], the family decided to withdraw
support for the patient.
On [**2101-10-5**], the patient was extubated and his ventricular
drains were clamped, and he expired approximately two hours
later. The [**Location (un) 511**] Organ Bank was [**Name (NI) 653**], however,
the family did not wish to pursue organ donation.
On [**2101-10-5**] at approximately 11:58 p.m., the patient was
found to have no spontaneous respirations, no pulse is
measured either by telemetry or by palpation, and was
subsequently pronounced dead.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Name8 (MD) 16207**]
MEDQUIST36
D: [**2101-10-6**] 00:07
T: [**2101-10-6**] 05:20
JOB#: [**Job Number 50460**]
ICD9 Codes: 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6033
} | Medical Text: Admission Date: [**2129-11-3**] Discharge Date: [**2129-11-12**]
Date of Birth: [**2062-6-2**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 66 year old woman who
presented to Dr. [**Last Name (STitle) 468**] approximately a year after an
episode of acute pancreatitis attributed to alcohol abuse.
At the time of that pancreatitis episode, she had a CT scan
which revealed a small pseudo cyst. However, on recent CT
scan, she was found to still have a small cyst, under the
size of one cm, in the head of her pancreas.
Clinically, she remained well over the previous year, without
fevers, chills, nausea, vomiting or other troubles. In
[**2129-9-19**], she developed rapid onset of painless
jaundice. CT scan at this time revealed only dilated extra
hepatic biliary tract. She had a right upper quadrant
ultrasound which showed a dilated common bile duct and
gallbladder but no evidence of common bile duct stones.
Endoscopic retrograde cholangiopancreatography was performed
and a high grade focal stricture of the distal common bile
duct was observed. A stent was placed and she was sent to
Dr. [**Last Name (STitle) 468**] for evaluation.
The patient denies fevers, chills or other symptoms of
cholangitis. She also denies weight loss, history of cancer
or recent exacerbation of alcohol use.
PAST SURGICAL HISTORY: Breast biopsy, appendectomy, a remote
laparoscopy.
PAST MEDICAL HISTORY: Hypercholesterolemia; paroxysmal
atrial fibrillation; mild mitral insufficiency and an alcohol
history of four Manhattans a day.
MEDICATIONS: Lanoxin, Norvasc, Zestril, Zocor, Allopurinol,
Axid, Folic acid and multi-vitamins.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a retired teacher.
PHYSICAL EXAMINATION: On examination, she has jaundice and
has scleral icterus. The rest of her Head, eyes, ears, nose
and throat examination was normal. She had normal carotid
pulses without bruits and no jugular venous distention. Her
chest was clear and her heart was regular rate and rhythm.
She did have grade II out of 6 mid systolic ejection murmur,
heard best at the apex. Her abdomen was soft, nondistended
and nontender. Her gallbladder was not palpable.
HOSPITAL COURSE: She underwent a high contrast CT arterial
study and was then brought into [**Hospital1 188**], where she underwent on [**2129-11-3**], a Whipple
procedure.
Postoperatively, she was placed on prophylactic
benzodiazepine for possible delirium tremens. She was also
placed on subcutaneous heparin, Zantac, Testall and her pain
was controlled with an epidural.
Initially, she was neo-synephrine dependent and she had very
subtle electrocardiogram changes postoperatively. Cardiology
was consulted and a myocardial infarction was ruled out with
negative enzymes. She remained in the Intensive Care Unit
overnight, secondary to the neo drip. However, throughout,
she had excellent urine output.
The evening of postoperative day one, her epidural was
switched to a PCA for better pain control; however, she was
found to be over narcotized and required a Narcan drip to
alleviate this problem.
On postoperative day number two, she was doing well and she
was transferred to the floor. Over the next few days, she
continued to do well. On postoperative day four, she
required some Lasix for mild pulmonary edema on clinical
examination. This resolved with upright positioning and the
diuresis with the Lasix.
On postoperative day number seven, she was noted to have a
large amount of wound drainage and her wound was open for
copious amounts of somewhat enteric looking drainage. She
went for CT scan to rule out fistula or leak. The only
finding was a possible SMB clot. Over this time as well, her
platelets dropped from 325 to 64 and then by postoperative
day number seven, down to nine. Hit antibody was sent. All
heparin was removed from her lines and subcutaneous. Zantac
was stopped. DIC laboratory studies were sent and found to
be unremarkable.
We placed Venodynes on her legs for deep vein thrombosis
prophylaxis and requested a hematology consult. The
hematology consult agreed with our management and
furthermore, advised holding any anticoagulation, secondary
to a risk of bleed, given that her platelet count was only
nine. Her platelet count remained nine over postoperative
day eight. Early in the morning on postoperative day number
nine, she became anuric, hypotensive and her hematocrit was
found to have dropped to 22. She was transferred to the
Intensive Care Unit. Swan-Ganz was placed for fluid
management. She was actively resuscitated with blood
products and fluid. She was taken to the operating room for
exploration of possible abdominal bleed.
Upon opening the abdomen in the operating room, however, the
small bowel was found to be entirely infarcted with
catastrophic abdominal findings. She was reclosed without
any further intervention and brought back to the Intensive
Care Unit. We supported her blood pressure with pressors and
fluids until her family could be fully present. At that
point, she was made comfort measures only. She expired.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 7589**]
MEDQUIST36
D: [**2129-11-12**]
T: [**2129-11-16**] 05:07
JOB#: [**Job Number **]
ICD9 Codes: 2762, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6034
} | Medical Text: Admission Date: [**2204-5-8**] Discharge Date: [**2204-5-12**]
Date of Birth: [**2152-1-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 7086**] is a 52 year old male with past medical history of
COPD on home oxygen and type two diabetes mellitus who presented
with shortness of breath.
.
He reported that over the past week to weeks, he has noted some
increasing white sputum production, but that was no accompanied
by any shortness of breath or fevers. He did note some chills
with the clear and white sputum. + Sick contact: nephew. [**Name2 (NI) **]
called [**Company 191**] on [**2204-5-7**] to discuss his worsening symptoms. He
was instructed to increase his prednisone to 10 mg daily (from
qOD) and initiated levofloxacin [**5-7**]. As per usual over the last
2 years (about 4 times), he had a COPD exacerbation that he
managed at home with nebulizers. This time, however, the meds
"didn't work". Th morning of admission, he woke up acutely short
of breath. He took one nebulizer treatment at home, but given
the degree of dyspnea and lack of improvement, EMS was called.
.
Per report from the ED, upon arrival EMS administered another
nebulizer treatment, and gave him magnesium en route to [**Hospital1 18**].
It was reported that he was moving "very little air." Upon
arrival to the ED, his initial vital signs were: temperature of
97.0, heart rate of 114, blood pressure 107/62, respirations of
24, and oxygen saturation of 100% on 60% face mask. Per
discussion with ED, his respiratory rate remained in the low
30's. He received three additional combivent nebulizer
treatments back-to-back, as well as 125 mg of methylprednisolone
and 500 mg of IV azithromycin. Lorazepam was given to see if
there was any improvement in his tachypnea; ED reported this
transiently improved his symptoms, but not significantly. At
time of sign-out, he was receiving his forth nebulizer
treatment. Vitals at time of ICU transfer were reported as heart
rate of 119, blood pressure of 132/70, respiratory rate of 29,
and oxygen saturaiton of 98% on 50% nebulizer treatment.
.
In the ICU, he was started on Prednisone 60mg daily, intended
for a long taper, received Azithro and plenty of nebs. He
required BiPAP at night and was at the mid 90's sats on 6L
during the day. He experienced an episode of [**2-1**] CP that
radiated down his left arm with flat troponins. On my exam, he
feels "100 times better"
.
Review of systems:
(+) Per HPI, + tightness
(-) Denies fever, 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:
- COPD, on 4 L home oxgyen and 10 mg prednisone every other day,
followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/[**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **], no prior intubations
- Diabetes Mellitus, type 2
- Obstructive sleep apnea, followed by [**First Name8 (NamePattern2) 450**] [**Last Name (NamePattern1) 437**], in
process of starting therapy but not currently on non-invasive
- Likely CAD (coronary calcifications on CT)
- Depression/Anxiety
- Diverticulosis
- Scrotal hydrocele
- Dupuytren contractures
Social History:
- Tobacco: Smokes one pack per day ([**11-27**] PPD) since age 13
- Alcohol: Occasional
- Illicits: Denies
Family History:
(per chart)
Multiple family members with DM
Brother with [**Name2 (NI) 499**] cancer
No family history of lung disease
Physical Exam:
ADMIT Vitals: T: pending BP: 119/59 P: 99-117 R: 25-29 O2: 99%
on 50%
ACCEPT VS: 98, 148/84, 91, 99on6L
General: Resting in bed, tachypneic with pursed lips using
accessory muscles, however NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD, no stridor appreciated,
using accessory muscles
Lungs: [**Last Name (un) 7016**] chested, Decreased aeration bilaterally, Diffuse
wheezes anteriorly and posteriorly, extremely prolonged
expiratory phase, no apparent rales.
CV: Tachycardic, however regular rate, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, speech fluent, following commands appropriately
Psych: Appropriate
Skin: No lesions
Pertinent Results:
ADMISSION
[**2204-5-8**] 08:28AM BLOOD WBC-13.5*# RBC-4.81 Hgb-13.3* Hct-42.2
MCV-88 MCH-27.6 MCHC-31.5 RDW-13.8 Plt Ct-271
[**2204-5-8**] 08:28AM BLOOD Neuts-79.9* Lymphs-13.4* Monos-4.5
Eos-1.8 Baso-0.5
[**2204-5-8**] 08:28AM BLOOD PT-13.1 PTT-25.0 INR(PT)-1.1
[**2204-5-8**] 08:28AM BLOOD Glucose-167* UreaN-15 Creat-0.8 Na-143
K-4.6 Cl-103 HCO3-32 AnGap-13
[**2204-5-9**] 02:16AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2
[**2204-5-8**] 11:03AM BLOOD Type-ART pO2-221* pCO2-75* pH-7.18*
calTCO2-29 Base XS--2 Intubat-NOT INTUBA Comment-NEBULIZER
[**2204-5-8**] 08:34AM BLOOD Lactate-2.1*
DISCHARGE
[**2204-5-11**] 06:20AM BLOOD WBC-9.1 RBC-4.15* Hgb-11.5* Hct-35.7*
MCV-86 MCH-27.6 MCHC-32.2 RDW-13.7 Plt Ct-245
[**2204-5-12**] 07:10AM BLOOD UreaN-16 Creat-0.6 Na-142 K-3.6 Cl-101
HCO3-35* AnGap-10
[**2204-5-11**] 02:26PM BLOOD Type-ART pO2-185* pCO2-56* pH-7.42
calTCO2-38* Base XS-10
CARDIAC
[**2204-5-10**] 11:18AM BLOOD CK(CPK)-189
[**2204-5-10**] 03:04AM BLOOD CK(CPK)-189
[**2204-5-9**] 08:27PM BLOOD CK(CPK)-171
[**2204-5-10**] 11:18AM BLOOD CK-MB-8 cTropnT-<0.01
[**2204-5-10**] 03:04AM BLOOD CK-MB-8 cTropnT-LESS THAN
[**2204-5-9**] 08:27PM BLOOD CK-MB-8 cTropnT-0.02*
[**2204-5-8**] 08:28AM BLOOD cTropnT-<0.01
[**2204-5-10**] 04:03PM BLOOD %HbA1c-6.6* eAG-143*
[**2204-5-10**] 11:18AM BLOOD Triglyc-154* HDL-35 CHOL/HD-4.4
LDLcalc-88 LDLmeas-84
CXR
1. No evidence of acute cardiopulmonary process.
2. Severe emphysema.
DOBUTAMINE MIBI Normal study without focal defects concerning
for ischemia. Left ventricular EF 65%.
Brief Hospital Course:
Mr. [**Known lastname 7086**] is a 52 year old male with past medical history of
COPD on home oxygen, diabetes mellitus, and OSA who presented
with respiratory distress. He was found to be in hypercarbic
respiratory failure that responded swiftly to IV (and then PO)
steroids, nebulized bronchodilators, antibiotics and NIPPV. He
had TWI with an episode of chest pain that was evaluated by
serial enzymes and a dobutamine-stress MIBI (both negative). He
was discharged on a prednisone taper with documentation of
nocturnal hypoxia to support a biPap prescription.
#) COPD, OSA ?????? Patient was found to by in hypercarbic
respiratory failure secondary to COPD exacerbation, improved on
bipap in ED. Was given methylprednisolone for 24 hours, changed
to prednisone 60mg PO qdaily which was subsequently tapered.
continued on azithromycine, iptropium/albuterol nebs standing
q4h. Patient did well. Completed abx. Had documented nocturnal
desaturation to merit BiPap at home. Bicarb rose on penultimate
day with improving ABG, likely related to metabolism of
admission hypercarbia.
#) chest pain - found to have non-exertional substernal chest
pain with radiation to the left shoulder. Had stress test in
[**2198**] that was nondiagnostic. ECG with dynamic inferior t wave
inversions. TIMI score calculated at 1. Coronary calcifications
on chest CT. Stress mibi was negative.
Medications on Admission:
- Albuterol nebulizer q4H PRN
- Citalopram 60 mg
- Fluticasone 50 mcg: 2 sprays daily
- Fluticasone-Salmeterol 250 mcg/50 mcg [**Hospital1 **]
- Metformin 500 mg daily
- Prednisone 10 mg every other day
- Temazepam 30 mg daily PRN
- Tiotropium 18 mcg daily
- Loratadine 10 mg
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*qs qs* Refills:*2*
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*30 Tablet(s)* Refills:*2*
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-26**] neb Inhalation Q2H (every 2 hours) as
needed for wheezing.
Disp:*qs qs* Refills:*0*
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Prednisone 20 mg Tablet Sig: as dir Tablet PO DAILY (Daily):
take 60 mg for 3 days. 40 mg for 3 days. 20 mg for 3 days. 10 mg
for 3 days and then 10mg qod.
Disp:*30 Tablet(s)* Refills:*2*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
11. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Bipap Sig: One (1) machine at bedtime: Inspiratory
pressure: 10 cm/h2o Expiratory pressure: 5 cm/h2o with heated
humidification.
Disp:*1 machine* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: Severe COPD, in exacerbation
Seconday: T2DM, HTN, Depression, Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 7086**],
You were admitted with shortness of breath and cough. This was
likely related to a "COPD Exacerbation" of unknown cause. You
responded swiftly to steroids, antibiotics and supplemental
oxygen. You spent more time in the ICU because of chest pain
that was not associated with heart damage and ultimately
evaluated with a stress test. This stress test revealed no areas
of low blood flow. You were discharged to follow up outpatient.
Please. Please stop smoking
.
BIPAP machine was delivered to you with instruction at the
hospital. Please use this each evening and contact your
[**Name2 (NI) 57073**] or primary care physician with questions.
.
NEW MEDICATION
1. Nicotine - take instead of cigarettes
2. Bactrim - an antibiotic to protect you while on steroids
3. Calcium and Vitamin D - take to prevent bone troubles while
on steroids.
NEW DOSES
1. Prednisone - taper as directed
.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2204-5-22**] at 4:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2204-5-29**] at 11:25 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: TUESDAY [**2204-5-29**] at 11:45 AM
PLEASE CALL DR.[**Doctor Last Name **] OFFICE ON MONDAY TO SET UP A SLEEP
STUDY. THIS IS VERY IMPORTANT.
Completed by:[**2204-5-15**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6035
} | Medical Text: Admission Date: [**2143-3-28**] Discharge Date: [**2143-4-11**]
Date of Birth: [**2067-1-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Captopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
increasing fatigue
Major Surgical or Invasive Procedure:
[**2143-3-28**] MVRepair(28 CE Band)/AVR(21 mm CE pericardial)/CABG
x3(Lima>lad,svg>pda,svg>om)
[**2143-4-10**] right hemicolectomy, cholecystectomy, aortagram, SMA
bypass graft from right common iliac artery, small bowel
resection
History of Present Illness:
Patient was a 76 male complaining of increasing fatigue who had
an echo showing worsening mitral reguritation. Cath showed
subtotal occlusion of the LAD, mod-severe MR, EF 30-35%.
Past Medical History:
HTN, hyperlipidemia
CAD with BMS x2 of RCA [**2137**]/instent restenosis [**7-25**]
arthritis, anemia
Social History:
quit smoking 25 years ago, occasional alcohol, retired, lives
with wife.
Family History:
Mother deceased from MI in late 80s.
Physical Exam:
(at exam [**3-13**]):HR 70 RR 15 157/49
NAD flat after cath
skin unremarkable
teeth in very poor repair
neck supple with full ROM
CTAB anteriorly
RRR no murmur
abd soft, NT, ND +BS
extrems warm, well-perfused, no edema or varicosities noted
neuro grossly intact
no carotid bruits appreciated
Pertinent Results:
[**2143-4-11**] 03:03AM BLOOD WBC-7.3 RBC-3.07* Hgb-9.2* Hct-26.3*
MCV-86 MCH-30.1 MCHC-35.1* RDW-15.4 Plt Ct-78*
[**2143-4-10**] 03:57PM BLOOD Neuts-75* Bands-1 Lymphs-18 Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-2* Promyel-1* NRBC-2*
[**2143-4-10**] 03:57PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Burr-1+
[**2143-4-11**] 03:03AM BLOOD PT-28.7* PTT-86.1* INR(PT)-2.9*
[**2143-4-11**] 03:03AM BLOOD Plt Smr-VERY LOW Plt Ct-78*
[**2143-4-11**] 03:03AM BLOOD Glucose-200* UreaN-55* Creat-2.2* Na-159*
K-6.4* Cl-99 HCO3-19* AnGap-47*
[**2143-4-11**] 03:03AM BLOOD ALT-586* AST-4466* LD(LDH)-4932*
AlkPhos-177* Amylase-28 TotBili-2.7*
[**2143-4-11**] 03:03AM BLOOD Lipase-36
[**2143-4-11**] 03:03AM BLOOD Albumin-1.6* Calcium-10.5* Phos-12.8*
Mg-3.6*
[**2143-4-11**] 05:15AM BLOOD Type-ART pO2-68* pCO2-35 pH-7.18*
calTCO2-14* Base XS--14
[**2143-4-11**] 05:15AM BLOOD Glucose-234* Lactate-26.4* K-6.6*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 73938**] (Complete)
Done [**2143-4-10**] at 3:06:05 PM PRELIMINARY
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: [**2067-1-25**]
Age (years): 76 M Hgt (in): 63
BP (mm Hg): / Wgt (lb): 135
HR (bpm): BSA (m2): 1.64 m2
Indication: Intraop sternal debridement, ex lap
ICD-9 Codes: 440.0, 396.9
Test Information
Date/Time: [**2143-4-10**] at 15:06 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: aw2
Echocardiographic Measurements
Results Measurements Normal Range
Mitral Valve - Mean Gradient: 3 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the aortic arch. Normal descending aorta diameter.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral
valve annuloplasty ring. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) 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. No TEE related complications. The patient appears
to be in sinus rhythm.
Conclusions
Pre Bypass: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is mildly depressed (LVEF=40%). Septal motion
is paradoxical, c/w post CABG. Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the ascending aorta. There are complex (>4mm) atheroma in the
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. A mitral valve
annuloplasty ring is present. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
Brief Hospital Course:
Mr [**Known lastname 1169**] was admitted on [**3-28**] after he underwent a mitral
valve repair, CABG x 3, and aortic valve replacement. For
details of the operation please see the operative report.
Extubated on POD #1. Postoperatively he was on milrinone,
levophed and epinephrine to maintain his cardiac output and
blood pressure. He received multiple blood transfusions as
well.Amiodarone started for A fib. Pressors/support weaned and
then restarted for decreasing C.I. Chest tubes removed. C diff.
positive with continuing diarhhea on POD #6 and flagyl started.
Beta blockade titrated. Echo showed global hypokinesis. Sub Q
heparin started for prophylaxis and mutiple BP agents added for
hypertension. Gentle diuresis restarted on POD #7, pacing wires
removed, and transferred to the floor to begin increasing his
activity level. on POD #11, his WBC rose to 18 and he was
pancultured. He c/o LLQ pain on POD #12. Cipro started for UTI.
Left pleural effusion tapped on POD #12.
At 6:30 AM on POD #13, he acutely decompensated with acute
respiratory failure on the floor. He had agonal breathing, was
bradycardic and had palpable pulses and was intubated by
anesthesia emergently during the code. Transferred back to CVICU
for stat TTE and left chest tube placed. Tamponade ruled out by
echo. Sternum found to be unstable on exam (no CPR had been
performed).Bronchoscopy done to rule out aspiration. Lactate
rose to 11 and general surgery was urgently consulted.Creatinine
rose to 2.2 and INR was 2.9. New subclavian accesss
established.He was taken directly to the OR and Dr. [**First Name (STitle) **]
debrided his sternum and re-wired it. The general surgery team
then did an exploratory laparotomy to evaluate for acute
mesenteric ischemia. He had a right hemicolectomy,
cholecystectomy, aortagram with right common iliac artery to SMA
bypass graft ( vascular team), and then a small bowel resection
by Dr. [**First Name (STitle) **]. He was profoundly acidotic.
He was aggressively resuscitated the rest of the night with
multiple pressor support to maintain a BP. The family was
consulted about his extremely grave prognosis and they agreed to
continue the drips but no CPR or additional drug resuscitation.
Made CMO by family with increasing pressor requirements and
acidosis. Expired at 8:00 AM on [**4-11**]. Family declined autopsy.
Medical Examiner elected to review the case.
Medications on Admission:
coreg 6.25 mg daily
zetia 10 mg daily
ASA 325 mg daily
plavix 75 mg daily
lovastatin 80 mg daily
lasix 40 mg daily
cozaar 50 mg [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
CAd with BMS to RCA x2, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**7-25**] and instent restenosis
HTN
hyperlipidemia
anemia
arthritis
Discharge Condition:
Expired
Discharge Instructions:
patient expired
Followup Instructions:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2143-4-11**]
ICD9 Codes: 4241, 5185, 9971, 5990, 5119, 4240, 4019, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6036
} | Medical Text: Admission Date: [**2190-7-4**] Discharge Date: [**2190-7-13**]
Date of Birth: [**2134-1-24**] Sex: M
Service: OME
HISTORY OF PRESENT ILLNESS: 56-year-old gentleman
with a history of myelodysplastic syndrome which has
progressed to acute myelogenous leukemia complicated by
pancytopenia, absolute neutropenia, and chronic infection
involving his lungs (presumptively fungal).
The patient was admitted to day with a cough which then
progressed to dyspnea and fever. The patient denied any
other acute complaints. In the Emergency Department, he was
noted to be tachycardic and febrile to 102. He received
intravenous fluids, cefepime, and vancomycin and was
transferred to the Intensive Care Unit for further
evaluation.
PAST MEDICAL HISTORY: Myelodysplastic syndrome diagnosed in
[**2189-6-21**] which progressed to acute myelogenous leukemia;
poor prognosis - cytogenetic was 5q negative and mono filmy
7. Acute myelogenous leukemia diagnosed in [**2189-8-21**];
status post induction with 7+3 which was completed on [**2189-10-21**] with overall poor response complicated by chronic
fungal pneumonitis - question Aspergillosis. Negative
bronchoalveolar lavage in [**2190-1-21**] and in [**2190-1-21**] for Pneumocystis carinii pneumonia and neuro fungi.
[**2190-1-21**] - right palate lesion consistent with
chloramine pathology.
Hypertension.
Type 2 diabetes.
Gastroesophageal reflux disease.
History of partial small bowel obstruction.
History of small-bowel bleed.
History of alloimmunization to platelets.
Coronary artery disease.
History of diabetes insipidus; status post lithium.
Chronic hyponatremia felt to be secondary to lithium.
Depression.
MEDICATIONS ON ADMISSION:
1. Glucotrol 20 mg by mouth once per day.
2. Protonix 40 mg by mouth once per day.
3. [**Doctor First Name **] 60 mg by mouth twice per day.
4. Lopressor 12.5 mg by mouth once per day.
5. Voriconazole 200 mg by mouth twice per day.
6. Caspofungin 50 mg by mouth once per day.
7. Risperidone.
8. Levofloxacin.
ALLERGIES: METFORMIN .
PHYSICAL EXAMINATION ON PRESENTATION: Temperature maximum
was 102.7 degrees Fahrenheit, his blood pressure was 107/55,
his heart rate was 93, his respiratory rate was 30, and his
oxygen saturation was 100 percent on room air. Generally, a
tired ill-appearing diaphoretic male. Head, eyes, ears, nose,
and throat examination revealed the oropharynx was dry, poor
dentition, white plaque on tongue, with a bruise over right
eye and over bridge of nose. Cardiac examination revealed a
regular rate. First heart sounds and second heart sounds.
No murmurs. Pulmonary examination revealed decreased breath
sounds at the bases. No rales or rhonchi. Abdominal
examination was benign. Extremity examination revealed the
extremities were warm and dry. Right Port-A-Cath with
granulation tissue and foul smelling. Neurologic examination
revealed affect was flat. Alert and oriented times three.
In no apparent distress. Speech was fluent. Cranial nerves
were intact.
RADIOLOGY: A chest x-ray revealed no focal pneumonia,
persistent right-sided effusion.
A computed tomography angiogram of the chest revealed no
pulmonary emboli, right pleural effusion, multiple nodular
densities throughout parenchyma.
PERTINENT LABORATORY VALUES ON ADMISSION: White blood cell
count was 0.8. His hematocrit was 30.2. Chemistry profile
was notable for a blood urea nitrogen of 32, creatinine of
1.4, platelets of 15, D-dimer was 4832, lactate was 2.5, and
INR was 1.4.
SUMMARY OF HOSPITAL COURSE:
1. ACUTE MYELOGENOUS LEUKEMIA: The patient's treatment has
been limited by persistent infection involving old line
infections and pulmonary issues. The patient had been on
Synercid two weeks prior to admission for persistent line
infection and a known history of vancomycin-resistant
enterococcus.
The [**Hospital 228**] hospital course was notable for an increased
level of blasts in circulation. As high as 37 percent blasts
were noted on complete blood count from [**2190-7-13**]. The
patient was persistently febrile and was treated broadly for
his known pulmonary infection as well as other possible
sources. The patient was maintained on transfusion parameter
scales. He did not have any evidence of disseminated
intravascular coagulopathy or tumor lysis during this
hospitalization.
1. HISTORY OF VANCOMYCIN-RESISTANT ENTEROCOCCUS STATUS POST
LINE REMOVAL: The patient has a history of old line site
infection with granulation tissue. Dr. [**Last Name (STitle) **] from
Surgery evaluated the site and felt that the line site was
not infected, and most likely his fevers were attributed
to his known pulmonary infection. The Surgery Service
debrided the patient's wound at bedside using silver
nitrate.
1. CHRONIC INFECTIOUS PNEUMONITIS: A Pulmonary consultation
was obtained. The patient had a bronchoscopy without any
evidence of a fungal or Pneumocystis carinii pneumonia or
bacterial pneumonia. A video-assisted thoracic surgery
was considered versus computed tomography-guided biopsy.
The decision regarding this was pending at the time of
discharge. However, the patient was persistently febrile
despite negative bronchoalveolar lavage.
A repeat chest computer tomography revealed slightly
worsening bilateral infiltrates, pulmonary edema, and stable
left-sided pleural effusion. The patient did not have an
oxygen requirement during his hospitalization, and his
breathing was stable. He had a nonproductive cough.
1. CORONARY ARTERY DISEASE: The patient was maintained on
metoprolol. He had no active issues during his hospital
course.
1. TYPE 2 DIABETES: The patient was maintained on twice per
day fingerstick glucose checks and a regular insulin
sliding scale.
1. INFECTIOUS DISEASE: An Infectious Disease consultation
was obtained to assist in the management of the patient's
pneumonitis. The patient was treated with Synercid in
light of his known history of vancomycin-resistant
enterococcus. He was also treated with imipenem after
intermittently being on Zosyn. The thought was that
imipenem would give no Cardia coverage. However, despite
broad coverage for gram-positive and gram-negative rods as
well as fungal organisms with both caspofungin and
voriconazole, the patient remained febrile.
1. PSYCHIATRY: The patient has a history of depression. The
patient is on lithium as an outpatient. He was maintained
on this. His lithium level on admission was within normal
limits. He was also maintained on Risperdal at bedtime.
1. HYPONATREMIA: There was no evidence of hyponatremia
during his hospital course.
1. MYOPATHY: The patient developed right hip flexor weakness
on [**7-10**]. A magnetic resonance imaging of his
lumbosacral spine revealed a L4-L5 disc herniation as well
as a right inferior ramus fracture. It was unclear
whether or not this was a new or old fracture. Plain
films may help in determining this. The patient was able
to ambulate.
The Orthopaedic Service was consulted to evaluate the
fracture. There was no evidence of cord compression on his
magnetic resonance imaging. The Orthopaedic Service felt
that the patient was able to weight bear as tolerated with
the assistance of physical therapy. The patient denied any
hip pain or pelvic pain, and overall right hip flexor
strength was [**3-26**].
NOTE: Discharge followup, medications, and Addendum to this
Discharge Summary to follow.
Dr.[**Last Name (STitle) **],[**First Name3 (LF) 51907**] [**MD Number(4) 51908**]
Dictated By:[**Last Name (NamePattern1) 12866**]
MEDQUIST36
D: [**2190-7-13**] 14:51:30
T: [**2190-7-15**] 11:42:34
Job#: [**Job Number 51909**]
ICD9 Codes: 2875, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6037
} | Medical Text: Admission Date: [**2180-2-11**] Discharge Date: [**2180-2-23**]
Service:
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 10269**] is a 79-year-old
woman who had intermittent claudication of both legs for many
years. The claudication has continued to worsen to the point
where she has rest pain in her right foot.
Over the several weeks prior to surgery, she had a small
ulcer and developed a right fifth toe and heel ulcer of that
foot. Her pain is worse at night, and she was referred to
Dr. [**Last Name (STitle) **] for possible surgical intervention.
PAST MEDICAL HISTORY: (Her past medical history is
significant for)
1. Coronary artery disease; status post angioplasty in [**2166**].
2. She had a carotid endarterectomy in [**2164**].
3. She had a left lower extremity bypass with a prosthetic
graft; she thinks a femoral to anterior tibial graft in [**2170**].
4. She also had a thyroidectomy.
5. Hysterectomy.
6. Open reduction/internal fixation of a lift hip fracture.
MEDICATIONS ON ADMISSION: Inderal, Cardizem, Capoten,
Coumadin, nitroglycerin patch, Beconase, [**Doctor First Name **], and Nexium.
ALLERGIES: Allergy to PROCARDIA, PERCODAN, and KEFLEX.
SOCIAL HISTORY: The patient does not smoke currently. The
patient is married and lives with her husband.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed a well-appearing elderly woman. Heart rate was 54,
blood pressure was 130/72, respiratory rate was 14. There
was a loud right cervical bruit. The chest was clear. The
heart was regular in rate and rhythm. The abdomen was soft
and nontender. No aneurysm or bruit palpated. Her right
femoral pulse was nonpalpable. A very faint palpable pulse
in the left groin. All distal pulses were absent. There was
a rubor of the right foot with elevational pallor. There was
a 3-mm shallow ulcer on the plantar surface of the right heel
and an even smaller ulcer in the lateral aspect of her right
fifth toe.
RADIOLOGY/IMAGING: The patient had an arteriogram done in
[**2179-12-5**] which showed extensive aortoiliac
atherosclerosis with critical stenosis in the right common
iliac and extensive high-grade stenosis throughout both
external iliac arteries. The common femoral arteries were
somewhat diseased. Both superficial femoral arteries were
occluded. There were good-looking profundi bilaterally.
There was also significant stenosis in the origin of both
renal arteries and possibly an superior mesenteric artery
stenosis as well.
HOSPITAL COURSE: The patient had a magnetic resonance
angiography done that showed similar findings as the
angiogram with high-grade left renal artery stenosis,
moderate right renal artery stenosis, moderate-to-severe
proximal superior mesenteric artery stenosis, diffuse
atheromatous plaques in the abdominal aorta, suprarenal,
infrarenal aneurysmal dilatation of the abdominal aorta. On
the right, severe proximal common iliac artery stenosis with
severe distal external iliac artery stenosis on the right.
An occluded superficial femoral artery on the right. The
profunda femoris artery which supplies collaterals that
reconstitute above the knee, the popliteal artery on the
right. On the left, there is moderate stenosis of the left
common iliac artery, and an occluded superficial femoral
artery graft. The profundus femoris artery supplies
collaterals. It also reconstitutes the popliteal artery on
that side.
The patient received cardiac clearance preoperatively, and
the surgical options were discussed. It was decided to
perform and aortobifemoral profunda bypass graft. The
patient agreed and was taken to the operating room on
[**2180-2-11**] with aortobifemoral profundus bypass graft
was performed by Dr. [**Last Name (STitle) **]. Estimated blood loss was
600 cc. Urine output during the case was 450 cc. The
patient received one unit of packed red blood cells and 5.6
liters of crystalloid. The patient was taken to the
Postanesthesia Care Unit in stable condition with good
affect.
Postoperatively, the patient had warm extremities, with a
dopplerable dorsalis pedis pulse on the right and a
dopplerable posterior tibialis pulse on the left with good
capillary refill. Her hematocrit was 27.1 and magnesium was
1.2. The patient was given one unit of blood.
Over the first night postoperatively, the patient had an
increasing volume requirement and an continued increasing
oxygen requirement. Blood gas in the morning was
7.24/59/169/27 and -3 on 70% oxygen. The patient also had
increasing complaints of pain overnight. At that time, the
patient was also on a fenoldopam drip at 0.15 mcg/kg per
minute to 30. At this time, the patient was on vancomycin
and Flagyl with no source of infection. The patient was
afebrile at that time.
On the evening on postoperative day two, the patient had
increasing heart rates into the 100s with a narrow complex
tachycardia on electrocardiogram. At this time, the patient
end-diastolic pressure was around 15, pulmonary artery
pressures in the middle 40s, saturating 98% on 3 liters face
mask.
Cardiology was consulted for the tachycardia. The diltiazem
drip was continued with rates in the middle 80s. The
tachycardia likely secondary to congestive heart failure.
With a rising white blood cell count, ischemia needed to be
ruled out, and the General Surgery team was consulted, and a
sigmoidoscopy was performed which just showed diverticulosis
of the sigmoid colon with normal mucosa up to 30 cm with no
evidence of ischemia to this 30-cm point.
On postoperative day four, the patient was continued on the
diltiazem drip and Lasix for diuresis with a total of four
liters out over the past 24 hours. The patient was also
continued on beta blockade as well as vancomycin. For pain
control, the epidural catheter was discontinued and a
Dilaudid patient-controlled analgesia was being used with
good affect.
On postoperative day five, the tachycardia had improved, with
pulses in the 80s with a diltiazem drop and Lopressor.
On postoperative day six, the patient's diet was advanced to
clear liquids. The patient was also on oral diltiazem and
intravenous Lopressor with good rate control in the 70s. The
patient was also in good pain control with a Dilaudid
patient-controlled analgesia. The patient continued to have
intermittent episodes of atrial fibrillation. A few of these
episodes of paroxysmal atrial fibrillation, but returned to
sinus rhythm in a short time with no specific treatment.
The rest of the [**Hospital 228**] hospital course was fairly
uneventful, but with a white blood cell count currently at
11. The patient had an ultrasound of the right upper
quadrant which showed an enlarged gallbladder with edema with
a normal common bile duct and the suggestion of a dilated
intrahepatic duct. The patient did have a [**Doctor Last Name **] sign, and
General Surgery was asked to evaluate the patient for
cholecystitis.
The patient's symptoms actually significantly improved. Her
abdominal pain completely dissipated. Her liver function
tests revealed AST was 16, ALT was 24, alkaline phosphatase
was 200, total bilirubin was 0.6, direct bilirubin was 0.5,
amylase was 31, and lipase was 56.
The patient was seen by Dr. [**Last Name (STitle) 13797**]. At that time, no
intervention was deemed necessary considering her remarkable
clinical improvement. A HIDA scan had been done on the same
day as the ultrasound and was consistent with acute
cholecystitis; however, the patient continued to improve with
antibiotics. The General Surgery consultation physician (Dr.
[**Last Name (STitle) 13797**] felt conservative management at this time was
appropriate. No further episodes of abdominal pain.
DISCHARGE DISPOSITION/CONDITION: The patient was in stable
condition and in sinus rhythm. The incisions were intact.
The incision of the left groin continued to drain some
serous fluid. There was no erythema, and no evidence of
infection.
MEDICATIONS ON DISCHARGE: (She was discharged on the
following medications)
1. Coumadin 5 mg p.o. q.o.d. and 2.5 mg p.o. q.o.d.
2. Flagyl 500 mg t.i.d. (for a 10-day course).
3. Levofloxacin 500 mg q.d. (for a 10-day course).
4. Lopressor 50 mg p.o. b.i.d.
5. Aspirin 81 mg p.o. q.d.
6. Captopril 25 mg p.o. t.i.d.
7. Diltiazem 60 mg p.o. q.i.d.
8. Ipratropium inhaler.
9. Albuterol inhaler.
10. Nexium.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with the Dr. [**Last Name (STitle) **] in two weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 7241**]
MEDQUIST36
D: [**2180-2-23**] 09:59
T: [**2180-2-23**] 10:32
JOB#: [**Job Number 46518**]
ICD9 Codes: 9971, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6038
} | Medical Text: Admission Date: [**2132-8-12**] Discharge Date: [**2132-8-22**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
abdominal distension, discomfort and liquid stool x 2 weeks.
Major Surgical or Invasive Procedure:
rectal tube placement
History of Present Illness:
[**Age over 90 **] yo F with [**Hospital 31756**] transfered from [**Hospital 100**] Rehab with abdominal
distension, discomfort, and liquid stool for 2 weeks. No
nausea, vomiting, fever, or anorexia. History fo fecal
impaction.
Past Medical History:
dementia, depression, COPD, dysphagia, spinal stenosis, legally
blind, urinary retention, GERD
Social History:
Lives at [**Hospital 100**] rehab
Family History:
Non-contributary
Physical Exam:
T 98.6 HR 65 BP 158/82 RR 18 SO2: 91% on RA
GEN: pt awake and responding appropriately to questions
HEENT: PERRLA
Resp: CTAB
CV: RRR
AB: + bs, soft, nt, nd
Ext: no edema
psych: oriented to person
Pertinent Results:
KUB [**8-12**] 4:30 pm: IMPRESSION: Massively dilated sigmoid colon
gas with a coffee bean appearance in the mid-abdomen, highly
suspicious for sigmoid volvulus.
KUB [**8-12**] 6:20 pm: IMPRESSION: Interval placement of sigmoid tube
with decompression of previously seen sigmoid volvulus.
KUB [**2132-8-13**] 8:10 IMPRESSION: Decompression of previously seen
sigmoid volvulus.
KUB [**2132-8-13**] 4:00 pm IMPRESSION:
1. Status post removal of the rectal tube, no evidence of
volvulus
recurrence.
2. Interval increase in extent of the right lower lung
opacities, a followup with a dedicated chest radiograph is
recommended.
KUB [**2132-8-14**] 7:22 AM IMPRESSION: Interval recurrence of sigmoid
colon dilatation, an asymmetric appearance and absence of
dilation of proximal large bowel, may represent pseudovolvulus.
KUB [**2132-8-14**] 5:21 PM IMPRESSION: Interval placement of rectal
tube into the sigmoid colon with decompression of a previously
seen sigmoid distention.
KUB [**2132-8-16**] 10:07 AM IMPRESSION: Rectal tube present. No
volvulus identified. No obstruction identified.
KUB [**2132-8-16**] 10:20 PM The rectal tube has been withdrawn to the
level of the rectum. Air is seen throughout the rectum. No
findings to suggest obstruction. No grossly dilated small bowel
is identified.
KUB [**2132-8-17**] 1:36 PM FINDINGS: Rectal tube appears to be placed
within the rectosigmoid, which contains air. Bowel loops
proximal to this appear to being decompressed. Bowel wall mucosa
cannot be well described as the bowel is decompressed. If there
is continuing clinical concern for ischemia, CT with intravenous
contrast may be helpful.
KUB [**2132-8-17**] 6:23 PM The rectal tube has been placed more
proximally within the sigmoid. Again noted is one abnormal
colonic loop with a thumbprinting pattern. This pattern is
nonspecific but can be associated with ischemia. Correlate with
clinical findings. The remainder of the bowel is otherwise
unremarkable. This finding was discussed by the radiology
resident with surgery.
KUB [**2132-8-17**] 8:20 AM IMPRESSION: No volvulus identified. One of
the colonic air filled loops appears to have a thumb-print
pattern, a findings that can be associated with ischemia.
Findings transmitted to the nurse caring for the patient at the
time of interpretation.
COLON (GASTROGRAF) [**2132-8-19**] 11:02 AM GASTROGRAFIN ENEMA:
Gastrografin was administered per rectum under constant
fluoroscopic guidance. Although there is a capacious sigmoid
colon, there is no evidence of sigmoid volvulus. Sacttered
sigmoid diverticuli are noted. Contrast passed through to the
cecum without evidence of obstruction. Scout image demonstrates
diffuse atherosclerotic calcification of the abdominal aorta and
iliac system.
IMPRESSION:
1. No evidence of obstruction or volvulus.
2. Sigmoid diverticulosis.
Cardiology Report ECHO Study Date of [**2132-8-20**]
Conclusions: The left atrium is normal in size. 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%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure(PCWP>18mmHg). Transmitral Doppler and tissue velocity
imaging are consistent with Grade II (moderate) LV diastolic
dysfunction. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The pulmonary artery systolic
pressure could not be determined. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Brief Hospital Course:
Pt was admited with abdominal distension and discomfort, with a
sigmoid volvulus seen on KUB. A rectal tube was placed in the ED
to decompress the air-filled sigmoid colon. Serial abdominal
exams showed improvement of tenderness, and the rectal tube was
removed on HD2. Serial KUB's showed resolution of volvulus. The
pt was initially npo and was advanced to clears on HD2. Bedside
swallow eval was performed on HD3 that yielded recommendations
to have a diet of p.o. thin liquids and puree-consistently
solids and 1:1 supervision at mealtimes. On HD3 the pt's diet
was advanced, however the pt became more distended and repeat
KUB demonstrated recurrence of her volvulus. Her volvulus was
again successfully decompressed with rectal tube placement. On
HD5 on transport back from radiology the pt desaturated on room
air and was transferred to the trauma-SICU. EKG and cardiac
enzymes were found to be negative for acute MI. On HD6 she was
started on cipro for a UTI and finished a 3 day course of cipro.
On HD8 her diet was advanced. On HD10 she was started on p.o.
lopressor for hypertension and given instructions to follow up
with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of this medication
and of her hypertension. Her foley was also discharged on HD10.
The pt was discharged in stable condition to [**Hospital1 10151**] on HD11.
Medications on Admission:
ativan, tylenol, [**Last Name (LF) 11346**], [**First Name3 (LF) **], dulcolax, zoloft, lovastatin,
senna, selsun
Discharge Medications:
Resume home meds: ativan, tylenol, [**Last Name (LF) 11346**], [**First Name3 (LF) **], dulcolax,
zoloft, lovastatin, senna, selsun
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Disp:*30 Suppository(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for cough, sob.
Disp:*30 nebs* Refills:*0*
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
Disp:*60 injection* Refills:*2*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for loose stools.
Disp:*30 Tablet(s)* Refills:*2*
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for cough, sob.
Disp:*30 nebs* Refills:*0*
13. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
Disp:*600 ml* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Sigmoid volvulus
urinary tract infection
Discharge Condition:
Stable to rehab facility
Discharge Instructions:
You came into the hospital with a sigmoid volvulus
Treatment:
* Drink plenty of liquids (unless your doctor has told you not
to.)
* A high fiber diet, containing fresh fruits and vegetables,
whole grain breads, and cereals, may help prevent constipation
and keep your bowel movemnents soft and regular. This diet is
recommended unless your doctor recommends otherwise.
* Exercising regularly can also help you avoid constipation. Do
not over-exert yourself if you have medical conditions for which
strenuous exercise could be harmful.
* Be sure to continue on a bowel medicine regemin, especially if
taking pain medications or other medications that can be
constipating.
* Be sure to take any prescribed medications as you were
instructed. Continue your previously prescribed medications
unless you were instructed to do otherwise.
Warning Signs:
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* [**Name2 (NI) **] are not getting better in 24 hours, or you are getting
worse in any way.
* New or worsening constipation, decreased or absent bowel
movements, pain with bowel movements, or lack of flatus
("passing gas.")
* New or worsening abdominal (belly) pain, discomfort, cramping,
pressure, or bloating.
* New or worsening nausea or vomiting.
* Shaking chills, or a fever greater than 102 degrees (F)
* Bleeding in your bowel movements, dark, black, tarry bowel
movements, or bloody vomiting.
* Weakness, numbness, tingling, urinary retention, or
incontinence or stool or urine.
* Dizziness, confusion or change in behavior.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
You should follow up with your primary care physician for
control of your blood pressure, which has been elevated during
this hospital admission. A blood pressure lowering medication
has been started and needs to be regulated by your primary care
physician.
ICD9 Codes: 496, 5990, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6039
} | Medical Text: Admission Date: [**2133-6-6**] Discharge Date: [**2133-6-19**]
Date of Birth: [**2078-2-6**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Paraesthesia, right visual impairment and right eye pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55 [**Name Initial (MD) **] IV RN who works at the [**Hospital1 2025**] was transfered from the
[**Hospital 27217**] Hospital with a right brainstem hemorrhage. Her
symptoms
started around 19:45 h while she was having dinner with her
husband, and she described the following sequence of events:
Symptoms started with left face and hand tingling and a right
retro-orbital pain. Her husband noted that her speech was
slurred and the left side of face was droopy. The paramedics
took her BP and the systolic at the scene was
greater than 260 mmHg.
Past Medical History:
She has not seen a PCP in years, and was not aware or any
medical problems
Social History:
Lives with husband. Non-[**Name2 (NI) 1818**], nil alcohol
Family History:
Mother had HTN controlled on medications.
Father died of a stroke in his 50s
Physical Exam:
Vitals: Apyrexial, BP 182/92, HR 74, RR 20, O2 sats 97% on air
General: Sleepy but rousable, high BMI
HEENT: no meningismus, moist mucosal membranes
CVS: systolic murmur in the aortic area with no radiation to the
carotids
Resp: Lungs clear to auscultation B/L
GI: Soft, non-tender, normal BS
Neurological Examination
Mental status: Sleepy but cooperative with exam. Oriented to
person, place, and date. Able to spell "world" backwards.
Speech is fluent with normal comprehension and repetition.
Naming
intact. Dysarthria. Registers [**1-26**], recalls [**1-26**] in 5 minutes.
No
right left confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 2 mm bilaterally.
Visual fields are full to confrontation. right eye deviated
inwards with several beats of lateral nystagmus. Sensation
intact
V1-V3 diminished to pinprick, cold and soft touch on the left
hand side of the face. Facial movement asymmetric, slight left
facial droop. Palate elevation symmetric. Trapezius power
normal ([**3-30**]) bilaterally. Tongue protrudes to the left due to
the
weakness of the facial muscles.
Upper & Lower limb examination
Motor:
Normal bulk bilaterally. Tone normal. No observed clonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS
Reflexes:
+2 and symmetric throughout.
Plantars equivocal
Coordination: finger-nose-finger normal, heel to shin normal
Pertinent Results:
[**2133-6-14**] 02:08AM BLOOD WBC-9.8 RBC-4.60 Hgb-13.7 Hct-40.7 MCV-89
MCH-29.8 MCHC-33.7 RDW-13.8 Plt Ct-249
[**2133-6-13**] 03:10AM BLOOD WBC-9.6 RBC-4.27 Hgb-12.9 Hct-38.6 MCV-90
MCH-30.2 MCHC-33.5 RDW-13.6 Plt Ct-256
[**2133-6-12**] 01:53AM BLOOD WBC-9.3 RBC-4.00* Hgb-12.5 Hct-36.5
MCV-91 MCH-31.3 MCHC-34.3 RDW-13.8 Plt Ct-253
[**2133-6-11**] 02:05AM BLOOD WBC-9.3 RBC-4.14* Hgb-12.4 Hct-38.4
MCV-93 MCH-29.9 MCHC-32.2 RDW-13.9 Plt Ct-260
[**2133-6-10**] 01:50AM BLOOD WBC-10.0 RBC-4.21 Hgb-12.7 Hct-38.3
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.1 Plt Ct-236
[**2133-6-9**] 02:47AM BLOOD WBC-12.5* RBC-4.62 Hgb-13.9 Hct-41.6
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.1 Plt Ct-214
[**2133-6-8**] 12:22AM BLOOD WBC-16.5*# RBC-4.78 Hgb-14.5 Hct-42.9
MCV-90 MCH-30.3 MCHC-33.7 RDW-14.3 Plt Ct-259
[**2133-6-7**] 01:50AM BLOOD WBC-10.4 RBC-4.66 Hgb-13.8 Hct-42.0
MCV-90 MCH-29.6 MCHC-32.9 RDW-14.2 Plt Ct-235
[**2133-6-6**] 07:00AM BLOOD WBC-8.5 RBC-4.71 Hgb-14.2 Hct-41.0 MCV-87
MCH-30.1 MCHC-34.5 RDW-14.1 Plt Ct-259
[**2133-6-5**] 10:40PM BLOOD WBC-12.0* RBC-4.80 Hgb-14.4 Hct-41.8
MCV-87 MCH-29.9 MCHC-34.4 RDW-14.1 Plt Ct-235
[**2133-6-6**] 07:00AM BLOOD Neuts-89.4* Lymphs-7.0* Monos-3.1 Eos-0.2
Baso-0.4
[**2133-6-5**] 10:40PM BLOOD Neuts-90.5* Lymphs-6.5* Monos-2.2 Eos-0.4
Baso-0.3
[**2133-6-14**] 02:08AM BLOOD Plt Ct-249
[**2133-6-13**] 03:10AM BLOOD Plt Ct-256
[**2133-6-12**] 01:53AM BLOOD Plt Ct-253
[**2133-6-11**] 02:05AM BLOOD Plt Ct-260
[**2133-6-10**] 01:50AM BLOOD Plt Ct-236
[**2133-6-9**] 02:47AM BLOOD Plt Ct-214
[**2133-6-8**] 12:22AM BLOOD Plt Ct-259
[**2133-6-7**] 01:50AM BLOOD Plt Ct-235
[**2133-6-6**] 07:00AM BLOOD Plt Ct-259
[**2133-6-6**] 07:00AM BLOOD PT-13.9* PTT-22.4 INR(PT)-1.2*
[**2133-6-5**] 10:40PM BLOOD Plt Ct-235
[**2133-6-5**] 10:40PM BLOOD PT-13.7* PTT-21.9* INR(PT)-1.2*
[**2133-6-15**] 09:30AM BLOOD Glucose-170* UreaN-30* Creat-1.3* Na-143
K-3.7 Cl-103 HCO3-30 AnGap-14
[**2133-6-14**] 02:08AM BLOOD Glucose-128* UreaN-30* Creat-1.2* Na-143
K-4.0 Cl-104 HCO3-30 AnGap-13
[**2133-6-13**] 03:10AM BLOOD Glucose-115* UreaN-26* Creat-1.0 Na-144
K-3.4 Cl-106 HCO3-27 AnGap-14
[**2133-6-12**] 01:53AM BLOOD Glucose-128* UreaN-27* Creat-0.9 Na-145
K-4.2 Cl-110* HCO3-27 AnGap-12
[**2133-6-11**] 02:05AM BLOOD Glucose-137* UreaN-26* Creat-1.0 Na-148*
K-3.9 Cl-111* HCO3-29 AnGap-12
[**2133-6-10**] 01:50AM BLOOD Glucose-144* UreaN-30* Creat-1.0 Na-150*
K-3.5 Cl-111* HCO3-32 AnGap-11
[**2133-6-8**] 12:22AM BLOOD Glucose-143* UreaN-20 Creat-0.9 Na-145
K-3.9 Cl-109* HCO3-28 AnGap-12
[**2133-6-7**] 01:50AM BLOOD Glucose-135* UreaN-23* Creat-1.1 Na-143
K-4.0 Cl-107 HCO3-28 AnGap-12
[**2133-6-6**] 07:00AM BLOOD Glucose-160* UreaN-20 Creat-1.1 Na-144
K-4.1 Cl-104 HCO3-29 AnGap-15
[**2133-6-5**] 10:40PM BLOOD Glucose-185* UreaN-18 Creat-1.0 Na-144
K-3.7 Cl-105 HCO3-29 AnGap-14
[**2133-6-11**] 02:05AM BLOOD ALT-14 AST-15 LD(LDH)-244 AlkPhos-39
TotBili-2.5*
[**2133-6-10**] 01:50AM BLOOD ALT-17 AST-18 LD(LDH)-254* AlkPhos-45
TotBili-3.8*
[**2133-6-8**] 08:00PM BLOOD ALT-18 AST-16 LD(LDH)-303* AlkPhos-52
Amylase-15 TotBili-4.2* DirBili-0.5* IndBili-3.7
[**2133-6-6**] 05:59PM BLOOD CK(CPK)-134
[**2133-6-6**] 07:00AM BLOOD ALT-32 AST-21 CK(CPK)-176* AlkPhos-60
TotBili-1.6*
[**2133-6-5**] 10:40PM BLOOD ALT-37 AST-26 TotBili-1.7*
[**2133-6-8**] 08:00PM BLOOD Lipase-16
[**2133-6-6**] 07:00AM BLOOD CK-MB-5 cTropnT-<0.01
[**2133-6-5**] 10:40PM BLOOD cTropnT-0.01
[**2133-6-6**] 05:59PM BLOOD CK-MB-5
[**2133-6-5**] 10:40PM BLOOD CK-MB-6
[**2133-6-15**] 09:30AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
[**2133-6-14**] 02:08AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.1
[**2133-6-13**] 03:10AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.1
[**2133-6-12**] 01:53AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.2
[**2133-6-11**] 02:05AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2
[**2133-6-10**] 01:50AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.3
[**2133-6-9**] 02:47AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.4
[**2133-6-8**] 12:22AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2
[**2133-6-7**] 01:50AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.2 Cholest-219*
[**2133-6-6**] 07:00AM BLOOD Calcium-9.4 Phos-4.8* Mg-2.0 Cholest-225*
[**2133-6-5**] 10:40PM BLOOD Calcium-9.3
[**2133-6-7**] 02:25AM BLOOD %HbA1c-5.6
[**2133-6-7**] 01:50AM BLOOD Triglyc-127 HDL-43 CHOL/HD-5.1
LDLcalc-151*
[**2133-6-6**] 07:00AM BLOOD Triglyc-75 HDL-53 CHOL/HD-4.2
LDLcalc-157*
[**2133-6-8**] 12:22AM BLOOD TSH-0.86
[**2133-6-7**] 01:50AM BLOOD TSH-0.98
[**2133-6-6**] 07:00AM BLOOD TSH-1.3
[**2133-6-11**] 06:28AM BLOOD Vanco-19.9
[**2133-6-10**] 06:19AM BLOOD Vanco-17.0
[**2133-6-6**] 07:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2133-6-14**] 05:39AM BLOOD Type-ART pO2-114* pCO2-49* pH-7.43
calTCO2-34* Base XS-7
[**2133-6-13**] 03:10AM BLOOD Type-ART pO2-113* pCO2-43 pH-7.46*
calTCO2-32* Base XS-6
[**2133-6-12**] 02:38AM BLOOD Type-ART pO2-121* pCO2-44 pH-7.44
calTCO2-31* Base XS-5
[**2133-6-11**] 02:22AM BLOOD Type-ART pO2-98 pCO2-44 pH-7.49*
calTCO2-34* Base XS-9
[**2133-6-10**] 02:06AM BLOOD Type-ART pO2-88 pCO2-51* pH-7.43
calTCO2-35* Base XS-7
[**2133-6-9**] 03:10AM BLOOD Type-ART Temp-35.9 PEEP-5 FiO2-40 pO2-91
pCO2-51* pH-7.44 calTCO2-36* Base XS-8 Intubat-INTUBATED
Vent-SPONTANEOU
[**2133-6-8**] 07:46PM BLOOD Type-ART Temp-38.3 PEEP-5 pO2-105
pCO2-48* pH-7.41 calTCO2-31* Base XS-4 Intubat-INTUBATED
Vent-SPONTANEOU
[**2133-6-8**] 04:54PM BLOOD Type-ART Temp-38.3 PEEP-5 pO2-99 pCO2-48*
pH-7.41 calTCO2-31* Base XS-4 Intubat-INTUBATED Vent-SPONTANEOU
[**2133-6-8**] 12:45AM BLOOD Type-ART Temp-37.6 pO2-115* pCO2-46*
pH-7.39 calTCO2-29 Base XS-2
[**2133-6-9**] 03:10AM BLOOD Lactate-0.9 K-4.2
[**2133-6-8**] 04:54PM BLOOD Lactate-1.1 K-3.5
[**2133-6-8**] 12:45AM BLOOD Lactate-1.0
[**2133-6-12**] 02:38AM BLOOD O2 Sat-98
[**2133-6-11**] 02:22AM BLOOD O2 Sat-96
[**2133-6-10**] 02:06AM BLOOD O2 Sat-97
[**2133-6-13**] 03:10AM BLOOD freeCa-1.17
[**2133-6-11**] 02:22AM BLOOD freeCa-1.19
[**2133-6-10**] 02:06AM BLOOD freeCa-1.17
[**2133-6-9**] 03:10AM BLOOD freeCa-1.22
[**2133-6-8**] 07:46PM BLOOD freeCa-1.11*
[**2133-6-8**] 12:45AM BLOOD freeCa-1.22
Brief Hospital Course:
This 55 yo F was admitted with a right brainstem bleed, thought
to be secondary to extreme hypertension. No AVM or cavernoma was
appreciated on MRI/MRA. Pt was initially treated in the ICU,
where she developed a LLL PNA, treated with Augmentin and
Flagyl. She also developed jaundice to propofol and was sedated
instead with versed. She initally failed swallow eval and had an
NG tube which remained until [**2133-6-15**] when she pulled it out,
however, susbequent repeat swallow eval suggested she could
tolerate oral nutrition.
Pt's BP originally controlled with labetalol gtt, but then
placed on oral regimen of labetalol, lisinopril, and HCTZ.
Systolic BP's are running 130-180, and titration of her BP meds
is ongoing.
Symptomatically, she showed significant improvement, becoming
drowsy with improved HA and nausea. Eye movements continued to
improve, although on discharge she still has some dysconjugate
gaze, giving her what appears as a partial one-and-a-half
syndrome. Her vertigo is also significantly improved, however,
she still experiences dizziness on standing and has trouble
taking more than a few steps without feeling like she is going
to fall. She is continuing to work with PT/OT, and was
discharged to rehab facility on [**2133-6-19**]
Medications on Admission:
ASA prn HA
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-26**]
Drops Ophthalmic PRN (as needed).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 1 weeks: last dose [**2133-6-21**].
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 weeks: last dose [**2133-6-21**].
6. Labetalol 100 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
7. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
8. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Ten (10) mg
Intravenous Q6H (every 6 hours) as needed for SBP>180.
9. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q4H
(every 4 hours) as needed for SBP > 160.
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: prn pain or fever.
12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
pontine hemorrhage
hypertension
Discharge Condition:
stable
Discharge Instructions:
You have had a stroke in your brainstem. We think that this was
most likely secondary to uncontrolled hypertension so
controlling your blood pressure is going to be very important.
You may also need to have repeat imaging of your brain in the
future to ensure that there is not a cavernous angioma
underlying the bleed. Follow up with your appointments as
below.
Followup Instructions:
Neurologist: [**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2133-7-21**] 1:30 [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **]
Please call ([**Telephone/Fax (1) 1300**] to get a PCP at [**Hospital 18**] [**Hospital **], unless you would like to get a PCP [**Name Initial (PRE) 79638**]. This
will be extremely important in managing your blood pressure.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2133-6-19**]
ICD9 Codes: 431, 486, 2760, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6040
} | Medical Text: Admission Date: [**2152-10-13**] Discharge Date: [**2152-10-22**]
Date of Birth: [**2110-1-16**] Sex: M
Service: PLASTIC
Allergies:
Amphotericin B / Ambisome / Campath
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
Right facial wound and cervicofacial sarcoma.
Major Surgical or Invasive Procedure:
1. Right anterolateral free flap to right face using the
right facial artery and common facial vein.
2. Repair of orocutaneous fistula.
3. Split thickness skin graft 14 x 20 cm at 0.014 inch.
4. Closure of extensive cervicofacial defect which included
exposed zygoma, exposed maxillary bone, exposed lateral
portion of the frontal bone.
History of Present Illness:
The patient is a 42-year-old male
who is a patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] with a history of
total body irradiation as well as graft versus host disease
following bone marrow transplant several years ago. The patient
then had subsequently developed lesion of the right facial
region
as well as the left cheek area that was biopsied approximately 1
week ago. He was seen in the operating room at [**Location (un) 37217**]
originally for assessment of the wound. The lesion was fully
excised and margins were sent off and a bolster dressing was
placed. He presents to the office for changes of the dressing
and removal of the bolster and preoperative planning.
Past Medical History:
#. MUD allo BMT [**10-8**] for CML, c/b GVHD, chronic
thrombocytopenia, anemia,
Donor Info: donor #[**Numeric Identifier 37214**]
Sex: female,
Age: 37,
# of pregnancies: 4,
ABO donor: Apos,
ABO recipient: Apos,
CMV donor: (+),
CMV recipient:(+)
#. GVHD--symptoms have included severe skin findings,
thrombocytopenia requiring transfusions, bronchiolitis
obliterans and mouth sores. treatment options are limited, since
the patient has also had HUS to calcineurin inhibitors such as
cyclosporine, FK 506, no response to rapamycin, has had multiple
trials of Rituxan as well as trial of endostatin all without
signficant improvement.
#. BOOP due to GVHD. He unfortunately has had multiple prior
therapies including Rituxan, pentostatin, Campath, steroids, and
CellCept. He has had a significant issue as in the past with
cyclosporin and FK-506. The patient had a repeat chest CT in
[**2150-12-8**] to reassess his lung disease. There were no
significant changes in the few opacities that may represent
underlying BOOP since his last scan several months ago.
#. RSV pneumonitis
#. HTN
#. CRI
#. portacath in place
#. chronic right extremity edema
#. episodic spasm of mouth muscles, unclear etiology.
#. Obstructive airways disease, possibly due to GVDH.
Social History:
no EtOH, tobacco, drugs
Family History:
Non-contributory
Physical Exam:
AOx3
Facial wound:
The wound measures at least 17 cm in greatest dimension by
another 15 cm which includes the entire right side of his face.
His zygomatic arch is exposed and the anterior maxillary wall is
exposed. There are elements of parotid gland that are also
exposed. There is no salivary fistula intraorally that is
noted.
He has cutaneous changes over
his entire body from the graft versus host disease.
Pertinent Results:
[**2152-10-13**] 01:47PM BLOOD WBC-7.9 RBC-2.48* Hgb-8.7* Hct-25.9*
MCV-104* MCH-35.2* MCHC-33.7 RDW-16.0* Plt Ct-378
[**2152-10-18**] 03:12AM BLOOD WBC-7.9 RBC-2.33* Hgb-7.9* Hct-23.6*
MCV-101* MCH-33.8* MCHC-33.4 RDW-17.2* Plt Ct-250
[**2152-10-13**] 01:47PM BLOOD Plt Ct-378
[**2152-10-13**] 09:40PM BLOOD PT-11.3 PTT-23.3 INR(PT)-1.0
[**2152-10-17**] 01:46AM BLOOD PT-11.2 PTT-25.4 INR(PT)-0.9
[**2152-10-18**] 03:12AM BLOOD Plt Ct-250
[**2152-10-13**] 09:40PM BLOOD Glucose-114* UreaN-15 Creat-1.0 Na-139
K-4.9 Cl-107 HCO3-27 AnGap-10
[**2152-10-18**] 03:12AM BLOOD Glucose-94 UreaN-20 Creat-1.0 Na-141
K-4.4 Cl-108 HCO3-24 AnGap-13
[**2152-10-13**] 09:40PM BLOOD Calcium-9.0 Phos-3.0 Mg-2.1
[**2152-10-18**] 03:12AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.6
[**2152-10-13**] 06:50PM BLOOD Type-ART Temp-36.6 Rates-/8 Tidal V-600
FiO2-40 pO2-176* pCO2-43 pH-7.44 calTCO2-30 Base XS-5
Intubat-INTUBATED Vent-CONTROLLED
[**2152-10-14**] 03:30AM BLOOD Type-ART Tidal V-550 pO2-186* pCO2-45
pH-7.40 calTCO2-29 Base XS-2 -ASSIST/CON Intubat-INTUBATED
[**2152-10-16**] 06:05AM BLOOD Type-ART pO2-178* pCO2-40 pH-7.43
calTCO2-27 Base XS-2
[**2152-10-17**] 09:25AM BLOOD Type-ART pO2-86 pCO2-36 pH-7.50*
calTCO2-29 Base XS-4
[**2152-10-13**] 06:50PM BLOOD Glucose-81 Na-137 K-4.3
[**2152-10-13**] 06:50PM BLOOD Hgb-10.1* calcHCT-30
[**2152-10-13**] 06:50PM BLOOD freeCa-1.16
[**2152-10-17**] 01:54AM BLOOD freeCa-1.18
Brief Hospital Course:
Pt. admitted and operation proceded with. Flap applied to face
from R ant. thigh, R ant. thigh covered with STSG from L ant.
thigh. Please see detailed Op Note for full details of this
operation. Pt. in PACU for frequent flap checks for first 24hr
post-procedure. Initial low UOP responded promptly to a 500cc
bolus. Pt.'s intubation continued, and pt. remained sedated and
ventilated due to tenuous nature of flap and prominent facial
edema. Pt. transferred to ICU for further care/ventilation/q2hr
flap checks without incident. Pt. remained hemodynamically
stable with excellent dop tones in the flap throughout this
period. An NG tube was placed and tube feeds were slowly
advanced during this time, begining on [**10-15**]. L thigh donor site
was open to air beginning on [**10-16**]. Nutrition was consulted and
provided excellent assisstance with tube feeding recs. Pt.
extubated without incident on [**10-16**]. Tube feeds were slowly
increased and eventually moved to bolus feeds. Facial/flap
edema slowly decreased and one drain was removed. PT saw the
patient and assissted with post-discharge care. Pt. came out to
floor on [**10-18**]. The Vac was taken off the R ant. thigh and the
STSG was observed to have good take. NGT was removed and the
patient advanced to full liquids. At some point the pt. had
transient dysuria, a U/A was done and was clean, and his
symptoms resolved. When the patient was D/C'd his pain was well
controlled, he was tolerating PO well, and was able to ambulate
and void on his own.
Medications on Admission:
acyclovir
Prednisone 5
metoprolol
Folic Acid
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-8**]
Drops Ophthalmic PRN (as needed).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*250 ML(s)* Refills:*1*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
10. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO twice a day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
11. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Cervicofacial sarcoma of the right
face.
Discharge Condition:
good
Discharge Instructions:
Please return to the hospital if you experience fevers greater
then 101.4, chills, or other signs of infection. Also return to
the hospital if you experience chest pain, shortness of breath,
redness, swelling, or purulent discharge from the incision site.
Return if you experience worsening pain or any other concerning
symptoms.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
Restart taking all your regular medications once you arrive at
home.
-Please do not shower until your follow-up visit.
.
Please do not place any pressure on your face, especially the
surgical site. Please keep track of JP
drain output for your follow-up visit. Please continue to take
antibiotics until your drains are out. If you run out of
antibiotics before your drains are removed, please call us
immediately to get a refill.
.
Please resume previous medications as prior to your surgery.
Please take pain medications and stool softener as prescribed.
.
Please follow-up as directed.
Followup Instructions:
F/u with Dr. [**First Name (STitle) **] as directed, please call monday for an
appointment.
ICD9 Codes: 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6041
} | Medical Text: Admission Date: [**2123-5-17**] Discharge Date: [**2123-5-18**]
Date of Birth: [**2123-5-11**] Sex: M
Service: Neonatology
HISTORY: [**Known lastname **] [**Known lastname **] is a former 35-6/7 week male infant
who is six days old with hyperbilirubinemia. He was
delivered on [**5-11**] by C section with Apgars of 8 and 9.
Mother's prenatal course was significant for cerclage at 28
weeks of gestation, history of chronic hypertension, and
borderline preeclampsia. Per report, mother's prenatal
screens were negative, blood type B+.
[**Known lastname 43967**] birth weight was 2705 grams and his newborn nursery
course was benign. His bilirubin on [**5-14**] was 12 at
which time he was discharged to home on the following day.
At home, he has been doing well. Has been receiving breast
milk every three hours, taking 2 ounces at each feeding. He
has been voiding well and stooling multiple times per day.
No change in his activity.
