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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6100
} | Medical Text: Admission Date: [**2105-3-3**] Discharge Date: [**2105-3-6**]
Date of Birth: [**2105-3-3**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] is a term male
infant who was the 3,125 gram product of a 29-year-old G2,
P1, now 2, mother. Prenatal screens included blood type B
positive, antibody negative, hepatitis B surface antigen
negative, RPR nonreactive, rubella immune, and GBS negative.
The pregnancy was reportedly uncomplicated. Delivery was a
normal spontaneous vaginal one, after two hours ruptured
membranes, and without maternal fever. Delivery was noted to
be rapid.
At three hours of life, Baby [**Name (NI) **] [**Known lastname **] was noted to have
tachypnea in the Newborn Nursery with respiratory rate
increasing to 80-110. He also seemed dusky, but did not have
any episodes of apnea. He was transferred to the Neonatal
Intensive Care Unit for further care.
ADMISSION PHYSICAL EXAM: Birthweight was 3,125 grams. In
general, Baby [**Name (NI) **] [**Known lastname **] was an alert and active term male
with mild to moderate respiratory distress. HEENT exam
revealed an anterior fontanel that was soft and flat, red
reflexes present bilaterally, intact palate, and normal
facies. Chest exam revealed mild retractions both
subcostally and sternally, with coarse, equal bilateral
breath sounds. Heart was noted to be regular rate and
rhythm, with a II-III/VI harsh, low-pitched systolic murmur
heard loudest at the left sternal border. Pulses were
palpable in his upper and lower extremities, though more
easily palpable in his upper extremities. Perfusion was
noted to be good. Four-extremity blood pressures revealed
right arm 70/47 with a mean of 64, right leg 60/40 with a
mean of 44, left arm 80/40 with a mean of 58, left leg 61/49
with a mean of 49. Abdomen was soft without distention and
with no hepatosplenomegaly. GU exam revealed normal male
external genitalia with testes descended bilaterally.
Neurologic exam revealed normal, symmetric tone throughout.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: On admission, Baby [**Name (NI) **] [**Known lastname **] was noted to
be in mild to moderate respiratory distress with tachypnea
in the 80s. He was requiring blow-by oxygen
supplementation. Chest x-ray revealed normal lung
volumes, a slightly increased cardiothoracic silhouette,
and hazy lung fields bilaterally. He was placed in nasal
cannula oxygen, and a cardiac evaluation was undertaken.
The cardiac evaluation, as detailed below, yielded normal
results, and his respiratory distress gradually improved.
A follow-up chest x-ray 24 hours after admission revealed
decreased haziness of the lung fields, and a normal heart
size. Baby [**Name (NI) **] [**Known lastname **] was able to wean from nasal cannula
oxygen by 48 hours of life, and at the time of discharge
has had a regular respiratory rate in the 50s in room air
for greater than 24 hours. He has had no episodes of
desaturation or apnea during this admission.
2. CARDIOVASCULAR: Baby [**Name (NI) **] [**Known lastname **] was noted to have a
murmur on admission to the Neonatal Intensive Care Unit.
Evaluation of this murmur included four-extremity blood
pressures, as detailed in the physical exam section. It
also included a hyperoxia test with a left radial ABG, but
had a pH of 7.29, PCO2 51, PO2 168, in 100 percent oxygen.
Echocardiogram revealed a small PDA and trivial tricuspid
regurgitation at 12 hours of life. EKG was unremarkable.
His murmur had resolved by 24 hours of life and has not
since been appreciated. He has remained hemodynamically
stable with good perfusion and blood pressures during the
remainder of his hospital stay.
3. FLUID, ELECTROLYTES AND NUTRITION: Baby [**Name (NI) **] [**Known lastname **] was
initially held NPO on D10W IV fluid at 60 cc/kg/D. Once
his respiratory distress had resolved, feedings were
initiated of breast milk and Similac 20. He has been
taking ad lib feeds well of 30-50 cc q 3-4 h with a total
fluid intake of 92 cc/kg/D over the 24 hours preceding
discharge. He has been voiding and stooling
appropriately. Electrolytes at 24 hours of life were
normal.
4. HEMATOLOGY: Baby [**Name (NI) **] [**Known lastname 58731**] initial hematocrit was 55.1
percent. A bilirubin at 24 hours of life was 7.2 with a
direct component of 0.3.
5. INFECTIOUS DISEASE: In light of his respiratory distress
and concern for pneumonia, Baby [**Name (NI) **] [**Known lastname **] underwent a
sepsis evaluation and was treated with ampicillin and
gentamicin. His CBC was reassuring with a white count of
17.9 with 64 percent polys and 1 percent bands. Platelets
were 295,000. As repeat chest x-ray at 24 hours of life
did not reveal any evidence of pneumonia, the haziness
seen on the first day was felt to be more consistent with
TTN than with pneumonia. Antibiotics were stopped when
blood cultures were negative at 48 hours.
6. SENSORY: Hearing screening was performed with automated
auditory brain stem responses, and he passed.
7. GI: Bilirubin drawn [**2105-3-6**] was 11.1. No photo therapy was
initiated.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: To home with parents in car seat.
PRIMARY PEDIATRICIAN: [**Hospital3 **].
CARE/RECOMMENDATIONS:
1. Feedings at discharge are Similac 20 or breast milk po ad
lib.
2. Baby [**Name (NI) **] [**Known lastname **] is on no medications.
3. State newborn screen has been sent.
4. Hepatitis B vaccination was given on [**2105-3-5**].
5. Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before
this age (and for the first 24 months of the child's
life), immunization against influenza is recommended for
household contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS: An appointment should be scheduled
with [**Hospital3 **] Pediatrics for [**Last Name (LF) 766**], [**2105-3-9**].
DISCHARGE DIAGNOSES: Respiratory distress/transient
tachypnea of the newborn--resolved.
Heart murmur--resolved.
Rule out sepsis--resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Name8 (MD) 58732**]
MEDQUIST36
D: [**2105-3-6**] 10:43:31
T: [**2105-3-6**] 11:34:23
Job#: [**Job Number 58733**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6101
} | Medical Text: Admission Date: [**2112-12-5**] Discharge Date: [**2112-12-12**]
Date of Birth: [**2060-11-12**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Upper GI Bleed
Major Surgical or Invasive Procedure:
Endoscopy with cauterization
Intubation/Extubation
Central line placement
History of Present Illness:
Ms. [**Known lastname 4427**] is a 52 year old F with HIV (CD4 488 and VL <48 [**7-8**])
who presented with 2days of hematemesis and melena. Pt called
Dr. [**First Name (STitle) 1075**] of ID with report of feeling dizzy with black stool,
and was referred to the ED. In the ED she initially vomited dark
material but this progressed to bright red emesis. In the ED,
vital signs were 98.4 125 111/51 22 100%. She was subsequently
intubated in the ED for airway protection (not respiratory
distress.) EKG had shown sinus tachycardia. She was given 2
PIVs, 1upRBCs, 3L IVF, and Protonix 40 IV x 1, then transferred
to the MICU. Pt has a history of viral illness and
tylenol/ibuprofen use of unknown amount. She has a history of
prior EGD [**4-7**] that showed esophagitis.
.
Allergies: Bactrim (rash)
Past Medical History:
HIV: >10 yrs. Contracted via heterosexual activity. CD4 488, VL
>48 as of [**7-8**].
h/o esophagitis s/p EGD [**4-7**]
hiatal hernia
HTN
Asthma
anemia
carpal tunnel
Obesity
HSV I/II
Crack cocaine abuse
Social History:
lives with daughter and [**Name2 (NI) 12496**]. no smoking or drinking, has
worked as school bus monitor ([**4-7**] OMR)
Family History:
noncontributory
Physical Exam:
ON ADMISSION TO MICU
Vitals T 97.9 P 87 Bp 117/68 RR 16 O2 100% on AC 500x14 0.4
General Obese woman intubated and sedated
HEENT Sclera pale, conjunctiva anicteric
Neck Larger neck, can't assess JVP
Pulm Lungs clear bilaterally
CV Regular S1 S2 no m/r/g
Abd Soft obese +bowel sounds nontender
Extrem Feet cool with palpable pulses
Neuro Opens eyes to voice, shakes head when asked about pain
with sedation lightened
ON ADMISSION TO THE FLOOR
VS: 97.1 114/84 90 22 95% RA
Gen: awake, sleepy, NAD
HEENT: oropharynx clear, no LAD, PERRL, EOMI grossly; [**Month/Year (2) **] in
place, no erythema
CV: RRR, no m/r/g, S1 S2
LUNGS: CTAB anteriorly
ABD: obese, soft, NTND, bs+
EXT: no c/c/e, wwp, pneumoboots on
Pertinent Results:
***LABS ON ADMISSION***
[**2112-12-5**] 08:15PM HCT-31.8*
[**2112-12-5**] 06:10PM TYPE-ART PO2-188* PCO2-46* PH-7.34* TOTAL
CO2-26 BASE XS--1
[**2112-12-5**] 05:56PM GLUCOSE-114* UREA N-33* CREAT-0.5 SODIUM-143
POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-26 ANION GAP-8
[**2112-12-5**] 05:56PM estGFR-Using this
[**2112-12-5**] 05:56PM ALT(SGPT)-11 AST(SGOT)-15 LD(LDH)-123 ALK
PHOS-39 TOT BILI-0.3
[**2112-12-5**] 05:56PM ALBUMIN-3.2* CALCIUM-7.8* PHOSPHATE-3.8
MAGNESIUM-2.0
[**2112-12-5**] 05:56PM WBC-6.5 RBC-3.49* HGB-11.1* HCT-31.6* MCV-91
MCH-31.8 MCHC-35.1* RDW-13.9
[**2112-12-5**] 05:56PM PLT COUNT-205
[**2112-12-5**] 05:56PM PT-13.5* PTT-22.5 INR(PT)-1.2*
[**2112-12-5**] 01:29PM TYPE-ART PO2-514* PCO2-41 PH-7.38 TOTAL
CO2-25 BASE XS-0
[**2112-12-5**] 01:29PM GLUCOSE-159* K+-3.7
[**2112-12-5**] 01:29PM HGB-10.4* calcHCT-31
[**2112-12-5**] 12:20PM WBC-8.3# RBC-3.64* HGB-11.2* HCT-33.4* MCV-92
MCH-30.7 MCHC-33.4 RDW-13.6
[**2112-12-5**] 12:20PM NEUTS-70.0 LYMPHS-26.8 MONOS-2.2 EOS-0.5
BASOS-0.6
[**2112-12-5**] 12:20PM PLT COUNT-258
***LABS DURING HOSPITAL STAY***
[**2112-12-9**] 08:12PM BLOOD Hct-25.2*
[**2112-12-9**] 03:56AM BLOOD Plt Ct-208
[**2112-12-9**] 03:56AM BLOOD Glucose-110* UreaN-13 Creat-0.5 Na-140
K-3.2* Cl-107 HCO3-29 AnGap-7*
[**2112-12-9**] 03:56AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.8
Urine culture- negative
MRSA Screen- negative
H.Pylori- pending
**IMAGING**
EKG [**2112-12-7**]
Sinus tachycardia. Low limb lead voltage. Since the previous
tracing
of [**2102-9-26**] limb lead voltage is lower.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
106 138 82 330/410 68 49 63
CXR [**2112-12-5**]
FINDINGS: Portable upright AP chest radiograph is obtained.
Right CP angle
is excluded thus limiting evaluation. Evaluation is also limited
by
underpenetrated technique. The lungs appear clear bilaterally.
Cardiomediastinal silhouette is stable. Osseous structures
appear intact.
Left AC joint hypertrophic changes are noted.
IMPRESSION: Limited study without evidence of acute process.
Right CP angle
exclusion limits evaluation.
CXR [**2112-12-8**]
There are relatively low inspiratory volumes on this
examination. Right-sided
IJ central venous catheter remains present, with the tip
difficult to
visualize but probably at the cavoatrial junction. The cardiac
and
mediastinal silhouettes remain unchanged. Allowing for low
inspiratory
volume, no gross pulmonary consolidation is seen. No evidence of
pneumothorax. Osseous structures remain unchanged and grossly
unremarkable
aside from mild degenerative changes at the right
acromioclavicular joint.
IMPRESSION: Low inspiratory volumes; no appreciable interval
change or
evidence of acute cardiopulmonary disease.
Brief Hospital Course:
#. GIB: Hematemesis has been consistent with an upper GI source.
Patient was transferred to the ICU from ED intubated for airway
protection and underwent emergent EGD, with clot in fundus that
was not unroofed, but no other sources of bleeding. Patient
then underwent placement of a Right Internal Jugular central
line and received a total of 3 units of blood for a hematocrit
which nadered at 26. She was initially started on a protonix
drip which was changed to [**Hospital1 **] dosing of 40 mg after her HCT was
stable. She was extubated on ICU day 2 and remained somewhat
confused and disoriented. This was thought to be related to the
Benzodiazepines administered for sedation. She underwent a
second EGD by GI, which found flat lesions and an ulcer in the
cardia treated with epinepherine and gold probe. She also had
some evidence of esophagitis. On the third ICU day, patient
remained somewhat confused, but was otherwise hemodynamically
stable and was transferred to the floor.
On the floor, crit continued to remain stable, ranging
between 25-27.3. Pt received one additional unit pRBC on the
floor. Pt continued to remain hemodynamically stable, and was
resumed on her home HCTZ. Pt did not have any additional
episodes of melena or hemetemesis. Mental status and lethargy
cleared up and patient as alert and oriented on day of
discharge. She was continued on a high dose PPI (40mg PO bid),
and will be following up as outpt with her PCP. [**Name10 (NameIs) **] was removed
prior to discharge (had been maintained on the floor as pt had
poor peripheral access.) PT was consulted, and initially felt
that pt would benefit from continued PT, but upon re-eval, pt
was doing much better and will be able to go home without PT.
H.pylori is pending and will need to be followed up as
outpatient.
.
# HIV: Pt is on anti-retroviral therapy. Her last CD4 count was
488 and VL <48 as of [**7-8**]. She was continued on her HAART during
her stay (Lamivudine, Abacavir, Tenofovir, Ritonovir,
Fosamprenivir.) CD4/VL was re-checked per pt request and results
are pending, so will need to be followed up as outpt. Pt will
need to follow-up for further HIV management with her PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 11528**] (appt scheduled.)
.
# HTN: Pt is on HCTZ at home. This was held on admission given
bleed. This was resumed at discharge as pt was hemodynamically
stable (systolic BPs stable in 100-130s)with no further obvious
signs of bleed on day of discharge.
.
# FEN: regular heart healthy diet. Pt was cleared by speech and
swallow evaluation for advancing as tolerated s/p extubation,
and pt was tolerating regular solids on day of discharge.
.
# PPX: Pneumoboots, PO PPI [**Hospital1 **]
.
# ACCESS: no PIVs (poor access), [**Hospital1 **] (pulled before discharge)
.
# Communication: patient
.
# Code: presumed full
.
# Dispo: discharge to home with PCP [**Last Name (NamePattern4) 702**].
Medications on Admission:
Epzicom
Tenofovir
Fosamprenavir, ritonavir
Albuterol
HCTZ
omeprazole
Oxybutynin
Tylenol
Sarna
Ferrous sulfate
Simethicone
Discharge Medications:
1. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
2. Ritonavir 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day.
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application
Topical twice a day as needed for itching.
12. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO bid
or tid as needed for urinary frequency.
13. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain: Please do not take more
than 4000mg per day.
14. Simethicone 60 mg Tablet Sig: One (1) Tablet PO once a day
as needed for bloating.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Upper GI bleed; ulcer
HIV
Anemia from acute blood loss
Discharge Condition:
hemodynamically stable, anemia stable, afebrile, tolerating PO
solids
Discharge Instructions:
You were admitted for uppger GI bleeding from a stomach ulcer.
You were in the ICU, and required blood transfusions. There was
also concern of your airway from all of the bleeding, therefore
you were intubated in the ICU as well. You were extubated and
did well. You had an ENDOSCOPY (camera in your throat) that saw
an ulcer, which was cauterized (medication to stop the
bleeding). Your blood counts remained stable. You were started
on OMEPRAZOLE 40 mg TWICE DAILY to help with the bleeding ulcer.
Please take all remaining medications as prescribed. Please
AVOID NSAIDS for pain relief (e.g. Advil, Aleve, Ibuprofen),
given your recent ulcer. Please keep all scheduled appointments.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: chest pains, shortness of breath,
fevers, chills, lightheadedness, dizziness, or blood from your
stools.
Followup Instructions:
Appt with Dr. [**Last Name (STitle) 8499**]: [**2111-12-15**] 10:15 AM. Please
have him follow up on your h.pylori antibody test and CD4/Viral
load test results.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] BLOOD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2113-1-4**]
11:00
Completed by:[**2112-12-12**]
ICD9 Codes: 2851, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6102
} | Medical Text: Admission Date: [**2162-12-19**] Discharge Date: [**2162-12-21**]
Date of Birth: [**2162-12-15**] Sex: M
Service: NBB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Name2 (NI) 58777**] [**Known lastname 58778**] delivered at
37 5/7 weeks gestation weighing 3890 grams and was readmitted
from home to [**Hospital1 69**] Newborn
Intensive Care Unit on day of life four for management of
hyperbilirubinemia.