[**Known lastname **] was seen in the Pedi office on the day of admission.
Given clinical symptoms of jaundice, the bilirubin level was
sent revealing a level of 19.2 (by heel stick), and
subsequently referred to [**Hospital1 69**]
for admission and management of hyperbilirubinemia.
PHYSICAL EXAMINATION: Current weight is 2590 grams.
Anterior fontanel is open and flat, well appearing. Normal
S1, S2, no murmurs. Breath sounds clear. Abdomen was soft,
nontender, nondistended. Extremities: Warm and well
perfused. Tone appropriate for gestation age. Testes
descended bilaterally. Circumcision site healing well.
HOSPITAL COURSE BY SYSTEMS:
Respiratory: [**Known lastname **] remained on room air with one episode
of choking with feeds. No other issues.
Cardiovascular: [**Known lastname **] had remained hemodynamically stable
during this admission.
FEN: [**Known lastname **] has maintained a minimum of 150 cc/kg/day po
feeding, tolerating breast milk well. His weight on
discharge was 2590 grams.
GI: Given the initial bilirubin level in the pediatrician's
office was done by heel sticks, a bilirubin level was resent
upon admission which was 17.6 by venipuncture. [**Known lastname **] was
started on triple phototherapy with subsequent lowering of
the bilirubin level to 15.9 at which time phototherapy was
decreased to double. The next morning [**Known lastname 43967**] bilirubin
level was 13.5 at which time phototherapy was discontinued.
Given the resolution of hyperbilirubinemia, [**Known lastname **] is to be
discharged home with a followup rebound bilirubin to be drawn
in the pediatrician's office the next morning.
Hematology: [**Known lastname **] was ruled out for infection with a
benign complete blood count with a white count of 11.3
thousand with 33 polys and 0 bands. No antibiotics was
started.
Baby's admission hematocrit was 58.6% with a retic of 1.5%.
Therefore it was felt that it was unlikely that hemolysis was
the cause of his hyperbilirubinemia.
CONDITION ON DISCHARGE: [**Known lastname 43967**] hyperbilirubinemia has
resolved with bilirubin on the morning of discharge of 13.5.
He has been taking po well and stooling well.
DISCHARGE/DISPOSITION: [**Known lastname **] is to go home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 52069**], telephone
#[**Telephone/Fax (1) 37875**].
CARE AND RECOMMENDATIONS: Feeds at discharge breast milk po
adlib.
MEDICATIONS: None.
FOLLOW-UP APPOINTMENT: Dr. [**Last Name (STitle) 52069**] tomorrow morning for a
rebound bilirubin level.
DISCHARGE DIAGNOSIS: Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Name8 (MD) 47839**]
MEDQUIST36
D: [**2123-5-18**] 14:00
T: [**2123-5-18**] 14:13
JOB#: [**Job Number 52070**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6042
} | Medical Text: Admission Date: [**2173-12-15**] Discharge Date: [**2173-12-18**]
Date of Birth: [**2111-12-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Bilateral shoulder and arm pain
Major Surgical or Invasive Procedure:
cabg x4 [**2173-12-15**] (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to
PDA)
History of Present Illness:
61 yo male with recent pain as above and + ETT.Carotid US showed
an occluded [**Country **] and 70-79% [**Doctor First Name 3098**] stenosis. Left carotid stent
placed [**12-9**]. Cath. revealed severe 3VD. Referred for CABG.
Past Medical History:
CAD:
-BMS to LCx, DES to 1st diagonal in [**12-16**]
-3 vessel disease on cath on [**12-6**]--99% mid RCA, 85% prox LAD,
80% OM1
severe carotid disease s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stent
CVA '[**68**]
HTN
HPLD
BPH
B/l inguinal herniorraphies
Basal Cell Cancer s/p resection
Lumbar radiculopathy
Social History:
Married, 2 children. Works in construction.
Denies drugs.
Quit smoking 15 years ago
Drinks 1 glass of wine per day
Family History:
CAD-Father, MI [**45**] years old
Physical Exam:
at discharge:
VS:99.4TEMP 140/80BP 88HR SR 20RR
Gen: NAD, appears stated age
Lungs:CTA B/L
CV:RRR, no murmurs, clicks, or rubs
Abd:distended, non-tender, decreased bowel sounds, positive
bowel movements
Ext:trace edema LE
Incision:C/D/I, no erythema, sternum stable
Pertinent Results:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Right ventricular
chamber size and free wall motion are normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to 22 cm from the incisors.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are structurally normal. There is no pericardial
effusion.
Post Bypass
Preserved LV function with EF of 65%
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD, Interpreting
physician
CXR:
[**Known lastname 80109**],[**Known firstname **] J [**Medical Record Number 80110**] M 61 [**2111-12-29**]
Radiology Report CHEST (PA & LAT) Study Date of [**2173-12-20**] 8:39 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2173-12-20**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 80111**]
Reason: f/u atx, effusion
[**Hospital 93**] MEDICAL CONDITION:
61 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
f/u atx, effusion
Provisional Findings Impression: JMGw MON [**2173-12-20**] 10:48 AM
Small bilateral pleural effusions. Improving bilateral basilar
atelectasis.
Less bowel dilatation.
Final Report
PA LATERAL CHEST RADIOGRAPH
HISTORY: 61-year-old man status post CABG. Evaluate for
pneumothorax or
effusion.
COMPARISON: Chest radiograph from [**2173-12-17**], [**2173-12-15**] and
[**2173-12-6**].
FINDINGS: There is stable cardiomegaly. The aorta is tortuous
but stable in
appearance and the hilar and mediastinal contours are unchanged
in appearance.
Patient is status post median sternotomy and CABG. Sternotomy
cerclage wires
are stable in appearance. There are small bilateral pleural
effusions. There
is improved bilateral basilar atelectasis. There is less bowel
dilatation
compared to [**2173-12-17**]. There is no pneumothorax.
IMPRESSION:
1. Small bilateral pleural effusions. Improving bilateral
basilar
atelectasis.
2. No pneumothorax.
3. Less bowel dilatation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 13879**] [**Name (STitle) 13880**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: MON [**2173-12-20**] 11:40 AM
Imaging Lab
[**2173-12-20**] 05:50AM BLOOD Plt Ct-283
[**2173-12-20**] 05:50AM BLOOD Glucose-143* UreaN-35* Creat-0.9 Na-142
K-3.6 Cl-107 HCO3-30 AnGap-9
[**2173-12-18**] 07:05AM BLOOD ALT-15 AST-18 LD(LDH)-312* AlkPhos-82
Amylase-23 TotBili-0.5
[**2173-12-20**] 05:50AM BLOOD Mg-2.3
Brief Hospital Course:
Admitted [**12-15**] and underwent coronary artery bypass surgery with
Dr. [**Last Name (STitle) **]. Please see operative note for further details.
Transferred to the CVICU in stable condition on titrated
propofol and phenylephrine drips. Extubated later that day.
Transferred to the floor on POD #1 to begin increasin his
activity level. Gently diuresed toward his preop weight. Chest
tubes and pacing wires were discontinued without complication.
On POD 3 the patient was noted to have significant abdominal
distention. KUB revealed evidence of colonic ileus, including
air-fluid levels. Nasogastric tube was placed in an effort to
decompress the GI tract. GI and general surgery services were
consulted. C-diff toxin was sent and returned negative. The
patient remained afebrile with a normal white blood cell count.
Rectal tube was placed, and eventually ileus resolved.
Additionally, the patient went into atrial fibrillation,
briefly, on POD 4. He received a fluid bolus, amiodarone, and
his beta blocker was increased. He returned to sinus rhythm
shortly thereafter, and would remain in sinus rhythm throughout
the hospital course.
The physical therapy service was consulted for assistance with
strength and mobility. The patient made excellent progress and
was discharged home on POD 6.
Medications on Admission:
lisinopril 10 mg daily
flomax 0.4 mg daily
plavix 75 mg daily
atenolol 50 mg daily
lipitor 80 mg daily
isosorbide 60 mg daily
finasteride 5 mg daily
ASA 81 mg daily
loratidine 10 mg 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*10 ML(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
13. 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:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
CAD s/p BMS to CX, DES to diag 1 ; s/p cabg x4
HTN
carotid stenoses s/p left carotid stent
s/p CVA 5 years ago
lumbar radiculopathy
basal cell CA s/p resection forehead and back
BPH
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness or drainage
call for weight gain greater than 2 pounds in one day , or 5
pounds in a week
no lifting greater than 10 pounds for 10 weeks
no driving for one month and until off all narcotics for pain
Followup Instructions:
see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-10**] weeks. [**Telephone/Fax (1) 28095**]
see Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**3-14**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
please call for all appts.
Completed by:[**2173-12-21**]
ICD9 Codes: 4019, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6043
} | Medical Text: Admission Date: [**2178-4-5**] Discharge Date: [**2178-4-7**]
Date of Birth: [**2117-12-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
60 yo F PMH of DM, HTN, fibroid s/p TAH who p/w symptomatic
anemia (weakness, SOB) and black tarry stools since last
Wednesday. She was her PCP today for the weakness and hct there
was 21 so she was referred to the ED. She has no prior h/o GIB
and had a colonoscopy [**2-/2178**] which showed only a polyp, no
diverticulosis. She does report that she has intermittently has
had dark stools. Never had an EGD. Baseline hct in [**2177-11-11**]
was 47. Takes ASA 81mg, no other NSAIDS or anticoac meds.
In the ED, initial vs were 98.4 105 144/82 28 98. NG lavage
negative for coffee grounds or active bleeding. Patient was
given 2L IVF and 2 units RBC and GI was consulted who
recommended ICU admission given dramatic drop in hct 47--->21.
She remained HD stable. EKG with sinus tach to low 100's without
ischemic change. No PPI given. VS prior to transfer: BP 147/65,
HR 104, Pox 98RA, RR 16.
Past Medical History:
DM
HTN
Obesity
Fibroid s/p TAH
Social History:
Works as SW at the [**Hospital1 **]. Lives with daughter and 2
grandchildren
- Tobacco: none
- Alcohol: 3 glasses red wine/week
- Illicits: none
Family History:
DM and HTN
Physical Exam:
Vitals T: 99.3 HR: 100 BP: 128/70 RR: 16 O2: 98%RA
General: NAD, sitting comfortably straight up in bed.
HEENT: Normocephalic, atraumatic, sclera anicteric, trachea
midline and no lymphadenopathy appreciated.
Pulm: CTAB
CV: RRR, S1S2, no m/r/g
Abd: Obese, soft, +BS, NT/ND, no guarding, no rebound
Extrem: + DP pulses b/l, no edema
Neuro: A+O x 3
Pertinent Results:
[**2178-4-5**] 05:00PM BLOOD WBC-11.8* RBC-2.42* Hgb-7.2* Hct-21.6*
MCV-89 MCH-29.8 MCHC-33.4 RDW-17.1* Plt Ct-307
[**2178-4-5**] 11:35PM BLOOD Hct-26.0*
[**2178-4-6**] 04:16AM BLOOD WBC-9.6 RBC-3.10*# Hgb-9.3*# Hct-27.4*
MCV-89 MCH-30.0 MCHC-34.0 RDW-16.3* Plt Ct-256
[**2178-4-6**] 11:19AM BLOOD Hct-30.3*
[**2178-4-7**] 06:44AM BLOOD WBC-9.0 RBC-3.70* Hgb-11.1* Hct-33.4*
MCV-90 MCH-30.0 MCHC-33.3 RDW-17.4* Plt Ct-269
[**2178-4-6**] 04:16AM BLOOD PT-12.6 PTT-19.4* INR(PT)-1.1
[**2178-4-5**] 05:00PM BLOOD Glucose-194* UreaN-5* Creat-0.5 Na-138
K-3.6 Cl-99 HCO3-29 AnGap-14
[**2178-4-6**] 11:19AM BLOOD Glucose-189* UreaN-4* Creat-0.5 Na-142
K-3.7 Cl-104 HCO3-29 AnGap-13
[**2178-4-5**] 05:00PM BLOOD ALT-24 AST-24 LD(LDH)-167 CK(CPK)-85
AlkPhos-51 TotBili-0.2
EGD: antral gastritis, non-bleeding 0.5cm gastric ulcer, and a
0.5cm duodenal ulcer.
Brief Hospital Course:
Ms. [**Known lastname 99210**] is a 60 yo F with a PMH of DM, HTN, fibroids s/p TAH
who p/w symptomatic anemia (weakness, SOB) and black tarry
stools since last Wednesday. She was seen by her PCP today for
the weakness and hct there was found to be 21 down from 47 on
[**11-19**] so she was referred to the ED.
.
# GI Bleed: The patient received 3U of PRBCs and was started on
IV PPI [**Hospital1 **] in the ED. Despite a negative NG lavage there, the
patients bleeding was postulated to be of an upper source given
that she had melenic stools and a recent clean colonoscopy. On
the morning following admission to the MICU, EGD was performed
and two small ulcers one in the gastric antrum and the other in
duodenal bulb were found. Neither with active bleeding.
Hematocrit was stable post-transfusion. H. pylori serologies
were sent and the patient was transitioned to po PPI [**Hospital1 **] prior
to transfer to the floor. On the floor, hematocrit remained
stable and she had no further episodes of bleeding. Hematocrit
was 33 on the day of discharge. Gastroenterology recommended an
outpatient capsule study to further evaluate potential other
sources of bleeding. The H. Pylori serology was still pending at
the time of discharge and will be followed up as an outpatient.
Patient will continue on PO BID PPI as outpatient per GI
recommendations.
.
# DM: PO anti-hyperglycemic medications were held and the
patient was covered with SSI while in house. Patient will resume
PO glycemic medications once discharged.
.
# HTN: Antihypertensives were held in the hospital and will be
re-started upon discharge. Patient instructed to stop aspirin
secondary to GI bleed.
Medications on Admission:
Metformin 1000mg [**Hospital1 **]
ASA 81mg qd
Glyburide 5mg [**Hospital1 **]
Lasix 10mg qd
Atenolol 50mg [**Hospital1 **]
Enalapril 10mg [**Hospital1 **]
Amlodipine 10mg qd
MVI
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. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Lasix 20 mg Tablet Sig: [**12-13**] Tablet PO once a day.
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
GI Bleed
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 symptomatic anemia which was
felt to be coming from your gastrointestinal tract. Given that
you were symptomatic from the anemia, you received a blood
transfusion to increase your red blood cell count.
You had an upper endoscopy by the Gastroenterologist. They saw
two small ulcers, one in the stomach and one in the beginning
part of the small intestine. They were not bleeding and no
intervention was required. You were started on an antacid and
your blood was checked for H. Pylori which is a bacteria which
can cause ulcerations.
Your blood count was checked and found to be stable and you had
no further bleeding. You should continue the antacid twice daily
as directed and you should follow-up with your PCP following
discharge.
The gastroenterologist recommend that you get an outpatient
capsule study to get a better look at your entire
gastrointestinal tract. Your primary care doctor can also
follow-up the H. Pylori study that is still pending. If this is
positive then you will be started on an antibiotic.
You should return to the ED if you develop: lightheaded,
dizziness, fainting, chest pain, shortness of breath, vomiting
blood, dark tarry stools or bright red blood from below.
You may restart your home medications. This includes your
medication for diabetes and high blood pressure. However, you
shuld NOT re-start the aspirin.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: [**2178-4-16**] 9:20am
Outpatient capsule endoscopy.
Completed by:[**2178-4-7**]
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6044
} | Medical Text: Admission Date: [**2151-10-31**] Discharge Date: [**2151-11-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o f with history of COPD, CAD, Alzheimer's disease
transferred from OSH s/p unwitnessed fall down the stairs.
According to chart, called out afterwards, so prolonged LOC
could not have occurred. Films at the outside hospital showed
right radial/ulnar fracture and fracture of C2 through the
odontoid process. Transferred for ortho evaluation, to medical
service. There is no evidence in OSH documentation that there
was a full trauma evaluation.
.
Pt was a direct transfer to the floor. During the early morning
after arrival, pt was found to be in significant respiratory
distress. Pt placed on NRB and was sat'ing in mid 80s,
tachypneic, and tachycardic to 120s. ABG was 7.36/46/43 with
lactate of 2.6. Pt was emergently intubated and transferred to
the MICU. CXR on arrival to MICU revealed hyperinflated lungs
without any infiltrate or CHF. FiO2 was decreased to 0.5.
.
Of note, pt was seen by ortho spine consult who recommended full
spine precautions with [**Location (un) 2848**] J collar, imaging of TLS spine, and
MRI of C-spine. Also recommended reduction/splint of RUE.
Past Medical History:
Dementia- Alzheimers Disease
CAD
COPD on Combivent
Social History:
Tobacco history (quit 15 years ago). No EtOH. 3 children. Lives
with daughter at home. Cannot cook, dress, or bath herself.
Family History:
Non contributory
Physical Exam:
Vitals: T 98.8, p96, 110/50, rr18, 100% AC 500/16/5
General: Cachectic, bruised, older woman, intubated, NAD
HEENT: bilateral peri-orbital ecchymosis
Neck: C-spine collar in place
CVS: RRR, no m/g/r
Lung: diffuse rhonchi
Abd: soft, NT, ND, +BS
Ext: no edema; ecchymosis on right knee
Neuro: moving all 4 ext
Pertinent Results:
Labs (FROM OSH):
WBC 10.3 (Neut 70.4%, Lymph 23.0%, Mono 5.2%, Eos 1.0%, Baso
0.4%)
Hgb 11.8
Hct 36.7
Plt 254
MCV 92.3
.
Na 147 K 3.0 Cl 108 HCO3 18 BUN 18 Creat 0.7 Gluc 162
Ca 8.5
AST 21 ALT 14 CK 221/656; CKMB 9.8/22.6 Trop I 0.02/0.02
Tot Prot 6.8
Alb 3.7
Alk Phos 70
Amylase 93 Lipase 33
.
PT 11.4 / PTT 23.7 / INR 0.9
.
ADMISSION LABS:
[**2151-11-1**] 06:25AM BLOOD WBC-12.7* RBC-3.42* Hgb-10.3* Hct-30.6*
MCV-89 MCH-30.2 MCHC-33.8 RDW-13.4 Plt Ct-201
[**2151-11-1**] 06:25AM BLOOD Neuts-83* Bands-8* Lymphs-4* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2151-11-1**] 06:25AM BLOOD PT-12.3 PTT-23.0 INR(PT)-1.1
[**2151-11-1**] 06:25AM BLOOD Glucose-114* UreaN-16 Creat-0.7 Na-138
K-4.9 Cl-104 HCO3-26 AnGap-13
[**2151-11-1**] 05:13PM BLOOD CK(CPK)-2037*
[**2151-11-1**] 11:06PM BLOOD CK(CPK)-2566*
[**2151-11-2**] 05:20AM BLOOD CK(CPK)-2539*
[**2151-10-31**] 08:40PM BLOOD CK-MB-22* cTropnT-<0.01
[**2151-11-1**] 05:13PM BLOOD CK-MB-23* MB Indx-1.1 cTropnT-0.02*
[**2151-11-1**] 11:06PM BLOOD CK-MB-30* MB Indx-1.2 cTropnT-0.04*
[**2151-11-2**] 05:20AM BLOOD CK-MB-35* MB Indx-1.4 cTropnT-0.13*
[**2151-11-1**] 06:25AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.8
[**2151-11-1**] 04:32AM BLOOD Type-ART pO2-43* pCO2-46* pH-7.36
calTCO2-27 Base XS-0
[**2151-11-1**] 04:32AM BLOOD Lactate-2.6*
.
CXR (OSH): Increased interstitial markings suggested. Comparison
with prior films and clinical correlation is suggested.
.
CT Head without contrast (OSH): No acute intracranial
hemorrhage. Central and cortical atrophy. Low attenuation
changes in the periventricular white matter. This is a
nonspecific but most likely secondary to chronic microvascular
ischemic changes. Clinical correlation suggested. Left frontal
scalp hematoma.
.
CT C-spine without contrast (OSH): Fracture of C2 through the
odontoid process.
.
Cardiology Report ECG Study Date of [**2151-10-31**] 10:39:58 PM
Sinus rhythm. Atrial premature beats. Possible left atrial
abnormality. Modest non-specific right ventricular conduction
delay pattern. Diffuse non-specific ST-T wave abnormalities. No
previous tracing available for comparison.
.
Discharge Labs:
[**2151-11-12**] 04:48AM BLOOD WBC-12.8* RBC-3.32* Hgb-9.8* Hct-30.8*
MCV-93 MCH-29.7 MCHC-31.9 RDW-15.4 Plt Ct-468*
[**2151-11-12**] 04:48AM BLOOD Neuts-89* Bands-0 Lymphs-7* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2151-11-12**] 04:48AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Stipple-OCCASIONAL
[**2151-11-11**] 03:53AM BLOOD PT-13.7* PTT-54.7* INR(PT)-1.2*
[**2151-11-12**] 04:48AM BLOOD Glucose-139* UreaN-12 Creat-0.7 Na-144
K-3.1* Cl-109* HCO3-27 AnGap-11
[**2151-11-11**] 03:53AM BLOOD Calcium-7.5* Phos-3.0 Mg-1.8
[**2151-11-4**] 03:58AM BLOOD calTIBC-173* VitB12-426 Folate-8.0
Ferritn-144 TRF-133*
.
RADIOLOGY Final Report
C-SPINE TRAUMA W.OBL 4 VIEWS [**2151-10-31**] 10:11 PM
C-SPINE TRAUMA W.OBL 4 VIEWS
Reason: ? dens fx
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with pain after fall
REASON FOR THIS EXAMINATION:
? dens fx
INDICATION: Pain after fall.
FINDINGS:
On the lateral view, there is a suggestion of a C2 fracture.
Some prevertebral soft tissue swelling is evident as well. The
spinous process of C4 also appears to have a fracture and small
fragment anteriorly off the endplate of C6, may have been
avulsed in an extension type injury. At the time of this
dictation, I was able to note that a CT had been obtained at
00:25 on [**2151-11-1**]. The findings on that study confirmed the
plain film findings.
IMPRESSION: Dens fracture, spinous process fracture C4 and
inferior endplate avulsion fracture at C6.
I conveyed the findings to Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 69203**] at 9:51 a.m. on
[**2151-11-1**] at the time of interpretation.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: MON [**2151-11-1**] 12:07 PM
.
RADIOLOGY Final Report
WRIST, AP & LAT VIEWS PORT RIGHT [**2151-11-1**] 5:18 AM
WRIST, AP & LAT VIEWS PORT RIG
Reason: x-rays s/p reduction and splint
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with pain after fall
REASON FOR THIS EXAMINATION:
x-rays s/p reduction and splint
RIGHT WRIST ON [**2151-11-1**], AT 05:17
INDICATION: Fracture reduction and splint.
FINDINGS:
Again identified are fractures of the distal radius and ulna.
The fragments are in good apposition and near anatomic
alignment. A splint is in place.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: MON [**2151-11-1**] 12:08 PM
.
RADIOLOGY Final Report
WRIST(3 + VIEWS) RIGHT [**2151-11-1**] 12:30 AM
FOREARM (AP & LAT) RIGHT; WRIST(3 + VIEWS) RIGHT
Reason: fx?
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with pain after fall
REASON FOR THIS EXAMINATION:
fx?
RIGHT FOREARM ON [**2151-11-1**] AT 00:31.
INDICATION: Pain after fall.
FINDINGS:
Transverse fractures of the distal radius and ulna are
demonstrated with some dorsal angulation to distal fragments.
The radiocarpal and carpometacarpal alignment appear intact.
Component of impaction is seen at both fracture sites.
Diffuse degenerative changes are evident in MCP and PIP joints
with some narrowing and sclerosis.
IMPRESSION:
Transverse fractures of the distal radius and ulna with an
element of impaction and slight dorsal angulation to the distal
fragments.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: MON [**2151-11-1**] 12:07 PM
.
RADIOLOGY Final Report
FOREARM (AP & LAT) RIGHT [**2151-11-1**] 12:30 AM
FOREARM (AP & LAT) RIGHT; WRIST(3 + VIEWS) RIGHT
Reason: fx?
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with pain after fall
REASON FOR THIS EXAMINATION:
fx?
RIGHT FOREARM ON [**2151-11-1**] AT 00:31.
INDICATION: Pain after fall.
FINDINGS:
Transverse fractures of the distal radius and ulna are
demonstrated with some dorsal angulation to distal fragments.
The radiocarpal and carpometacarpal alignment appear intact.
Component of impaction is seen at both fracture sites.
Diffuse degenerative changes are evident in MCP and PIP joints
with some narrowing and sclerosis.
IMPRESSION:
Transverse fractures of the distal radius and ulna with an
element of impaction and slight dorsal angulation to the distal
fragments.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: MON [**2151-11-1**] 12:07 PM
.
RADIOLOGY Final Report
CT C-SPINE W/O CONTRAST [**2151-11-1**] 12:15 AM
CT C-SPINE W/O CONTRAST
Reason: ? fx
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with pain after fall
REASON FOR THIS EXAMINATION:
? fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Pain after fall, question fracture.
COMPARISON: None.
TECHNIQUE: Non-contrast axial CT imaging of the cervical spine
with coronal and sagittal reformats.
FINDINGS: There is prevertebral soft tissue swelling. There is a
nondisplaced fracture through the base of the dens that extends
down into the C2 body, thus making the fracture type III dens
fracture. There is a small fracture fragment off the anterior
inferior aspect of C6 that likely represents an avulsion
fracture from flexion or extension injury. There is a minimally
displaced fracture through the spinous process of C4. There is a
small osseous fragment anterior to the body of left C1 (3:20)
that appears well corticated. A donor site cannot be identified
and thus this may represent calcification within ligaments.
There is some evidence for ligamentous calcification on the
right anterior C1 body (3:18). A fracture given the multitude of
other fractures cannot entirely be excluded. Evaluation of the
spinal canal elements is limited with CT, but there is evidence
for some spinal canal narrowing and mild compression of the cord
at the C2-C3 to a lesser degree at other levels. This may be
chronic. There is no evidence for subluxation. There is scarring
and emphysematous changes in the lung apices. Note is made of
partial opacification of the nasopharynx and sphenoid sinuses.
IMPRESSION: Multiple fractures as described above including a
type III dens, C6 vertebral body avulsion fracture and C4
spinous process fracture. Ligamentous injury is suspected given
the pattern of fractures, an MR is recommended.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: MON [**2151-11-1**] 10:59 AM
.
RADIOLOGY Final Report
CT T-SPINE W/O CONTRAST [**2151-11-2**] 2:29 PM
CT T-SPINE W/O CONTRAST
Reason: pls evaluate for fx or cord compression
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman s/p fall with C2 fracture.
REASON FOR THIS EXAMINATION:
pls evaluate for fx or cord compression
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: [**Age over 90 **]-year-old woman status post fall with cervical
spine fractures.
COMPARISONS: None.
TECHNIQUE: Axial non-contrast CT images of the thoracic spine
were obtained and sagittal and coronal reconstructions were also
performed.
FINDINGS: The patient is intubated. There is a nasogastric tube
coursing into the stomach. Coronary artery and aortic
calcifications are noted. There is a moderate low-density
pleural effusion on the left, and a small one on the right, with
adjacent areas of dependent opacity with air bronchograms. These
areas could represent atelectasis, pneumonia, or aspiration.
There is also moderately severe emphysema. Incidental note is
also made of a punctate 3-mm calcification in the right lobe of
the thyroid gland.
There is no evidence of acute fracture, dislocation, or bony
destruction. Multilevel small anterior osteophytes are present
in the thoracic spine, as well as degenerative calcifications
within the intervertebral disc spaces. There is fragmentation of
the tip of the spinous process of T4, with well corticated
margins, an appearance likely due to old trauma or congenital in
origin.
Although CT is not ideal for visualization of the thecal sac,
the visualized thecal sac contour is unremarkable.
IMPRESSION:
1. No evidence of fracture or dislocation.
2. Non-united appearance of tip of T4 spinous process, probably
from old trauma or congenital etiology.
3. Bilateral pleural effusions with adjacent opacities, which
may represent atelectasis, aspiration, or pneumonia.
Findings discussed [**Last Name (STitle) 17290**] from Medicine service.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: WED [**2151-11-3**] 7:53 PM
.
RADIOLOGY Final Report
CT L-SPINE W/O CONTRAST [**2151-11-2**] 2:28 PM
CT L-SPINE W/O CONTRAST
Reason: pls evaluate Lumbar and sacral spine for fx, cord
compressio
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman s/p fall with C2 fracture.
REASON FOR THIS EXAMINATION:
pls evaluate Lumbar and sacral spine for fx, cord compression
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: [**Age over 90 **]-year-old woman with cervical spine fractures.
COMPARISONS: None.
TECHNIQUE: Axial CT images of the lumbar spine were obtained
without intravenous contrast, and sagittal and coronal
reconstructions were also performed.
FINDINGS: There is no evidence of fracture. There is minimal
spondylolisthesis of L4 on L5, which is likely degenerative in
origin.. There are mild multilevel degenerative changes with
osteophytes, most notably at L2- L3 where there is a mild,
likely chronic, compression fracture of L2. Sclerosis and
narrowing at the L2-L3 intervertebral disc space are also
present. At the same level, there is a small disc bulge with
spinal stenosis, and similarly at L3-L4 and L4- L5. There are
also proliferative changes of the ligamentum flavum at the same
levels, extending from L2-L3 through L4-L5. At these levels,
where posterior mild disk herniations are present, there is
moderate spinal stenosis.
Calcified gallstones and aortic calcifications are noted, as
well as moderate left-sided and small right-sided pleural
effusions. Bibasilar opacities with air bronchograms may
represent either atelectasis, pneumonia or aspiration.
IMPRESSION:
1. No evidence of acute fracture or dislocation.
2. Degenerative changes, and a probably old mild compression
fracture of L2.
3. Moderate spinal stenosis, associated with small disc bulges
and thickening of the ligamentum flavum.
4. Bibasilar pleural effusions and opacities, which may
represent atelectasis, aspiration or pneumonia.
5. Aortic calcifications.
6. Cholelithiasis.
Major findings including pulmonary effusions and opacities
discussed [**Last Name (STitle) 17290**] from Medicine.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: [**Doctor First Name **] [**2151-11-4**] 12:37 PM
.
RADIOLOGY Final Report
MR CERVICAL SPINE W/O CONTRAST [**2151-11-2**] 12:04 PM
MR CERVICAL SPINE W/O CONTRAST
Reason: Assess for cord injury, ligamentous injury
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with C2, C4 and C6 fractures
REASON FOR THIS EXAMINATION:
Assess for cord injury, ligamentous injury
MRI OF THE CERVICAL SPINE ON [**11-2**]
CLINICAL HISTORY: C2, C4, and C6 fractures.
TECHNIQUE: Sagittal T1-weighted, T2-weighted, STIR, and
gradient-echo images, and axial gradient-echo and T2-weighted
images were obtained. There is slight limitation by patient
motion.
FINDINGS:
As seen on the CT examination of the preceding day, there is
considerable prevertebral soft tissue swelling particularly
superiorly. There is an underlying C2 fracture with a
horizontally oriented fracture line across the base of the dens
which extends inferiorly at the posterior C2 body, most
consistent with type III fracture. As expected fluid signal
intensity is seen in that fracture. No significant epidural
fluid collection is seen and there is no spinal cord compression
or abnormal signal intensity in the spinal cord at that level.
The abnormalities in the region of the anterior arch of C1 are
poorly visualized.
There is also edema associated with the fracture through the tip
of the C4 spinous process, consistent with acute fracture. There
is some increased signal intensity in the C6/7 disc, on the STIR
images and the avulsion fracture from the anterior inferior
endplate of C6 is to some extent visualized. No clear abnormal
signal intensity is seen in the spinal cord nor is there any
epidural hematoma. The foramina are grossly well maintained and
on the T2-weighted images, normal low-signal intensity is seen
in both vertebral arteries.
IMPRESSION:
1. No definite spinal cord contusion identified.
2. There are acute fractures across the base of the dens,
through the tip of the C4 spinous process and involving the
anterior inferior aspect of C6 with apparent disruption of the
anterior longitudinal ligament at the C6/7 level.
3. As seen on the CT, there is minimal anterior displacement of
the odontoid fragment relative to [**Name (NI) 12952**], but no significant
stenosis of the spinal canal at any of the imaged levels.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: WED [**2151-11-3**] 7:01 AM
.
RADIOLOGY Final Report
[**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [**2151-11-10**] 10:14 AM
[**Last Name (un) **]-INTESTINAL TUBE PLACEMENT
Reason: please place post pyloric tube under fluoro guidance as
posi
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with cervical fracture, in [**Location (un) 2848**] J collar,
failed speech and swallow.
REASON FOR THIS EXAMINATION:
please place post pyloric tube under fluoro guidance as
positioning an issue
INDICATION: [**Age over 90 **]-year-old female with cervical fracture, in [**Location (un) 2848**]
J collar, failed speech and swallow. Place post-pyloric tube.
TECHNIQUE/FINDINGS: The left naris was anesthetized with 1%
lidocaine. An 8 French 120-cm weighted feeding tube was advanced
into the third portion of the duodenum under fluoroscopic
guidance. Approximately 50 cc of Conray was injected into the
nasogastric tube to confirm intended position. No extravasation
of contrast was identified.
IMPRESSION: Successful nasointestinal tube placement with tip in
the third portion of the duodenum.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: WED [**2151-11-10**] 2:31 PM
.
[**2151-10-31**] 8:49 pm URINE
**FINAL REPORT [**2151-11-3**]**
URINE CULTURE (Final [**2151-11-3**]):
ESCHERICHIA COLI. >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------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2151-11-1**] 8:33 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2151-11-4**]**
GRAM STAIN (Final [**2151-11-1**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2151-11-4**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
PENICILLIN------------ S
.
[**2151-11-1**] 4:27 pm BLOOD CULTURE
**FINAL REPORT [**2151-11-7**]**
AEROBIC BOTTLE (Final [**2151-11-7**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2151-11-7**]): NO GROWTH.
.
[**2151-11-1**] 4:19 pm BLOOD CULTURE
**FINAL REPORT [**2151-11-7**]**
AEROBIC BOTTLE (Final [**2151-11-7**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2151-11-7**]): NO GROWTH.
.
[**2151-11-10**] 5:09 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2151-11-11**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2151-11-11**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
[**2151-11-10**] 4:28 pm URINE RECEIVED IN LAB AT 6.35PM.
**FINAL REPORT [**2151-11-12**]**
URINE CULTURE (Final [**2151-11-12**]): NO GROWTH.
.
Cardiology Report ECHO Study Date of [**2151-11-4**]
PATIENT/TEST INFORMATION:
Indication: Coronary artery disease. Left ventricular function.
Height: (in) 63
Weight (lb): 115
BSA (m2): 1.53 m2
BP (mm Hg): 132/56
HR (bpm): 91
Status: Inpatient
Date/Time: [**2151-11-4**] at 14:56
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W046-0:00
Test Location: West Echo Lab
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.0 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 1.6 cm
Left Ventricle - Fractional Shortening: 0.47 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 80% (nl >=55%)
Aorta - Valve Level: 2.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.2 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.70
Mitral Valve - E Wave Deceleration Time: 237 msec
TR Gradient (+ RA = PASP): *21 to 29 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is
normal in diameter
with appropriate phasic respirator variation.
LEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Suboptimal
technical
quality, a focal LV wall motion abnormality cannot be fully
excluded.
Hyperdynamic LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root.
Normal ascending aorta diameter. Focal calcifications in
ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No
MVP. Mild mitral
annular calcification. Moderate thickening of mitral valve
chordae. Calcified
tips of papillary muscles. No MS. Trivial MR. Normal LV inflow
pattern for
age.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Thickened/fibrotic
tricuspid valve supporting structures. Mild [1+] TR. Borderline
PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - poor parasternal views. Suboptimal image quality
- poor apical
views.
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity is unusually small. Due
to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded.
Left ventricular systolic function is hyperdynamic (EF 80%).
Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened.
There is no mitral valve prolapse. There is moderate thickening
of the mitral
valve chordae. Trivial mitral regurgitation is seen. The
tricuspid valve
leaflets are mildly thickened. The supporting structures of the
tricuspid
valve are thickened/fibrotic. There is borderline pulmonary
artery systolic
hypertension. There is no pericardial effusion.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2151-11-4**] 15:25.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Brief Hospital Course:
[**Age over 90 **]yF with history of CAD and COPD s/p fall, transferred for mgmt
of Type 3 Dens/C4/C6 fracture and distal radial/ulnar fracture,
transferred to ICU for acute hypoxic respiratory failure.
.
# Hypoxic respiratory failure: CHF, PNA, left pleural effusion,
and COPD contributing. Pt s/p intubation [**2151-11-1**], extubated on
[**2151-11-3**], reintubated [**2151-11-5**], extubated [**2151-11-7**]. Weaned to
NRB, then VM, then O2 by nC. Now on 3L O2 by NC. Saturations in
high 90's. s/p nafcillin 10/10 days for pna. Diuresed several
days on [**2151-11-6**] and [**2151-11-7**]. Left pleural effusion not tapped
as afebrile and likely due to CHF. COPD treated with nebs.
Please try to wean O2 as tolerated.
.
# COPD: Ipratropium/albuterol nebs. No wheezing. Lungs sound
clear.
.
# Afib with RVR: Loaded with Amiodarone(IV) on [**2151-11-2**]. Got one
week of 200 mg by NG TID. Now getting 200 mg [**Hospital1 **] for one week
(to change to 200 mg QD) on [**2151-11-19**]. Continue amiodarone 200 mg
[**Hospital1 **] for one week (until [**2151-11-18**]), then 200 mg QD after that.
Will need TFT's, LFT's, and PFT's monitored in the future while
on amiodarone. Currently in SInus rhythm on discharge.
.
# h/o CAD: Unknown history. No evidence of wall motion
abnormalities on Echo, though poor windows. No Q waves on EKG.
On ASA.
.
# PNA: Strep pneumo in sputum. Sensitive to penicillin. Treated
with nafcillin for 10 days, completed [**2151-11-9**].
.
# UTI: E coli grew in culture. Pansensitive. Treated with
Levofloxacin for 7 days, completed10/16/06. Repeat U/A had
WBC's, but improved after foley change. Urine culture after
foley change had no growth.
.
# Odontoid process fracture: Type 3 dens fracture, c4 fracture,
C6 fracture. Needs [**Location (un) 2848**] J collar until; mid [**Month (only) **]. Needs f/u
with Dr. [**Last Name (STitle) 1352**] (need to schedule app for mid [**Month (only) 321**]).
Orthopedics (Spine) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] ([**Telephone/Fax (1) 2007**]
.
# Right wrist fx: had distal ulnar/radius fracture. Immobilized
with splint. Needs f/u with Dr. [**Last Name (STitle) **] [**Location (un) **] (need to schedule for
the end of [**Month (only) **]). Orthopedics Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 15940**]
.
# Dementia: Known Alzheimer's Disease. Currently back to
baseline. Not on medications.
.
# Prophylaxis: Needs Hep SubQ, Colace/Senna, needs frequent
turns for decubitus ulcer.
.
# FEN: Post-pyloric feeding placed by IR, geting tube feeds
(surrently at goal of 50). Will need further discussion with
family per PEG if she fails future swallowing evaluations.
.
# code status: DNR/DNI
.
# Communication: [**Doctor First Name 7798**] [**Telephone/Fax (1) 69204**] Home, [**Telephone/Fax (1) 69205**] Cell
# She needs to be seen by her primary care Doctor. Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 2455**]. FINE,[**Doctor Last Name **] H. [**Telephone/Fax (1) 65335**]
Medications on Admission:
Combivent
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): can be decreased to 200 mg daily starting [**2151-11-19**].
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) mL PO
BID (2 times a day).
10. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q6H (every
6 hours) as needed.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Cervical Fracture
Radial/Ulnar Fracture
Streptoccoccus pneumoniae Pneumonia
E. Coli Urinary Tract Infection
Discharge Condition:
Cervical Collar in place. Right arm/wrist splint. Non
ambulatory. Demented. Not oriented. Foley catheter in place. NG
tube (post pyloric) in place.
Discharge Instructions:
You had fractures to your upper spine. You will need to keep the
cervical collar on until the middle of [**2151-11-24**]. You will
need to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**], ([**Telephone/Fax (1) 2007**], in mid [**Month (only) **]
to see how long you will need the cervical collar.
You had a fracture of both bones of the lower part of your right
arm. You will need to keep the splint on your right arm for the
next two weeks, until the end of [**2151-10-24**]. You should see
the orthopedic surgeon, Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],([**Telephone/Fax (1) 2007**], at
the end of [**Month (only) 359**].
You had a pneumonia, which was treated with antibiotics for ten
days.
You had a urinary tract infection which was treated with
antibiotics for seven days.
You had a tube placed to help feed you because you were unable
to swallow. You will need to have your swallowing reevaluated
while at rehab to see if you still need the tube.
Followup Instructions:
Orthopedics Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 2007**]
Orthopedics (Spine) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] ([**Telephone/Fax (1) 2007**]
Primary Care Doctor- Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2455**] ([**Telephone/Fax (1) 69206**]
Completed by:[**2151-11-13**]
ICD9 Codes: 496, 4280, 5990, 5070, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6045
} | Medical Text: Admission Date: [**2144-3-22**] Discharge Date: [**2144-3-25**]
Date of Birth: [**2096-3-2**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
48M with history of HTN and DM2 previously on metformin presents
with hyperglycemia to 400-445 at home. Notably the patient
hasn't been taking his diabetes medications for 5 months because
he started pursuing homeopathy and was told to stop all of his
medications.
He recently went on a plane ride 5 days prior to admission. He
had been sucking candy to help with the air pressure changes.
When he returned home, he felt ill with nausea, gassy abdominal
pain, polyuria and polydipsia. He also had 1 episode of chest
pressure that lasted 1 hour. The night before admission he had
chills and sweats, but no diarrhea, vomiting and dysuria.
In the ED, T 99.9 HR 116 BP 111/69 RR 16 98% RA. The patient
was given 3L IV fluids, and 10 units regular insulin sc. Anion
gap was 22. Insulin gtt was started. Prior to transfer, last
fingerstick was 424, Vitals were T 99.3 HR 101 BP 124/79 99% on
RA.
On the floor, the patient is feeling thirsty, with abdominal
discomfort.
Past Medical History:
DM2 -diagnosed several years ago
HTN
h/o gout
Social History:
- Tobacco: None
- Alcohol: None
- Illicits: None
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T: 99.4 BP: 133/74 P: 104 R: 18 O2: 95% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE
Pertinent Results:
ADMISSION LABS:
[**2144-3-22**] 09:36PM GLUCOSE-445* UREA N-28* CREAT-1.3*
SODIUM-130* POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-13* ANION
GAP-25*
[**2144-3-22**] 09:36PM WBC-9.3 RBC-3.76* HGB-11.7* HCT-34.5* MCV-92
MCH-30.8 MCHC-33.8 RDW-14.3
[**2144-3-22**] 09:36PM NEUTS-88.4* LYMPHS-8.2* MONOS-3.1 EOS-0.1
BASOS-0.2
[**2144-3-22**] 09:37PM LACTATE-2.0
[**2144-3-22**] 06:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2144-3-22**] 06:50PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
DISCHARGE LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2144-3-25**] 06:03 6.8 3.59* 11.8* 32.8* 91 33.0* 36.1* 14.6
270
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2144-3-25**] 06:03 186 15 0.7 136 4.3 101 27
CHEMISTRY TotProt Calcium Phos Mg
[**2144-3-25**] 06:03 8.5 4.3 2.2
MICRO:
BCX [**2144-3-23**]: PENDING
BCX [**2144-3-25**] x 2: PENDING
STUDIES:
CXR [**2144-3-22**]:
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
48 yo male with HTN, DM 2, with history of medication
non-compliance who presented with DKA. Pt initially presented to
MICU and was placed on insulin gtt with IVF's. AG closed, and pt
was transitioned to SC insulin and discharged on a combination
of lantus and oral agents.
Active issues:
# DKA/Diabetes: The patient had an anion gap of 21, with ketones
in his urine on presentation. Underlying etiology likely
secondary to medication non-compliance. No focal signs of
infection, though did have some chills and sweats. UA negative.
Patient did have 1 hour of chest pressure, though no further
symptoms. CXR unremarkable. Pt was placed on insulin gtt and
lytes were frequently monitored. AG closed. Potassium was
repleted agressively with IVF's. A1c was sent and was 13.8.
Blood cultures were pending at time of discharge. [**Last Name (un) **] was
consulted recommended starting metformin and glipizide as well
as continued lantus. He was discharged on all three and will
follow up with [**Last Name (un) **] in 1 week.
# Chest pain: Brief chest pain, thought unlikely to be cardiac
related. CE's were cycled and negative. His pain resolved.
# Normocytic anemia: Unclear baseline. Iron studies consistent
with anemia of chronic disease or acute illness. His Hct was
stable during this hospitalization with no clinical evidence of
bleeding. It was recommended that he discuss further workup
with his PCP and obtain [**Name Initial (PRE) **] colonscopy.
# Acute kidney injury: Likely secondary to profound hypovolemia
in the setting of DKA. Cr improved after hydration and was
normal upon discharge.
# Hypertension: The patient had been on lisinopril, but had
stopped it. He was hypertensive here and restarted on
lisinopril 10 mg daily. He will need lytes checked in follow
up.
Transitions of care:
- F/u pending blood cultures
- Patient requires workup for anemia and Hct trend
- Check electrolytes/creatinine on lisinopril
Medications on Admission:
Metformin
Lisinopril
(not taking prior to admission)
Discharge Medications:
1. Insulin Syringe 1 mL 29 x [**12-8**] Syringe Sig: One (1) syringe
Miscellaneous once a day.
Disp:*40 syringes* Refills:*2*
2. insulin needles (disposable) 31 Needle Sig: One (1) needle
Miscellaneous once a day.
Disp:*45 needles* Refills:*2*
3. One Touch Ultra Test Strip Sig: One (1) stip
Miscellaneous four times a day.
Disp:*120 strips* Refills:*2*
4. lancets Misc Sig: One (1) lancet Miscellaneous four times
a day.
Disp:*120 lancets* Refills:*2*
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. insulin glargine 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous at bedtime.
Disp:*500 units* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic ketoacidosis
Hypertension
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 due to very high blood sugars.
Your sugars were elevated likely because you had stopped your
diabetes medications. No evidence of infection were found.
While hospitalized it was noted that your red blood counts were
low. You will need to discuss workup and colonscopy with your
primary doctor.
You were also restarted on lisinopril (a blood pressure
medication). You will need labs checked in [**1-9**] weeks to ensure
your kidney function and electrolytes are stable on this
medication. Please discuss having labs checked at your follow
up appointment with [**Last Name (un) **].
Check blood sugars fasting and before meals and at bedtime. If
blood sugars are < 90, drop lantus dosing by 2 units. If you
feel like your blood sugar is low, check your blood sugar and
call your doctor.
Medication changes:
1. START lantus 16 units every night.
2. START lisinopril 10 mg every day.
3. START metformin 1000 mg twice daily.
4. START glipizide 10 mg twice daily.
It is very important that you take your medications every day
and do not miss a dose.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2144-4-28**] at 1:45 PM
With: [**Name6 (MD) 3688**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
***Please be sure and call your insurance company to change your
pcp to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 88708**] works with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Name: [**Last Name (LF) 15279**], [**Name8 (MD) **] MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2384**]
Appt: We are working on an appt for you within the next week.
The office will call you at home with an appt. If you dont hear
from them by tomorrow, please call them directly to book.
Completed by:[**2144-3-25**]
ICD9 Codes: 5849, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6046
} | Medical Text: Admission Date: [**2166-2-11**] Discharge Date: [**2166-2-12**]
Service: NEUROLOGY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
transfer from OSH for intracerebral hemorrhage
Major Surgical or Invasive Procedure:
extubation
History of Present Illness:
This is a 86year old woman with an unknown pmh who was alone at
restaurant and appeared suddenly confused and "unresponsive."
EMTs arrived, patient was "not answering or even acknowledging
anyone." On arrival to OSH ED - patient "awake and alert, but
does not respond to questions or commnads." Apparently vomited
after head ct and was then intubated. Appeared to be posturing
by ED staff at OSH and given mannitol 50gm x1. Transferred here
intubated, not following commands and bleed worse on head ct on
arrival here. Family contact[**Name (NI) **] and states that patient's wishes
would be for extubation and cmo.
Past Medical History:
essentially unknown, but patient's neice said she had a history
of "dementia" for the past year or so, and may have had
hypertension because she had decided not to take her BP meds.
Social History:
lives alone, very independent, never married, no kids, former
business woman. HCP is her [**Last Name (LF) 802**], [**Name (NI) 319**] [**Name (NI) 19442**].
Family History:
sister died of stomach cancer in her 60's, other sibs are in
their 90's and still alive and well.
Physical Exam:
Physical Exam: afebrile; BP 200s/100s; HR 80s-90s; RR 14; O2
sat 100% on vent
gen - intubated
heent - mmm. o/p clear. no scleral icterus or injection.
neck - supple. no lad or carotid bruits appreciated.
lungs - cta bilaterally
heart - rrr, nl s1/s2
abd - soft, nt/nd, nabs
ext - warm, 2+ peripheral pulses throughout. no edema.
neurologic:
MS: not following commands or opening eyes. not breathing over
the vent.
CN: PERRL - pinpoint. intact corneals. intubated, not sure if
has
facial asymmetry.
Motor: not moving RUE. does move LUE to pain, holding LUE
flexed.
in LLEs, some minimal movement in LLE to pain, and triple
flexion
on right.
Reflexes: hyperreflexic in the right more than the left. toes
upgoing.
Sensation: withdraws to pain in LUE and minimally in LLE. triple
flexion in RLE.
Coordination:
cannot test
Gait: cannot test
Pertinent Results:
NCHCT: large left temporoparietal occipital bleed with
intraventricular extension and shift to the right. also right
intraventricular extension. early signs of uncal herniation.
more blood since ct at OSH.
Brief Hospital Course:
This patient was admitted to the Neurology ICU after she
suffered a massive intracerebral bleed with early signs of uncal
herniation on head CT. Discussions were held with the [**Hospital 228**]
health care proxy, [**Name (NI) 319**] [**Name (NI) 19442**] ([**Name (NI) 802**]), and code status was
changed to CMO. She was extubated and placed on morphine drip.
Time of death: 5:30pm on [**2166-2-12**].
Family denied autopsy. Medical examiner was called as patient
died within 24 hrs of admission and they waived the case (per
Dr. [**Last Name (STitle) **].
Medications on Admission:
none
Discharge Medications:
none, deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
hemorrhagic stroke with herniation
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6047
} | Medical Text: Admission Date: [**2150-2-27**] Discharge Date: [**2150-3-5**]
Date of Birth: [**2084-7-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 922**]
Chief Complaint:
Exertional/rest angina
Major Surgical or Invasive Procedure:
[**2150-2-27**]
emergent coronary artery bypass grafting x4
(LIMA-LAD,SVG-RI,SVG-OM!,SVG-PDA)
left heart catheterization, coronary angiogram [**2150-2-27**]
History of Present Illness:
This 65 year old gentleman with no prior cardiac history
describes a 9 month history of episodic exertional chest
discomfort and dyspnea. These episodes have
occurred while walking 2 or more blocks while carrying books or
groceries. He also reports having less frequent chest
discomfort occurring at rest but only lasting seconds and
resolving spontaneously or with SL nitroglycerin that he was
recently prescribed. The patient was seen by Dr. [**First Name (STitle) **] and
had an
abnormal stress test, as noted below, so has now been referred
for catheterization. Cath revealed 90% Left main 100% RCA
occulsion. He was referred for urgent operation.
Past Medical History:
Unstable angina
Bicuspid aortic valve.
Pectus excavatum.
anal cancer [**2125**] (s/p chemo and radiation therapy)
iron deficieny anemia
hypothyroidism
anxiety/depression
basal cell cancer of the face
gastroesophageal reflux
prostate cancer
Social History:
Lives with: Alone in [**Location (un) **]. Retired.
Tobacco: has smoked 45+ years/1ppd since age 17; now trying to
quit - down [**12-29**] ciagarettes / day
ETOH: socially ~ 5 wines/ week
Contact upon discharge: [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **]- [**Telephone/Fax (1) 111461**]
Family History:
non-contributory
Physical Exam:
Pulse: 75 Resp: 12 O2 sat:94% RA
B/P Right: Left: 113/79
Height: 5'8" Weight: 153#
General: AAO x 3 in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] Pectis excavatum
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x, well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:cath site Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2150-3-4**] 05:00AM BLOOD WBC-8.9 RBC-4.37* Hgb-12.2* Hct-35.6*
MCV-82 MCH-28.0 MCHC-34.4 RDW-15.5 Plt Ct-221
[**2150-3-4**] 05:00AM BLOOD Glucose-103* UreaN-18 Creat-0.7 Na-135
K-4.3 Cl-101 HCO3-24 AnGap-14
[**2150-2-27**] 10:30AM BLOOD Glucose-123* UreaN-21* Creat-1.0 Na-136
K-4.1 Cl-105 HCO3-22 AnGap-13
[**2150-2-27**] 10:30AM BLOOD ALT-14 AST-18 CK(CPK)-168 AlkPhos-62
Amylase-63 TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2150-2-27**] 10:30AM BLOOD %HbA1c-6.0* eAG-126*
Findings
LEFT ATRIUM: Moderate LA enlargement. Good (>20 cm/s) LAA
ejection velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Aneurysmal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Normal descending aorta
diameter. Simple atheroma in descending aorta. No thoracic
aortic dissection.
AORTIC VALVE: Bicuspid aortic valve. Mild AS (area 1.2-1.9cm2).
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate
([**12-29**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. 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.
The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. Results were
Conclusions
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. There are simple atheroma
in the descending thoracic aorta. No thoracic aortic dissection
is seen. The aortic valve is bicuspid. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild to
moderate ([**12-29**]+) central mitral regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results at time of
study.
POST-CPB:
The patient is on a phenylephrine infusion.
The left ventricular systolic function remains normal. Estimated
EF>55%. The right ventricular systolic function remains normal.
Valvular function remains unchanged.
There is no evidence of aortic dissection.
Brief Hospital Course:
Upon finding the severe left main disease, emergent
revascularization was undertaken. He went to the Operating Room
where quadruple bypass grafting was performed. He weaned from
bypass on Vasopressin, NeoSynephrine and Propofol.
He did well, extubating and weaning from Vasopressin the day of
surgery. NeoSynephrine weaned over the next 24 hours. A Lasix
infusion was begun and he responded with a brisk diuresis. Beta
blockade was also started. CTs were removed per protocol as were
temporary pacing wires. On POD 4 he transferred to the step down
unit, where diuresis was continued and beta blockade titrated as
he remained tachycardic.
Physical Therapy worked with him for mobility and strength. He
did well and on POD 6 was ready for transfer to rehabilitation
for further recovery. Arrangements were made for follwo up and
medications and restrictions are as noted elsewhere.
He was discharged [**Hospital6 1643**] Center.
Medications on Admission:
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 (One) Tablet(s) by mouth
once a day First dose 300 mg then 75 mg daily
ISOSORBIDE MONONITRATE - 30 mg Tablet Extended Release 24 hr - 1
(One) Tablet(s) by mouth once a day
LEVOTHYROXINE - (Prescribed by Other Provider) - 100 mcg Tablet
- 1 (One) Tablet(s) by mouth once a day
LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 1 mg
Tablet - 1 (One) Tablet(s) by mouth as needed
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
(One) Tablet(s) by mouth once a day
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1 (One)
Tablet(s) sublingually As needed as needed for chest pain Take
one SL NTG for chest pain. [**Month (only) 116**] repeat iafter 5 minutes x2, call
911 if pain persists after 3rd pill
TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg
Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth daily
ZOLPIDEM [AMBIEN] - (Prescribed by Other Provider) - 5 mg
Tablet
- [**12-29**] Tablet(s) by mouth at bedtime
Discharge Medications:
1. flu vaccine [**2148**] (36 mos+)(PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO
three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
unstable angina
Bicuspid aortic valve.
s/p emergency coronary artery bypass grafts
anxiety/depression
prostate cancer
gastroesophageal reflux
Pectus excavatum.
anal cancer [**2125**] (s/p chemo and radiation therapy)
iron deficieny anemia
hypothyroidism
basal cell cancer of the face
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or
drainageleg(left) clean and dry. healing well
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Surgeon Dr. [**Last Name (STitle) 914**]([**Telephone/Fax (1) 170**]) on [**2150-3-30**] at 1:30pm
Cardiologist :have Dr [**Last Name (STitle) 6420**] recommend one
Please call to schedule the following:
Primary Care:Dr.[**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 6420**] ([**Telephone/Fax (1) 5723**]in [**4-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2150-3-5**]
ICD9 Codes: 3051, 4111, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6048
} | Medical Text: Admission Date: [**2102-4-23**] Discharge Date: [**2102-4-23**]
Date of Birth: [**2033-4-8**] Sex: M
Service:
CHIEF COMPLAINT: Cardiac arrest.
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old
male with a history of coronary artery disease status post
remote myocardial infarction, hypertension,
hypercholesterolemia, and chronic obstructive pulmonary
disease who presented status post witnessed arrest at home in
the presence of his wife. The patient was reported to have
fallen backwards without prodrome or complaint, hitting the
floor near his bed. EMS was contact[**Name (NI) **] and arrived upon the
scene within five minutes. The patient was found to be
pulseless and apneic.
CPR was started, the patient was intubated and pads were
placed revealing ventricular fibrillation. The patient was
defibrillated at 200, 300 and 300, with no response. He was
given 1 mg of epinephrine which converted him to systole,
then given Atropine times two and Epinephrine times three,
which converted him to PEA, which transitioned to an
idioventricular rhythm at 20 beats per minute. The patient
had pacing attempted without success. He reverted to
asystole.
He was given an ampule of bicarbonate and epinephrine which
converted the patient to ventricular fibrillation. He was
defibrillated at 03:16, given 300 mg of Amiodarone. He was
transferred to [**Hospital3 417**] and then transferred to [**Hospital1 1444**].
His EKG showed inferoposterior injury changes. He arrived on
Dobutamine, Neo-Synephrine and Amiodarone. Cardiac
catheterization revealed diffuse three-vessel disease. He
has elevated left filling pressures.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease status post remote myocardial
infarction.
3. Hypercholesterolemia.
4. Hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Atenolol.
2. Lipitor.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] has a
positive smoking history.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: The patient's pulse was 83; blood
pressure 123/60; respiratory rate of 14 and oxygen saturation
of 98%, on mechanical ventilation of AC-800 by 14;
respiratory rate of 15. He was on 100% FIO2. On general
examination, the patient was an ill appearing intubated man
in no apparent distress. HEENT examination reveals scleral
edema and moist mucous membranes. Neck examination revealed
no lymphadenopathy. Cardiac examination revealed a regular
rate and rhythm, normal S1 and S2 that were distant and no
murmurs, rubs or gallops. Pulmonary examination revealed
diffuse inspiratory and expiratory wheezes. Abdominal
examination revealed a belly that was soft, moderately
distended, nontender, with no bowel sounds appreciated.
Extremities revealed trace edema and no dorsalis pedis
pulses.
LABORATORY: Pertinent laboratory findings were the patient's
white count of 8.0 with a hematocrit of 36.5 and platelets of
188. The patient's creatinine was 1.5. His CK was 138 with
an MB of 28.7, a troponin of 1.98.
Initial arterial blood gas was 7.19 with pCO2 of 37 and pAO2
of 301.
EKG revealed normal sinus rhythm, normal axis and massive ST
elevations in II, III and AVF with reciprocal changes in I
and L. The patient also had early transition and massive ST
depressions in V2 through V5. These findings were consistent
with an inferoposterior myocardial infarction.
Cardiac catheterization revealed diffusely diseased three
vessel coronary system. The mid-left circumflex was totally
occluded as was the mid right coronary artery. The left
anterior descending was diffusely diseased. The patient had
two stents, one to the ostium and one to the mid-portion of
the right coronary artery. Pulmonary capillary wedge was 40.
SUMMARY OF HOSPITAL COURSE: This 69 year old man with a
history of coronary artery disease status post remote
myocardial infarction, hypertension, hypercholesterolemia as
well as chronic obstructive pulmonary disease, presented with
witnessed cardiac arrest and large inferoposterior myocardial
infarction.
1. Cardiovascular: The patient presented with ventricular
fibrillation arrest at home with prolonged resuscitation in
the setting of an inferoposterior myocardial infarction. He
had total occlusions of the mid right coronary artery and mid
circumflex with a diffusely diseased left anterior
descending. He received stents times two to his mid right
coronary artery. He was transferred from the Catheterization
Laboratory on Dopamine and an intra-aortic balloon pump. The
patient had no palpable pulses in his lower extremities, and
the move was made to remove the intra-aortic balloon pump.
The patient had a worsening lactic acidosis throughout the
morning of admission. He remained in normal sinus rhythm on
Amiodarone and Lidocaine drips. He required mechanical
ventilation for control of his acid-based status as well as
for airway protection. Increasing respiratory rate and total
volumes were not able to control the patient's overwhelming
acidosis.
The patient was markedly oliguric and volume control was not
able to be obtained. The patient had a markedly distended
abdomen and there was concern for ischemic bowel. A KUB
showed wall thickening and no free air. The intra-aortic
balloon pump was removed and the patient continued to have a
worsening acidosis.
After discussion with the family, the decision was made to
abandon aggressive efforts.
The patient experienced at 06:55 p.m. on [**2102-4-23**].
CONDITION AT DISCHARGE: Deceased.
DISCHARGE DIAGNOSES:
1. Ventricular fibrillation arrest.
2. Inferoposterior myocardial infarction.
3. Coronary artery disease.
4. Hypercholesterolemia.
5. Chronic obstructive pulmonary disease.
6. Hypertension.
7. Overwhelming lactic acidosis.
8. Acute renal failure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2102-4-25**] 08:32
T: [**2102-4-26**] 14:57
JOB#: [**Job Number 9742**]
ICD9 Codes: 4280, 5849, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6049
} | Medical Text: Admission Date: [**2176-6-3**] Discharge Date: [**2176-6-6**]
Date of Birth: [**2106-3-30**] Sex: F
Service: Neurology
DIAGNOSIS: Cerebral Infarction.
HISTORY OF PRESENT ILLNESS: Patient is a 70-year-old
right-handed woman, who presented to our Emergency Department
with right arm and leg weakness with a sudden onset at around
10 a.m. on the day of admission. Patient was working in her
work place when she noticed sudden onset of severe dizziness
and loss of strength on the right side of the body involving
her leg and the arm. She was seen to have fallen on the
ground with loss of consciousness. Over the next minutes,
she gained consciousness, and was transferred urgently to our
hospital.
MEDICATIONS ON ADMISSION:
1. Accupril 10 mg b.i.d.
2. Ambien prn.
ALLERGIES: None.
SOCIAL HISTORY: Patient works in [**University/College 56117**]Laboratory. Lives in studio next door to her daughter. Is
an ex-smoker. Denies alcohol or drug abuse. Works three
days per week.
PAST MEDICAL HISTORY:
1. Miscarriage several times in the past.
2. Hypertension.
3. Anxiety.
PHYSICAL EXAM ON ADMISSION: Patient was alert and oriented
to person, place, and date. Speech was fluent and
comprehension was intact. Patient did not have any apraxia
or neglect. Naming and repetition were intact. Visual
fields were clear. Cranial nerve exam did not reveal any
abnormalities. On motor exam, patient had extensor weakness
in the right arm and flexor weakness in the leg. Deep tendon
reflexes were 2+ and plantars were upgoing on the right.
Sensation was diminished to pinprick, light touch, and cold
over the right arm and leg. No truncal ataxia could be seen.
Gait was unable to be performed.
HOSPITAL COURSE: This lady was admitted to our service and
received IV TPA within 3 hours. She was admitted to ICU for
frequent neuro checks. Her vitals were checked and no
irregularities could be seen. Telemetry recordings from the
ICU revealed only infrequent PVCs and sinus tachycardia.
Patient was moved towards to the General Service in [**Hospital Ward Name 121**] 5.
We detected urinary tract infection and started her on
antibiotics for this reason. Twenty-four hours after TPA we
initiated aspirin treatments. She received one full dose of
aspirin the first day and on the second day the patient
received aspirin 81 mg per day and Aggrenox one tablet a day.
Blood laboratories indicated no abnormalities except for
abnormal homocysteine levels, which were detected on day
three of her admission. We initiated treatment with folic
acid and multivitamin for this reason.
Patient's right elbow was noted to have arthritic changes,
and the patient was suffering from pain in this joint. She
received six doses of 500 mg naproxen for this, and the
arthritic inflammation was found to have subsided on day two
of this treatment. Patient received GI prophylaxis with
Protonix.
Her blood pressure was erratic after she was transferred from
the ICU. We could detect systolic pressure in the range of
180-190 at several occasions, which were treated with
hydralazine IV and also reinitiation of her preadmission
antihypertensive, namely Accupril 10 mg b.i.d. We later
changed this medication to 10 mg 3x a day.
Upon admission, MRI, angio, and diffusion-weighted images
indicated, respectively, poor flow in the branches of the MCA
and abnormal diffusion in the parietal region. Repeat MRI
including repeat DWI showed she has several lesions in the
left hemisphere involving the parietal as well as frontal
cortices and some underlying white matter branches of the
corona radiata.
Patient's neurological status improved especially in the
upper extremities, but not in the lower extremities. Her
right arm had gained strength in the range of [**5-5**]+ in
extensor musculature group, but the right leg had minimal, if
any movement in the flexors or extensor musculature. Patient
received frequent physical therapy and upon their assessment,
she is being transferred to a rehabilitation facility for
aggressive exercise.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg p.o. q.d.
2. Aggrenox one capsule p.o. q.d. for two more days, and then
change to one capsule p.o. b.i.d. Please note if the patient
continues with headache after Aggrenox treatment, this needs
to be discontinued and then one could start her on Plavix 75
mg p.o. q.d. from there on. If patient's headache subside
and she tolerates, please change the dose of Aggrenox to one
capsule p.o. b.i.d. as noted.
3. Lipitor 10 mg p.o. q.h.s. This medication was initiated,
although her lipid panel did not reveal any gross
abnormality. The rationale was to gain preventive effects on
future cerebrovascular disease.
4. Folic acid 1 mg p.o. q.d.
5. Levofloxacin 250 mg p.o. q.24h., last dose scheduled for
today before the patient leaves.
6. Multivitamin one capsule p.o. q.d.
7. Naproxen 500 mg p.o. q.8h. prn for elbow arthritis.
8. Percocet one tablet p.o. q.4-6h. for headaches associated
with Aggrenox treatment.
9. Protonix 40 mg p.o. q.24h.
10. Accupril 10 mg p.o. b.i.d.
FOLLOWUP: With Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**5-7**] weeks.
DIAGNOSES:
Left MCA stroke
Hyperhomocysteneimia
? Coagulopathy (We are, however, awaiting the coagulopathy
workup. This needs to be checked at the follow-up appointment)
DISCHARGED TO: Rehabilitation facility.
DISCHARGE CONDITION: As described above.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**Last Name (NamePattern1) 728**]
MEDQUIST36
D: [**2176-6-6**] 11:38
T: [**2176-6-6**] 11:39
JOB#: [**Job Number 56118**]
ICD9 Codes: 5990, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6050
} | Medical Text: Admission Date: [**2157-3-1**] Discharge Date: [**2157-3-1**]
Date of Birth: [**2073-4-5**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo male with recent complicated admission significant for:
1. Bladder CA, 7 cm mass, hematuria, with innumberable pulmonary
nodules, likely metastases
2. Urosepsis, UCx + pseudomonas, h/o mutliple drug resistant
UTIs, treated with 14 days of meropenem
3. Massive DVT, with IVC filter, not on anticoagulation [**1-25**]
hematuria
During this admission, palliative care was consulted, and
significant efforts were made to address goals of care, given
his poor prognosis. He was made DNR/DNI. He was discharged to a
[**Hospital1 1501**] with the eventual goal of putting him under hospice care.
He was then found at his [**Hospital1 1501**] unresponsive. His VS on arrival to
the ED were: T 98.0, HR 160s, BP 82/50, SpO2 40% on NRB, with
rhonchi on exam. He received Vancomycin 1g IV, Levofloxacin
750mg IV, and Flagyl 500mg IV.
On arrival to the floor, patient was unresponsive, was agonal
breathing, with an SpO2 in the 60's on a 100% FM with 6L NC.
Past Medical History:
1. Pulmonary Embolism ([**2156-12-24**], IVC filter, not on
anticoagulation)
2. Pancreatitis
3. Dementia
4. Type 2 Diabetes Mellitus
5. Hypertension, but not on antihypertensives
6. BPH
7. Bladder Cancer
- s/p transurethral resection in [**7-31**]
- completed [**3-29**] BCG treatment (missed treatment 5 [**1-25**] UTI)
8. s/p Stab Wounds
9. h/o RPR - treated in [**2119**]
10. s/p Penile Implant
11. Osteoarthritis
Social History:
Per previous records, patient could not complete full history
with me due to his delirium and dementia.
Home: lives in [**Location 4367**] [**Hospital3 400**] Facility
Occupation: retired long-distance truck driver
EtOH: remote history of social alcohol use; denies EtOH in > 45
years
Tobacco: remote history of 1 PPD smoking history, could not tell
me when he quit
Drugs: denies
Family History:
Could not complete due to patient's dementia.
Physical Exam:
Vitals: BP: 52/31 P: 126 RR: 8
General: Agonal breathing, unresponsive
CV: Regular
Lungs: Coarse breath sounds bilaterally
Ext: warm, well perfused
Pertinent Results:
[**2157-3-1**] 01:15AM BLOOD WBC-19.4* RBC-4.96 Hgb-11.0* Hct-40.1
MCV-81* MCH-22.2* MCHC-27.4* RDW-18.2* Plt Ct-481*
[**2157-3-1**] 01:15AM BLOOD PT-18.2* PTT-34.3 INR(PT)-1.6*
[**2157-3-1**] 01:15AM BLOOD Fibrino-821*
[**2157-3-1**] 01:15AM BLOOD UreaN-33* Creat-1.9*
[**2157-3-1**] 01:15AM BLOOD Lipase-42
[**2157-3-1**] 01:27AM BLOOD Glucose-135* Lactate-11.0* Na-166* K-4.8
Cl-115* calHCO3-23
Brief Hospital Course:
83 year old man with a h/o of metastatic bladder CA, mutliple
drug resistant UTIs,
& massive DVT s/p IVC filter who presented in respiratory
failure likely [**1-25**] pneumonia.
On admission, the patient's HCP (his wife) expressed her desire
to focus on his comfort. He received supplemental oxygen,
antibiotics, and was placed on a morphine gtt and he expired
within 2 hours of arriving in the ICU.
Medications on Admission:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*30 Tablet(s)* Refills:*2*
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily). Tablet(s)
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dryness.
Disp:*1 bottle* Refills:*2*
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Insulin Sliding scale
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 0389, 486, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6051
} | Medical Text: Admission Date: [**2181-3-26**] Discharge Date: [**2181-4-3**]
Date of Birth: [**2120-5-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Right Parietal Brain Mass
Major Surgical or Invasive Procedure:
[**3-26**]:Right sided craniotomy for mass resection
History of Present Illness:
Patient is an 60F known to the neurosurgery service, who
presents for elective surgery for resection of right sided
parietal brain mass on [**3-26**].
Past Medical History:
None; however the patient states she has not been to a physician
in more than 10 yrs. She does state that she has been smoking
for "longer than she can remember" and has had a "benign" mass
resected from her left breast "many years" ago.
Social History:
Married
Family History:
non-contributory; denies familial history of brain
masses/cancer.
Physical Exam:
On d/c she remains afebrile. She is awake, alert and oriented
x3. PRRLA . Rt pupil is 4mm to 3mm and the left remains
slightly smaller at 3.5 to 3.0mm. EOM's are full. There is no
nystagmus. Tongue is midline with even facial symmetry. She
continues to have a left pronator drift. Motor strength 4/5 in
the left bicep and tricep only, otherwise she is full in the
upper extremities. In the lower extremities she is decreased in
the left lower extremity as follows: IP-4+, Quad 5, Ham 4,
Gastra 4, AT 4, [**Last Name (un) 938**] 4. Otherwise she is full in the right lower
extremity. She has been ambulating in her room and on the
nursing unit with staff and Physical therapy. Gait is slow
without listing. She is tolerating all p.o. food and fluid well
with no nausea or vomiting. She is passing flattus, urine and
stool without issues. Her clinical exam has remained stable.
Pertinent Results:
Anatomical Pathology report
DIAGNOSIS:
I. Brain, right parietal lesion (A-B):
glioblastoma, (WHO IV), see note.
Note: Necrosis, mitosis, and vascular proliferation are present.
II. Brain, right parietal lesion-research (C-E):
Glioblastoma, (WHO IV), see note.
Note: MIB-1 immunohistochemistry reveals a focal proliferation
index of 80% in a dense small cell focus and 15-20% overall
(block D).
III. Dural, right parietal (F-G):
Leptomeninges focally involved by [**Last Name (un) **].
IV. Brain, white matter (H):
White matter is diffusely infiltrated by [**Last Name (un) **] with mild
hypercellularity and prominent microvascular proliferation.
V. Brain, right parietal lesion (I-K):
Diffusely infiltrating [**Last Name (un) **] with areas of solid [**Last Name (un) **] cell
nodules.
Radiology Report MR HEAD W/CNTRST&[**Last Name (un) **] VOLUMETRIC Study Date of
[**2181-3-26**] 6:08 AM
[**2181-3-26**] 6:08 AM
MR HEAD W/CNTRST&[**Year/Month/Day **] VOLUMET; CT 3D RENDERING W/POST PROCESS
Clip # [**Clip Number (Radiology) 82765**] Reason: pre-surgical mapping for craniotomy
Contrast: MAGNEVIST Amt: 12
Provisional Findings Impression: RXCg MON [**2181-3-26**] 6:41 PM
PFI: Large 4.1 x 3.1 cm heterogeneously enhancing mass in the
right
parietotemporal region causing mass effect on the ipsilateral
lateral
ventricle and effacement of the Ambien cistern.
Final Report
HISTORY: 60-year-old female patient with a right brain mass.
TECHNIQUE: Post-gadolinium contrast images were obtained in the
axial,
coronal, and sagittal planes as per presurgical planning
protocol. MR [**First Name (Titles) **] [**Last Name (Titles) 82766**]y was also obtained of the enhancing portion of the
[**Last Name (Titles) **].
FINDINGS:
There has been slight interval increase in size of the right
parietotemporal heterogeneously enhancing mass. The volume of
enhancing [**Last Name (Titles) **] measures 18.85 cm3. This mass is closely opposed
and appears to involve the overlying dura as indicated by
adjacent dural thickening and enhancement. There is surrounding
perilesional T1 hypointensity reflecting edema versus [**Last Name (Titles) **]
infiltration. There is a mass effect involving the ipsilateral
lateral ventricle as well as midline shift of approximately 4.9
mm, not significantly changed when compared to the prior exam.
There is effacement of the ipsilateral ambient cistern with no
evidence for frank herniation. No other abnormal enhancing
lesions are identified.
IMPRESSION:
Large right parietotemporal heterogeneously enhancing mass.
Differential
diagnostic considerations include primary CNS malignancy (such
as GBM) or
solitary metastases.
CT brain Wet Read: JXKc TUE [**2181-3-27**] 11:54 PM
Post-op changes from right parietal resection with increase in
vasogenic
edema, and leftward shift of midline and subfalcine herniation
of 10 mm
(previously, 4mm). New right subdural hypodense collection,
measuring 4 mm.
Final Report
HISTORY: 60-year-old female with recent right craniotomy for a
mass, with
small bleeding this morning, now increased lethargy and left
hemiparesis.
Evaluate for increase in hemorrhage.
COMPARISON: [**2181-3-26**].
TECHNIQUE: Contiguous axial images of the head were obtained
without IV
contrast.
FINDINS: Changes from a right parietal craniotomy and resection
of the mass are again noted, with a small amount of hemorrhage
and pneumocephalus seen within the resection bed. There
continues to be residual vasogenic edema, which may be slightly
increased, particularly near the vertex, compared to prior
study. There is, however, a marked increase in associated mass
effect and leftward subfalcine herniation, with herniation of
approximately 10 mm (previously 4 mm); there is also evidence of
early left uncal herniation. There is also mass effect on the
ipsilateral lateral ventricle, with an increase in caliber of
the contralateral lateral ventricle, with the frontal [**Doctor Last Name 534**]
measuring approximately 8 mm (previously approximately 6.5 mm).
There is also new dilatation of the left temporal [**Doctor Last Name 534**]. Since
the interval study,there is also a new right subdural
collection, which is relatively hypodense, could reflect a small
subdural hygroma. No new foci of intracranial hemorrhage are
identified.
Visualized paranasal sinuses and mastoid air cells are normally
aerated.
Previously noted dilated superior ophthalmic veins are improved.
Post-surgical
changes are also noted within the soft tissues and scalp
overlying the
craniotomy site, with soft tissue swelling and air.
IMPRESSION:
1. Status post resection of right parietal mass, with increase
in vasogenic
edema and mass effect, with an increase in leftward subfalcine
and early uncal
herniation.
2. Increased caliber of the left lateral ventricle, likely
"trapped" at the
level of the foramen of [**Last Name (un) 2044**], with obliteration of the frontal
[**Doctor Last Name 534**] of the
right lateral ventricle.
3. Small new right subdural collection, measuring 4 mm in
maximal dimension,
could reflect a small subdural hygroma.
MR HEAD W/O CONTRAST Study Date of [**2181-3-29**] 12:26 PM
Final Report
COMPARISON: CT [**2181-3-27**]; MR [**2181-3-27**]; [**2181-3-20**].
TECHNIQUE: Diffusion technique images were obtained.
FINDINGS: There is no diffusion abnormality. Again seen is a
surgical
resection site in the right parietal lobe. Signal change due to
T2
prolongation in this area and representing edema appears little
changed from
the prior MR studies.
IMPRESSION:
1. No diffusion-weighted abnormalities to suggest infarction.
2. Similar appearance to edema in the right parietal
postsurgical area.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2181-3-31**]
12:00 N
Provisional Findings Impression: GWp SAT [**2181-3-31**] 2:17 PM
PFI:
1. New 3.3 x 1.0 cm focus of hyperdensity within the right
parietal resection area consistent with new bleed.
2. Similar leftward subfalcine shift.
3. Persistent right subdural hypodense collection, essentially
unchanged from prior.
Final Report
Right craniotomy, evaluate for reduction of edema.
COMPARISON: [**2181-3-27**]; [**2181-3-26**].
TECHNIQUE: Non-contrast head CT.
There is a new 3.3 x 1.0 cm focus of hyperdensity within the
right parietal
resection site, compatible with new bleed. Vasogenic edema
persists and the
amount of leftward subfalcine herniation is similar to prior at
10 mm. There
is evidence of uncal herniation. Again seen is mass effect on
the right
lateral ventricle with the frontal [**Doctor Last Name 534**] on the left, again
mildly dilated.
There is a stable appearance to the right subdural collection,
which is
relatively hypodense. Visualized paranasal sinuses and mastoid
air cells are
normal. Post-surgical changes are seen in the soft tissues of
the scalp
overlying the craniotomy site with soft tissue swelling and air.
IMPRESSION:
1. Status post resection of right parietal mass with a new
hyperdense focus
compatible with new bleed. Stable appearance of leftward
subfalcine and uncal
herniation.
2. Stable appearance of left lateral ventricle likely trapped at
the level of
foramen of [**Last Name (un) 2044**] with distortion of the frontal [**Doctor Last Name 534**] of the
right lateral
ventricle.
3. Persistent right subdural collection, unchanged in size, may
reflect some
small subdural hygroma.
Brief Hospital Course:
Patient was electively admitted on [**3-26**] for surgical resection
of right sided parietal brain mass. Post-operatively she was
transferred to the ICU for monitoring overnight. On POD#1 pt
was transfered to the floor with left neglect (old) with left
drift/ CT stable. On the early evening, pt with lethargy, Ct
stable, dilantin changed to Keppra. Later that evening of that
same day - pt with increased lethargy. Second stat CT of the
day showed increased edema with MLS. She was treated
aggressively with mannitol, lasix and decadron and transfered to
step down status. MRI completed wihtout signs of stroke. She
was seen by Dr. [**Last Name (STitle) 724**] / neuro-onc to formulate a plan as her
pathology was finalized as GBM stage IV. The following day she
was more awake and passed speech and swallow. Her exam continued
to improve. On [**2181-3-31**] a routine CT was done to follow
resolution and or improvement of edema. Of note there was a new
area of bleeding into the postop bed. A decision was made to
follow her clinically as she coninues to do well. Her mannitol
was d/c'd after discussion with the attending. On [**2181-4-2**] CT
imaging was completed and she was cleared for d/c to home with
services by Physical therapy. She has also been seen by Dr. [**Last Name (STitle) 724**]
while inpatient and will see him again on [**2181-4-30**] for
further management.
Medications on Admission:
Dilantin
Decadron
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Dexamethasone 4 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours).
Disp:*135 Tablet(s)* Refills:*1*
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Outpatient Physical Therapy
For evaluation and continued treatment as needed
6. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for headache.
Disp:*85 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right parietal mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Keppra for seizure control.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? 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.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**5-25**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2181-4-30**]@
3:00pm with Dr. [**Last Name (STitle) 724**]. The Brain [**Hospital 341**] Clinic is located on the
[**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your hospitalization.
Completed by:[**2181-4-3**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6052
} | Medical Text: Admission Date: [**2193-5-24**] Discharge Date: [**2193-5-29**]
Date of Birth: [**2117-8-12**] Sex: M
Service:
CHIEF COMPLAINT: Increased shortness of breath with exertion
and occasional chest discomfort.
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
male with a history of coronary artery disease since [**2184**].
He has been on medical treatment since then. He developed
congestive heart failure in the Summer of [**2192**] with increased
fatigue and increased shortness of breath on exertion. He
also developed atrial fibrillation for which he was
cardioverted times two, both of which failed. He was then
radioablated with repeat catheterization in [**4-9**]. He also
had a positive exercise tolerance test in [**4-9**].
PAST MEDICAL HISTORY: 1) Coronary artery disease. 2)
Rheumatic fever at age 12. 3) Paroxysmal atrial
fibrillation, status post cardioversion times two, status
post ablation. 4) Lower back pain. 5) Osteoarthritis
bilateral hips. 6) Emphysema on Theophylline. 7) Congestive
heart failure. 8) Hypertension.
PAST SURGICAL HISTORY: Status post appendectomy, status post
tonsillectomy.
MEDICATIONS: On admission, Coumadin discontinued [**5-10**],
Zestril 10 mg q d, Atenolol 25 mg q d, Maxzide 37.5 mg q d,
ASA 81 mg q d, MVI, Theophylline 300 mg q d.
ALLERGIES: None known.
HOSPITAL COURSE: The patient underwent an elective coronary
artery bypass graft times one on [**2193-5-24**]. His intraoperative
course was uneventful and he was transferred to the CSRU. He
was extubated on the same day. He recovered well in the CSRU
though he needed Neo-Synephrine for blood pressure control on
postoperative day #1. On postoperative day #2 he was weaned
off the Neo-Synephrine and his chest tubes were discontinued.
He was transferred to the regular floor on postoperative day
#2 in a stable condition. On postoperative day #3 he
developed atrial fibrillation which was treated with IV
Lopressor. He reverted back to sinus rhythm with a small
dose of IV Lopressor. He was started on po Amiodarone. He
remained in sinus rhythm and he is ready for discharge on
postoperative day #5.
DISCHARGE MEDICATIONS: Lopressor 25 mg [**Hospital1 **], Lasix 20 mg q d
times one week, KCL 20 mEq q d times one week, Colace 100 mg
[**Hospital1 **], Aspirin enteric coated 325 mg q d, Plavix 75 mg q d,
Theodur 300 mg q d, Amiodarone 400 mg q d times one month,
Percocet 1-2 tablets q 4-6 hours prn.
DISCHARGE STATUS: To home.
FO[**Last Name (STitle) **]P: With primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
in two weeks and with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2193-5-28**] 19:54
T: [**2193-5-28**] 20:57
JOB#: [**Job Number 42528**]
ICD9 Codes: 4254, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6053
} | Medical Text: Admission Date: [**2143-6-29**] Discharge Date: [**2143-7-31**]
Date of Birth: [**2061-12-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Chest and Abdominal pain
Major Surgical or Invasive Procedure:
ERCP x2
NJ Tube placement
PICC line placement right side, replaced onto left side
History of Present Illness:
81M p/w cp/abd pain x 2d. Pt reports nausea with emesis x 3
yesterday. Reports that the pain is over the L side of his chest
and abdomen, radiating to his back.
In the ED, initial VS were: 10:01 96 102 134/88 20 97%. Given
morphine and pressures dropped to the 100s, switched to fentanyl
for pain control. A stat CTA was performed which demonstrated no
evidence of dissection/ aortic rupture. Lipase 3200 and CT
abdomen consistent with pancreatitis. Lactate 3.8, troponin
<0.1, BNP 1451.
88 155/84, 16, 100% NC
On arrival to the MICU, patient is febrile and rigoring, but
comfortable, getting fluids, in no acute distress. Not
struggling to breathe, no leg pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, states that he has
gained weight due to a good appetite. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. No orthopnea, PND, claudication.
Denies nausea, vomiting, diarrhea, constipation, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
PMH per admission note
- DM2
- Aortic stenosis (mild per [**9-1**] echo)
- HTN
- Peripheral artery disease
- Myelodysplasia/leukopenia/thrombocytopenia
PSH per admission note
- [**2141-3-2**] - Open AAA repair with aortobifemoral bypass using
Dacro 18x9 bifurcated graft
- [**2141-3-9**] - bilateral femoral exploration and iliofemoral
embolectomy
- [**2141-3-22**] - RP percutaneous drain
- [**2141-3-27**] - RLQ perc drain
- [**2141-3-28**] - anterior abd drain
Social History:
The patient immigrated from [**Country 532**] in [**2119**] having previously
been a chemist. Lives in [**Location **] with wife who has metastatic
cancer, he is the sole caretaker. [**Name (NI) **] is active and walks
around. Son is [**Name (NI) **].
The patient reports a remote history of tobacco use. He quit in
[**2124**] following many years at one to two packs per day. The
patient denies alcohol or illicit drug use.
Family History:
Family History:
1. CVA - father.
2. Diabetes mellitus - brother.
3. Coronary artery disease - brother.
Physical Exam:
Admission exam:
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, but difficult to tell. No LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
murmur, radiating to carotids, no rubs, gallops
Lungs: Trace crackles at bases
Abdomen: soft, tender, non-distended, bowel sounds present, no
organomegaly
GU: foley
Ext: positive cap refill, but somewhat cool, no pain, only
doplerable at right DP, no clubbing 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 exam:
O: Physical Exam:
98.6 121/63 99 22 96%RA
General: Alert, oriented, appears comfortable
HEENT: oropharynx clear
Neck: supple, JVP not elevated
Lungs: CTA
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: mildly distended, nontender to palpation throughout
including over drain site, bowel sounds present. Drain with
dark brown/green fluid.
Ext: PICC site on the Left demonstrates no tenderness to
palpation. No streaking or cellulitis present. Temperature in
each hand is symmetric. temperature in right foot is cooler then
left foot to touch. PT pulses are dopplerable B/L. Lower
extremeties demonstrated diffuse extreme pitting edema.
Pertinent Results:
Admission labs:
[**2143-6-29**] 10:30AM GLUCOSE-268* UREA N-26* CREAT-1.3* SODIUM-135
POTASSIUM-8.2* CHLORIDE-102 TOTAL CO2-19* ANION GAP-22*
[**2143-6-29**] 10:30AM ALT(SGPT)-65* AST(SGOT)-81* ALK PHOS-78 TOT
BILI-1.4
[**2143-6-29**] 10:30AM LIPASE-3200*
[**2143-6-29**] 10:30AM cTropnT-<0.01
[**2143-6-29**] 10:30AM proBNP-1451*
[**2143-6-29**] 10:30AM ALBUMIN-4.5
[**2143-6-29**] 10:30AM WBC-14.4*# RBC-6.37*# HGB-18.7*# HCT-57.9*#
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.0
[**2143-6-29**] 10:30AM TRIGLYCER-124
[**2143-6-29**] 10:30AM NEUTS-79.1* LYMPHS-17.2* MONOS-3.4 EOS-0.1
BASOS-0.3
[**2143-6-29**] 10:30AM PLT COUNT-105*
[**2143-6-29**] 10:30AM PT-35.7* PTT-52.3* INR(PT)-3.5*
[**2143-6-29**] 05:54PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.050*
[**2143-6-29**] 05:54PM CALCIUM-8.5 PHOSPHATE-1.7* MAGNESIUM-1.8
[**2143-6-29**] 05:54PM URINE RBC-15* WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
Discharge labs:
[**2143-7-31**] 04:42AM BLOOD WBC-6.5 RBC-2.62* Hgb-7.6* Hct-23.9*
MCV-91 MCH-29.1 MCHC-32.0 RDW-20.1* Plt Ct-195
[**2143-7-30**] 06:32AM BLOOD Neuts-58.9 Lymphs-34.8 Monos-5.0 Eos-0.8
Baso-0.6
[**2143-7-31**] 04:42AM BLOOD PT-14.6* PTT-65.3* INR(PT)-1.4*
[**2143-7-31**] 04:42AM BLOOD Glucose-139* UreaN-18 Creat-0.7 Na-128*
K-4.3 Cl-95* HCO3-27 AnGap-10
[**2143-7-31**] 04:42AM BLOOD ALT-22 AST-28 AlkPhos-89 TotBili-1.3
[**2143-7-31**] 04:42AM BLOOD Lipase-63*
[**2143-7-31**] 04:42AM BLOOD Calcium-7.5* Phos-3.6 Mg-2.1
All Blood, urine and wound cultures were negative
[**2143-6-29**] 10:08:50 AM Cardiovascular Report ECG
Sinus tachycardia. Non-specific ST segment changes in the
precordial leads and in the inferior leads. Compared to the
previous tracing of [**2141-6-9**] the rate has increased and the
non-specific ST segment changes are new.
[**2143-6-29**] CHEST (PORTABLE AP)IMPRESSION: No evidence of acute
cardiopulmonary process.
[**2143-6-29**] 11:00 AM # [**Telephone/Fax (1) 76388**] CTA ABD & PELVIS and CHEST
1. No evidence of acute aortic syndrome, no aortic dissection.
2. Focal area of hypoenhancement and edema centered in the
pacreatic head and neck, consistent with acute pancreatitis.
Moderate amount of simple free fluid in the abdomen and pelvis
is new since [**2142-1-15**] exam and likely relates to underlying
panreatitis. No pseudcyst formation or vascular complications
at this time.
3. Coarse hepatic calcification is longstanding and likely
represents sequela of prior infection or trauma.
4. Emphysema.
5. Severe coronary artery calcifications.
6. Post-surgical changes related to left axillary-bifemoral
graft. Femoral arteries appear patent. Persistent thrombosis
of the infrarenal aorta.
[**2143-6-30**] 9:02 AM # [**Telephone/Fax (1) 76389**]
LIVER OR GALLBLADDER US-IMPRESSION: Sludge ball in the
gallbladder neck, but no evidence of acute cholecystitis on US.
Normal 5-mm CBD without evidence of obstruction.
[**2143-6-30**] 3:40 PM # [**Telephone/Fax (1) 76390**] MRCP (MR ABD W&W/OC)
MRCP (MR ABD W&W/OC)-IMPRESSION:
1. Diffuse signal abnormality involving the pancreas with
hypointensity on the T1 sequences and hyperintensity on the T2
sequences most consistent with diffuse pancreatitis. A more
focal region of hypoenhancement involving the pancreatic neck is
suspicious for early necrosis. If the clinical situation of the
patient worsens over the next few days/weeks, then a followup
MRCP examination may be obtained.
2. 1.2 cm pancreatic cyst. A followup MRI may be obtained in
six months to ensure stability.
3. Gallstones.
4. No evidence of intra- or extra-hepatic biliary ductal
dilatation.
[**2143-7-8**] Cardiovascular ECG
Sinus rhythm. Borderline prolonged Q-T interval. Compared to the
previous
tracing of [**2143-6-29**] the T waves in leads V2-V6 are taller. This
may represent acute ischemia or, more likely, an electrolyte
abnormality.
[**2143-7-8**] CT ABD W&W/O C
IMPRESSION:
1. New focus of gas within paripancreatic fluid anterior to the
pancreatic head is highly concerning for infection. This
collection is not yet organized. No drainable collections are
present.
2. Markedly increased stranding and neighboring fluid
throughout the
pancreas, with two evolving foci of necrosis within the
pancreatic head.
3. New moderate narrowing of the SMV/portal vein confluence;
the vessels
remain patent.
4. New moderate right pleural effusion with adjacent
compressive atelectasis is new since [**2143-6-29**].
5. Moderate amount of fluid surrounding the inferior aspect of
the liver and along the right paracolic gutter.
6. Chronic occlusion of the infrarenal abdominal aorta. A left
axillary-extremity bypass appears patent.
[**2143-7-13**] Radiology PORTABLE ABDOMEN
There is no interval development of substantial bowel
dilatation, neither
small nor large. Calcification projecting over the liver is
redemonstrated, known. If clinically warranted, correlation
with cross-sectional imaging
might be considered.
[**2143-7-13**] Radiology MRCP (MR ABD W&W/OC)
IMPRESSION:
1. Interval increase in size of hemorrhagic peripancreatic
collections and increased size of right subhepatic collection.
2. Extrinsic compression of the distal CBD by the enlarged
peripancreatic
collection at the pancreatic head. The CBD now measures 0.9 cm
versus 0.3 cm on the previous MRCP.
3. Severely attenuated portal vein, splenic vein, SMV and
splenic artery,
again secondary to compression by the peripancreatic
collections. No definite evidence of thrombus or pseudoaneurysm
formation; focal contour deformity of the main portal vein is
unchanged and probably secondary to mass effect from adjacent
inflammatory change and collections; nonocclusive thrombus is
felt less likely.
4. Decreased amount of free fluid within the peritoneal cavity.
5. Occluded infrarenal abdominal aorta with patent axillary
[**Hospital1 **]-fem bypass
graft.
6. 3.2 cm calcified lesion within segment [**Doctor First Name 690**]/VIII of the liver
- this is
unchanged since [**2140**] and could be secondary to previous
infection or trauma or calcification of a nonaggressive lesion.
[**2143-7-15**] 11:01 AM # [**Telephone/Fax (1) 76391**] CHEST (PORTABLE AP)
CHEST (PORTABLE AP)
FINDINGS: In comparison with the study of [**7-9**], there is
increasing
prominence of interstitial markings consistent with elevation of
pulmonary
venous pressure. Bibasilar opacifications are consistent with
pleural
effusion and compressive atelectasis.
[**2143-7-16**] Radiology CHEST PORT. LINE PLACEM
FINDINGS: AP single view of the chest has been obtained with
patient in
semi-upright position. A right-sided PICC line has been placed,
seen to
terminate overlying the right atrial contours. The tip is
located 8 cm below the level of the carina and it is recommended
to withdraw the line by 5 cm so to have optimal position in the
mid portion of the SVC. In comparison with the next preceding
chest examination of [**2139-7-15**], no new pulmonary or
cardiovascular abnormalities identified. No pneumothorax is
seen. [**Doctor First Name 8513**] was paged at 3:28 p.m.
[**2143-7-17**] Radiology GB DRAINAGE,INTRO PERC
CONCLUSION:
1. Could not drain the intrahepatic bile ducts directly. While
the ducts
could be opacified and appeared normal in caliber, they could
not be securely
accessed for further intervention.
2. Uncomplicated ultrasound-guided placement of a
cholecystostomy tube.
3. Unsuccesful attempt to advance dobhoff tube into the
duodenum with
fluoroscopy.
[**2143-7-25**] Radiology UNILAT UP EXT VEINS US
IMPRESSION: No evidence of deep vein thrombosis.
[**2143-7-26**] Radiology CHEST PORT. LINE PLACEM
CONCLUSION:
New left-sided PICC line is somewhere in the neck in left
jugular vein. IV nurse has been contact[**Name (NI) **] for the results.
[**2143-7-26**] Radiology [**Numeric Identifier 76392**] EXCH PERPHERAL W/
IMPRESSION:
1. Successful exchange of a left-sided PICC with tip in the
distal SVC. Line
is ready for use.
Brief Hospital Course:
81M with history of AAA s/p repair presenting with chest/abd
pain x 2d with labs and imaging consistent with pancreatitis.
Active Diagnoses
# Necrotizing Pancreatitis: Patient diagnosed with pancreatitis
given classic pain radiating to the back, elevated lipase, and
findings on CT c/w pancreatitis. In terms of etiology, gallstone
pancreatitis is most likely, given evidence of gallstones on
MRCP and mild transaminitis, despite no evidence of ductal
dilitation (likely stone passed). Ischemic pancreatitis
initially considered due to significant vascular history;
however, improved with fluid resuscitatation. Autoimmune
pancreatitis ruled out given normal IgG panel. No clear
medication or viral cause. BISAP initially 2 but elevated Hct
and Cr raised concern for severe pancreatitis. His lactate was
initially elevated, but trended down. He was fluid resuscitated
in the ICU and by [**2143-7-1**], he was tolerating clears PO. By
[**2143-7-2**], he was tolerating a full diet and his pain had
resolved. On [**7-8**] he developed fever and CT scanning noted air
with an area of pancreatic necrosis concerning for infection; he
was started on meropenem/flagyl for infected necrotizing
pancreatitis and continued for a full 14 day course. After
discontinuation of antibiotics he was never febrile or developed
a WBC count. On [**7-13**] he was noted with increasing LFTs and
lipase; MRCP was performed which showed worsening pancreatic
necrosis and edema as well as worsening hemorrhagic collections
around the pancreas (at this time he was coagulopathic with an
INR of ~6). The edema was felt to be extrinsically compressing
the ductal system causing biliary obstruction. ERCP was
performed for stent placement but was unable to access the
ampulla due to extensive duodenal edema. Therefore IR was
consulted for percutaneous biliary drain placement; they were
unable to place this drain and so defaulted to a percutaneous
cholecystostomy tube. After tube placement his bili (which
peaked at ~12) and LFTs/lipase downtrended back to normal and
remained normal after starting oral feeds. The drain initially
had ~1L per day output which tapered off to ~100-200cc daily,
suggesting (per GI) that his duodenal edema had resolved and the
ampulla was no longer extrinsically compressed or obstructed.
The drain needs to remain in place until he is evaluated by
pancreaticobiliary surgery as an outpatient, who will determine
drain removal and cholecystectomy timing. He had a dobhoff tube
placed which was advanced endoscopically into the proximal
jejunum; tube feeds were started ATC and continued to discharge.
His diet was advanced to full liquids and tolerated well; when
attempting to advance to a bland solid diet, he experienced GI
upset with some abdominal discomfort and a small elevation in
his lipase, suggesting that he would require a prolonged course
of gradual dietary advancement prior to being able to eat
normally.
# Volume overload: due to volume resuscitation for severe
pancreatitis, patient has developed extensive third spacing of
fluid including ascites, pleural effusions (initially had O2
requirement, no longer) and extensive anasarca with pitting
edema throughout. He was placed on daily lasix 20mg IV for goal
diuresis 1L net negative daily; IV was utilized throughout due
to concern of bowel edema and poor PO absorption. He should
receive standing lasix IV daily with daily chemistry panels
until his edema has improved.
# Peripheral vascular disease: noted with complicated history
from AAA repair that clotted off requiring conversion to an
axillobifemoral bypass graft that is high risk for clot. He was
on coumadin which was allowed to downtrend as he remained
coagulopathic. As above, when he was noted to have hemorrhagic
conversion of his pancreatitis his INR was reversed with IV
vitamin K and his anticoagulation was managed with a heparin
drip up until the day of discharge. He was given coumadin 2
days prior to discharge (home dose 6mg) and will need to
continue heparin bridge with goal PTT 60-90 until his INR is [**1-25**]
for 48 hours, at which point he can be maintained on coumadin
only. He remained with dopplerable PT/DP pulses bilaterally
(PT>DP) and [**1-25**] second capillary refill throughout.
# Thrombocytopenia: patient developed in the past in [**2140**].
Negative HIT antibodies and negative serotonin release assay.
Perhaps related to his history of MDS compounded by critical
illness and marrow suppression.
# Elevated INR to 4.7: Possibly due to nutritional changes
versus illness. No recent antibiotics. Warfarin was initially
held. By [**2143-7-1**], the INR was 2.8, and warfarin was restarted;
once again became supratherapeutic and warfarin was held prior
to surgery, transition to heparin drip on [**2143-7-7**] when INR was
2.3. This was then turned off when he became coagulopathic
again; he was finally reversed with IV vitamin K after
hemorrhagic pancreatitis was noted on MRCP on [**7-13**].
# DM: at home on GlipiZIDE 5 mg PO QHS and GlipiZIDE 2.5 mg PO
QAM. This was initially held, and paitent was placed on insulin
sliding scale. Due to his worsening pancreatic function, he
required escalating doses of insulin eventually stabilizing on
34u lantus daily with an aggresive sliding scale.
Chronic Diagnoses
# HTN: at home, on home Lisinopril 20 mg PO DAILY and Metoprolol
Tartrate 12.5 mg PO BID. These were held upon discharge due to
him having no issues with blood pressure while in hospital.
They should be restarted upon discharge or by his PCP when he is
more stable. Metoprolol was restarted prior to discharge.
# HL: at home, on Atorvastatin 10 mg PO DAILY.
# Constipation: Bowel regimen.
Transitional Issues
# Communication: Patient, son [**Name (NI) **] [**Telephone/Fax (1) 76393**]
# [**Name2 (NI) 7092**]: Full (confirmed)
- percutaneous cholecystostomy tube to remain in place and
course dictated by pancreaticobiliary surgery
- cholecystectomy at some point to be determined by surgery
- ongoing heparin bridge to coumadin, goal INR [**1-25**] for bypass
graft
- ongoing gradual diet advancement with continuation of tube
feeds till regular low fat diet is acheived without abdominal
symptoms or LFT/lipase elevation
- ongoing evaluation for insulin requirement
- restarting home blood pressure medications when more medically
stable and required
- daily diuresis with IV lasix for goal of -1L net negative
- pancreatic cyst noted on initial MRCP - will need repeat in 6
months.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR PCP.
1. Lisinopril 20 mg PO DAILY
2. Metoprolol Tartrate 12.5 mg PO BID
3. Senna 5 TAB PO HS
4. Warfarin 10 mg PO DAILY16
5. Atorvastatin 10 mg PO DAILY
6. GlipiZIDE 5 mg PO QHS
7. GlipiZIDE 2.5 mg PO QAM
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Warfarin 6 mg PO DAILY16
3. Acetaminophen 1000 mg PO Q6H:PRN pain, fever
4. Bisacodyl 10 mg PR HS:PRN constipation
Patient may refuse. Hold for loose stools.
5. Docusate Sodium 100 mg PO BID
6. 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.
7. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Pantoprazole 40 mg PO Q24H
9. Polyethylene Glycol 17 g PO DAILY
10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
11. Heparin IV per Weight-Based Dosing Guidelines
12. Furosemide 20 mg IV DAILY
hold for sbp<100
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute gallstone pancreatitis
Pancreatic necrosis with superinfection
Hemorrhagic pancreatitis
Coagulopathy
Peripheral vascular disease with axillobifemoral graft
Type 2 Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 76385**],
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted for abdominal pain due to acute pancreatitis. You had a
very protracted course with multiple complications from your
pancreatitis, including necrosis and hemorrhage.
You were treated with IV fluids, antibiotics, anticoagulants and
with a feeding tube. You will have this tube removed when you
are tolerating a full diet. You will also have your PICC line
removed when you do not need heparin any longer.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2143-8-14**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2143-8-30**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please discuss with the staff at the facility a follow up
appointment with your PCP below when you are ready for
discharge.
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 28089**], MD Location:[**Hospital **]/[**Hospital1 18**]
[**Location (un) **]., [**Location (un) 86**], MA
[**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Phone:[**Telephone/Fax (1) 2010**]
ICD9 Codes: 2875, 2761, 4280, 4019, 4241, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6054
} | Medical Text: Admission Date: [**2118-5-24**] Discharge Date: [**2118-5-27**]
Date of Birth: [**2055-6-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Proton Pump Inhibitors / hayfever
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Anterior STEMI
Major Surgical or Invasive Procedure:
-Cardiac catheterization with bare metal stents x3 to left
anterior descending artery
-Cystoscopy, bilateral ureteroscopy, bilateral laser
lithotripsy, bilateral stent placement.
History of Present Illness:
Patient is a 62 yo male with history of CAD sp two DES to
proximal and mid LAD after positive stress test in [**2109**],
anterior STEMI in [**2112**] with late in-stent restenosis sp DES to
LAD and ostium of diagnoal, HLD, renal calculi sp bilateral
lithotripsy and ureteral stents who presents after this
procedure today with anterior STEMI.
.
Patient was in his normal state of health until he presented for
urologic procedure for treatment of bilateral renal calculi. He
was instructed to stop Plavix for his urological procedure and
has been holding this for 5 days. He did continue aspirin.
Procedure included bilateral ureteroscopy, bilateral laser
lithotripsy, bilateral ureteral stents. In PACU sp procedure
patient developed chest pain and EKG revealed anterior STEMI. He
was taken to the for cardiac cath.
.
In the cath lab, LAD stent was dilated. Procedure complicated by
dissection of the LAD. BMS were placed in the mid LAD, distal
LAD, and proximal LAD to restablish excellent flow. Patient was
hemodynamically stable during the case. Thought of
interventional cardiology is that this represents in stent
restenosis. Patient to continue on Clopidogrel indefinitely.
Given 245 ml of omnipague dye.
.
In the CCU, patient is pain free and hemodyncamically stable.
.
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:
1. CARDIAC RISK FACTORS: + Diabetes, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**2109**]: two drug-eluting stents in the proximal and mid LAD.
[**2112**]: presented with an anterior ST elevation infarct and was
found to have late stent thrombosis. Treated with two additional
drug-eluting stents in the LAD as well as at the ostium of a
diagonal branch. Coronary artery disease otherwise consisted of
60% disease in a circumflex marginal and 50% disease in the mid
right coronary artery.
.
3. OTHER PAST MEDICAL HISTORY:
- GERD
- Renal Calculi sp lithotripsy
Social History:
Retired [**Company 2318**] driver.
He drives kids for q. day care now.
Wife is [**Name (NI) **].
He does the treadmill for exercise.
Denies , recreational drugs, or alcohol excess.
Family History:
Mother died at 85 of colon cancer, MI in her 70s, DM2
Father with prostate cancer at 60, pacemaker, DM2
Brother with prostate cancer at 51
Brother with prostate cancer
Sister with DM2
Physical Exam:
Admission:
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 *** 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. 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.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge:
Gen: A/o, NAD
HEENT: supple, no JVD
CV: RRR, no M/R/G
RESP: CTAB post
ABD: soft, NT
EXTR: no edema
NEURO: A/O, no focal defects
Extremeties: right radial without bruising or swelling.
Pulses:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Skin: intact
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2118-5-27**] 07:00 11.1* 4.97 14.5 40.0 81* 29.3 36.3* 13.9 168
[**2118-5-26**] 07:20 11.6* 5.32 15.7 43.1 81* 29.5 36.4* 13.9 184
[**2118-5-25**] 04:09 12.9* 5.27 15.1 42.2 80* 28.7 35.8* 14.0 196
[**2118-5-24**] 22:34 13.1* 5.11 15.5 41.8 82 30.2 37.0* 13.8 205
[**2118-5-24**] 18:00 14.3* 4.80 14.5 39.1* 82 30.3 37.1* 13.8 195
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2118-5-27**] 07:00 308*1 17 0.6 135 4.1 102 24 13
[**2118-5-26**] 07:20 291*1 15 0.7 135 3.9 98 26 15
[**2118-5-25**] 04:09 296*1 24* 0.8 133 4.1 96 27 14
[**2118-5-24**] 22:34 399*1 26* 1.0 132* 4.6 96 25 16
[**2118-5-24**] 18:00 345*1 27* 0.9 132* 4.1 98 25 13
CKs
[**2118-5-25**] 04:09 418*1
[**2118-5-24**] 22:34 453*1
[**2118-5-24**] 18:00 338*1
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2118-5-25**] 04:09 20* 4.8 0.59*1
[**2118-5-24**] 22:34 17* 3.8 0.43*2
[**2118-5-24**] 18:00 0.02*1
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2118-5-27**] 07:00 8.7 1.7* 1.9
[**2118-5-26**] 07:20 9.0 1.7* 1.7
[**2118-5-25**] 04:09 8.9 3.7 1.6
[**2118-5-24**] 22:34 8.8 4.3 1.3*
DIABETES MONITORING %HbA1c eAG
[**2118-5-26**] 07:20 11.5*1 283*2
Brief Hospital Course:
62 yo male with CAD sp 2 DES to LAD in [**2109**], 2 DES to LAD and
Diag in [**2112**] in the setting of late instent restenosis, HLD,
Renal Calculi who presents with anterior STEMI sp urological
procedure in the setting of holding plavix.
.
ACTIVE ISSUES:
# Anterior LAD In-Stent Thrombosis: Pt was sp 2 DES to LAD in
[**2109**], 2 DES to LAD and Diag in [**2112**] in the setting of late
instent restenosis, now with instent restensis vs thrombosis
while off plavix leading to anterior STEMI now sp 3 BMS to LAD.
Procedure complicated by dissection. Pt remained CP free.
Continued integrillin for 18 hours and then transitioned to
heparin sc. The pt will be on Plavix 75 mg forever, ASA 325mg
Daily. Restarted Beta-Blocker, ACE-I. Continue Atorvastatin 80mg
Daily.
.
#. Bilateral Renal Calculi sp B lithotripsy, B ureteral stents.
Continued continuous bladder irrigation x 3 days. HCT remained
stable. Will follow up with urology s/p hospitalization.
.
# Type II Diabetes Mellitus: A1C 11.5%. Started on metformin
500mg [**Hospital1 **], diabetic Diet, Insulin Sliding Scale. The pt is to
f/u nutritionist and physician at [**Name9 (PRE) **] Clinic in the next
month.
.
CHRONIC ISSUES:
# Chronic Diastolic CHF: Post STEMI ECHO ([**5-25**]) showed preserved
EF (>55%), mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild resting outflow tract gradient. No signs of heart failure
while in house.
.
# RHYTHM: Sinus. Monitored on Tele.
.
# HTN: Restarted Beta Blocker and Lisinopril as pressure
tolerates.
.
# HLD: Continue Atorvastatin 80mg Daily.
.
# Depression: Pt continued on fluoxetine
.
TRANSITIONAL ISSUES:
Full Code. Pt to f/u with [**Last Name (un) **].
Medications on Admission:
- atenolol 25 mg q. day
- lisinopril 10
- Lipitor 80
- Plavix 75 (holding for procedure)
- aspirin 81 mg
- Prozac 20
- Zantac/omeprazole 20 mg
- Claritin or [**Doctor First Name **]
- Flonase
- Viagra or [**Doctor First Name **]
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day.
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. 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*
7. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Zantac 75 75 mg Tablet Sig: 1-2 Tablets PO once a day.
9. [**Doctor First Name **] Oral
10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain: Interacts wtih
[**Last Name (LF) **], [**First Name3 (LF) **] not take within 24 hours. .
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Nephrolethiasis
ST Elevation myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You had stents placed in your ureters and while you were
recovering in the PACU you had a heart attack. You were brought
to the cardiac catheterization lab where a three bare metal
stents placed in your left anterior descending artery. We
believe the stents blocked off because you were not taking
Plavix. You will need to take plavix and aspirin every day
forever, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking plavix unless Dr.
[**Last Name (STitle) **] tells you to. The foley catheter was removed and we
expect that you will have some blood tinged urine for a few
days. Please call Dr.[**Name (NI) 825**] office if you notice that your
urine is frank blood or if you are having trouble urinating.
Your blood sugars have been very high here and your A1C is 11.5
which means that your average blood sugar at home is 280. We
have started you on a diabetes medicine and Dr. [**Last Name (STitle) 2472**] can
increase this medicine next week. You also have an appt with a
nutritionist and physician at [**Name9 (PRE) **] Clinic in the next month.
It is crucially important that you control your blood sugars
better to protect your kidneys and heart. Please check your
blood sugars before breakfast and dinner for a week and record
the readings to show to the [**Last Name (un) **] nutritionist and physician.
.
We made the following changes to your medicines:
1. STOP taking Atenolol
2. Start taking Metoprolol XL to slow your heart rate and help
your heart recover from the heart attack
3. Increase the aspirin to 325 mg daily for at least one month
and possibly longer
4. Continue to take Plavix every day to prevent the stent from
clotting off
5. Decrease Lisinopril to 5 mg daily for now to lower your blood
pressure
6. Take the nitroglycerin as needed for chest pain but don't
take it within 24 hours of [**Last Name (un) **]. Call 911 if you still have
chest pain after taking nitroglycerin.
7. Start Metformin to lower your blood sugars
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 133**]
Appointment: Thursday [**2118-6-2**] 9:45am
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2118-6-9**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2118-6-13**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
[**Hospital **] Clinic: please go to the [**Location (un) 1773**].
[**6-29**] at 4:00pm with Dr. [**Last Name (STitle) **] for medication adjustment
Monday [**5-30**] at 1:00pm with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], nutritionist.
Completed by:[**2118-5-29**]
ICD9 Codes: 4280, 9971, 2724, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6055
} | Medical Text: Admission Date: [**2128-11-26**] Discharge Date: [**2128-12-27**]
Date of Birth: [**2100-8-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
[**11-26**] a.m. Ventriculostomy placemtent
[**11-26**] A-Comm Aneurysm coiling
[**11-26**] Ventriculostomy placement
[**12-2**] Cerebral angiogram
[**12-8**] IVC filter
[**12-8**] Tracheostomy
[**12-8**] Peg
History of Present Illness:
28y/o male who reportidly had a sudden onset [**10-29**] occipital
headache after intercourse. Question of a seizure prior to
arrival at outside facility. Patient alert prior to head CT, and
then rapidly declined requiring sedation and intubation. CT
revealed diffuse SAH with early HCP. Pt. Transferred to [**Hospital1 18**]
and arrived at approx. 12:30 am, heavily medicated, proceeded to
CT
for a CT and CTA which revealed a L MCA aneursym.
Past Medical History:
Non contributory
Social History:
Per mother: no Tobacco
[**Name (NI) 80077**] use
Family History:
Non contributory
Physical Exam:
VSS. Afebrile.
Eyes open throughout 90% of evaluation with increased verbal and
tactile stimulation to maintain eyes open when in supine
position. Eyes track to voice, cross midline. PERRL 4mm to 2mm
bilaterally. +Corneal,+Cough. Following approximately 20% of
commands with Bilateral upper extremities. Has not been moving
the lower extremities to this point. MRI imaging of the spine
has not demonstrated pathology to account for this. No seizure
activity, pt to continue on Keppra upon discharge.
CV: Pt continues to remain hemodynamically stable. Recieving
B-blockade to control his episodic tachycardia. Pt remains on
coumadin for treatment of his DVT. Coumadin was begun on
[**2128-12-19**].
Resp: Pt with Cuffed 8.0mm [**Last Name (un) 295**] tracheostomy. Course breath
sounds throughout with copious amouts of thick white secretions.
RR 16-40. O2 sat 100%
GI/GU: PEG functioning as expected. Estimated nutritional needs
based on adjusted weight is 1710-2137 calories (20-25cal/kg) and
103-128 (1.2-1.5G/kG) of protien.
Foley draining clear yellow urine. Essentially Euvolemic. No
evidence of DI.
Code Status: Full
Pertinent Results:
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2128-11-26**] 12:30 AM
Final Report CTA OF THE BRAIN/CIRCLE OF [**Location (un) **]
FINDINGS:
There is diffuse subarachnoid hemorrhage as well as a small
amount of
intraventricular hemorrhage in the occipital horns. There is
enlargement of ventricles. There is effacement of the basilar
cisterns compatible with edema. There is a small amount of mls
to the left. There is a 2.5-mm aneurysm at the junction of the
AComm and the right A1-A2 junction. No other aneurysms are seen.
There is no evidence for vasospasm. There is a hypoplastic left
A1 segment. There is a tiny fenestration at the origin of the
basilar artery.
IMPRESSION:
2.5-mm aneurysm at the junction of the right A1, A2 and ACom
segments.
The study and the report were reviewed by the staff radiologist.
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND
FINDINGS: Grayscale and color Doppler images of the left and
right common
femoral, superficial femoral, and popliteal veins were obtained.
There is
non-compressibility and absence of wall-to-wall flow in the
proximal
superficial left femoral vein, consistent with a non-occlusive
deep venous
thrombosis. The remainder of the interrogated vessels
demonstrate normal
flow, compressibility, and augmentation.
IMPRESSION: Non-occlusive deep venous thrombosis of the left
proximal
superficial femoral vein. The findings were conveyed directly to
the ICU
nurse caring for the patient at the conclusion of the study.
[**2128-10-28**]: CT perfusion
IMPRESSION:
1. Status post extensive right frontal craniectomy with
placement of paired ventricular drains, with persistent
herniation of a significant portion of the right frontal lobe
through the craniectomy defect.
2. Hemorrhage and edema involving the paramedian frontal lobes,
bilaterally, which may represent evolving hemorrhagic
transformation of acute infarcts, or, less likely, contusions.
3. Continued blood in the interhemispheric fissure as well as
within the
ventricular chain, with a very small amount of residual
subarachnoid
hemorrhage.
4. Perfusion abnormality corresponding to the abnormal portion
of both frontal
lobes, but, elsewhere, perfusion is normal, and the CTA
demonstrates no
evidence of vasospasm or flow-limiting stenosis.
5. Chronic inflammatory changes involving the left sphenoidal
air cells and
bilateral maxillary antra.
see attached. Results pending at this time
Brief Hospital Course:
On [**11-26**] pt was brought to angio to have 5 coils placed into
A-comm aneurysm. Later in the day he was emergently brought to
the OR for emergent R craniectomy and bilat. EVD's placed. His
mental status remained poor and elevated ICP's. Pt was
chemically paralyzed, sedated and on Pentobarb in order to
decrease ICPs along with HHH therapy for vasospasm. On [**11-28**] the
R EVD was not-functioning and CT head showed increasing edema.
The pentobarb was weaned and paralytic d/c'd. He also had an
angio on [**11-29**] which did not show any vasospasm. Pentobarb was
then d/c'd on [**12-2**] and angio on that day showed mild vasospasm.
During this time pt was febrile and CSF was sent for culture
however pt was found to have LLL PNA which was treated and ID
was involved due to gram + cocci in CSF. On [**12-6**] the R EVD was
clamped and then removed on [**12-9**]. On [**12-9**] His exam remained
poor with only external rotation of BUE and triple flexion of
BLE with noxious. He was then found to have a L common fem DVT
and an IVC filter was placed. He also had elevated LFTs and
abdominal US was negative however an Abd CT was done to confirm
these findings. A CTA of the head was done as well to look for
vasospasm On [**12-10**], which was positive. he was Trached and
Peg'd. On [**12-11**] Patients exam has slowly improved, he is
opening his eyes and tracking the examiner and following simple
commands with his upper extremities, with minimal to no movement
of his lower extremities. During his ICU stay the patient has
been bronched multiple times for theraputic lavage and to obtain
a BAL. His sputum is positive for Coag negative staph. He is at
this time recieving Nafcillin per recommendations made by ID.
[**12-13**] Left EVD d/c'ed. [**12-14**] slight development of
hydrocephalus.
Medications on Admission:
None
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Acetaminophen 650 mg Suppository Sig: [**1-21**] Suppositorys Rectal
Q6H (every 6 hours) as needed.
6. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every
6 hours) as needed for fever >101.5.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Monitor INR weekly once theraputic .
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: Per sliding Scale AC and hs.
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO Q6H
(every 6 hours).
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. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. Vancomycin 1000 mg IV Q 8H
16. Piperacillin-Tazobactam Na 4.5 g IV Q8H
17. Med end dates
Vancomycin and Zosyn dosing will end [**2128-12-28**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Aneursymal Subarachnoid Hemorrhage
Anterior communicating artery aneurysm
Atrial fibrillation
L common fem DVT
Respiratory failure
Cerebral Vasospasm
Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? 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.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Follow-Up Appointment Instructions
?????? Please return to the office in [**7-29**] days for removal of your
staples or sutures.
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 2 weeks.
?????? You will / will not need a CT scan of the brain with / without
contrast.
?????? You will / will not need an MRI of the brain with/ or without
gadolinium contrast.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? 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.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
?????? If you brain imaging for this appointment it can be arranged
by the office.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks please call [**Telephone/Fax (1) 1669**]
Completed by:[**2128-12-24**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6056
} | Medical Text: Admission Date: [**2130-8-29**] Discharge Date: [**2130-9-7**]
Date of Birth: [**2055-1-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Ace Inhibitors / Lidoderm / Codeine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2130-8-31**] Mitral valve replacement utilizing [**Street Address(2) 11599**]. [**Male First Name (un) 923**]
porcine valve. Maze procedure utilizing radio frequency
ablation. Ligation of left atrial appendage.
History of Present Illness:
This is a 75 year old female with history of non-ischemic
cardiomyopathy and atrial flutter. She was recently admitted to
[**Hospital3 35813**] Center on [**2130-8-14**] with congestive heart failure
and hypotension. Workup revealed severe mitral regurgitation and
severely depressed left ventricular function with an ejection
fraction of 30%. Her coronary arteries were angiographically
normal. Based on the above results, she was subsequently
transferred to [**Hospital1 18**] for operative care.
Past Medical History:
Non-ischemic cardiomyopathy, Hypertension, Atrial flutter with
history of failed ablation, s/p PPM/AICD placement, Chronic
anemia, Osteoporosis with multiple lumbar compression fractures,
History of non-Hodgkins lymphoma, Spinal stenosis with chronic
low back pain, History of seizures, History of herpetic
neuralgia, s/p chole, s/p appendectomy
Social History:
No history of tobacco or ETOH. Lives with sister-in-law.
Family History:
Son diagnosed with coronary artery disease in his 40's.
Physical Exam:
Vitals: Temp 99.2, BP 106/50, HR 65 AV paced, R 18, SAT 99% RA
General: Elderly female in no acute distress
HEENT: oropharynx benign, PERRL, sclera anicteric
Neck: suppple, no JVD, no carotid bruits
Chest: lungs clear bilaterally
Heart: regular rate, s1s2, [**2-19**] holosystolic murmur
Abdomen: benign
Ext: warm, no pedal edema
Pulses: palpable distal pulses, no femoral bruits
Neuro: nonfocal
Pertinent Results:
[**2130-9-5**] 04:04AM BLOOD WBC-11.8* RBC-3.64*# Hgb-10.6*#
Hct-31.5*# MCV-87 MCH-29.2 MCHC-33.7 RDW-16.8* Plt Ct-112*
[**2130-9-7**] 04:12AM BLOOD PT-15.8* INR(PT)-1.7
[**2130-9-7**] 04:12AM BLOOD K-4.4
[**2130-9-5**] 04:04AM BLOOD Glucose-83 UreaN-16 Creat-0.5 Na-137
K-4.1 Cl-100 HCO3-28 AnGap-13
Brief Hospital Course:
Patient was admitted and underwent further preoperative
evaluation which included a repeat echocardiogram. This was
notable for 3+ mitral regurgitation with moderate to severe
tricuspid regurgitation. The overall left ventricular systolic
function was mildly depressed but compared to previous studies,
her ejection fraction had improved to 50%. There was moderate
pulmonary artery systolic hypertension. Her left atrium was
dilated. She had a normal aortic root and her aortic valves were
mildly thickened with only 1+ aortic insufficiency. Workup was
otherwise unremarkable and she was eventually cleared for
surgery. She remained stable on medical therapy. Antibiotics
were started for her preoperative urinary tract infection -
cutlture grew out E. coli sensitive to Bactrim and Ancef.
On [**8-31**], Dr. [**Last Name (STitle) **] performed a mitral valve
replacement([**Street Address(2) 11599**]. [**Male First Name (un) 923**] porcine valve) and MAZE procedure.
Surgery was uneventful. The intraoperative TEE showed no mitral
regurgitation with an ejection fraction around 35-40%. After the
operation, she was brought to the CSRU in stable condition. She
initially required multiple blood products for an anemia and a
postoperative coagulopathy. She concomitantly experienced a
transient increasing pressor requirement which prompted a TEE
which found no evidence of cardiac tamponade. Over the next 48
hours, she successfully weaned from inotropic support and was
extubated without difficulty. Amiodarone was eventually started
given her history of atrial fibrillation/flutter as well as
Warfarin for her porcine mitral valve replacement. She
maintained stable hemodynamcis and adequate urine output. She
was intermittently transfused with additional packed red blood
cells to maintain hematocrit near 30%.
Postop, she continued to experience a persistent leukocystosis.
All lines were changed and pan cultures were obtained. Her white
count peaked to 25K on POD#3. All cultures remained negative. On
POD#4, she transferred to the SDU. There medical therapy was
optimized. She required additional diuresis. By discharge, chest
x-ray was notable for improving pleural effusions. Amiodarone
was titrated and Warfarin was dosed for a goal INR between 2.0 -
2.5. By discharge, her white count improved to 11K. She remained
afebrile. At discharge, she was tolerating 1L nasal cannula with
oxygen saturations of 95%.
Medications on Admission:
Warfarin - stopped PTA, ASA 325 qd, Coreg 6.25 [**Hospital1 **], Digoxin
0.125 qd, Cozaar 25 qd, Sotalol 160 [**Hospital1 **], Protonix 40 qd,
Spironolactone 12.5 qd, Tegretol 100 [**Hospital1 **], lasix 40 qd, Lexapro
10 qd, Colace, Senna, Oxycodone
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): [**9-4**] 2 mg
[**9-5**] 3 mg
[**9-6**] 3 mg INR 1.2
[**9-7**] INR 1.7
goal INR [**1-19**].
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg Qd x 1 week then 200 mg QD.
10. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
12. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name 62491**]Rehabilitation
Discharge Diagnosis:
Congestive Heart Failure, Mitral regurgitation, Non-ischemic
cardiomyopathy - s/p porcine MVR and MAZE, Hypertension, History
of Atrial flutter with history of failed ablation, s/p PPM/AICD
placement, Chronic anemia, Osteoporosis with multiple lumbar
compression fractures, History of non-Hodgkins lymphoma, Spinal
stenosis with chronic low back pain, History of seizures,
History of herpetic neuralgia, s/p chole, s/p appendectomy,
Postoperative leukocytosis, Preoperative UTI, Plueral effusions
Discharge Condition:
Good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
No lifting more than 10 lbs for at least 10 weeks.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 62492**] on [**2130-9-21**] @ 2PM
Local cardiologist in 2 weeks
Local PCP [**Last Name (NamePattern4) **] 2 weeks
Completed by:[**2130-9-7**]
ICD9 Codes: 4280, 4240, 4254, 5990, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6057
} | Medical Text: Admission Date: [**2154-6-7**] Discharge Date: [**2154-6-14**]
Date of Birth: [**2082-7-14**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 yo F with PMH of CAD, CHF, DM, HTN, CVA who developed acute
onset SOB the night prior to admission. She additionally had an
approximate 5 minute period of chest pain with burning
sensation. During the course of the night she noted difficulty
lying flat. SOB seemed somewhat positional. The day of
presentation, she went to her PCP who then sent her to [**Hospital1 6591**]. There she was found to have elevated Troponin 0.12,
0.13. CXR was not exemplary but CTA with massive pulmonary
embolism. Given Lovenox 80 mg SC at [**2154-6-6**] at [**2161**]. Has history
of R hemorrhagic CVA in [**2148**] with resultant left hemiparesis.
Hemodynamically stable and transferred to [**Hospital1 18**].
.
At [**Hospital1 18**], initial VS 97.7, 128/93, 85, 14 and 97 on unknown
oxygen. Pulmonary exam noted to be clear to auscultation
bilaterally. EKG with SR, multiple PVCs and diffuse new TWI
V2-V6 compared to [**2148**]. Labs revealed hypernatremia, low
bicarbonate to 20 and UA with pyuria and bacteria. She was not
given additional medication but IR was contact[**Name (NI) **] for potential
thrombectomy.
Past Medical History:
Chronic obstructive pulmonary disease.
Systolic CHF, Ef 10-15% [**2148**] (Patient unsure)
s/p Hemorrhagic CVA (left sided hemiparesis) due to right middle
cerebral artery infarction who underwent a craniotomy
Hyperlipidemia
HTN
Diabetes mellitus
Constipation
UTIs
h/o Tracheostomy
Social History:
Lives with husband with daughter upstairs. Previously smoked (20
years x 1.5 ppWeek)
Family History:
No family history of thrombus or bleeding disorders. Father with
history of MIs.
Physical Exam:
VS 98, 79, 125/90, 14, 99/2L NC
GEN: NAD
HEENT: NCAT, PERRL, MMM
PULM: CTAB without w/r/r
CV: RRR without m/g/r
Abd: Soft, NT, active bowel sounds
LE: without e/o edema, symmetric
Pertinent Results:
[**2154-6-7**] 09:25PM HCT-41.5
[**2154-6-7**] 09:25PM PT-14.8* PTT-150.0* INR(PT)-1.3*
[**2154-6-7**] 01:17PM CK(CPK)-114
[**2154-6-7**] 01:17PM CK-MB-6 cTropnT-0.07*
[**2154-6-7**] 01:17PM PT-15.5* PTT-150* INR(PT)-1.4*
[**2154-6-7**] 05:39AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM
[**2154-6-7**] 12:01AM GLUCOSE-163* UREA N-15 CREAT-0.8 SODIUM-146*
POTASSIUM-3.4 CHLORIDE-113* TOTAL CO2-20* ANION GAP-16
[**2154-6-7**] 12:01AM CK(CPK)-88
[**2154-6-7**] 12:01AM cTropnT-0.11*
[**2154-6-7**] 12:01AM CK-MB-NotDone
[**2154-6-7**] 12:01AM WBC-11.4* RBC-4.91# HGB-15.0# HCT-44.1#
MCV-90 MCH-30.5 MCHC-33.9 RDW-14.7
[**2154-6-7**] 12:01AM PLT COUNT-182
[**2154-6-7**] 12:01AM PT-13.2 PTT-36.4* INR(PT)-1.1
EKG [**6-6**]:
Normal sinus rhythm with occasional ventricular premature beats.
Low voltage in the standard leads and in the precordial leads.
Very poor R wave progression. RSR' pattern in lead V1. QRS
duration of 90 milliseconds. Non-specific ST-T wave changes
throughout the tracing. Compared to the previous tracing of
[**2148-4-25**] the patient has gone from atrial fibrillation at a rate
of 117 to normal sinus rhythm at 86 beats per minute with
occasional atrial premature beats. The T wave inversions in the
lateral leads are new. The poor R wave progression out through
V6 is new. This may be related to altered lead placement.
Consider anterior wall myocardial infarction of undetermined
age.
ECHO [**6-7**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. No aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
There is a very small pericardial effusion.
IMPRESSION: Dilated and hypokinetic right ventricle with
evidence of pressure overload. Small left ventricle with normal
global systolic function. At least mild mitral regurgitation.
Suboptimal study.
Compared with the report of the prior study (images unavailable
for review) of [**2148-4-9**], LV function appears to have improved.
At the same time, there is new RV dilation/dysfunction.
CXR [**6-7**]:
IMPRESSION:
1. No evidence of pneumonia or congestive heart failure.
2. Diminished vascularity in lung, likely due to known large
pulmonary
embolism.
bilateral LE u/s [**6-7**]:
IMPRESSION: Partially occlusive DVT of the left common femoral
vein extending through the entire left superficial femoral vein
where it is nearly completely occlusive and into the left
popliteal vein where again it is partially occlusive. Left calf
veins cannot be seen. Right lower extremity venous structures do
not demonstrate any thrombus.
Brief Hospital Course:
# Pulmonary embolus: Pt was admitted to MICU and started on
heparin gtt. LLE u/s positive for DVT as above. An ECHO showed
moderate RV dilation as above. An IVC filter was placed. She
continued to have borderline blood pressures which were fluid
responsive, likely in part do to her right heart failure, after
transition to regular medicine unit, pt remained normotensive.
Otherwise, she remained HD stable and did not require
significant O2 supplementation. Pt was transitioned to lovenox
and then to coumadin. INR WAS 5 ON THE DAY OF DISCHARGE. Pt had
previously recieved 5mg coumadin x2 days and was held on the day
of discharge. Coumadin was held on the day of discharge. Rehab
facility will continue to adjust coumadin dose as needed. Pt has
no family history or prolonged recumbency, though clot is in
hemiparetic leg. CA screening appears to be mostly uptodate with
colonoscopy in [**2152**], mammogram in [**2151**] though she has not had a
pap recently.
-PT SCHEDULED FOR LOWER EXTREMITY ULTRASOUND ON [**2154-7-8**] FOR
CONSIDERATION OF IVC FILTER REMOVAL.
-Interventional Radiology (Dr [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 6989**] [**Last Name (NamePattern1) 6745**])
to review LENI and [**First Name8 (NamePattern2) 6989**] [**Last Name (NamePattern1) 6745**] will call pt to arrange
for removal of IVC filter at that time.
.
# UTI: pt was noted to have a +UA and initially started on
cipro. However, pt's urine grew esbl e coli s to nitrofurantoin
but not cipro and so pt was switched to nitrofurantoin for total
course of 7 days.
.
# History of hemorrhagic stroke: Review of records indicates
conversion from ischemic to hemorrhagic stroke. Seemingly
minimal risk for recurrent bleeding approximately 6 years
post-event. Pt had been on secondary stroke ppx with plavix but
this was transitioned to coumadin.
.
# CAD/?CHF: Pt reports history of EF 10-15%, however, TTE was
repeated and showed preserved LV function (no LV systolic or
diastolic dysfunction). Metoprolol was initially held for
hypotension and then restarted prior to discharge in setting of
frequent ectopy (including one 16 beat run of NSVT) and normal
blood pressures. Pt is not on aspirin [**2-19**] allergy. Crestor was
continued.
.
# COPD: continued tiotroprium
.
# HTN: Held BBlocker initially in setting of potential HD
instability, restarted prior to discharge.
.
# Hyperlipidemia: Continued home Crestor
.
# Low bicarbonate: felt to be compensatory [**2-19**] elevated
respiratory rate and low pCO2 as pt's VENOUS pCO2 was only 36.
.
Family contact: [**Name (NI) **] (daughter) [**Telephone/Fax (1) 54798**]
Medications on Admission:
Metoprolol Tartrate 25 mg Tab Oral 1 Tablet(s) Twice Daily
Plavix 75 mg Tab Oral 1 Tablet(s) Once Daily
Tiotropium Bromide 18 mcg Caps w/Inhalation Device(s) Once Daily
Crestor 20 mg Tab Oral 1 Tablet(s) Once Daily
Glipizide 5 mg Tab Oral 1 Tablet(s) Once Daily
Trazodone 50 mg Tab Oral 1 Tablet(s) QHS
Topamax 200 mg Tab Oral QPM
Topamax 150 mg QAM
Allergies: Aspirin / Penicillins / Sulfa
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Topiramate 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. Topiramate 100 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
8. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 3 days: last day [**2154-6-16**].
9. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: limit tylenol to less that 4g per
day.
13. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 2 weeks: apply to rash underneath right knee
and behind right ankle.
14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 2 weeks: apply to rash in right axilla.
15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: 12 hours on, 12 hours off. apply to sore
shoulder as needed.
16. Coumadin 2 mg Tablet Sig: as below Tablet PO once a day:
HOLD ALL COUMADIN ON [**6-14**] (INR 5 today).
RECHECK INR TOMORROW ([**4-15**]), IF inr 3.5 OR LOWER WOULD GIVE 2MG.
NP ON CALL DAILY WITH INR TO HELP WITH COUMADIN ADJUSTMENT UNTIL
SHE'S ON A STABLE DOSE OF COUMADIN (JUST STARTED COUMADIN 2D
AGO).
Discharge Disposition:
Extended Care
Facility:
Cape Code Nursing & Rehabilitation Center - [**Location (un) 10072**]
Discharge Diagnosis:
primary: pulmonary embolus, UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for a large blood clot in the
lungs. We started you on a blood thinner called lovenox (which
is a shot), but are transitioning you to coumadin (which is a
pill). You will need to get your coumadin levels checked very
closely for the next few weeks to confirm that your your
coumadin levels are not too high (which can cause bleeding) or
low (which can lead to clotting).
You are going to rehab but when you go home, please weigh
yourself every morning, call your primary doctor if your weight
goes up more than 3 lbs.
We have made several changes to your medications. Please ensure
that your rehab gives you a copy of your medicine list when you
go. In brief, we STOPPED your plavix, DECREASED your metoprolol
tartrate (lopressor), STARTED coumadin, STARTED lidocaine patch
Followup Instructions:
Please go to the following appointment which we have arranged
for you:
1. You need to return to [**Hospital3 **] to see if you still have
clot in your leg. It is very important that you go to this
appointment. THe radiologists will call you after they see the
result of the leg ultrasound and arrange a time to take out the
filter they placed in the veins near your heart.
ULTRASOUND APPOINTMENT:
[**Hospital3 **] Hospital, [**Location (un) 86**]
[**Hospital Ward Name **]
Monday [**2154-7-8**] at 12:30 pm in the clinical center on the [**Location (un) **] in the radiology suite
*** After your ultrasound the radiologists should call you to
arrange your next appointment (to get the filter out). If they
don't call within 1 week, please call them at [**Telephone/Fax (1) 8243**]. Your
appointment should be with Dr [**Last Name (STitle) 9441**].