The mother is a 30 year old gravida IV, para II, now III
woman with estimated date of delivery [**2162-12-29**].
Her prenatal screens included: blood type A positive, antibody
screen negative, RPR nonreactive, Rubella immune, hepatitis B
surface antigen negative, and group B strep positive.
The pregnancy was complicated by elevated blood pressure treated
with Aldomet. Labor was induced due to elevated blood
pressure. Artificial rupture of membranes around five hours
prior to delivery for clear fluid. No maternal fever. She
received intrapartum penicillin for GBS colonization around
12 hours prior to delivery. The infant was vigorous at
delivery, Apgars were 9 at one minute and 9 at five minutes.
The infant did well in the Newborn Nursery and was discharged
home on day of life two. His bilirubin at 36 hours of life
was 12. Physical examination was notable for a left flank
mass. An abdominal ultrasound was done at [**Hospital3 18242**] following discharge which showed the following
findings: Examination of the abdomen demonstrated a normal
liver, pancreas, gallbladder, and spleen. The kidneys have a
mildly echogenic cortex and markedly echogenic regions at the
inferiormost portion of the medullary pyramid. This finding
is consistent with TAMM Horsfall protein, which can be seen
in the newborn and resolves over the first two days to weeks
of life. The kidneys are generous in size, the right kidney
measuring approximately 5.5 cm and the left kidney measuring
approximately 5.3 cm. There is no evidence of hydronephrosis
or renal masses. There was no free fluid in the abdomen or
pelvis. The bladder was normal. No follow-up was recommended.
A bilirubin was done as an outpatient on [**2162-12-18**] and was 16.
A follow up bilirubin done the following day on [**2162-12-19**] was
20.4 prompting an admission to the Newborn Intensive Care
Nursery.
PHYSICAL EXAMINATION ON ADMISSION: Weight 3880 grams.
Anterior fontanelle open, flat. Alert and active. Diffuse
jaundice. Clear breath sounds with good aeration. Regular
rate and rhythm without murmur. Abdomen soft, nondistended,
no masses, no hepatosplenomegaly. Normal male genitalia,
circumcised, patent anus.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: There
have been no issues. He is comfortable on room air. The
respiratory rate has been in the 30s to 50s.
CARDIOVASCULAR: He has been hemodynamically stable during
hospitalization. Heart rate ranges in the 1-teens to the
140s. Recent blood pressure 87/55 with a mean of 67. No
heart murmur.
FLUIDS, ELECTROLYTES AND NUTRITION: On admission was placed
on intravenous fluid of D10W at 80 ml per kilo per day which
ran for about 24 hours. He also had been ad lib feeding
breast or bottle feeding since admission, voiding and
stooling appropriately. Discharge weight 3990 grams.
GASTROINTESTINAL: The mother's blood type is A positive,
antibody negative. The infant's blood type is O positive,
Coombs negative. He was placed on triple phototherapy on
admission for a bilirubin of 20. A bilirubin about four
hours later on triple phototherapy remained at 20.5. Another
phototherapy with light was added to give him four
phototherapy lights and a follow up bilirubin was 18.5.
Twenty four hours after admission under phototherapy the
bilirubin dropped down to 13 and the phototherapy was
decreased to 2 lights. On [**2162-12-21**] the bilirubin total was
12.3 with a direct of .4. The phototherapy was discontinued.
Rebound bilirubin about six hours later was 11.6. There has
been no evidence of hemolysis. The final diagnosis is
exaggerated physiologic jaundice.
HEMATOLOGY: Hematocrit on admission was 54 percent,
reticulocyte count was 3.1 percent. Did not receive any
blood products during this admission.
INFECTIOUS DISEASE: A CBC and blood culture was drawn on
admission. The CBC was benign. The blood culture was
negative. He did not receive any antibiotics.
NEUROLOGY: His examination has been age appropriate.
SENSORY: A hearing screening was performed with automated
auditory brain stem responses. He passed both ears.
CONDITION ON DISCHARGE: A six day old term infant, feeding
well with resolving hyperbilirubinemia.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, [**Hospital 58779**] [**Hospital 40483**]
Pediatrics, telephone number [**Telephone/Fax (1) 58780**]. Fax [**Telephone/Fax (1) 58781**].
CARE AND RECOMMENDATIONS:
1. Feeds: Ad lib breast or bottle feeding. Mother had a
lactation consult on [**12-22**] and has been given phone numbers to set
up further support services. She also plans on renting a
breastpump.
2. Medications: None.
3. State Newborn Screen was drawn after birth in the Newborn
Nursery and is pending.
4. Immunizations: He received his hepatitis B immunization
on [**2162-12-17**].
5. Follow up appointments: Has a follow up appointment with
Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] [**Hospital 40483**] Pediatrics in [**Location (un) 38**] on
[**2162-12-23**] at 11:45AM. [**First Name (Titles) 407**] [**Last Name (Titles) 28085**]
has been made to [**Hospital3 **] [**Hospital6 407**].
DISCHARGE DIAGNOSES:
1. Term appropriate gestational age male.
2. Exaggerated physiologic jaundice.
3. Sepsis ruled out.
Addednum - FU bilirubin done at the [**Hospital1 **] on [**2162-12-22**] was 14.0/13.6 -
follow up bili is recommended tomorrow [**2162-12-23**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2162-12-21**] 17:19:02
T: [**2162-12-21**] 18:28:36
Job#: [**Job Number 58782**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6103
} | Medical Text: Admission Date: [**2190-2-8**] Discharge Date: [**2190-2-15**]
Date of Birth: [**2144-2-23**] Sex: M
Service: ENT SURGERY
CHIEF COMPLAINT: Chronic aspiration.
HISTORY OF THE PRESENT ILLNESS: This is a 45-year-old male
with Down's syndrome with frequent aspirations resulting in
several episodes of aspiration pneumonia. The patient has
had a gastric feeding tube since [**2182-1-3**]. A
swallowing video fluoroscopy in [**2180**] revealed moderate to
severe oropharyngeal swallowing disturbance with aspiration
after the swallow and poor laryngeal sensitivity noted by
absent cough following the aspiration.
PAST MEDICAL HISTORY:
1. Down's syndrome with profound mental retardation.
2. Hepatitis B carrier.
3. Osteoporosis.
4. Hiatal hernia.
5. Allergic rhinitis.
6. Constipation.
7. Left retractile testis.
8. Right hip subluxation.
9. Atopic dermatitis.
PAST SURGICAL HISTORY:
1. Right total hip replacement in [**2188-6-2**].
2. G tube placement in [**2182-1-3**].
3. Excision of thigh lipoma in [**2182-5-4**].
4. Left cataract extraction with lens implant.
ALLERGIES: Keflex which causes a rash, Reglan which causes
dystonia, and acetazolamide.
ADMISSION MEDICATIONS:
1. Protonix 40 b.i.d.
2. Theophylline 200 q.p.m.
3. Multivitamin.
4. Milk of magnesia.
5. Loratadine 10 mg every evening.
6. Lactobacillus 40 b.i.d.
SOCIAL HISTORY: The patient is a resident of [**Location 6151**]
Developmental Center.
PHYSICAL EXAMINATION ON ADMISSION: Cardiac: Regular rate
and rhythm. Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nondistended, nontender with a G tube in
place. Extremities: Severe muscular atrophy, no edema,
clubbing, or cyanosis.
HOSPITAL COURSE: The patient was admitted to preop and
holding where he underwent narrow-field laryngectomy. The
patient tolerated this procedure well. Please see the
operative note for details. Chest x-ray postoperatively
revealed a tracheostomy tube in good position with no
pneumothorax. The patient was transferred to the Surgical
Intensive Care Unit on the ventilator. He was placed on IV
Clindamycin and IV Flagyl.
On postoperative day number one, it was attempted to wean the
patient off the ventilator. The patient was weaned to CPAP;
however, he was placed back on the ventilator due to
desaturations. Pink frothy sputum was noted at the site of
the tracheostomy. Chest x-ray showed a small amount of CHF;
however, the patient's lungs were clear to auscultation and
it was again attempted to wean the ventilator. Tube feeds
were also started on postoperative day number two at 10 cc
per hour and tube feeds were advanced conservatively to a
goal of 50 cc per hour.
The patient was weaned from the ventilator on postoperative
day number three successfully. The patient was transferred
from the ICU to a floor bed on postoperative day number five.
His tracheostomy tube was removed and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-Singer
tracheostomy tube was put in its place to support the stoma
until it had matured. Duoderm was placed in the parastomal
area to protect skin from breakdown. The patient was placed
in a continuous 02 sat monitor setting. He was kept n.p.o.
and tube feeds were advanced to goal.
On postoperative day number seven, it was attempted to obtain
a Barium swallow study to test for any esophageal leak;
however, per the Radiology staff, the patient was unable to
cooperate with the Barium swallow in that he was unable to
maintain proper positioning during the study and was unable
to follow commands as to when to swallow the barium contrast.
However, the patient was felt to be stable and was discharged
on postoperative day number seven. Throughout his hospital
stay, his electrolytes were monitored and repleted as needed.
Nutrition was consulted for advice regarding the patient's
tube feeds and he remained stable throughout his hospital
stay.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To an extended care facility.
DISCHARGE DIAGNOSIS:
1. Chronic aspiration.
2. Status post narrow-field laryngectomy.
DISCHARGE INSTRUCTIONS: The patient should follow-up with Dr.
[**Last Name (STitle) 1837**] in one week. The office should be contact[**Name (NI) **]
for an appointment.
DISCHARGE INSTRUCTIONS FOR THE TRANSFER FACILITY:
1. Remove and clean the [**Last Name (un) **]-Singer tracheostomy device with
warm water twice a day.
2. Clean the crust from his stoma using moist Q-Tips twice a
day.
3. Keep Duoderm on the parastomal areas.
4. Continue humidified air to his stoma.
DIET: The patient should follow a clear liquid diet. He
should receive Probalance full-strength tube feeds at 50 cc
per hour and residuals should be checked every four hours and
tube feedings should be held for residuals greater than or
equal to 150 milliliters. His tube should be flushed with 30
milliliters of water q. four hours and as needed.
DISCHARGE MEDICATIONS:
1. Theophylline 200 mg per the G tube once a day.
2. [**Doctor First Name **] 60 mg twice a day per G tube.
3. Calcium carbonate 12.5 milliliters once a day per the G
tube.
4. Flovent inhaler two puffs twice a day.
5. Colace 100 mg twice a day per the G tube.
6. Percocet [**4-12**] milliliters every four to six hours as
needed for pain.
7. Benadryl 25 mg one capsule every six hours as needed for
itching per the G tube.
8. Albuterol inhaler, one nebulizer treatment every six
hours as needed for shortness of breath or wheezing.
9. Protonix 40 mg once a day per the G tube.
10. Lopressor 37.5 mg three times a day per the G tube.
11. Lasix 20 mg one tablet twice a day per the G tube.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 6152**], M.D.
[**MD Number(1) 6153**]
Dictated By:[**Last Name (NamePattern1) 6154**]
MEDQUIST36
D: [**2190-2-15**] 12:22
T: [**2190-2-15**] 12:35
JOB#: [**Job Number 6155**]
cc:[**Numeric Identifier 6156**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6104
} | Medical Text: Admission Date: [**2200-1-19**] Discharge Date: [**2200-1-27**]
Date of Birth: [**2147-7-2**] Sex: F
Service:
CHIEF COMPLAINT:
1. Seizure.
HISTORY OF PRESENT ILLNESS: The patient is a 52 year-old
female with a history of hydrocephalus status post right
posterior occipital shunt placement in a prior seizure
disorder who presented to an outside hospital for seizures.
According to her prior records the patient had the onset of a
focal seizure possibly involving the right arm for which she
presented to an outside hospital. She was treated with up to
20 milligrams of prn Ativan as well as additional doses of
her prior anti-epileptic drugs without improvement. She was
subsequently intubated and started on an Ativan drip and was
transferred to the [**Hospital1 69**] for
further management.
At the outside hospital her particular treatment had
including Fentanyl 50 micrograms, Ativan 4 milligrams,
Phenobarbitol 300 milligrams bolus, ativan drip, Valium 5
milligrams, Ativan 2 to 4 milligrams up to eight doses,
Neurontin 400 milligrams, Trileptal 300 milligrams. The
patient had also been given Versed prior to her transfer.
REVIEW OF SYSTEMS: Unable to assess.
PAST MEDICAL HISTORY:
1. Seizure disorder described previously as a focal seizure
with occasional generalization.
2. Hypercholesterolemia.
3. Normal pressure hydrocephalus.
4. SIADH.
5. Hypertension.
ALLERGIES: Include
1. Penicillin.
2. Codeine.
3. Aspirin.
4. Dilantin.
MEDICATIONS ON ADMISSION:
1. The patient had recently been started on Trileptal.
2. Neurontin.
SOCIAL HISTORY: The patient is college educated. She has
occasional alcohol use, no tobacco use.
PHYSICAL EXAMINATION: On initial physical exam her heart
rate was 100, blood pressure 139/87, respiratory rate 15,
FIO2 60, assist control at 12 and tidal volume of 600. In
general the patient appeared older than her stated age and
was lying in bed intubated with minimal spontaneous movement.
HEENT was normocephalic, atraumatic with white sclerae. Her
neck was supple without JVD or bruits. Her lungs were clear
to auscultation with vented breath sounds bilaterally.
Cardiovascular exam revealed a regular rate and rhythm with
normal S1, S2 and no murmurs, rubs, or gallops. Her abdomen
had normal bowel sounds. It was soft, nontender,
nondistended. Extremities were warm without cyanosis,
clubbing or edema.
NEUROLOGIC EXAMINATION: The patient was not responsive to
voice and had no spontaneous ability to open her eyes.
Cranial nerves - her face appeared symmetric and her eyes
were conjugate with forward gaze. Pupils were fixed at 1 mm
and nonreactive to light. OCR was not present and corneal
reflexes as well as blinking to threat were also absent. Gag
reflex was present. Funduscopic demonstrated small ectatic
retinal vasculature but sharp disc borders bilaterally. On
motor and sensory exam the patient withdrew from painful
stimuli in the upper extremity with triple flexion response
in the lower extremities. She grimaced to pain in all
extremities. Reflexes were equal and symmetric bilaterally
with upgoing plantar responses. There was no ankle clonus.
LABORATORY DATA: Initial labs demonstrated a head CT scan
obtained at the outside hospital that showed bilateral
hydrocephalus with the presence of a right posterior
occipital shunt. Brain MRI obtained in [**2199-6-16**] had a
previous [**Location (un) 1131**] of a right frontal craniotomy, bilateral
craniotomies. There was right frontal encephalomalacia.
Initial EKG showed sinus tachycardia with a normal axis, a Q
wave in the inferior leads and early R wave progression.
Her initial labs of note include a WBC 15.5, with 87%
neutrophils, and a hematocrit of 36.6 and a normal MCV. Her
urine tox screen was negative. Her coags as well as her LFTs
were normal. Her initial sodium was slightly decreased at
134 and her chloride was slightly elevated at 134. Her
bicarb was decreased at 19.
The patient was admitted to the Neuro ICU and continued
initially on the Ativan drip while she was loaded with
Depakote.
SUMMARY OF HOSPITAL COURSE: A Neurosurgery consult was
obtained to assess the possibility of a shunt malfunction.
On review of her prior images it was felt that there was no
significant change in the size of her hydrocephalus according
to the Neurosurgical consult. It was subsequently determined
that Dr. [**Last Name (STitle) **] in the Department of Neurosurgery had been her
surgeon in the past and the consult was deferred to Dr. [**Last Name (STitle) **]
who saw the patient later in her hospital course and also
felt that it was unlikely that her subsequent ataxia was
related to shunt malfunction.
In the Intensive Care Unit the patient continued to have
decreased mental status presumably from ativan and postictal
stated that required continued intubation until approximately
[**2200-1-21**]. The patient was then transferred to the General
Neuro Medical Service. During her ICU stay she had an EEG
that demonstrated occasional left temporal and generalized
burst of beta slowing. She also had a wide spread faster
beta rhythm background particularly in the frontal regions.
This is felt to be most likely a medication affect probably
due to her Ativan. No clear epileptiform features were
documented.
On transfer to the General Neurology Service the patient was
noted to be quite ataxic both trunkly and in her extremities.
The etiology of this was unclear but the patient reported
that she had prior episodes of gait instability related to
Neurontin which she was being continued on. It was decided
to taper her Neurontin and continue Depakote for the time
being. After discussing her anti-epileptic regimen with her
outside neurologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40860**], at [**Telephone/Fax (1) 103122**] the
decision was made to start the patient on Trileptal and
maintain her on Depakote until her Trileptal had reached a
therapeutic range. Otherwise the patient has continued to do
well.
DISCHARGE DIAGNOSIS:
1. Focal status epilepticus.
2. Gait ataxia of unclear etiology possibly from medication
affect.
3. History of hydrocephalus status post shunt placement.
DISCHARGE DIET: Low sodium diet, low cholesterol diet.
DISCHARGE ACTIVITIES: As defined by Physical Therapy.
DISPOSITION: The patient is to be discharged to a
rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Neurontin 100 milligrams po tid. This could be tapered to
[**Hospital1 **] one day after transfer and then q day and then off.
2. Trileptal 300 milligrams po bid which should be increased
after seven days of treatment by 600 milligrams to Trileptal
600 milligrams po bid. Trileptal was started on [**2200-1-26**].
While the patient is on Trileptal her sodium levels need to
be followed closely given her history of SIADH. She has a
prior adverse affect from Tegretol which has included
hyponatremia.
3. Robitussin DM 30 cc po q six hours prn.
4. Depakote 250 milligrams po q A.M., 250 milligrams po q
noon, 500 milligrams po q P.M. The patient's Depakote level
should be followed as well as her CBC and LFTs.
5. Heparin 5000 units subcutaneous [**Hospital1 **].
FOLLOW UP INSTRUCTIONS: On arrival to the rehab facility the
patient's neurologist described above should be contact[**Name (NI) **] to
inform him of her status. The patient should follow up with
her neurologist on an outpatient basis.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1941**], M.D. [**MD Number(1) 37533**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2200-1-27**] 14:10
T: [**2200-1-27**] 14:16
JOB#: [**Job Number 44176**]
ICD9 Codes: 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6105
} | Medical Text: Admission Date: [**2123-1-8**] Discharge Date: [**2123-1-21**]
Date of Birth: [**2058-3-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2123-1-10**] ERCP
[**2123-1-11**] Transjugular Liver Biopsy
[**2122-1-30**] Cardioversion
History of Present Illness:
Mrs. [**Known lastname 6692**] is a 64 year old female who recently underwent a
bioprosthetic mitral valve replacement and Maze procedure on
[**2122-12-31**]. Her hospital course was rather uneventful and she was
discharged on postoperative day seven. She re-presented with
multiple vague complaints including RUQ abdominal pain and right
flank pain. The pain was described as dull and was rated a [**6-29**].
Patient also admitted to some nausea and vomiting which was
associated with some fevers, and chills. She denied rigors,
weight loss/gain, bleeding and change in bowel habits. She did
describe her urine as a dark, amber color. Initial evaluation
was notable for elevated LFT's, elevated BNP, elevated white
count, supratherapeutic INR along with a slight increase in
creatinine. She was therefore admitted for further evaluation
and treatment.
Past Medical History:
History of Mitral Regurgitation/Stenosis and Atrial Fibrillation
s/p Mitral Valve Replacement(Bioprosthesis) and Full Left Sided
Maze Procedure on [**2122-12-31**], Diastolic Congestive Heart Failure,
Systemic Lupus Erythematosus with History of Lupus Anticoagulant
and Hypercoagulable state, Anti-cardiolopin Antibody, History of
Stroke [**2106**], History of Coronary Artery Disease - s/p RCA stent
in [**2121-1-19**], Dyslipidemia, Asbestos exposure with pleural
plaque, s/p Vein ligation and stripping
Social History:
Married, lives with husband. [**Name (NI) 1403**] as a registered nurse [**First Name (Titles) **] [**Last Name (Titles) **]
[**Location (un) 620**]. Smoked 1 [**1-20**] ppd x 30 years, quit 16 years ago. 1 glass
red wine/day
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother - deceased age 76 DM, CAD. Father -
deceased age 84, CAD. Two brothers s/p CABG. Daughter -
deceased age 36, leukemia.
Physical Exam:
Vitals: Afebrile, BP 150/70, HR 70, RR 14, SAT 100% RA
General: WDWN female in no acute distress
HEENT: Oropharynx benign, EOMI, sclera anicteric
Neck: Supple, no JVD
Lungs: soft bibasilar rales, otherwise CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2
Abdomen: Soft, slightly tender to deep palpation in RUQ.
normoactive bowel sounds, no ascites, negative [**Doctor Last Name **] sign
Ext: Warm, no edema
Pulses: 1+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2123-1-7**] 06:35AM BLOOD WBC-7.5 RBC-2.95* Hgb-9.1* Hct-26.1*
MCV-89 MCH-30.7 MCHC-34.7 RDW-15.0 Plt Ct-120*
[**2123-1-8**] 05:20AM BLOOD Neuts-84.9* Bands-0 Lymphs-9.5* Monos-3.8
Eos-1.5 Baso-0.3
[**2123-1-7**] 06:35AM BLOOD PT-42.7* PTT-52.8* INR(PT)-4.7*
[**2123-1-7**] 06:35AM BLOOD Glucose-115* UreaN-15 Creat-1.3* Na-135
K-4.0 Cl-101 HCO3-26 AnGap-12
[**2123-1-8**] 05:20PM BLOOD ALT-300* AST-321* AlkPhos-441* Amylase-71
TotBili-1.5
[**2123-1-8**] 05:20AM BLOOD proBNP-7858*
[**2123-1-8**] RUQ Ultrasound: 1. Normal gallbladder and liver, with
no evidence of cholecystitis or gallstones. 2. Right-sided
pleural effusion.
[**2123-1-9**] HIDA Scan: Images show prompt uptake of tracer into the
hepatic parenchyma. No tracer activity is seen during this time
within the gallbladder, biliary tree, or GI tract. The above
findings are consistent with cholestasis.
[**2123-1-9**] Abdominal MR: 1. Limited study secondary to motion
artifact from patient's breathing throughout the examination. 2.
Cholangitis involving the left lobe of the liver, better
visualized on recent CT. No focal fluid collections identified
within the liver. 3. Dilated side branch within the tail of the
pancreas likely representing side branch IPMT.
[**2123-1-9**] Abdominal CT Scan: 1. Multiple enhancing tubular and
rounded hypodensities within the left hepatic lobe, likely
representing microabscesses with reactive cholangitis.
[**2123-1-9**] Transthoracic ECHO: The left atrium is mildly dilated.
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. A bioprosthetic mitral valve prosthesis is present. The
mitral prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. Trivial mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is a
small pericardial effusion which is most prominent posterior to
the atria.
[**2123-1-11**] RUQ Ultrasound: There is no biliary dilatation
identified, but there is pneumobilia seen throughout the liver.
The portal vein is patent with hepatopetal flow. Flow is
identified in the right hepatic vein, middle hepatic vein and
the left hepatic vein. There is no ascites identified. There is
a right pleural effusion seen.
[**2123-1-14**] Renal Ultrasound: The right kidney measures 12.1 cm,
and demonstrates diffusely increased echogenicity. A tiny
subcentimeter cyst is identified in the interpolar region. There
is no evidence of stone, mass or hydronephrosis. The left kidney
measures 13.2 cm. There is no evidence of stone, mass, or
hydronephrosis.
[**2123-1-21**] 05:42AM BLOOD WBC-8.0 RBC-2.73* Hgb-8.0* Hct-24.1*
MCV-88 MCH-29.4 MCHC-33.3 RDW-17.5* Plt Ct-259
[**2123-1-20**] 08:39AM BLOOD WBC-11.4* RBC-3.00* Hgb-8.9* Hct-25.9*
MCV-86 MCH-29.5 MCHC-34.1 RDW-16.2* Plt Ct-212
[**2123-1-21**] 05:42AM BLOOD PT-32.1* PTT-47.1* INR(PT)-3.3*
[**2123-1-20**] 08:39AM BLOOD PT-26.1* PTT-43.0* INR(PT)-2.6*
[**2123-1-19**] 06:00AM BLOOD PT-23.6* INR(PT)-2.3*
[**2123-1-21**] 05:42AM BLOOD Glucose-109* UreaN-22* Creat-1.7* Na-136
K-3.6 Cl-97 HCO3-28 AnGap-15
ABDOMEN U.S. (COMPLETE STUDY) [**2123-1-18**] 8:23 AM
ABDOMEN U.S. (COMPLETE STUDY)
Reason: evaluate for ascites
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with elevated LFTs s/p MVR and MAZE
REASON FOR THIS EXAMINATION:
evaluate for ascites
STUDY: Abdominal ultrasound.
INDICATION: 64-year-old female presenting with elevated LFTs.
Status post MVR and MAZE procedure.
COMPARISONS: MRCP dated [**2123-1-9**] and CT dated [**2123-1-9**].
FINDINGS: Multiple hypoechoic foci present within the left lobe
of the liver are consistent in appearance with small abscesses
and appear unchanged compared to the recent CT and MR
evaluations. These hypoechoic foci appear solid. The right lobe
of the liver appears normal in echotexture. There is prominent
pneumobilia which is new compared to the previous examinations
and consistent with the recent history of ERCP and common bile
duct stent placement. A stent is visualized within the common
bile duct which measures approximately 6 mm in diameter. There
is no intra- or extra-hepatic biliary dilatation. The
gallbladder wall appears mildly thickened. There is no
pericholecystic fluid or wall edema and overall the gallbladder
is not distended. Note is made of prominent sludge within the
gallbladder. A small amount of perihepatic free fluid is noted.
There are bilateral small pleural effusions. The spleen is
prominent in size measuring 12.5 cm in length. Images of the
head and body of the pancreas are unremarkable. The pancreatic
duct is not distended. The main portal vein is patent with
appropriate direction of flow.
IMPRESSION:
1. Multiple hypoechoic foci within the left lobe of the liver
consistent in appearance with small abscesses. All foci appear
solid and non-drainable.
2. Pneumobilia and common bile duct stent placement are new
compared to CT and MRI of [**2123-1-9**].
3. Tiny amount of abdominal ascites.
4. Bilateral small pleural effusions.
5. Gallbladder sludge.
Brief Hospital Course:
Mrs. [**Known lastname 6692**] was admitted and underwent extensive evaluation. An
echocardiogram was unremarkable while the abdominal CT scan was
notable for multiple enhancing tubular and rounded hypodensities
within the left hepatic lobe, likely representing microabscesses
with reactive cholangitis. She was made NPO and pan-cultures
were obtained. The ID and hepatology services were consulted
along with general surgery. They all agreed with broad spectrum
antibiotic therapy. Given her supratherapeutic INR, Warfarin was
held and several units of fresh frozen plasma were given. ERCP
with stenting was performed on [**1-11**] without
complication.
The renal service was also consulted as she continued to
experience further decline in renal function. Her creatinine
peaked to 2.4 on [**1-12**]. Her acute renal failure was
attributed to acute tubular necrosis from intravenous contrast.
Renal ultrasound was obtained and was unremarkable.
Liver biopsy on [**1-12**] revealed no necrosis, changes
consistent with cholangitis vs biliary obstruction.
Despite antibiotics, she continued to experience intermittent
fevers. She remained on broad spectrum antibiotics for ?
bartonella and was followed very closely by the ID service.
Serial abdominal exams were performed while liver function tests
were monitored daily. Antibiotics were titrated accordingly.
She was transferred to the floor on [**1-14**].
Her abdominal pain improved as did her liver and renal function.
She continued to be diuresed. She awaited return of her
creatinine to baseline prior to repeat CT scan. She was seen by
EP, Flecainide was dc'd and restarted and cardioversion was
successfully performed. She was ready for discharge to rehab on
hospital day 14.
Medications on Admission:
Aspirin 81 qd, Zetia 10 qd, Crestor 20 qd, Flecanide 150 [**Hospital1 **],
Lopressor 150 [**Hospital1 **], Warfarin, Vicodin prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
Disp:*120 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*0*
10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous once a day: until [**2123-2-5**].
Disp:*16 gm* Refills:*0*
11. Ertapenem 1 gram Recon Soln Sig: One (1) gm Intravenous once
a day: until [**2123-2-5**].
Disp:*16 * Refills:*0*
12. Outpatient Lab Work
Please check a weekly CBC/diff, chem 7, LFTs, and Vanco trough
and fax results to [**Hospital **] clinic nurse ([**Telephone/Fax (1) 16411**]
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous once a day as needed.
Disp:*16 ML(s)* Refills:*0*
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Cholestasis with Hepatic Microabscesses, Acute Renal Failure,
History of Mitral Regurgitation/Stenosis and Atrial Fibrillation
s/p Mitral Valve Replacement and Maze Procedure on [**2122-12-31**],
Systemic Lupus Erythematosus with History of Lupus Anticoagulant
and Hypercoagulable state, History of stroke, History of
Coronary Artery Disease - s/p RCA stent in [**2121-1-19**],
Dyslipidemia
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2123-1-27**]
2:40
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2123-1-28**]
11:00
[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2123-2-3**] 2:00
[**Hospital **] clinic [**2123-2-4**] at 1:30 PM LMOB Basement [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 6732**]
Weekly CBC, LFT, Chem 7, and Vancomycin trough should be taken
and sent to ([**Telephone/Fax (1) 16411**] ([**Hospital **] clinic)
Abdominal ultrasound Wednesday [**2123-2-3**] 9 AM [**Location (un) **] [**Hospital Ward Name **] 5B,
please do not eat or drink anything after midnight the night
before the ultrasound
Completed by:[**2123-1-21**]
ICD9 Codes: 5849, 2761, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6106
} | Medical Text: Admission Date: [**2139-7-31**] Discharge Date: [**2139-8-3**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with hypertension, hypercholesterolemia, CVA, who experienced
severe chest pain at 14:30 on the day of admission. The
patient had chest pain previously with associated shortness
of breath and diaphoresis, and recently had a positive stress
test and was recommended for cardiac catheterization. She
refused catheterization, went home with instructions for bed
rest.
On the day of admission, she experienced [**11-20**] chest pressure
which decreased to [**5-21**] with three sublingual nitroglycerin.
The pain was substernal associated with shortness of breath
and diaphoresis. She called 911 and was taken to an outside
hospital, where she was noted to have [**Street Address(2) 1766**] elevations in
leads V2 through V4. She received aspirin and Heparin drip,
Lopressor, and Integrilin with resolution of her chest pain,
but had persistent electrocardiogram changes. She was
transferred to the [**Hospital1 69**] for
catheterization, but refused.
PHYSICAL EXAM ON ADMISSION: Temperature 98.5, heart rate 60,
blood pressure 90/50, respiratory rate 18, oxygenating 96% on
2 liters nasal cannula at 57 kg. General: Elderly female in
no apparent distress. HEENT: Pupils are equal, round, and
reactive to light. Clear oropharynx. Neck is supple, normal
jugular venous distention. Pulmonary: Clear to auscultation
bilaterally. Cardiovascular: Regular, rate, and rhythm, 2/6
systolic murmur. Abdomen: Positive bowel sounds, soft,
nontender, nondistended. Extremities: Trace edema, 2+
dorsalis pedis. Neurologic: Cranial nerves II through XII
are grossly intact, alert and oriented times three.
LABORATORIES ON ADMISSION: White count 5.8, hematocrit 35.2,
platelets 236. Sodium 145, potassium 3.8, chloride 110,
bicarb 24, BUN 21, creatinine 0.9, glucose 107. CK 140, MB
20.
Electrocardiogram at the outside hospital showed normal sinus
rhythm at 80 with left axis deviation, Q's in leads V1 and
V2, [**Street Address(2) 1766**] elevations in leads V2 through V4.
Electrocardiogram at [**Hospital3 **]: Normal sinus rhythm at 60
beats per minute, left axis deviation, Q's in leads V1
through V3, [**Street Address(2) 4793**] elevations in V3 through V4.
HOSPITAL COURSE: Once in the catheterization laboratory
after the patient refused the catheterization, she was
started on a Heparin drip and sent to the CCU for medical
management. Once in the CCU, the patient was asymptomatic
and was hemodynamically stable. In the CCU, she was placed
on aspirin, Heparin drip, Integrilin, Lopressor 12.5,
captopril 6.25, Lipitor 10, and Zantac. She showed no
arrhythmias on Telemetry.
On day two of her hospitalization, her CKs dropped from 140
to 128. MB dropped from 20 to 15, and the patient remained
asymptomatic. Based on the low CK MB with downward trend, it
was thought that the myocardial infarction was a nonacute
event, and that she probably had a prior myocardial
infarction or possible two in the past weeks. Patient was
continued to be monitored and her CKs were observed.
However, she was transferred to the floor on [**2139-8-1**].
On [**8-2**], on the floor, a Physical Therapy consult was
obtained which recommended that the patient was safe to go
home with normal activity. On the evening of [**8-2**], the
patient's blood pressure was minimally hypotensive to 90/50
and her blood pressure medications (beta blocker and ACE
inhibitor) were held. It was decided that her ACE inhibitor
should be discontinued, but her beta blocker would be
re-administered at the next scheduled dose.
On [**8-3**], the patient was observed to have some swelling and
erythema at the peripheral IV site, felt to be consistent
with cellulitis, and the patient was placed on Keflex for
seven days. The patient remained hemodynamically stable at
the time of discharge.
CONDITION ON DISCHARGE: Stable/satisfactory condition with
home health services (Physical Therapy and teaching regarding
medications) and home health services of VNA for medical
teaching.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg tablet take one oral q day.
2. Atorvastatin.
3. Calcium 10 mg tablet one tablet oral q day.
4. Ranitidine HCL 1 mg tablet one tablet oral [**Hospital1 **].
5. Warfarin sodium 5 mg tablet take 1 mg oral q hs.
6. Clopidigrel bisulfate 75 mg tablet one tablet oral q day,
dispensed 30 tablets, refills three.
7. Isosorbide mononitrate 60 mg tablets one tablet oral q
day.