2. We also arranged for you to see a dermatologist for the rash
on your shoulder and knee. If these rashes have disappeared, you
can cancel this appointment.
Department: DERMATOLOGY AND LASER
When: WEDNESDAY [**2154-7-17**] at 2:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], MD [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2154-6-15**]
ICD9 Codes: 2760, 5990, 2762, 4280, 4019, 496, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6058
} | Medical Text: Admission Date: [**2144-12-16**] Discharge Date: [**2144-12-18**]
Service: MEDICINE
Allergies:
Penicillins / Ciprocinonide
Attending:[**Doctor First Name 1402**]
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86f with lingual scc s/p xrt developed lightheadedness on the
morning of admission, was transferred by EMS to [**Hospital1 18**] where she
was found to be in afib with rvr. She was initially bolused
with diltiazem with little response, was moved to a diltiazem
gtt with modest response, and per her cardiologist was loaded
with digoxin and started on propranolol. Her bp remained
80-90's throughout, and she was given 4L NS as felt to be
hypovolemic.
Past Medical History:
-Lingual SCC s/p xrt (15/25 treatments), no chemo
-HTN
-Hypercholesterolemia
-CAD: IMI in [**12/2141**], cath with 99% rca (cypher stent) and 90%
LAD with PCWP 12; cath [**2-/2142**] with stent to LAD lesion
-Depressed EF of 45% on [**12/2141**] echo
-Tachy-brady
-Atrial fibrillation
-1+ MR [**First Name (Titles) **] [**Last Name (Titles) **] on [**12/2141**] echo
-Lymphoid inflammator infilitrate vs organizing pna on wedge bx
[**8-/2141**], done for abnormality seen on cxr
-Osteoporosis with left ankle fx, femur fx, knee fx
.
PSH:
-CCY [**1-/2142**]
-Wedge resection lung, RML [**8-/2141**]
-ORIF [**1-/2143**] of L femur fx
-Left hip replacement
Social History:
Pt is married and lives with her husband. She smoked about 1ppd
for about 30 years, quit in the [**2097**]'s. She used to drink 1
vodka drink nightly.
Family History:
Father had CAD, brother died of unknown malignancy, has one
child with breast cancer.
Physical Exam:
t 98.1, bp 102/68, hr 94, rr 16, spo2 95% 2lNC
gen- cachectic, chronically-ill appearing, dehydrated, functions
fairly-well, non-tox, nad
heent- anicteric, op with erythema and edema of tongue, mucosa
slightly dry
neck- no jvd, lad, or thyromegaly
cv- irreg irreg, [**1-27**] apical holosystol murmur
pul- decr throughout, fair air movement, no acc muscle use, no
w/r/r
abd- soft, nt, nd, nabs
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/color change/indentations
neuro- a&ox3, hard of hearing, no other focal cn deficits, no
focal motor or sensory deficits
Pertinent Results:
[**2144-12-16**] 11:40AM WBC-3.1* RBC-4.14* HGB-10.9* HCT-32.4*
MCV-78* MCH-26.2* MCHC-33.5 RDW-18.8*
[**2144-12-16**] 11:40AM NEUTS-76.5* LYMPHS-15.5* MONOS-7.8 EOS-0.1
BASOS-0.1
[**2144-12-16**] 11:40AM PLT COUNT-326
[**2144-12-16**] 11:40AM PT-14.6* PTT-26.4 INR(PT)-1.3*
[**2144-12-16**] 11:40AM GLUCOSE-122* UREA N-31* CREAT-1.0 SODIUM-135
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-28 ANION GAP-18
[**2144-12-16**] 11:40AM CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-1.9
[**2144-12-16**] 11:40AM DIGOXIN-0.2*
[**2144-12-16**] 11:40AM CK(CPK)-83
[**2144-12-16**] 11:40AM CK-MB-NotDone proBNP-6981*
[**2144-12-16**] 11:40AM cTropnT-0.03*
.
ECG: afib with ventric rate 120's, no q's or st-t changes; prior
ecg nsr with lad
.
CXR: Mild interstitial edema, no effusions or focal infiltrate
Brief Hospital Course:
.
#Afib -- She has had decreased po intake for the last 2 weeks
due to mouth pain resulting in severe hypovolemia on
presentation. The combination of hypovolemia and medication
noncompliance likely led to her atrial fibrillation with rapid
ventricular response. She received 4L IVF in the ED and 2 more
in the CCU. She was initially maintained on a diltiazem drip.
She converted to NSR a few hours after admission so her
diltiazem drip was stopped and she was transitioned to
metoprolol with her home regimen of digoxin. She remained in
NSR with episodes of SVT on metoprolol 25 tid and digoxin 0.125.
She was somewhat resistant to care here, refusing medications
on occasion. She was opposed to drastic change in her
medication regimen as an inpatient. She should likely be
considered for amiodarone and ablation but is currently
refusing. She was started on Toprol XL in an effort to improve
medication compliance with once-daily dosing. She was
discharged on her home digoxin as well. The importance of
continuing these medications was stressed to the patient and her
family. Per her outpatient cardiologist, she is not a candidate
for anticoagulation due to risk of bleeding.
.
#CAD -- No active ischemia. Continued on her outpatient regimen
of aspirin, clopidogrel, and atorvastatin. She was started on
Toprol XL as above.
.
#Oral cancer -- Much of patient's problems have come from her
inability to take medications secondary to severe oral pain and
odynophagia s/p XRT. She was maintained on a Fentanyl patch.
The dose was increased to 50mcg but she had mild delirium with
this dose, so she was dropped back down to her home regimen. In
addition, she was offered lidocaine swish and swallow as well as
GelClair and magic mouthwash for symptomatic relief. She was
intermittently compliant with these medications. She was
discharged with prescriptions for these meds, and is scheduled
for Oncology follow up 5 days after discharge.
.
#Renal insufficiency -- Baseline cr 0.5-0.8, Cr decreased fom 1
to 0.6 with IV hydration initially. It was 1.0 on the day of
discharge. The importance of adequate fluid intake was stressed
to the patient and her family.
.
#Anemia -- Microcytic anemia with baseline hematocrit of 26-30.
Studies indicate iron deficiency; patient non-compliant with
iron at home. She was maintained on iron supplements and
further workup was deferred to the outpatient setting.
.
# Leukopenia: Her WBC count was noted to be 1.7 the day after
admission. Her baseline WBC count appears to be 4-7,000. She
was not neutropenic by ANC. She was not started on any
medications suspicious for causing leukopenia. She has not
received any chemotherapy. She had 1 isolated temperature of
100.4, but no infectious symptoms. She was started on
ciprofloxacin for a suspected UTI by UA. Her leukopenia in
combination with her anemia may be suspicious for MDS. She will
be following up with her oncologist in 5 days and should likely
have a CBC checked at that time. She was instructed to contact
her oncologist should she have a temperature >100.4.
.
#Code -- FULL CODE, patient refused to discuss code status,
states she wants to discuss with her husband and PCP at [**Name Initial (PRE) **] later
date
.
Medications on Admission:
-Oxycodone-acetaminophen elixir
-Fentanyl 25mcg transdermal
-Aspirin 81mg daily
-Folic acid 1mg daily
-Digoxin 0.125mg daily
-Levothyroxine 0.050mg daily
-Atorvastatin 10mg daily
-Niferex 150mg p.o. daily
-Plavix 75mg per day
-Propranolol 5mg b.i.d.
-Pantoprazole 40mg daily
-Vitamin B12 50mg daily.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4-6H (every 4 to 6 hours) as needed.
2. Oral Wound Care Products Packet Sig: One (1) ML Mucous
membrane [**Hospital1 **] () as needed for mouth comfort.
Disp:*60 packets* Refills:*3*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: 300mg PO twice a
day: Please start after you complete ciprofloxacin.
Disp:*qs mL* Refills:*2*
7. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane QID (4 times a day) as needed for mouth pain: Swish and
spit.
Disp:*qs ML(s)* Refills:*0*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): please do not take with ciprofloxacin.
12. magic mouthwash
maalox/diphenhydramine/lidocaine 15-30mg po QID prn
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 2646**]
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular rate
dehydration
anemia and leukopenia
lingual squamous cell cancer
Discharge Condition:
fair. AFVSS
normal sinus rhythm
Discharge Instructions:
Please continue to take all of your regular home medications.
The most important of these medications is your metoprolol XL;
these will help to keep your heart rate in a range that is safe
and should keep you out of the hospital. You also need to drink
2 liters of fluids per day and try to eat more.
.
You should seek medical attention if you have a temperature
greater than 100.4, if you have worsening mouth pain, light
headedness, dizziness, passing out, palpitations, or for any
other concerns.
.
We have also given you a prescription of gelclaire to help with
your mouth pain.
.
You also have a urinary infection and you should take
ciprofloxacin for one week.
.
Lastly, your blood counts are low; you will need to see Dr. [**First Name (STitle) **]
next week (your hematologist/oncologist) for a blood check.
.
You should call Dr.[**Name (NI) 9920**] office and your oncologist's office
for an appointment within the next 1-2 weeks.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 10012**] for a follow up
appointment within 1-2 weeks.
.
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2144-12-24**] 2:30
Completed by:[**2144-12-18**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6059
} | Medical Text: Admission Date: [**2178-1-26**] Discharge Date: [**2178-1-31**]
Date of Birth: [**2111-7-14**] Sex: F
Service: UROLOGY
Allergies:
Sulfa (Sulfonamides) / Zocor
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Metastatic renal cancer with primary
on left side
Major Surgical or Invasive Procedure:
Radical nephrectomy with adrenalectomy and
multiple nodes.
History of Present Illness:
This is a 66-year-old female who was detected
to have a large renal mass during work up for abdominal pain.
She has imaging to confirm that she has a large left renal
mass with apparent adrenal metastatic involvement and a small
thrombus extending into the left renal vein to the position
of the medial aortic side. She presented to the [**Hospital1 18**] for
elective resection of the mass.
Past Medical History:
PMH: anemia (gammaglobulinopathy), OA, hyperlipidemia, chr back
spasm
PSH: tonsillectomy, appy, TAH-BSO, deviated septum repair
Physical Exam:
NAD, AAOx3
RRR, S1S2
CTAB, mildly decreased BS on R base
Abd: soft, ND, aprop. tender
incision c/d/i
Ext: no c/c/e
Pertinent Results:
[**2178-1-30**] 05:55AM BLOOD WBC-6.0 RBC-4.38 Hgb-11.5* Hct-36.0
MCV-82 MCH-26.2* MCHC-31.9 RDW-17.5* Plt Ct-354
[**2178-1-29**] 05:55AM BLOOD WBC-8.6 RBC-4.39 Hgb-11.4* Hct-34.6*
MCV-79* MCH-25.9* MCHC-32.8 RDW-17.3* Plt Ct-362
[**2178-1-28**] 04:04AM BLOOD WBC-11.1* RBC-4.35 Hgb-11.4* Hct-35.1*
MCV-81* MCH-26.2* MCHC-32.5 RDW-16.9* Plt Ct-351
[**2178-1-27**] 06:44PM BLOOD WBC-10.6 RBC-3.87* Hgb-9.9* Hct-30.0*
MCV-78* MCH-25.6* MCHC-33.1 RDW-17.4* Plt Ct-352
[**2178-1-27**] 12:50AM BLOOD WBC-7.7 RBC-4.13* Hgb-10.2* Hct-33.1*
MCV-80* MCH-24.8* MCHC-31.0 RDW-17.8* Plt Ct-402
[**2178-1-27**] 06:44PM BLOOD Neuts-79* Bands-2 Lymphs-12* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2178-1-27**] 06:44PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Burr-1+
[**2178-1-30**] 05:55AM BLOOD Plt Ct-354
[**2178-1-29**] 05:55AM BLOOD Plt Ct-362
[**2178-1-29**] 05:55AM BLOOD PT-13.1 PTT-34.0 INR(PT)-1.1
[**2178-1-28**] 04:04AM BLOOD Plt Ct-351
[**2178-1-28**] 04:04AM BLOOD PT-13.4* PTT-29.1 INR(PT)-1.2*
[**2178-1-27**] 06:44PM BLOOD Plt Ct-352
[**2178-1-27**] 06:44PM BLOOD PT-14.0* INR(PT)-1.2*
[**2178-1-27**] 12:50AM BLOOD Plt Ct-402
[**2178-1-30**] 06:15PM BLOOD Glucose-128* UreaN-14 Creat-0.9 Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
[**2178-1-30**] 05:55AM BLOOD Glucose-72 UreaN-13 Creat-0.8 Na-140
K-4.0 Cl-106 HCO3-23 AnGap-15
[**2178-1-29**] 04:00PM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-138
K-4.2 Cl-103 HCO3-23 AnGap-16
[**2178-1-29**] 05:55AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-136
K-4.0 Cl-102 HCO3-24 AnGap-14
[**2178-1-28**] 04:04AM BLOOD Glucose-121* UreaN-12 Creat-0.9 Na-138
K-4.3 Cl-107 HCO3-23 AnGap-12
[**2178-1-27**] 06:44PM BLOOD Glucose-142* UreaN-14 Creat-0.7 Na-140
K-4.3 Cl-111* HCO3-20* AnGap-13
[**2178-1-27**] 12:50AM BLOOD Glucose-93 UreaN-12 Creat-0.7 Na-140
K-4.2 Cl-104 HCO3-18* AnGap-22*
[**2178-1-30**] 06:15PM BLOOD Calcium-8.6 Phos-1.4* Mg-2.1
[**2178-1-30**] 05:55AM BLOOD Calcium-7.9* Phos-2.0* Mg-2.1
[**2178-1-29**] 05:55AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.3
[**2178-1-28**] 04:04AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.2
[**2178-1-27**] 12:50AM BLOOD Calcium-10.2 Phos-2.9 Mg-2.2
[**2178-1-27**] 06:44PM BLOOD RedHold-HOLD
[**2178-1-28**] 04:32AM BLOOD Type-ART pO2-99 pCO2-43 pH-7.37
calTCO2-26 Base XS-0
[**2178-1-28**] 01:01AM BLOOD Type-ART pO2-106* pCO2-43 pH-7.33*
calTCO2-24 Base XS--3
[**2178-1-27**] 10:31PM BLOOD Type-ART pO2-115* pCO2-48* pH-7.29*
calTCO2-24 Base XS--3
[**2178-1-27**] 06:44PM BLOOD Type-ART pO2-107* pCO2-50* pH-7.26*
calTCO2-23 Base XS--4
[**2178-1-27**] 04:26PM BLOOD Type-ART pO2-218* pCO2-38 pH-7.31*
calTCO2-20* Base XS--6 Intubat-INTUBATED
[**2178-1-27**] 02:29PM BLOOD Type-ART pO2-224* pCO2-35 pH-7.38
calTCO2-22 Base XS--3 Intubat-INTUBATED Vent-CONTROLLED
[**2178-1-28**] 04:32AM BLOOD Lactate-0.7
[**2178-1-28**] 01:01AM BLOOD Glucose-140* Lactate-0.6 Na-137 K-4.2
Cl-110
[**2178-1-27**] 10:31PM BLOOD Lactate-0.5
[**2178-1-27**] 04:26PM BLOOD Glucose-143* Lactate-0.5 K-3.9
[**2178-1-27**] 02:29PM BLOOD Glucose-111* Lactate-0.4* Na-138 K-3.7
Cl-112
[**2178-1-27**] 04:26PM BLOOD Hgb-9.9* calcHCT-30
[**2178-1-27**] 02:29PM BLOOD Hgb-9.7* calcHCT-29
[**2178-1-28**] 04:32AM BLOOD freeCa-1.16
[**2178-1-28**] 01:01AM BLOOD freeCa-1.17
[**2178-1-27**] 10:31PM BLOOD freeCa-1.15
[**2178-1-27**] 04:26PM BLOOD freeCa-1.25
[**2178-1-27**] 02:29PM BLOOD freeCa-1.30
Brief Hospital Course:
This is a 66-year-old female who was detected
to have a large renal mass during work up for abdominal pain.
She has imaging to confirm that she has a large left renal
mass with apparent adrenal metastatic involvement and a small
thrombus extending into the left renal vein to the position
of the medial aortic side. She presented to the [**Hospital1 18**] for
elective resection of the mass.
On [**2178-1-27**] the patient underwent a radical nephrectomy with
adrenalectomy and
multiple nodes. She tolerated the proceudre well and was
transferred to the ICU to monitor here respiratory status for
the night. Her chest tube was placed to suction and a CXR
obtained overnight revealed no PTX and she had no air leak. She
remained stable and her post-op acidosis resolved with pain
control and fluid resuscitation. On POD #1 she was transferred
to the floor. Her CXR remained stable so her chest tube was
D/C'd. Her pain was controlled with IV meds and she was kept
NPO/NGT/IVF. Her calcium levels, which were very high pre-op,
came down into normal range. Her HCT and other labs remained
stable. On POD #2 her NGT was d/c'd. On POD #3 the patient
passed gas and her diet was advanced. She was changed to PO pain
meds and her calcium values were borderline low so she was
started on Ca and Vit D. She was able to ambulate and her foley
was d/c'd after which she had not trouble voiding. She was kept
in house to further monitor her changing calcium levels. On POD
#4 she continued to do well without any issues and was
discharged to home in good condition.
Medications on Admission:
Tussionex prn, FeS 150 mg, Procrit injections, lovastatin 20 mg,
Extra Strength Tylenol
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic renal cancer with primary
on left side
Discharge Condition:
Good
Discharge Instructions:
[**Name8 (MD) **] M.D. if fever > 101.5, nausea, vomiting, shortness of
breath, chest pain, redness or drainage from incision, inability
to urinate or any other concerns. You may shower, but do not
take a tub bath for 10 days. Do not drive while taking
narcotics.
Followup Instructions:
Please call Dr.[**Doctor Last Name **] office to schedule a followup in 2
weeks. [**Telephone/Fax (1) 25444**].
Completed by:[**2178-2-5**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6060
} | Medical Text: Admission Date: [**2129-8-27**] Discharge Date: [**2129-8-28**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
female with a history of peptic ulcer disease and CVA who
presented to an outside hospital the day prior to death with
hypotension of 40/palp, unresponsiveness. She rapidly
developed respiratory failure and hypotension was refractory
to four pressor agents. Over the subsequent six hours
patient developed increasing hypoxemia, acidemia, was
intubated for airway control and continued on aggressive IV
fluids rehydration and multiple pressor agents. She was
subsequently transferred to [**Hospital1 188**] for further care for presumed septic shock.
PHYSICAL EXAMINATION: The patient was an obese, elderly
female, intubated, sedated, unresponsive. Pupils were 5 mm
and sluggishly reactive. Neck was supple. Heart sounds were
mildly distant, normal S1, S2, no murmurs, gallops or rubs
appreciated. Lungs had scattered expiratory wheezes, but no
rales or rhonchi. Abdomen was soft and nondistended with
decreased bowel sounds. Extremities were cool and mottled.
She had a right femoral line. There was 1+ pitting edema
throughout. Neurologic the patient was unresponsive, did not
withdraw to pain.
LABORATORY DATA: The patient had labs that were notable for
admission white count of 3.1 with 11 percent polys, 31
percent bands, 39 percent lymphs, 4 percent monos, hematocrit
34.4, platelets 184. Chemistry-7 was sodium 139, potassium
4.3, chloride 112, bicarb 11, BUN 48, creatinine 2.0, glucose
105. Calcium 7.0, magnesium 1.6, phosphate 6.8. CK was
initially 247 that rose to 1400. MB was 12 and rose to 55.
UA was notable for trace leukocyte esterase, large blood, 21
to 50 red cells, no white cells, no nitrite, trace ketones.
ABG on arrival was 6.96, 48, 91; subsequently 7.01, 36, 72.
Lactate was 5.4. She had CT of her head which showed no
hemorrhage, but chronic microvascular change. CT of the
chest showed bilateral infiltrates and small effusion. Chest
x-ray was read as anterior consolidation, collapse of the
left lower lobe, ill-defined perihilar opacities and possible
right pleural effusion. Blood and urine cultures were
pending. The latest EKG at 17:30 showed multifocal atrial
tachycardia at 120, normal axis, normal QRS, normal QT,
decreased voltage in limb leads, [**Street Address(2) 4793**] elevation in leads
2, 3 and aVF.
HOSPITAL COURSE: Over the course of hospitalization, the
patient developed progressive acidemia with pH dropping to
6.8 with refractory hypoxemia despite aggressive oxygenation
with PO2 of 30 and oxygen saturation of 60. Patient's
hypotension remained refractory to triple pressors.
Hypoxemia was refractory to aggressive oxygenation with 100
percent FIO2 and PEEP as high as 16. Despite these
interventions, we could not restore the patient's blood
pressure nor her oxygenation level to normal.
The family was called and apprised of the critical nature of
the situation. They decided to make the patient do not
resuscitate. Over the next several hours the patient's blood
pressure slowly dropped despite the pressors and she became
more acidemic and refractory in terms of her hypoxemia. She
eventually passed away at 5:00 a.m. on the morning of [**2129-8-28**].
CONDITION ON DISCHARGE: Dead.
FINAL DIAGNOSES:
1. Septic shock.
2. Myocardial infarction.
3. Acidemia.
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2129-8-28**] 05:19
T: [**2129-8-31**] 11:47
JOB#: [**Job Number 51666**]
ICD9 Codes: 0389, 2762, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6061
} | Medical Text: Admission Date: [**2129-1-17**] Discharge Date: [**2129-1-27**]
Date of Birth: [**2052-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Shellfish
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic stenosis
Major Surgical or Invasive Procedure:
[**2129-1-19**] - Core Valve Placement Percutaneous aortic valve
replacement with a 26-mm [**Company 1543**] CoreValve device, model
#MCS-P3-640, serial
#[**Serial Number 71148**].
Balloon aortic valvuloplasty.
History of Present Illness:
This 76 year old white female with known critical aortic stensis
was referred for Corevalve placement as she was deemed a high
risk operative candidate due to heavy calcification of the
aortic annulus.
Core valve data:
EXTREME risk cohort
STS score 5. % (morbid/mortality 27.7 %)
Euroscore 17.6 %
Creat 1.3. CrCl 40
Past Medical History:
critical aortic stenosis
s/p coronary artery bypass
s/p aortic valvuloplasty
Hypertension
Autoimmune Hepatitis with cirrhosis (Child's Class A)
Anemia
subclavian steal phenomenon
Peripheral Vascular Disease
Seizure in [**5-5**] 8. L sided subclavian steal
h/o paroxysmal atrial fibrillation
s/p appendectomy
Social History:
She is retired, married and lives with her husband and 2 adult
children.
She formerly worked at [**Company 2892**] as a telephone operator for 20
years.
She denies tobacco, illicit drug, or ETOH use.
Family History:
There is a strong family history of CAD. Five brothers and
sisters who are currently in their 60s all with CAD. Many of
them
have required CABG.
Physical Exam:
admission:
VS: T 97.2 BP 171/66 P 74 RR 16 O2 100 RA
Weight 149.3 lbs (prior weight 141 lbs)
HEENT: PERRL. No JVD. Carotid bruit vs. radiation of murmur
bilaterally
Neck: The mucous membranes were moist.
Lungs: Clear to auscultation
Cardiovascular: There was no jugular venous distension. S1
was
normal and S2 was diminished. There was a II/VI late peaking
systolic murmur at the left sternal border.
Abdomen: Soft without hepatosplenomegaly
Neurologic Examination: Alert and Oriented x 3
Skin: No CCE. There were no petechia or purpura. There was
no edema.
Pulse: Left radial pulse 1+, right radial pulse 2+, DP/PT 1+
bilat
Pertinent Results:
[**2129-1-25**] 04:14AM BLOOD WBC-6.1 RBC-3.82* Hgb-11.5* Hct-34.6*
MCV-91 MCH-30.0 MCHC-33.1 RDW-15.9* Plt Ct-158
[**2129-1-20**] 04:24AM BLOOD WBC-8.8# RBC-2.69* Hgb-8.6* Hct-25.4*
MCV-94 MCH-31.9 MCHC-33.8 RDW-13.9 Plt Ct-139*
[**2129-1-17**] 06:00PM BLOOD WBC-5.3 RBC-3.23* Hgb-10.7* Hct-30.7*
MCV-95 MCH-33.2* MCHC-35.0 RDW-13.7 Plt Ct-162
[**2129-1-26**] 03:24AM BLOOD PT-25.6* INR(PT)-2.5*
[**2129-1-25**] 04:14AM BLOOD PT-22.0* INR(PT)-2.1*
[**2129-1-24**] 03:58AM BLOOD PT-21.7* PTT-96.6* INR(PT)-2.0*
[**2129-1-23**] 05:58AM BLOOD PT-19.2* PTT-71.9* INR(PT)-1.7*
[**2129-1-22**] 01:48PM BLOOD PT-16.9* PTT-63.2* INR(PT)-1.5*
[**2129-1-22**] 05:09AM BLOOD PT-15.2* PTT-32.0 INR(PT)-1.3*
[**2129-1-26**] 03:24AM BLOOD Glucose-96 UreaN-69* Creat-2.4* Na-131*
K-4.4 Cl-95* HCO3-26 AnGap-14
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 2671**] [**Hospital1 18**] [**Numeric Identifier 71149**]Portable
TTE (Complete) Done [**2129-1-26**] at 12:07:13 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-2-13**]
Age (years): 76 F Hgt (in): 61
BP (mm Hg): 96/61 Wgt (lb): 145
HR (bpm): 59 BSA (m2): 1.65 m2
Indication: Aortic valve disease. Left ventricular function.
ICD-9 Codes: 424.1, 424.0, 424.3, 424.2
Test Information
Date/Time: [**2129-1-26**] at 12:07 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2011W000-0:00 Machine: Vivid q-2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.3 m/s
Left Atrium - Peak Pulm Vein D: 0.7 m/s
Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.2 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *22 < 15
Aorta - Sinus Level: 2.2 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *20 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 8 mm Hg
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 1.30
Mitral Valve - E Wave deceleration time: 164 ms 140-250 ms
TR Gradient (+ RA = PASP): *>= 36 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2129-1-20**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Aortic CoreValve. Normal AVR gradient. Mild (1+)
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild to moderate ([**11-28**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
An aortic CoreValve prosthesis is present. The transaortic
gradient is normal for this prosthesis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-28**]+) 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 [**2129-1-20**],
the left ventricular cavity size is now normal. Function is
normal rather than hyperdynamic. CoreValve prosthesis is in the
appopriate position with normal gradients and mild
per-prosthetic regurgitation. Degrees of mitral regurgitation
and pulmonary hypertension are similar.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2129-1-26**] 16:28
?????? [**2120**] CareGroup IS. All rights reserved.
[**Known lastname **],[**Known firstname 2671**] R [**Medical Record Number 71150**] F 76 [**2052-2-13**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2129-1-24**]
3:14 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2129-1-24**] 3:14 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 71151**]
Reason: ? stroke post [**Hospital **]
[**Hospital **] MEDICAL CONDITION:
76 year old woman with s/p corevalve
REASON FOR THIS EXAMINATION:
? stroke post corevalve
CONTRAINDICATIONS FOR IV CONTRAST:
cr 2.5
Final Report
HISTORY: S/P core valve ? stroke.
TECHNIQUE: MRI brain without contrast, sagittal T1, axial FLAIR,
T2, gradient
echo, diffusion images with ADC maps.
COMPARISON: CT head [**2129-1-20**].
FINDINGS: There are multiple small foci of slow diffusion in the
supratentorium and infratentorium consistent with acute embolic
infarcts.
There is a background of T2 and FLAIR hyperintensity in the
cerebral white
matter consistent with microangiopathic small vessel disease. An
old lacunar
infarct is seen in the right [**Last Name (un) **] internal capsule/putamen.
There is no mass
effect. The ventricles and sulcal configuration are
age-appropriate. There
is no intracranial hemorrhage. The major vascular flow voids are
maintained.
IMPRESSION:
Multiple small areas of slow diffusion in the supratentorium and
infratentorium consistent with acute embolic infarcts.
The study and the report were reviewed by the staff radiologist.
DR. [**Last Name (STitle) 71152**] [**Name (STitle) 71153**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: TUE [**2129-1-25**] 3:29 PM
Imaging Lab
Brief Hospital Course:
Mrs. [**Known lastname 71146**] was admitted to the [**Hospital1 18**] on [**2128-12-17**] for
preoperative work-up for a Core Valve. The Electrophysiology
Service was consulted for evaluation of a new right bundle
branch block. Although it is possible that she may require a
pacemaker following her Core Valve, there was no indication for
preoperative placement of a pacemaker.
On [**2129-1-19**], Mrs. [**Last Name (STitle) 71154**] was taken to the Operating Room where
she underwent placement of percutaneous aortic valve. Please see
operative note for details. Postoperatively she was taken to the
intensive care unit for monitoring. She later awoke
neurologically intact and was extubated. Her medications were
resumed including Plavix. She developed AV nodal re-entry
tacycardia (AVNRT) which converted with Adenosine. As her
transvenous pacer was not capturing, it was readjusted under
fluoroscopy. She experienced another burst of AVNRT which
responded to Adenosine. She later developed atrial flutter which
was rate controlled with diltiazem. The Electrophysiology
Service recommended anticoagulation with the possibility of
cardioversion and amiodarone at some point.
On POD 1 she was briefly apashic and unresponsive. She had some
apashia and mild left sided weakness. A neurology consult was
obtained and head CT was obtained. This revealed hypodensity of
the white matter adjacent to the anterior [**Doctor Last Name 534**] of the rigth
lateral ventricle and some reduced density of the right basalk
ganglia. A subsequent MRI demonstrated multiple small areas of
supratentorial and infratentorial infarcts. She recovered
neurologically.
EP continued to see her and she had episodic supraventricular
arrhythmia and sinus bradycardai with pauses. Medications were
adjusted. She was anticoagulated with Coumadin. The remainder
of her hospital course was essentially uneventful. Prior to
discharge a cardionet was arranged. On POD# 8 Mrs.[**Known lastname 71146**] was
cleared for discharge to [**Hospital3 7665**] in [**Hospital1 3597**]. All follow up
appointments were advised.
Medications on Admission:
FUROSEMIDE - 40 mg daily
METOPROLOL TARTRATE 50 mg twice daily
PRAVASTATIN - 20 mg [**Hospital1 8426**] daily
VALSARTAN [DIOVAN] - 160 mg twice daily
ASPIRIN 81 mg daily
Discharge Medications:
1. valsartan 40 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
2. tramadol 50 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO Q4H (every 4
hours) as needed for pain.
3. amiodarone 200 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
6. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
7. furosemide 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a
day).
8. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two
(2) [**Hospital1 8426**] Extended Release PO BID (2 times a day).
9. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ACHS: per RISS.
10. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily):
INR goal=[**12-30**] for postop AFib.
11. pravastatin 20 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO HS (at
bedtime).
12. metoprolol tartrate 25 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO BID
(2 times a day).
13. hydralazine 25 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO Q6H (every 6
hours).
14. warfarin 2 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO once a day.
15. acetaminophen 325 mg [**Month/Day (3) 8426**] Sig: Two (2) [**Month/Day (3) 8426**] PO Q4H
(every 4 hours) as needed for pain, fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] - [**Hospital1 **]
Discharge Diagnosis:
Aortic stenosis
hyperlipidemia
s/p Corevalve
periprocedural stroke
s/p coronary artery bypass
s/p appendectomy
peripheral vascular disease
subclavian steal syndrome
autoimmune hepatitis with cirrhosis
cerbrovascular disease
osteoporosis
chronic anemia
siezure disorder
hypertension
Discharge Condition:
Good
Discharge Instructions:
1) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
2) 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) 914**] ([**Telephone/Fax (1) 170**]) appointment arranged for Fri
[**2129-2-4**] at 1pm
Cardiologist: Dr. [**Last Name (STitle) **] appointment arranged for Fri [**2129-2-4**] at
1pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 17859**] ([**Telephone/Fax (1) 40171**]) in [**3-1**] 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 :postop Atrial
Fibrillation
Goal INR :[**12-30**]
First draw:[**2129-1-28**]
Completed by:[**2129-1-27**]
ICD9 Codes: 4280, 9971, 4241, 5715, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6062
} | Medical Text: Admission Date: [**2151-8-4**] Discharge Date: [**2151-8-9**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Briefly this is a [**Age over 90 **] y.o female w/ pmhx of HTN,
parkinson/alzheimer's,on chronic prednisone (10mg daily)started
this year ([**1-/2151**]) for temporal arteritis, who initially
presented with fatigue and question of aspiration with oxygen
saturation of 80% RA at rehab who was admitted [**8-4**]. She was
initially doing well on 3L NC,and was found to have lactate 3.0.
500-1000cc fluid given in the ED. Her dyspnea worsened
throughout the day [**8-5**], and pulm. edema and questionable right
lower lobe infiltrate noted on CXR,however clinically looked
dehyrdated. She also had low urine output, been afebrile, with
WBC 20, 2% bands,and LDH approx. 5000. She is now being
transferred to the MICU for resp. distress.
.
Of note a [**Month/Day (2) 53767**] in [**Name2 (NI) 73564**] was contact[**Name (NI) **] prior to transfer
to the MICU and her DNR/DNI status was confirmed.
.
On arrival to the MICU, the patient's vitals were: P-92,
BP-138/100, 97% venti mask 30%. The patient denies abdominal
pain,cough, chest pain, but notes difficulty breathing.She
cannot speak in full sentences and is in moderate distress.
.
Please find the original floor admission HPI below:
.
[**Age over 90 **] year old woman with dementia and Parkinson's disease who
presents with shortness of breath. Over the past two days she
has felt weak and unable to walk (usually walks with a walker).
She has been having trouble swallowing and has not been eating
well. Her aid thought she might have choked after drinking water
this morning. Shortly after drinking she developed shortness of
breath and cough. EMS was called and the patient was found to
have hypoxia with sats low 80s% on RA.
In the ED, initial vitals: (unknown temp), HR 83, BP 80/60, RR
16 O2 99% NRB. She subsequently required 3L via NC. Labs notable
for lactate 6.0, trop 0.08, creatinine 1.1 (baseline 0.6), WBC
17 with 2% bands, HCT 24 (baseline 31), HCO3 17 with AG 17, pBNP
[**Numeric Identifier **]. ECG showed sinus rhythm at 88 bpm, TWI in lead III, no
other ST/T changes. She received 500cc IVF in the ED, after
which lactate dropped to 3.1. CXR showed pulmonary edema and
possible RLL infiltrate. Blood cultures were sent and the
patient then received 2g cefepime and 750mg levofloxacin. Vitals
prior to transfer: 77 96% 2L 122/43 20 99F.
.
Upon arrival to the floor, the patient notes malaise, minimal
nonproductive cough, dyspnea at rest and a change in her voice.
She notes that she has had increasing dyspnea with exertion over
the last several months, which has acutely worsened within the
last two weeks -- she now becomes very short of breath with 2-3
steps. Her cough and change of voice have accompanied this
diminished functional ability. The patient also notes some BRBPR
a couple of days ago.
Review of systems:
Cannot be fully obtained given patient is in resp. distress.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- HTN
- Dementia
- Parkinsons
- Depression
- Osteoarthritis
- Dental Disease, now has dentures
- Rectal prolapse s/p repair in [**2145**]
Social History:
Pt. lives in a nursing home. She never married or had children.
She has one [**Year (4 digits) **] in the area who is her HCP. Endorses some
distant tob use none currently, social EtOH use, no illicit drug
use.
Family History:
CAD in several members of her father's family.
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.0 BP:133/104 P:92 R:18 O2:96% 30% venti mask
General: Alert, oriented X 2, mild acute distress, speaking in
full sentences, moving extremities spontaneously in rhythmic
pattern consistent with parkinson disease
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
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:foley with yellow urine
Ext: warm, well perfused, 1+ pulses dP b/l, no clubbing,
cyanosis or edema
Neuro: Does not cooperate but moving all limbs spontaneously
skin: 2+ turgor
DISCHARGE EXAM:
deceased
Pertinent Results:
ADMISSION LABS:
[**2151-8-4**] 11:30AM BLOOD WBC-17.1*# RBC-2.66* Hgb-8.0* Hct-24.2*
MCV-91 MCH-30.1 MCHC-33.0 RDW-17.4* Plt Ct-114*#
[**2151-8-4**] 11:30AM BLOOD Neuts-90* Bands-2 Lymphs-3* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-8*
[**2151-8-4**] 11:30AM BLOOD PT-15.6* PTT-20.4* INR(PT)-1.5*
[**2151-8-5**] 03:20PM BLOOD Fibrino-466*
[**2151-8-5**] 03:20PM BLOOD FDP-40-80*
[**2151-8-6**] 04:08AM BLOOD Ret Aut-1.1*
[**2151-8-4**] 11:30AM BLOOD Glucose-93 UreaN-48* Creat-1.1 Na-135
K-5.0 Cl-101 HCO3-17* AnGap-22*
[**2151-8-4**] 11:30AM BLOOD ALT-58* AST-170* CK(CPK)-259*
AlkPhos-217* TotBili-0.4
[**2151-8-4**] 11:30AM BLOOD CK-MB-6 cTropnT-0.08* proBNP-[**Numeric Identifier **]*
[**2151-8-5**] 05:55AM BLOOD Calcium-7.2* Phos-3.0 Mg-2.2
[**2151-8-5**] 05:55AM BLOOD Hapto-298*
[**2151-8-4**] 11:38AM BLOOD Lactate-6.0*
[**2151-8-5**] 04:59PM BLOOD O2 Sat-94
DISCHARGE LABS:
[**2151-8-9**] 04:04AM BLOOD WBC-14.6* RBC-2.75* Hgb-7.9* Hct-24.8*
MCV-90 MCH-28.8 MCHC-31.9 RDW-18.4* Plt Ct-67*
[**2151-8-9**] 04:04AM BLOOD PT-19.9* PTT-32.4 INR(PT)-1.9*
[**2151-8-9**] 04:04AM BLOOD Glucose-89 UreaN-38* Creat-0.7 Na-151*
K-4.1 Cl-118* HCO3-20* AnGap-17
[**2151-8-7**] 01:58AM BLOOD ALT-22 AST-85* LD(LDH)-3852* AlkPhos-180*
TotBili-0.5
[**2151-8-9**] 04:04AM BLOOD Albumin-2.4* Calcium-7.5* Phos-1.5*
Mg-2.3
[**2151-8-6**] 04:19AM BLOOD Lactate-2.9*
IMAGES:
CXR [**8-4**]: There is mild cardiomegaly with increased vascular
markings, consistent with mild pulmonary edema. Again noted are
extensive tracheal bronchial wall calcifications. Pacemaker
battery pack and leads terminate in appropriate positions.
Osseous structures are demineralized. No focal
opacities concerning for an infectious process. Non-united
clavicle racture of uncertain acuity by radiological studies,
please correlate with history and physical exam.
ECHO [**8-5**]: Normal global and regional biventricular systolic
function. Calcific aortic valve disease with mild stenosis and
mild regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
[**Age over 90 **] y.o female w/ pmhx of HTN, parkinson/alzheimer's,on chronic
prednisone (10mg daily)started [**1-/2151**] for temporal arteritis,
who initially presented with fatigue and question of aspiration
found to have leukocytosis, elevated LDH to 5000, and pulm
edema/interstial pattern on [**Hospital **] transferred to MICU with
hypoxemia and resp. distress. Pt was covered with broad spec
[**Hospital 621**] for PNA, including aspiration and PCP. [**Name10 (NameIs) **] were removed as
culture data came back negative. Had a d-dimer of 5000 however
in setting of acute illness, no tachycardia, no calf/lower
extremity swelling/tenderness on physical with other
explanations for hypoxemia suspicion was low for PE and this was
not worked up. She was also treated with lasix as needed for
pulmonary edema.
When pt was initially admitted, she was noted to have
transaminitis, coagulopathy, thrombocytopenia, lactic acidosis,
and hypoalbuminemia that, all together, were concerning for
liver disease, especially since lactate did not compeltely
normalize with fluids. Obtained RUQ u/s which showed targetoid
lesions concerning for mets of unknown primary (otherwise
unremarkable). Decision was made not to pursue diagnostic work
up after discussion with patient and family, as work up would be
invasive and treatment would not be of benefit. It is possible
pt also had lung metastases that were contributing to her
hypoxia, but this could not be verified as pt could not tolerate
CT scanner without intubation/sedation due to movement disorder.
Given the new findings suggestive of cancer, palliative care was
consulted to discuss options for her care. She became
increasingly SOB throughout her stay and less responsive to
nebulizer treatments. She stated that she would prefer to be
made comfortable. She was transitioned to a morphine drip on
[**2151-8-9**]. On exam at the time of death, she had pacer spikes on
telemetry but no heartbeat, no pulse, no breath sounds, pinpoint
unreactive pupils, and no dolls eyes. Time of death [**2047**] on
[**2151-8-9**]. [**Name (NI) 53767**] [**Name (NI) 382**] [**Name (NI) **] declined autopsy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73565**], MD
PGY2
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Aquaphor Ointment 1 Appl TP [**Hospital1 **]
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. traZODONE 25 mg PO HS
4. Donepezil 10 mg PO HS
5. Acetaminophen 500 mg PO HS
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 1 TAB PO HS
8. Loperamide 2 mg PO QID:PRN diarrhea
9. Omeprazole 20 mg PO DAILY
10. Ibuprofen 400 mg PO Q8H:PRN pain
11. Mirtazapine 22.5 mg PO HS
12. Lidocaine 5% Patch 1 PTCH TD DAILY
13. Carbidopa-Levodopa (10-100) 3 TAB PO QID
14. PredniSONE 10 mg PO DAILY
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
pneumonia
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 0389, 5070, 2762, 5849, 2761, 2875, 4019, 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6063
} | Medical Text: Admission Date: [**2141-8-7**] Discharge Date: [**2141-8-21**]
Date of Birth: [**2094-3-19**] Sex: F
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
obesity/desire for surgical treatment
Major Surgical or Invasive Procedure:
laparascopic gastric band
emergent trachostomy
Open reduction, internal fixation of laryngeal fracture with
plate
History of Present Illness:
The patient is a 47 year old who complains of
morbid obesity. She has been on multiple supervised diets
with an 80 pound weight loss and regain. She is currently at
325 pounds with a BMI of 50 and was deemed a good candidate
by the [**Hospital1 **] Bariatric Program for surgical
weight loss. The patient was admitted for a laparascopic
gastric band procedure
Past Medical History:
laparascopic cholecystectomy
eye surgery
anxiety
obesity
hypertension
osteoarthritis
Physical Exam:
General: no apparent distress
Head and neck: neck supple, no lymphadenopathy. pupils equal
round and reactive to light
Card: regular rate and rhythm
Lungs: clear to auscultation
abdomen: obese, soft, nontender, nondistended
extremities: no clubbing cyanosis or edema
On discharge the patients abdominal exam was benign, with a
soft, nontender abdomen, and well healing laparascopic port
incision sites.
She also had a tracheostomy incision that was healing well.
Pertinent Results:
[**2141-8-9**] Upper GI with small bowel follow through:
FINDINGS: Preliminary scout film demonstrates a gastric band
around the proximal stomach, in expected location and alignment.
Clips are noted within the gallbladder fossa consistent with
prior cholecystectomy. There is no evidence of free air under
the diaphragms.
Water soluble contrast followed by thin barium was administered
to the patient in the standing position. Contrast flowed freely
from the esophagus into the gastric pouch, through the band and
into the distal stomach. There is no evidence of obstruction or
leakage. Contrast emptied from the distal stomach into the small
bowel after approximately 15 minutes.
IMPRESSION: No evidence of obstruction or leakage s/p gastric
banding.
Brief Hospital Course:
The patient had been in the operating room undergoing a surgical
procedure and had a successful laparascopic gastric band
procedure. At the end
of the surgical procedure the patient was extubated, had loss
of airway and underwent emergency tracheotomy. After the
airway was secured, the throat was examined. It was noted
that the tracheotomy was performed at a higher level than
normal, and this was moved down to the second and third
tracheal ring. ENT was called for evaluation of injury to the
larynx. Upon arrival the laryngeal injury appeared to be a
vertical incision on the left side of the thyroid cartilage,
which extended the length of the thyroid cartilage, through
the thyroid cartilage into the larynx. A laryngoscope was
passed. There was noted to be mucosal tear around the false
cord extending to the retinoid region. The subglottic region
was normal. The vocal cords appeared to be both intact
without injury. Externally the injury site was examined.
There was noted to be a second opening into the trachea
between the cricoid thyroid membranes, which appeared to be a
clean horizontal incision.
The patient had an ORIF of the tracheal injury.
Postoperatively, the patient was vented and admitted to the
intensive care unit. the patient was weaned off of the vent on
postoperative day 2 without difficulty and the patient tolerated
CPAP well. on postoperative day 3, the patient had a trach mask
trial and she was successfully weaned from the vent by
postoperative day 4. ENT continued to evaluate the patient and
requested that the patient have antibiotics including ancef and
flagyl. an NG tube remained in place. Nutrition services was
consulted for TPN initiation. She was transferred to the
surgical floor by postoperative day 4.
On post operative day 8, the patient returned to the operating
room for direct laryngoscopy and a downsizing of her trach. She
also recieved 3 doses of IV decadron and transitioned to PO
prednisone. The patient was then given a cap trial on
Postoperative day [**9-9**], which she tolerated well. At this time
the patient was also evaluated by speech and swallow and had an
upper GI (which was negative) and she was started on a stage I
diet. The trach was removed by postoperative day [**10-11**], and the
patient was breathing comfortably. She was advanced to a stage
III diet which she was tolerating well. The patient was stable
and ready for discharge to home on postoperative days 13/5, with
ENT/speech and swallow and general surgery follow up. The
patient will remain on voice rest until follow up with ENT.
Medications on Admission:
xanax prn
Discharge Medications:
1. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day): crush pill before administering.
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
3. Colace 150 mg/15 mL Liquid Sig: Ten (10) ml PO twice a day.
Disp:*600 ml* Refills:*2*
4. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day.
Disp:*600 ml* Refills:*2*
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: crush pill before administering.
Disp:*3 Tablet(s)* Refills:*0*
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: crush pill before administering.
Disp:*3 Tablet(s)* Refills:*0*
7. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: Ten (10) ml PO Q8H (every 8 hours) for 6
doses.
Disp:*60 ml* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Obesity
status post laparascopic gastric band
Laryngeal injury
respiratory distress requiring emergent tracheostomy
status post open reduction internal fixation of larynx
Discharge Condition:
Good
Discharge Instructions:
You should continue voice rest until you follow up with Dr.
[**Last Name (STitle) **] in ENT.
Stay on Stage III until follow up. Do not self advance diet
Do not drink out of a straw. Do not chew gum
You may shower (no bathing or swimming) if no drainage from
wound
If clear drainage, cover wound with clean dressing, stop
showering
No heavy (10 pounds or heavier) for 6 weeks
If severe pain, persistent nausea, vomiting, fevers >101.5,
redness of wound, call surgeon
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2349**] in [**12-9**]
weeks.
You should have a vidoe stroboscopy before your visit and call
[**Telephone/Fax (1) 2349**] to schedule this.
You will also follow up with Speech and swallow. You should be
on voice rest until you follow up with Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] they will
send you to speech and swallow after they evaluate you in [**12-9**]
weeks.
You should follow up in [**Hospital 1560**] clinic [**Telephone/Fax (1) **] at 2 weeks
(Do not call surgeons office)
ICD9 Codes: 5185, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6064
} | Medical Text: Admission Date: [**2165-11-3**] Discharge Date: [**2165-11-8**]
Date of Birth: [**2090-2-13**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / A.C.E Inhibitors
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75 yo M hx Parkinson's presentes with acute dyspnea following an
episode of n/v during dinner, with dyspnea following. He has
had a gradual decline from his baseline with Parkinsons but was
able to ambulate with assistance and eat dinner that evening. He
complained of nausea and vomitted food particles that evening,
and later vomitted pills that evening. Then when he was being
brought to bed became increasingly dyspneic and EMS was called.
.
In the ED, 101.1 111 121/53 19 98NRB, cxr unremarkable with
only possible ? RML, given levo/flagyl, and in discussion with
family would escalate to CPAP as necessary but DNR/DNI. Also
received 1.5L NS.
.
On presentation hear, appears in NAD, family not present,
patient nonverbal at this point.
.
Per Family, has had gradual decline last year with Parkinsons,
less movement.
Past Medical History:
OBESITY
CORONARY ARTERY DISEASE s/p 3 stents MI
HYPERTENSION
DIABETES TYPE II
PARKINSON'S DISEASE
CIRRHOSIS
ANEMIA
DEGENERATIVE DISC DISEASE
GASTROESOPHAGEAL REFLUX
DIABETIC NEPHROPATHY
Social History:
Lives with wife, no smoking, previous ETOH drinker quit, retired
iron worker
Family History:
NC
Physical Exam:
VS 97.8 75 118/51 25 100% 15lpm FaceT
GEN: NAD, intermittently follows commands
HEENT: Eye shut, PERRL, dry MM, tongue out,
CV: rrr no mrg
CHEST: coarse BS, rhonchi throughout anteriorly
ABD:+BS soft, nt/nd, no organomegaly
EXT: No c/c/e
NEURO: awake, follows commands to squeeze hands.
Pertinent Results:
Admit Labs:
[**2165-11-3**] 02:30AM BLOOD WBC-14.0* RBC-4.33* Hgb-13.5* Hct-39.3*
MCV-91 MCH-31.1 MCHC-34.2 RDW-13.7 Plt Ct-236
[**2165-11-3**] 02:30AM BLOOD Neuts-91* Bands-4 Lymphs-3* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2165-11-3**] 02:30AM BLOOD Plt Ct-236
[**2165-11-3**] 02:30AM BLOOD Glucose-167* UreaN-26* Creat-1.1 Na-140
K-3.8 Cl-101 HCO3-26 AnGap-17
[**2165-11-3**] 02:30AM BLOOD CK(CPK)-129
[**2165-11-3**] 02:30AM BLOOD cTropnT-0.01
[**2165-11-3**] 02:30AM BLOOD CK-MB-4
[**2165-11-3**] 02:30AM BLOOD Calcium-9.1 Phos-1.7* Mg-1.8
[**2165-11-3**] 03:10AM BLOOD Lactate-1.8
EKG: Sinus tachy 113bpm, NA, NI, Q II, AVF unchanged from old
Studies:
SINGLE AP UPRIGHT BEDSIDE CHEST RADIOGRAPH: Fluffy retrocardiac
opacity is suspicious for pneumonia. The remainder of the lungs
are clear. Cardiomediastinal silhouette is within normal
limits. No effusion or pneumothorax. Discoid atelectasis at the
left lung base is also noted.
Brief Hospital Course:
MICU COURSE:
75 M pmhx of parkinson presents with shortness of breath
# SOB- acute onset in the setting of vomitting, most likely
aspiration PNA.
- abx empirically levofloxacin and flayl day 2
- aspiration precautions
- supportive o2
- f/u sputum cx
.
# LEUKOCYTOSIS - Dramatic does not temporally associate with
aspiration event, given pyuria, most likely represents a UTI
- monitor fever curve
- abx levaquin
.
# CAD: Will cont asprin (even though has questionable history of
allergy). Patient has tolerated asa well in the past and post
MI with stent placements.
.
# HYPERTENSION - cont metoprolol
.
# Hyperlipidemia - cont lovastatin
.
# DIABETES TYPE II - hold oral meds, cont RISS
.
# PARKINSON'S DISEASE - Tolerating oral meds. Cont out pt
meds.
.
# PPX - PPI, bowel regiment
.
# FEN : Could consider speech/swallow. Advance diet.
.
# CODE: DNR/DNI
.
# ACCESS: peripheral
.
Contacts: [**Name (NI) 8214**] Wife [**Telephone/Fax (1) 110335**] [**Doctor First Name 401**] cell [**0-0-**] (Son)
Once on the floor, the patient's levofloxacin and metronidazole
was continued for his aspiration pneumonia, as well as for his
Enterobacter UTI. Over the subsequent two days on the floor, the
patient's oxygen requirement improved, his interval CXR
improved, and he was discharged home with services.
Medications on Admission:
Clonazepam 0.5 mg Daily
Rasagiline 0.5mg Daily
Losartan [Cozaar] 50mg Daily
Metformin 500mg Daily
LOVASTATIN 40mg Daily
CARBIDOPA/LEVODOPA 25/250 QID
Entacapone [Comtan] 200mg QID
Metoprolol Tartrate 25mg [**Hospital1 **]
REQUIP 4mg TID, 6mg 7am, 10pm
Glipizide 10mg Daily
Vit B12 500mcg Daily
Folic Acid 1mg Daily
Aspirin 325mg Daily
Discharge Medications:
1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
3. Entacapone 200 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Ropinirole 1 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
6. Ropinirole 1 mg Tablet Sig: Six (6) Tablet PO BID (2 times a
day).
7. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Glipizide 5 mg Tablet Sig: 1-2 Tablets PO twice a day: Take 2
tablets at breakfast and 1 tablet at dinner.
Disp:*90 Tablet(s)* Refills:*1*
10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
12. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
Disp:*30 suppositories* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
1. Aspiration pneumonia
2. Enterobacter urinary tract infection
3. Parkinson's disease
4. Type 2 diabetes mellitus c/b nephropathy
5. Hypertension
6. 3-veseel coronary artery disease s/p stents and h/o
myocardial infarction
Discharge Condition:
Fair, without dyspnea
Discharge Instructions:
Call your primary care physician or go to the emergency
department if you develop fevers or have difficulty breathing.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2165-12-11**] 2:00
Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2166-1-30**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 1040**]
Date/Time:[**2166-4-8**] 1:00
ICD9 Codes: 5070, 5990, 2724, 4019, 3572, 5715, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6065
} | Medical Text: Admission Date: [**2121-8-1**] Discharge Date: [**2121-8-9**]
Date of Birth: [**2056-10-31**] Sex: M
Service: SURGERY
Allergies:
Atorvastatin / Crestor
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
64y M w/prolapsing ostomy, parastomal hernia, ventral hernia,
resetting colostomy
Major Surgical or Invasive Procedure:
Ventral hernia, parastomal hernia repair with mesh
History of Present Illness:
Pt is a 64y M w/ underwent an [**Month (only) **] for rectal cancer,
subsequently had a prolapsing ostomy that was repaired, from
repaired and from that operation he developed the parastomal
hernia with a ventral hernia. He was offered repair.
Past Medical History:
Atrial fibrillation, on coumadin
CHF, EF of 40%
Type 2 Diabetes, poorly controlled on insulin, w/ neuropathy
Hypothyroidism
Right-sided lung mass that will require bronchoscopy
s/p colectomy, colostomy for colon cancer 5 years ago
Hernia at site of colostomy
Right foot debridement and skin graft 2 years ago
Social History:
The patient is married, his wife's name is [**Name (NI) **]. [**Name2 (NI) **] has a 40py
tobacco history. He used to drink a significant amount of
alcohol but quit about two years ago. No illicits. He is a
retired master plumber. He has three children.
Family History:
Mother died suddenly of presumed MI at age 62, father had
valvular disease and died of stroke at age 80. 3 children, in
good health; 3 siblings, in good health. No family history of
DM, cancer.
Physical Exam:
GEN: AXOx4, NAD,
HEENT: Atraumatic, normocephalic, PERRL,
RESP: CTAB, no wheezes, crackles, rubs
CV: RRR, no murmurs, gallops, rubs
ABD: Obese, colostomy on Left, large ventral hernia
EXT: no clubbing, cyanosis, [**12-18**]+ LE edema
Pertinent Results:
[**2121-8-2**] 12:40AM BLOOD Glucose-253* UreaN-37* Creat-2.9*# Na-142
K-4.9 Cl-104 HCO3-26 AnGap-17
[**2121-8-2**] 04:54AM BLOOD Glucose-189* UreaN-39* Creat-3.3* Na-143
K-4.9 Cl-104 HCO3-27 AnGap-17
[**2121-8-3**] 02:34AM BLOOD Glucose-184* UreaN-45* Creat-3.1* Na-143
K-4.3 Cl-106 HCO3-24 AnGap-17
[**2121-8-4**] 03:04AM BLOOD Glucose-69* UreaN-45* Creat-2.6* Na-150*
K-3.7 Cl-111* HCO3-31 AnGap-12
[**2121-8-6**] 06:10AM BLOOD Glucose-34* UreaN-39* Creat-2.1* Na-150*
K-3.1* Cl-110* HCO3-33* AnGap-10
[**2121-8-8**] 08:29AM BLOOD Glucose-145* UreaN-31* Creat-1.9* Na-142
K-3.3 Cl-104 HCO3-30 AnGap-11
[**2121-8-9**] 04:49AM BLOOD Glucose-67* UreaN-29* Creat-2.0* Na-143
K-3.4 Cl-105 HCO3-30 AnGap-11
[**2121-8-1**] 07:30PM BLOOD CK-MB-7 cTropnT-0.07*
[**2121-8-2**] 04:54AM BLOOD CK-MB-10 MB Indx-1.5 cTropnT-0.10*
[**2121-8-2**] 01:28PM BLOOD CK-MB-9 cTropnT-0.06*
[**2121-8-2**] 12:40AM BLOOD WBC-17.4*# RBC-4.78 Hgb-12.0* Hct-38.8*
MCV-81* MCH-25.1* MCHC-30.9* RDW-16.8* Plt Ct-277
[**2121-8-4**] 03:04AM BLOOD WBC-12.8* RBC-4.00* Hgb-9.9* Hct-32.6*
MCV-82 MCH-24.7* MCHC-30.3* RDW-16.8* Plt Ct-209
[**2121-8-9**] 04:49AM BLOOD WBC-9.7 RBC-3.95* Hgb-10.3* Hct-30.9*
MCV-78* MCH-26.0* MCHC-33.2 RDW-16.4* Plt Ct-358
Brief Hospital Course:
Pt admitted for same day procedure noted previously. Case
lasting approximately 5 hrs, patient received 1800cc of
crystalloid, procedure was without complications.
Post-operatively, patient resuscitated in PACU with total of 6L
of crystalloid. Epidural was decreased, then held at
apporximately 10pm. Pt [**Name (NI) **] responding to resuscitation
initially, then decreasing to 6cc/hr at 12am. Fluid bolus of
1500mL given, [**Name (NI) **] did not respond. Echo from [**4-23**] demonstrated
evidence of diastolic CHF with EF of 45-60%.
POD1 [**8-2**] : Pt admitted to SICU w/oliguria and hypotension,
cardiology service was consulted, enzymes were cycled, cardiac
echo was obtained, Vanc, Zosyn, Flagyl were continued. BP 90's
systolic, CVP was 15-17. Dopamine was initiated. Creatinine 3.3
POD2 [**8-3**] : Dopamine tirated off, urine output improving, O2
sat's stable on 6LNC. BP's systolic 100-140, CVP 15. Creatinine
3.1->2.8
POD3 [**8-4**] : Lasix drip started, goal net neg 1-2L/day.
Creatinine-2.6/ Na-150, free water given, await return of bowel
function. Rhythum a-fib w/ventricular rate 70-90's controlled
with lopressor. SBP 110-130's, CVP 15-17.
POD4 [**8-5**] : Lasix drip continued at 1mg/hr, creatinine-2.3/
Na-152. Free water deficit replacement, continued Abx
Vanc/Zosyn/Flagyl, plan for transfer to floor.
SBP 120-150, CVP 9-11.
POD5 [**8-6**] : Transfer to floor, on IV lasix 20mg q6h, NGT out,
comfortable with no N/V
Cr-2.1/ Na-150. Deit advanced, free water given, lasix held.
drain #1 d/c'd, abx continued.
POD6 [**8-7**] : Cr 2.0/ Na 143. Tolerating diet, out of bed, refuses
rehab, worked with PT. Drain #2 d/c'd. Abx continued.
POD7 [**8-8**] : Cr 1.9/ 142. No events, ambulation, CVL d/c'd.
Worked with PT, plan for discharge. Abx continued
POd8 [**8-9**] : d/c home
Medications on Admission:
Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
7. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
Discharge Disposition:
Home
Discharge Diagnosis:
Ventral hernia, parastomal hernia
Discharge Condition:
Improved
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. Return to ED if fever >101.4, Chest
pain, shortness of breath, severe pain not relieved by
medication, intractable nausea and vomiting, significant
discharge or drainage from wound. Call office for other
concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2998**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2121-9-30**] 8:00
Completed by:[**2121-8-13**]
ICD9 Codes: 5849, 4280, 3572, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6066
} | Medical Text: Admission Date: [**2117-10-3**] Discharge Date: [**2117-10-7**]
Date of Birth: [**2071-3-18**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a morbidly obese
46 year-old female transferred to the Coronary Care Unit from
an outside hospital for management of malignant hypertension.
The patient reports a two year history of hypertension with
moderate control on Hydrochlorothiazide and propanolol. She
has never had a history of coronary artery disease,
myocardial infarction or congestive heart failure. She was
in her usual state of health until approximately one month
ago when she began to have what she describes as a flu like
illness. She had severe fatigue, congestion, myalgias and
arthralgias. No fevers or chills. She was seen by her
primary care physician who diagnosed her with "mono" and sent
her home without treatment. She continued to feel poorly
staying out of work for the following two weeks and spending
much of her time in bed due to severe fatigue.
She was finally brought to clinical attention when several
days prior to this admission she began to have new pedal
edema, which she had never had before. She also reports some
paroxysmal nocturnal dyspnea, but no orthopnea. She went to
the [**Hospital1 **] Nishoba Emergency Department two days ago when
she noted that her lower extremities had become edematous and
were weeping fluid and red. She was noted in the Emergency
Department to have severely elevated blood pressure at that
time to 230/160, which she states is higher then her blood
pressure has ever been before. She states it is usually in
the 140/90 range. She had an echocardiogram at the outside
hospital, which by report showed an EF of 25%. Also by
report there was 2+ protein in her urine and her creatinine
was elevated to 2.2. At the outside hospital she was started
on Norvasc, Labetalol and intravenous nitro for blood
pressure control and Ceftriaxone and Clindamycin for lower
extremity cellulitis. She reportedly had negative lennies
and an intermediate probability VQ scan. She had an
abdominal ultrasound also, which reportedly showed normal
kidneys.
The interventions to control her blood pressure were
unsuccessful and she was transferred to [**Hospital3 **] for
further evaluation.
REVIEW OF SYSTEMS: Negative for headache, changes in vision,
neck stiffness, change in mental status, chest pain,
shortness of breath, abdominal pain, flank pain and dysuria.
PAST MEDICAL HISTORY: Significant for hypertension over the
past two years with typical blood pressures less then 140/90.
Obesity.
MEDICATIONS PRIOR TO ADMISSION: Hydrochlorothiazide 25 mg
q.d., Propanolol 80 b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient smokes one pack per day times
twenty years. Rare alcohol. No drugs. She is married with
two children. She lives with her family and works in a
machine shop out of her house.
FAMILY HISTORY: Negative for hypertension, coronary artery
disease.
PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 194/102.
Pulse 98 and regular. Breathing at a rate of 16. Sating 99%
on room air. In general, she was well appearing, morbidly
obese female. HEENT revealed pupils are equal, round, and
reactive to light and accommodation. Anicteric sclera.
Oropharynx clear. Mucous membranes are moist. Neck revealed
JVP to the angle of the jaw. Respiratory examination was
clear to auscultation bilaterally without evidence of rales
or rhonchi. Coronary examination was regular rate and
rhythm. No murmurs, rubs or gallops. Abdominal examination
was benign. Extremities revealed 2+ pounding pulses. 2+
pitting edema to the knee with weeping erythematous lesions
over the posterior lower extremities.
Electrocardiogram on admission showed normal sinus rhythm at
112 and intraventricular conduction delay, left ventricular
hypertrophy, left atrial enlargement and poor R wave
progression.
HOSPITAL COURSE: 1. Refractory hypertension: The patient
was believed to have hypertension refractory to medical
treatment up to the point of admission. Initially a central
line and arteriole line were inserted without event and the
patient was started on intravenous nitroprusside. On this
medication she was able to get her blood pressure down to 140
systolic over approximately 80s diastolic. On hospital day
two she was titrated off the nitride and onto Labetalol
initially at 200 b.i.d. and Captopril initially [**Company 36482**].i.d.
Once off the Nipride she continued to have elevated blood
pressures as high as the 180s systolic, so her Labetalol dose
and Captopril dose were progressively titrated higher. Over
the remainder of her hospital course she continued to require
greater increasing amounts and number of antihypertensive
medications in order to control her blood pressure. Her
Labetalol was ultimately increased to 400 b.i.d. Her
Captopril was increased to 100 t.i.d. Norvasc was added at
10 q.d. Lasix was added 20 mg b.i.d. and finally Clonidine
patch, which is administered once a week and delivers .2 mg
per day of medication.
Despite these five different antihypertensive medications the
patient's blood pressures continued to be in the 180 systolic
over 80s diastolic. The patient was ultimately discharged
home on these five medications. The patient was ultimately
discharged home with instructions to follow up with her
primary care physician and have him continue to titrate these
medications as needed. However, because the patient was
requiring so many medications and because of her high degree
of apparently new onset of severe hypertension we were highly
suspicious of a secondary form of hypertension. Because of
this a workup was begun in house, although it could not be
completed as many results are still pending. Her TSH was
checked, which was within normal limits essentially ruling
out hyperthyroidism as a cause. Prior to her leaving she had
a Dexamethasone suppression test to look for a hypercortisol
state, which was pending at the time of discharge. She had a
24 hour urine collection to look for evidence of
pheochromocytoma. Results of this test are still pending.
She also had a random aldosterone level sent off, the results
of which are still pending to rule out a hyperaldosterone
state. She furthermore made MR angiogram of her renal
arteries to rule out renal artery stenosis, which was
negative.
When the patient follows up with her primary care physician
he can review the results of these tests and continue workup.
Furthermore on the day of discharge her renal consultation
was obtained and they recommended a renal biopsy, although
after reviewing her urine sediment they found that it was
benign. This additionally can be done as an outpatient
basis. Finally, because the patient was obese there were
many concerns for diabetes and a fasting blood sugar was
obtained on the day of discharge, which was 72 essentially
making the patient a nondiabetic.
2. Cardiomyopathy: A repeat echocardiogram was done on
approximately hospital day three, which showed an ejection
fraction of 30% and global hypokinesis. We were suspicious
that this may be related to her hypertension and that if the
cause of her hypertension could be determined and her blood
pressures got back to normal her cardiomyopathy may resolve.
We deferred specific workup for this cardiomyopathy other
then treating her hypertension working up causes of her
hypertension. We will recommend to her primary care
physician that as an outpatient once her hypertension is
better controlled she have this further worked up.
3. Cellulitis: The patient presented with evidence of
cellulitis already on antibiotics. She was initially started
on Ofloxacin intravenous ultimately changed to Dicloxacillin
po. Additionally we obtained records from the outside
hospital where a culture had been sent, which grew out an
organism sensitive to Ciprofloxacin, so because of this
Ciprofloxacin was added to regimen. She was discharged home
on a ten day course of Dicloxacillin and Ciprofloxacin. Her
rash appeared to be marginally improving during the course of
her hospital stay. We questioned whether or not this rash
could be something other then cellulitis and related to her
hypertension. Although we could not ascertain a cause and we
had positive skin cultures from the outside hospital. At the
present time we will send her home on these antibiotics and
she can follow up with her primary care physician who can see
if her rash improves on the antibiotics and if not he perhaps
will consider obtaining a dermatology consult.
4. Renal function: Again we suspected that any problems
with renal function were likely due to the patient's
hypertension. The patient's creatinine was followed in
house, which fluctuated between 1.2 and 1.4. Again as per
the renal team, renal biopsy is likely indicated in this
patient and can be done on an outpatient basis.
5. Social Services: The patient was self pay and because of
this cost of medications was an issue. We obtained free care
for her to get two weeks worth of medications and discharged
her with prescriptions for two weeks worth of
antihypertensive and antibiotic medications, which she will
get for free. An additional issue for this woman will
ultimately be paying for this hospital stay. Her Intensive
Care Unit stay at the outside hospital and here in addition
to the workup of her hypertension will likely be very
expensive. This is an additional part of the reason for
preferring to continue the workup as an outpatient. The
patient actually requested this. It is our hope that she can
follow up with Social Services and we offered her to see a
Social Services person at the [**Hospital 191**] Clinic, which she declined
to help set her up with services to pay for her medical care.
I did give her the number of the [**Hospital 191**] Clinic and she can call
us if she changes her mind and would like to meet with the
Social Services people. However, [**Location (un) 86**] is approximately an
hour and a half away from where she lives, so I suspect she
may not wish to come all the way back here to further address
this issue.
CONDITION AT DISCHARGE: Stable and under medical treatment.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
Refractory hypertension.
FOLLOW UP: Follow up is with the patient's primary care
physician within one to two days for further evaluation of
her blood pressure, its treatment and her cellulitis and
consideration of further workup of her hypertension.