8. Metoprolol succinate 50 mg tablet one q hs.
9. Cephalexin monohydrate 250 mg capsule, take one capsule
oral q8h for seven days.
DISCHARGE DIAGNOSES:
1. Acute ST segment elevation myocardial infarction
2. Hypotension
3. Cellulitis
4. Coronary artery disease
5. Chest pain
FOLLOW-UP INSTRUCTIONS: The patient was advised to followup
with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **],
[**0-0-**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Female First Name (un) 48072**]
MEDQUIST36
D: [**2139-8-7**] 17:17
T: [**2139-8-14**] 08:48
JOB#: [**Job Number 48073**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6107
} | Medical Text: Admission Date: [**2127-11-3**] Discharge Date: [**2127-11-3**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Fever, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F with h/o MGUS, CHF [**2-12**] severe MR/TR (EF >55%), afib not on
coumadin, presents with fever and cough. Patient is currently
not conversant, therefore details of HPI are obtained from
family. Per her family, pt was in her USOH until a fall 4 days
ago. Fall was witnessed, no head trauma or LOC. She appeared
to be back at her baseline until the following morning when she
developed fevers at home to 101.3 and cough x 2 days. She did
not seek medical attention because she has preferred not to see
a doctor for the past 2 years. Family notes that she was
generally at her baseline (AAOx3, playing cards), but was
intermittently "out of it" for the past 2 days. This AM she was
more lethargic, and they persuaded her to go to the ED for
evaluation.
.
In the ED, initial vitals were T 100.0, HR 101, BP 104/58, RR
16, O2 sat 94% 2L. BP gradually decreased to 80s/50s and she
became increasingly tachypneic, switched to NRB. Received 1.5L
NS in boluses, SBP increased to 90s. CXR showed e/o LLL pna.
She was given 2g IV cefepime and 500mg IV levofloxacin. She was
transferred to MICU for further management.
.
On arrival to MICU vitals were T 102.6, HR 93, BP 73/35, RR 26,
O2 sat 100% on NRB. Currently she appears awake but is not
conversant. Family states that she was always very clear about
her decision to be DNR/DNI and would not want aggressive
interventions, including central lines or pressors.
.
ROS: Unable to obtain. To family's knowledge, only notable as
described in HPI.
Past Medical History:
- Chronic pancytopenia seconary to suspected underlying
myelodysplastic syndrome, followed by Heme/Onc until [**2125**] (pt
elected not to continue f/u)
- IgM kappa monoclonal gammopathy of unknown significance
- Atrial fibrillation, not on coumadin [**2-12**] thrombocytopenia
- H/o CHF [**2-12**] severe MR/TR (last EF in [**2125**] >55%)
- Hypertension
- Hyperlipidemia
Social History:
Lives with daughter and son-in-law in [**Name (NI) 2312**]. Per family,
independent in ADLs at baseline. Non-smoker.
Family History:
NC
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
CBC:
[**2127-11-3**] 10:35AM WBC-13.9*# RBC-3.43* HGB-9.5* HCT-28.3*
MCV-83 MCH-27.6 MCHC-33.4 RDW-17.0*
[**2127-11-3**] 10:35AM NEUTS-80* BANDS-3 LYMPHS-6* MONOS-8 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-1*
[**2127-11-3**] 10:35AM PLT SMR-VERY LOW PLT COUNT-61*
[**2127-11-3**] 10:35AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SCHISTOCY-1+
Chem-7:
[**2127-11-3**] 10:35AM GLUCOSE-158* UREA N-52* CREAT-1.4*
SODIUM-129* POTASSIUM-3.1* CHLORIDE-91* TOTAL CO2-25 ANION
GAP-16
UA:
[**2127-11-3**] 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0
LEUK-NEG
[**2127-11-3**] 10:50AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2127-11-3**] 10:50AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
CXR [**2127-11-3**]:
FINDINGS: Portable AP radiograph of the chest was obtained. Low
lung
volumes. There is airspaze opacity seen over the left mid lung
most likely
representing a pneumonia. There is stable cardiomegaly. The
aorta is
tortuous with calcifications seen in the aortic knob. There are
no pleural
effusions or pneumothorax. Bony structures are unremarkable.
IMPRESSION: Left mid lung consolidation consistent with
pneumonia. Recommend followup to resolution.
Brief Hospital Course:
Primary Reason for MICU Admission:
Hypotension, hypoxia
Brief Hospital Course:
On arrival to MICU vitals were T 102.6, HR 93, BP 73/35, RR 26,
O2 sat 100% on NRB. Currently she appears awake but is not
conversant. Family states that she was always very clear about
her decision to be DNR/DNI and would not want aggressive
interventions, including central lines or pressors. She
continued to receive IV NS, however her blood pressure continued
to decline to 50s-60s/30s. At 6:38PM, Ms. [**Known lastname 11949**] passed away
with daughter and son-in-law at bedside. Family declined
autopsy.
Medications on Admission:
-Furosemide 40mg qAM, 20mg qPM
-Metoprolol tartrate 25mg PO BID
-Timolol maleate
-Valsartan 160mg PO daily
-Acetaminophen 500mg PO BID prn hip pain
-Docusate 100mg [**Hospital1 **]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Community-acquired pneumonia (organism unknown)
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 0389, 486, 4240, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6108
} | Medical Text: Admission Date: [**2163-1-30**] Discharge Date: [**2163-2-5**]
Date of Birth: [**2146-12-9**] Sex: M
Service: Trauma.
HISTORY OF PRESENT ILLNESS: This is a 16 year old male, rear
seat passenger, of an auto into a tree accident at high
speed. Extensive damage to vehicle with 30 minute extraction
time and two fatalities on scene.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
ALLERGIES: Penicillin, unknown reaction.
PHYSICAL EXAMINATION: The patient was transferred from an
outside hospital with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 15. He was
intubated at the outside hospital for pain control. Cervical
spine was in a collar. Pupils were equal, round and reactive
to light. The pupil was 3 to 2 mm. The left was 3 to 2 mm.
Blood was coming from the nares. Heart had regular rate and
rhythm. Lungs were clear to auscultation bilaterally. There
were no deformities or tenderness to the chest. Abdomen was
nondistended. Pelvis was stable. There were no deformities at
either flank with no CVA tenderness. No deformities of the
back. No deformities or step-off of tenderness to the
cervical spine. TLS: No deformities, step-off or tenderness.
The patient had good rectal tone with a negative guaiac.
There were no deformities of the upper extremities. The
right lower extremity had an open femur fracture; left lower
extremity had a closed femur fracture. Dorsalis pedis pulses
were 2+/4 bilaterally.
LABORATORY DATA: CT of the head was negative. CT of the
cervical spine negative. CT of the chest: Questionable
bilateral pulmonary contusion. CT of the abdomen with
periportal fluid, no duodenal leak with p.o. contrast. TLS
negative. Bilateral femur fracture.
Hematocrit was 36.2; hemoglobin of 12.5; white blood cell
count of 24.5. Platelet count 246. PT 18.6; PTT 30.0; INR
of 2.3. Fibrinogen 83. Glucose 126. BUN 8; creatinine 0.6.
Sodium of 141; potassium of 3.6; chloride 113; bicarbonate
22; anion gap of 10. ALT 193; AST 231; alkaline phosphatase
144; amylase 78; total bilirubin of 0.4. Lipase 38. Calcium
7.6; phosphorus of 3.5; magnesium of 1.4. Toxicology screen,
including alcohol, was negative.
Arterial blood gas: P02 of 569; PC02 of 33; pH of 7.36;
calculated bicarbonate 19; excess base -5. The patient was
intubated. Lactate 1.0.
incomplete report -- cut off!
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 52643**]
MEDQUIST36
D: [**2163-2-4**] 08:42
T: [**2163-2-4**] 08:54
JOB#: [**Job Number 53246**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6109
} | Medical Text: Admission Date: [**2103-9-15**] Discharge Date:
Service:
HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman
with a past medical history of dermatomyositis on chronic
steroids, and hypertension, who was transferred from [**Hospital6 3622**] on [**2103-9-15**], after presenting with
chest pain radiating to the left arm, shortness of breath,
diaphoresis, and malaise. She then demonstrated a non-Q wave
myocardial infarction with CPK greater than 1100, and
troponin-T of .82. She underwent echocardiogram and
catheterization, which showed three vessel disease with 50 to
80% stenosis in the left anterior descending, and 95%
stenosis in the D1, 50% stenosis of the circ, 80% stenosis of
the obtuse marginal I, 90% stenosis of the obtuse marginal
II, an ejection fraction of 65%, and 4+ mitral regurgitation.
She additionally had been found to be in atrial flutter at
the outside hospital, and was started on a Diltiazem drip as
well as heparin.
On [**9-15**], she was transferred to [**Hospital1 190**] for further management, and was admitted to
Cardiothoracic Surgery service.
PAST MEDICAL HISTORY: Significant for dermatomyositis, on
chronic prednisone, hypertension, gastroesophageal reflux
disease, macular degeneration, status post colectomy, status
post cholecystectomy, status post right total hip
replacement, and depression.
MEDICATIONS: Medications on transfer included Diltiazem
drip, heparin drip, Digoxin .25 once daily, aspirin 325 once
daily, Losartan 25 once daily, atenolol 25 twice a day, and
prednisone 5 mg once daily.
ALLERGIES: She was admitted with no known drug allergies,
but subsequently developed a poor tolerance for morphine,
which caused confusion and hallucinations.
PHYSICAL EXAMINATION: On admission, blood pressure was
145/65, heart rate 145, respiratory rate 20, oxygen
saturation 99%, temperature 97.7, weight 59.4 kg. Her lungs
had minimal crackles bilaterally. The heart was tachycardic
and regular. The abdomen was soft, nontender, nondistended.
The extremities had minimal edema.
LABORATORY DATA: On admission, white count 9.8, hematocrit
37.0, platelets 242. PT 13.3, PTT 93. Sodium 138, potassium
4.0, chloride 96, bicarbonate 27, BUN 15, creatinine 0.4,
glucose 120. Calcium 1.05, magnesium 1.9.
HOSPITAL COURSE: The patient underwent a three vessel
coronary artery bypass graft on [**9-17**], including a left
internal mammary artery to the left anterior descending,
saphenous vein graft to the obtuse marginal, and saphenous
vein graft to the D1. Additionally, she continued to have
atrial flutter, for which she was started on Lopressor and
amiodarone, and her heparin drip was continued. A TSH was
checked and was within normal limits. She additionally had a
urinary tract infection, for which she was treated with Cipro
for three days.
Postoperatively, she was extubated on [**9-18**], however, she
required reintubation on [**9-20**] secondary to pulmonary
secretions and respiratory distress. She was started on
levofloxacin and Flagyl for presumed aspiration. On [**9-21**], she underwent a repeat catheterization, which showed her
grafts to be patent, her mitral regurgitation to be decreased
to 1 to 2+, and an ejection fraction of 50%. She was again
extubated on [**9-22**], and underwent a swallowing study on
[**9-25**], which was positive for aspiration. Subsequently
the patient was started on tube feeds.
The patient was noted to have bloody stools on [**9-26**],
and her heparin was discontinued. On [**9-28**], she again
required reintubation for respiratory failure, and she
underwent a bronchoscopy which showed aspirated barium from
her swallowing study in her right bronchial system.
Additionally, Infectious Disease consultation was requested,
and the patient was changed from levofloxacin to Zosyn 4.5 mg
every eight hours in addition to Flagyl, for worsening
pneumonia.
On [**9-29**], she continued to have bloody bowel movements,
and she was lavaged, which was clear. She was transfused
packed cells, and a Gastroenterology consultation was
requested. The patient subsequently had an
esophagogastroduodenoscopy and percutaneous endoscopic
gastrostomy tube placement on the 11th.
Esophagogastroduodenoscopy revealed gastritis.
On [**9-29**] as well, the patient had a blood culture
return positive for coag negative staph. Vancomycin had been
added to the patient's regimen of Zosyn and Flagyl starting
on [**9-29**], and was continued for a ten day total.
On [**9-30**], a Rheumatology consultation was obtained,
which concluded that the patient was not having a flare of
her dermatomyositis, and she was switched to Solu-Medrol 8 mg
intravenously twice a day.
On [**10-1**], the patient had a tracheostomy performed,
and a repeat bronchoscopy to check tracheostomy placement and
suction secretions. On [**10-1**], the patient's Flagyl
was discontinued, given low suspicion for anaerobic
infection.
On [**10-3**], the patient had had recurrent atrial
flutter, and she underwent DC cardioversion, which was
successful. She was continued on her Lopressor and
amiodarone. After receiving approximately two weeks of 400
mg by mouth twice a day, the patient was decreased to 400 mg
by mouth once daily, which was ultimately reduced to 200 mg
once daily after approximately ten days due to bradycardia.
On [**10-5**], the patient was noted to have again a rising
white blood cell count. Chest CT and thoracentesis were
recommended. Her anticoagulation was held prior to this
procedure. She underwent a thoracentesis on the 16th, where
300 cc of serous fluid was removed. Prior to the
thoracentesis, she had a chest CT which showed multilobar
pneumonia, large effusions, consolidation in multiple lobes,
bilateral lower lobe collapse. A CT had been performed prior
to her thoracentesis.
On [**10-8**], the patient underwent a repeat bronchoscopy,
where a small amount of barium was noted to be present.
Additionally, the patient was noted to have vesicles
throughout the right main stem bronchus area, which was felt
to be possibly a chemical irritation vs. possible infectious
etiology. Specimens were sent to the Laboratory, which
showed cultures all negative at the time of this dictation,
and pathology of the biopsy taken during the bronchoscopy
showed squamous metaplasia and acute inflammation. The
patient was continued on her Zosyn.
On [**10-9**], the patient's vancomycin was discontinued
after a ten day course. Additionally, she was noted to have
bloody pulmonary secretions. Because of this and her recent
history of gastritis with bloody stools, and the fact that
she was now in normal sinus rhythm, the patient's
anticoagulation was held. On [**10-9**], the patient was
transferred from the general floor back to the Intensive Care
Unit, as her pulmonary secretions required more frequent
suctioning.
In the Intensive Care Unit, she received aggressive pulmonary
toilet. Cultures were followed, which were all negative at
the time of this dictation. The patient's white count was
decreasing, and she remained afebrile. A chest x-ray on
[**10-11**] raised a question of a possible area of aerated
lung vs. cavity, and the patient underwent repeat CT scan on
[**10-12**], which revealed no abscess, but pockets of
aerated lung.
The patient's pulmonary secretions decreased considerably
over the next several days, and rehabilitation planning was
arranged. The patient remained in normal sinus rhythm and,
as noted above, her amiodarone was decreased to 200 mg by
mouth once daily secondary to bradycardia. She was continued
on her lasix and afterload reducing agents as well as the
rest of her antihypertensive medications. She was continued
on Zosyn for her pneumonia, with the last day, per Infectious
Disease consult service, to be [**10-13**]. Additionally,
her Solu-Medrol was continued for her dermatomyositis.
During her time in the Intensive Care Unit, the patient also
requested that her code status be changed to Do Not
Resuscitate/Do Not Intubate. This was discussed with both
the patient and her daughter, and they both agree.
Currently rehabilitation screening is taking place. The
patient has been maintained on trach mask and FIO2 of 0.4,
with very acceptable saturations, and significant improvement
in her pulmonary secretions. She will need follow up after
discharge with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
here in [**Location (un) 86**], as well as with Dr. [**Last Name (STitle) **], her
cardiothoracic surgeon.
DISCHARGE MEDICATIONS: Prozac 10 mg once daily, Ambien 10
mg daily at bedtime, Solu-Medrol 8 mg intravenously every 12
hours, Norvasc 5 mg once daily, Zosyn 4.5 grams intravenously
every eight hours through [**2103-10-13**], ProMod with fiber tube
feeds, Lopressor 25 mg twice a day, Colace 100 mg twice a
day, Hydralazine 5 mg four times a day, Lisinopril 80 mg once
daily, Prevacid 30 mg once daily, amiodarone 200 mg once
daily, lasix 20 mg once daily.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 29900**]
MEDQUIST36
D: [**2103-10-12**] 20:35
T: [**2103-10-13**] 00:45
JOB#: [**Job Number 6368**]
ICD9 Codes: 4280, 4240, 5070, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6110
} | Medical Text: Service: Date: [**2161-7-2**]
Date of Birth: [**2089-2-6**] Sex: F
Surgeon: [**Last Name (LF) 3662**], [**First Name3 (LF) 3661**] 12-269
CHIEF COMPLAINT: Headache, nausea, vomiting, chest pain
HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old female
with a history of atrial fibrillation, bradycardia, resulting
in syncope, status post pacemaker placement on [**6-15**], who
complains of headache, nausea, vomiting, and jaw and chest
pain. Patient stated that these symptoms came on over the
course of a one-hour period. She laid down and was unable to
get out of bed secondary to weakness. Patient then went to
[**Hospital1 43954**], where her blood pressure was found to be
60/palp. Echocardiogram there was consistent with an
effusion. She was given 2 liters of normal saline and
started on dopamine and transferred to [**Hospital1 36918**] Emergency Room, where a repeat echocardiogram
showed a moderate-size effusion, but no evidence of
tamponade.