MEDICATIONS ON DISCHARGE: Labetalol 400 b.i.d., Captopril
100 t.i.d., Norvasc 10 q.d., Lasix 20 b.i.d., Clonidine patch
one per week delivering 0.2 mg per day. Dicloxacillin 500 mg
q.i.d. times ten days. Ciprofloxacin 500 mg b.i.d. times ten
days.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Last Name (NamePattern1) 1213**]
MEDQUIST36
D: [**2117-10-9**] 10:46
T: [**2117-10-13**] 06:21
JOB#: [**Job Number 36483**]
ICD9 Codes: 4254, 2768, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6067
} | Medical Text: Admission Date: [**2109-8-20**] Discharge Date:
Date of Birth: [**2109-8-20**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby boy [**Name2 (NI) 56714**] was the 2.02 g
product of a 35 and [**4-26**] week twin gestation born to a 39-year-
old, gravida 2, para 0, woman. Pregnancy was complicated by
shortened cervix prompting admission at 28 weeks and treated
with Betamethasone.
PRENATAL SCREENS: Maternal blood type 0 positive, antibody
negative, hepatitis surface antigen negative, RPR
nonreactive, GBS unknown. The mother was followed closely by
Maternal Fetal Medicine. On the day of delivery, she was in
Dr.[**Name (NI) 9920**] office with this twin noting to have
decelerations prompting admission and cesarean delivery.
At delivery, the patient was pink and active, and was given
blow-by oxygen and stimulation. Apgar scores were 7 and 8.
ADMISSION PHYSICAL EXAMINATION: Birth weight 2.02 g, 25th
percentile, length 44 cm, less than 25th percentile, head
circumference 30.5 cm, 25th percentile. Examination was
notable for pink, active, nondysmorphic infant. Skin was
without lesions. Head, ears, nose, and throat notable for
flattened top of scalp, most likely due to positioning.
Sutures mobile. Cardiovascular normal S1 and S2 without
murmurs. Lungs clear. Abdomen benign. Neurologic nonfocal.
Spine intact. Hips normal. Anus patent.
HOSPITAL COURSE: Respiratory: [**Known lastname **] has been stable in
room air throughout his hospital course with mild apnea and
bradycardia of prematurity. His most recent episode of apnea
and bradycardia was on [**2109-8-31**]. He has not
required any Methylxanthine treatments.
Cardiovascular: He has been cardiovascularly stable without
issue.
Fluids and electrolytes: Birth weight was 2.02 g. The infant was
initially started on 60 cc/kg/day of D10W. Enteral feedings were
initiated on day oflife 1. The infant is currently ad lib
feeding breast milk 24 cal concentrated with 4 cal of Similac
powder, taking in excess of 150 cc/kg/day.
Of note over the past week, the infant has been having guaiac
hemoccult positive stools. Rectal fissures were noted at 11
o'clock, 1 o'clock, 5 o'clock, and 7 o'clock. Abdominal
examination was reassuring.
Gastrointestinal: Peak bilirubin, on day of life 3, was 7.4.
He did not require any bilirubin phototherapy.
Hematology: Hematocrit on admission was 50.9. The infant
has not required any blood transfusions during this hospital
course.
Infectious disease: The infant received a CBC and blood
culture on admission. CBC was benign. Blood culture
remained negative at 48 hours at which time Ampicillin and
Gentamicin were discontinued.
Neurologic: The infant has been appropriate for gestational
age.
Sensory/audiology: Hearing screen was performed with
automated auditory brain stem response. The infant passed in
both ears.
Psychosocial: [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] was the social worker involved
with this family and can be contact at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 56715**] [**Last Name (NamePattern1) 56597**], [**Telephone/Fax (1) 43701**].
CARE RECOMMENDATIONS: Feeds at discharge: Continue ad lib
feeding breast milk concentrated to 24 cal.
DISCHARGE MEDICATIONS: Nonapplicable.
CAR SEAT POSITION SCREENING: Screening has been performed,
and the infant passed a 90 min screening.
STATE NEWBORN SCREENS: Sent per protocol with the most
recent being sent on [**2109-9-3**], and have been within
normal limits.
IMMUNIZATION RECEIVED: The infant has not received any
immunizations during this hospital course.
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: 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 mos of the child's life)
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DIAGNOSIS: Preterm twin 1.
Apnea and bradycardia of prematurity.
Rule out sepsis with antibiotics.
Mild hyperbilirubinemia.
Reviewed By: [**Last Name (LF) **], [**First Name3 (LF) **] A. 50-622
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2109-9-4**] 17:22:46
T: [**2109-9-4**] 18:26:56
Job#: [**Job Number 56716**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6068
} | Medical Text: Admission Date: [**2159-8-24**] Discharge Date: [**2159-8-28**]
Service: [**Hospital Unit Name 196**]
ADMISSION DIAGNOSIS:
Hypertrophic obstructive cardiomyopathy.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 108667**] is a 78 year-old
woman with a history of HOCM. She was admitted to the
hospital on [**2159-8-24**] for elective ETOH ablation.
the procedure was performed on the [**8-24**]. This
was uncomplicated. Prior to this admission the patient had
noticed an increase in shortness of breath on exertion over
the past three to four years. This had increased despite
medical management with Verapamil and Lasix.
PAST MEDICAL HISTORY: 1. HOCM. 2. Hypothyroidism. 3.
Hypercholesterolemia. 4. Migraines. 5. Degenerative joint
disease. 6. History of colon polyps. 7. Osteoporosis. 8.
Appendectomy. 9. Tonsillectomy. 10. Basal cell carcinoma.
MEDICATIONS AT HOME: Lasix 160 q.d., Verapamil 80 t.i.d.,
Synthroid 100 five days of the week and 50 two days of the
week. Aldactone 25 b.i.d., Timolol 5 mg q.h.s., Evista 60 mg
q.d., Fosamax 60 mg po q Wednesdays. Potassium supplements,
vitamin C, vitamin E, B-complex, multivitamin, calcium 600 mg
t.i.d., Ultram prn, Tylenol prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a nonsmoker, nondrinker.
PHYSICAL EXAMINATION ON ADMISSION: This is per a note by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The vital signs were heart rate of 98 and
regular. Blood pressure 91/36. Respiratory rate 16. Sating
93% on room air. Afebrile. The head and neck examination
was unremarkable. The lungs were clear to auscultation
bilaterally. Heart was regular rate and rhythm. S1 and S2
were normal. There was a harsh grade 3 out of 6 systolic
ejection murmur heard best at the mid left sternal border.
JVP was 4 cm above the sternal angle. The carotids
demonstrated a brisk upstroke. The abdomen was benign. The
extremities showed no edema. Peripheral pulses palpable. The
patient was alert and oriented times three with nothing focal
on neurological examination.
ADMISSION LABORATORIES: Her CBC and chem 7 were within
normal limits. Her electrocardiogram revealed normal sinus
rhythm at 98. There was a right bundle branch block. There
were Q waves in 2, 3 and AVF and small Q in V4 to V6.
HOSPITAL COURSE: The alcohol ablation procedure went
smoothly. The patient was transferred to the Coronary Care
Unit for observation after her procedure. The pacer wire was
removed two days after the procedure. She did well and was
transferred to the floor on the [**8-27**]. She
continued to do well from a cardiovascular point of view.
A routine urinalysis at admission was positive for nitrites
and white blood cells. Urine culture showed Pseudomonas.
The patient was started on Ciprofloxacin 500 mg b.i.d. She
was instructed to continue this for a course of three days.
DISCHARGE DIAGNOSES:
1. HOCM status post alcohol ablation.
2. Pseudomonas urinary tract infection.
DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg po b.i.d. for
three days, Furosemide 20 mg po b.i.d., Timolol 5 mg po
q.h.s., Verapamil 80 mg po q 8 h, Diphenhydramine 25 mg po
q.6.h. prn, calcium carbonate, aspirin 325 mg po q.d.,
Levothyroxine 50 mcg q Monday and Thursday, Levothyroxine 100
micrograms Sunday, Tuesday, Wednesday, Friday, Saturday.
Alendronate 70 mg po once a week.
DISCHARGE FOLLOW UP: The patient has been instructed to see
her cardiologist within the next week.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 4066**]
MEDQUIST36
D: [**2159-8-28**] 12:33
T: [**2159-9-3**] 10:33
JOB#: [**Job Number **]
ICD9 Codes: 5990, 2765, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6069
} | Medical Text: Admission Date: [**2114-3-20**] Discharge Date: [**2114-3-22**]
Date of Birth: [**2092-10-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
Abdominal pain, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 21 yo M with a history of DM1 who had several
alcoholic drinks on [**First Name3 (LF) 2974**] night. On Saturday he had 3 episodes
of nausea and vomiting. He states that he was afraid to check
his blood sugar at home, and has been taking his usual dose of
insulin. He woke up on Saturday wtih lightheadedness, polyuria
and polydipsia. He thought he had food poisoning and didn't eat
yesterday. This morning he came to the ED because he had chest
pain, abdominal pain, and severe tachypnea.
.
.
.
In the ED, initial vs were: T 96.8 P 125 BP 178/70 R 39 O2 sat
100% on RA. Patient endorsed having abdominal pain, but no other
discomfort. Blood sugars were over 500cc. Exam was notable for
tachypnea, but no abdominal tenderness. Labs were notable for
ABG of 6.93/20/66. K of 5.4, Cr 1.6, WBC of 24.7, HCT of 59.1.
Patient was given 2L IV fluids. He was started on an insulin gtt
at 9u/hr. Vitals prior to transfer: HR 112 BP 115/84 RR 30, 99%
on RA
.
.
On the floor, the patient continues to be short of breath. His
chest pain and abdominal pain have resolved. He denies any
recent fevers or chills.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies nausea,
vomiting, diarrhea, constipation, or changes in bowel habits.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
-type one diabetes mellitus
-"mild aspergers syndrome" per father
Social History:
- Tobacco: None
- Alcohol: Last drink 3-4 days prior to admission.
- Illicits: None
Family History:
NC
Physical Exam:
Admission Exam:
Vitals: T: 98 BP: 158/87 P: 125 R: 27 O2: 100% on RA
General: Alert, oriented, tachypneic. Using accessory muscles to
breathe.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic. Regular rhythm. No murmurs.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2114-3-20**] 09:10PM GLUCOSE-231* UREA N-11 CREAT-0.9 SODIUM-125*
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-14* ANION GAP-13
[**2114-3-20**] 09:10PM CALCIUM-8.4 PHOSPHATE-1.1* MAGNESIUM-1.7
[**2114-3-20**] 01:49PM GLUCOSE-150* UREA N-15 CREAT-0.9 SODIUM-131*
POTASSIUM-3.4 CHLORIDE-108 TOTAL CO2-9* ANION GAP-17
[**2114-3-20**] 01:49PM ALBUMIN-3.8 CALCIUM-8.2* PHOSPHATE-1.0*
MAGNESIUM-1.6
[**2114-3-20**] 10:55AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2114-3-20**] 10:55AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-3-20**] 10:55AM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2114-3-20**] 10:55AM URINE MUCOUS-RARE
[**2114-3-20**] 10:54AM GLUCOSE-257* UREA N-18 CREAT-1.2 SODIUM-129*
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-8* ANION GAP-26*
[**2114-3-20**] 10:54AM ALT(SGPT)-20 AST(SGOT)-12 LD(LDH)-163 ALK
PHOS-94 TOT BILI-0.7
[**2114-3-20**] 10:54AM LIPASE-16
[**2114-3-20**] 10:54AM CALCIUM-10.6* PHOSPHATE-1.5* MAGNESIUM-2.0
[**2114-3-20**] 10:54AM WBC-24.2* RBC-5.69 HGB-18.2* HCT-50.9 MCV-89
MCH-31.9 MCHC-35.7* RDW-12.7
[**2114-3-20**] 10:54AM PLT COUNT-362
[**2114-3-20**] 10:54AM PT-11.7 PTT-22.2 INR(PT)-1.0
[**2114-3-20**] 07:59AM PO2-66* PCO2-20* PH-6.93* TOTAL CO2-5* BASE
XS--29 COMMENTS-GREEN TOP
[**2114-3-20**] 07:59AM LACTATE-5.8* K+-5.0
[**2114-3-20**] 07:57AM GLUCOSE-635* UREA N-21* CREAT-1.6*
SODIUM-124* POTASSIUM-5.4* CHLORIDE-94* TOTAL CO2-LESS THAN
[**2114-3-20**] 07:57AM estGFR-Using this
[**2114-3-20**] 07:57AM ACETONE-SMALL
[**2114-3-20**] 07:57AM WBC-24.7* RBC-6.20 HGB-19.8* HCT-59.1* MCV-95
MCH-32.0 MCHC-33.5 RDW-12.7
[**2114-3-20**] 07:57AM NEUTS-92.7* LYMPHS-3.0* MONOS-3.6 EOS-0.2
BASOS-0.5
[**2114-3-20**] 07:57AM PLT COUNT-460*
Micro:
Blood culture x2 [**2114-3-20**] PENDING
Urine culture [**2114-3-20**] PENDING
Imaging:
CXR [**2114-3-20**]:single view of the chest has been obtained with
patient in
sitting semi-upright position. The heart size is within normal
limits. No typical configurational abnormality is present.
Thoracic aorta and mediastinal structures are unremarkable.
Pulmonary vasculature is not congested. No signs of acute
parenchymal infiltrates are present and the lateral pleural
sinuses are free. No pneumothorax in apical area. The frontal
view discloses a moderate degree of right-sided convex scoliosis
in the mid portion of the thoracic spine. No other gross
skeletal abnormalities are seen on this portable chest
examination. However, one suspects a skeletal injury in the
upper portion of left scapula. Clinical correlation recommended.
IMPRESSION: No evidence of acute pneumonia in young male patient
with history of leukocytosis.
Discharge Labs:
[**2114-3-22**] 06:15AM BLOOD WBC-8.5 RBC-4.90 Hgb-15.8 Hct-42.4 MCV-87
MCH-32.3* MCHC-37.3* RDW-12.5 Plt Ct-213
[**2114-3-22**] 06:15AM BLOOD Plt Ct-213
[**2114-3-22**] 03:30PM BLOOD Creat-0.5 Na-130* K-3.1* Cl-97
[**2114-3-22**] 06:15AM BLOOD Amylase-22
[**2114-3-22**] 06:15AM BLOOD Calcium-8.6 Phos-1.3* Mg-2.1
[**2114-3-22**] 06:15AM BLOOD %HbA1c-12.9* eAG-324*
Brief Hospital Course:
Mr [**Known lastname 73657**] is a 21 year old male with type 1 diabetes mellitus
who presents with DKA.
ACTIVE PROBLEMS:
1. DIABETIC KETOACIDOSIS: He presented with severe DKA with a
sugar of 635, an anion gap of around 25, and a pH of 6.93. This
was felt to be due to poor compliance with insulin over the
preceding several days, with increased insulin demand based on
his nausea/vomiting/and alcohol intake. Per conversations with
his parents, his insulin and FSG compliance has been poor
throughout his adolescence, and he had a prior episode of DKA 2
years ago of lesser intensity. He was started on an insulin gtt
on admission to the ICU, was aggressively rehydrated, and
supplemented with both D5 and potassium when necessary. He was
extremely hypovolemic based on initial exam, and lab evidence of
[**Last Name (un) **] and hemoconcentration (HCT 59). His anion gap closed on the
evening of admission and he was placed on his home dose
equivalent NPH (42units [**Hospital1 **]). His insulin gtt was stopped, and
he was covered with a humalog sliding scale. His FSG and gap
remained closed, though persisting abdominal pain prevented good
oral intake. He was called out of the ICU on [**2114-3-21**]. On the
floor his BS were less than 200. He was tolerating PO with some
abdominal pain that was epigastric and associated with food. A
[**Last Name (un) **] consult was initiated to help initiate a new sliding
scale regiment since he was only taking meal time Humalog
coverage in the morning. He remained hypokalemia and required
additional IV repletion. He was given a prescription for PO K
for three days and encouraged to take PO.
2. ABDOMINAL PAIN: He had diffused abdominal discomfort likely
related to DKA. His oral intake slowly improved. He continued
to have pain with solid food, but not liquids. The DDX included
gastritis, gastropathy or less likely [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear. Of
note, his abdominal pain was only associated with food. Maalox
provided minimal relieve, and therefore he was started on a PPI
and calcium carbonate. He will need follow up with his [**Last Name (un) **]
provider and PCP.
Medications on Admission:
Insulin 75/25 56units [**Hospital1 **]
Discharge Medications:
1. Maalox Maximum Strength 400-400-40 mg/5 mL Suspension Sig:
Ten (10) ML PO TID (3 times a day) as needed for indigestion,
abd pain.
Disp:*250 ML(s)* Refills:*0*
2. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: [**12-10**]
Tablet, Chewables PO QID (4 times a day) as needed for
indigestion.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day for 3 days.
Disp:*6 Tablet, ER Particles/Crystals(s)* Refills:*0*
5. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
One (1) 44 Subcutaneous twice a day.
6. Humalog KwikPen 100 unit/mL Insulin Pen Sig: One (1) variable
Subcutaneous four times a day: Please see attached sliding
scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
DKA
Secondary Diagnosis:
Type I DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 73657**]-
You were diagnosed with DKA after you had alcohol and were
unable to take your insulin. You were admitted to the ICU for
insulin and intravenous fluids. You were discharged to the
floor with stable blood sugars, but your HgBA1C is 12.9. You
will need to see your [**Last Name (un) **] provider to help adjust your
insulin regiment.
The following medications were changed:
CHANGED: Humalog SS
ADDED: Famotidine, Calcium Carbonate, Maalox
Followup Instructions:
Name: [**Last Name (LF) 14840**], [**Name8 (MD) **] MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
When: Tuesday, [**3-27**], 1PM
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 45369**]
When: [**Last Name (LF) 2974**], [**4-6**], 3PM
Completed by:[**2114-3-22**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6070
} | Medical Text: Admission Date: [**2182-11-23**] Discharge Date: [**2182-11-28**]
Service: NEUROSURGERY
ADMITTING DIAGNOSIS: Subdural hematoma.
CHIEF COMPLAINT: Slurred speech and word finding
difficulties transiently since the morning.
HISTORY OF THE PRESENT ILLNESS: This is an 83-year-old
right-handed white male, retired accountant, with a history
of coronary artery disease, status post CABG times six
vessels in [**2174**] who presents with a transient episode of
slurred speech and word finding difficulties on the morning
of admission. The patient came to the Emergency Room for
further evaluation.
He denied any weakness, numbness, paresthesias, headache,
nausea or vomiting. His speech was reportedly garbled and
incomprehensible for brief episodes during the course of the
morning but the patient denied any comprehension problems.
[**Name (NI) **] did note word finding difficulties episodically.
The family brought the patient to the Emergency Room in the
midafternoon. The Stroke Service was called and stroke
protocol was begun with an MRI obtained which was positive
for a large subacute left hemisphere subdural hematoma
measuring up to 1.5 cm in thickness and moderate midline
shift. The patient stated that his word finding difficulty
abated since arrival in the Emergency Room. The patient and
the family report a fall with an Emergency Room visit
approximately three weeks prior to admission at an outside
hospital and a one to two day stay for observation at that
time. The family is uncertain whether any abnormality was
seen on the CT scan at that time.
PAST MEDICAL HISTORY:
1. Above mentioned coronary artery disease, status post MI
and CABG in [**2174**].
2. History of hypercholesterol.
PAST SURGICAL HISTORY:
1. CABG, as mentioned.
2. Remote herniorrhaphy.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Atenolol.
2. Aspirin 325 mg q.d.
3. Prinivil.
4. Lipitor.
5. Cardura.
REVIEW OF SYSTEMS: History of syncopal episode in [**2181-10-13**] for which an echocardiogram was done and he showed an
ejection fraction 60% with 3+ mitral valve regurgitation.
There is a history of occasional migraines.
PHYSICAL EXAMINATION: On physical examination, the vital
signs were within normal limits. He was awake, alert, and
oriented times three, in no acute distress. He was
conversant without slurring or dysarthria at the time of
examination. His short-term memory was intact. He repeated
test questions appropriately. He named all common objects
appropriately. The pupils were equal, round, and reactive to
light and accommodation. The extraocular movements were
intact. The neck was supple. There was no jugular venous
distention. The chest was clear. The heart rate was regular
and rhythmic without murmur, gallop, or rub. The abdominal
examination was unremarkable. There was no costovertebral
angle tenderness and no suprapubic tenderness or fullness.
The extremities were without clubbing, cyanosis or edema.
The neurological examination, including strength of the upper
and lower extremities, was [**6-16**] throughout. He was moving all
extremities spontaneously through a full range. Sensory was
intact to light touch throughout. The deep tendon reflexes
were essentially within normal limits with the exception of a
mildly decreased left knee or patellar reflex and absent
bilateral Achilles reflex. The plantar response was
downgoing. There was no ankle clonus. Gait and Romberg were
not tested. There was no upper extremity drift. The face
was symmetric and the tongue was midline.
LABORATORIES/OTHER STUDIES: The admission laboratories were
all considered to be within normal limits, particularly his
coagulation studies with a PT of 12.8, PTT 30.5, and INR 1.1.
Review of the MRI did confirm the presence of a large
left-sided subdural hematoma.
HOSPITAL COURSE: Due to these findings, the patient was
admitted to the Neurosurgical Service and to the
Neurosurgical Intensive Care Unit for overnight observation.
On the morning following admission, the patient underwent a
bedside drainage of the subdural hematoma with a subdural
drain placed. The patient tolerated the procedure well and
remained in the Surgical Intensive Care Unit for
approximately 48 hours, at which time he was noted to be
doing fine. A follow-up CT scan showed marked decrease in
the size of the subdural hematoma. The subdural drain was,
therefore, removed and the patient was transferred from the
unit to the [**Hospital 16364**] Medical Surgical floor where he
remained throughout the remainder of his hospitalization in
stable condition.
CONDITION ON DISCHARGE: Stable and improved.
DISCHARGE MEDICATIONS: The patient was told to resume all
preoperative medications with the exception of his aspirin.
He was told not to renew his aspirin and to follow-up with
his primary care physician within one weeks time and to
follow-up with Dr. [**Last Name (STitle) 6910**] at approximately one months
time with a follow-up CT scan to be done at that time.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2182-11-28**] 11:04
T: [**2182-12-1**] 11:48
JOB#: [**Job Number 103499**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6071
} | Medical Text: Admission Date: [**2179-10-9**] Discharge Date: [**2179-10-12**]
Date of Birth: [**2094-2-16**] Sex: F
Service: MEDICINE
Allergies:
Niacin / Ultram / Valacyclovir / Neurontin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
85 yo female witih history of GERD who presents from the
[**Hospital3 2558**] after nurse [**First Name (Titles) 13431**] [**Last Name (Titles) **] stool in diaper this
morning. She also reports 1 episode of coffee ground emesis
yesterday and current epigastric pain. She reports intermittent
nausea x 1 month, along with recent diarrhea, though she cannot
characterize this as she wears a diaper. She uses OTC PPI
intermittently and is on SQ heparin, likely secondary to recent
hip fracture in [**Month (only) 216**]. She denies any history of alcohol use or
NSAID use.
On presentation, her vital signs: 96.6, 100, 108/52, 18, 100%.
Exam was notable for diffuse abdominal tenderness, worse in
epigastric area, and dark maroon stools in rectal vault. She was
started on a PPI drip and received zofran 8mg. Her hct has been
stable with lactate 1.4. Potassium was markedly elevated though
this was a hemolyzed specimen. Repeat K 4.5.
Pt is DNR/DNI, however she wishes to reverse this for EGD. She
was evaluated by GI in the ED and will have bedside scope on
arrival.
Review of systems:
(+) Per HPI, also endorses multiple months of shortness of
breath, also generalized weakness. She has been bed bound since
[**Month (only) **] when she had a femur fracture.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies dysuria, frequency,
or urgency. Denies rashes or skin changes.
Past Medical History:
herpes zoster R face [**7-22**]
polychondritis
osteoporosis with compression fracture - not on treatment except
ca and vit D
bells palsy [**2174**]
pancreatic cyst
hiatal hernia
melanoma
Left hip hemiarthroplasty [**7-22**]
hysterectomy
right THR
Social History:
lives at [**Hospital3 2558**] since recent hip arthroplasty
Family History:
Noncontributory
Physical Exam:
per admitting resident:
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,
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
General: Alert, oriented, flat affect
HEENT: Sclera anicteric, MMM
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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
labs on admission:
[**2179-10-9**] 12:45PM WBC-9.0 RBC-3.20* HGB-10.2*# HCT-29.8* MCV-93
MCH-32.0 MCHC-34.4 RDW-14.1
[**2179-10-9**] 12:45PM NEUTS-72.2* LYMPHS-21.2 MONOS-5.1 EOS-0.5
BASOS-1.0
[**2179-10-9**] 12:45PM PLT COUNT-418#
[**2179-10-9**] 12:45PM PT-14.0* PTT-31.3 INR(PT)-1.2*
[**2179-10-9**] 12:45PM GLUCOSE-123* UREA N-43* CREAT-0.7 SODIUM-130*
POTASSIUM-7.0* CHLORIDE-97 TOTAL CO2-17* ANION GAP-23*
[**2179-10-9**] 03:00PM ALT(SGPT)-11 AST(SGOT)-13 LD(LDH)-118 ALK
PHOS-68 TOT BILI-0.2
[**2179-10-9**] 03:00PM LACTATE-1.4
Hct trend:
[**2179-10-9**] 12:45PM Hct-29.8
[**2179-10-9**] 07:20PM Hct-25.7
[**2179-10-10**] 03:10AM Hct-20.9
[**2179-10-10**] 10:51AM Hct-30.7
[**2179-10-10**] 02:38PM Hct-34.0
[**2179-10-10**] 10:02PM Hct-30.8
[**2179-10-12**] 04:44AM Hct-34.1
Imaging:
CXR: [**10-9**]
moderately enlarged heart and large hiatal hernia. The lungs are
clear, with limited visualization in the retrocardiac region due
to the superimposed hiatal hernia.
EGD: [**10-9**]
A single cratered non-bleeding 18 mm ulcer was found in the
distal bulb.
Impression:
Medium hiatal hernia
Ulcer in the distal bulb
Otherwise normal EGD to third part of the duodenum
HIP FILMS:Stable-appearing left hip hemiarthroplasty.
Brief Hospital Course:
85 y/oF with large hiatal hernia and GERD who was admitted with
GI bleed.
GI bleed: Patient presented with coffee ground emesis and
melanotic stools with Hct near recent baseline of 27- 28. Home
heparin SC was discontinued. She was initially started on a
protonix gtt and underwent emergent EGD in the ICU which
revealed a single nonbleed duondenal ulcer which was thought to
be the etiology of her bleed. Following endoscopy, she was
monitored with serial Hcts. Hct did drop to 20 on [**10-10**] but
this was thought to represent re- equilibration following fluid
resuscitation rather than continued active bleeding. She
received 2 UpRBC with Hct stabilizing at 30 initially, then up
to 34 at discharge. She passed a maroon stool the morning after
admission but this was thought to be secondary to old blood and
her hematocrit was stable. She did not pass any other [**Month/Year (2) **]
stool. Protonix gtt was switched to [**Hospital1 **] dosing and her hct
remained stable for remainder of her stay.
asymptomatic bacturia: patient was admitted with asymptomatic
bacturia with urine cx growing entercoccus sensitive to
ampicillin. She was given a prescription for 3d course of
ampicillin.
metabolic abnormalities: initially presented with hyponatremia,
anion gap metabolic acidosis, and hyperkalemia in setting of
hemolyzed sample. All normalized with IVF suggesting that she
was intravascularly depleted. Anion gap attributed to ketosis
and poor nutrition.
hip arthroplasty: pt has significant weakness and bilateral LE
atrophy. ortho was consulted and recommended plain films of hip
which showed no new changes. she was discharged to rehab to
improve her LE strength.
Medications on Admission:
MVI
colace 100mg [**Hospital1 **]
senna 2 tabs at bedtime
vit D3 800 units daily
calcium carbonate 500mg QID
heparin SQ TID
fibercap one tab TID
tylenol 500mg PO QID
ferrous sulfate 325mg daily
tylenol 500 mg QID
remeron 15 mg qHS
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO once a day.
2. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
6. Fiber-Caps 0.52 g Capsule Sig: One (1) Capsule PO three times
a day.
7. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
11. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): inject subcutaneously.
12. ampicillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
upper GI bleed from duodenal ulcer (H. pylori negative, likely
secondary to hiatal hernia)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you
had bleeding from your GI tract. You were given a blood
transfusion and your red blood cell count stabilized. You had an
upper GI scope which showed an ulcer in your duodenum, which is
likely what caused your bleeding. You had no further bleeding
episodes so you were sent home. You should follow up with a GI
doctor in one month.
You were found to have a urinary tract infection while you were
in the hospital so you should complete a 3 day course of
antibiotics for this (prescription below).
The following changes were made to your medications:
STARTED
pantoprazole 20mg by mouth twice a day
ampicillin 500mg by mouth every 6 hours for 3 days for urinary
tract infection.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2179-11-16**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 22337**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2761, 2762, 2851, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6072
} | Medical Text: Admission Date: [**2121-5-6**] Discharge Date: [**2121-5-14**]
Date of Birth: [**2045-7-26**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Urosepsis
Major Surgical or Invasive Procedure:
Intubation (from OSH)
Extubation [**2121-5-6**]
History of Present Illness:
Mr. [**Known lastname 1313**] is a 75y/o gentleman with a DM2, HTN, and history of
nephrolithiasis (no interventions in the past) who is
transferred with urosepsis and an obstructing ureteral calculus.
.
He presented to [**Hospital3 **] on [**5-5**] due to 2 weeks of
feeling generally weak and nauseated, with occasional emesis.
Of note, he had been started on Cipro 11 days prior for UTI,
with no relief, and had been on Nitrofurantoin for the past 4
days. He started feeling more fatigued so he presented to
[**Hospital1 **] ER where VS were: T 99.2, HR 112 (but up to 130), BP
97/52, RR 20, POx 100% 2L NC. He was found to be in AFib with
RVR to 130 requiring Diltiazem 10mg IV x3 with subsequent drop
in BP so was switched to Lopressor IV. 18 Fr foley was placed
releasing 4 liters of purulent urine. Was started on
Vanc/Zosyn. He was admitted to their ICU where CT showed
moderate hydronephrosis and hydroureter on the right secondary
to an obstructing calculus just above the UVJ measuring about 4
mm. Urology attempted a right ureteral decompression but was
unable to advance past the stone so he was transferred to [**Hospital1 18**]
for I.R.-guided urostomy tube placement. Of note, patient was
intubated for the procedure and remains so. He reportedly had
hypotension in the OR (low blood pressures not documented) so he
required Neosynephrine and Levophed.
.
On arrival to the MICU, he is intubated and sedated. Arrived
only on Levophed which was just turned off.
Past Medical History:
nephrolithiasis
class III obesity
DM2
HTN
gout
Social History:
retired dry cleaning machine manufacturerer
no ETOH
no tobacco
no illicits
Family History:
Father lost kidney due to stones
Physical Exam:
On admission:
Vitals: T: 98.5 BP157/90: P:146 Vented: CMV TV 600 PeeP 5 FiO2
50% O2: 98%
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular. Distant heart sounds. no murmurs,
rubs, gallops
Lungs: Coarse breath sounds anterioly. Otherwise no wheezes,
rales, ronchi
Abdomen: Obese abdomen otherwise soft, non-tender,
non-distended, bowel sounds present, no organomegaly
GU: foley with dark urine.
Ext: cold extremities. Poorly palpable pulses. Trace edema
but otherwise no clubbing or cyanosis.
Neuro: Pupils reactive. Winces to pain.
On discharge:
Vitals: 98.2 98.0 112/56 90 20 98%
General: Obese, Alert, oriented, no acute distress
HEENT: PERRL, EOMI, MMM, sclera anicteric, oropharynx clear
Neck: JVP flat, no LAD
Lungs: CTA anteriorly, unable to auscultate lung bases due to
limited mobility
CV: RRR, nl S1 + S2, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly; nephrostomy
tube in place, no tenderness or erythema around site
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2121-5-6**] 02:04AM BLOOD WBC-16.6* RBC-3.15* Hgb-9.5* Hct-31.5*
MCV-100* MCH-30.3 MCHC-30.2* RDW-15.1 Plt Ct-277
[**2121-5-6**] 03:03AM BLOOD PT-14.9* PTT-26.7 INR(PT)-1.4*
[**2121-5-6**] 02:04AM BLOOD Glucose-230* UreaN-70* Creat-3.2* Na-137
K-4.4 Cl-110* HCO3-13* AnGap-18
[**2121-5-10**] 12:05AM BLOOD CK-MB-4 cTropnT-0.92*
[**2121-5-10**] 02:05AM BLOOD CK-MB-4 cTropnT-1.00*
[**2121-5-10**] 06:39AM BLOOD CK-MB-4 cTropnT-1.10*
[**2121-5-6**] 02:04AM BLOOD Albumin-3.3* Calcium-7.9* Phos-4.6*
Mg-1.6
[**2121-5-6**] 05:00PM BLOOD calTIBC-150* VitB12-397 Ferritn-560*
TRF-115*
[**2121-5-6**] 02:18AM BLOOD Lactate-1.4
DISCHARGE LABS:
[**2121-5-13**] 06:00AM BLOOD WBC-9.8 RBC-2.90* Hgb-8.8* Hct-28.9*
MCV-100* MCH-30.3 MCHC-30.3* RDW-15.9* Plt Ct-342
[**2121-5-13**] 06:00AM BLOOD PT-13.8* PTT-56.0* INR(PT)-1.3*
[**2121-5-13**] 06:00AM BLOOD Glucose-119* UreaN-21* Creat-1.4* Na-136
K-4.2 Cl-104 HCO3-24 AnGap-12
[**2121-5-10**] 06:39AM BLOOD CK(CPK)-57
[**2121-5-13**] 06:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.3*
CTA CHEST [**2121-5-10**]:
1. No evidence of acute aortic bony injury or pulmonary embolus.
2. Bronchiectasis and bronchial wall thickening at the lung
bases bilaterally with associated minimal central
lymphadenopathy.
3. Severe calcified atherosclerotic disease.
4. Trace left pleural effusion.
5. Prominent pumlonary artery suggestive of underlying pulmonary
hypertension.
TTE:
Technically suboptimal image quality. The left atrium is mildly
dilated. There is an apical left ventricular aneurysm. Overall
left ventricular systolic function is moderately depressed (LVEF
= (?) 35 %). Anterior and septal hypokinesis is present, and
extensive apical akinesis with focal dyskinesis is present. The
right ventricle is not well seen but may also be hypokinetic.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mitral regurgitation is present but cannot be
quantified. Tricuspid regurgitation is present but cannot be
quantified. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 1313**] is a 75y/o gentleman with nephrolithiasis, DM2, and
HTN presenting with urosepsis, [**Last Name (un) **], and AFib in the setting of
obstructive uropathy and urinary retention.
.
#. Obstructive uropathy with infection: urosepsis.
Pt presented from OSH with concerns for urosepsis. CT at OSH
showed moderate hydronephrosis and hydroureter on the right
secondary to an obstructing calculus just above the UVJ
measuring about 4 mm. He was placed initially on broad spectrum
antibiotics (vanc/cefepime) initially. This was narrowed to
ceftriaxone when urine culture from OSH was reported to be > 100
K E.COLI resistant to Levofloxacin, Bactrim and sensitive to all
other agents. Planned for a two week antibiotic course.
Percutaneous nephrostomy tube was placed by IR (pt was kept
intubated for the procedure) on [**2121-5-6**]. This was complicated
by bleeding from nephrostomy tube when pt was started on heparin
gtt for afib. IR reassessed the tube and found it to be in
calyx instead of kidney; this was replaced ON [**5-9**] and bleeding
from nephrostomy tube resolved. Creatinine > 4 on admission from
obstructive [**Last Name (un) **], now trending down to 1.4 after nephrostomy tube
placement. Patient was discharged on IV ceftriaxone, last day =
[**5-18**] for total 2 week course.
# [**Last Name (un) **] and urinary retention: Creatinine > 4 on admission, now
1.4 s/p nephrostomy tube placement. Urology was consulted who
recommended initiation of tamsulosin and voiding trial in [**2-14**]
days. Patient failed subseuqent voiding trial with 750 cc of
urine in his bladder. He was intermittently straight - cathed,
but it became increasingly difficult likely secondary to his
BPH. Thus, a foley was placed prior to discharged. Per urology
recommendations, the foley should remain in place until the
patient sees his urologist.
.
#. AFib with RVR: new-onset, in the setting of infection.
Per OSH records, pt had no known h/o AFib but was in afib with
rvr at OSH. Rate-control was attempted with several different
agents including metoprolol, diltiazem, and esmolol drip.
However, he became hypotensive on these agents. He was then
started on an amiodarone drip. Given his CHADS of 3 and
increased risk of stroke with potential cardioversion on
amiodarione drip, he was started on heparin gtt. This was
complicated by bleeding from foley as well as nephrostomy tube.
Cardiology consult was obtained who recommended stopping
amiodarone drip and placing pt back on metoprolol. Metoprolol
doses were adjusted several times for continued elevated heart
rates and low blood pressures, and he was eventually able to be
rate controlled on 50 QID metoprolol tartrate, tansitioned to
200 metoprolol succinate on discharge. He was continued on
heparin gtt and was initiated on coumadin the day prior to
discharge. On discharge, he was well rate controlled in the
90s-110s with bursts into the 130s-140s when eating breakfast or
lunch. These rates would only last for several minutes and
patient remained stable and asymptomatic until resolution. A
TTE was obtained that revealed EF of 35%, left ventricular
aneurysm, and possibly hypokinetic right ventricle, mild aortic
stenosis. Cardiology recommended that he undergo non urgent
cardiac catheterization when stable. He was started on a baby
aspirin.
# Chest Pain and Increased Troponins: On [**2121-5-9**] pt complained
of chest pain radiating to his arm as well as N/V. ECG showed no
changes. CTA negative for PE, but did show evidence of pulmonary
hypertension. He has no known CAD, but cards recommended a
cardiac cath at some point as based on his TTE, likely has 3VD.
Trops have increased to 1.10 with flat CKs and MBs. Likely
demand ischemia in the setting of sepsis. He was started on
aspirin 81 mg and atorvastatin. Cardiology did recommend a
non-urgent cardiac cath at some point in the near future. This
will be discussed at patient's outpatient cardiology
appointment.
# Transaminitis: On day of discharge, patient's AST and ALT were
mildly elevated to 117 and 80, respectively (had been normal on
admission). Possibly secondary to initiation of atorvastatin.
Atorvastatin was held on day of discharge. His AST and ALT
should be monitored and trended while at the MACU.
#. HTN: intermittently hyptonsive off home BP meds.
He became hypotensive with IV nodal agents for AFib/RVR in the
OSH ED. Again became hypotensive in the OR during attempted
ureteral stenting (possibly from vagal response vs. evolving
septic shock). He also became hypotensive with several
different agents for rate-control for afib. His home BP
medications,(Hydrochlorothiazide-Triamterene, Spironolactone,
Hydralazine) were held. He was started on metoprolol for
rate-control. Given findings of depressed EF on TTE, he was
started on an ACE-I, which should be uptitrated as an
outpatient.
# Loose stools/diarrhea: Patient had frequent loose stool
throughout hospital stay, brown but guiac positive. A C diff
PCR was negative on [**5-8**], patient's white count remained stable,
and patient looked clinically well. Given the small amount of
loose stools and his clinical status, the team felt that there
was a low pre test probability for C diff on discharge. If
patient's loose stools continue at rehab, or if clinical status
changes, another C diff PCR test should be sent.
.
#. DM2: stable. Home oral hypoglycemics were held and he was
placed on home lantus and HISS.
.
#. Anemia: Hct 32 (unclear baseline). He was guaiac positive at
OSH. Hct dropped to high 20s but was stable during ICU stay.
He initially had bleeding from foley and nephrostomy tube when
heparin gtt was started which eventually resolved. He will need
outpatient colonoscopy and GI follow-up.
# Transitional Issues:
- Outpatient cardiac catheterization
- Management of INR and coumadin dose
- Nephrostomy tube removal to be determined by urology
- Trending of AST/ALT and reinitiation of statin
- Colonoscopy
CODE STATUS: DNR/DNI
** In patient's discharge paperwork, states that ACE/[**Last Name (un) **] not
prescribed on discharge because not tolerated. This is a
malfunction in the new electronic med reconciliation form. This
is to clarify that the patient was in fact discharged on an
ACE-I.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient Outside hospital records.
1. Metoprolol Tartrate 50 mg PO BID
2. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
3. Spironolactone 25 mg PO DAILY
4. HydrALAzine 25 mg PO QHS
5. Levemir 15 Units Breakfast
6. Nateglinide 120 mg PO TIDAC
7. Allopurinol 300 mg PO DAILY
8. ibuprofen *NF* 800 mg Oral TID
9. TraMADOL (Ultram) 50 mg PO QID
10. Nitrofurantoin (Macrodantin) 50 mg PO Q6H
Discharge Medications:
1. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. TraMADOL (Ultram) 50 mg PO BID:PRN pain
3. Aspirin 81 mg PO DAILY
4. CeftriaXONE 1 gm IV Q24H
Day 1= [**5-5**]
LAST DAY = [**5-18**]
5. Heparin IV Sliding Scale
6. Metoprolol Succinate XL 200 mg PO DAILY Start: In am
Hold for HD <60 or systolic BP <100.
7. Miconazole Powder 2% 1 Appl TP QID:PRN fungal rash
8. Tamsulosin 0.4 mg PO HS
9. Warfarin 2.5 mg PO DAILY16
10. Lisinopril 2.5 mg PO DAILY
HOLD FOR SBP < 100
11. Allopurinol 100 mg PO DAILY
12. Simethicone 40-80 mg PO QID:PRN Bloating
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Urosepsis
Obstructive uropathy with percutaneous nephrostomy tube
placement
Atrial Fibrillation
Systolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were seen in the hospital because of severe obstruction of
your urinary tract which caused an infection in your urine.
This obstruction was cleared with a nephrostomy tube and your
infection was treated with IV antibiotics. The nephrostomy
tubes will stay in place for at least the next several week
until you follow-up with a urologist listed below.
While in the hospital, you also developed a fast irregular heart
rate called atrial fibrillation. We controlle your rate by
increasing your metoprolol. Because atrial fibrillation
increases your risk of stroke, we also put you on a blood
thinner called coumadin. Once you are discharged from the
hospital, you will need to have your coumadin levels checked
periodically.
You also had an echocardiogram, or an ultrasound of your heart,
which showed that your heart pumping function has been reduced.
You were seen by our cardiology team, who recommended that you
eventually have a cardiac catheterization to look to see of
there are blockages in your arteries. You will see a
cardiologist to discuss this procedure with you, as listed
below.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]
[**Hospital3 **]
[**5-28**] 1:45 PM
Urology:
Dr. [**Last Name (STitle) 9780**]
[**Name (STitle) 5871**] Hospital
[**2119-6-5**]:30 AM
Once you are discharged from the rehab facility, an appointment
will be made for you to see your primary care doctor.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
ICD9 Codes: 0389, 5990, 5849, 4280, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6073
} | Medical Text: Admission Date: [**2111-8-25**] Discharge Date: [**2111-8-31**]
Service: MEDICINE
Allergies:
Epinephrine / Adhesive Tape
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
hypotension and retroperitoneal bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is an 84 y.o male with h.o HTN, s/p CABG, PM/ICD, CMP with EF
35%, PAF, MDS/anemia, hypothyroidism, h.o prostate ca, DVT, with
recently diagnosed metastatic adenoca with unknown primary who
presented to the ED with symptoms suggestive of presyncope.
.
Pt had been seen by rad onc for ciber knife eval. Had large dye
load for CT scan (then diuresed ~1500cc) and likely became
orthostatic. Pt then fell at NH, hit his back, and presented to
the ED hypotensive. Pt underwent a FAST exam that looked
"positive", underwent CT torso showing large RP bleed. Pt given
blood and fluid with good effect. SBP now 120's. U.O good
50-100cc/hr. Pt mentating.
.
Upon conversation with pt's son with Dr. [**Name (NI) 496**], pt is
DNR/DNI and does not want CVL.
.
Past Medical History:
1. Dyslipidemia.
2. Hypertension.
3. CABG in [**2103**]
4. Pacemaker/ICD due to AV block and tachybrady syndrome
5. Cardiomyopathy with LVEF = 35% in [**10-6**].
6. PAF
7. TIA in [**2103**].
8. Macrocytic anemia, attributed to MDS with bone marrow biopsy
in [**State 531**].
9. Spinal stenosis.
10. Hypothyroidism.
11. H/o gastric ulcer; GERD.
12. OSA on nocturnal CPAP.
13. Prostate cancer s/p XRT.
14. Adenocarcinoma of unknown primary metastatic to the left
occipitoparietal region s/p resection in [**7-7**]
15. DVT/PE s/p IVC filter on Lovenox [**Hospital1 **]
Social History:
He lives with his wife in a senior center and is independent in
his ADLs. He quit smoking in [**2060**] after 3 ppd for many years. He
does not drink EtoOH.
Family History:
Father died of lung cancer at age 50. Mother had an MI and died
at age 86. A brother also had lung cancer. He has two children
that are healthy.
Physical Exam:
Vitals: T 95.4, BP 102/52, HR 73, RR 23, sat 100% on RA
General: Alert, oriented, no acute distress, pale.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
chest: [**Doctor Last Name **] chest with pacer/no erythema.
Abdomen: soft, TTP R.periumbilical/R.flank. +bs, no guarding/no
rebound.
Ext: warm, 2+pulses, 1+ pitting edema, +multiple areas of
ecchymoses.
Pertinent Results:
LABS ON ADMISSION:
HCT 19
lactate 3.4,
WBC 16.1
LABS ON TRANSFER FROM ICU:
135 / 101 / 36
===============< 134
4.0 / 25 / 0.9
CBC 18.9 > 11.0 / 31.3 < 94
Ca: 7.2 Mg: 2.3 P: 2.7
LABS ON DISCHARGE:
EKG: Vpaced @70, STD I, AVF, unchanged from prior on [**2111-8-7**]
CXR [**8-26**]: The pacemaker leads terminate in right atrium and
right ventricle, unchanged. There is interval decrease in the
left pleural effusion with still present area of left basal
atelectasis. The left upper lung and the right lung are
unremarkable. Cardiomediastinal silhouette is stable. Overall,
the lung volumes are lower than on the prior radiograph that
might be explained by suboptimal inspiratory effort.
CT Torso [**8-25**]: Large right-sided retroperitoneal hematoma,
stable bilateral pleural effusions, left greater than right,
patient appears anemic and may be hypovolemic as indicated by a
spleen, which is smaller than on prior study, and a narrowed
IVC. IVC filter in unusual position with the distal aspect at
the level of the iliac vein bifurcation. Extensive stool within
the colon and fluid within the stomach, but no evidence for
bowel obstruction. Stable pulmonary nodule. Stable spine
degenerative changes and compression fractures and chronic right
posterior rib fracture.
CT Head. [**2111-8-25**]. IMPRESSION: Status post left parietooccipital
craniotomy with small hyperdense focus at the margin of the
resection bed, corresponding to the enhancing focus on the most
recent study, which may represent residual tumor, as suggested
previously. Otherwise, there is no hemorrhage or other acute
process.
Brief Hospital Course:
1. Retroperitoneal bleed: Patient was initially hypotensive upon
arrival to the hospital shortly after falling at his nursing
home and was found on CT to have a large retroperitoneal bleed.
Hematocrit on admission was 19.3 and hit a nadir of 18.6 shortly
after admission. Patient has MDS with baseline HCT of 30. He was
trasnfused a total of 9 units PRBCs in the MICU. He did not
require a procedure to stop the bleed. His lovenox and
antihypertensives were held.
2. Leukocytosis: He had an elevated WBC reaching 23.0 on the day
of admission, likely related to a stress response and ?UTI in
the setting of chronic steroid use and malignancy. Initial UA
showed > 50 WBCs and positive leukocytes and nitrites. Notably,
the patient had been on a suppressive macrodantin which had been
stopped a few weeks prior to admission. He had no other clear
source of infection. Blood cultures were negative. He was
treated with 2 days of Levaquin which was stopped when his urine
culture grew out yeast.
3. Acute Renal Failure: Patient was in acute renal failure when
admitted with a creatinine at 1.7 from baseline of 1.0. This was
most likely due to his pre-renal etiology in the setting of an
acute bleed. His creatinine resolved with resolution of his
bleed and correction of his volume status. His creatinine on
discharge was 0.9.
4. Recent History of DVT: The patient was recently admitted for
a DVT and has had an IVC filter placed. In addition he was on
Lovenox, which was held on the current admissions. Given his
severe risk of internal bleeding, it was decided to permanently
discontinue his Lovenox on discharge.
5. Positive U/A: On admission patient was found to have a
positive UA showed > 50 WBCs and positive leukocytes and
nitrites. Patient was asymptomatic and notably has lived with an
indwelling catheter for several months. He was treated with 2
days of Levaquin which was stopped when his urine culture grew
out yeast.
5. PICC Line: A PICC line was placed for access and proper
placement was confirmed on CXR.
6. Brain Metastesis: Patient known to have a brain metastesis of
adenocarcinoma of unknown origin. Patient was undergoing
cyberknife evaluation the day he was admitted. During his
admission he was continued on dexamethasone and gabapentin
7. CHF and AF: Patient has a history of CHF with EF of 40-45% in
[**2108**] and PAF. Patient is s/p AICD. During this admission this
patient was monitored for arrythmias, and transufused blood to
maintain a goal hematocrit above 30. Patient remained in NSR
across his admission. He is currently controlled on amiodarone.
8. HTN: Patient was admitted on daily doses of Carvedilol and
Lasix, both of which were initially held in the setting of acute
bleed. The carvedilol was initially restarted at half his home
dose, with good effect, and then resumed to his normal dose.
Lasix was restarted. The patient was discharged on all of his
home cardiac medications.
9. Code Status: Per discussions with patient's family, this
patient was considered DNR but not DNI. His wishes are only to
be intubated only if it is considered likely that his would make
a relatively rapid recovery.
10. MRSA Status: MRSA screen on admission was positive. Patient
was placed on contact precautions. Specific MRSA treatment was
not initiated at this time.
11. Wound Care: Wound care recommendations from this patient's
previous admission were followed. No new complications
developed.
Medications on Admission:
1. IV access: PICC, heparin dependent Location: Right, Date
inserted: [**2111-8-27**] Order date: [**8-28**] @ 1300 11. Levothyroxine
Sodium 75 mcg PO DAILY Order date: [**8-28**] @ 1300
2. IV access: Peripheral line Order date: [**8-28**] @ 1300 12.
Lidocaine 5% Patch 1 PTCH TD DAILY Order date: [**8-28**] @ 1300
3. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever Order date:
[**8-28**] @ 1300 13. Omeprazole 40 mg PO DAILY Order date: [**8-28**] @
1300
4. Amiodarone 200 mg PO DAILY Order date: [**8-28**] @ 1300 14.
Ondansetron 4 mg IV Q8H:PRN nausea Order date: [**8-28**] @ 1300
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date:
[**8-28**] @ 1300 15. Oxycodone-Acetaminophen 1 TAB PO Q6H severe
pain
pls hold for SBP <100, sedation Order date: [**8-28**] @ 1300
6. Carvedilol 12.5 mg PO BID
Hold for HR less than 60 or SBP less than 100mmHg Order date:
[**8-28**] @ 1703 16. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN
pain
hold for sedation, RR <10 Order date: [**8-28**] @ 1300
7. Dexamethasone 4 mg PO Q12H Order date: [**8-28**] @ 1300 17.
Polyethylene Glycol 17 g PO DAILY:PRN constip Order date: [**8-28**]
@ 1300
8. Docusate Sodium 100 mg PO BID Order date: [**8-28**] @ 1300 18.
Senna 1 TAB PO BID:PRN Constipation Order date: [**8-28**] @ 1300
9. Gabapentin 400 mg PO HS Order date: [**8-28**] @ 1300 19.
Simvastatin 10 mg PO DAILY Order date: [**8-28**] @ 1300
10. 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. Order date: [**8-28**] @
1300 20. 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.
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. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for severe pain.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constip.
16. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
PRIMARY:
1. Retroperitoneal hemorrhage
2. Brain metasteses of unknown primary adenocarcinoma
3. Recent history of DVT
SECONDARY:
1. Hypertension
Discharge Condition:
stable, afebrile
Discharge Instructions:
It was a pleasure to help care for you during your stay at [**Hospital1 1535**].
You were admitted to the hospital with low blood pressure. In
our emergency department you were found to have an internal
bleed.
While you were here you were treated with intravenous fluids and
given 9 units of blood. We also continued most of your home
medications.
You should continue to refraine from taking your Lovenox when
you leave the hospital. We have decided to stop this medication.
We did not stop any of your other medications while you were
here. Please take all of your other medications exactly as
prescribed.
Please call your physician or return to the emergency department
if you experience any of the following: worsening shortness of
breath, chest pain, nausea or vomiting, any fevers above 100.4,
dizziness or light-headedness, headache, worsening pain, loss of
consciousness, or any other concerning signs or symtoms.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 3520**] [**Last Name (NamePattern1) 3521**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2111-9-10**]
10:20
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-9-28**]
1:55
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2111-9-28**]
4:00
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
ICD9 Codes: 5849, 2762, 2851, 4254, 2767, 2449, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6074
} | Medical Text: Admission Date: [**2153-5-28**] Discharge Date: [**2153-6-2**]
Date of Birth: [**2073-5-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2153-5-29**] Aortic Valve Replacement utilizing a 21mm Mosaic Porcine
Bioprosthesis
History of Present Illness:
This is a very healthy 79 year old female who was noted to have
a heart murmur on routine examination. Serial echocardiograms
have shown significant progression of her aortic valve stenosis,
most recently [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.7cm2, with a peak gradient of 74 mmHg.
Subsequent cardiac catheterization showed normal coronary
arteries. Based on the above results, she was referred for
cardiac surgical intervention. She is asymptomatic and remains
very active.
Past Medical History:
Aortic Valve Stenosis
s/p Vein Stripping
s/p Benign Breast Mass Removal
Social History:
Denies history of tobacco. Rare ETOH. She lives alone and still
works part-time at an office.
Family History:
Denies premature coronary disease
Physical Exam:
Vitals: T afebrile, BP 142/80, HR 88, RR 20
General: pleasant elderly female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, grade 4/6 systolic ejection
murmur which radiates to carotids
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2153-6-2**] 07:05AM BLOOD WBC-9.2 RBC-3.18* Hgb-10.0* Hct-28.8*
MCV-91 MCH-31.4 MCHC-34.7 RDW-14.2 Plt Ct-313#
[**2153-5-30**] 02:10AM BLOOD PT-11.6 PTT-27.8 INR(PT)-1.0
[**2153-6-2**] 07:05AM BLOOD Glucose-98 UreaN-10 Creat-0.6 Na-140
K-4.0 Cl-102 HCO3-31 AnGap-11
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2153-6-1**] 4:38 PM
CHEST (PA & LAT)
Reason: evaluate for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman s/p AVR
REASON FOR THIS EXAMINATION:
evaluate for pleural effusions
HISTORY: Evaluate pleural effusions in 80-year-old female status
post AVR.
Comparison is made to prior radiographs dated [**2153-5-30**].
PA AND LATERAL CHEST RADIOGRAPHS:
FINDINGS:
There has been interval increase in bilateral pleural effusions
(right greater than left), both small in size with fluid noted
tracking within the major fissure on the left. There is no
evidence of new parenchymal consolidation with persistent
retrocardiac opacity likely representing atelectasis. No
pneumothorax or pulmonary edema. Symmetric biapical pleural
thickening is stable.
IMPRESSION:
Interval increase in small bilateral pleural effusions, right
greater than left.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Cardiology Report ECHO Study Date of [**2153-5-29**]
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for AVR
Height: (in) 64
Weight (lb): 122
BSA (m2): 1.59 m2
Status: Inpatient
Date/Time: [**2153-5-29**] at 09:07
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW06-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: *0.13 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *4.8 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 90 mm Hg
Aortic Valve - Mean Gradient: 60 mm Hg
Aortic Valve - LVOT Peak Vel: 1.00 m/sec
Aortic Valve - LVOT Diam: 1.9 cm
Aortic Valve - Valve Area: *0.6 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Overall normal
LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter. No atheroma in
ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Severe AS (AoVA <0.8cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. No MS. Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data
Conclusions:
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. Left
ventricular wall thicknesses and cavity size are normal. Overall
left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2).
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly
thickened. Trivial mitral regurgitation is seen.
POST-BYPASS: Well-seated valve. Normal biventricular systolic
function.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2153-6-4**] 09:55.
Brief Hospital Course:
Mrs. [**Known lastname 73317**] was admitted and underwent an aortic valve
replacement by Dr. [**Last Name (STitle) 68853**]. For surgical details, please see
seperate dictated operative note. Following the operation, she
was brought to the CSRU for invasive monitoring. Within several
hours, she awoke neurologically intact and was extubated without
difficulty. Initially tachycardic with frequent premature atrial
contractions, she was started on low dose beta blockade and
Amiodarone to prevent atrial fibrillation. She otherwise
maintained stable hemodynamics and transferred to the SDU on
postoperative day two. Over several days, she continued to make
clinical improvements with diuresis. She remained in a normal
sinus rhythm as beta blockade was advanced as tolerated. She
continued to progress and was discharged to home on POD#4 in
stable condition.
Medications on Admission:
Aspirin 81 qd, Vitamin, Calcium
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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Lopressor 50 mg PO BID.
5. Amiodorone 400 mg PO daily for 7 days, then decrease dose to
200 mg PO daily.
6. Ultram 50 mg PO q 4 hours PRN
7. Lasix 20 mg PO BID x 7 days.
8. Potassium Chloride 20 mg PO BID x 7 days.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Valve Stenosis - s/p AVR
s/p Vein Stripping
s/p Benign Breast Mass Removal
Discharge Condition:
Good
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**4-19**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-17**] weeks - call for appt.
Local cardiologist, [**Last Name (un) 32255**] in [**2-17**] weeks - call for appt.
Completed by:[**2153-6-4**]
ICD9 Codes: 4241, 9971, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6075
} | Medical Text: Admission Date: [**2110-5-25**] Discharge Date: [**2110-6-2**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2110-5-25**]
Exploratory laparotomy and small-bowel resection,anterior
enterostomy
History of Present Illness:
92-y.o. male p/w acute onset constant suprapubic abdominal pain
since yesterday morning, without radiation, no
ameliorating/exacerbating factors. Denies fever, nausea,
vomiting, diarrhea, and constipation, though reports dry
retching
and anorexia. Similar episodes of pain have occurred in the
past, and the patient was prescribed medication (which he cannot
recall) and the pain resolved.
Past Medical History:
CHF- EF 30% by report, s/p biventricular ICD in [**2102**]
Hypertension
Hyperlipidemia
Paroxysmal atrial fibrillation, not on coumadin due to risk for
fall and history of hematuria
CAD, s/p MI in [**2084**], s/p stents to RCA and LAD with the last one
placed in ostial RCA in [**10/2106**]
Prostate cancer, s/p XRT, now with radiation cystitis
Gait instability
Presyncope
Ulcerative colitis, stable
GERD
Restless leg syndrome
Pernicious anemia
Social History:
He is married and is primary caretaker for his wife who has
Alzheimer??????s. His son [**Name (NI) **] is involved in his care. The
patient does not drink or smoke.
Family History:
N/C
Physical Exam:
T: 98.2 P: 80 BP: 144/71 RR: 18 O2sat: 99% on RA
General: awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
Heart: RRR
Lungs: CTAB, normal excursion, no respiratory distress
Back: no vertebral tenderness, no CVAT
Abdomen: soft, moderate diffuse tenderness, severe focal
tenderness at suprapubis, non-distended, no guarding/rebound, no
mass, no hernia, no scars
Pelvis: normal rectal tone, enlarged prostate, no occult blood
Neuro: strength intact/symmetric, sensation intact/symmetric
Extremities: WWP, no CCE, no tenderness, 2+ B radial/DP
Pertinent Results:
CT A/P [**5-25**] -
1. Marked wall edema of long segment of jejunum consistent with
areas of
mucosal hyperemia and some smaller areas suggesting relative
lack of mucosal enhancement, highly concerning for ischemia.
Infectious or inflammatory etiologies are in the differential,
but felt less likely. Surrounding perijejunal fat stranding.
Complex small amount of perihepatic and pelvic free fluid.
2. Right pleural effusion with mild enhancement of the adjacent
parietal
pleura may represent a chronic process; however, infection
cannot be excluded. Adjacent chronic atelectasis versus
infection (aspiration or pneumonia) should be considered.
3. Ectatic abdominal aorta.
[**2110-5-30**] KUB :
Diffusely dilated loops of large and small bowel likely
representing postoperative ileus. No evidence of any
intra-abdominal free
air.
[**2110-5-25**] 04:00PM WBC-16.4*# RBC-4.55* HGB-12.5* HCT-37.2*
MCV-82 MCH-27.5 MCHC-33.6 RDW-16.3*
[**2110-5-25**] 04:00PM NEUTS-80.5* LYMPHS-14.2* MONOS-4.0 EOS-0.7
BASOS-0.6
[**2110-5-25**] 04:00PM PLT COUNT-335
[**2110-5-25**] 04:00PM PT-139.2* PTT-59.4* INR(PT)-17.6*
[**2110-5-25**] 04:00PM ALT(SGPT)-10 AST(SGOT)-55* ALK PHOS-53 TOT
BILI-0.5
[**2110-5-25**] 04:00PM LIPASE-181*
[**2110-5-25**] 04:05PM GLUCOSE-155* LACTATE-2.1* NA+-136 K+-5.4*
CL--101 TCO2-26
[**2110-5-25**] 04:00PM UREA N-26* CREAT-1.7*
[**2110-5-25**] 09:09PM PT-26.8* PTT-35.4* INR(PT)-2.6*
Brief Hospital Course:
Mr. [**Known lastname 24770**] was evaluated by the Acute Care service in the
Emergency Room and his Abdominal CT was reviewed showing areas
if ischemic bowel along the jejunum. Based on his physical exam,
CT scan and elevated WBC of 16K, exploratory laparotomy was
recommended. He was transfused with 4 units of FFP as his INR
was 17.6 on admission and broad spectrum antibiotics were also
initiated. After his INR decreased he was taken to the
Operating Room on [**2110-5-25**] and underwent an exploratory
laparotomy, small bowel resection and anterior enterostomy for
infarcted small bowel. He tolerated the procedure well and
returned to the SICU in stable condition. He maintained stable
hemodynamics and his pain was well controlled.
Following transfer to the Surgical floor his diet was advanced
on post op day #2 after his bowel function returned but
unfortunately he developed an ileus and returned to NPO. His
BUN and creatinine peaked at 56 and 2.3 after receiving Lasix
and he required increased IV fluids for 24 hours. He gradually
trended down to 27 and 1.4 and maintained adequate hemodynamics.
As his bowel function returned, he was restarted on a liquid
diet and gradually advanced to regular. His abdomen was soft
and his incision was healing well. He was seen by the Physical
Therapy service who recommended a short term rehab prior to
returning to his [**Hospital3 **].
Of note, his daily lasix was not resumed and his Coumadin for
atrial fibrillation may resume on [**2110-6-2**].
Medications on Admission:
metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day). aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
lasix 40 meq daily
potassium 20 meq daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP < 100, HR < 60.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. oxycodone 5 mg/5 mL Solution Sig: 0.5 to 1 tab PO Q6H (every
6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11790**] Health Center
Discharge Diagnosis:
Infarcted small bowel
Systolic heart failure
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital with abdominal pain due to
poor blood supply to your small bowel.
* On [**2110-5-25**] you underwent surgery to remove the diseased
portion of the small bowel.
* You are improving every day and should continue to do so.
* Continue to eat a regular diet and restrict your salt intake.
Stay well hydrated.
* Due to the difficulty of going through such a big operation
along with your other medical problems, you will need to spend
some time in rehab prior to going home so that you can regain
your strength and increase your calories so that you can return
home safely.
* Your abdominal staples will be removed in rehab.
* If you develop any increased incisional pain, abdominal pain
or any other symptoms that concern you please call your doctor
or return to the Emergency Room.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**3-13**] weeks.
Call Dr. [**Last Name (STitle) 24717**] for a follow up appointment after your discharge
from rehab.
Completed by:[**2110-6-2**]
ICD9 Codes: 4254, 5849, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6076
} | Medical Text: Admission Date: [**2162-1-25**] Discharge Date: [**2162-2-2**]
Date of Birth: [**2087-1-28**] Sex: M
Service:
ADMISSION DIAGNOSIS: Dyspnea on exertion.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Myocardial infarction.
3. Status post coronary artery bypass graft x2.
HISTORY OF PRESENT ILLNESS: Patient is a 74-year-old male
who is referred by his cardiologist/primary care doctor, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for complaints of exertional dyspnea and
syncope. The patient had been experiencing shortness of
breath and lightheadedness with three presyncopal episodes
since [**Month (only) **]. These occurred with exertion such as daily
chores like carrying trash to the curb.
The patient had a Persantine Myoview test performed on
[**2161-10-23**] which revealed a small mild inferobasilar infarct
with small anterior adjacent ischemia. The ejection fraction
was 57%. Patient denies claudication, orthopnea, PND, or
edema. Patient now presents for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Twenty pack year smoker, quit approximately 30 years ago.
4. Type 2 diabetes mellitus.
5. Family history of coronary artery disease.
6. Hypothyroidism secondary to thyroidectomy for thyroid
cancer.
7. Chronic atrial fibrillation.
MEDICATIONS:
1. Glucophage 1,000 mg [**Hospital1 **].
2. Glyburide 2.5 mg q day.
3. Lipitor 20 mg q day.
4. Atenolol 100 mg q day.
5. Imdur 90 mg q day.
6. Diltiazem 120 mg q day.
7. Coumadin 5 mg q day, last dose [**2162-1-22**].
8. Cozaar 100 mg q day.
9. Protonix 40 mg q day.
10. Levoxyl 0.125 mg q day.
11. Nitroglycerin patch 0.2 mg/hour.
12. Potassium chloride 10 mEq q day.
13. Lasix 20 mg q day.
PHYSICAL EXAMINATION: The patient is a pleasant-elderly man
in no acute distress. HEENT is atraumatic, normocephalic.
Extraocular movements are intact. Pupils are equal, round,
and reactive to light. Anicteric. Throat is clear. Neck is
supple, midline without masses or lymphadenopathy. Chest was
clear to auscultation bilaterally. Cardiovascular is
regular, rate, and rhythm without murmurs, rubs, or gallops.
Abdomen is soft, nontender, nondistended, obese without
masses or organomegaly. Extremities are warm, noncyanotic,
nonedematous x4. Neurologic is grossly intact. Height is 5
foot 6 inches, weight 194 pounds.
LABORATORIES ON ADMISSION: Complete blood count:
8.3/11.0/32.8/188. Chemistry: 141/4.7/108/27/30/1.4. INR
is 1.24.
HOSPITAL COURSE: The patient presented for cardiac
catheterization secondary to his positive Persantine stress
test. Cardiac catheterization revealed mild-to-moderate
mitral regurgitation with an ejection fraction of 50%. He
had a right dominant coronary artery system with severe
three-vessel disease. Recommendation was made for
revascularization and the Cardiothoracic Surgery service was
consulted.
Patient was added on as an urgent coronary artery bypass
graft. This was performed on [**2162-1-26**] x2 with LIMA to the
left anterior descending artery, saphenous vein graft to the
OM. On the postoperative period, the patient was in the
Intensive Care Unit for closer monitoring. He was extubated
overnight on postoperative day #0.
Patient had unremarkable postoperative course and was
transferred to the floor on postoperative day #2. Subsequent
to this, the patient was cleared by Physical Therapy for home
discharge on postoperative day #3. The patient was
maintained on therapeutic anticoagulation using a Heparin
drip and the Coumadin was restarted.
Patient was ultimately discharged after his INR became
therapeutic, occurred on postoperative day #7. There were no
other complications, and the patient was discharged
tolerating regular diet, and in adequate pain control on po
pain medications and without any anginal symptoms or dyspnea
on exertion.
DISCHARGE CONDITION: Good, INR 2.2.
DISPOSITION: Home.
DIET: Cardiac and diabetic.
MEDICATIONS:
1. Aspirin 325 mg q day.
2. Percocet 3/325 [**12-24**] q4h prn.
3. Colace 100 mg [**Hospital1 **].
4. Glucophage 1,000 mg [**Hospital1 **].
5. Glyburide 2.5 mg q day.
6. Lipitor 20 mg q day.
7. Levoxyl 125 mcg q day.
8. Lopressor 100 mg [**Hospital1 **].
9. Lasix 20 mg q day x10 days.
10. Potassium chloride 20 mEq q day x10 days.
11. Coumadin 7.5 mg on Monday, Wednesday, Friday, 5 mg all
other days of the week.
DISCHARGE INSTRUCTIONS: The patient was to followup with his
cardiologist in [**12-24**] weeks time. He should address the need
for diuretics as well as adjustment of cardiac medications at
that time. The patient should followup with Dr. [**Last Name (STitle) 70**] in
six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2162-2-2**] 12:31
T: [**2162-2-2**] 12:44
JOB#: [**Job Number 46560**]
ICD9 Codes: 4240, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6077
} | Medical Text: Admission Date: [**2116-8-16**] Discharge Date: [**2116-8-19**]
Date of Birth: [**2098-2-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
18 yo male reportedly s/p assault to his abdomen, he was taken
to an area hospital and was then transferredto [**Hospital1 18**] because of
his Grade III splenic laceration.
Past Medical History:
Denies
Family History:
Noncontributory
Physical Exam:
Upon admission:
BP 128/palp HR 72 room air sats 100% GCS 15
Airway intact
BS equal bilaterally
Abdomen soft with guarding
FAST positive
Rectal tone normal
MAE x4
Pertinent Results:
[**2116-8-16**] 10:29PM GLUCOSE-88 LACTATE-2.3* NA+-143 K+-3.7
CL--102 TCO2-25
[**2116-8-16**] 10:29PM HGB-14.7 calcHCT-44 O2 SAT-72 CARBOXYHB-1.9
MET HGB-0.1
[**2116-8-16**] 10:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2116-8-16**] 10:15PM ASA-NEG ETHANOL-48* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2116-8-16**] 10:15PM WBC-16.9* RBC-4.31* HGB-13.4* HCT-37.7*
MCV-88 MCH-31.0 MCHC-35.4* RDW-13.0
[**2116-8-16**] 10:15PM PLT COUNT-246
[**2116-8-16**] 10:15PM PT-14.3* PTT-26.1 INR(PT)-1.2*
[**2116-8-16**] CT ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST
CT ABDOMEN WITH INTRAVENOUS CONTRAST: With the exception of the
mild
dependent atelectasis, lung bases are clear. Within the liver,
there is a
periportal edema, no focal lesion or sign of parenchymal
hemorrhage is noted.
There is a irregular linear area of low attenuation within the
spleen, with a
focus of high attenuation superiorly, which does not persist on
delayed views,
and probably reflect presence of a clot. There is perisplenic
hematoma.
There is no retroperitoneal hemorrhage. Kidneys enhance equally
and excrete
contrast normally. No filling defects are noted within the
collecting
systems. No sign of renal parenchymal injury is noted. The
adrenal glands,
pancreas, gallbladder are unremarkable. There is a high density
free
intraperitoneal fluid, mainly in the right paracolic gutter.
Non-contrast
evaluation of the small bowel is unremarkable in absence of a
oral contrast.
CT PELVIS WITH INTRAVENOUS CONTRAST: There is a moderate amount
of free high-
density fluid within the pelvis. Urinary bladder and left distal
ureters
unremarkable. The right distal ureter is not opacified with
contrast. No
contrast extravasation seen. The rectum, sigmoid colon,
prostate, seminal
vesicles are all unremarkable.
BONE WINDOWS: No concerning lytic or sclerotic lesions are
present. No
fracture is appreciated.
IMPRESSION:
1. Grade 3 splenic laceration and hematoma. No active arterial
extravasation.
2. Moderate-to-large hemoperitoneum, centered in the right
paracolic gutter,
probably tracking from the splenic injury. Overall the
appearance is unchanged
from prior outside study of [**2116-8-16**]. Normal appearance of the
bowel in absence
of oral contrast.
3. No evidence of renal parenchymal injury.
Brief Hospital Course:
He was admitted to the Trauma service. He was kept NPO, given IV
fluids; serial hematocrits and abdominal exams were followed
closely. His hematocrits remained stable. He was initially given
IV narcotics for pain control and was later changed to oral
narcotics. His diet was advanced for which he tolerated.
On HD #3 he began to complain of severe abdominal pain; a repeat
abdominal CT scan was performed and was unchanged from the
previous CT scan. His pain did subside and he was discharged
with a prescription for Dilaudid, which he had been taking
during his hospital stay.
Social work was consulted due to the nature of his trauma and
the alcohol associated with the incident.
He was provided with explicit instruction on not participating
in any contact sports of any kind because of his spleen injury;
he acknowledged an understanding of these instructions. He was
discharged to home and will follow up in trauma clinic within
1-2 weeks.
Medications on Admission:
None
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Blunt trauma to abdomen
Grade III splenic laceration
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
controlled adequately.
Discharge Instructions:
DO NOT participate in any contact sports of any kind or other
activities that may cause injury to your abdominal area for the
next 6-8 weeks.
Go to the nearest Emergecny room immediately if you become
dizzy, lightheaded, feeling faint as if you are going to pass
out as these may be signs of internal bleeding from your spleen
injury.
Return to the Emergency room if you develop fevers, chills,
shortness of breath, chest pain, abdominal pain, nausea,
vomting, diarrhea and/or any other symptoms that are concerning
to you.
Followup Instructions:
Follow up next week with Dr. [**Last Name (STitle) **], Trauma Surgery. Call
[**Telephone/Fax (1) 6429**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2116-8-27**]
ICD9 Codes: 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6078
} | Medical Text: Admission Date: [**2163-5-15**] Discharge Date: [**2163-5-27**]
Service: VASCULAR SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female with a one month history of right first toe pain. The
patient has been recently treated with antibiotics, but this
pain has not improved. She has also developed an area of
ulceration on the first toe. She denied any fevers, chills,
chest pain, shortness of breath, or nausea and vomiting. She
also denied any claudication or rest pain, and has no history
of diabetes, hypertension or coronary artery disease. She is
admitted for evaluation of right first toe pain.
PAST MEDICAL HISTORY: 1) Congestive heart failure, 2)
Osteoarthritis, 3) Rheumatoid arthritis.
PAST SURGICAL HISTORY: She is status post a right leg
fracture in [**2138**] which included rodding of the tibia.
ALLERGIES: No known drug allergies.
MEDICATIONS: 1) lasix 40 mg po qd, 2) digoxin 0.125 po qd,
3) Aleve for pain prn.
SOCIAL HISTORY: She denies tobacco use. No ETOH use. Lives
alone and has children in the area.
PHYSICAL EXAM: The patient is in no acute distress. Tongue
is midline. Neck is supple with palpable carotids and no
bruits. Chest is clear to auscultation bilaterally. Heart
is regular. Abdomen is soft, nontender, nondistended. On
pulse exam, she has palpable pulses bilaterally of her radial
artery, femoral artery, popliteal artery. On the left, she
has a palpable dorsalis pedis, and she has monophasic Doppler
signals of the posterior tibial bilaterally. Her right great
toe appears dusky at the tip with dry gangrene at the distal
phalanges. There is no erythema or purulence.
LABORATORIES ON ADMISSION: White count 8.1, hematocrit 40,
BUN 26, creatinine 1.1, INR 1.2.
Chest x-ray demonstrates cardiomegaly with no evidence of
congestive heart failure or infiltrate. EKG - atrial
fibrillation with a left bundle branch block, T waves in V1
and 2, and J-points in V3 through V5.
HOSPITAL COURSE: The patient was admitted to the vascular
surgery service. She was placed on broad-spectrum
antibiotics and was prepared for angiography of the right
lower extremity. This was done on hospital day #2 and this
demonstrated mild disease of the superficial femoral artery.
There was single vessel run-off via the anterior tibial and
this occludes at the level of the ankle. The right peroneal
occludes at the proximal calf, and the right posterior tibial
artery was occluded. There was reconstitution of a markedly
diffuse and diseased attenuated plantar branch. There was no
dorsalis pedis, and a right tibial intramedullary rod was
present during the examination.
The patient was prepared for angiography in appropriate
fashion with preangio Mucomyst and IV hydration. She
tolerated this well. On hospital day #3, the results of this
were reviewed, and the decision was made that there would be
no possibility of an extra-anatomic bypass to revascularize
the foot, and the decision was made that the patient would be
best suited to have a below-knee amputation. She underwent a
cardiology evaluation which included a Persantine MIBI which
showed an ejection fraction of 68% and normal wall motion.
On hospital day #5, the patient was taken to the operating
room where she underwent a right below-knee amputation. She
tolerated this procedure well and postoperatively was
returned to the floor.
On postoperative day #1, her fluids were Hep-Locked, and her
diet was advanced. A physical therapy consult was obtained.
On postoperative day #2, the patient was found by staff to be
in respiratory distress. She had apparently aspirated during
lunch, and due to her failing respiratory status she was
intubated on the floor and transferred to the Intensive Care
Unit. She underwent an immediate bronchoscopy in the
Intensive Care Unit which demonstrated some debris within the
larger bronchi and this was suctioned. She also had a
bronchoalveolar lavage sent for culture which has shown no
growth to date.
Over postoperative day # and #4, the patient was awake,
following commands, and her ventilator support was weaned.
Her chest x-ray showed improvement. She was extubated on
postoperative day #4 and was transferred to the VICU in
stable condition. She remained hemodynamically stable and
underwent a swallow study which demonstrated aspiration with
thin liquids. The speech and swallow therapist recommended
patient to receive ground solids and honey thickened liquids.
She was also placed on aspiration precautions with her head
of bed at 90??????, and supervised PO intakes.
Physical therapy reassessed the patient, and her below-knee
amputation stump has been healing well. She is stable and
ready for discharge with aspiration precautions, and to
receive physical therapy for her surgery.
DISCHARGE DIAGNOSES: 1) Nonhealing right first toe ulcer.
2) Status post below-knee amputation. 3) Aspiration. 4)
Emergent intubation for aspiration. 5) History of congestive
heart failure. 6) History of osteoarthritis.
DISCHARGE MEDICATIONS: 1) digoxin 0.125 mg po qd, 2)
Levofloxacin 250 mg po qd x 7 days, 3) Protonix 40 mg po qd,
4) lasix 20 mg po qd, 5) Dulcolax 10 mg PR prn, 6) insulin
sliding scale, 7) heparin 5,000 units subcu [**Hospital1 **].
DISCHARGE INSTRUCTIONS TO REHAB: 1) To receive physical
therapy. 2) The right BK stump can remain with a dry
dressing as needed. 3) The patient will remain in a knee
immobilizer at all times until follow-up. 4) The patient may
have activity as tolerated. 5) The patient will continue to
remain on aspiration precautions, supervised PO intakes, and
head of bed elevated at 90??????. 6) Her diet will consist of
ground solids and honey thickened nectars. 7) She will
follow-up with Dr. [**Last Name (STitle) 1391**] in two weeks.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2163-5-26**] 10:00
T: [**2163-5-26**] 08:59
JOB#: [**Job Number 49245**]
ICD9 Codes: 5070, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6079
} | Medical Text: Admission Date: [**2151-6-22**] Discharge Date: [**2151-6-25**]
Date of Birth: [**2083-5-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
fever, unresponsivness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 68 yo M with h/o anoxic brain injury s/p cardiac
arrest [**2149**], PAF, DM 2, and HTN who presents with fever and
intermittent unresponsivness. Per NH notes, pt became
unresponsive at 7:45 am while perfomring ADLs. Pt afebrile at
the time with BP 150/83, HR 90, O2 sat 95% on RA, FS 471. He was
given 10 units of lispro and became more responsive around 8:15
am. The pt also received 6 units of lispro at noon and had KUB
checked given complaints of abdominal pain that revealed a
distended bladder. He again had an episode of unresponsiveness
at 1:30pm after lunch. At that time, he had a temperature of
100.0, HR 62, BP 180/100, RR 20, and O2 sat 93% on RA. At this
point, he was transported to the ED for further evaluation.
.
In the ED, T 104.2 rectally, BP 194/112, HR 170, RR 24, O2 sat
91% RA. EKG revealed afib with RVR with slight ST depressions in
the lateral leads. He was given 1 L of NS with improvement in
his HR to 94. Foley placed with 1.5 L of urine drained. Port CXR
without definitive evidence of consolidations, UA negative, CT
abd/pelvis without acute inflammatory processes. Labs
significant for WBC 13.9, Na 159, Cr 1.9, trop 0.79, CK 227,
lactate 2.7. Given vancomycin 1 gm IV X 1, levoquin 500 mg IV X
1, flagyl 500 mg IV X 1, tylenol 1 gm PR, ASA 325 mg po X 1,
metoprolol 50 mg po X 1, and a total of 3L NS and 1 L D5W with
HCO3. Cardiology was consulted who felt that ACS was unlikely.
As SBPs remained elevated > 180, he was started on a nitro gtt
and admitted to the MICU for further care.
.
The pt cannot say why he was taken to the hospital and does not
recall any precipitating factors of his episodes of
unresponsiveness earlier today. He does report a new cough with
sputum. On ROS, otherwise denies fevers, chills, headache, stiff
neck, chest pain or pressure, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, constipation, dysuria, and
urinary frequency. No rashes. Per pt's daugther, pt has been
intermittently complaining of lower abdominal pain and had an
episode of emesis last Friday. He apparently was also
complaining of a headache in the ED, which the pt denies.
Past Medical History:
1. DM2
2. Hypertension
3. Hyperlipidemia
4. h/o VFIB arrest in [**12-18**] secondary to cocaine/EtOH use,
complicated by coma, anoxic brain injury, and evidence if IMI,
inferior ischemia with resultant improvement in heart function
5. Paroxysmal AFib: not on anticoagulation due to fall risk
6. Anoxic Brain Injury/Dementia
7. Pulmonary Hypertension
8. BPH with urinary retention
9. GERD
Social History:
Lives in [**Hospital3 537**] after cardiac arrest and anoxic brain
injury. Is ambulatory though with memory delay. Legal guardian
is daughter [**Name (NI) 7346**] [**Name (NI) 3924**] who is a nurse. Past h/o cocaine, EtOH
use. NO IVDA.
Family History:
noncontributory
Physical Exam:
T 98.6 BP 156/90 HR 68 RR 12 O2 sat 100% 4L NC
Gen - pleasant male in NAD
HEENT - NCAT, sclerae anicteric, PERRL, EOMI, dry MM, OP clear,
neck supple, no LAD
CV - RRR, nl s1/s2, no m/r/g appreciated
Lungs - coarse upper airway breath sounds bilaterally but
otherwise CTA b/l
Abd - Soft, NT, ND, normoactive BS, no masses or HSM appreciated
Ext - no LE edema, WWP
Skin - no rashes, no pressure ulcers noted
Neuro - AAO X 2 (to person and place "hospital" but unable to
name specific hospital, unable to state year or month, unable to
say who is running for president), moving all 4 extremities
purposefully
Pertinent Results:
IMPRESSION: No acute intra-abdominal pathology identified
Brief Hospital Course:
68 yo M with h/o cardiac arrest with anoxic brain injury, PAF,
HTN, and DM 2 who presents with fever, intermittent
unresponsiveness, and elevated cardiac enzymes.
.
# Atrial fibrillation/ elevated troponin
On arrival to MICU service, treated AF with RVR with lopressor
5mg IV x 2. Patient reverted to NSR without recurrence of AF.
Nitro gtt was quickly weaned off, and BP stabilized with BPs
130s/70s. Covered broadly with vanc/ceftaz/azithro, with no
fevers overnight. Satting 98% RA with no complaints. Much more
alert, eating well. Cardiology evaluated patient and believes
elevated cardiac enzymes likely due to demand ischemia from RVR.
.
# Aspiration pneumonia
Likely aspiration event in setting unresponsiveness. Cover with
levofloxacin for 7 days. Urine culture no growth, blood cultures
with no growth thus far. Ambulatory saturations were above 94%.
.
# Urinary retention
Failed 2 voiding trials. Likely related to medications,
currently not on any medications which would exacerbate the
problem. [**Name (NI) **] has follow up scheduled with Urology on [**2151-7-5**] with
Dr. [**Last Name (STitle) **].
# Diabetes
Placed back on metformin and glipizide. Needs adjustment as
indicated. HgBA1c was pending at the time of discharge.
.
# Altered mental status
Poor baseline given anoxic brain injury due to ventricular
fibrillatiobn arrest. This acute change was likely related to
hypertensive encephalopathy and severe hypernatremia. He was
back to baseline per HCP which is the daughter. [**Name (NI) **] has short
term memory problems but is easily re-oriented.
.
# Acute renal failure
Resolved with IVF and back to baseline.
.
# Communication
Daughter and HCP is [**Name (NI) 7346**] [**Name (NI) 3924**], [**Telephone/Fax (1) 19907**]
Medications on Admission:
Lasix 10 mg daily
Lipitor 40 mg daily
Lisinopril 2.5 mg daily
Metformin 1000 mg [**Hospital1 **]
Glipizide 5 mg daily
Avodart 0.5 mg daily
Flomax 0.4 mg qhs
Pantoprazole 40 mg daily
Trazodone 25 mg q2pm and qhs
Metoprolol 50 mg [**Hospital1 **]
Aricept 10 mg qhs
Prozac 20 mg daily
Reglan 5 mg prior to meals
Compazine prn
Lactulose qid prn
Tylenol prn
Duoneb prn
Discharge Medications:
1. GlipiZIDE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
20. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
22. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
23. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Health care associated pneumonia
Urinary retention
Diabetes mellitus type II, uncontrolled with complications
Hypertension
Acute renal failure
Discharge Condition:
stable
Discharge Instructions:
You were admitted with fever and abdominal pain. You are being
discharged to complete 7 days levofloxacin for a pneumonia. You
are leaving with a foley catheter in place given you failed 2
voding trials, you have an appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**7-5**] of
Urology to pull the foley catheter.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2151-7-5**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2151-8-25**] 8:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5070, 5849, 2760, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6080
} | Medical Text: Admission Date: [**2187-7-23**] Discharge Date: [**2187-7-26**]
Date of Birth: [**2128-7-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Aortic Dissection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 year old left handed man with h/o ascending aortic dissection
(repaired in [**2182**] at [**Hospital1 2177**]), HTN and CAD s/p CABG p/w aortic
dissection. The patient reported falling on [**7-21**], two days prior
to presentation. He thinks he tripped on a brick and did not
have difficulty getting up afterwards. That night he woke up
having found that he wet his bed without tongue or extremity
soreness. He does not usually wet his bed. Then on [**7-23**] @6am he
was trying to get out of bed for breakfast when he fell towards
the right hitting a birdcage and then eventually landed on the
floor. No LOC or head trauma. He reportedly had difficulty
getting back up and required help from his wife. [**Name (NI) **] figured
out that his difficulty picking himself up was due to weakness
in his right arm and leg. Weakness lasted approximately 30
minutes so that by the time his wife brought him to the [**Name (NI) **] at an
OSH, his symptoms were gone and head CT normal. Workup at OSH,
revealed an aortic dissection starting between the left carotid
and left sublclavian then extending to the left common iliac
artery. Patient was subsequently transferred from OSH to [**Hospital1 18**]
on esmolol for further managment of type A+B aortic dissection
and recent h/o TIA.
Past Medical History:
Aortic Aneurysm repair in [**2182**]
CABG
Hypertension
Hyperlipidemia
?TIA
Hernia repair
Social History:
Grew up in [**State 9512**]. Lives in [**Location 686**] but often stays with a
friend who lives in [**Name (NI) 8**]. He is married wife [**Telephone/Fax (1) 69605**].
He is on disability for his ht problems. Used to work loading
and unloading trucks. No tobacco, 40 oz of beer/day usually on
the weekends and +cocaine use, last used [**7-23**].
Family History:
Non-contributory
Physical Exam:
PE: 97.3 106/57 68 15 100RA
sitting up in bed, NAD, pleasant
NCAT, anicteric sclerae, mmm, OP clear
neck supple, no carotid bruits
nl S1 S2, RRR, scar from midline sternotomy incision
CTAB no wheeze
ABD soft +BS nontender
ext nonedematous
Pertinent Results:
[**2187-7-23**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2187-7-23**] 06:45PM GLUCOSE-83 UREA N-11 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-31 ANION GAP-10
[**2187-7-23**] 06:45PM cTropnT-<0.01
[**2187-7-25**] Carotid Duplex Ultrasound
Duplex and color Doppler demonstrate no appreciable plaque or
wall thickening involving either carotid system. The peak
systolic velocities bilaterally are normal as are the ICA/CCA
ratios. There is normal antegrade flow involving both vertebral
arteries.
[**2187-7-25**] MRA of Head
Unremarkable MRA of the circle of [**Location (un) 431**] given the limitations
of the exam. A preliminary report was entered into the computer
by Dr. [**First Name (STitle) **] at 5:25 p.m.
[**2187-7-24**] MRA chest
1. Type B aortic dissection, straddling the takeoff of the left
subclavian artery, but not extending into any of the great
vessels of the arch.
2. Dissection extends into the left common iliac artery.
3. Right renal artery arises from the false lumen; left renal
artery as well as the celiac axis, SMA, and [**Female First Name (un) 899**] arise from the
true lumen.
4. Circumaortic renal vein.
Brief Hospital Course:
Mr. [**Known lastname 14477**] was admitted to the [**Hospital1 18**] on [**2187-7-23**] for evaluation of
his aortic dissection. He was admitted to the cardiac surgical
intensive care unit and continued on an esmolol drip. The
vascular surgery service was consulted for assistance in his
care. A chest MRA was performed which revealed a Type B aortic
dissection, straddling the takeoff of the left subclavian
artery, but not extending into any of the great vessels of the
arch extending into the left common iliac. The right renal
artery arises from the false lumen and the left renal artery as
well as the celiac axis, SMA, and [**Female First Name (un) 899**] arise from the true lumen.
When compared to previous films, it was believed that these
findings were consistent with an old dissection. As he had some
right sided weakness, the neurology service was consulted. A
carotid duplex ultrasound was obtained which revealed normal
bilateral internal carotid arteries. A brain MRI was also
obtained which revealed an unremarkable MRA of the circle of
[**Location (un) 431**]. No evidence of stroke was found and Mr. [**Known lastname 69606**] strength
and mobility remained stable. Aspirin threapy was recommended.
On [**2187-7-25**], Mr. [**Known lastname 14477**] was transferred to the step down unit. His
blood pressure was aggressively controlled. He continued to make
steady progress and was discharged home on [**2187-7-26**]. He will
follow-up with his cardiologist and primary care physician as an
outpatient.
Medications on Admission:
Doxazosin
Nifedipine
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
3. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Type B aortic dissection
s/p Ascending Aorta replacement [**2182**]
Discharge Condition:
Good.
Discharge Instructions:
Monitor blood pressure.
Followup Instructions:
Dr. [**First Name (STitle) **] in 3 months with CT Scan. Please call for scheduling:
[**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] (Neurology) as soon as possible for additional
testing
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2187-8-3**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6081
} | Medical Text: Admission Date: [**2197-9-17**] Discharge Date: [**2197-9-29**]
Date of Birth: [**2155-11-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
CP and SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41yo m w/ hx of dilated cardiomyopathy (EF 30%), HTN, NSTEMI,
and EtOH and cocaine abuse presented to OSH on [**9-14**] complaining
of worsening CP and SOB over previous 48hrs. Pt first developed
[**8-22**] substernal non-radiation CP he desribed as pressure. He
developed SOB several hrs after onset of CP. In ED, trop was
(+)and ECG notable for no ST changes with prev r-bundle. He was
started on a hep ggt and pressure relieved with 1-inch nitro
paste. Utox (+) for benzos, cocaine.
Pt was admitted and treated for NSTEMI w/ hep drip and acute on
chronic CHF exacerbation with IV lasix 40 [**Hospital1 **]. Following
admission he beame increasingly confused and diaphoretic with a
fever to 103.3 and was started on Zosyn and switched to
ceftriaxone/azithro. BC, UC, and legionella ag sent. Legionella
urine ag (+) and BG and UC no growth at 48hrs. On [**9-16**] pt noted
to be somulent and diaphoretic and thought to be in opioid
withdrawl. Given narcan with no response. He developed N/V
thought to be [**3-16**] narcain. He was treated with IV lasix as it
was believed he was fluid overloaded. He continued to be
tachypneic and tachycardic with hr over 200bpm and was
cardioverted with 120J. It is uncertain which rhythm he was in
at this time (discharge summ says afib w/ rvr but original
signout says VT, nursing said SVT, no ECG provided. He was
intubated for airway protection and he was sedated with
propofol. A CXR showed worsening b/l infiltrates.
On transfer, pt continued to be febrile to 103, tachycardic and
became hypotensive requiring phenylephrine. Pt given 250cc NS
bolus in transit. ABG prior to transfer was 7.32/39.9/141/20.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG:n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: neg cath [**2190**]
-PACING/ICD: N/a
3. OTHER PAST MEDICAL HISTORY:
HTN
CHF
Substance abuse
Social History:
Pt lives alone in an apt that has been described as cluttered
and dirty. He has a history of cocaine and alcohol abuse, has
never smoked. See social work note. Pt is presently unemployed
and MA Health application is in progress. He has an involved
mother and sister.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
VS: T=102 BP=89/51 HR=117 RR=18 O2 sat= 100%
GENERAL: Intubated and sedated
HEENT: ET tube in place with visible blood. NCAT. Sclera
anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. Unable to assess JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachycardic with (+)s3. No murmurs, rubs. No thrills,
lifts.
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: Cold to touch, b/l ecchymosis above ankle
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Exam at Discharge:
Vitals - Tm/Tc:97.5/97.2 HR:90-100 BP:112-118/71-81 RR:20 02
sat: 96% RA
In/Out:
Last 24H: 2850/2258 with mult diarrhea
Last 8H: 122/700
Weight: 89.7 (91.3)
.
HEENT: JVD at 12 cm
CV: RRR, no M/R/G, distant HS
Resp: clear
ABD; soft, NT, pos BS
Extr: no edema and feet warm, pulses palpable
Pertinent Results:
Admission Labs:
[**2197-9-18**] 12:17AM BLOOD WBC-11.7* RBC-4.11* Hgb-12.4* Hct-36.7*
MCV-89 MCH-30.2 MCHC-33.8 RDW-14.2 Plt Ct-294
[**2197-9-18**] 12:17AM BLOOD Neuts-83* Bands-6* Lymphs-8* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2197-9-18**] 12:17AM BLOOD PT-14.2* PTT-60.4* INR(PT)-1.3*
[**2197-9-18**] 12:17AM BLOOD Glucose-123* UreaN-49* Creat-4.7* Na-135
K-4.4 Cl-97 HCO3-23 AnGap-19
[**2197-9-18**] 12:17AM BLOOD ALT-43* AST-131* LD(LDH)-580*
CK(CPK)-738* AlkPhos-50 TotBili-0.9
[**2197-9-18**] 12:17AM BLOOD CK-MB-12* MB Indx-1.6 cTropnT-0.48*
[**2197-9-18**] 12:17AM BLOOD Albumin-3.1* Calcium-8.2* Phos-3.9 Mg-2.3
[**2197-9-18**] 12:32AM BLOOD Lactate-4.0*
.
Discharged Labs:
[**2197-9-29**] 08:00AM BLOOD WBC-8.0 RBC-4.02* Hgb-11.7* Hct-35.4*
MCV-88 MCH-29.1 MCHC-33.0 RDW-14.8 Plt Ct-721*
[**2197-9-29**] 08:00AM BLOOD PT-30.8* PTT-150* INR(PT)-3.0*
[**2197-9-29**] 08:00AM BLOOD UreaN-16 Creat-0.9 Na-140 K-3.9 Cl-109*
HCO3-21* AnGap-14
[**2197-9-28**] 05:15AM BLOOD ALT-112* AST-71* AlkPhos-67 TotBili-0.4
[**2197-9-29**] 08:00AM BLOOD Mg-2.1
CXR: [**2197-9-25**]:
HISTORY: Pneumonia and dilated cardiomyopathy, to assess for
fluid overload.
FINDINGS: In comparison with a series of films from [**9-22**] and
through [**9-24**], there has been progressive decrease in the
bilateral pulmonary opacifications. The right lung is almost
clear with only some mild residual medially at the base. There
is some more diffuse opacification involving the mid and lower
zones on the left. The findings are consistent with the
clinical impression of clearing of pneumonia, though there may
well have been some associated elevation of pulmonary venous
pressure.
.
ECHO [**9-18**]:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is severely dilated with
severe global hypokinesis (LVEF = 20-25 %). The basal lateral
wall contracts best. There is visual dyssnchrony. No masses or
thrombi are seen in the left ventricle. The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild to
moderate ([**2-13**]+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Marked left ventricular cavity dilation with severe
global hypokinesis c/w diffuse process. Mild-moderate mitral
regurgitation. Pulmonary artery hypertension.
.
ECG [**9-22**]:
Sinus rhythm with borderline prolongation of the P-R interval.
Right axis
deviation. Left bundle-branch block. Compared to the previous
tracing of [**2197-9-20**] the heart rate has increased. Other findings
are similar.
Brief Hospital Course:
41yo m w/ hx of dilated cardiomyopathy (EF 30%), HTN, NSTEMI,
and EtOH and cocaine abuse presented to OSH with SOB and
CP,found to have legionella PNA and ectopy with an episode of
sustained VT and is s/p conversion. Transferred to [**Hospital1 18**] for
further EP evaluation.
.
#Septic Shock: Prior to transfer from OSH, patinet became
hypotensive and required phenylephrine on transfer. On arrival
to [**Hospital1 18**], it was believed he was most likely in septic shock
secondary to legionella PNA. Levophed and vasopressin were
started for BP support. Goal was to minimize levophed as pt was
having ectopy in the hrs following transfer. He was sedated with
Fentenyl/Versed as paramedics noted BP dropped very low with
propofol prior to transfer. An IJ central line, a-line and Swan
Ganz catheter were placed. Swan confirmed that shock most likely
secondary to sepsis with low SVR and normal CO. On [**9-18**], pt
received several fluid boluses with target CVP 8-12. BP
responded with good urine output. Vasopressin was discontinued
and pt kept on levophed.
.
#Atrial Fibrillation: Developed AF/RVR concurrent with pressor
therapy requiring cardioversion to NSR where he has remained.
Was initially started on amiodarone IV, then transitioned to
400mg PO TID on [**9-22**] but was eventually discontinued as pt
developed a confluent rash on his back thought to be secondary
to amio.
He was started on warfarin with heparin bridge that was d/c'ed
today for INR 3.0. Warfarin dose was cut in half today and
should be continued for the next 2-3 weeks depending on
cardiology input.
# Legionella PNA: On admission to OSH, CXR was unremarkable. On
[**9-16**] the patient became febrile to 103 and CXR showed bilateral
perihilar infiltrates. ID consulted and recommended treating for
CAP with ceftriaxone/Azithro. Legionella urine ag sent and was
subsequently (+). BC and UC were no growth at 48hrs. He was not
treated for legionella prior to transfer. After transfer to [**Hospital1 **],
repeat urine ag confirmed legionella and he was started on
Levofloxacin. CXR was notable for b/l perihilar infiltrates.
Patient contined to be febrile w/ Tmax of 104 and cooling
blanket was used. He was given acetaminophen q8hrs. Repeat CXRs
showed worsening b/l infiltrates with no signs of fluid overload
or pleural effusion. Blood and urine cx on admission remained
negative.
# Bacteremia: On [**9-23**], a routine blood culture from pt's L IJ
was found to be growing gram positive cocci in clusters and he
was started on vancomycin. Thought to secondary to central line
infection and IJ was discontinued. He remained normotensive
throughout treatment. Speciation and Sensitivity showed coag
negative staff sensitive to vancomycin but resistant to several
other abx. He will continue a 2 week course of vancomycin, last
day to be [**10-7**]. PICC line placed and needs to be removed after
ABX are finished.
# Acute on Chronic Systolic CHF: Patient was SOB at OSH and was
intubated prior to transfer. He remained intubated with heavy
sedation due to agitation. He passed an SBT on [**9-22**] and was
extubated. However, he became increasingly tachypneic and a ABG
showed primary respiratory alkolosis. Pt began to decompensate
and was reintubated on the morning of [**9-23**]. Tachypnea was
thought to be secondary to PNA and possible fluid overload. He
was diuresed with lasix drip. Benzos were weaned in hopes to
imoprove AMS. Pt was extubated on [**9-25**] without complication. He
saturated well and did not require supplementory 02 for the
remained of CCU admission. He was restarted on his home dose of
Lasix 60 mg daily and potassium supplementation and appears
euvolemic with weight 89.7 kg at discharge. This should be
considered his dry weight. He will need extensive teaching
regarding low Na foods and medication compliance.
#Arrhythmia: Patient was originally transferred to [**Hospital1 18**]
following an episode of tachycardia at OSH requiring
cardioversion secondary to hemodynamic instability. Folling
transfer, the pt had numerous runs of NSVT. This has continued
but inpproved with uptitration of metoprolol XL and potassium
repletion.
# NSTEMI: Patient was found to have elevated troponins (.4)prior
to transfer from OSH with no ECG changes and treated for an
NSTEMI. At [**Hospital1 **], it was believed the elevated cardiac markers
were most likely secondary to demand ischemia in setting of
spesis with underlying cardiomyopathy. Pt had reportedly had an
unremarkable cath following an NSTEMI 4 years prior. Heparin ggt
was stopped and pt remained on ASA. A repeat echo showed dilated
cardiomyopathy with an EF of 20-25% with global LV hypokinesis.
A BB and [**Last Name (un) **] were held in setting of hemodynamics and restarted
when hemodynamics improved.
.
#Dilated cardiomyopathy: Pt has a hx of dilated cardiomyopathy
most likely secondary to EtOH and cocaine abuse. Pt did have an
elevated BNP to 7,000 at OSH and was treated for acute on
chronic CHF exacerbation prior to transfer. Echo on [**9-18**] notable
for left ventricular cavity severely dilated with severe global
hypokinesis (LVEF = 20-25 %). He was positive 13L since
admission and was diuresed when bp improved with good urine
output. He was started back on home dose 60mg of lasix. He will
need social work and counseling during his rehab stay and
arrangement for addiction services after discharge.
#[**Last Name (un) **]: On transfer pt's cr had doubled to 4.7. FeUrea was <35%
indicating a pre renal vs intrarenal etiology. Meds were renally
dosed. His renal function greatly improved over the next 48hrs
with fluid boluses. Pt's renal function normal at discharge.
#Transaminitis: Thought to be secondary to either legionella vs.
shock liver. LFTs trended down throughout admission.
#Substance abuse: Pt has a history of drug and EtOH abuse. U tox
at outside hospital was notable for postive benzos, cocaine, and
marjiuana. On transfer, pt was very diaphoretic, tachycardic,
with liable bp. He displayed seizure like activity (eyes rolled
back with flailing of extremities, no ET biting) on several
occasions thought to be secondary to EtOH withdrawal. Activity
was controlled with versed boluses. He was transitioned to PO
valium as versed was weaned. Benzos were stopped on [**9-25**] and pt
had no further withdrawal symptoms.
.
#HTN: BP at goal on metoprolol and [**Last Name (un) **].
Transitions of Care:
2.Patient needs a PCP in the [**Name9 (PRE) 487**] area at discharge to
follow INR
3.Full Code
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy OSH records.
1. Aspirin 162 mg PO DAILY
2. Furosemide 60 mg PO DAILY
3. Metoprolol Tartrate 100 mg PO BID
4. Potassium Chloride 40 mEq PO DAILY
Discharge Medications:
1. Furosemide 60 mg PO DAILY
2. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K >
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
Hold SBP < 90, HR < 60
5. Warfarin 2.5 mg PO DAILY16
6. traZODONE 50 mg PO HS:PRN insomnia
7. 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.
8. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
9. FoLIC Acid 1 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. Vancomycin 1250 mg IV Q 8H
12. Outpatient Lab Work
Please check INR at 8am on [**2197-9-30**] and check vanco level before
fourth dose, goal level [**12-2**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Non Ischemic Cardiomyopathy
Acute on Chronic Systolic congestive heart failure
Legionella Pneumonia
Septic Shock
Coag neg Staph bacteremia
Acute on Chronic Kidney Injury
Atrial Fibrillation with rapid ventricular response
Alcohol Withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a pneumonia that may have been caused by mold in your
apartment and an infection in your blood. You recieved
antibiotics for these infections but will need to receive
intravenous antibiotics for the blood infection for the next 9
days. Your heart is weaker now because of your substance abuse
and it is very important that you refrain from alcohol or any
illegal drugs from now on to let your heart recover. The
infections caused an abnormal heart rhythm called atrial
fibrillation that increases your risk of stroke. Because of
this, we have started you on a blood thinner called warfarin to
prevent blood clots. You will need to have your blood levels of
warfarin monitored closely by a health care provider. [**Name10 (NameIs) **] had
too much fluid in your lungs and needed medicines to remove the
extra fluid. Weigh yourself every morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
NP if weight goes up more than 3 lbs in 1 day or 5 pounds in 3
days. It is very important that you do not eat salt and avoid
processed or prepared foods. A list of these foods was provided
to you.
Followup Instructions:
Department: Primary Care
Notes: Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: CARDIAC SERVICES
When: MONDAY [**2197-10-2**] at 10:30 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**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: 0389, 5849, 4254, 2760, 4280, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6082
} | Medical Text: Admission Date: [**2106-8-16**] Discharge Date: [**2106-8-18**]
Date of Birth: [**2054-6-14**] Sex: M
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 57100**] is a 52 y/o male who resides in prison was
transferred to [**Hospital1 18**] from [**Hospital **] Hospital via ambulance with a
known subarachnoid hemorrhage. He was reportedly found on the
ground unresponsive by prison guards earlier today and at that
point taken to [**Hospital **] Hospital. He was reportedly awake and
conversant in the ambulance but decompensated at the OSH and was
intubated. He underwent a CT of the head which revealed a
subarachnoid hemorrhage and temporal hemorrhage. He received
Dilantin 1gram IV x1 at [**Hospital **] Hospital. INR was 2.6. He was
intubated and transferred to [**Hospital1 18**] for management. He presents
intubated. Repeat head CT upon arrival showed worsening bleed.
He received Prolifine/Vit K and was started on Mannitol 25mg IV
Q6 while in the ED.
Past Medical History:
HIV positive; Hepatitis C; Mental Illness. liver disease
NOS
Social History:
currently incarcerated
Family History:
unknown
Physical Exam:
O: BP: 111/47 HR:115 R 16 O2Sats 100%
Gen: Intubated. Skin jaundice.
HEENT: NCAT. PERRL 2.5-2.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Sedated and intubated (propofol held for exam).
Pupils round and equal in size bilaterally. PERRL 2.5-2.
Positive cough/gag and corneal reflexes bilaterally. Withdraws
to pain in all four extremities; flexed in the upper extremities
bilaterally.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors.
Pertinent Results:
[**2106-8-16**] 04:14PM URINE HOURS-RANDOM
[**2106-8-16**] 03:30PM PT-24.6* PTT-39.5* INR(PT)-2.4*
[**2106-8-16**] 03:30PM FIBRINOGE-125*
[**2106-8-16**] 02:56PM TYPE-ART TEMP-36.7 PO2-259* PCO2-42 PH-7.43
TOTAL CO2-29 BASE XS-3
[**2106-8-16**] 02:56PM GLUCOSE-130* LACTATE-4.2*
[**2106-8-16**] 02:56PM O2 SAT-99
[**2106-8-16**] 02:56PM freeCa-1.05*
[**2106-8-16**] 02:30PM GLUCOSE-128* UREA N-30* CREAT-1.1 SODIUM-123*
POTASSIUM-4.9 CHLORIDE-90* TOTAL CO2-26 ANION GAP-12
[**2106-8-16**] 02:30PM ALT(SGPT)-101* AST(SGOT)-288* LD(LDH)-1137*
CK(CPK)-236 ALK PHOS-154* TOT BILI-8.6* DIR BILI-5.9* INDIR
BIL-2.7
[**2106-8-16**] 02:30PM cTropnT-0.49*
[**2106-8-16**] 02:30PM ALBUMIN-2.4* CALCIUM-7.9* PHOSPHATE-4.2
MAGNESIUM-2.6
[**2106-8-16**] 02:30PM WBC-23.5* RBC-2.53* HGB-9.0* HCT-27.4*
MCV-108* MCH-35.6* MCHC-33.0 RDW-18.8*
[**2106-8-16**] 02:30PM PLT COUNT-46*#
[**2106-8-16**] 11:54AM TYPE-ART PO2-71* PCO2-42 PH-7.40 TOTAL CO2-27
BASE XS-0
[**2106-8-16**] 10:20AM UREA N-29* CREAT-1.2
[**2106-8-16**] 10:20AM estGFR-Using this
[**2106-8-16**] 10:20AM ALT(SGPT)-122* AST(SGOT)-332* ALK PHOS-162*
TOT BILI-8.7*
[**2106-8-16**] 10:20AM LIPASE-68*
[**2106-8-16**] 10:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2106-8-16**] 10:20AM WBC-21.0* RBC-3.01* HGB-10.6* HCT-32.9*
MCV-109* MCH-35.1* MCHC-32.1 RDW-18.3*
[**2106-8-16**] 10:20AM PLT COUNT-19*
[**2106-8-16**] CT Head : There is interval increase of the bilateral
frontal hemorrhagic contusions. There is interval increase of
the subdural hemorrhage along the falx and tentorium. The size
of the temporal hematoma on the right is unchanged.
Brief Hospital Course:
Mr. [**Known lastname 57100**] is a 52 year old male who was found down and
unresponsive at
the prison. He was transferred to [**Hospital **] Hospital and scans
revealed a subarachnoid hemorhage. He was intubated and
transferred to [**Hospital1 18**]. Serial CT scans show enlarging
intracerebral hemorrhage in the presence of elevated INR and low
platelet count. The patient was admitted to the Surgical ICU
where his coagulopathy was corrected with FFP, platelets and
clotting factors.
On [**8-16**], The patient was able to eye open spontaneously,pupils
are equal and reactive, +corneals,+cough,+gag. The patient
flexes bilaterally upper extremities, the patient withdraws
bilaterally in teh lower extremities. The patient did not
follow commands.
On [**8-17**], The patient was placed on mannitol every six hours with
holding parameters for serum osmoality > 320. The patient
continued on 3% saline at 30 cc/hr. In the morning the serum
sodium was 125 and the goal was 135. renal/hepatology
consultations were placed. A NCHCT was performed which was found
to be unchanged. The lactate 11.3. Continuous dialysis was
initiated per the renal service. The corrected dilantin level
was 8.7 and the patient was given a Dilantin bolus of 500 mg IV
dilantin. An echocardiogram was performed and was consistent
with vegetation on the aortic valve and a cardiology
consultation was placed. Infectious disease was consulted for
findinh noted on teh echocardiogram. The patient continued
vanccomycin/flagyl/micafungin for broad spectrum coverage for
pneumonia and aortic vegetation. Over the evening hours the
patient's lactate began to elevate to 11 and his renal function
deteriotated. He was placed on CVVH. Given the evidence of
progressive multiorgan failure the decision was made n
conjunction with family to begin withdrawal of care.
On [**8-18**] the patient's blood pressure drifted down off pressors
and he passed.
Medications on Admission:
unknown
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Right Temporal Intracranial hemorrhage
Renal Failure
Endocarditis
Acute on Chronic Liver Failure
Hepatorenal syndrome
Discharge Condition:
expired
Discharge Instructions:
n/a
n/a
Followup Instructions:
n/a
ICD9 Codes: 0389, 486, 5849, 2875, 2762, 2761, 431, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6083
} | Medical Text: Admission Date: [**2128-4-3**] Discharge Date: [**2128-4-7**]
Date of Birth: [**2071-6-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
NGT tube placed - removed [**4-5**]
History of Present Illness:
HPI: 56 year old male with Hep C cirrhosis transferred from
[**Hospital3 3583**] with change in mental status. He was recently
admitted to [**Hospital1 18**] [**Date range (1) 46019**] with encephalopathy, which
improved with lactulose. 5 BM yesterday. No BRBPR, no melena, no
vomiting, no hemetemesis, no abdominal pain, no F/C/R. At 5 a.m.
on DAT, wife unable to arouse him from sleep and called 911. He
was transported to [**Hospital3 **], where HCT 21.7 (from 32.5
[**2128-3-29**]). NG lavage (-), gauiac (-). He received 1uPRBC, 100 g
lactulose down NGT, and levofloxacin 500 mg IV X 1 and
transferred to [**Hospital1 18**]. In [**Hospital1 18**] ED, gauiac (-), NG lavage
pink-tinged w/o clots or evidence of active bleeding.
*
Past Medical History:
PMHx
1) Cirrhosis [**2-18**] HCV: awaiting liver transplant
- [**2127-11-20**] EGD petechiae and erythema in antrup and pyloris c/w
hemorrhagic gastritis; portal gastropathy
- [**2126-8-20**] cls: wnl
- currently enrolled in clinical trial Tolvaptan for chronic
hyponatremia
2) Chronic HCV: likely [**2-18**] IVDU
- s/p INF/ribavarin [**2126**]; d/c'd [**2-18**] low plt/alb
3) Depression
4) PVD
5) h/o CHF: [**11-19**] TTE: mod LA/RA dilation, mild sym LVH, minimal
AS, trivial MR, trivial TR
6) Type II DM
7) HTN
8) s/p cervical spine fusion
9) s/p appendetomy
10) s/p laryngeal polyp removal
11) Arthritis
12) Barrett's esophagus
*
Social History:
The patient actively smokes a pipe/day x 30 yrs, no ETOH, no
IVDU for past 30 yrs, lives w/ wife, has 2 grown children (21yo
and 25yo), retired rec center worker.Wife: [**Name (NI) **] (?[**Telephone/Fax (1) 46017**]
Family History:
brother - MI age 45
father - MI age 67
no h/o liver dz or cancers
Physical Exam:
PE: Temp: 98.3 BP: 100/58 HR: 68 RR; 20 99% on RA
gen: awake, able to answer questions, AEO x 2
HEENT: +icteric scleric, NGT tube in place
CV: RRR, nl s1, s2, no m/r/g
Resp: cta-blt
Abd: slightly distended, soft, nt, nabs
Ext: no c/c, 1+ edema blt
Pertinent Results:
Abd CT: bibasilar atelectasis, small amt ascites, gynecomasty,
cirrhotic liver, spleen enlarged, splenorenal shung, SC edema.
No RP bleed.
CXR: no infiltrate effusion, pulmonary edema
*
[**2128-4-3**] 02:15PM URINE RBC-21-50* WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2128-4-3**] 02:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR
[**2128-4-3**] 02:15PM URINE COLOR-LtAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2128-4-3**] 02:15PM FIBRINOGE-96.0*
[**2128-4-3**] 02:15PM PT-15.6* PTT-45.2* INR(PT)-1.5
[**2128-4-3**] 02:15PM PLT COUNT-54*
[**2128-4-3**] 02:15PM ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+
[**2128-4-3**] 02:15PM NEUTS-78.0* BANDS-0 LYMPHS-14.1* MONOS-7.1
EOS-0.4 BASOS-0.3
[**2128-4-3**] 02:15PM WBC-6.8 RBC-3.22* HGB-11.1* HCT-32.9*
MCV-102* MCH-34.5* MCHC-33.7 RDW-19.1*
[**2128-4-3**] 02:15PM AMMONIA-170*
[**2128-4-3**] 02:15PM calTIBC-174* HAPTOGLOB-<20* FERRITIN-1167*
TRF-134*
[**2128-4-3**] 02:15PM TOT PROT-5.3* CALCIUM-8.0* PHOSPHATE-3.0
MAGNESIUM-1.9 IRON-170*
[**2128-4-3**] 02:15PM LIPASE-33
[**2128-4-3**] 02:15PM ALT(SGPT)-61* AST(SGOT)-72* LD(LDH)-312* ALK
PHOS-110 AMYLASE-31 TOT BILI-10.7*
[**2128-4-3**] 02:15PM GLUCOSE-181* UREA N-28* CREAT-1.0 SODIUM-138
POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-24 ANION GAP-11
[**2128-4-3**] 03:20PM LACTATE-3.5*
[**2128-4-3**] 05:30PM HCT-34.6*
[**2128-4-3**] 05:49PM HGB-9.2* calcHCT-28
[**2128-4-3**] 05:49PM LACTATE-2.2*
[**2128-4-3**] 05:49PM TYPE-ART PO2-97 PCO2-31* PH-7.48* TOTAL
CO2-24 BASE XS-0
[**2128-4-3**] 06:07PM URINE RBC-21-50* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2128-4-3**] 06:07PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-1 PH-6.5 LEUK-SM
[**2128-4-3**] 06:07PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2128-4-3**] 10:45PM HCT-32.4*
Brief Hospital Course:
1) Change in MS:likely hepatic encephalopathy, originally it was
thought that this may have been precipitated by UTI. Patient had
a dirty UA and was originally treated with levofloxacin, however
cultures grew out coag neg staph (likely staph epi), thus levo
was stopped after 5 days. CXR (-). Head CT (-) at OSH. Blood
cx, ucx, sputum cx showed no growth. Patient had an NGT placed
with lactulose q 2hours, with good result. Patient quickly
became more oriented and therefore NGT was pulled and patient
was allowed to eat. Patient was dc'ed on lactulose QID.
*
2) Anemia: HCT stable 32-34 while in ICU, following 1 u PRBC at
OSH, HCT 21.7 -> 34.6; it was thought that thet HCt of 21.7
likely represents lab error at OSH
While in the hospital, patient was both gauic (-) and w/ (-) NG
lavage; benign abd exam (-) abd CT. After being transferred to
floor, patient hct was 28, but no signs of bleed. It was
attributed to fluid shifts (as patient had received fluids
secondary to being dry) and closely monitored.
*
3) Cirrhosis: Patient was continued on rifaximin, propranolol,
ursodiol (initially held). He was also continued on
spironolactone, furosemide. Patient was also continued on the
experimental drug, tolvartan.
*
4) Type II DM: RISS and with glargine.
Medications on Admission:
1. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Disp:*60 Tablet(s)* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day). Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO qd. Disp:*30
Tablet(s)* Refills:*2*
5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day). Disp:*120 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0*
7. TOLVAPTAN Sig: Sixty (60) QD ().
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO four times
a day. Disp:*3600 ML(s)* Refills:*1*
9. medications continue all diabetes meds as previously
prescribed
10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO twice a
day. Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO qd.
Disp:*30 Tablet(s)* Refills:*2*
5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
7. TOLVAPTAN Sig: Sixty (60) QD ().
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO four times
a day.
Disp:*3600 ML(s)* Refills:*1*
9. medications
continue all diabetes meds as previously prescribed
10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic encephalopathy
1) Cirrhosis [**2-18**] HCV: awaiting liver transplant
- [**2127-11-20**] EGD petechiae and erythema in antrup and pyloris c/w
hemorrhagic gastritis; portal gastropathy
- [**2126-8-20**] cls: wnl
- currently enrolled in clinical trial Tolvaptan for chronic
hyponatremia
2) Chronic HCV: likely [**2-18**] IVDU
- s/p INF/ribavarin [**2126**]; d/c'd [**2-18**] low plt/alb
3) Depression
4) PVD
5) h/o CHF: [**11-19**] TTE: mod LA/RA dilation, mild sym LVH, minimal
AS, trivial MR, trivial TR
6) Type II DM
7) HTN
8) s/p cervical spine fusion
9) s/p appendetomy
10) s/p laryngeal polyp removal
11) Arthritis
12) Barrett's esophagus
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or come to ED if you develop chest pain,
shortness of breath, confusion, nausea, vomiting, fevers,
abdominal pain
Please call your doctor or come to ED if you develop chest pain,
shortness of breath, confusion, nausea, vomiting, fevers,
abdominal pain
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2128-4-22**] 11:00
Follow up with [**First Name8 (NamePattern2) 19313**] [**Last Name (NamePattern1) 11805**] for tolvapatan study in early
[**Month (only) 547**]
Your labs should be drawn an [**Hospital3 3583**] next Monday, 28th
Completed by:[**2128-4-7**]
ICD9 Codes: 5715, 4280, 5990, 2761, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6084
} | Medical Text: Admission Date: [**2119-5-1**] Discharge Date: [**2119-5-9**]
Date of Birth: [**2059-11-3**] Sex: M
Service: Cardiac Surgery
CHIEF COMPLAINT: Mitral valve disease.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
male with a prior cardiac history including ASD repair in
[**2099**], mitral valve disease, atrial fibrillation/flutter,
status post ablation. He was followed by serial
echocardiograms and a recent echocardiogram showed EF greater
than 55% with moderate to severe mitral regurgitation. He
was schedule for mitral valve replacement.
PAST MEDICAL HISTORY: Mitral valve disease, atrial
fibrillation, status post ablation.
PAST SURGICAL HISTORY: ASD repair in [**2099**].
ALLERGIES: None known.
MEDICATIONS: Aspirin 325 mg q d, Zestril 10 mg q d,
Amiodarone 200 mg q d.
HOSPITAL COURSE: The patient underwent mitral valve
replacement with a #27 mosaic valve on [**2119-5-1**]. He was
transferred to the CSRU post-operatively. He was A-paced on
arrival in the CSRU with intermittent loss of capture, with
hypotension. His underlying rhythm was junctional in the
40's. AV pacing was attempted but ventricular ectopic
activity occurred. There was loss of both A and V capture
with inappropriate sensing despite various measures. He
continued to be bradycardic with hypotension. He was started
on Dopamine, and emergent pacing Swan was placed with
appropriate pacing and sensing. He was also started on
Dopamine drip. He was extubated later on in the same day.
His hemodynamic status stabilized. He was seen by Dr.
[**Last Name (STitle) **] who is his regular electrophysiologist.
Subsequently he continued to be V paced with complete heart
block. He was continued on his Amiodarone. A tentative
decision was made for pacemaker placement because of the
complete heart block. On postoperative day #3 he had
converted to a junctional rhythm and was maintaining his
blood pressure. He was transferred to the regular floor on
postoperative day #3 in a junctional rhythm with pacing
wires. He was hemodynamically stable at this point. On
postoperative day #4 he converted to atrial fibrillation.
His Amiodarone dose was increased per EP and he was started
on a Heparin infusion. Decision was made for cardioversion
on [**2119-5-8**]. The following days he remained hemodynamically
stable while awaiting therapeutic PTT with Heparin and he
continued to be in atrial fibrillation. On [**2119-5-8**],
postoperative day #7, he underwent cardioversion
successfully. He converted to a sinus rhythm with a
prolonged PR interval. He was stable with this rhythm. He
was deemed ready for discharge by both electrophysiology and
cardiac surgery on postoperative day #8. He was discharged
home on postoperative day #8.
DISCHARGE MEDICATIONS: Lasix 20 mg q day times one week, KCL
20 mEq q d times one week, Colace 100 mg [**Hospital1 **], Aspirin,
enteric coated, 325 mg q d, Amiodarone 400 mg q d for one day
followed by 200 mg q d, duration to be decided by EP,
Percocet 1-2 tablets q 4-6 hours prn.
CONDITION ON DISCHARGE: Stable.
FO[**Last Name (STitle) **]P: His primary care physician in two weeks, Dr.
[**Last Name (STitle) **], Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2119-5-9**] 20:28
T: [**2119-5-9**] 21:19
JOB#: [**Job Number 18071**]
ICD9 Codes: 4240, 9971, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6085
} | Medical Text: Admission Date: [**2166-4-1**] Discharge Date: [**2166-4-5**]
Date of Birth: [**2103-9-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
morphine / Percocet
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**4-1**]: Mitral valve repair with a 26 mm Future CG annuloplasty
ring.
History of Present Illness:
62 year old female with no significant past medical history who
developed palpitations 2 years ago which was initially treated
with beta blockade. Over the past year, she has noted
progressive dyspnea on exertion and exercise intolerance. She
has also noted worsening palpitations which prompted a referral
to a cardiologist in [**Month (only) 216**] where her beta blocker was changed.
As she
continued to not feel well, she was seen by another cardiologist
who performed an echocardiogram which revealed moderate to
severe mitral regurgitation. Given the findings, her primary
care physician has referred her to Dr. [**Last Name (STitle) **] for surgical
evaluation.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: no
-PERCUTANEOUS CORONARY INTERVENTIONS: no
-PACING/ICD: no
3. OTHER PAST MEDICAL HISTORY:
Fibromyalgia
nephrolithiasis
hiatal hernia
hypercholesterolemia
hypothyroidism
headaches
Social History:
Race: Caucasian
Last Dental Exam: Every 6 months
Lives with: Husband in [**Name2 (NI) 17927**]
Occupation: Teacher
Tobacco: Never
ETOH: Social
Caffeine: One beverage per day
Family History:
Father with sudden death at 58. Both son's age 28-30 with palps
and one apparently need to be "shocked" at a gym
Physical Exam:
Pulse: 63 Resp: 16 O2 sat: 98%
B/P Right: 124/83 Left: 138/77
Height: 63" Weight: 175 lbs
General: NAD WDWN
Skin: Warm, Dry, intact. No lesions and rashes.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign, teeth in
good repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-Split S2, II/VI late systolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X] SPider varicosities
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right: None Left: None
Pertinent Results:
[**2166-4-1**]:
PREBYPASS: 62 year old female for mitral valve repair. Moderate
to severe mitral insufficiency is present. Depending on the
loading conditions, the degree of MR varied between moderate and
severe. Vena contracta in the ME long axis view measured >0.7cm
consistent with severe MR, and the left atrium was dilated for
this small women (4.6cm). The mechanism of MR was consistent
with Type 3b [**Last Name (un) 3843**] leaflet motion with billaterl
restriction of the leaflets, and a central MR jet. The other
valves were essentially normal. There was normal LV systolic
function with an LVEF>55% with no segmental wall motion
abnormalities. The RV was mildly dilated, but RV function was
preserved. LV diastolic function was preserved with E'>8 cm/sec.
E/E' = 10. Normal transmitral inflow velocites with E>A, and
Normal pulmonary venous flow. There was mild descending thoracic
aortic atherosclerosis, with no significant aortic dilaton and
NO dissection seen. The interatrial septum was intact. The
coronary sinus was of normal size and should be adequate for
antegrade cardioplegia.
POSTBYPASS:
S/P mitral valve repair with ring. No MR. [**First Name (Titles) **] [**Last Name (Titles) **] with mean
gradient of [**3-21**] mmHg. Normal systolic funciton on no inotropes.
LVEF>55% No dissection seen following decannulation of the
aorta. No significant valvular problems or wall motion changes
were observed following chest closure.
[**2166-4-3**] 04:55AM BLOOD WBC-11.3* RBC-2.85* Hgb-9.2* Hct-25.8*
MCV-90 MCH-32.1* MCHC-35.6* RDW-14.2 Plt Ct-143*
[**2166-4-3**] 04:55AM BLOOD Glucose-115* UreaN-15 Creat-0.8 Na-137
K-4.3 Cl-104 HCO3-25 AnGap-12
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**4-1**] where the patient underwent mitral valve
repair with a 26 mm Future CG annuloplasty ring. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. POD 1 found the patient extubated, alert
and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. Dilaudid was changed to Ultram and Ibuprofen due to
nausea. The patient was discharged home with services in good
condition with appropriate follow up instructions and
appointments.
Medications on Admission:
CLONAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet -
0.5 (One half) Tablet(s) by mouth once a day
EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg Tablet
-
1 Tablet(s) by mouth once a day
NADOLOL - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth twice a day
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth once a day
TRIAMTERENE-HYDROCHLOROTHIAZID - (Prescribed by Other Provider)
- 75 mg-50 mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day.
Disp:*60 Tablet, ER Particles/Crystals(s)* Refills:*0*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
13. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram, Tylenol, Ibuprofen
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr [**Last Name (STitle) **] on [**4-24**] at 1:30pm
Cardiologist: Dr [**Last Name (STitle) 1923**] on [**4-25**] at 11:10am.
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 1356**] in [**4-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2166-4-5**]
ICD9 Codes: 4240, 2724, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6086
} | Medical Text: Admission Date: [**2184-3-27**] Discharge Date: [**2184-3-28**]
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88yo woman with PMH CAD on plavix was found down by her
daughter at 7AM today. Initially she was arousable and
complained
of headache. She was taken to OSH by ambulance where she
reportedly decompensated in the ED requiring intubation. BP was
recorded as 184/84. Head CT revealed large posterior fossa IPH.
She was life flighted to [**Hospital1 18**] and Neurosurgery consultation was
requested.
Past Medical History:
Celiac Disease
CAD
DM
Pacemaker
Hysterectomy
MI s/p stents and plasty. most recently in [**2179**] @ [**Hospital1 2025**]
Social History:
married, lives with husband and daughter. no e/t/d
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
GCS: E-3 V-1 M-6
O: BP: 184/84 HR: 83 R 14 O2Sats 100%
Gen: Intubated and sedated (prop held for exam)
HEENT: Pupils: 3mm sluggish b/l. + corneals, + gag
Neck: hard collar
Extrem: Warm and well-perfused
Neuro:
Mental status: EO to voice
Cranial Nerves:
II: Pupils equally round and reactive to light 3mm, very
sluggish
mm bilaterally.
Motor: MAE's. B/L UE's antigravity to command
On Discharge:
No [**Last Name (LF) **], [**First Name3 (LF) 2995**] to noxious
Pertinent Results:
[**2184-3-27**] 03:00PM PLT COUNT-226
[**2184-3-27**] 03:00PM PT-13.8* PTT-18.8* INR(PT)-1.2*
[**2184-3-27**] 03:00PM NEUTS-92.9* LYMPHS-4.2* MONOS-1.9* EOS-0.6
BASOS-0.4
[**2184-3-27**] 03:00PM WBC-10.3 RBC-3.86* HGB-12.2 HCT-35.5* MCV-92
MCH-31.5 MCHC-34.3 RDW-13.6
[**2184-3-27**] 03:00PM CALCIUM-9.6 PHOSPHATE-3.1 MAGNESIUM-1.3*
[**2184-3-27**] 03:00PM CK-MB-3 cTropnT-<0.01
[**2184-3-27**] 03:00PM CK(CPK)-48
[**2184-3-27**] 03:00PM estGFR-Using this
[**2184-3-27**] 03:00PM GLUCOSE-186* UREA N-20 CREAT-1.0 SODIUM-136
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18
[**2184-3-27**] 03:08PM GLUCOSE-181* LACTATE-3.1* K+-4.7
[**2184-3-27**] 03:45PM TYPE-ART PO2-252* PCO2-38 PH-7.38 TOTAL
CO2-23 BASE XS--1 INTUBATED-INTUBATED
[**2184-3-27**] 05:40PM URINE MUCOUS-RARE
[**2184-3-27**] 05:40PM URINE RBC-1 WBC-125* BACTERIA-FEW YEAST-NONE
EPI-<1 RENAL EPI-<1
[**2184-3-27**] 05:40PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2184-3-27**] 05:40PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.026
CHEST (PORTABLE AP) Study Date of [**2184-3-27**] 2:50 PM FINDINGS:
Endotracheal tube ends 3.0 cm above the carina. An NG tube
passes beyond the GE junction into the antrum of the stomach.
There are low lung volumes but no evidence of pleural effusion
or pneumothorax. Mild left retrocardiac opacity likely
represents atelectasis.
IMPRESSION:
1. ET tube ends 3 cm above the carina.
2. Left basilar opacity, likely atelectasis, but aspiration is
not excluded.
CTA HEAD W&W/O C & RECONS Study Date of [**2184-3-27**] 3:38 PM
Preliminary Report !! WET READ !!
No evidence of aneuryms. However, reformats which are necessary
for
interpretation are still pending.
CT HEAD W/O CONTRAST Study Date of [**2184-3-27**] 11:12 PM
Findings compatible with rapidly-evolving obstructive
hydrocephalus due to extensive intraventricular hemorrhage,
predominately in the fourth ventricle, with extension into
prepontine cisterns and occipital horns. Focal hemorrhage may
also be present in the left cerebellum. Left parietal and left
supratentorial subdural hemorrhage are not well seen on
preceding outside exam.
Brief Hospital Course:
Pt was admitted to the neurosurgery service for close
observation. Upon admission a discussion was held with the
daughter (official HCP). She wished to make her mother DNR. She
was told the risk of developing hydrocephalus and need for EVD
placement. She said she would think about this but was not sure
if she would want to proceed with it.
Overnight on [**3-27**] - [**3-28**] the patient became less responsive. A
head CT was obtained which revealed developing hydrocephalus.
The daughter was [**Name (NI) 653**] and said that she did not want to
proceed with the EVD. The patient was made CMO at that time and
extubated at approximately 6AM.
The daughter [**Name (NI) 653**] the ICU later in the morning and
requested that the patient be transferred to [**Hospital3 15402**] so that
she would be closer to home. The bed facilitator was [**Hospital3 653**]
and once transport was arranged she was discharged.
Medications on Admission:
Medications prior to admission:
Nitroglycerine
Plavix
glucophage
metoprolol
gemfibrozil
alprazolam
isosorbide mononitrate
flagyl
Discharge Medications:
1. morphine (PF) in D5W 100 mg/100 mL (1 mg/mL) Parenteral
Solution Sig: 5-20 mg Intravenous TITRATE TO (titrate to desired
clinical effect (please specify)).
2. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
3. midazolam in 0.9 % NaCl 1 mg/mL Solution Sig: 5-20 mg
Intravenous TITRATE TO (titrate to desired clinical effect
(please specify)).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
cerebellar hemorhage, hydrocephelus
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - always.
Discharge Instructions:
Pt is DNR/DNI and CMO. Transfer to [**Hospital3 15402**] per family's
request.
Followup Instructions:
N/A
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2184-3-28**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6087
} | Medical Text: Admission Date: [**2168-6-23**] Discharge Date: [**2168-6-24**]
Date of Birth: [**2131-1-26**] Sex: F
Service: MICU
DISCHARGE DIAGNOSES:
1. Hypercapnia.
2. Breast biopsies.
3. Status post pneumonectomy.
CHIEF COMPLAINT: PCO2 equal to 89 on an arterial blood gas
in the operating room.
HISTORY OF PRESENT ILLNESS: This is a 37-year-old female
admitted for outpatient breast biopsy on the 24th when an
arterial blood gas checked at the end of her procedure showed
a pCO2 of 89. The total arterial blood gas was 7.18, pCO2
89, pO2 173. Patient was monitored under LMA. Conscious
sedation, breathing at her own rate.
PAST MEDICAL HISTORY:
1. Tuberculosis at the age of 16, she was treated with 4-5
drugs in [**Country 651**] for 6-9 months.
2. Status post a left pneumonectomy in [**2160**] for a chronically
scarred and infected left lung.
3. Pulmonary hypertension, baseline lung values after her
pneumonectomy included baseline arterial blood gas of 7.39,
57, 62, and spirometry of a FEV1 of 0.88 liters which is 32%
of predicted and a FVC 0.91 which is 26% of predicted. The
patient has a baseline bicarb on her Chem-7 approximately
30-35.
Based on the elevated pCO2, patient was admitted for close
observation to the Intensive Care Unit.
MEDICATIONS: Albuterol as needed.
ALLERGIES: Tetracycline causes a rash.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No tobacco or alcohol, immigrated from [**Country 651**]
in [**2155**]. She is a homemaker. She lives with her husband,
who is a chef and her son.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96.6, heart rate 92, blood pressure 103/65, respiratory rate
16, oxygen saturation 98-100% on room air. Physical
examination was remarkable for a thin Asian woman in no acute
distress. Cardiac examination: A 1/6 systolic ejection
murmur at the left upper sternal border with a
physiologically split S2. Lungs were clear on the right and
absent breath sounds on the left. Remainder of examination
was normal.
RELEVANT LABORATORY DATA: Preoperative complete blood count
was normal. Arterial blood gas at 3:30 pm: 7.18/89/173. At
04:02 pm, arterial blood gas: 7.24/78/199. Arterial blood
gas was done while the patient was breathing spontaneously.
Partial chemistries were all within normal limits.
Portable chest x-ray was unchanged from prior.
ASSESSMENT ON ADMIT: Patient is status post a pneumonectomy
with baseline CO2 retention with a pCO2 approximately 50-55
admitted to the Intensive Care Unit with an elevated pCO2 for
close observation of her mental status and respiratory
distress.
HOSPITAL COURSE: Patient was monitored closely overnight in
the Intensive Care Unit with continuous pulse oximetry and
close monitoring by the nursing staff. The patient did well
without any complaints. She had no respiratory complaints or
desaturations or other problems. [**Name (NI) **] further laboratories
were checked overnight.
In the morning, the patient had no complaints. Was feeling
well and looked to be in her usual state of health. The
baseline arterial blood gas was performed to establish a
baseline for further future reference. This arterial blood
gas came back as pH 7.42, pCO2 54, pO2 69, that was done on
room air.
Patient was discharged in good condition on the 25th. She is
to followup with her primary care physician [**Last Name (NamePattern4) **] [**1-5**] weeks, and
her pulmonologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8325**] also in [**1-5**] weeks.
Prescriptions for Tylenol #3 for pain as needed, and will
continue on her albuterol.