Patient was given 6 more liters of IV fluid of normal saline
and dopamine was continued at 10 mcg per hour. In the
Emergency Department, patient had an episode of nausea and
vomiting, denied fever, abdominal pain, dysuria, neck
stiffness, chest pain at the time of admission, or cough and
was transferred to the medical Intensive Care Unit for
further management.
PAST MEDICAL HISTORY: Significant for atrial fibrillation,
recent pacemaker placement in [**Hospital6 1129**]
on [**6-15**], gastroesophageal reflux disease,
hypercholesterolemia.
ALLERGIES: No known drug allergies.
MEDICATIONS: Sotalol 160 mg p.o. b.i.d., Toprol, Coumadin 5
mg p.o. q.d., Nexium one tab p.o. q.d.
FAMILY HISTORY: Significant for her father with coronary
artery disease, sister and brother with history of
unspecified thyroid disorder.
SOCIAL HISTORY: No tobacco or alcohol use, lives alone at
home, has no children
PHYSICAL EXAMINATION: Vital signs: Afebrile, blood pressure
124/55 on dopamine, pulse 68, respirations 20, O2 saturation
96% on 4 liters. In general, an elderly female, lethargic
but arousable. HEENT exam: Pupils equal, round and reactive
to light and accommodation. Mucous membranes dry. Neck was
supple, no evidence of jugular venous distention. Heart:
Normal S1, S2, no murmurs, rubs or gallops. Lungs clear to
auscultation bilaterally. Abdomen soft, nontender,
nondistended, normal active bowel sounds. Extremities:
Trace 1+ edema. Extremities cool
LABORATORY DATA ON ADMISSION: White blood count 19.3,
hematocrit 34.7, platelet count 353,000. Neutrophils 89,
bands 2, sodium 141, potassium 4.2, chloride 111, bicarb 14,
BUN 13, creatinine 0.7, glucose 162, calcium 7.3, magnesium
1.8, phosphorus 2.8. INR 2.0, PTT 31.2, ALT 73, AST 64,
alkaline phosphatase 80, lipase 33, amylase 24, total
bilirubin 0.7.
Urinalysis significant for 6 to 10 white blood cells, small
leukocyte esterase.
BK (no. 1) was 69, BK (no. 2) 63, troponin less than 0.3
times two.
Arterial blood gas: pH 7.38, CO2 29, O2 74, lactate 2.0.
Electrocardiogram: Atrial fibrillation with a rate of 109,
normal axis, Q wave in lead 3, no acute ST or T wave changes.
Head CT scan: No mass, no shift or bleed.
Chest x-ray: Cardiomegaly, right internal jugular line in
place, increased cephalization, peribronchial cuffing.
IMPRESSION: Patient is a 72-year-old female with persistent
hypertension admitted with evidence of a pericardial
effusion, possibly secondary to pacer placement.
HOSPITAL COURSE: 1) Cardiovascular: Patient was volume
resuscitated over the course of two days with 8 liters of IV
fluids and was also on a dopamine drip, which was gradually
weaned over the course of three days. By [**6-28**], her
dopamine drip had been stopped. No IV fluids were needed and
her pressures were now in the systolic blood pressure range
of the 130s. Repeat echocardiogram showed no change in the
size of her pericardial effusion with no evidence of
tamponade. However, there was a note made that there was
perforation of the right ventricular free wall with the pacer
wire on repeat echocardiogram on [**6-29**]. The pericardial
effusion was also noted to be significantly smaller in size
on that date.
Patient also had note of increased pulmonary edema and O2
requirements secondary to significant volume resuscitation,
was able to diurese on her own with improvement of her
hypoxia as well as her lung exam.
On [**6-30**], [**2160**], her pacer leads were repositioned within
the right ventricle. There was no evidence of tamponade or
increasing pericardial effusion after the procedure was done.
The following day, patient had a repeat echocardiogram, which
confirmed these findings.
At the time of discharge, patient's pressure was normotensive
and her O2 saturation was 94 to 95% on room air, including on
ambulation. Patient will be sent home on sotalol 160 mg
b.i.d., is still in atrial fibrillation; however, will likely
need to be switched from sotalol to a different medication
such as amiodarone in the near future, potentially after her
LFTs have normalized after the hepatic congestion has
cleared. Will also start Lopressor for rate control and
anticoagulation with Lovenox and Coumadin.
2) Infectious Diseases: Patient was noted to have a urinary
tract infection, was treated with Levofloxacin for a
seven-day course, was also given Vancomycin peri-procedure
for repositioning of her leads and was sent home on Keflex.
DISCHARGE DIAGNOSIS: 1) Hemopericardium secondary to
pacer lead perforation through
right ventricle
2) Atrial fibrillation
DISCHARGE CONDITION: Good. Patient was once again
normotensive and will follow up with Dr. [**First Name (STitle) 437**] in about one
month and with the Electrophysiology service at [**Hospital3 **]
in about one week and will follow up with the [**Hospital 197**] clinic
in three days for adjustment of her Coumadin dosing.
DISCHARGE MEDICATIONS: Sotalol 160 mg p.o. b.i.d., Lopressor
25 mg p.o. b.i.d., Coumadin 5 mg p.o. q.d., Enoxaparin 80 mg
subcutaneously b.i.d., Levofloxacin 500 mg p.o. q.d. times
two days, Keflex 500 mg p.o. t.i.d. times two days, Zantac
150 mg p.o. b.i.d.
[**Last Name (LF) 3662**], [**First Name3 (LF) 3661**] 12-269
Dictated By:[**First Name3 (LF) 11194**]
MEDQUIST36
D: [**2161-7-2**] 10:59
T: [**2161-7-5**] 17:20
JOB#: [**Job Number 43955**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6111
} | Medical Text: Admission Date: [**2138-12-2**] Discharge Date: [**2138-12-12**]
Date of Birth: [**2071-12-12**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 66-year-old man
with a past medical history significant for coronary artery
disease, status post coronary artery bypass grafting in
[**2128-10-21**], at which time they performed a left internal
mammary artery to the left anterior descending, saphenous
vein graft to the OM-I and OM-II sequential and saphenous
vein graft to the PDA. He is also status post stenting of
his saphenous vein graft to the OM-I, OM-II territory in
[**2135-3-21**], and PTCA and brachytherapy to the saphenous
vein graft to the OM-I, OM-II in [**2137-12-21**]. The
patient also has a past medical history significant for
insulin-dependent diabetes mellitus, hypertension,
hypercholesterolemia, depression, mild dementia, history of
TIA, status post bilateral carotid endarterectomies in [**2134**].
The patient is a 66-year-old male with a long-standing
history of coronary artery disease, who was admitted [**2138-12-2**] due to unstable angina with a troponin level ranging
between 4.5 and 5.9. Cardiac catheterization was performed
on [**2138-12-2**] which revealed a patent left internal
mammary artery graft, occluded OM-1 and OM-2 graft, and a 90%
occlusion in the in-stented segment of the PDA. The last
echocardiogram was performed in [**2137-5-21**] which revealed a
left ventricular ejection fraction of 40%.
ADMISSION MEDICATIONS:
1. Atenolol 50 mg p.o. q.d.
2. Lipitor 40 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Aricept 5 mg p.o. q.d.
5. Zestril 20 mg p.o. q.d.
6. Metformin 850 mg b.i.d.
7. Terazosin 5 mg q.h.s.
8. Paxil 5 mg p.o. q.d.
9. Buspar 15 mg t.i.d.
10. Depakote 750 mg b.i.d.
11. Vitamin E.
12. Nitroglycerin patch.
13. Plavix which is being held.
14. NPH insulin 12 units q.a.m., 8 units q.p.m., regular
insulin 4 units q.a.m.
HOSPITAL COURSE: An off-pump redo coronary artery bypass
grafting was performed on [**2138-12-8**]. It was a
coronary artery bypass grafting times one with the saphenous
vein graft to the obtuse marginal via left thoracotomy
incision.
The patient was transferred to the Cardiac Surgery Recovery
Unit in stable condition on Neo-Synephrine at 0.6 micrograms
per kilogram per minute and propofol in normal sinus rhythm
at 57 beats per minute. He was extubated the same day of
surgery without any incidents around 6:00 p.m.
On postoperative day number one, the patient had a low-grade
temperature at 100.3 in sinus rhythm at 88. The vital signs
were stable. The white count was 9.1, hematocrit 31.3,
platelet count 147,000 with an unremarkable physical
examination. The plan was to continue to keep his blood
pressure down on Nipride and to start the patient on his p.o.
medications as well as his p.o. diet. If able to wean off
the Nipride, the plan was to transfer the patient to the
floor.
On postoperative day number two, the patient was mildly
disoriented, however, calm without complaints with his pain
well controlled. He was still with a low-grade temperature
of 100.1 in sinus rhythm at 88, mildly hypertensive at
170/88. On physical examination, he had mild crackles
bilaterally, otherwise his examination was benign. The plan
was just to continue monitor his mental status and pain
control.
On postoperative day number three, the patient was still
without complaints, however, still requiring a sitter for his
disorientation. Currently, afebrile. The vital signs were
stable, saturating at 94% on room air. The physical
examination was benign. The plan was to go for a cardiac
catheterization this morning with a possible PTCA with plus
or minus stenting of the stenotic area.
He did undergo cardiac catheterization on [**2138-12-11**]
which now revealed a saphenous vein graft to the obtuse
marginal patent and a saphenous vein graft to the posterior
descending artery with a 90% distal stenosis with a 3 by 13
mm stent with distal protection and 0% residual with normal
flow. The plan was to continue the patient on aspirin and
Plavix 75 mg p.o. daily for 30 days and to administer
Integrelin overnight.
The anticipated date of discharge is [**2138-12-12**]. The
patient is to be discharged home on the following
medications.
DISCHARGE MEDICATIONS:
1. Metformin 850 mg p.o. b.i.d.
2. Lisinopril 2.5 mg p.o. q.d.
3. Sliding scale of insulin.
4. Metoprolol 50 mg p.o. b.i.d.
5. Divalproex 500 mg p.o. b.i.d.
6. Buspar 15 mg p.o. t.i.d.
7. Paxil 5 mg p.o. q.d.
8. Atrovastatin 40 mg p.o. q.d.
9. Plavix 75 mg p.o. q.d. for three months.
10. Donepezil 5 mg p.o. q.h.s.
11. Dulcolax, milk of magnesia, p.r.n.
12. Percocet 5 one to two tablets p.o. q. 4-6 hours p.r.n.
pain.
13. NPH 3 units at breakfast, 4 units at bedtime.
14. Ibuprofen 400 mg q.i.d.
15. Acetaminophen 650 mg q. four hours p.r.n.
16. Aspirin 325 mg p.o. q.d.
17. Colace 100 mg p.o. b.i.d.
18. Lasix 20 mg p.o. b.i.d.
19. Potassium chloride 20 mEq p.o. q.d.
PLAN: The plan is for the patient to arrange a follow-up
visit with Dr. [**Last Name (STitle) 1537**] in one month, Dr. [**Last Name (STitle) 120**] in one month,
and his primary care physician in two to four weeks.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
re-do off-pump coronary artery bypass grafting times one.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Doctor Last Name 2011**]
MEDQUIST36
D: [**2138-12-12**] 13:20
T: [**2138-12-14**] 15:05
JOB#: [**Job Number 2012**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6112
} | Medical Text: Admission Date: [**2144-1-12**] Discharge Date: [**2144-1-23**]
Date of Birth: [**2096-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
SVC central line placement and removal.
PICC placement and removal.
History of Present Illness:
47yo F with history of DM, HTN and CRI presents with weakness
and dehydration. He was recently discharged on [**2143-12-30**] for DKA.
Patient signed out AMA when glucose better controlled. He was
again admitted on [**2144-1-7**] for DKA at [**Hospital1 2177**].
.
In ED, his VS were T96.7 P103 BP184/64 R24 100% on RA. His BP
went up to as high as 221/88 and he was given Sl nitro. His
glucose was found to be in 800s, insulin gtt started and he
received 2L fluid. He has old STE in V2-V4 and new TWI in V5-6.
He was given aspirin.
.
On ROS, he complains of polyuria and polydipsia today. Patient
claims to be compliant with insulin. The last time he checked
his FS was this AM and it was 140s. He denies chest pain,
shortness of breath, cough, recent URI, abdominal pain, nausea,
diarrhea, urinary complaints, headahce, dizziness, fever,
chills, recent sick contact or recent travel. He claims that he
had been abstinent from alcohol for more than a month and has
not used any drugs recently.
Past Medical History:
# HTN
# Insulin dependent DM
- has had multiple admissions for DKA in setting EtOH use
- last HgbA1C 7.6 ([**2143-10-31**])
- has peripheral neuropathy, retinopathy
# CRI - thought to be due to diabetic and hypertensive
nephropathy
# Sarcoid
- CT [**6-/2129**] = hilar/subcarinal [**Doctor First Name **], nodules in parenchyma
- [**1-/2134**] = L eye proptosis -> CT showed L maxillary mass -> bx
showed non caseating granulomas c/w sarcoid
- decision was made not to begin systemic tx since pt asx
# H/o Chronic RUQ pain
- Present for over 13 yrs (by [**Hospital1 18**] records), evaluated with at
least 12 abdominal/RUQ ultrasounds and multiple abdominal CT's
without evidence of suspicious pathology
# Polysubstance abuse
- Pt drinks regularly 2-3drinks daily; occasionally uses cocaine
(last use many weeks ago)
Social History:
Lives w/ a friend, no children. Works part time as a
tire-changer. Denies tobacco use. Denies recent EtOH or
cocaine use (per report daily EtOH use in past).
Family History:
Mother had diabetes, niece has diabetes. Denies FH of coronary
artery disease, hypertension, cancer, liver disease, or renal
disease.
Physical Exam:
T98.1 P96 BP 169/73 R23 98% on RA
Gen- sleepy but easily arousable
HEENT- left eye injected, right pupil reactive to light, no
sinus tenderness, dry mucus membrane, neck supple, no JVD
CV- regular, no r/m/g
RESP- clear bilaterally, no distress, no accessroy muscle use
ABDOMEN- soft, nontender, nondistended, no hepatosplenomeglay,
normal bowel sounds
EXT- no edema, no lacerations, DP 2+ bilaterally
NEURO- A+O x3, CNII-XII intact, muscle strengh [**6-14**] bilateral
upper and lower extremity, sensation grossly intact
Pertinent Results:
[**2144-1-12**] 09:30PM TYPE-ART PO2-102 PCO2-29* PH-7.25* TOTAL
CO2-13* BASE XS--12
[**2144-1-12**] 09:30PM LACTATE-1.7
[**2144-1-12**] 09:18PM GLUCOSE-515* UREA N-46* CREAT-3.3* SODIUM-136
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-11* ANION GAP-22*
[**2144-1-12**] 09:18PM CALCIUM-7.8* PHOSPHATE-3.1# MAGNESIUM-2.2
[**2144-1-12**] 09:18PM OSMOLAL-331*
[**2144-1-12**] 09:18PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
CXR: [**1-12**] - Satisfactory positioning of this central venous
catheter.
Brief Hospital Course:
AP: 47yo HTN, CRI, sarcoidosis, & poorly controlled DM w/ mult
admissions for DKA who p/w DKA, then hospital course complicated
by fevers thought to be secondary to pneumonia.
.
.
# DKA: In the MICU, he initially had: AG 29, CXR clear, no
intraabdominal complains, afebrile w/ no leukocytosis, EKG show
TWI and troponin of 0.36, but in [**2143-11-28**] clean cath, CK
remained flat and troponin stable. Underlying cause of DKA
thought to be medication non-compliance. No obvious other cause
of DKA--pt does not appear to be infected, no clear ischemic
event (trop elevation [**3-14**] leak in setting of CRI). Patient was
given aggressive hydration and started on insulin gtt in the
ICU. electrolytes checked q2hours initially. His anion gap
closed and he was able to be transitioned to SC insulin. [**Last Name (un) **]
was consulted and assisted in control of sugars during
hospitalization. He was discharged on a simple and effective
regimen of 30U of 75/25 [**Hospital1 **]. He has outpatient follow up with
[**Last Name (un) **].
.
# Trop elevation: Likely leak in setting of CRI. EKG unchange
(non-specific TWI in inferior & lateral precordial leads). Pt
had clean cath [**2143-11-25**]. Trop trending down. Continued on
aspirin, lipitor, Beta-blocker.
.
# HTN: He was continued on all of his home medications
(nifedipine, furosemide, and labetalol) with an increase in
dosage of his labetolol from 400mg TID to 600mg TID.
.
# ARF on CKD: Admission Cr of 3.5, with baseline of [**4-12**].2, was
likely pre-renal in setting of DKA and improved w/ hydration.
CKD is thought to be due to HTN & diabetic nephropathy. Protein
to Cr ratio of 6.0. Improved to 2.8-3.1 during hospitalization.
.
# Anemia: Baseline hct 27-29, during his hospitalization he was
between 24-27. No obvious sources of bleeding. Likely [**3-14**] renal
insufficiency. We continued epogen. Iron studies from [**Month (only) **]
[**2143**] show a mix of iron deficiency anemia (low fe, low fe/tibc
ratio)and anemia of chronic disease (ferritin > 100). Could
consider outpatient iron supplementation to help with epogen.
.
# Cardiomyopathy: EF 40-45%, likely related to
hypertension/alcohol. No active issues during hospitalization.
.
# acute angle glaucoma: Patient was seen by opthamology. We
continued all eyedrops per their recommendations. He will need
outpatient follow up.
.
# Barrett's esophagus: We continued his protonix.
.
# RUE swelling: RUE slightly swollen and uncomfortable at sight
of Right SVC line. Ultrasound was negative for clot. See below.
.
# Pneumonia: Patient had fevers and leukocytosis with right
lower lobe opacity on chest x-ray, oxygen sats around 95% and
right flank pain. The fever and leukocytosis was initially
attributed to ?line infection while central line was in (red
tender at site) and treated temporarily with vancomycin, but the
blood cultures were all negative. He had negative lenis. He
also had a negative RUQ ultrasound. He was discharged on a 7
day course of levofloxacin.
.
# code- full
Medications on Admission:
Aspirin 325 mg DAILY
Atorvastatin 80 mg DAILY
Nifedipine 90 mg DAILY
Labetalol 400 mg PO TID
Albuterol prn
Tobramycin-Dexamethasone 0.3-0.1 % Drops QID
Latanoprost 0.005 % Drops HS
Epoetin Alfa 3,000 Units QMOWEFR
Pantoprazole 40 mg Q12H
Scopolamine HBr 0.25 % Drops [**Hospital1 **]
Dorzolamide-Timolol 2-0.5 % Drops [**Hospital1 **]
Apraclonidine 0.5 % Drops [**Hospital1 **]
Furosemide 40 mg PO DAILY
Insulin Lisp & Lisp Prot (75-25) 25 units QAM and 25 units QPM
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Furosemide 40 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 once a day.
5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): OS.
7. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl
Ophthalmic QID (4 times a day): OS.
8. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 doses: Please take for 7 days. Last day will be
[**2144-1-28**].
Disp:*7 Tablet(s)* Refills:*0*
10. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic TID
(3 times a day): OS.
11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): OU .
12. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day): OS.
13. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25) Insulin
Pen Sig: Thirty (30) Units Subcutaneous QAM.
14. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25) Insulin
Pen Sig: Thirty (30) Units Subcutaneous 30 minutes after dinner.
15. Insulin Lispro (Human) 100 unit/mL Solution Sig: Sliding
Scale Subcutaneous QACHS: Per sliding scale attached.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic ketoacidosis
Type I diabetes mellitus
Community acquired Pneumonia
Secondary
Hypertension
Glaucoma
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed. In particular please
take your insulin as prescribed, 30U twice a day. This will
help reduce need to be admitted to the hospital and help with
your vision. Please also take the right amount of your blood
pressure medicine labetalol. We increased your dose from 400mg
to 600mg three times daily.
Followup Instructions:
Please follow up in [**Company 191**] with Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2144-1-29**] 2:00.
.
Please follow up with your PCP [**Name Initial (PRE) 2169**]: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D.
Date/Time:[**2144-2-26**] 9:00.
.
Please follow up with [**Last Name (un) **] ([**Telephone/Fax (1) 2378**]). You have an
appoinment [**2144-1-28**] at 10:10am for vision and another at 11am
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**].
.
Please follow up with opthamology [**2144-1-22**] at 3:45pm in [**Hospital Ward Name 23**]
[**Location (un) 442**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 5849, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6113
} | Medical Text: Admission Date: [**2131-5-8**] Discharge Date: [**2131-5-10**]
Date of Birth: [**2057-6-22**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
thoracic aortic aneurysm
Major Surgical or Invasive Procedure:
[**2131-5-8**]: Endovascular Thoracic Aortic Aneurysm Repair with stent
graft
History of Present Illness:
The patient is a 73-year-old gentleman with an increasing in
size descending thoracic aortic aneurysm measuring 7 cm who
presents for thoracic endograft repair.
Past Medical History:
Past Medical History:
-COPD
-? Atrial fibrillation vs atrial tachycardiac
-CHF with diastolic dysfunction
-Severe aortic stenosis
-Psoriasis
-Renal cancer s/p ablation
-known ventral hernia, followed by Dr [**Last Name (STitle) **]
- thoracic aortic aneurysm
Past Surgical History:
-Appendectomy
-Ventral herniorrhaphy
-Exlap/LOA/hernia repair ([**Doctor Last Name **] [**2128**])
-cardiac cath
Social History:
H/O Smoked 2-3 packs daily, ceased tobacco use 3 years ago
Family History:
non-contributory
Physical Exam:
BP114/65 HR 100 RR 20
Card:S1S2, 2/6 systolic murmur
Lungs:Scattered wheezes throughout
Abd:Soft, non tender
Extremities: warm, well perfused, pulses palpable throughtout
Groin puncture site dry, no drainage.
Pertinent Results:
[**2131-5-10**] 05:50AM BLOOD WBC-11.0 RBC-4.58* Hgb-13.1* Hct-41.0
MCV-90 MCH-28.7 MCHC-32.0 RDW-13.5 Plt Ct-142*
[**2131-5-10**] 05:50AM BLOOD Glucose-92 UreaN-17 Creat-1.0 Na-138
K-4.0 Cl-102 HCO3-26 AnGap-14
[**2131-5-10**] 05:50AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 87780**] was admitted on [**5-8**] after undergoing endovascular
repair of thoracic aortic aneurysm with thoracic stent graft. He
tolerated the procedure well,and was transfered to the CVICU
post operatively. He remained neurovascularly intact with good
blood pressure control. On POD 1 he tolerated a regular diet,
was de-lined and transfered to the vascular floor. He remained
in sinus rhythm with brief episodes of tachycardia to the 160s
treated with lopressor IV with good response. Cardiology was
consulted and felt this represented atrial tachycardia and not
atrial fibrillation. We increased his metoprolol to 50 mg [**Hospital1 **]
from 25mg [**Hospital1 **]. He will follow up with his cardiologist within 2
weeks and Dr. [**Last Name (STitle) **] in 1 month with CTA.
Medications on Admission:
ProAir 180"", Spiriva 18', Symbicort 160/4.5", ASA 81',
furosemide 20', metoprolol 25", O2 2L nc prn
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Symbicort 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation twice a day.
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q8H PRN () as needed for wheeze.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
thoracic aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a repair of a thoracic
aneurysm. During the hospitalization, your heart rate was
elevated. We consulted with cardiology service and made the
following changes to your medications:
*Please increase your metoprolol to 50mg twice daily.
Division of Vascular and Endovascular Surgery
Endovascular Aortic Aneurysm Repair Discharge Instructions
Medications:
?????? Take Aspirin 81mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery.
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-26**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
Followup Instructions:
Dr.[**Name (NI) 14643**] office will call you to arrange an appointment
within the next 1-2 weeks.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 590**] Date/Time:[**2131-6-13**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2131-6-13**] 3:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2131-8-16**] 11:00
Completed by:[**2131-5-10**]
ICD9 Codes: 496, 4280, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6114
} | Medical Text: Admission Date: [**2180-5-9**] Discharge Date: [**2180-5-20**]
Service:
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female who
has a history of hypertension, congestive heart failure, and
aortic stenosis. She was admitted in [**2179-4-2**], to
[**First Name8 (NamePattern2) **] [**Location (un) 620**] with congestive heart failure and was
readmitted with left lower lobe pneumonia and congestive
heart failure from [**2180-5-4**], to [**2180-5-8**]. She was
transferred to [**Hospital1 69**] for
cardiac catheterization and underwent catheterization on
[**2180-5-9**], which revealed left ventricular ejection fraction
of 60%, ascending aorta 0.47 centimeters squared, coronaries
without disease. Echocardiogram at the outside hospital
revealed affect gradient of 62 mmHg and an ejection fraction
of 25%. She was also noted to have moderate mitral
regurgitation and mild tricuspid regurgitation She is now
being evaluated for aortic valve repair.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease.
3. Congestive heart failure.
4. Colon cancer.
5. Aortic stenosis.
6. Bundle branch block.
7. Gastrointestinal bleed in [**2179**].
8. Diverticulosis.
9. Hemorrhoids.
10. Cholecystectomy.
11. Interstitial obstructive pneumonia.
12. Chronic urinary tract infections.
13. Pyelonephritis.
14. Uremia.
15. Uterine cancer.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. once daily.
2. Cholestyramine one package three times a day.
3. Macrobid 100 mg p.o. twice a day times three days.
4. Heparin intravenous per protocol.
5. Combivent p.r.n.
6. Metoprolol 25 mg p.o. twice a day.
7. Pepcid 20 mg p.o. twice a day.
8. Lisinopril 40 mg p.o. once daily.
9. Lipitor 10 mg p.o. once daily.
ALLERGIES: Sulfonamides.
ALLERGIES: The patient lives in an [**Hospital3 **] facility
in [**Location (un) 620**]. She is a nonsmoker and does not drink alcohol.
PHYSICAL EXAMINATION: Temperature is 98.6, heart rate 110,
blood pressure 122/68, oxygen saturation 96% on two liters.
In general, the patient is a pleasant, thin, elderly woman in
no acute distress. Head, eyes, ears, nose and throat -
Conjunctiva erythematous. The pupils are 2.0 millimeters.
Neck - delayed upstroke, carotids bilaterally. The heart is
regular rate and rhythm, III/VI soft systolic ejection
murmur. The abdomen is soft, nontender, nondistended.
Extremities - 1+ bilaterally pitting edema. Symmetrical 2+
dorsalis pedis pulses.
HOSPITAL COURSE: The patient was initially admitted on
[**2180-5-9**], and treated by the medicine team and also seen by
cardiology who recommended cardiothoracic surgery
consultation. Cardiothoracic surgery saw the patient on
[**2180-5-10**], and also recommended an aortic valve replacement.
The patient was taken to the operating room on [**2180-5-11**], and
underwent aortic valve replacement with a 21 millimeter C/A
pericardial valve by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. The operation was
complicated by a partial aortic dissection which was
repaired.
Postoperatively, the patient required a Dobutamine and
Propofol drip. Also, postoperatively, the patient was
started on Neo-Synephrine drip and Dobutamine drip. The
patient was sent to the operating room with mediastinal chest
tubes and pacing wires. She also received perioperative
antibiotic. Postoperatively, the patient had an episode of
arrhythmia requiring an Amiodarone drip.
The patient at appropriate times had her chest tubes and
pacing wires removed. Her Vancomycin perioperatively and
antimicrobial prophylaxis was stopped after four doses. The
patient was started on beta blocker and Lasix. When the
patient was stable, the patient was transferred to the
regular cardiothoracic floor. Her pacing wires were
discontinued. The atrial wires required cutting because they
were tied into the atrial muscle. The ventricular wires were
removed.
On postoperative day six, the patient had an episode in which
her white blood cell count increased to 20.5. House officer
was called to the scene while the patient had decreased
oxygen saturation, labile blood pressure and excessive low
pelvic pain. The Foley catheter was manipulated and
immediately 350cc of urine flowed. The patient's pain
quickly improved although after some time the pelvic pain
returned and the patient continued to have fluctuating blood
pressure and she was sent back to the Intensive Care Unit
where her condition spontaneously improved as her urine
output was maintained with a patent Foley catheter. The
patient was therefore seen by urology who indicated they
would like to follow-up on the patient's condition although
not in the acute setting. They requested that the Foley
catheter be left until the patient was able to use the rest
room on her own and the patient be started on empiric
Levofloxacin therapy. This was done, however, the Foley
catheter was removed and she will be electively straight
catheterized because there is a great concern of seating her
aortic valve due to urinary tract infection. The patient
when straight catheterized was noted to have a quite
prominent yeast infection and the patient was given
Miconazole cream, Miconazole suppositories and one dose of
Diflucan 150 mg. The patient did well with the straight
catheterization and has been free of any cardiac episodes or
respiratory episodes.
It is now [**2180-5-20**], and the patient is being discharged to
rehabilitation center. She is to avoid strenuous activity.
She is to avoid baths but may shower. She may not drive
while on pain medication. She should be straight
catheterized every six hours and p.r.n.
FOLLOW-UP: She is to follow-up with Dr. [**Last Name (STitle) 261**] of the
urology department in approximately two weeks. She is to
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in four weeks. She is to
follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5293**], in one to two weeks.
MEDICATIONS ON DISCHARGE:
1. Miconazole vaginal suppositories, one application
vaginally for seven days.
2. Lasix 20 mg p.o. twice a day for seven days and need for
Lasix to be reassessed.
3. Nystatin Ointment topically applied four times a day
p.r.n.
4. Levofloxacin 250 mg p.o. once daily until her urological
issue is sorted out.
5. Lopressor 25 mg p.o. twice a day.
6. Colace 100 mg p.o. twice a day.
7. Atorvastatin 10 mg p.o. once daily.
8. Cholestyramine 4 grams p.o. three times a day.
9. Albuterol Ipratropium two puffs inhaled q6hours.
10. Pantoprazole 40 mg p.o. once daily.
11. Percocet one tablet p.o. q6hours p.r.n. pain.
12. Enteric Coated Aspirin 325 mg p.o. once daily.
13. Potassium Chloride 20 meq p.o. q12hours for seven days to
have need reassessed thereafter.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2180-5-20**] 11:34
T: [**2180-5-20**] 12:01
JOB#: [**Job Number 49822**]
ICD9 Codes: 4241, 4280, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6115
} | Medical Text: Admission Date: [**2189-6-23**] Discharge Date: [**2189-6-30**]
Date of Birth: Sex: F
Service:
DIAGNOSIS: Spontaneous left renal hemorrhage.
DISCHARGE DIAGNOSIS: Same.
HISTORY: Mrs. [**Known lastname **] is a 62-year-old female who was admitted
to the urology service with acute onset of left flank pain.
Radiologic studies which included CT scan of the abdomen and
pelvis and CT angiography demonstrated a spontaneous renal
hemorrhage in the left kidney and perinephric hematoma.
During this hospitalization she underwent a CT guided coiling
of the renal artery and her condition stabilized. Her course
was stable throughout her hospitalization and she was
discharged on [**2189-6-30**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 8918**], MD
Dictated By:[**Last Name (NamePattern4) 19074**]
MEDQUIST36
D: [**2190-6-9**] 18:34:58
T: [**2190-6-9**] 22:30:29
Job#: [**Job Number 97800**]
ICD9 Codes: 7907, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6116
} | Medical Text: Admission Date: [**2158-6-22**] Discharge Date: [**2158-9-16**]
Date of Birth: [**2103-6-1**] Sex: F
Service: MEDICINE
Allergies:
Dilaudid / Codeine / Ativan
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 F with complicated medical history who has been transferred
from Rehab/[**Hospital3 417**] for dyspnea, acute on chronic renal
failure, volume overload, and fungemia. In [**Month (only) 116**] of this year,
presented to [**Hospital1 18**] ED with abdominal pain. Has significant PMHx
for T1DM, HTN, PVD and was found in the ED to have extensive
calcification of her mesenteric arteries. She was taken to the
OR and found to have infarction of her colon with intact small
bowel. She under went a colectomy with iliostomy at that time.
Post op had respiratory failure requiring prolonged intubation
and eventual tracheostomy. The etiology of her respiratory
failure was unclear at her discharge. She was discharged to [**Location (un) 4368**] [**Hospital 21079**] rehab on [**2158-6-1**] after ~30 day hospitalization on
TPN via CVL with tube feeds started. The plan was to advance
tube feeds and wean TPN.
On [**2158-6-17**], she was still on TPN at rehab and spiked a
temperature up to 103 and blood cultures were positive for yeast
([**Female First Name (un) **] albicans by telephone report but not documented in
transfer records). She was transferred to [**Hospital3 417**] in
[**Hospital1 1474**] for further management. There she was initially given
voriconazole and her central line replaced. Culture from the
line again reportedly grew [**Female First Name (un) **]. She was then switched to
fluconazole and finally to caspofungin today. She was also
treated with ticarcillin/clavulanate for unclear reasons. During
her hospitalization, she also had a "troponin leak" without EKG
changes thought to be demand ischemia by their cardiology
consultants. An echo done on [**2158-6-18**] showed global hypokinesis
with EF 25-30%, dilated LA, LVH, moderated MR, moderate TR,
although image quality was poor. Her hospitalization was also
complicated by hyponatremia of unclear [**Name2 (NI) 10810**].
Her hospitalization was also complicated by acute on chronic
renal failure (s/p transplant in [**2143**]). She did have episode of
ATN in setting of her mesenteric ischemia with peak Cr of 4.3
with return to her baseline of 1.4-1.8 at time of discharge.
Upon admission to [**Hospital3 417**] her Cr was 3.7 and remained
elevated. It is unclear what work up was done for this. On the
day of admission, she also developed respiratory distress with
increasing volume retention. Attempts at diuresis with Lasix 400
mg IV were unsuccesful. She was transferred to [**Hospital1 18**] for
management of her fungemia, renal failure and repiratory
distress. Immediately prior to discharge or in the ambulance she
was started on a nitro dip for again unclear reasons.