DISCHARGE DIAGNOSES:
1. Bilateral breast biopsies.
2. Status post pneumonectomy in [**2160**].
3. Carbon dioxide retention.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-319
Dictated By:[**Last Name (NamePattern1) 8228**]
MEDQUIST36
D: [**2168-6-24**] 10:58
T: [**2168-7-5**] 14:44
JOB#: [**Job Number 8326**]
ICD9 Codes: 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6088
} | Medical Text: Admission Date: [**2153-5-23**] Discharge Date: [**2153-5-26**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Chest pain, shortness of [**First Name3 (LF) 1440**], abdominal pain, nausea,
vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 60yo female with PMH significant for Mast Cell
Degranulation Syndrome with history of multiple flares who
presents with SOB, chest pain, abdominal pain, and flushing. Per
patient, these symptoms are consistent with her typical flare.
She has an allergist at [**Hospital1 112**]. She was recently discharged from
[**Hospital1 18**] on [**5-17**] after presenting with similar symptoms. She came
to the hospital because she was extremely nauseous and was not
able to take her oral medications. She did inject herself with
an EpiPen prior to coming to the emergency room. She has
symptoms almost every day but got worse yesterday evening. No
recent viral illness.
In the ED initial vitals were T 99 BP 191/120 AR 122 RR 30 O2
sat 100% RA. She immediately received Benedryl 50mg, Albuterol
neb, Dilaudid 2mg IV, Solumedrol 80mg IV, and Zofran 4mg IV. She
received an additional Solumedrol 80mg IV and Dilaudid 6mg IV.
She is being transferred to the MICU for further management.
Past Medical History:
1)Mast cell degranulation syndrome (MCDS)
*** EMERGENCY PLAN *** (as posted in chart)
administer:
1. Epinephrine 0.3cc of 1/1000 SC and repeat x3 at 5 min
intervals if BP <90 systolic in setting of flare
2. Benadryl 25-50 IV q4 hr for 24-48 hrs
3. Solu-medrol 80mg IV/IM
4. Oxygen by mask or cannula
5. Albuterol nebs q2-4 hr prn
6. Dilaudid 2mg IV q 3hrs or PCA pump
7. Zofran 8mg IV q 12h for 24-48 hrs
PRE-MEDICATION for major/minor procedures:
1. Prednisone 50mg po q24 hrs and 1-2 hours prior to surgery
2. Benadryl 25-50mg 1 hour prior to surgery
3. Ranitidine 150mg 1 hour prior to surgery
2)Depression/anxiety
3)Bipolar disorder
4)MI in [**2147**] after receiving cardiac arrest dose epi instead of
anaphylactic dose epi
5)HTN
6)Erosive osteoarthritis
7)GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
8)Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
9)laryngoscopy
9)Anemia, iron studies c/w AOCD
10)Hemorrhoids
11)EGD with vegetable bezoar (?[**12-7**])
12)Status post hysterectomy and oophorectomy
13)h/o MRSA infection (porthacath associated)
14)portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection; portacath
replaced [**2151-6-9**]
Social History:
Born and raised in [**State 4260**]. Father is still living. Has 3 sibs. Pt
divorced approx 2 [**State 1686**] ago after 37 [**State 1686**] of marriage. Husband was
doctor. Pt had worked at magazine and as preschool teacher.
Currently works as ED tech at [**Hospital 2436**] Hosp. Denies legal
problems, denies h/o abuse. Son is HCP [**Telephone/Fax (1) 21738**].
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
vitals T 98 BP AR 106 RR 16 O2 sat 97% RA
Gen: Patient appears tired, currently in no acute distress
HEENT: Dry mucous membranes
Heart: RRR, no m,r,g
Lungs: Poor air movement posteriorly, scattered wheezes
Abdomen: Soft, NT/ND, +BS
Extremities: Mild 1+ bilateral LE edema, swelling of PIP/DIP
joints consistent with underlying osteoarthritis, multiple areas
of ecchymosis on upper extremities
Pertinent Results:
[**2153-5-23**] 03:45AM WBC-6.4 RBC-3.74* HGB-10.2* HCT-32.8* MCV-88
MCH-27.3 MCHC-31.2 RDW-16.0*
[**2153-5-23**] 03:45AM NEUTS-95.0* LYMPHS-3.6* MONOS-1.2* EOS-0.2
BASOS-0.1
[**2153-5-23**] 03:45AM PLT COUNT-255
[**2153-5-23**] 03:45AM CK-MB-NotDone cTropnT-<0.01
[**2153-5-23**] 03:45AM cTropnT-<0.01
[**2153-5-23**] 03:45AM ALT(SGPT)-22 AST(SGOT)-16 CK(CPK)-63 ALK
PHOS-96 TOT BILI-0.2
[**2153-5-23**] 03:45AM LIPASE-32
[**2153-5-23**] 03:45AM GLUCOSE-237* UREA N-15 CREAT-0.9 SODIUM-142
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
[**2153-5-23**] 03:45AM BLOOD cTropnT-<0.01
.
CXR [**2153-5-23**] - Right-sided port again seen with tip overlying the
cavoatrial junction. Cardiac and mediastinal contours are
unchanged. Pulmonary vascularity is within normal limits. There
are no focal consolidations or large pleural effusions. Linear
opacities at the bases bilaterally suggests atelectasis.
IMPRESSION: No evidence of focal consolidation.
Brief Hospital Course:
Ms. [**Known lastname **] is a 59 y.o. F with h/o Mast Cell Degranulation
Syndrome presented with typical MCDS symptoms including SOB,
chest, abdominal pain, diarrhea, admitted to MICU for close
monitoring.
1)Mast Cell Degranulation Syndrome: The patient presented with
nausea/ vomiting, flushing, chest pain, SOB, and diarrhea; these
symptoms are consistent with her usual flares. Per protocol she
received Zofran, dilaudid, Solu-medrol, Albuterol nebs, O2 by
NC, and benadryl. She was continued on these medications on
transfer to the ICU. She did not received any additional
steroids. The MICU team spoke with Dr. [**Last Name (STitle) **], the allergist here
at [**Hospital1 18**] who has seen the patient on prior admissions. He felt
that her current medication regimen was reasonable, and he also
felt that she there is a major anxiety component. She will need
follow-up with her allergist at [**Hospital6 **] who
is an expert in this field. The patient continued to have
recurrent complaints of dyspnea and headache, responsive to
benadryl and dilaudid IV. She also had episoded in which she
appeared markedly anxious, with no evidence of flushing,
developing tachypnea followed by dyspnea which were resolved
with ativan 1mg IV, consistent with panic attack. Prior to
discharge, she had another episode of dyspnea and tachypnea, and
requested treatment with epinephrine via epipen, IV benadryl, IV
dilaudid, IV solumedrol, and albuterol per protocol with
resolution of symptoms. She wanted to proceed with her discharge
home after this episode which occurred while she was waiting for
her discharge paperwork to be competed.
2)Hypertension: Continued on Diltiazem.
3)Anxiety/Depression: Patient has symptoms suggestive of anxiety
and/or panic attacks. She has been evaluated by psychiatry in
the past and was thought to have bipolar disorder. She was
continued on Duloxetine. She was also started on Valium as well.
4)Postmenopausal symptoms: Continued outpatient regimen of
Premarin.
5)Osteoarthritis: Patient is followed closely by Dr. [**Name (NI) 9620**]
here in rheumatology. She was continued on Plaquenil.
Medications on Admission:
Diltiazem HCl 180mg PO daily
Premarin 0.3mg PO daily
Hydroxyzine 25mg PO QID
Ranitidine 150mg PO QHS
Duloxetine 30mg PO daily
Hydroxychloroquine 200mg PO BID
Amphetamine-Dextroamphetamine 15mg PO daily
Fexofenadine 180mg PO BID
Omeprazole 20mg PO BID
Zolpidem 10mg PO QHS
Zofran 8mg PO TID
Asmanex Twisthaler twice a day.
Dilaudid 4mg PO every 4-6 hours as needed for pain.
Fioricet 50-325-40mg PO Q6H PRN
Ativan 0.5mg PO Q4-6 hours PRN
Benadryl 25mg PO Q4-6H PRN
Albuterol MDI
Ferrous Sulfate 325mg PO BID
Zyflo 600mg PO QID
Discharge Medications:
1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO four
times a day.
6. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO at
bedtime.
7. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day.
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q4H (every 4 hours) as needed for flare.
14. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every four (4) hours as needed for shortness of [**Name (NI) 1440**] or
wheezing.
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Amphetamine-Dextroamphetamine 15mg PO daily
Zyflo 600mg PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Mast Cell Degranulation Syndrome
.
Secondary:
- Hypertension
- GERD
- Anemia
- Bipolar disorder
- Depression
Discharge Condition:
Clinically improved, afebrile, VSS
Discharge Instructions:
You were admitted with shortness of [**Name (NI) 1440**] and chest pain
concerning for a flare of your mast cell degranulation syndrome.
Your medications have not changed. Please continue to take your
medication as directed.
.
Please maintain your scheduled follow up listed below.
.
Please seek medical attention if you experience any fevers >
101, chills, increasing chest pain or shortness of [**Name (NI) 1440**],
abdominal pain, flushing, or any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in the Allergy Department of
[**Hospital6 1708**] on [**2153-7-19**] at 10:30am in the
[**Location (un) 55**] Office. Please call [**Telephone/Fax (1) 21743**] with any
questions.
.
Please maintain your scheduled follow up listed below:
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2153-6-4**] 1:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2153-8-22**] 1:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6089
} | Medical Text: Admission Date: [**2124-2-29**] Discharge Date: [**2124-3-29**]
Date of Birth: [**2055-8-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
s/p central line placement x 2 (HD catheter)
History of Present Illness:
Mr. [**Known lastname 2795**] is a 68 yo with met renal cell carc admitted on
[**2124-2-29**] for week 2 of high dose IL-2 therapy. His last dose was
complicated by shock requiring dopamine and brief atrial
fibrillation, spontaneously reverting back when dopamine was
changed to neo. His current course was given from [**2-29**] to [**3-4**]
and has been complicated by nausea/vomiting, encephalopathy,
diarrhea, rigors, and desquamation, but also by hypotension in
the 70s systolic requiring neo for 90 min on [**3-2**] and restarted
again on [**3-5**], ARF with decreasing UOP (355 total cc's on [**3-5**],
none on [**3-4**], + ~ 14L LOC but without detailed recording of his
UOP), and progressive metabolic acidosis despite bicarb
infusion. Vancomycin was started empirically in the setting of
severe dermatitis, and he has been on prophylactic cipro
throughout his stay. His last dose 9am on [**3-4**]. His Cr has
risen progressively from 1.9 on admission to 6.6 on the evening
of transfer. Because of his progressive renal failure, dopamine
was added to improve renal perfusion. He was also transiently
in afib. His Tmax during his stay has been 99.5 on [**3-1**] with no
other elevated temps, though he has been intermittently around
95F.
.
REVIEW OF SYSTEMS:
(+)ve: as per HPI
(-)ve: chest pain, palpitations, rhinorrhea, nasal congestion,
cough, sputum production, hemoptysis, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, constipation, hematochezia,
melena, dysuria, urinary frequency, urinary urgency, focal
numbness, focal weakness
Past Medical History:
metastatic renal cell carcinoma, s/p nephrectomy. metastatic to
lung, adrenal gland, brain. s/p cyberknife [**12-19**].
Bleeding ulcers
HTN
Hyperlipidemia
GERD
Diverticulosis
Migraines
Barrett's esophagus
Anemia with folate deficiency
Appendectomy in [**2076**]
Hemorrhoidectomy [**2094**]
Back surgery in [**2113**]
Vasectomy
Social History:
He is a chief of police in [**Location (un) 82875**] Police.
He is married and he is seen with his wife today. [**Name2 (NI) **] has two
adult children. He does not smoke. He has about five to eight
glasses of bourbon weekly.
Family History:
No history of any kidney cancer, but his mother
had ovarian cancer, no obvious signs of Burkitt lymphoma, who is
now healthy.
Physical Exam:
97.8 119 105/44 16 100%2L
.
PHYSICAL EXAM
GENERAL: dry and desquamated
HEENT: Normocephalic, atraumatic. conjunctival erythema. No
scleral icterus. PERRLA/EOMI but tracks slowly and incompletely.
mucous membranes dry. OP clear. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. 2/6 SEM in
RUSB, rubs or [**Last Name (un) 549**]. JVP=flat
LUNGS: CTAB, good air movement biaterally anteriorly.
ABDOMEN: hypoABS. Soft, NT, ND. No HSM
EXTREMITIES: diffuse [**3-15**]+edema, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: diffuse erythema and desquamation. skin breakdown on
grown and buttocks.
NEURO: A&Ox3 though with difficulty with word finding.
Appropriate. CN 2-12 intact. Preserved sensation throughout. [**6-14**]
strength throughout. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately
.
Pertinent Results:
[**2124-2-29**] 09:49AM PT-13.9* PTT-21.6* INR(PT)-1.2*
[**2124-2-29**] 09:49AM PLT COUNT-386#
[**2124-2-29**] 09:49AM WBC-8.0 RBC-3.21* HGB-9.5* HCT-29.3* MCV-91
MCH-29.6 MCHC-32.4 RDW-13.9
[**2124-2-29**] 09:49AM ALBUMIN-3.4* CALCIUM-8.1* PHOSPHATE-3.2
MAGNESIUM-2.0
[**2124-2-29**] 09:49AM ALT(SGPT)-19 AST(SGOT)-21 LD(LDH)-169
CK(CPK)-55 TOT BILI-0.6
[**2124-2-29**] 09:49AM estGFR-Using this
[**2124-2-29**] 09:49AM GLUCOSE-121* UREA N-17 CREAT-1.6*# SODIUM-144
POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-25 ANION GAP-11
[**2124-3-24**] hand x-ray
No previous images. The distal [**Hospital1 **] and adjacent soft tissues
are
essentially within normal limits on the images presented. No
evidence of
erosions or dystrophic calcification.
[**2124-3-23**] CT abd/pelvis
1. Small bowel dilation without a clear transition point to
suggest
mechanical obstruction. A 7 cm segment of small bowel wall
thickening may
represent ischemia, infection, or inflammation. A repeated CT
with i.v.
contrast may help evaluate the transit of oral contrast as well
as the
mesenteric vasculature
2. Nasogastric tube just passed the gastroesophageal junction.
Consider
reposition of nasogastric tube in the body of the stomach.
3. Metastatic disease, incompletely evaluated on this
non-contrast study.
4. Bibasilar consolidative opacity concerning for pneumonia
5. Florid colonic diverticulosis without evidence of
diverticulitis.
6. Decrease in size of right adrenal nodule suggestive of
response to
therapy.
7. Extensive therosclerotis including coronary artery, abdominal
aorta and
mesenteric vessels.
[**2124-3-23**]
MRI head
1. Near-complete interval resolution of the enhancing lesion
within the left anterior temporal lobe. Only minimal residual
enhancement and FLAIR signal hyperintensity persist. No new
enhancing lesions are identified.
TTE [**2124-3-6**]: The left atrium is elongated. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
TTE [**2124-3-8**]: IMPRESSION: small pericardial effusion located
mostly posterior to the left ventricle. There is minimal fluid
anterior to the right ventricle. There is significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, which can be consistent with impaired ventricular
filling but is more likely due to the irregularity of the heart
rate. There is no frank tamponade seen. Normal biventricular
function. No evidence of endocarditis although the valves are
not well seen.
Compared with the prior study (images reviewed) of [**2124-3-6**],
this is a limited study. The valves are not well seen. The
patient remains tachycardic but is now in atrial fibrillation.
The size of the pericardial effusion is similar
Renal Ultrasound [**2124-3-6**]:
1. No hydronephrosis of the right kidney. Left kidney is
surgically absent.
CXR [**2124-3-6**]:
Lung volumes are lower, pulmonary vasculature more engorged, and
distended
mediastinal veins, unchanged, pointing toward volume overload or
cardiac
decompensation. A more focal opacity at the left lung base
laterally would be better evaluated after hemodynamic status is
optimized. It could be a small region of infection or
infarction, pleural effusion, or transient atelectasis.
Heart is top normal size, though increased since yesterday.
Right subclavian line ends in the upper SVC. No pneumothorax.
CT head/chest non-con [**2124-3-7**]:
Slightly decreased vasogenic edema in region of known left
temporal lobe metastasis.
1. Extensive new strikingly peripheral/subpleural ground-glass
opacities with a slight upper lobe predominance is highly
suggestive of drug-induced toxicity (likely IL-2 drug-induced
eosinophilic lung disease). The more confluent lower lobe
opacities are most suggestive of atelectasis, although infection
cannot be excluded by imaging.
2. Persistent findings suggestive of vascular engorgement with
mild
interstitial edema and small bilateral pleural effusions.
3. No significant interval change to some of the previously
noted metastatic lesions with many of the previously noted foci
obscured by the new lung parenchymal opacities. Slight
enlargement of prevascular lymph nodes can be seen in the
setting of underlying pulmonary edema/elevated CVP.
CXR [**2124-3-8**]:
FINDINGS: As compared to the previous examination, a new central
venous
access line has been inserted over the left anterior jugular
vein. The tip of the line projects over the upper SVC. There is
no evidence of complication, notably no pneumothorax.
The other monitoring and support devices are in unchanged
position.
Also unchanged is the size of the cardiac silhouette and the
bilateral
multifocal parenchymal opacities. The retrocardiac opacity could
have
minimally increased in the interval.
Lower Extremity U/S:
IMPRESSION: No evidence of DVT in either lower extremity. Left
peroneal vein not well visualized.
BAL: Bronchial lavage, right mid lobe:
NEGATIVE FOR MALIGNANT CELLS.
Bronchial epithelial cells, pulmonary macrophages, and
neutrophils; no viral inclusions noted.
CXR [**2124-3-11**]:
Tip of the endotracheal tube is no less than 48 mm from the
carina, standard placement for patient of this size. Diffuse
infiltrative pulmonary abnormality, more pronounced in the
perihilar right lung has progressed could by virtue of asymmetry
be pneumonia rather than pulmonary edema, although pulmonary
vascular congestion is present. The heart is moderately
enlarged. Moderate right pleural effusion is stable. Right
jugular line ends in the low SVC, left jugular line in the mid
SVC, nasogastric tube passes below the diaphragm and out of
view. Mediastinal widening in the right lower paratracheal
station is due to a combination of adenopathy and venous
engorgement.
Portable Abdomen [**2124-3-10**]:
FINDINGS: Supine AP abdomen radiograph demonstrates a
nasogastric tube
following a normal course and terminating in the distal stomach.
There is no evidence of pneumoperitoneum. The bowel gas shadow
appears unremarkable
[**2124-3-6**] 7:08 am URINE Source: Catheter.
**FINAL REPORT [**2124-3-8**]**
URINE CULTURE (Final [**2124-3-8**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML
[**2124-3-7**] 4:21 pm URINE Source: Catheter.
**FINAL REPORT [**2124-3-8**]**
URINE CULTURE (Final [**2124-3-8**]): NO GROWTH
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2124-3-7**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2124-3-7**]):
Negative for Influenza B.
[**2124-3-8**] 4:22 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2124-3-10**]**
FECAL CULTURE (Final [**2124-3-9**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2124-3-10**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2124-3-8**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2124-3-9**] 10:09 am BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2124-3-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2124-3-11**]):
~1000/ML Commensal Respiratory Flora.
POTASSIUM HYDROXIDE PREPARATION (Final [**2124-3-9**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies if
pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2124-3-9**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Virus isolated so far.
[**2124-3-9**] 10:09 am Rapid Respiratory Viral Screen & Culture
**FINAL REPORT [**2124-3-11**]**
Respiratory Viral Culture (Final [**2124-3-11**]):
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 [**2124-3-9**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
[**2124-3-9**] 12:11 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2124-3-9**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2124-3-11**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2124-3-6**] 2:29 am BLOOD CULTURE Source: Line-R SCTL -> MSRA
(+)
[**2124-3-10**]: VRE blood culture from a-line
[**2124-3-11**], [**2124-3-12**] blood cultures pending
Brief Hospital Course:
#. Shock: Felt initially most likely due to sepsis and he was
covered broadly with antibiotics. Initially broadened
antibiotics to vanc/levo/cefepime to cover above sources. Goal
CVP was [**9-21**], MAP > 65. Initial central venous O2 saturation
was 91%. Patient was transferred from floor to ICU on dopamine
and neo; dopamine was converted to levophed. Pulsus was normal
at 5. Echocardiogram as above, largely unremarkable.
Hypotension persisted and was thought to be septic in etiology
with IL-2 distributive physiology contributing. Shock was
refractory to fluid boluses; received normal saline and water
with bicarb given renal failure. Blood cultures eventually grew
out MRSA, successive cultures negative until [**2124-3-10**], with
[**2124-3-10**] culture growing vancomycin-resistant Enterococcus.
During this time, patient was actually weaned off pressors. The
right subclavian triple lumen was removed and a right internal
jugular triple lumen was placed. Goals of care were discussed
with family, who requested continued aggressive treatment.
Linezolid replaced vancomycin for VRE bacteremia. The patient's
pressures stabilized and pressors were discontinued. He did not
have further hypotension after transfer to the oncology floor.
# MRSA/VRE bacteremia: S/p line removals; Patient completed 15
day course of linezolid. Also added Meropenem on [**3-24**] given MS
decline and asterixis. Antibiotics were d/c'd on [**3-25**] and
patient has been stable, afebrile without leukocytosis since.
Repeat blood and urine cultures have been negative.
# partial/early SBO: On [**3-25**] patient developed worsening
abdominal distention and confusion. This early SBO was likely
due to narcotics though concerning that is ongoing and limiting
nutrition. MRI head with improved findings. An NGT was placed
for 24 hours and the patient's MS cleared as did his SBO. There
was initially some concern for messenteric ischemia given guiaic
positive stool, known necrotic fingers and subsequent CT abd
findings, so GI and surgery were consulted. Patient however
soon improved clinically so further work-up with colonoscopy was
not done. He was able to tolerate a regular diet for 48H prior
to discharge. A PICC had been placed for access and for ability
to start TPN if needed, however TPN was never started.
# Anemia: likely multifactorial due to poor nutrition, acute
nutrition, and marrow suppression. Patient is also FOB+ s/p 2U
PRBC since [**3-17**]. then another 1U [**3-24**]. He was continued on iron,
folate and B12 on [**3-27**]. Mr. [**Known lastname 2795**] did have guiaic positive
stools during admission which should be followed-up by
gastroenterology as an outpatient.
# gangrene: [**3-14**] pressors, shock as below. Patient was treated
with wound care and transitioned to a fentanyl patch with
breakthrough morphine for pain.
# thrombocytopenia: Resolved. Likely due to myelosuppression.
# coagulopathy: Patient was supplemented with vitamin K X3 days
to decrease his INR.
# Respiratory failure- Patient was intubated electively in
setting of persistent hypervolemia and renal failure.
Maintained on minimal ventilatory support during dialysis.
Patient received antibiotic coverage for aspiration pneumonia.
The patient was extubated on [**2124-3-15**] and continued to improve
significantly. The patient was called out to the OMED floor team
for further managment.
#. ARF: IL-2 mediated ARF most likely, however prerenal or
postrenal etiology also possible. K wnl, phos elevated though
stable from last draw. Patient likely had IL-2 induced renal
injury, with possible ischemic acute tubular necrosis. Despite
aggressive fluids, renal function did not improve. Patient was
showing signs of uremia and hypervolemia, and continuous
[**Last Name (un) **]-venous hemodialysis was started following intubation and
placement of HD line. On the last days of admission he did not
require diuresis and continued to auto-diurese with a creatinine
of 1.1-1.3. He was not continued on his anti-hypertensives as
his SBPs were 130-140. Mr. [**Known lastname 2795**] should have his renal function
checked as an outpatient in the next 1-2 weeks. If there are
concerns with worsening kidney function as an oupatient, he
should be followed by renal.
# Atrial fibrillation with rapid ventricular response- Occurred
on morning of [**2124-3-7**]. Became more hypotensive, received two
attempts at DC cardioversion, transient sinus rhythm restored,
then converted back into a. fib. Amiodarone load and drip was
started. Converted to sinus rhythm day later, maintained on
amio drip. Cardiac enzymes were flat, lower extremity
ultrasound negative for DVT. Repeat TTE showed no right heart
strain. The amiodarone drip was discontinued and the patient
remained in normal sinus rhythm.
#. HA/MS changes: Known metastatic disease to brain and IL-2 can
cause swelling. He is AOx3, though slightly agitated. Clinical
picture not c/w meningitis/encephalitis and most likely
toxic-metabolic. CT head showed slight improvement in
metastatic disease, less vasogenic edema. Lumbar puncture was
deferred given intracranial mass. As patient stayed on the
oncology floor his mental status gradually returned to [**Location 213**].
He can have a formal neurocognitive outpatient work-up if deemed
necessary by his PCP.
# skin/eye/mucous membrane breakdown: Patient developed
significant skin breakdown, particularly on his fingertips
likely due to pressors and IL-2. He was evaluated by plastic
surgery and hand x-ray found no need for intervention. He was
continued on: nystatin, miconazole, benadryl, sarna, Hydrocerin,
HydrOXYzine, eye drops, Gelclair.
#. RCC: finished week 2 of IL-2. Maintained contact with
outpatient oncologist.
CODE STATUS: Full (confirmed)
Medications on Admission:
MEDICATIONS upon transfer:
Hydrocerin 1 Appl TP QID:PRN dry skin
50 mEq Sodium Bicarbonate/1000 ml D5 1/2 NS Continuous at 75
ml/hr
HydrOXYzine 25-50 mg PO/NG Q6H:PRN pruritis
Lorazepam 0.5-1 mg PO/IV Q4H:PRN
Acetaminophen 975 mg PO Q6H prn
Meperidine 25-50 mg IV Q2H:PRN Rigors
Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN
Morphine Sulfate 1-2 mg IV Q2H:PRN pain
Ciprofloxacin HCl 250 mg PO/NG Q24H
Pantoprazole 40 mg PO Q24H
DOPamine 4 mcg/kg/min IV DRIP
Phenylephrine 1 mcg/kg/min IV DRIP
DiphenhydrAMINE 25-50 mg PO/IV Q6H:PRN pruritis
Diphenoxylate-Atropine [**2-12**] TAB PO PRN after each loose stool
Prochlorperazine 10 mg PO/IV Q6H:PRN nausea/vomiting
Erythromycin *NF* 5 mg/g OU TID
Sarna Lotion 1 Appl TP QID:PRN pruritus
Gabapentin 100 mg PO/NG TID pruritus
Gelclair 15 mL ORAL TID:PRN mucositis
*Stopped* Aldesleukin 47.4 Million Units IV Q8H on Days 1, 2, 3,
4 and 5.
.
Home Medications:
lipitor 20mg
diltiazem 240mg [**Hospital1 **]
folate 1mg qday
protonix 40mg qday
triamterene/hydrochlorothiazide 75/50mg qday
valsartan 320mg qday
vit C 1g qday
citrucel 1g [**Hospital1 **]
cyanocobalamin 1g sc monthly
Discharge Medications:
1. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
once a month: next due [**4-24**].
5. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
6. Diphenhydramine HCl 25 mg Capsule Sig: [**2-12**] Capsules PO Q6H
(every 6 hours) as needed for pruritis.
Disp:*60 Capsule(s)* Refills:*0*
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea/vomiting, insomnia or anxiety.
Disp:*30 Tablet(s)* Refills:*0*
8. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for dry skin.
Disp:*QS 1 month* Refills:*0*
9. Oral Wound Care Products Gel in Packet Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day) as needed for mucositis.
Disp:*QS 1 month* Refills:*0*
10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pruritis.
Disp:*60 Tablet(s)* Refills:*0*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritus.
Disp:*QS 1 month* Refills:*2*
12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: do note take more than 4 grams per
day.
Disp:*120 Tablet(s)* Refills:*0*
13. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): remove previous patch before
applying. Do not drive while using this.
Disp:*20 Patch 72 hr(s)* Refills:*0*
15. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
pkt PO DAILY (Daily) as needed for constipation.
Disp:*60 pkt* Refills:*2*
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
20. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] health care
Discharge Diagnosis:
Primary:
Metastatic RCCA - s/p C1W2 HD IL-2 therapy
Secondary:
VRE/MRSA sepsis
acute renal failure, resolved
SBO, resolved
peripheral necrosis of digits
acute mental status changes, resolved
Discharge Condition:
Alert, oriented, ambulatory
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
IL-2 therapy for your Renal Cell Carcinoma. While you were here
you had a very complicated hospital course.
-You developed bacteria in your blood and you were treated with
antibiotics for MRSA and VRE. You have finished your courses of
antibiotics and your blood cultures have been normal.
-You had a UTI with e-coli and you were treated with
antibiotics. Your urine cultures have since been normal.
-You needed dialysis. Your kidney function has since improved
and your creatinine was 1.2 at discharge. This should be
monitored closely and you should see a renal doctor if it
worsens.
-You were in the intensive care unit and you were intubated for
confusion. This improved. You should ask Dr. [**Last Name (STitle) **] if
neurocognitive evaluation is needed.
-You had necrosis (damage) to your fingertips from some of the
medications in the ICU. Plastic surgery saw you and your finger
tips started to improve.
-You also had skin damage to your sacrum (above your buttocks)
from the IL-2. The VNA services should help you change these
dressings.
While you were here some of your medications were changed.
You should CONTINUE taking:
lipitor 20mg
folate 1mg qday
protonix 40mg qday
vit C 1g qday
cyanocobalamin 1g sc monthly (you received this on [**3-27**])
You should STOP taking:
citrucel 1g [**Hospital1 **]
diltiazem 240mg [**Hospital1 **]
triamterene/hydrochlorothiazide 75/50mg qday
valsartan 320mg qday
You should START taking:
Benadryl, hydroxyzine, camphor-methol, petrolatum-mineral oil as
needed for itching
Lorazepam as needed for nausea, vomiting or anxiety (do not
drive or drink alcohol while taking this)
oral care and wound care products
tylenol as needed for pain
ferrous gluconate twice a day
fentanyl patch every 72 hours (do not drive or drink alcohol
while taking this)
morphine as needed for pain (do not drive or drink alcohol while
taking this)
You should take senna and colace every day to prevent
constipation and take miralax and bisacodyl if you become
constipated.
Notify [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, at ([**Telephone/Fax (1) 82663**] for fever, chills,
shortness of breath, or inability to take oral fluids
Followup Instructions:
You have the following appointment's with Dr. [**Last Name (STitle) 1729**],
[**Telephone/Fax (1) 22**].
[**2124-4-25**] 02:00p XCT (TCC) [**Apartment Address(1) **]: Catscan appointment
[**Hospital6 29**], [**Location (un) **]
[**2124-5-2**] 02:30p [**Doctor Last Name **],TUESDAY BIOLOGICS
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Dr. [**Last Name (STitle) 82876**] [**Doctor First Name 82877**] PCP [**Telephone/Fax (1) 82878**]
[**4-3**] at 2:15pm
We will fax a copy of your discharge paperwork to Dr. [**Last Name (STitle) **].
Visiting Nursing: [**Telephone/Fax (1) 82879**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
ICD9 Codes: 5849, 5070, 2762, 5990, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6090
} | Medical Text: Admission Date: [**2138-4-14**] Discharge Date: [**2138-4-18**]
Service: MEDICINE
Allergies:
Codeine / Benzodiazepines
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
tracheal intubation, central venous catheter placement, and
radial arterial catheter placement
History of Present Illness:
Ms. [**Known lastname 94926**] is an 87 year old Russian-speaking woman with history
of breast cancer, esophageal cancer (requiring esophogeal
stent), afib, DMII, apparently went to Pul office to drain
pleural effusuion, but was noted to have small episode of
hematemesis, Dr. [**Last Name (STitle) **] was called and advised to come to ED
for further evaluation. Pt suwsequently had another episode of
hematemesis in ED.Claims to have dark stools day pta. Denied CP
but have exertional SOB. Denied HA, recent ASA use, denied abd
pain.
.
Last EGD on [**1-10**] demonstrated narrowing in the distal esophagus
suggestive of granulation tissue, and a metal stent was
successfully deployed distal to the previous stent.
Daughter informed us that pt apparently does not know about her
diagnosis and prefers not to inform her.
Past Medical History:
1. Right breast cancer, status post radiation therapy excision
in [**2130-12-4**].
2. Hypertension.
3. History of exertional angina; negative Persantine thallium in
[**2132-4-2**].
4. Back pain.
5. Carpal tunnel.
6. History of positive PPD.
7. Glaucoma.
8. History of atrial fibrillation with hypokalemia during
previous hospitalization.
9. DM diet-controlled Hb A1c 7.1 in [**12-8**]
10. Obesity.
11. Osteopenia.
12. s/p cholecystectomy in [**Country 532**].
13. Squamous cell esophogeal cancer with esophageal obstruction
requiring stent
Social History:
Lives at elderly home, nurse helps with ADLs. Her daughter is
very supportive and active in her care. She denies history of
tobacco use.
Family History:
Esophageal cancer in father - 80s
Physical Exam:
vital - T 98.6, BP 118/74, HR 94, RR 16, O2 93% on room air.
gen -In no distress.
heent - Sclera anicteric, moist mucus membranes, OP clear
cv: Irregular, S1 S2 present, no murmurs, rubs, gallops
pulm - Decreased on right.crackles in bases
abd - Soft, non-tender , good BS, rectal- guaiac positive, brown
stool
ext - Warm. Mild edema.
neuro -awake and alert
Pertinent Results:
[**2138-4-14**] 01:45PM WBC-13.0* RBC-3.65* HGB-10.0* HCT-30.1*
MCV-82 MCH-27.4 MCHC-33.2 RDW-14.4
[**2138-4-14**] 01:45PM NEUTS-83.5* LYMPHS-11.8* MONOS-3.8 EOS-0.6
BASOS-0.3
[**2138-4-14**] 01:45PM PLT COUNT-360
[**2138-4-14**] 01:45PM PT-13.7* PTT-23.8 INR(PT)-1.2*
[**2138-4-14**] 01:45PM GLUCOSE-155* UREA N-17 CREAT-0.6 SODIUM-139
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-29 ANION GAP-14
[**2138-4-14**] 01:45PM ALT(SGPT)-12 AST(SGOT)-34 ALK PHOS-77 TOT
BILI-0.4
[**2138-4-14**] 01:45PM LIPASE-11
[**2138-4-14**] 01:45PM ALBUMIN-3.1*
SINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST: There are bilateral
moderate-sized pleural effusions unchanged. There is also
bilateral lower lobe atelectasis also largely unchanged. There
is also minimal pleural fluid extending into the right minor
fissure. There is no pneumothorax. Cardiomediastinal silhouette
is obscured by the left lower lobe atelectasis and effusion.
Pulmonary vasculature is within normal limits. There is no
evidence of volume overload. Esophageal stent is noted. There is
mild dextroconvex thoracic scoliosis.
IMPRESSION: Moderate bilateral pleural effusions and lower lobe
atelectasis, both of which are unchanged allowing for slight
differences in technique.
Atrial fibrillation with rapid ventricular response.
Non-specific ST-T wave changes. Poor R wave progression. Suspect
arm lead reversal. Compared to the previous tracing of [**2138-1-19**]
the ventricular rate is faster and the arm leads are reversed.
Brief Hospital Course:
87 year old Russian-speaking female with h/o breast cancer,
esophageal cancer (requiring esophogeal stent), afib, DMII, s/p
EGD with additional stent placement adm with dyspnea and large
recurrent right pleural effusion s/p pleurodesis with small
volume hematemesis in pulmonary clinic.
Hematemesis: Patient was intubated for airway control. Two large
bore PIV, active type and cross. Pt was transfused to keep Hct
>=30 given coronary disease. She briefly required pressors for
hemodynamic support. GI consult team attempted EGD, which
revealed large clot adherent to the wall of the esophagus distal
to the patent esophageal stent. GI attending recommended to
family that any attempt at further intervention would likely
result in massive GI bleeding and catastrophic outcome. Extended
family flew in from abroad to visit with patient and then the
entire family, after reviewing the options for end of life care,
decided that she would have wanted to be made comfortable given
her pre-terminal condition. Planning for home hospice was
offered, but the family was justifiably concerned about the
possibility of further hematemesis and therefore asked that she
remain intubated while all medications other than analgesics and
anxiolytics were stopped. Mechanical ventilation was changed to
T-piece oxygen. She subsequently expired with family at her
bedside.
Medications on Admission:
1. Aspirin 325mg daily
2. Lasix 20mg PO daily
3. Glipizide SR 2.5mg q 24
4. Lisinopril 10mg once daily
5. Metoprolol tartrate 300mg once daily
6. Ranitidine 15mg/mL
7. Valacardine
8. Calcium carbonate 500mg TID
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
esophageal cancer
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 5789, 2851, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6091
} | Medical Text: Admission Date: [**2147-1-1**] Discharge Date: [**2147-1-7**]
Service:
CHIEF COMPLAINT: Fevers, unresponsiveness.
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
man with prostate cancer and cerebrovascular accident who was
struck by an automobile earlier this year. He has had
several admissions to [**Hospital1 69**],
the last one culminating in failure to wean from the
ventilator, for which he received a tracheostomy and a
percutaneous esophagogastrostomy. He was transferred to
rehabilitation center in [**2146-11-12**] after a similar
presentation, marked by fevers and altered mental status.
His work-up at that time was unrevealing (Head computed
tomograph and lumbar puncture which were normal).
On the day of admission, the patient's percutaneous
esophageal gastrostomy tube was flushed. Shortly after the
percutaneous esophageal gastrostomy tube was flushed, water
was found to be coming out from his tracheostomy site. His
heart rate was in the 150's and his temperature was 101.8.
The patient was emergently suctioned, bagged and placed on
assist control ventilation. Two hours later, his temperature
climbed to 105 and his heart rate and systolic blood pressure
had dropped to the 80's and he was transferred to [**Hospital1 346**] for further care.
PAST MEDICAL HISTORY: 1. Status post motor vehicle accident
in [**2146-9-12**], as described in detail in the OMR. 2.
Prostate cancer (not active disease). 3. Left frontal
cerebrovascular accident. 4. Left lower lobe pneumonia.
ALLERGIES: None known.
MEDICATIONS ON TRANSFER:
Vancomycin 750 mg every 24 hours.
Gentamycin 30 mg every 24 hours.
Albuterol.
Ipratropium.
Ranitidine.
Aspirin 81 mg.
HOSPITAL COURSE: In the Emergency Department, the patient
was enrolled in the sepsis protocol. Central venous access
was obtained. 2.5 liters of normal saline were infused and
his blood pressure climbed to 107 systolic. Copious amounts
of sputum were appreciated on transfer to the medical
Intensive Care Unit.
PHYSICAL EXAMINATION: Temperature 104; heart rate of 125;
blood pressure 107/56; respiratory rate of 32. SP02 99% on
room air. General: He is cachectic, chronically
ill-appearing, minimally responsive elderly man. HEAD, EYES,
EARS, NOSE AND THROAT: Anicteric with normal conjunctiva and
dry mucous membranes. Neck: The tracheostomy site was
clean, dry and intact. Lungs: Crackles at both bases.
Heart: Tachycardiac with normal S1 and S2. There is no S3,
S4, murmurs, rubs or gallops. The abdomen was scaphoid.
Normal bowel sounds. Soft, nontender, nondistended. There
was no organomegaly appreciated. Extremities: No rash,
clubbing, cyanosis or edema. Vascular: Radial, carotid,
dorsalis pedis, posterior tibial pulses were brisk and equal
bilaterally.
LABORATORY DATA: Arterial blood gases revealed pH of 7.44,
PC02 of 35, P02 of 275; lactate 1.6. The remainder of his
laboratory evaluation is unremarkable. Chest x-ray showed
left retrocardiac opacity.
HOSPITAL COURSE: The patient was admitted to the medical
Intensive Care Unit and received broad antibiotics initially
on hospital day number three. Gentamycin was discontinued.
Standard trichomonas was identified in the sputum and Bactrim
was added to Vancomycin. The patient continued to produce
copious amounts of yellow sputum; however, was relatively
easy to ventilate and oxygenate him mechanically. The
patient remained minimally responsive for the remainder of
his hospital course and he was also hypotensive with a
systolic blood pressure below 100.
On hospital day number two through five, he was rather
agitated and responded only to Haloperidol. After extensive
discussions with his wife and his granddaughter, [**Name (NI) **],
aggressive care was withdrawn. Antibiotics were
discontinued. The patient's tracheostomy tube was
disconnected from the ventilator on [**2147-1-7**]. The
patient's comfort was ensured with intravenous morphine
infusion. The patient was transferred to the medical floor
for further management.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Status post motor vehicle accident.
3. Prostate cancer (not active disease).
4. Left frontal cerebrovascular accident.
DISPOSITION: To the medical floor for comfort measures only.
[**Name6 (MD) 50136**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2147-1-7**] 07:58
T: [**2147-1-7**] 08:04
JOB#: [**Job Number 50137**]
ICD9 Codes: 0389, 5070, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6092
} | Medical Text: Admission Date: [**2143-7-1**] Discharge Date: [**2143-7-22**]
Date of Birth: [**2122-1-10**] Sex: F
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Trauma s/p MVC
Major Surgical or Invasive Procedure:
1. Open tracheostomy
2. Right craniectomy for evacuation of
venous epidural hematoma.
3. Dissection of the dura and
duraplasty for intracranial hypertension.
History of Present Illness:
20yo F s/p rollover MVC. Pt was restrained passenegr but
partially ejected by report. Pt was GCS6 at field and was
intubated.
Past Medical History:
none
Social History:
unknown
Family History:
unknown
Physical Exam:
PHYSICAL EXAM:
O: T: 99.8 BP:133/67 HR:49-76 O2Sats87-100
Gen: WD/WN, in hard collar on backboard examined in CT scanner.
Multiple abrasions on body, blood in nares
Neuro/HEENT:intubated, sedated for intubation. Moving bilat
legs and
left arm spontaneously with good strength, minimal movement
right
arm- did see fingers move. Toes downgoing right, upgoing left.
eyes closed. pupils 3mm equal bilat reactive to light.
Cardiovascular: RRR
Pulmonary: CTA B/L Equal breath sounds B/L
ABD: Soft, Non-distended
Rectal Exam: good tone, hemoccult negative.
Pertinent Results:
[**2143-7-17**] 06:50AM BLOOD WBC-8.3 RBC-2.93* Hgb-8.6* Hct-27.3*
MCV-93 MCH-29.4 MCHC-31.6 RDW-16.2* Plt Ct-[**2040**]*
[**2143-7-16**] 07:00AM BLOOD WBC-8.1 RBC-2.73* Hgb-8.3* Hct-25.1*
MCV-92 MCH-30.5 MCHC-33.1 RDW-16.1* Plt Ct-1827*
[**2143-7-15**] 09:30AM BLOOD WBC-10.3 RBC-2.80* Hgb-8.4* Hct-25.5*
MCV-91 MCH-30.2 MCHC-33.1 RDW-15.6* Plt Ct-1834*
[**2143-7-14**] 02:10PM BLOOD WBC-14.7* RBC-2.91* Hgb-8.8* Hct-26.8*
MCV-92 MCH-30.2 MCHC-32.8 RDW-15.3 Plt Ct-[**2095**]*
[**2143-7-13**] 06:25AM BLOOD WBC-19.1* RBC-3.28* Hgb-9.7* Hct-30.2*
MCV-92 MCH-29.6 MCHC-32.3 RDW-15.0 Plt Ct-2051*
[**2143-7-12**] 02:37AM BLOOD WBC-18.8* RBC-3.24* Hgb-9.4* Hct-29.4*
MCV-91 MCH-29.1 MCHC-32.1 RDW-14.6 Plt Ct-1689*
[**2143-7-11**] 02:24AM BLOOD WBC-20.0* RBC-3.07* Hgb-9.2* Hct-27.7*
MCV-90 MCH-29.9 MCHC-33.1 RDW-14.3 Plt Ct-1361*
[**2143-7-10**] 03:04AM BLOOD WBC-20.7* RBC-3.07* Hgb-9.3* Hct-27.7*
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.1 Plt Ct-1033*
[**2143-7-9**] 03:44AM BLOOD WBC-15.4* RBC-3.10* Hgb-9.3* Hct-27.8*
MCV-90 MCH-30.1 MCHC-33.6 RDW-14.0 Plt Ct-804*
[**2143-7-8**] 03:58AM BLOOD WBC-14.0* RBC-3.19* Hgb-10.0* Hct-28.3*
MCV-89 MCH-31.3 MCHC-35.3* RDW-13.8 Plt Ct-599*
[**2143-7-7**] 02:32AM BLOOD WBC-11.2* RBC-2.90* Hgb-9.0* Hct-26.6*
MCV-92 MCH-31.1 MCHC-34.0 RDW-13.8 Plt Ct-407
[**2143-7-17**] 06:50AM BLOOD Plt Ct-[**2040**]*
[**2143-7-16**] 07:00AM BLOOD Plt Ct-1827*
[**2143-7-15**] 09:30AM BLOOD Plt Ct-1834*
[**2143-7-14**] 02:10PM BLOOD Plt Ct-[**2095**]*
[**2143-7-13**] 06:25AM BLOOD Plt Ct-2051*
[**2143-7-12**] 02:37AM BLOOD Plt Ct-1689*
[**2143-7-11**] 02:24AM BLOOD Plt Ct-1361*
[**2143-7-10**] 03:04AM BLOOD Plt Smr-VERY HIGH Plt Ct-1033*
[**2143-7-9**] 03:44AM BLOOD Plt Ct-804*
[**2143-7-8**] 03:58AM BLOOD Plt Ct-599*
[**2143-7-1**] 05:42PM BLOOD Fibrino-140*
[**2143-7-1**] 02:15PM BLOOD Fibrino-147*
[**2143-7-14**] 02:10PM BLOOD Glucose-97 UreaN-25* Creat-0.6 Na-139
K-5.4* Cl-101 HCO3-26 AnGap-17
[**2143-7-13**] 06:25AM BLOOD Glucose-90 UreaN-27* Creat-0.7 Na-139
K-5.4* Cl-99 HCO3-31 AnGap-14
[**2143-7-12**] 02:37AM BLOOD Glucose-131* UreaN-24* Creat-0.6 Na-138
K-4.8 Cl-101 HCO3-28 AnGap-14
[**2143-7-11**] 02:24AM BLOOD Glucose-158* UreaN-17 Creat-0.6 Na-138
K-4.8 Cl-102 HCO3-26 AnGap-15
[**2143-7-10**] 03:04AM BLOOD Glucose-134* UreaN-16 Creat-0.6 Na-141
K-4.2 Cl-104 HCO3-27 AnGap-14
[**2143-7-4**] 02:05AM BLOOD Glucose-163* UreaN-6 Creat-0.8 Na-142
K-4.2 Cl-110* HCO3-25 AnGap-11
[**2143-7-3**] 12:31AM BLOOD Glucose-139* Na-141
[**2143-7-2**] 08:06PM BLOOD Glucose-56* Na-141 K-4.2
[**2143-7-1**] 11:48PM BLOOD Glucose-200* UreaN-10 Creat-0.8 Na-137
K-4.3 Cl-107 HCO3-18* AnGap-16
[**2143-7-1**] 05:42PM BLOOD Glucose-198* UreaN-12 Creat-0.8 Na-134
K-4.5 Cl-102 HCO3-22 AnGap-15
[**2143-7-1**] 02:15PM BLOOD Glucose-172* UreaN-16 Creat-0.9 Na-138
K-4.2 Cl-106 HCO3-23 AnGap-13
[**2143-7-2**] 12:01PM BLOOD Type-ART pO2-227* pCO2-36 pH-7.41
calTCO2-24 Base XS-0
[**2143-7-2**] 07:05AM BLOOD Type-ART pO2-230* pCO2-32* pH-7.46*
calTCO2-23 Base XS-0
[**2143-7-2**] 06:16AM BLOOD Type-ART pO2-234* pCO2-27* pH-7.53*
calTCO2-23 Base XS-1
[**2143-7-2**] 03:23AM BLOOD Type-ART pO2-233* pCO2-28* pH-7.50*
calTCO2-23 Base XS-0
[**2143-7-2**] 12:42AM BLOOD Type-ART pO2-233* pCO2-33* pH-7.42
calTCO2-22 Base XS--1
[**2143-7-1**] 02:19PM BLOOD pO2-42* pCO2-51* pH-7.31* calTCO2-27 Base
XS--1
[**2143-7-1**] 10:09PM BLOOD Glucose-165* Lactate-3.2* Na-134* K-4.4
Cl-106 calHCO3-22
Brief Hospital Course:
The patient is a 20-year-old female status post severe motor
vehicle accident. She came in our hospital with severe head
injury on [**2143-7-1**], and an intracranial pressure monitor showed
pressures in the high- 30s despite optimal medical management.
Another CT showed an expanding venous epidural hematoma, she was
emergently taken to the OR for Craniectomy. Risks and benefits
were discussed with her family.
The extent of her injuries at the time of her admission to ED
was diagnosed as following:
1.Extensive complex comminuted fracture of the calvarium
involving both frontal lobes, both parietal lobes, the squamous
portion of the left temporal lobe, left greater [**Doctor First Name 362**] of the
sphenoid, left lateral aspect of the maxillary sinus, left and
possibly right aspect of the sphenoid sinus.
2. Right frontoparietal subdural hematoma and left frontal acute
subdural hematomas. The hemorrhage is thicker and more
longitudinally extensive on the right side.
3. Blood within the left maxillary, ethmoid, and sphenoid air
cells.
4. Fracture of the ring of C1. For additional details refer to
the CT of cerevical spine report
5. [**Location (un) 5621**] fracture and mild leftward rotation, possibly a
subluxation, of C1 on C2.
6. Anterior flexion teardrop fractures of C5 and C6. Vertically
oriented fracture through the C7 vertebral body, all of which
likely are unstable.
7. Bilateral hazy opacities within both lung fields may
represent pulmonary edema or hemorrhage.
Following the procedure she was admitted to the Trauma Intensive
Care Unit under the supervision of Dr [**Last Name (STitle) 519**]. She was sedated
majority of her time there and lightened for neuro checks. She
was started on tube feeds. By HD#10 it was determined that this
pt was having respiratory failure although her neuro status was
improving. She was taken to the OR on HD#10 for it was felt
that she needed to have
a tracheostomy. A #7 cuffed tracheostomy tube was placed into
the trachea and a
tracheostomy collar was put in place. She continued to show
improvements in her neurologic status.
On HD#12, Pt was transferred to the step down unit and was felt
that she did not need to be in an intensive care setting given
her improving status. Pt. remained on tube feeds on the step
down unit. After evaluation from speech and swallow, she was
cleared for oral feeds on [**2143-7-20**] and her tube feed was
discontinued. She continues to tolerate oral feeds well.
Compalined of some Left sided chest pain on [**2143-7-21**], CXR
negative, Likely Musculoskeletal in nature. Pt is D/C to
[**Hospital3 **] and will follow up with Neurosurgery in 4 weeks
with a repeat Head CT. Pt is to Follow up in Trauma Clinic in
[**1-14**] weeks.
Medications on Admission:
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation
Metoclopramide 10 mg IV Q6H
Insulin 100 Units/100 ml NS @ 0.5 UNIT/HR IV DRIP
Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation
Famotidine 20 mg IV Q12H
Phenylephrine HCl 0.5 mcg/kg/min IV DRIP TITRATE TO CPP >60
Labetalol HCl 0.5-2 mg/min IV DRIP TITRATE TO keep CPP<80
Magnesium Sulfate 2 gm / 100 ml NS IV ONCE MED Mannitol 50 gm IV
ONCE
Mannitol 25 gm IV Q6H
Morphine Sulfate 5 mg IV ONCE Duration: 1 Doses
Phenytoin 100 mg IV Q8H
Cefazolin 1 gm IV Q8H
Discharge Medications:
1. Docusate Sodium 100 mg Tablet Sig: 1-2 Tablets PO BID PRN as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
2. Erythromycin 5 mg/g Ointment Sig: 0.5 in OU Ophthalmic QID
(4 times a day) as needed for bil. canthotomies.
Disp:*1 tube* Refills:*0*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
6. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*0*
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-14**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 Inhaler* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
11. Artificial Tears Drops Sig: 1-2 Drops Ophthalmic PRN.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1.Bilateral Subdural Hematomas
2.Complex Skull Fracture involving Left squamous temporal and
greater [**Doctor First Name 362**] sphenoid
3.Cervical Spine Fx: C1 ring, [**Location (un) 5621**] Fracture, anterior
flexion teardrop of C5-C6, unstable body fracture of C7.
4.Left sphenoid Sinus/Maxillary Sinus/foramen rotundum Fracture
5.Right Orbitlal Fracture
6.Bilateral Pulmaonry Contusions
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency Room for:
Loss of Consciousness
Severe Headache
Visual Changes
Fever >101.5
Severe Nausea/Vomiting
Difficulty Breathing
Bloody Stools
Severe Diarrhea
Followup Instructions:
Follow up in Trauma Clinic in [**1-14**] weeks. Please call ([**Telephone/Fax (1) 9946**] to schedule an appointment.
Follow up with [**Hospital 4695**] Clinic (Dr. [**Last Name (STitle) 26803**] in 4
weeks. Please call ([**Telephone/Fax (1) 11314**] to schedule an appointment and
a Head CT without contrast prior to that appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2143-7-22**]
ICD9 Codes: 5185, 5180, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6093
} | Medical Text: Admission Date: [**2125-4-10**] Discharge Date: [**2125-5-19**]
Date of Birth: [**2125-4-10**] Sex: M
Service: NB
HISTORY: This is a 1785 gram 32-3/7 week male who was
admitted to the Neonatal Intensive Care Unit secondary to
prematurity. He was born to a 35 year-old gravida IV, para I
to II female with the following prenatal screens: Blood type
B positive, antibody negative, RPR nonreactive, rubella
immune, hepatitis B surface antigen negative, GBS unknown.
The pregnancy was complicated by cervical shortening which
was treated by cerclage in [**2124-11-9**], preterm labor and
premature rupture of membranes 7 hours prior to delivery.
There was a question of abruption. The cerclage was removed
and labor was allowed to progress. Intrapartum antibiotics
were given more than 4 hours prior to delivery. The baby was
delivered vaginally. He was depressed initially, floppy with
poor respiratory effort treated with positive pressure bag and
mask ventilation and then CPAP. Apgars were 2 at one
minute, 6 at five minutes and 7 at ten minutes. The patient
was transferred to the Neonatal Intensive Care Unit with blow-
by oxygen.
PHYSICAL EXAMINATION ON ADMISSION:
Weight 1785 grams, about 50th percentile. Length 45.5 cm (about
75th percentile). Head circumference 28.5 cm (25 to 50th
percentile. Temperature 97.9, pulse 180, respiratory rate 38,
blood pressure 53/24 with a mean of 35, O2 saturation 98% in
room air. Anterior fontanelle was open and flat, soft, baby
was [**Name2 (NI) 43619**] with intact palate, mild retractions, fair
aerations, coarse breath sounds, no murmur, normal pulses.
Soft abdomen, 3 vessel cord, no hepatosplenomegaly, normal
male testes high in the scrotum. Patent anus. Mongolian spot
on buttocks. No sacral dimple. No hip click. Decreased tone.
Moving all extremities.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The baby had some initial respiratory
distress which required CPAP for 4 days. The baby was on
nasal cannula for about 24 hours and has been in room air
since day of life 5. He has had some occasional apnea
spells with desaturations. His last spell was on [**5-13**].
He has had no apnea and bradycardia since then.
2. CARDIOVASCULAR: The baby has had an intermittent soft
murmur. Four extremity blood pressures were reassuring
and the hyperoxia test was also reassuring with a PAO2 of
greater than 300. The electrocardiogram showed a left
axis that was prominent for age but thought to be
clinically insignificant.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The baby was started
on feeds on day of life 3 and has been working up on
calories as well as volume. He is currently meeting a
minimum of 130 ml of kilo per day feeding ad lib Similac
Special Care 24kcal/oz. His weight the day of discharge was
3015 grams.
4. GASTROINTESTINAL: The baby is currently on iron
supplementation. He is voiding and stooling consistently
guaiac negative stools. He was on phototherapy for a few
days in the first week of life with a maximum bilirubin
of 10.6/0.4. The phototherapy was discontinued on [**4-16**].
5. HEMATOLOGY: As mentioned earlier the baby is on iron
supplementation. His last hematocrit was 39.1 at 2 weeks
of age. He has never been transfused.
6. INFECTIOUS DISEASE: The baby received ampicillin and
gentamicin for 48 hours rule out. Initially at birth the
blood culture was negative. He has had no documented
infections during this hospitalization.
7. NEUROLOGY: The baby had 2 normal head ultrasounds, 1 on [**4-23**] and 1 on [**5-14**].
8. SENSORY: Audiology - Hearing screening was performed with
automated auditory brain stem responses. The baby was
did not pass in both ears and will need follow up. The follow
up appointment is scheduled in [**Location (un) 38**] Audiology on
[**5-30**] at 2:30 P.M.
Ophthalmology - did not meet screening criteria.
9. PSYCHOSOCIAL: No major issues.
CONDITION AT DISCHARGE: Baby is stable. Feeding while ad lib
with no spells for more than 5 days.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) 40483**], phone #[**Telephone/Fax (1) 66642**]. Fax #[**Telephone/Fax (1) 58781**]. Dr. [**Last Name (STitle) 66643**] was covering for
Dr. [**Last Name (STitle) 40483**] the day prior to discharge and he has been given
a brief summary regarding the baby.
CARE RECOMMENDATIONS:
1. The baby will be feeding Special Care Formula 24 calories
at home.
2. Medications: The baby will be on iron supplementation.
3. The baby passed the car seat testing.
4. State Newborn Screening has been sent per routine.
5. The hepatitis B vaccine was given on the 23rd.
6. Recommended immunizations: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1) Born at less
than 32 weeks; 2) Born between 32 and 35 weeks with 2 of
the following: Day care 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 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. The baby has a follow up appointment
with Dr. [**Last Name (STitle) 40483**] on [**5-21**] at 11:10 A.M. As mentioned
earlier, the baby also needs a follow up audiology screen
in [**Location (un) 38**] on [**5-30**] at 2:30 P.M.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Hyperbilirubinemia.
3. Respiratory distress.
4. Rule out sepsis.
5. Apnea of prematurity.
6. Abnormal newborn hearing screen.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Name8 (MD) 66644**]
MEDQUIST36
D: [**2125-5-18**] 15:41:24
T: [**2125-5-18**] 16:46:59
Job#: [**Job Number 66645**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6094
} | Medical Text: Admission Date: [**2132-11-25**] Discharge Date: [**2132-12-2**]
Date of Birth: [**2064-6-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
68 yo male with history of mental retardation and recurrent UTIs
[**2-20**] urethral stricture with chronic Foley admitted from group
home for [**10-27**] lower abdominal pain since this AM. His pain was
accompained by fever to 104 (decreased to 100.9 with tylenol),
chills, nausea and vomiting, also decreased urine output.
Patient last had foley changed on [**11-10**]. He has a history of
playing with his foley and manipulating the placement.
.
In the ED inital vitals were 97.6 91 114/60 16 90% RA. His exam
in the ED was concerning for a distended lower
abdomen/suprapubic area. His foley was replaced with improvement
in pain to [**5-27**], and immediate UOP of 1.4L. He received a total
of 5L NS with BP remaining 96/53 with HR 61. Since placement of
foley, he has had an additional 3L of urine output. Labs were
remarkable for WBC 11.8 with left shift and creatinine of 1.6
(baseline 1.1), lactate 1.2. His UA showed positive nitirite,
large leuks, >182 WBC, moderate bacteria. He had a CT abdomen
without contrast which revealed chronic hydronephrosis (L>R),
thickening of the bladder (suggestive of chronic obstruction),
could not rule out/in pyelo b/c no IV contrast. He had a chest
xray which was not concerning for any acute processes. He was
started empirically on vanc/ceftriaxone for history of E. coli
and MRSA UTI, and flagyl for possible other intra-abdominal
processes.
.
Of note, pt was recently discharged on [**11-4**] for similar
complaints of UTI and urinary retention. Urine cultures at that
time revealed E. Coli resistant to cipro and bactrim. He was
initially treated with ceftriaxone, and transitioned to PO
cefpedoxime to complete a 10 day course. He was seen by urology
on [**11-10**] who recommended intermittent catheterization, thought
it is unclear if this is a plausible option for this patient
given his mental capacity. Per notes, his group home is not
equiped to help with intermittent catheterization.
On the floor, pt is still complaining of lower abdominal pain.
He is complaining of being very hungry.
.
Review of systems:
(+) Per HPI, chronic pelvic pain per previous notes, occasional
blood stools, none recently
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
-recurrent urethral stricture: followed by Dr. [**Last Name (STitle) **], s/p
cystoscopy, direct-vision internal urethrotomy and fulguration
of a bladder lesion on [**2132-10-14**]
-Mental Retardation: mild to moderate, independent in ADLs
-Traumatic R knee inflamatory arthritis
-hx of eczema in the past rx with hydrocortisone cream,
-dx with open angle glaucoma R eye [**2121**]
-chronic onychomycosis of b/l toe nails
-diabetes, based on HbA1c 6.7%
-hypertension
-elevated PSA
-hyperlipidemia: [**3-26**] t chol 192, LDL 118, HDL 64, TG 51
-ECHO [**2130-7-7**] EF 60-70% normal sytolic function
-Diverticulosis: [**Last Name (un) **] [**12/2130**]
-B 12 Defic
Social History:
lives in a group home; Bay Cove Human Services. Worked at a
Recycling Center few hours daily, retired '[**30**]. Denies tobacco,
alcohol or drugs.
Family History:
Father: unknown
Mother: unknown
Physical Exam:
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, pupils equal and reactive to light,
MMM, oropharynx clear
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 with lower abdominal distension, diffusely tender
to palpation worse in lower abdomen, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, no CVA
tenderness though does have diffuse lower back pain, no spinal
tenderness
GU: foley draining cloudy yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Exam:
AVSS
CV: No M/R/G
Abdomen: soft NT ND
GU: yellow clear urine.
Pertinent Results:
[**2132-11-25**] 05:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
[**2132-11-25**] 05:30PM URINE BLOOD-MOD NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2132-11-25**] 05:30PM URINE RBC-16* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-0
[**2132-11-25**] 03:13PM UREA N-31* CREAT-1.6*
[**2132-11-25**] 03:13PM estGFR-Using this
[**2132-11-25**] 03:13PM ALT(SGPT)-18 AST(SGOT)-21 CK(CPK)-31* ALK
PHOS-99 TOT BILI-0.5
[**2132-11-25**] 03:13PM LIPASE-22
[**2132-11-25**] 03:13PM CK-MB-2 cTropnT-0.13*
[**2132-11-25**] 03:13PM PH-7.51* COMMENTS-GREEN TOP
[**2132-11-25**] 03:13PM GLUCOSE-111* LACTATE-1.2 NA+-135 K+-4.4
CL--101 TCO2-23
[**2132-11-25**] 03:13PM freeCa-1.09*
[**2132-11-25**] 03:13PM WBC-11.8*# RBC-3.93* HGB-11.3* HCT-33.7*
MCV-86 MCH-28.7 MCHC-33.5 RDW-13.5
[**2132-11-25**] 03:13PM NEUTS-93.5* LYMPHS-4.3* MONOS-1.0* EOS-0.9
BASOS-0.2
[**2132-11-25**] 03:13PM PLT COUNT-395
[**2132-11-25**] 03:13PM PT-13.7* PTT-25.0 INR(PT)-1.2*
EKG: new TWI in II, III, AVF
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final [**2132-11-26**]):
Blood Culture, Routine (Final [**2132-11-29**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
334-3294R
[**2132-11-25**].
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Aerobic Bottle Gram Stain (Final [**2132-11-26**]):
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) 251**] [**Last Name (un) **] (4I) @ 0956
[**2132-11-26**].
Anaerobic Bottle Gram Stain (Final [**2132-11-26**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**2132-11-25**] 5:30 pm URINE Site: CATHETER
**FINAL REPORT [**2132-11-26**]**
URINE CULTURE (Final [**2132-11-26**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
[**2132-11-26**] 12:05 pm SWAB Source: Urethral.
**FINAL REPORT [**2132-11-27**]**
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
[**2132-11-27**]): Negative for Chlamydia trachomatis by PCR.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final [**2132-11-27**]): Negative for Neisseria Gonorrhoeae by
PCR.
[**2132-11-28**] Transthoracic ECHO:
IMPRESSION: Normal left ventricular cavity size and regional
systolic function. Mild pulmonary artery hypertension. Dilated
ascending aorta. No valvular pathology or pathologic flow
identified.
Compared with the prior study (images reviewed) of [**2130-7-7**],
global left ventricular systolic function is less vigorous (and
the heart rate is much slower).
.
[**2132-12-2**] TEE:
No spontaneous echo contrast or thrombus is seen in the body of
the left or right atrium. No atrial septal defect is seen by 2D
or color Doppler. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the descending
thoracic aorta to 40 cm from the incisors. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Trivial mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No vegetations or clinically-significant valvular
disease seen.
Brief Hospital Course:
68M history of mental retardation and recurrent UTI secondary to
urethral stricture admitted for recurrent UTI, urinary retention
and resulting in urosepsis, fluid responsive hypotension.
.
ACTIVE ISSUES:
# MRSA and E. Coli Septicemia: Pt presented with fever to 104,
SBPs to 90s that was responsive to 5L of IVF. Likely due to
urinary track infection in etiology. Pt presented in severe
sepsis that was responsive to IVF and antibiotics. BCx (last +
[**11-27**]) revealed E.Coli and Staph Aureus. TTE and TEE unrevealing
for vegetations. I.D. consutled and agreed with CTX and
Vancomycin until [**2132-12-11**]. Vanco trough should be rechecked, as
well as labs, on [**2132-12-5**]. The I.D. team does not need to
follow-up with the patient per team.
.
# Bacterial UTI: Pt has history of recurrent UTI secondary to
urethral stricture. UA had >182 WBC and the source of his sepsis
was thought to be likely GU. Pt was maintained with foley in
place during admission and will be due to follow-up in Dr. [**Last Name (STitle) **]
(urology clinic) on [**2132-12-18**].
.
# Hyperglycemia - nor prior diagnosis of DM2: A1c 6.7 in 2/[**2132**].
Not on any medications at home. Repeat check of HbA1c in house
was <6.0.
.
# Positive troponins - thought to be due to demand ischemia in
the setting of hypotension. Upon transfer to he floor, routine
EKG was obtained that showed new TWI. Cardiac enzymes continue
to downtrend. Pt otherwise asymptomatic and recommend outpatient
follow-up.
- Consider rechecking ECG as outpatient to look for resolution
of TWIs in inferior leads. Pt otherwise asymptomatic.
.
INACTIVE ISSUES:
# h/o Hypertension: not on any antihypertensives - confirmed
with group home.
.
# Depression: confirmed with group home, pt is on sertraline.
.
# Glaucoma: Patient with a known history of open angle glaucoma,
- continue eye drops
.
TRANSTIONAL ISSUES:
- Patient will be discharged to [**Hospital 100**] Rehab on [**12-2**]. Accepting
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will be emailed the summary
above.
- Direct verbal signout was provided to pt's PCP via phone on
[**12-2**]. PCP recommends [**Name Initial (PRE) **]/u following discharge from [**Hospital 100**] Rehab.
- Full Code
- Patients Visting Nurse
Medications on Admission:
colace 100 mg po bid
aspirin EC 81 mg po daily
zoloft 25 mg po q hs
vitamin B12 1000 mcg q day
lumigan 0.03% 1 gtt each eye q hs
Alphagan 0.2% 1 gtt each eye [**Hospital1 **]
Tinactin power q hs to toes
robitussin 100 ml/5ml q 4 hrs prn cough
Tylenol 325-650 mg po q 6 prn pain, fever,
Discharge Medications:
1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): Continue through [**2132-12-11**].
2. ceftriaxone 1 gram Piggyback Sig: One (1) Intravenous once a
day: Continue through [**2132-12-11**].
3. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Outpatient Lab Work
Please check Basic Metabolic Panel and Vanco trough Friday
[**2132-12-5**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary Diagnosis
- E.Coli Septicemia
- MRSA Septicemia
- Urinary Retention
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 and were found to have a
urinary track infection and were found to have a bacterial
infection in your blood.
.
The following changes have been made to your medications:
1) Vancomycin 1gm every 12 hours until [**12-11**]
2) Ceftriaxone 1gm every day until [**12-11**]
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2132-12-18**] at 2:30 PM
With: PELVIC FLOOR UNIT [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2133-5-18**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 9420**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 5990, 5849, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6095
} | Medical Text: Admission Date: [**2155-12-24**] Discharge Date: [**2156-2-4**]
Date of Birth: [**2106-8-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 year-old man with a history of bipolar/schizoaffective
disorder, hypothyroidism, recent admission to OSH with HA who
was transferred with recurrent HA, nausea and new left parietal
hemorrhage.
At admission, patient was found to be a poor historian and much
of the history was apparently taken from medical records per OSH
and the pt's sister.