Past Medical History:
PMH:
-Mesenteric ischmia requiring coloectomy [**2158-4-24**]
-Respiratory failure requiring trach [**4-/2158**]
-CRI s/p transplant in [**2143**] (followed by Dr[**Doctor Last Name **] at [**Last Name (un) **],
transplant followed by Dr. [**Last Name (STitle) 15473**]
-b/l Breast Cancer s/p lumpectomy/XRT and Chemo 199 (followed by
Dr. [**Last Name (STitle) 3274**]
-PVD s/p L BKA (followed by Dr.[**Last Name (STitle) 21080**]) - [**6-/2147**], fem-[**Doctor Last Name **] '[**48**]
with [**Doctor Last Name **]-DP bypass,
-MI X2 s/p CABG times 2
-hypercholesterolemia
-DM1 with retinopathy/neuropathy/nephropathy
-left eye prosthesis
-bilateral breast cancer
-chronic anemia
-gout
Social History:
lives with husband (a math professor [**First Name (Titles) **] [**Last Name (Titles) **]).
Family History:
NC
Physical Exam:
Vitals: T:96.0 P:98-107 R:22-24 BP:163-176/76-95 SaO2:98% on 4L
CVP 21
General: Awake, alert, .
HEENT: NC/AT, Pupil reactive on right, EOMI without nystagmus,
no scleral icterus noted, MMM, no lesions noted in OP
Neck: supple, no carotid bruits appreciated. unable to assess
JVP
Pulmonary: crackles bilaterally
Cardiac: distant RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, obese, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: 2+ edema in upper and lower ext, 2+ radial, DP and
PT pulses on right.
Skin: diffuse brusing on abdomen. No other rash noted.
Neurologic:
-mental status: Alert, oriented x 3.
-cranial nerves: II-XII
Pertinent Results:
POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-16* ANION GAP-23*
[**2158-6-22**] 08:23PM WBC-18.9*# RBC-3.13* HGB-9.9* HCT-29.5*
MCV-94 MCH-31.7 MCHC-33.6 RDW-18.9*
NEUTS-95* BANDS-1 LYMPHS-1* MONOS-2 EOS-0 BASOS-0 ATYPS-0
METAS-1* MYELOS-0
[**2158-6-22**] 08:53PM PT-12.8 PTT-25.9 INR(PT)-1.1
[**2158-6-22**] 08:51PM TYPE-ART TEMP-36.7 O2 FLOW-3 PO2-40* PCO2-29*
PH-7.36 TOTAL CO2-17* BASE XS--7 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2158-6-22**] 08:51PM LACTATE-2.4*
[**2158-6-22**] 08:23PM GLUCOSE-293* UREA N-131* CREAT-3.1*#
SODIUM-125*
[**2158-6-22**] 08:23PM CK(CPK)-17*
[**2158-6-22**] 08:23PM CK-MB-4 cTropnT-0.26*
[**2158-6-22**] 08:23PM CALCIUM-8.3* PHOSPHATE-4.7*# MAGNESIUM-2.5
Brief Hospital Course:
55 YOF with volume overload, dyspnea, renal failure, elevated
WBC, fungemia, chest pain, and hyponatremia; details below.
.
## Fungemia: Patient was diagnosed with fungemia by blood
culture at [**Hospital1 **] and [**Hospital3 417**], likely due to
TPN. Other sources include possible seeding of chronic thrombus
in UE. TTE on [**2158-6-23**] demonstrated no evidence of vegetations.
Ophthalmology eval demonstrated no opthalmic candidemia. Patient
was initially started on PO fluconazole from 6.30.06-7.13.06.
Patient did however continue to spike fevers while on antibiotic
therapy, concerning for a new or resistant infection in the
context of patient's immunosuppresion. Another possible source
was pulmonary since patient's CT chest from [**2158-7-6**] demonstrated
interval development of bilateral pulmonary nodules. Unclear
etiology for bilateral pulmonary nodules. Nodules may have
represented septic emboli from endocarditis, although no
vegetations were demonstrated by echo on [**2158-6-23**] or [**2158-7-11**].
Patient was converted to IV caspofungin on [**2158-7-6**] until
[**2158-7-12**]. During this time, patient remained afebrile and was
converted back to PO fluconazole prior to discharge.
Blood cultures from [**7-23**] had come back positive for yeast and
per ID was switched to caspofungin. The evening before transfer
to the floor, the patient's HD cath was removed as a possible
site for infection. She was given a loading dose of 70mg IV and
then given a daily dose of 50mg IV. She remained afebrile.
Further workup was done to search for the source of the
fungemia. A renal ultrasound was done which was normal.
Ophthalmology was consulted to evaluate eye grounds and they did
not feel the eye was a source of infection. A TTE was done
which showed a small (0.7 x0.7 cm) mass attached to the highly
calcified mitral annulus which may be a vegetation or a mobile
piece of calcification coming off the larger mitral annular
calcification. A follow up TEE was recommended, however the
patient began to have increased emesis and it was unable to be
performed. ID further recommended the PICC line to be replaced
which was to be done with HD catheter placement. Cultures from
[**Date range (1) 21081**] remained negative and a urine culture from this time was
negative as well.
.
## Klebsiella PNA: retrocardiac, pt received 10d of cefepime.
course completed.
.
## Renal Failure: Patient was admitted to MICU initally and
received hemodialysis which greatly improved mental status.
Renal u/s [**2158-6-23**] showed stable borderline hydronephrosis in the
transplant kidney with elevated resistive indices and CT
ab/pelvis [**2158-6-23**] showed air within the transplant kidney
collecting systems, new from comparison, likely iatrogenic from
foley placement. Then upon admission to the floor, patient had
intractable fluid overload with associated edema and shortness
of breath. Patient underwent hemodialysis three times which
greatly improved fluid overload and shortness of breath. The
patient's creatinine fell to a low of 1.9 while on the floor.
However, the creatinine soon began to rise again to a high of
3.3 on the floor. The patient's acute on chronic renal failure
was believed to be ATN vs. prerenal. The renal service was
closely following the patient and recommended placement of an HD
catheter in preparation for hemodialysis based on her worsening
renal function and fluid status. She was given boluses and
started on NS at 50cc/hr per renal. She was started on Bicitra
30 mL TID for acidosis. Allopurinol was decreased to q48h from
q24 based on the renal function. The tacrolimus dose was halved
and then held.
.
## s/p renal transplant: Pt is normally on prednisone,
tacrolimus, and azathioprine for immunosuppression. Patient was
continued on steroids but tacrolimus and azathioprine were
temporarily discontinued during this admission secondary to
fungemia. Patient was eventually restarted on tacrolimus once
she demonstrated improved control of her infection. Tacrolimus
and prednisone was continued while the patient was on the floor.
The FK506 was elevated and the tacrolimus dose was halved.
When the level did not decrease, tacrolimus was held.
Tacrolimus levels were followed with a goal trough [**2-26**].
Azathioprine was held.
.
## Respiratory failure and shortness of breath: Patient
initially had respiratory failure in the MICU, likely secondary
to a combination of acid-base abnormalities, stiffness from
fluid overload, and infectious process. Patient was started on
cefepime and vancomycin initially for concern of gram negatives
and MRSA, which was noted on OSH blood culture. Cefepime was
discontinued since there was no obvious target and vancomycin
was maintained for MRSA. Vancomycin was then discontinued given
negative blood cultures and concern for vancomycin-induced
thrombocytopenia. After transfer from the MICU, patient
developed increasing shortness of breath with concern for fluid
overload and infectious process. Patient's shortness of breath
improved significantly with three rounds of hemodialysis.
However, a CT scan of chest demonstrated interval development of
pleural effusions and bilateral pulmonary nodules, concerning
for an infectious process. Thoracentesis demonstrated a
transudate effusion. Patient received antibiotic treatment with
PO fluconazole and IV caspofungin. The patient was transferred
on a trach collar, 40%, satting 100%, with upper airway
secretions. She was suctioned frequently and O2 sats remained
within normal limits. She was given nebulizers as indicated.
Her fluid status was closely monitored as she was getting an
increasing fluid load for hypercalcemia treatment. The patient
was triggered on 8/? for altered mental status and question of
respiratory distress. A CXR was done which showed worsening
pulmonary edema however the patient had good oxygen saturation
The patient's mental status did not impro
.
## Hypercalcemia: Ms. [**Known lastname **] had a persistently elevated Ca with
unknown cause. A bone scan was negative for metastatic osseous
disease. TSH and PTH were within normal limits. She was
treated with calcitonin and pamidronate, given lasix and fluids
with some response. Per renal, further calcitonin was held as
the patient did not respond adequately to it and they did not
recommend pamidronate as it can contribute to renal failure.
PTHrp was sent and was normal. Hypercalcemia thought to be
secondary to imobilization.
.
## Hyponatremia: Pt was initially hyponatremic to 125 on
admission, likely in setting of volume overload from CHF/renal
failure. Patient's sodium resolved with hemodialysis and was
stable during admission. The patient's sodium remained stable
while on the floor.
.
## Type 1 Diabetes melitus: Patient has type 1 diabetes with
major complications as listed above. She initially was started
on an insulin drip and her insulin regimen was adjusted with
help from [**Last Name (un) **].
.
## Anemia: Patient had anemia of chronic disease, most likely
secondary to chronic renal insufficiency. HCT was trending down
and guiac was positive, and patient received 1unit pRBC. She was
stable post transfusion on [**6-26**]. No other transfusions were
given, and th pt may require outpt colonoscopy.
..
## Thrombocytopenia: Patient developed thrombocytopenia during
admission. Thrombocytopenia was thought to have developed
secondary to vancomycin and platelets increased after
discontinuing vancomycin.
.
## UTI: During admission, patient's urine culture began growing
vancomycin-resistant enterococcus. Patient was treated with
linezolid. She again grew out many bacteria on a urine culture
and was treated with ciprofloxacin and fluconazole (last day of
cipro [**2158-9-23**], last day of fluconazole [**2158-9-18**])
.
## CAD: Patient is s/p MI x 2. Patient had no symptoms during
admission. Patient was maintained on home meds of ASA, BB, and
isosorbide dinitrate.
.
## HTN: Patient's blood pressures have been occasionally
elevated and hydralazine was increased to 15mg PO qid to assess
for improved BP control. Patient was otherwise maintained on
home doses of Clonidine, Metoprolol, and Isosorbide without
other problems.
.
## Depression/anxiety
Patient was maintained on paxil. Ativan and ambien were
discontinued secondary to increased somnolence with these meds.
.
.
.
MICU Transfer [**2158-8-21**] - [**2158-9-3**]
Pt was admitted for hypotension. There was no clear source,
with possiblities being septic (LLL opacity and 4+ MRSA in
sputum, though no fever or WBC), adrenal insufficiency (started
empirically on stress dose steroids), or cardiogenic. As she
was not felt to clearly be septic and didn't seem to briskly
respond to stress dose steroids, she had an echo performed,
showing an EF of 25%, down from an echo one month prior showing
35-45%. Cardiology was consulted who felt that this was not
acute ischemia, and that the decrement in function was likely
overstated; it was felt that her prior study had been of
sub-optimal quality and that probably had not been a significant
interval change in LV-EF, and that this low EF was probably a
mix of a baseline ischemic cardiomyopathy with a superimposed
toxic/infectious cardiomyopathy. There was also concern,
despite the physiologic controversy of this theory, that she was
grossly volume overloaded and thus had tipped over to the
disadvantageous arm of Starling's curve. In the setting of this
gross volume overload with associated large bilateral pleural
effusions (that had been tapped one month prior and found to be
transudative, thought to be due to heart failure), she developed
worsening respiratory distress and was placed back on the
ventilator on minimal settings (p/s [**9-28**], fio2 40%) with
immediate relief of her dyspnea. Over the next few days, she
continued with treatment of her VAP and was diuresed during
CVVH. She tolerated this well and was able to be weaned off
pressure support and onto a trach mask without difficulty. By
the time she was called out of the unit she had been tolerating
trach collar alone for several days.
.
She was treated for ten days with vancomycin and ceftazidime for
a hospital acquired pneumonia. Her stress dose steroids were
tapered after three days of full dose, over the course of the
following week. She was started on CVVHD to relieve her gross
volume overload. With the combined effect of these
interventions, her bp slowly climbed over the week, and she
eventually became hypertensive with bp's in the 140-160's. She
was then switched from CVVHD back to intermitten HD.
.
During the course, she had one episode of afib with RVR. At the
time, her hr was in the 140's to 160's and a bp was not able to
be obtained, though she did not lose conciousness. She was
bolused 500cc of NS and a phenylephrine drip was started. She
received 20mg of diltiazem IV with heart rate decreasing to the
90's to low 100's and bp up to the 120's. She receieved a 24`
IV amiodarone load with reversion to sinus rhythm and was then
switched over to oral amiodarone.
.
FLOOR COURSE:
.
## Hallucinations/delusions: Pt having active hallucinations.
Being treated for urine bacterial and fungal infections. No
other abnormalities other than encephalopthy per EEG to explain
new hallucinations. Unlikely to be from new-onset psyichiatric
disease. MRI was unrevealing, Ca under control, head CT negative
x2. Continue ciprofloxacin until [**9-23**]. Continue fluconazole
until [**9-18**].
.
## Atrial fibrillation: Pt went into atrial fibrillation in the
unit. Now in sinus rhythm after being treated with amiodarone.
Rate-controlled. INR goal is 2.0-3.0. Pt's warfarin dosing has
not been finalized, so should be adjusted daily. She was
continued on metoprolol 50 [**Hospital1 **] for rate control and amiodarone
200 for rhythm control.
.
## Coronary artery disease: No evidence of active ischemia.
Continued metoprolol 50 PO bid, aspirin 81 PO qd
.
## HTN: Pt is relatively normotensive. Continued metoprolol,
hydralazine, isosorbide.
.
## Ischemic cardiomyopathy: Total body volume overloaded given
sacral edema and bilateral pleural effusions. Not symptomatic.
.
## End stage renal disease s/p transplant: Needed HD and CVVH in
unit. Now being evaluated daily for HD requirement.
.
## Diabetes mellitus, Type 1: Mildly hyperglycemic throughout
the day. Followed by [**Last Name (un) **] service to adjust insulin daily.
.
## Respiratory failure: Pt c/o mild shortness of breath, but
ascribes this to the valve on the trach collar. Has required
intermittent nebs for wheeziness.
.
## Hypercalcemia: Unlikely to be related to breast cancer as she
has had a negative bone scan during this hospitalization. [**Month (only) 116**] be
hypercalcemia from immobility. Received pamidronate 30 mg IV x2
with some normalization of calcium.
.
## Breast cancer: Pt was started back on letrozole, but then
discontinued again when she started having hallucinations.
Medications on Admission:
-hydrocortisone 100 mg iv q8h
-SSI
-azathioprine 50 mg qd
-tylenol prn
-allopurinol 100mg qd
-clopidogrel 75 mg qd
-metoclopramide 20 mg qid
-nystatin swish and spit qid
-epo 10K qwk
-Femara 2.5 mg qd
-tacrolimus 1mg [**Hospital1 **]
-clonidine 0.2 mg tid
-Colshicine 0.6 mg qd
-colace
-emeprazole 40 qd
-Caspofungin 70 mg iv times 1 given [**6-22**]
-lasix 40 mg iv bid
-ASA 81 mg qd
-paroxetine 20mg qd
-metoprolol 50 mg tid
-lorazepam 0.5 prn
-Calcium [**Last Name (un) **] 500 mg tid
-calcium acetate 667 tid
-isosorbide dinitrate 50mg tid
-albuterol prn
-ipratropium prn
-Ticarcillin/clavulanate 3.1g q8h
-Nitro drip
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY
- s/p renal transplant in [**2143**]
- Candidemia
- Urinary tract infection
- Fluid Overload
- Acute on Chronic Renal Failure
- Thrombocytopenia
- Anemia
- Type 1 Diabetes Mellitus
- Hypertension
SECONDARY
- Depression
Discharge Condition:
Fair - Patient is taking oral intake and breathing well on room
air. Patient still requires PT to help her mobilize.
Discharge Instructions:
Please take all medications as prescribed. If you have symptoms
of fevers, chills, night sweats, chest pain, worsening shortness
of breath, or worsening swelling in lower extremities, please
seek immediate medical attention.
Followup Instructions:
-- Please see your kidney transplant [**Last Name (LF) 5059**], [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**],
MD on Date/Time:[**2158-7-25**] 10:45. His phone number is
[**Telephone/Fax (1) 673**].
-- Please see your infectious disease physician, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6400**],
MD on Date/Time:[**2158-8-17**] 11:00. Her phone number is
[**Telephone/Fax (1) 457**].
-- Please see your cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. at
Date/Time:[**2158-8-29**] 11:20. His phone number is [**Telephone/Fax (1) 5003**]
ICD9 Codes: 5845, 5990, 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6117
} | Medical Text: Admission Date: [**2189-10-16**] Discharge Date: [**2189-10-26**]
Date of Birth: [**2115-9-22**] Sex: M
Service: MEDICINE
Allergies:
Lactose
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Low back pain, shortness of breath
Major Surgical or Invasive Procedure:
Thoracentesis
Pigtail pleural catheter placement
History of Present Illness:
The patient is a 74M who presented to the ED with back pain. He
has had three mechanical falls in the past two weeks. He has had
difficulty ambulating secondary to pain. He denied fevers,
chills, chest pain, cough or cold symptoms, nausea, vomiting,
abdominal pain, and dysuria though does endorse worsened
dyspnea.