Per sister, pt first presented to PCP [**Last Name (NamePattern4) **] [**11-29**] with ~8-9 days of
nearly daily headache, nausea and vomiting. She was unable to
provide details of headache. PCP arranged for head CT which was
normal, and pt sent home. Sister accompanied him home, and
realized that pt having difficulty with tasks such as dialing
phone or using spoon. Normally pt lives alone, and sister felt
he was unsafe so brought him to [**Hospital3 1443**] Hospital,
where he was admitted from [**Date range (1) 65003**]. While there, he had MRI
that per OSH discharge summary showed small bilateral strokes in
postrior parietal parasaggital region near the parieto-occipital
fissure, thought to be watershed however this was not observed.
Also in differential was possible viral meningoencephalitis.
Stroke workup with negative carotid US, echo, normal lipids and
A1C, no arrythmias. He was started on ASA. On discharge he had
full strength, was still having difficulty making phone calls.
Headache had improved, though not fully resolved. Sister reports
that he was getting percocet in hospital, though he was not
discharged with any.
Since discharge, sister reports that pt complaining of slowly
worsening headache. Also has been complaining of trouble seeing,
"I can't see the kitchen sink." He saw his PCP yesterday who
thought headaches might be migraines, and gave him Zomig. Today
the headache worsened and pt returned to OSH ED. Head CT showed
left parieto-occipital bleed and pt transferred for further
management.
Per sister and brother-in-law, pt "does OK on all your tests,
but he still has trouble functioning, such as trouble getting
dressed." At baseline (prior to recent headaches) pt did have
some cognitive difficulties, and some trouble articulating. He
is worse now, but it is not entirely clear the time course of
this. The trouble making phone calls is definitely new. Also of
note, he has had some recent med changes after psych
hospitalization at [**Hospital1 **] ~3 months ago. Also, while at OSH pt
refused risperdal and was started on seroquel instead.
Currently, pt reports vertex headache, am unable to get any more
details. Also reports +nausea, trouble talking and trouble
seeing. No chest pain, abdominal pain. Notes some left leg
weakness as well.
Social History:
Lives alone, is own guardian. Sister had been his guardian in
the past but apparently a court has determined that she is no
longer allowed to hold this position.
Family History:
Sister with mental illness.
Physical Exam:
Admission Physical
BP 135-152/70s-80s HR 50s-60s RR 18
General: Appears stated age, in no acute distress
HEENT: NC/AT Sclera anicteric. OP clear
Neck: Supple
Lungs: Clear to auscultation anterolaterally
CV: Brady, reg rhythm, nl S1, S2, no murmur. No carotid or
vertebral bruit
Abd: Soft, overweight, nontender, normoactive bowel sounds
Extr: No edema, good dorsalis pedis pulses
Neurologic Examination:
Mental Status: Awake, oriented to person, place and "[**Month (only) 359**],
[**2152**]", mostly cooperative with exam though got mildly irritable
near end
Attention: Can say days of week backward, but slow
Language: Fluent, maybe slight dysarthria, no paraphasic errors,
repetition intact. Does not name "hand", says "clock" for
"watch", does not name "watchband" but does get "pen" Can name
my
coat color as "white" but does not name "green" or "blue"
No apraxia for combing hair, brushing teeth, salute. However,
cannot tell me how to make a phone call. No neglect
Cranial Nerves: Visual fields with right hemianopsia. Pupils
equally round and reactive to light. Extraocular movements
intact, no nystagmus. Facial sensation and facial movement
normal
bilaterally. Hearing intact to finger rub bilaterally. Normal
oropharyngeal movement. Tongue midline, no fasciculations.
Motor: Normal bulk and tone bilaterally, fasiculations absent in
upper and lower extremities. No tremor. No pronator drift. Full
strength bilateral deltoid, triceps, finger ext, finger flexion,
IP, dorsiflexion
Sensation was intact to light touch and temperature (cold).
Reflexes: DTRs decreased and symmetric throughout, except absent
at knees. Toes were mute bilaterally
Coordination is normal on finger-nose-finger
Gait deferred.
Pertinent Results:
MRI/MRA [**12-24**]: 1. MR features of a 43 x 34 mm intracerebral
hematoma at the left parietal/occipital region, with surrounding
vasogenic edema, and extension of hemorrhage into the adjacent
subarachnoid spaces and ventricular system. 2. No obstructive
hydrocephalus is seen at present. 3. No pathological enhancement
to identify an underlying lesion relating to
the left parietal-occipital hematoma. 4. Normal brain MR
angiography.
.
TTE: No valvular vegetations or intracardiac thrombi seen.
EF>55%. No PFO/ASD.
.
CT head [**1-8**]: There has been evolution of the previously noted
blood products in the left parieto-occipital region, overall
unchanged in extent in the interval. However, new in the
interval is hypodensity in the left internal capsule and
thalamus, which is exerting slight mass effect on the frontal
[**Doctor Last Name 534**] of the left lateral ventricle. This is concerning for acute
or subacute infarction. No new intracranial hemorrhage or other
new suspicious areas of hypodensity are noted. There is no
hydrocephalus. The basilar cisterns are visible. The mastoid air
cells are opacified bilaterally. The remainder of the paranasal
sinuses and the orbits are unremarkable.
.
EEG [**1-8**]: IMPRESSION: This is a mildly abnormal EEG due to the
presence of a focal
area of slowing in the left anterior quadrant suggestive of a
subcortical abnormality in this region. Background frequencies
were
also somewhat slower than normal, suggesting the presence of a
mild
encephalopathy of toxic, metabolic, or anoxic etiology.
.
CTA neck [**1-10**]: 1. Left internal jugular vein thrombosis as
described. Question of left sigmoid sinus partial thrombosis,
versus mixing artifact.
2. Mastoid and partial ethmoid and sphenoid sinus opacification.
.
CT head [**1-12**]: 1. New hemorrhagic transformation of left caudate
nucleus infarction. Blood products within the fourth ventricle.
Close clinical followup and followup CT scan recommended.
2. Probable superior sagittal sinus thrombosis and possible
thrombosis of the left sigmoid sinus, with continued thrombosis
of the left internal jugular vein.
.
CT head [**1-29**] (compared to [**1-19**]): There has been no significant
change from [**2156-1-20**] with a stable appearing left
frontal hemorrhage with surrounding edema. There is also a
resolving region of hypodensity from hemorrhage in the left
temporal lobe. There is stable appearance of the effaced frontal
[**Doctor Last Name 534**] of the left lateral ventricle. No new foci of hemorrhage
are indicated. There is no shift of normally midline structures.
There is some left sphenoid sinus mucosal thickening.
IMPRESSION: Multiple stable hemorrhages as described above with
no new significant change from [**2156-1-20**].
.
[**2155-12-23**] 06:50PM PT-13.3 PTT-20.5* INR(PT)-1.2
[**2155-12-23**] 06:50PM PLT COUNT-170
[**2155-12-23**] 06:50PM NEUTS-80.4* LYMPHS-15.2* MONOS-3.9 EOS-0.4
BASOS-0.1
[**2155-12-23**] 06:50PM WBC-14.8* RBC-4.61 HGB-14.6 HCT-39.9* MCV-87
MCH-31.7 MCHC-36.6* RDW-12.7
[**2155-12-23**] 06:50PM VALPROATE-37*
[**2155-12-23**] 06:50PM CALCIUM-9.5 PHOSPHATE-4.6* MAGNESIUM-1.9
[**2155-12-23**] 06:50PM CK-MB-1 cTropnT-<0.01
[**2155-12-24**] 12:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2155-12-24**] 06:00AM T3-104 FREE T4-1.0
[**2155-12-24**] 06:00AM TSH-5.7*
[**2155-12-24**] 06:00AM LIPASE-40
[**2155-12-24**] 06:00AM ALT(SGPT)-10 AST(SGOT)-13 CK(CPK)-31* ALK
PHOS-101 AMYLASE-52 TOT BILI-0.3
[**2155-12-24**] 03:13PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2155-12-24**] 03:13PM AMMONIA-48*
[**2155-12-24**] 03:13PM ALBUMIN-3.9
[**2156-1-12**] 09:45AM BLOOD Fibrino-482* D-Dimer-2839*
[**2156-1-11**] 09:36PM BLOOD FDP-10-40
[**2156-1-9**] 12:50PM BLOOD ESR-75*
[**2156-1-14**] 01:55PM BLOOD ESR-47*
[**2156-1-26**] 01:19PM BLOOD FacVIII-154*
[**2156-2-1**] 06:30AM BLOOD LMWH-1.06
[**2156-1-26**] 01:19PM BLOOD ACA IgG-4.6 ACA IgM-7.8
[**2156-1-21**] 11:10AM BLOOD ProtCFn-119 ProtCAg-88 ProtSFn-96
ProtSAg-148*
[**2156-1-9**] 07:00PM BLOOD Lupus-NEG AT III-74
[**2156-1-9**] 07:00PM BLOOD ProtCAg-63* ProtSAg-146*
[**2156-1-29**] 11:00AM BLOOD TSH-4.1
[**2155-12-24**] 06:00AM BLOOD T3-104 Free T4-1.0
[**2156-1-12**] 11:58AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2156-1-14**] 01:55PM BLOOD CRP-11.0*
[**2156-1-29**] 11:00AM BLOOD Lithium-0.8
Brief Hospital Course:
Mr. [**Known lastname 65004**] is a 49 yo RHM with h/o bipolar/schizoaffective
disorder, hypothyroidism, who was transferred with complaints of
headache for about a month and nausea. Upon admission he was
found to have a large left parietal hemorrhage. The exam upon
admission was notable for inattention, anomia, right field cut,
mild-moderate R hemiparesis, and perseveration.
.
Neuro:
The patient was transferred to the Neuro/ICU for telemetry and
aggressive blood pressure control. Neurosurgery evaluated him
and no surgical intervention was necessary. His MRI/MRA scans
revealed a large (~40cc) hemorrhage near the [**Doctor Last Name 352**]-white junction
in the left parietal lobe. There was no clear underlying mass
and there were no underlying vascular abnormalities per MRA (no
aneurysms/AVM). An ECHO, to look for a cardio-embolic etiology,
was negative (no valvular vegetations or intracardiac thrombi;
no PFO/ASD, but not with certainty as the image quality was
poor).
Mr [**Known lastname 65004**] then developed a L thalamic infarct [**1-8**], and was
less alert, with increased R hemiparesis. An EEG ([**1-8**]) showed
focal slowing in the L anterior quadrant. A hemorrhagic
conversion of the infract was then noted on [**1-12**] with some
intraventricular blood (found incidentally when getting CTV).
The CTV ([**1-12**]) showed a L superior sagittal sinus thrombosis
and ?L sigmoid sinus thrombosis with extension into the
internal jugular vein. A repeat head CT [**1-14**], showed no
evidence of hydrocephalus, and no further blood in 4th
ventricle.
Mr. [**Known lastname 65004**] was started on anticoagulation with Lovenox on [**1-13**].
He was also given a short course of Diamox for L hemisphere
edema. Neurosurg was re-consulted to monitor the hemorrhage into
the 4th ventricle given the risk of hydrocephalus. No
intervention was necessary. Follow up CT-head series showed a
stable picture.
.
Psychiatry:
The patient was maintained on seroquel. Depakote was
discontinued, and lithium was started [**1-6**]. Lithium levels
should be monitored closely (every 2 weeks) and the dosing
should be adjusted accordingly. The patient has been closely
followed by the psychiatry service. Please contact Dr. [**Last Name (STitle) 65005**],
[**Numeric Identifier 65006**] if any questions arise. Close follow up will be
arranged. Haldol was given on a PRN basis.
.
Cardiovascular:
An Echo showed an EF>55%. The patient was ruled out for an MI
[**1-8**]. Goal SBP<160. Lipids profile was within normal limits.
EKG should be checked if the patient receives haldol on a
regular basis (risk for prolonged QT).
.
FEN/GI:
-cardiac prudent diet
.
Hematology:
The patient was noted to be thrombocytopenic w/nadir in 80s,
likely secondary to Depakote. Plt normalized after Depakote was
discontinued.
As part of a workup related to the sinus thrombosis the
following tests were done:
-No LE DVT on [**1-11**] U/S.
-Hypercoagulable workup: Fibrinogen 482, D-dimer 2938.
Homocysteine wnl, [**Doctor First Name **] neg, Lupus anticoagulant neg, ATIII wnl,
FVL neg. Prot C slightly low 63, Prot S elevated (?acute phase
reactant). Factor VIII and anticardiolipin normal. Prothrombin
gene mutation pending. Please resend hypercoag workup again in
the future if Pt ever comes off anticoagulation.
The patient was started on anticoagulation with lovenox as he is
not a coumadin candidate. Lovenox level 2.0 on [**1-26**], after which
the dose was decreased; level on [**2-1**]: 1.06; level on [**2-3**]: 0.9
(i.e. within goal range).
.
Other:
The patient has had multiple falls [**12-31**], [**1-5**], [**1-6**] x2, all
secondary to orthostasis, a R field cut, and impulsivity. Please
check orthostatics in case the patient is unsteady.
.
Endocrine:
-TSH 3.4; Levoxyl was continued. Please continue to monitor.
-HbA1C 5.2, no intervention needed.
.
ID:
On Cipro [**Date range (1) 14813**] for E. coli UTI. UA on [**2-2**] was negative.
.
ENT:
Sinus opacification upon admission. This has resolved. If
patient becomes symptomatic he will need ENT follow up.
.
Legal: Mr [**Known lastname 65004**] has a legal guardian since [**1-30**]. [**Name2 (NI) **] is
incompetent to sign consent for procedures as he cannot clearly
understand its risks and benefits. His sister who had been his
previous guardian was legally not permitted to hold this
position any longer.
Medications on Admission:
Depakote 1[**Telephone/Fax (1) 65007**], seroquel 75 hs, cogentin 1 [**Hospital1 **], ASA 325,
levoxyl 12.5
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed.
4. Quetiapine 100 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
5. Quetiapine 100 mg Tablet Sig: 2.5 Tablets PO QHS (once a day
(at bedtime)).
6. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
7. Haloperidol Lactate 5 mg/mL Solution Sig: Two (2) mL
Injection Q4H (every 4 hours) as needed for agitation.
8. Lithium Carbonate 300 mg Capsule Sig: Three (3) Capsule PO
QHS (once a day (at bedtime)).
9. Levothyroxine 25 mcg Tablet Sig: 0.75 Tablet PO DAILY
(Daily).
10. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
11. Benztropine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
Hollywell - [**Location (un) 5110**]
Discharge Diagnosis:
1. Intracranial hemorrhage
2. intracranial ischemic stroke
3. venous sinus thrombosis
4. psychosis
5. urinary tract infection
6. hypothyroidism
Discharge Condition:
Stable
Impulsivity, very mild residual hemiparesis and subtle R-upper
quadrant field cut;
Discharge Instructions:
Please take your medications as instructed.
.
Please check Lithium level every 2 weeks.
.
Please f/u with Neurology, Psychiatry, and your PCP.
Followup Instructions:
Please follow up at the Neurology/[**Hospital 4038**] clinic: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**],
MD, [**MD Number(3) 13795**]:[**Telephone/Fax (1) 657**] Date/Time:[**2156-4-6**] 1:00
.
The patient will need cery close follow up with Psychiatry. Dr.
[**Last Name (STitle) 65005**] [**Numeric Identifier 65006**]) from the Dept. of Psychiatry will leave
instructions for follow up. If you do not hear from him within
one week, please call his number.
.
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week after discharge
from rehab.
.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2156-2-4**]
ICD9 Codes: 5990, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6096
} | Medical Text: Admission Date: [**2136-8-31**] Discharge Date: [**2136-9-7**]
Date of Birth: [**2064-3-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
N/V/diarrhea
Major Surgical or Invasive Procedure:
intubation, placement of femoral line
History of Present Illness:
72 yoF with h/o HIV(CD4 312, VL <50 [**2136-8-23**]),CHF(EF 10%), h/o
endocarditis, who p/w N/V and diarrhea for two days. Diarrhea is
watery, nonbloody. Vomitus is non-bloody. Also reports abdominal
pain.
In ED, patient reported fevers at home to 103. Denied recent
travel, dietary changes, chest pain. Did note mild HA.
.
In the ED, T 96.7, SBP in 80s. Patient's abdomen diffusely
tender and distended. Laboratory studies showed lactate 6.8,
transaminitis with INR 9.1, pancreatitis, acute on chronic renal
failure with hyperkalemia and hyperphosphatemia. Patient
received vancomycin 1 gram, levo 750 mg, and falgyl 500 mg, as
well as 10 mg of vitamin K, 15 grams of kayexalate, 1 amp of
biarb, and calcium gluconate with insulin. She had a femoral CVL
placed and was volume resuscitated but rapidly developed SOB. By
report from ED resident, long discussion with patient held and
patient voiced desire to be DNR but would like to be intubated
and dialyzed. Patient was then intubated and volume
resuscitation continued. Was also briefly placed on levophed for
hypotension which was quickly weaned off. She received a CT of
the abdomen/pelvis which showed some concern for ischemic
changes. Surgery evaluated patient and did not feel there was
any acute indication for surgery. Renal was also consulted and
felt that she did not need emergent dialysis.
.
Of note, recent admit [**Date range (1) 105349**] after presenting with
bradycardia and treated for digoxin and amiodarone toxicity,
acute on CRI, and CHF. Amiodarone stopped (had been started
during prior hospitalization due to runs of Vtach. Also started
on coumadin given severely depressed EF. [**Date range (1) 2775**] therapy was also
discontinued which was verified with her PCP.
Past Medical History:
1. HIV- Diagnosed in [**2116**], has taken [**Year (4 digits) 2775**] therapy
intermittently. Stopped taking her pills three months ago
because stated she had foamy vomit every time she took them. CD4
274, VL<50 in [**12-10**]
2. CHF- EF 10% 7/07 followed by Dr. [**First Name (STitle) 437**]
3. HCV- VL >700K in [**12-9**], not a good candidate for interferon
therapy or liver biopsy per gi note in 04.
4. mild COPD- PFTs [**7-/2129**] showed a normal study
5. IVDU--last abuse heroin several days ago, skin popping
6. Arthritis
7. chronic pancreatitis
8. ventricular tachycardia
Social History:
Has 20 grandchildren, tobacco: [**4-8**] cig/day, 40 py
Heavy EtOH in past. States that last used heroin in the past few
days (skin popping) and also used cocaine in the last month.
Family History:
NC
Physical Exam:
PE: T: 96.2 BP: 83/60 HR: 53 Vent: AC 450x12, PEEP 5, FiO2 1
Gen: intubated, sedated
HEENT: No icterus. Dry MMs. ET tube in place
NECK: Supple, No LAD. JVP ~14 cm H2O.
CV: RRR. nl S1, S2. II/VI holosystolic murmur. +S3.
LUNGS: crackles at bases
ABD: NABS. moderately distended. Soft. Left femoral CVL in place
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: Diffuse scarring from skin popping on lower extremities.
Scarring from presumed IVDU in anticubital fossas
NEURO: pupils equal, dilated, minimally reactive
Pertinent Results:
[**2136-8-30**] 05:59PM HGB-9.4* calcHCT-28
[**2136-8-30**] 05:59PM GLUCOSE-37* LACTATE-6.8* NA+-134* K+-6.1*
CL--101 TCO2-16*
[**2136-8-30**] 06:35PM PT-70.8* PTT-50.9* INR(PT)-9.1*
[**2136-8-30**] 06:35PM PLT SMR-NORMAL PLT COUNT-247
[**2136-8-30**] 06:35PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ BURR-1+
[**2136-8-30**] 06:35PM NEUTS-85* BANDS-0 LYMPHS-10* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2136-8-30**] 06:35PM WBC-7.3 RBC-3.21* HGB-9.4* HCT-29.2* MCV-91
MCH-29.3 MCHC-32.2 RDW-15.4
[**2136-8-30**] 06:35PM CALCIUM-8.8 PHOSPHATE-8.8*# MAGNESIUM-2.9*
[**2136-8-30**] 06:35PM CK-MB-NotDone
[**2136-8-30**] 06:35PM cTropnT-0.04*
[**2136-8-30**] 06:35PM LIPASE-111*
[**2136-8-30**] 06:35PM ALT(SGPT)-345* AST(SGOT)-777* CK(CPK)-91 ALK
PHOS-123* AMYLASE-173* TOT BILI-1.1
[**2136-8-30**] 06:35PM GLUCOSE-168* UREA N-88* CREAT-5.1*#
SODIUM-129* POTASSIUM-6.0* CHLORIDE-92* TOTAL CO2-14* ANION
GAP-29*
[**2136-8-30**] 06:48PM GLUCOSE-165* LACTATE-5.9* K+-5.9*
[**2136-8-30**] 08:19PM PO2-32* PCO2-43 PH-7.30* TOTAL CO2-22 BASE
XS--5 INTUBATED-INTUBATED
[**2136-8-30**] 09:30PM PT-76.8* PTT-68.8* INR(PT)-10.0*
[**2136-8-30**] 09:30PM PLT COUNT-185
[**2136-8-30**] 09:30PM NEUTS-87.1* LYMPHS-8.3* MONOS-4.3 EOS-0.3
BASOS-0
[**2136-8-31**] 03:17AM URINE MUCOUS-FEW
[**2136-8-31**] 03:17AM URINE RBC-21-50* WBC-[**7-15**]* BACTERIA-FEW
YEAST-NONE EPI-<1
[**2136-8-31**] 03:17AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2136-8-31**] 03:17AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2136-8-31**] 03:17AM FIBRINOGE-234 D-DIMER-1335*
[**2136-8-31**] 03:17AM FDP-0-10
[**2136-8-31**] 03:17AM PT-84.2* PTT-52.8* INR(PT)-11.2*
[**2136-8-31**] 03:17AM PLT COUNT-206
[**2136-8-31**] 03:17AM WBC-8.7 RBC-3.30* HGB-9.3* HCT-29.5* MCV-90
MCH-28.4 MCHC-31.6 RDW-15.1
[**2136-8-31**] 03:17AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-POS
[**2136-8-31**] 03:17AM URINE HOURS-RANDOM
[**2136-8-31**] 03:17AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2136-8-31**] 03:17AM CORTISOL-39.6*
[**2136-8-31**] 03:17AM HAPTOGLOB-123
[**2136-8-31**] 03:17AM CALCIUM-8.2* PHOSPHATE-8.7* MAGNESIUM-2.7*
[**2136-8-31**] 03:17AM CK-MB-6 cTropnT-0.03*
[**2136-8-31**] 03:17AM CK(CPK)-68
[**2136-8-31**] 03:17AM GLUCOSE-72 UREA N-84* CREAT-4.9* SODIUM-134
POTASSIUM-6.5* CHLORIDE-99 TOTAL CO2-17* ANION GAP-25*
[**2136-8-31**] 04:35AM CORTISOL-42.2*
[**2136-8-31**] 04:43AM TYPE-ART TEMP-36.1 RATES-12/ TIDAL VOL-450
PEEP-5 O2-100 PO2-348* PCO2-36 PH-7.25* TOTAL CO2-17* BASE
XS--10 AADO2-335 REQ O2-61 -ASSIST/CON INTUBATED-INTUBATED
[**2136-8-31**] 05:43AM CORTISOL-38.6*
[**2136-8-31**] 05:52AM POTASSIUM-5.3*
[**2136-8-31**] 06:06AM O2 SAT-95
[**2136-8-31**] 06:06AM TYPE-[**Last Name (un) **]
[**2136-8-31**] 11:38AM PT-36.2* PTT-49.4* INR(PT)-4.0*
[**2136-8-31**] 11:38AM DIGOXIN-0.5*
[**2136-8-31**] 11:38AM VANCO-<1.7
[**2136-8-31**] 11:38AM POTASSIUM-5.0
[**2136-8-31**] 02:28PM K+-4.1
[**2136-8-31**] 02:28PM TYPE-ART TEMP-35.9 RATES-14/4 TIDAL VOL-450
PEEP-5 O2-50 PO2-91 PCO2-41 PH-7.43 TOTAL CO2-28 BASE XS-2
-ASSIST/CON INTUBATED-INTUBATED
[**2136-8-31**] 06:45PM estGFR-Using this
[**2136-8-31**] 06:45PM GLUCOSE-88 UREA N-84* CREAT-4.3* SODIUM-137
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17
.
CT ABDOMEN W/O CONTRAST [**2136-8-30**] 9:32 PM
1. Linear focus of air within the left renal vein. Approximate
volume is 0.7 cubic centimeters. This is of unclear clinical
significance, but likely relates to injected air from IV
placement or medication administration.
2. Diffuse stranding of the mesentery and abdominal ascites.
Please note, lack of intravenous contrast administration limits
detailed evaluation of the intra-abdominal and pelvic organs.
3. Non-obstructive left upper pole renal calculus.
4. Nasogastric tube should be advanced at least 5 cm for optimal
placement.
.
CT HEAD W/O CONTRAST [**2136-8-31**] 12:41 AM
IMPRESSION: Limited examination secondary to patient motion. No
acute intracranial hemorrhage.
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2136-8-3**].
LEFT ATRIUM: Marked LA enlargement. LA volume markedly
increased.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. The
patient is
mechanically ventilated. Cannot assess RA pressure.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Severe
global LV hypokinesis. No LV mass/thrombus. No resting LVOT
gradient.
RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV
free wall
hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
thickening of
mitral valve chordae. Moderate (2+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate to severe
[3+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Significant
PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Ascites.
Conclusions:
The left and right atria are markedly dilated. The left atrial
volume is
markedly increased. Left ventricular wall thicknesses are
normal. The left ventricular cavity is severely dilated with
severe global hypokinesis (LVEF <20%). No masses or thrombi are
seen in the left ventricle. The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is moderate
thickening of the mitral valve chordae. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2136-8-3**],
the severity of tricuspid regurgitation has progressed.
Biventricular systolic function is similar.
Brief Hospital Course:
Shock:
In the MICU, pt had evidence of multisystem organ dysfunction.
Ddx included septic vs. cardiogenic. There was initial concern
for septic shock given reported high fever, symptoms of GI
infection, and hypotension. However, after volume resuscitation,
pt was extubated, off all pressors and mounting excellent BP for
her EF. It was thought that her hypotension was likely due to
cardiogenic shock in the setting of dehydration from diarrhea
and preload dependence. No source for infection was isolated
during her hospital stay. Mrs [**Known lastname **] was treated with a full 7
day course of levofloxacin and flagyl for presumed
gastroenteritis in immunocompromised patient. Stool cultures,
blood cultures, urine cx remained negative throughout stay.
Was ruled out for MI with serial cardiac enzymes.
CHF: An ECHO was completed on [**2136-8-31**] that revealed marked
dilatation of the left and right atria, normal left ventricular
wall thicknesses. The left
ventricular cavity was severely dilated with severe global
hypokinesis (LVEF
<20%). No masses or thrombi were noted. The right ventricle was
moderately dilated with severe hypokinesis. Moderate (2+)
mitral regurgitation and moderate to severe [3+] tricuspid
regurgitation was seen. There was moderate pulmonary artery
systolic hypertension with significant pulmonic regurgitation.
Patient has been treated with anticoagulation with goal INR [**3-10**]
in setting of her global hypokinesis and poor EF. At the time of
discharge her INR was 1.7 on Coumadin 2mg.
Throughout her hospital course, Mrs. [**Known lastname **] felt short of
breath, was unable to lie flat secondary to orthopnea, and had
cough. CXR on [**2136-9-4**] demonstrated small bilateral pleural
effusion, left greater than right, and left atelectasis vs.
consolidation. She was treated with diuresis, oxygen via nasal
cannula and incentive spirometry. It was felt that her symptoms
were likely secondary to her severe CHF and pulmonary edema.
Patients sats remained good. By the time of discharge she was
comfortable, experienced no SOB but remained on 4L via nasal
cannula for symptomaitc relief. She would have labored breathing
if that aws not administered.
Chronic renal failure- Patients baseline Cr is 1.5-2. Her peak
cr during hospitalization was 4.3 and had returned to baseline
(1.8) by the time of discharge.
Renal failure was thought to be prerenal.
HIV/AIDS
Mrs [**Known lastname **] [**Last Name (NamePattern1) **] most recent labs revealed CD4 count of 312, Viral
load less than 50 on [**2136-8-23**]. She was not started on
antiretrovirals or during her hospital course. Patient was on
PCP prophylaxis with bactrim.
# CODE STATUS: lengthy discussion with pt. and grandson by
primary and CHF teams and pt. made decision that she would like
to seek hospice with focus on comfort and would not want to be
intubated or resuscitated in the future and would like to avoid
future hospitalizations. Her code status was changed and
palliative care consult was called to aid in placement and
delineation of goals. She was screened for hospice.
Medications on Admission:
Methadone 90 mg PO DAILY
Lansoprazole 30 mg PO DAILY
Trimethoprim-Sulfamethoxazole 160-800 mg PO DAILY
Furosemide 100 mg PO BID
Digoxin 125 mcg PO every other day
Coumadin 5 mg PO once a day
Discharge Medications:
1. Warfarin 2 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
2. Ipratropium Bromide 0.02 % Solution [**Year (4 digits) **]: One (1) Inhalation
Q4-6H (every 4 to 6 hours).
3. Digoxin 125 mcg Tablet [**Year (4 digits) **]: Half tablet Tablet PO QMOWEFR
(Monday -Wednesday-Friday).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Year (4 digits) **]: One (1)
Inhalation Q4H (every 4 hours).
5. Furosemide 40 mg Tablet [**Year (4 digits) **]: 2.5 Tablets PO BID (2 times a
day).
6. Methadone 10 mg/mL Concentrate [**Year (4 digits) **]: Three (3) PO TID (3
times a day).
7. Morphine 10 mg/5 mL Solution [**Year (4 digits) **]: One (1) PO Q3H (every 3
hours) as needed for pain or Shortness of breath.
8. Lorazepam 0.5 mg Tablet [**Year (4 digits) **]: [**2-7**] to 1 tablet Tablet PO Q4H
(every 4 hours) as needed for anxiety.
9. Aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11729**] Home - [**Location (un) 686**]
Discharge Diagnosis:
HIV/AIDS (CD4 312, VL< 50 on [**2136-8-23**])
CHF (EF 10%)
Chronic hepatitis C
Discharge Condition:
Stabe
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 0389, 5849, 5859, 4280, 2767, 496, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6097
} | Medical Text: Admission Date: [**2149-11-29**] Discharge Date: [**2149-12-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
black stools and weakness x 7 days.
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
87 yo f w/ h/o CHF, htn, afib, and h/o recent fall resulting in
a compression [**Hospital **] transferred from [**Hospital3 **] for c/o black
stools w/ hct 16.3 and INR 32.3 due to no available ICU beds at
[**Hospital1 392**]. Patient was AF, bp 130/44 and hr 87. She received 2 U
PRBC, 40 IV protonix, and 10 mg IV vit K for this. On arrival to
[**Hospital1 18**] ER, hct 25.2 and INR 2.1. BP 150/54 and hr 70. Patient
received additional 5 mg SQ vit K, in addition to 2 U FFP. NG
lavage was done and yielded coffee ground emesis w/ the first
250 cc, followed by a pink-tinged fluid with the second 250 cc.
On hx patient reports no po x 2 weeks due to nausea w/o c/o pain
w/ eating. She has never had black stools in the past. She is on
coumadin and her level was low 3 weeks ago (per her report) and
thus her coumadin was increased. Patient denies any diarrhea w/
the black stool. She is N but no V, and she denies abd pain. No
h/o NSAIDs and no h/o PUD. No BRBPR or hematemesis. She also
denies c/o LH, COP, or SOB. However, she has been completely
exhausted for the past week.
Past Medical History:
## CHF
## HTN
## afib on coumadin
## h/o compression fx due to fall
## s/p recent fall (2 wks ago)
Social History:
+ h/o tob: [**11-20**] pk yr hx, quit 25 yrs ago.
No Etoh x 4 yrs, occasional in the past.
Married and has 1 daughter. Contact for emergencies: [**Name (NI) **] [**Name (NI) **]
(sister).
Family History:
NC
Physical Exam:
T 99.1 hr 71 bp 155/65 rr 18 O2 92% RA (100% on 4L NC)
genrl: in nad, pleasant
heent: perrla (3->2 mm), MMM, OP clear, NGT in place (120 cc
lavage continues to produce coffee grounds)
neck: no JVD
cv: rrr, no m/r/g
pulm: cta bilaterally
abd: nabs, soft, nt/nd, no masses/hsm
rectal: black, guiac positive stool surrounding anus
extr: no [**Location (un) **]
neuro: a, o x 3, strength and soft touch sensation [**6-5**] grossly
in UE/LE
Pertinent Results:
[**2149-11-29**] 02:42PM WBC-16.8* RBC-2.81* HGB-9.0* HCT-25.2* MCV-90
MCH-31.9 MCHC-35.6* RDW-16.0* PLT COUNT-281
[**2149-11-29**] 02:42PM NEUTS-82.8* LYMPHS-13.3* MONOS-3.5 EOS-0.3
BASOS-0.2
[**2149-11-29**] 02:42PM PT-17.5* PTT-26.8 INR(PT)-2.1
[**2149-11-29**] 02:42PM GLUCOSE-115* UREA N-45* CREAT-1.0 SODIUM-141
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-30 ANION GAP-14
.
[**2149-12-3**] 05:03AM BLOOD WBC-11.7* RBC-3.53* Hgb-11.4* Hct-32.7*
MCV-93 MCH-32.2* MCHC-34.8 RDW-15.5 Plt Ct-325
[**2149-12-3**] 05:03AM BLOOD Plt Ct-325
[**2149-12-3**] 05:03AM BLOOD Glucose-91 UreaN-21* Creat-1.0 Na-139
K-4.2 Cl-99 HCO3-31 AnGap-13
[**2149-12-3**] 05:03AM BLOOD Mg-1.8
.
CXR [**2149-11-29**]:
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with bibasilar crackles w/ h/o chf
REASON FOR THIS EXAMINATION:
r/o CHF
HISTORY: Bibasilar crackles, rule out CHF.
CHEST, SINGLE AP VIEW. No previous chest x-rays on PACS record
for comparison.
The lungs are hyperinflated. There is moderate to moderately
severe cardiomegaly. There is subsegmental atelectasis and/or
scarring at both bases. There is minimal blunting of both
costophrenic angles. There is no CHF or frank consolidation. I
doubt the presence of an infectious infiltrate. There is right
upper hilar peribronchial cuffing. Linear atelectasis or
scarring noted in the right mid zone. An NG tube is present, tip
over proximal stomach. There is osteopenia and an old ununited
left clavicle fracture.
IMPRESSION: Hyperinflation and cardiomegaly. Right upper hilar
peribronchial cuffing. No CHF. Doubt acute infectious
infiltrate.
.
CT HEAD W/O CONTRAST [**2149-11-29**] 4:59 PM
CT HEAD W/O CONTRAST
Reason: r/o ich
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with recent head trauma, INR 35
REASON FOR THIS EXAMINATION:
r/o ich
CONTRAINDICATIONS for IV CONTRAST: None.
CT HEAD
INDICATION: Recent head trauma, INR 35.
No prior studies are available for comparison.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no intraparenchymal or extra-axial
hemorrhage. There is no shift of normally midline structures,
mass effect or hydrocephalus. There is mild prominence of the
ventricles and sulci consistent with age-related involutional
change. Encephalomalacic changes are demonstrated in the
anterior and medial portions of the frontal lobes bilaterally.
There is also encephalomalacic change demonstrated in the left
occipital lobe. Periventricular white matter hypodensities are
also noted consistent with chronic small vessel ischemic change.
The visualized paranasal sinuses and osseous structures are
within normal limits.
IMPRESSION:
1. No intracranial hemorrhage or mass effect.
2. Encephalomalacic changes in the bifrontal lobes and left
occipital lobe.
.
CXR [**2149-11-29**]:
Atrial fibrillation
Modest nonspecific intraventricular conduction delay
Modest ST-T wave changes with probable QT interval prolonged
although is
difficult to measure - are nonspecific but clinical correlation
is suggested for possible in part metabolc/drug effect.
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 0 118 446/479 0 -21 107
.
Patient: [**Known firstname 2127**] [**Known lastname 780**]
Ref.Phys.:
Birth Date: [**2062-8-14**] (87 years) Instrument: GIF XQ140
gastroscope
ID#: [**Numeric Identifier 62551**] ASA Class: P2
Medications: Cetacaine topical spray
Meperidine 25mg
Midazolam 1mg
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
Conscious sedation anesthesia. The patient was placed in the
left lateral decubitus position and an endoscope was introduced
through the mouth and advanced under direct visualization until
the second part of the duodenum was reached. Careful
visualization of the upper GI tract was performed. The procedure
was not difficult. The patient tolerated the procedure well.
There were no complications.
Findings: Esophagus:
Lumen: A small size hiatal hernia was seen.
Excavated Lesions A single non-bleeding 6mm ulcer was found in
the gastroesophageal junction.
Stomach:
Contents: Old blood was seen in the stomach. No sites of active
bleeding were identified.
Duodenum: Normal duodenum.
Impression: Blood in the stomach
Ulcer in the gastroesophageal junction
Small hiatal hernia
Brief Hospital Course:
87 yo f w/ h/o CHF, HTN, fib, and h/o recent fall transferred
from OSH w/ likely UGI in setting of elevated INRX (on
Coumadin).
.
## UGI: The patient's HCT was 16.3 with INR 32.3 at OSH. The
patient received 2 units of PR BC, Protonix 40 mg iv, and 10 mg
IV Vit K at the OSH. Due to no ICU availability, the patient
was transferred to [**Hospital1 18**]. On arrival to [**Hospital1 18**], her HCT was 25.2
with INR 2.1. She received additional mg sc Vit K and 2 u FFP.
NG lavage showed coffee ground emesis followed by a pink-tinged
fluid. CT of head was neg for bleeds. The patient was started
on Protonix 40 mg iv bid and observed overnight in the MICU, and
GI did not feel that urgent EGD was necessary as the patient was
hemodynamically stable with stable HCT after blood transfusion.
The patient was transferred to the floor in a hemodynamically
stable and hct was stable at 33.2. EGD was performed on [**12-1**]
which showed an ulcer at GE junction and old blood in the
stomach without signs of active bleeding. The patient was
switched to po Protonix [**Hospital1 **] after the procedure and hct
continued to remain stable at the time of discharge. The
patient is to follow up with Dr. [**First Name (STitle) 1356**], her PCP, [**Name10 (NameIs) **] decide on
when to restart coumadin and close monitor of INR when she gets
placed on coumadin again.
.
## CHF: After a total of 4 units of PRBC transfusion, the
patient became hypoxemic and required supplemental O2 to keep O2
sat above 92. Her lung exam was consistent with pulmonary
edema. She was given IV lasix and her hypoxemia resolved. Once
satting 95-97% on RA, she was restarted on her outpatient po
lasix regimen.
.
## Afib: Held beta blocker initially given UGIB. Once stable
hemodynamically, outpatient atenolol 100mg qday and amlodipine
5mg qday were restarted for rate control. No coumadin was given
during this hospitalization. GI felt that she can be restarted
on coumadin but with close monitor of INR with goal of [**3-6**].
.
## HTN: No antihypertensives given while in the MICU. Received
lasix iv for pulmonary edema and gradually added her outpatient
antihypertensives, atenolol, amlodipine, and lasix.
.
## S/p recent fall: Head CT w/o bleed or shift. The patient did
not have other musculoskeletal pain anywhere.
.
## Leukocytosis: No clear sources and the patient remained
afebrile. WBC continued to trend down and at the time of
discharge, wbc was 11.7. Ua/ucx and bcx and CXR were negative
for infection.
.
## PPX: pneumoboots, ppi
- PT recommended outpatient PT as the patient became
deconditioned during this hospitalization. The patient was
discharged home with PT services.
.
## FEN: Cardiac diet. Repleted 'lytes/prn.
.
## Full code (confirmed w/ patient)
Medications on Admission:
coumadin 1 mg po qd
lasix 40 mg po qam, 20 mg po qpm
atenolol 100 mg po qd
amlodipine 5 mg po qd
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. Furosemide 40 mg Tablet Sig: One (1) Tablet PO qam.
Disp:*30 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Ativan 0.5 mg Tablet Sig: [**2-2**] Tablet PO once a day as needed
for anxiety for 10 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Principal:
1. Upper GI bleed.
2. Gastric Ulcer.
3. Blood Loss Anemia.
Secondary:
1. Atrial Fibrillation.
2. Heart Failure (EF unknown)
3. Hypertension.
4. Vertebral Compression Fracture.
Discharge Condition:
Stable. Hematocrit stable at 32.7.
Discharge Instructions:
Return to the emergency department or call your primary care
physician if you develop chest pain, shortness of breath, blood
in your stools, abdominal pain, nausea, vomiting, bloody sputum,
or any other worrisome symptoms.
Do not take coumadin until you see you primary care physician
tells you so. You may resume all your blood pressure
medications as previously prescribed. We've added Protonix 40mg
twice a day for your stomach ulcer. You have a follow-up
appointment with Dr. [**First Name (STitle) 1356**] on [**2149-12-4**], Thursday at 10:50 am.
Discuss with your primary care physician about starting calcium,
vitamin D, and possibly bisphophonates for osteoporosis.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 1356**], [**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Phone number: [**Telephone/Fax (1) 17465**].
Date/Time: [**2149-12-4**] at 10:50am.
2. Outpatient H. Pylori antibody assay - to be performed by Dr.
[**First Name (STitle) 1356**].
3. Please ask Dr. [**First Name (STitle) 1356**] to start you on calcium and vitamin D
supplementation for osteoporosis. She may also add another
medication callled a Bisphosphonate for this as well.
ICD9 Codes: 4280, 4019, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6098
} | Medical Text: Admission Date: [**2126-7-3**] Discharge Date: [**2126-7-12**]
Date of Birth: [**2100-9-21**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
CC: Increasing lethargy, malaise and chest secretions
Major Surgical or Invasive Procedure:
Replacement of G-tube on [**2126-7-11**] after it fell out.
History of Present Illness:
25 year old female with h/o [**Date Range 14165**] cell anemia, 2 strokes,
wheelchair bound, recently had aspiration pneunomia which was
treated with ceftriaxone and Unasyn. Patient was sent to rehab
after a brief hospitalization and then from rehab to home.
Patient had increased secretions from 5 days PTA. From the
morning of [**7-2**], patient had increased lethargy and had fevers
to 102. Seen at [**Hospital **] Hospital where there was concern for
stroke; she was noted also to have guaic positive drainage from
J-tube site. CT raised the concern of possible stroke with new
bleed in the R external capsule. INR measured there was 3.9, as
patient had been on coumadin since stroke in [**2123**]. Patient was
transferred here because of concern for intracranial hemorrhage.
There is also a history of a bloody stool; it is unclear when
that bloody stool happened. [**Name (NI) **] mother reports dark
discharge from the J-tube.
ER Course: Patient had leukocytosis to 51.7 with 81%
neutrophils, 1% bands. Repeat head CT shows R basal ganglia
calcification, however bleed could not be excluded; size has not
increased from CT at OSH taken 8 hours earlier; multiple old
bilateral hemispheric infarcts and likely pontine infarct.
MICU Admission for: Initial concern for new intracranial
hemorrhage.
Past Medical History:
PMH: s/p CVA x 2; 1st at age 7 years which left her mildly
mentally retarted, 2nd in [**2123**] gave her L foot and R arm plegia,
wheelchair bound, aphasic, s/p PEG, s/p J-tube, chronic
leukocytosis, urinary tract infections, seizure disorder,
chronic aspiration pneumonia, vertigo.
Social History:
Lives at home; mother is primary caregiver[**Telephone/Fax (3) 58519**]) . Does
not smoke, drink alcohol or use illicit drugs. Patient has a 5
year old child. She receives VNA services. Patient at baseline
is unable to take care of herself; dependent on assistance for
ADLs.
Family History:
[**Name (NI) **] son has [**Name2 (NI) 14165**] trait vs [**Name2 (NI) 14165**] disease, as does a
cousin.
Physical Exam:
Examination: T:102, HR:110, BP: 112/69, R:13, 93% on RA.
Gen: Young AAF, eyes open, responsive through gestures, lying in
bed looking fatigued.
HEENT: PERRL, EOMI, Anicteric
Neck: Supple, NT.
Skin: WWP; no rashes.
Chest: Crackles at both bases; patient unable to respond to
request to cough.
CVS: Tachycardia, normal S1/S2.
Abd: J-tube and G-tube in place; purulent, greenish drainage
surrounding J-tube.
Ext: Tender L foot; no obvious swelling or sign of trauma; no
warmth.
Neuro: Mental status as described above.
CNII-XII: Appears to be grossly intact.
Motor: R arm 0/5, L arm [**1-10**]; able to grasp with L hand.
DTRs: [**Name2 (NI) 35632**], Elbow 2+/2 bilat.
Sensory: Hard to examine.
Pertinent Results:
CXR [**2126-7-2**]: Low lung volumes, no radiographic evidence of
pneumonia.
CT head w/o contrast [**2126-7-2**]: 1) Amorphous area of increased
attenuation in the right basal ganglia/subinsular white
matter/periventricular white matter near the atrium of the right
lateral ventricle. This has the appearance of calcification,
but blood products cannot be excluded. The area has not
increased in size since the head CT scan from eight hours
earlier. 2) Multiple bilateral hemispheric infarcts and likely
pontine infarct as well. 3) Decreased size of brain, with
expansion of maxillary sinuses and inner table, consistent with
the patient's chronic mental retardation.
MR head w/o contrast [**2126-7-3**]: 1) No evidence of acute
infarction, although diffusion-weighted imagining would be more
sensitive for acute infarction. 2) Evidence of multiple past
infarcts, including evidence of past hemorrhage in the right
putamen and in a small region of the right parietal lobe.
CT head w/o contrast [**2126-7-3**]: 1) Stable appearance of the brain
with no interval change noted since the previous exam. Multiple
old hemispheric infarcts noted. Diffusion-weighted images are
more sensitive to detect acute infarct. 2) A small area of
increased attenuation in the right basal ganglia is suggestive
of amorphous calcificatinos rather than blood by-products. A
followup scan might be helpful based on clinical findings.
CXR [**2126-7-4**]: Interval development of bibasilar patchy
opacities, which may represent aspiration.
MRA brain w/o contrast [**2126-7-5**]: 1) No significant interval
change in the brain MR. On this study, however, diffusion
weighted images were performed, and these showed no evidence of
acute infarction. There is evidence of a chronic resolved slit
hemorrhage in the right putamen, likely related to previous
ischemic infarction. There are widespread areas of chronic
infarction in the subcortical white matter. 2) The MRA shows
absent flow signals in multiple major arteries of the circle of
[**Location (un) **] with evidence of extensive formation of collaterals. This
appearance is consistent with Moyamoya syndrome related to
chronic occlusions among the major cerebral arteries.
CXR [**2126-7-6**]: 1) Since the previous study there has been some
improvement in the degree of right lower lobe partial
atelectasis. 2) Areas of patchy infiltration in the right upper
lobe and left upper lobe and left lower lobe are unchanged. 3)
The tip of the SVP line remains in the right atrium.
CT head w/o contrast [**2126-7-6**]: 1) No new intracranial
hemorrhage. Appearance of brain unchanged since [**2126-6-3**].
CT abd/pelvis w contrast [**2126-7-6**]: 1) Bilateral lower lobe
patchy consolidations consistent with patient's known chronic
aspiration. 2) No evidence of acute intraabdominal abnormality.
Multiple small mesenteric lymph nodes are present which do not
meet CT criteria for pathological enlargement. Spleen small and
dense, likely reflecting calcification.
Video oropharyngeal swallow study [**2126-7-8**]: Penetration and
aspiration with nectar thick and thin liquids secondary to poor
bolus control and premature spillover. Aspiration was silent,
and cued coughs were inefective for clearing the airway of
barium. She showed evidence of phonatory apraxia in her delayed
and discoordinated cued coughs. Pureed and honey think liquids
(by tsp) were not penetrated or aspirated during this study
today. 1) Maintain PEG for primary source of nutrition,
hydration, meds. 2) Pureed foods and honey thick liquids by
teaspoon for pleasure may be allowed.
[**2126-7-2**] 08:50PM PT-19.3* PTT-44.8* INR(PT)-2.5
[**2126-7-2**] 08:50PM PLT COUNT-453*
[**2126-7-2**] 08:50PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-3+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-2+ SPHEROCYT-OCCASIONAL
[**Month/Day/Year **]-2+ STIPPLED-2+ PAPPENHEI-2+
[**2126-7-2**] 08:50PM NEUTS-81* BANDS-1 LYMPHS-9* MONOS-9 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2126-7-2**] 08:50PM WBC-51.7* RBC-2.84* HGB-9.1* HCT-26.1* MCV-92
MCH-31.9 MCHC-34.7 RDW-21.7*
[**2126-7-2**] 08:50PM CALCIUM-9.3 PHOSPHATE-4.4 MAGNESIUM-2.1
[**2126-7-2**] 08:50PM GLUCOSE-114* UREA N-15 CREAT-0.4 SODIUM-144
POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-26 ANION GAP-17
[**2126-7-2**] 10:45PM URINE RBC->50 WBC-[**2-8**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2126-7-2**] 10:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-7.0 LEUK-SM
[**2126-7-2**] 10:45PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2126-7-3**] 04:15AM WBC-34.9* RBC-2.59* HGB-8.0* HCT-24.2* MCV-93
MCH-30.8 MCHC-33.0 RDW-21.2*
[**2126-7-3**] 06:30AM HAPTOGLOB-<20*
[**2126-7-3**] 01:33PM HCT-23.1*
[**2126-7-3**] 06:30AM TSH-1.2
Brief Hospital Course:
MICU course: While in the MICU, the patient was seen by
neurology and neurosurgery to further evaluate the possibility
of a new intracranial hemorrhage. In light of this, coumadin
was discontinued, pending the results of the workup. The
patient had multiple head CTs, described in pertinent results
section. The conclusion from the scans was that Ms. [**Known lastname **] did
not have any new CVA, ischemic or hemorrhagic. Of note, the
findings raised a suggestion of Moyamoya disease. Also while in
the MICU, the patient was found to have one blood culture bottle
positive for enterococcus that was ampicillin sensitive. The
change in mental status and elevated wbc count and temperature
on admission were thought to be secondary to chronic aspiration,
as a CXR on [**7-4**] revealed bilateral opacities consistent with
aspiration pneumonia.
Also while in the MICU the patient was seen by gastroenterology
to investigate the guaiac positive drainage noted from the
J-tube site while the patient was at [**Hospital **] hospital, and the
report of one episode of bloody stool, as per the mother. They
did not feel that the patient was having a GI bleed, as the
patient's hematocrit remained stable, and there was noted to be
no melanotic drainage from J-tube since arrival in our hospital,
nor hematochezia. Stool was found to be negative for
salmonella, shigella, campylobacter, C.Difficile. We followed
with serial hematocrits, which have been stable between 19 and
22 (unclear baseline), with no further melena/hematochezia
noted.
The patient was transferred from the MICU to the general floors
on [**2126-7-4**].
While on the floors, we addressed the patient's numerous
problems, with the common difficulty being uncertainty regarding
the rational for medical decisions made for her in the past.
1) Infectious disease: We continued to treat the patient for
her presumed aspiration pneumonia with ceftriaxone and flagyl.
A TTE was performed to rule out endocarditis in light of the
enterococcus cultured from her blood, which was negative. At
this time, on [**2126-7-8**], flagyl was discontinued and a two week
course of IV ampicillin for treatment of the positive
enterococcal blood culture was begun. At the time of this
discharge summary ([**2126-7-12**]), the patient is on day [**4-19**] of
ampicillin, and has completed a 10 day course of ceftriaxone.
2) Neuro: An extensive effort was made at obtaining CT scan
reports from the patient's [**2123**] stroke, which the mother says
was managed at [**Name (NI) **] (Medical College of [**State 4260**]), phone number
([**Telephone/Fax (1) 58520**], however they claim that the patient was not there
in [**2123**]. After a review of all CT/MRI reports from our
hospital, and a thorough investigation of the issue, we have
decided to stop this patient's coumadin treatment. The
rationale behind this is many-fold. First, we have to assume
that the coumadin was initially begun due to concern for strokes
that were embolic in nature. However, patients with [**Year (4 digits) 14165**] cell
disease are known to develop ischemic strokes, and coumadin has
no demonstrated efficacy in these patients (see review in the
American Journal of Medicine, [**2125-11-19**]).
Additionally, there is still some uncertaintly as to whether or
not the patient has had a hemorrhagic stroke in the past, as the
MRI of [**7-3**] revealed evidence of past hemorrhage, in which case
coumadin would most definitely be contraindicated.
Additionally, the finding of changes characteristic of Moyamoya
syndrome on MRI also preclude the use of coumadin, as these
patients are prone to ischemic strokes as children, followed by
hemorrhagic strokes as adults due to the fragility of the
collateral vessles that develop in response to the stenotic
vessels of the Circle of [**Location (un) 431**]. For all of these reasons, we
believe that holding coumadin is the most rational approach to
the management of this patient's unfortunate neurologic status.
The patient also has a history of seizures, and was maintained
on Oxcarbazepine 300 mg PO BID without any seizure activity.
3) Heme: The patient continued to have a chronically low
hematocrit, which fluctuated between 19 and 22 without receiving
any transfusions. We obtained iron studies, which demonstrated
iron overload, which was expected in this patient who has been
transfusion dependent, as per mother, and was on deferoxamine
therapy 12 mL IV before admission to our hospital. We restarted
her deferoxamin at 1g IM per day, however the patient should be
switched to IV so that she doesn't have to get painful IM shots
everyday in the future. Her reticulocyte count was 10.4, which
indicates appropriate marrow response to her severe anemia. A
B12 level was within normal limits. We started the patient on
Folic Acid 3 mg per day, which should be continued in this
patient with chronic hemolysis from [**Location (un) 14165**] cell disease.
Additionally, her peripheral smear persistently demonstrates not
only sickled cells but also target cells, which is not typical
of SSD, therefore a hemoglobin electrophoresis was ordered, and
the patient was seen by hematology. She will follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with whom she has an appointment on [**2126-8-20**]
([**Telephone/Fax (1) 9645**]).
[**Known firstname 58521**] should be on iron chelators chronically however it would
be safe for her not to be on chelators for a few weeks while at
rehab. This would only be acceptable for 2-3 weeks at most.
Ms. [**Known lastname **] also appears to have a chronic leukocytosis, usually in
the 20,000 range. She is currently at her baseline after being
as high as 50,000 on admission.
4) GI: The patient has had a G and a J tube for unknown
duration, with multiple adjustments and replacements. There was
noted to be scant purulent drainage around both tubes, which
surgery evaluated. As per the mother, there is always some
drainage around the tubes, however it was noted to have
increased. Surgery felt that the drainage was simply the tube
feeds, as the areas were not noted to be erythematous,
indurated, or tender. A would culture from [**7-3**] revealed sparse
growth of MRSA, which was presumed to be colonization rather
than infection in this chronically ill and hospitalized patient,
without obvious signs of infection around the tube site.
The question of the rationale behind the coexistance of a G-tube
and a J-tube was discussed. We do not have any records, however
it was assumed that the G-tube may have been placed in order to
decompress the stomach and prevent aspiration if gastroparesis
was present. The patient was also on Reglan, assumedly for the
same rationale. The G-tube has not been used while in our
hospital, as the J-tube is used for the tube feeds, therefore it
is unclear whether or not the patient really needs this
additional tube. We are keeping it capped for now, not on
continuous suction, and flushing it periodically to maintain
patency. This tube should be kept in and flushed periodically
for now, but if there continues to be no use for the tube, Dr.
[**Last Name (STitle) **] (her new PCP) will consider having the tube removed.
Additionally, the patient has not received Reglan for the 3 days
prior to discharge, without any problems, therefore we will
leave this medication on a PRN basis, and it may be safe to
completely discontinue if there continues to be no need.
There continued to be no evidence of GI bleed for the remainder
of the [**Hospital 228**] hospital course. GI recommended that if there
is ever again any suspicion, the patient can at that time have
an EGD.
5) FEN - The patient had a video swallow study in light of the
suspicion of chronic aspiration, which is detailed in the
pertinent results section. The outcome of this was that the
patient may try pureed and honey thick foods for pleasure, still
maintaining tube feeds as her primary source of nutrition -
Probalance Full strength at 55 mL/hour. The patient aspirated
with non-thickened fluids. For now, the patient has been taking
pureed and honey-thick foods, however if the patient continues
to develop aspiration pneumonias, these may have to be
discontinued. The patient's aspiration, however, is most likely
gastric contents rather than food.
6) Chronic Pain: The patient has a history of chronic pain and
came in on a Fentanyl patch, which was continued while in house.
In the future it would be useful to clarify the necessity of
maintaining this. In light of the chronic opiate use and
immobility, Ms. [**Known lastname **] was given a bowel regimen while here, which
should be continued.
7) Psych: Ms. [**Known lastname **] was on Lexapro 20 mg PO qd on admission, and
was maintained on this. However, the mother reports that the
patient has continued to have depressed mood and lack of
motivation, with behavior indicating hopelessness since her
stroke in [**2123**], and therefore psychiatry was consulted regarding
the appropriate medication choice. In patients with multiple
medical problems and a clear organic basis for depression,
Ritalin can be helpful, and this should be considered in the
future.
8) Lines: Ms. [**Known lastname **] has had a portacath for 4 years, as per
admission note. For now this should be left in as she is on IV
abx and with chronic aspiration is likely to need IV abx in the
future, in addition to multiple other IV medications. Also see
discussion of G and J tubes above.
9) Prophylaxis: Ms. [**Known lastname **] was given Lansoprazole Oral Suspension
30 mg NG QD while here, which does not need to be continued as
there is no clear indication (no high dose steroids, respirator,
sepsis, etc.) for a PPI. However, if the G-tube were ever to
resume function this might be a good addition, as it could help
prevent the development of alkalosis (would be removing a less
acidic fluid from the stomach).
She was started on prophylactic lovenox 40 mg SQ per day on the
day of discharge, as she is largely immobile with multiple
medical problems.
10) PT/OT - [**Known firstname 58521**] was seen by PT and OT on [**2126-7-11**], who both
felt that the patient could benefit from continued therapy. PT
felt the patient has good potential to improve her functioning,
and felt she would benefit from a rehab facility to include [**2-8**]
hours of combined therapy per day. OT also felt that [**Known firstname 58521**]
has good potential for progress given cognitive status,
willingness to work with therapy, and AROM of all 4 extremities,
and recommended d/c to acute rehab facility with goal of
eventually returning home with family once functional status is
maximized.
Medications on Admission:
Coumadin 10 mg po once daily, Deferoxamine, escitalopram 20 mg
qpm, miralax, colace 100, reglan 10 mg q6, Xanax 0.125 mg [**Hospital1 **]
prn, morphine 20 mg q6, baclofen, fentanyl patch 150 Q72H,
Trileptal 300 mg Q6H, Percocet.
Discharge Medications:
1. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
8. Folic Acid 1 mg Tablet Sig: Three (3) Tablet PO QD (once a
day).
9. Deferoxamine Mesylate 500 mg Recon Soln Sig: Two (2) Recon
Soln Injection Q24H (every 24 hours).
10. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day) as needed.
11. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous Q24H (every 24 hours).
12. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
[**Location (un) **] Cell Disease, previously transfusion dependent
Cerebrovascular accident x 2 with residual aphasia, mild mental
retardation, plegia L>R.
Chronic pain syndrome
Chronic aspiration
Aspiration pneumonia
Absence seizure disorder
Recurrent UTI
Chronic leukocytosis
Discharge Condition:
Stable, at baseline.
Discharge Instructions:
Please continue medications as directed.
Please keep G-tube capped for now, with TID flushes to maintain
patency (will consider removal at a later date).
Continue IV Ampicillin for 9 more days (pt. on day 5 out of 14
on [**2126-7-12**]).
Acute PT/OT.
Can wean off O2, keeping sats above 90-93% (currently on NC 1L).
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2126-8-20**] 11:00
-call to confirm appointment
Primary Care Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. Call for appointment
([**Telephone/Fax (1) 1921**].
ICD9 Codes: 5070, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6099
} | Medical Text: Admission Date: [**2195-4-9**] Discharge Date: [**2195-4-19**]
Date of Birth: [**2127-2-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain s/p hip replacement
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4
urgent with a left internal mammary artery graft to left
anterior descending and reverse saphenous vein graft to the
marginal branch, diagonal branch and posterior descending
artery.
History of Present Illness:
68 yo male underwent a R total hip
replacement [**4-7**] for osteoarthritis. The procedure was
uncomplicated, but the night of POD 0 and early morning on POD 1
he develpoed indigestion, nausea, vomiting with chest pain
radiating to both hands with a tingling sensation. He develpoed
EKG changes with ST depression in inferior and lateral leads
which have resolved. His peak troponin was 22 at 6am on [**4-9**].
He underwent cardiac cath on [**4-9**] which showed elevated LVEDP
and
severe 3vd. He is transfered to [**Hospital1 18**] for surgical evaluation.
Past Medical History:
hypertension
hyperlipidemia
Past Surgical History:
s/p R hip replacement [**2195-4-7**]
Social History:
Lives with:wife
Occupation:truck driver for Shaws
Tobacco: Nonsmoker
ETOH: about 1 beer/day
Family History:
Positive for father with arthritis and
hypertensiion. mother s/p valve replacement x3
Physical Exam:
Pulse:84 Resp: 18 O2 sat:96% on 3L NC
B/P Right: 144/66 Left:
Height:5'[**95**]" Weight:208#
General:
Skin: Dry [x] intact [x] L leg w/dry skin and mild chronic
venous
stasis discoloration
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No Murmur
Abdomen: Softly distended [x] non-tender [x] bowel sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema none[x]
Varicosities: None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right:post cath TR band in place Left:2+
Carotid Bruit Right:? soft bruit Left:none
R hip incision no erythema or obvious bleeding, transparent
dressing with small amount of blood. Area edematous, slightly
tender, no bruising noted
Discharge Physical
VS: T: 98.1 HR: 80-90 SR BP: 120-130's/ 60-70 RR 18 Sats: 98
2L
Wt: 94.6 ([**2195-4-19**])
General: 68 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: decreased breath sounds with crackles 1/4 up bilateral
GI: bowel sounds positive, abdomen soft non-tender/on-distended
Extr: warm R 3+ edema, L 2+
Incision: sternal clean/dry/intact, stable, Right hip site
ecchymotic with 3+ edema
Neuro: awake, alert oriented
Pertinent Results:
[**2195-4-18**] WBC-13.7* RBC-3.75* Hgb-11.6* Hct-32.1* MCV-86 MCH-31.0
MCHC-36.2* RDW-13.9 Plt Ct-301
[**2195-4-9**] WBC-12.4* RBC-3.57* Hgb-11.0* Hct-30.7* MCV-86 MCH-30.8
MCHC-35.8* RDW-13.3 Plt Ct-156
[**2195-4-18**] PT-36.1* INR(PT)-3.6* [**2195-4-17**] PT-17.4* INR(PT)-1.6*
[**2195-4-16**] PT-14.5* INR(PT)-1.3*
[**2195-4-18**] UreaN-26* Creat-0.9 Na-137 K-4.0 Cl-96
[**2195-4-9**] Glucose-122* UreaN-18 Creat-0.9 Na-140 K-3.9 Cl-104
HCO3-31
[**2195-4-18**] ALT-21 AST-22 LD(LDH)-364* AlkPhos-118 Amylase-126*
TotBili-1.9*
[**2195-4-16**] ALT-21 AST-21 AlkPhos-74 Amylase-73 TotBili-1.9*
[**2195-4-18**] Lipase-249
[**2195-4-16**] Lipase-93*
[**2195-4-17**] Abdomen: Persistent bowel dilatation, consistent with
ileus.
CXR: [**2195-4-15**]: FINDINGS: The patient has been extubated. The
left chest tube has been removed without evidence for
pneumothorax. The right internal jugular line and intestinal
tube have been removed. The stomach is distended. Persistent
small left pleural effusion and basilar atelectasis are
unchanged. Mild pulmonary vascular congestion persists.
Brief Hospital Course:
The patient was brought emergently to the operating room on
[**2195-4-13**] with a NSTEMI post-operatively from a right total hip
replacement on [**2195-4-7**]. The patient underwent a coronary
artery bypass grafting x4 with a left internal mammary artery
graft to left anterior descending and reverse saphenous vein
graft to the
marginal branch, diagonal branch and posterior descending
artery. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. On POD #1 the
patient was extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. On POD#1 the patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication on POD #2.
Respiratory: Sucessfully extubated POD1. Aggressive pulmonary
toilet, nebs, incentive spirometer his oxygen requirements
improved to 98% 2L via nasal cannula
Cardiac: pacing wires removed [**2195-4-16**]. Beta-blockers were
initiated he weaned off NTG. On [**2195-4-15**] he developed atrial
fibrillation rate 130-160's converted to sinus rhythm with
amiodarone IV load, Dilt drip he converted to sinus rhythm. He
continued to have intermittent RAF 130-160's. His was
transitioned to PO 30 qid, Beta-block 37.5 mg [**Hospital1 **] and amiodarone
PO 400 mg [**Hospital1 **]. Heart rate 80-90's SR. ACE and statins were
restarted. He was hypertensive his home meds clonidine,
doxazosin were restarted with SBP 120-130's.
GI: aggressive bowel regime and PPI were continued. His diet
was slowly advanced but was found to an ileus on [**2195-4-17**]. He
was kept NPO, KUB showed stool in colon/air in small bowel.
Aggressive bowel regime continued with good results on [**2195-4-18**].
His diet was slowly increased which he tolerated.
Renal: gently diuresed. Renal function remained within normal
limits with good urine output. His electrolytes were repleted
as needed.
Heme: [**2195-4-14**] he was transfused 2 units PRBC for HCT 23 to Hct
of 27. Heparin SQ DVT prophylaxis was transitioned to Lovenox
40 mg [**Hospital1 **] was started [**4-17**], Warfarin 3 mg was given [**4-16**] & [**4-17**],
INR [**4-18**] 3.2 warfarin was held. INR [**4-19**] 2.9 0.5 mg ordered. He
will follow-up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 21448**] for warfarin managment as
an outpatient.
Endocrine: insulin sliding scale and lantus were given. His
blood sugars were less than < 200. Please adjust and titrate
off.
Pain: IV Dilaudid transitioned to PO Dilaudid which was stopped
when his ileus developed. He was given acetaminophen with good
pain control.
Disposition: he was seen by physical therapy recommended rehab.
He was discharged to [**Hospital3 **] TCu on [**2195-4-19**]. He will
follow-up as an outpatient with Dr. [**Last Name (STitle) **], his orthopedic
surgeon, and PCP for outpatient warfarin follow-up.
Medications on Admission:
Bisoprolol-HCTZ [**11-24**] daily, Doxazosin 4mg daily, dilt ER 240
daily, lisinopril 40 daily, simvastatin 40 daily, clonidine 0.3
daily, ASA 81, MVI, Vit E
Discharge Medications:
1. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
10. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): hold for HR < 60 SBP < 100.
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
12. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO DAILY (Daily).
13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO once a day.
14. Senna-S 8.6-50 mg Tablet Sig: One (1) Tablet PO twice a day.
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation.
16. warfarin 1 mg Tablet Sig: One (1) Tablet PO as directed to
maintain INR 2.0-3.0: dose to maintain INR 2.0-3.0.
17. Insulin sliding scale
71-109 mg/dL 0 Units 0 Units 0 Units 0 Units
110-140 mg/dL 3 Units 3 Units 3 Units 0 Units
141-180 mg/dL 5 Units 5 Units 5 Units 1 Units
181-210 mg/dL 7 Units 7 Units 7 Units 3 Units
211-240 mg/dL 9 Units 9 Units 9 Units 5 Units
241-280 mg/dL 11 Units 11 Units 11 Units 7 Units
18. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous with breakfast.
19. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety .
20. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5016**] [**Doctor Last Name 1495**] Raphaels TCU - [**Location (un) 7661**]
Discharge Diagnosis:
Coronary artery disease with a NSTEMI, and post-operative atrial
fibrillation.
hypertension
hyperlipidemia
Past Surgical History:
s/p R hip replacement [**2195-4-7**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**5-7**] 1:15 in the [**Last Name (un) 2577**]
Building [**Last Name (NamePattern1) **], [**Location (un) 551**].
Cardiologist Dr. [**Last Name (STitle) 5017**], [**First Name3 (LF) 4597**]: follow-up on [**2194-5-14**]:45
Primary Care Dr. [**Last Name (STitle) 21448**] [**Telephone/Fax (1) 69547**] for warfarin follow-up once
discharged from rehab
Warfarin for atrial fibrillation. INR Goal 2.0-3.0
Last dose of Warfarin [**2195-4-19**], 0.5 mg. INR [**2195-4-19**] 2.9
Follow-up with your orthopedic surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 89929**] for
your right hip surgery.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2195-4-19**]
ICD9 Codes: 9971, 4019, 2724 |
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