On arrival to the ED, he triggered for hypoxia to 88% which
improved with supplemental oxygen. A head CT was negative, CXR
showed PNA in RLL and CT torso showed a loculated effusion and
compression fractures. He was started on vanc and zosyn and 1L
NS. He was also given morpinge 4mg IV and percocet. Spine was
consulted for the compression fractures and recommended a TLSO
brace and an MRI on a non-urgent basis.
Past Medical History:
BPH
Anemia
Dyspepsia
Weight Loss
Atrial flutter diagnosed in [**2187**], s/p ablation in [**2188-4-26**]
Vitamin D Deficiency
DMII
MDS
Colonic adenomas
h/o Sigmoid diverticulitis.
h/o Basal cell carcinoma.
h/o Left hip fracture, status post ORIF in [**2183**].
Social History:
Retired, lives with wife. [**Name (NI) **] denies any alcohol. Is
currently smoking tobacco pipes, 50y history. Denies any other
illicit drug use.
Family History:
Maternal aunt with diabetes. There is no family history of
premature coronary artery disease, arrhythmias, or sudden death.
Physical Exam:
Physical Exam on admission:
GENERAL - cachectic male appearing older than stated age
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous
membranes with poor dentition
NECK - supple, no thyromegaly, no JVD, no lymphadenopathy
LUNGS - bronchial on right
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Physical Exam on discharge - Unchanged from above except for:
HEENT - moist MM
LUNGS - Mild crackles and bronchial breath sounds in the right
lung base.
Pertinent Results:
Labs on admission:
[**2189-10-15**] 08:21PM BLOOD WBC-27.6*# RBC-3.48* Hgb-9.2* Hct-30.7*
MCV-88 MCH-26.3* MCHC-29.8* RDW-17.3* Plt Ct-179
[**2189-10-15**] 08:21PM BLOOD Neuts-85* Bands-1 Lymphs-3* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-2* NRBC-1* Other-1*
[**2189-10-15**] 08:21PM BLOOD PT-13.3 PTT-27.4 INR(PT)-1.1
[**2189-10-15**] 08:21PM BLOOD Glucose-140* UreaN-36* Creat-1.1 Na-139
K-4.2 Cl-101 HCO3-29 AnGap-13
[**2189-10-15**] 08:21PM BLOOD ALT-35 AST-71* AlkPhos-373* Amylase-51
TotBili-0.3
[**2189-10-16**] 03:43AM BLOOD TotProt-6.1* Albumin-2.3* Globuln-3.8
Calcium-10.6* Phos-3.7 Mg-2.0
[**2189-10-16**] 03:43AM BLOOD PTH-6*
[**2189-10-15**] 08:26PM BLOOD Lactate-3.8* K-4.4
[**2189-10-16**] 02:53AM BLOOD Lactate-2.3*
[**2189-10-16**] 04:42AM PLEURAL WBC-[**Numeric Identifier 38617**]* RBC-1625* Polys-97*
Lymphs-3* Monos-0
[**2189-10-16**] 04:42AM PLEURAL TotProt-4.2 Glucose-15 LD(LDH)-2507
[**2189-10-17**] 05:44PM PLEURAL WBC-[**Numeric Identifier 43204**]* RBC-2500* Polys-94*
Lymphs-2* Monos-4*
[**2189-10-17**] 05:44PM PLEURAL TotProt-3.1 Glucose-2 LD(LDH)-2393
Cholest-44
Blood culture [**10-15**] and [**10-16**]: Pending
[**2189-10-16**] 2:40 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2189-10-18**]**
GRAM STAIN (Final [**2189-10-16**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2189-10-18**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2189-10-16**] 4:42 am PLEURAL FLUID
GRAM STAIN (Final [**2189-10-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Legionella antigen: negative
[**2189-10-17**] 5:44 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2189-10-17**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
Images:
-CXR [**2189-10-18**]:
Small residual of right pleural effusion has remained stable
since insertion of the pigtail pleural drain at the base of the
lung. Consolidation primarily in the right lower lobe, to a
lesser degree anterior segment of the right upper and middle
lobes is improving. Infrahilar atelectasis in the left lower
lobe, however, is worsening. Heart size normal. Normal pulmonary
vasculature. No edema. No pneumothorax.
-CT head [**2189-10-15**]: no acute intracranial process
-CXR ([**2189-10-23**]): 1. No evidence of pneumothorax following right
pigtail pleural catheter removal.
2. Improving mass-like consolidation in right lower lobe
consistent with
pneumonia.
3. Small pleural effusions, right greater than left.
-Abd US ([**2189-10-23**]): No evidence of gallstones or biliary
dilatation. Splenomegaly. Ascites.
EKG at admission: sinus tachy, LAD, q waves v1-2
Discharge labs:
[**2189-10-16**] 03:07PM BLOOD PTH-7*
[**2189-10-20**] 04:55AM BLOOD VITAMIN D [**1-20**] DIHYDROXY-24 (nl)
[**2189-10-17**] 06:56AM BLOOD PARATHYROID HORMONE RELATED
PROTEIN-negative
[**2189-10-16**] 03:43AM BLOOD VITAMIN D 25 HYDROXY- 27
[**2189-10-26**] 06:25AM BLOOD WBC-5.6 RBC-3.04* Hgb-7.8* Hct-26.1*
MCV-86 MCH-25.8* MCHC-30.0* RDW-18.1* Plt Ct-221
[**2189-10-26**] 06:25AM BLOOD Glucose-76 UreaN-16 Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-32 AnGap-9
[**2189-10-26**] 06:25AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.4
Brief Hospital Course:
74 year old male with history of MDS, weight loss of 70-80
pounds, multiple falls, diabetes mellitus, who presented for low
back pain, found to have multifocal pneumonia and complicated
parapneumonic effusion.
#) Pneumonia with complicated parapneumonic effusion/loculation:
On admission to the MICU he had a thoracentesis and 1L of cloudy
non-purulent fluid was drained. He was initially covered broadly
with Vanc/Zosyn/Levofloxacin. On [**10-17**], he had an additional
throacentesis with chest tube placement by IP. There was concern
for aspiration versus community acquired PNA. Once legionella
antigen was negative levofloxacin was discontinued. Early in the
hospitalization, he had occasional desaturations overnight which
required oxygen via facemask. This was not occurring for the
5-6 days prior to discharge. At time of discharge, he had
completed a 9 day course of antibiotics and will not need
further antibiotics. Clinically, his breathing was improved at
discharge, he was maintaining good oxygen saturation on room air
and there was no reaccumulation of the pleural effuion on repeat
CXR.
#) Leukocytosis: Persistent in the in the high 20's on
admission, but decreased to normal range at the time of
discharge. Increased WBC likely secondary to his pneumonia. C.
diff was negative x3.
#) Hypercalcemia: Given unintentional weight loss of 70-80 lbs
and smoking history, there is concern for malignancy. PTH was
appropriately low at 7. 1,25-OH-VitD was normal and PTHrP was
also negative. Skeletal survey did not show evidence of lytic
lesions, only suggestive of osteoporotic changes. He was given
a dose of pamidronate 60mg on [**2189-10-20**] and his calcium level
decreased to the normal range. A urine N-telopeptide was sent
and was elevated, suggesting some process leading to increased
bone turnover. Paget's is another possible explaiantion given
elevated alk phos and calcium, no evidence of Paget's on
skeletal survery per radiology. Had a bone scan in [**2-/2188**] which
also did not show evidence of Paget's.
#) Weight loss: PSA was 0.5 in [**2188**]. Per pt he had a normal
colonoscopy last year. As mentioned above, no obvious cause
despite negative PET/CT as well as negative bone marrow biopsy
prior to admission. Has follow-up with hematology/oncology
arranged.
#) Pain control: He was treated with acetaminophen 1g q8h,
toradol 15 mg IV q8h for three days, lidocaine patch, morphine
sulphate prn, oxycodone prn. A TLSO brace was placed. MRI showed
compression fracture in L1 and L2, recommended follow-up in 4
weeks. At discharge, pain well controlled only on PRN tylenol
and lidocaine patch, not requiring narcotics.
#) DM: Metformin was held and he was covered with insulin
sliding scale. Blood sugars remained well controlled during
admission and he will be restarted on metformin at discharge.
#) Diarrhea: Had diarrhea during this admission with 4-5 BMs per
day. C. diff was negative x3. It is thought that he had
antibiotic-associated diarrhea which should improve at discharge
now that he is off antibiotics. Also encouraged yogurt to
improve the diarrhea.
#) Code status during this admission: FULL CODE
Trnasitional Issues:
-Follow-up MRI in 4 weeks from [**2189-10-18**] to follow-up on lumbar
compression fractures
-Ongoing work-up for weight loss and hypercalcemia, as described
above
-Emailed pt's Hemotologist who is aware of weight loss and has
talked with PCP regarding concern for malignancy
-Received Pamidronate 60mg IV on [**2189-10-20**], would be due for this
every month if ongoing therapy with bisphosphonates is desired
Medications on Admission:
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - one
Tablet(s) by mouth daily
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - one
Tablet(s) by mouth twice a day
PRAVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet -
one Tablet(s) by mouth daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider) -
Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (Prescribed by
Other Provider) - 1,000 unit Tablet, Chewable - one Tablet(s) by
mouth daily
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) application
Topical three times a day: Apply to buttocks.
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
6. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
7. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ml PO every six (6) hours as needed for cough or chest
congestion.
8. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection three times a day.
10. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
11. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: Apply to L1-L2 area. 12 hours
on, 12 hours off.
12. pamidronate 60 mg/10 mL (6 mg/mL) Solution Sig: Sixty (60)
mg Intravenous once a month: Last given [**2189-10-20**].
13. aluminum-magnesium hydroxide 200-200 mg/5 mL Suspension Sig:
Five (5) mL PO four times a day as needed for indigestion.
14. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every
four (4) hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehabilitation & [**Hospital **] Care Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
Aspiration pneumonia
Lumbar Compression fracture
Rib fractures
Hypercalcemia
Secondary:
Diabetes Mellitus
Myelodysplastic Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 5749**],
It was a pleasure taking care of you during your
hospitalization at [**Hospital1 69**]. You
were admitted with low back pain, for which we found that you
had a new compression fracture. Orthapedics did not recommend
surgery and instead placed you in a special type of brace.
You also presented with shortness of breath and oxygen
saturation. We discovered that you had a pneumonia, for which
we treated you with two different intravenous antibiotics. We
also placed a tube to drain some of the fluid that had
accumalated in the pneumonia. At discharge, you were breathing
more comfortably and do not need any more antibiotics after
discharge.
Your calcium level was found to be elevated. We did not
find a cause for this, although you have had an extensive
work-up priot to this admission which also did not find a cause.
You were given Pamidronate and your calcium level improved,
this medication should be given every month.
You also had significant diarrhea, which was negative for
the infection C. diff 3 times. It is likely related to the
antibiotics, which we have stopped now. Eating foods like
yogurt can help improve your symptoms, and you should feel
better now that the antibiotics are stopped.
MEDICATION CHANGES:
START guaifenesin-dextromethorphan 5mL by mouth as needed for
cough
START Pamidronate 60mg IV every month (last given [**2189-10-20**])
START lidoderm patch 1 patch apply to L1-L2 area, on for 12
hours and off for 12 hours.
START Duonebs 1 nebulizer every 4 hours as needed for shortness
of breath of chest tightness
START miconazole powder 1 application to buttocks and groin
three times daily
Followup Instructions:
PCP appointment to be arranged by rehab
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2189-11-6**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5070, 2875, 5119, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6118
} | Medical Text: Admission Date: [**2199-12-4**] Discharge Date: [**2199-12-13**]
Date of Birth: [**2133-9-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Benadryl / Phenytoin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
HEADACHE
Major Surgical or Invasive Procedure:
Angiogram [**2199-12-5**]
Angiogram [**2199-12-12**]
History of Present Illness:
66 y/o male with history of headache since Friday presents to
[**Hospital1 18**] from OSH. Patient states that while watching TV on Friday
night felt a "splitting" headache, [**11-19**] with nausea. He states
that the headache was present throughout the weekend, but was
not
as severe as on Friday. On Sunday, he reports that he also began
to experience neck pain with the headache. On Tuesday, headache
became worse and patient was unable to go to work. His wife
noticed that the patient was more weak and encouraged the
patient
to come to [**Hospital3 **] ED. At the OSH, a head CT was done
which showed a basilar aneurysm with trace SAH. Patient was then
transferred to [**Hospital1 18**] for further neurosurgical workup. Patient
states that he has a headache that is [**2200-3-17**], dizziness upon
standing with increase in headache, nausea. He denies any nuchal
rigidity, blurred vision, or vomiting.
Past Medical History:
appendectomy, tonsillectomy, hypercholesteremia,
costochondritis, LBP
Social History:
Denies any tobacco, 6 pack of beer/year
Family History:
NC
Physical Exam:
T:99.5 BP:177/94 HR: 88 R:21 O2Sats: 91% RA
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, normocephalic
Pupils:3-2mm bilaterally EOMs: intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-12**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-14**] throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
ON DISCHARGE
Pertinent Results:
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83988**] M 66 [**2133-9-12**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2199-12-4**]
10:34 PM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2199-12-4**] 10:34 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 83989**]
Reason: SUBARACHNOID HEMORRHAGE
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with SAH, evaluate for infectious process
REASON FOR THIS EXAMINATION:
66 year old man with SAH, evaluate for infectious process
Final Report
REASON FOR EXAMINATION: Fever in a patient with subarachnoid
hemorrhage.
Portable AP chest radiograph was reviewed with no prior studies
available for
comparison.
Heart size is top normal. Mediastinal position, contour and
width are
unremarkable. Lungs are essentially clear except for bibasal
atelectasis and
questionable right suprahilar opacity that also might represent
asymmetric
calcification within the first right rib cartilage. No evidence
of infection
is present on the current study. Further evaluation with PA and
lateral view
whenever possible is recommended for clarification of the
suprahilar
abnormality on the right.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83988**] M 66 [**2133-9-12**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2199-12-4**] 10:51 PM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2199-12-4**] 10:51 PM
CTA HEAD W&W/O C & RECONS Clip # [**Clip Number (Radiology) 83990**]
Reason: 66 year old man with SAH, evaluate for aneurysm or AVM
Contrast: OPTIRAY Amt: 70
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with SAH, evaluate for aneurysm or AVM
REASON FOR THIS EXAMINATION:
66 year old man with SAH, evaluate for aneurysm or AVM
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: [**First Name9 (NamePattern2) 42546**] [**Doctor First Name **] [**2199-12-5**] 12:48 AM
No aneurysm or malformation noted. Hyperdense material in
prepontine cistern,
could be blood, or less likely mass.
Final Report
EXAM: CT angiography of the head.
CLINICAL INFORMATION: Patient with subarachnoid hemorrhage.
TECHNIQUE: Axial images of the head were obtained without
contrast. Following
this, using departmental protocol, CT angiography of the head
was acquired.
FINDINGS HEAD CT: There is subarachnoid hemorrhage seen in the
perimesencephalic region. There is no midline shift or
hydrocephalus.
CT ANGIOGRAPHY HEAD:
CT angiography of the head demonstrates no evidence of vascular
occlusion,
stenosis or an aneurysm greater than 3 mm in size.
IMPRESSION: Head CT shows subarachnoid hemorrhage. CT
angiography of the
head demonstrates no obvious abnormalities including no obvious
aneurysms.
Correlation with scheduled cerebral angiography is recommended.
COMMENT: This report is provided without the availability of 3D
reformatted
images. When these images are available, an addendum will be
given if
additional information is obtained.
Brief Hospital Course:
Patient presented to OSH s/p "splitting" headache on Friday
night. He stated that his headache was persistent throughout the
weekend and he developed a stiff neck as well as weakness. His
wife urged him to go to the [**Name (NI) **] where a head CT was performed.
Result showed a basilar tip aneurysm that measure 1.2cm with
trace SAH. He was transferred to [**Hospital1 18**] for further neurosurgical
workup. Upon arrival to [**Hospital1 18**] patient was nonfocal, a&ox3 with
full strength. A CTA was ordered and he was admitted to the ICU
for Q1H neuro checks. On [**12-5**], patient was taken to angiogram,
where no aneurysm was seen, but a subarachnoid blood was
observed. Post angio, patient remained non-focal in ICU. On
[**12-6**], the patient was to be transferred to step down but he
was slightly lethargic in the evening. The femoral incison
remain intact. This lethargy improved and he was transfered to
the SDU on [**2199-12-7**].
He had a mild temp on [**2199-12-9**] for which a UA was sent and
dopplers performed and were both negative.
An MRI of the brain and C-spine to r/o underlying mass and
AV-fistula were performed and negative.
His angiogram on [**2199-12-12**] was negative for aneurysm and patient
remains non focal on post angiogram check. Femoral incision was
clean, dry, and intact with no hematoma or bleeding. Patient is
stable for discharge home.
Medications on Admission:
prilosec, statin, ibuprofen
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-11**]
Tablets PO Q4H (every 4 hours) as needed for PAIN.
Disp:*60 Tablet(s)* Refills:*0*
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Headache.
Disp:*40 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
SAH
Discharge Condition:
Neurologically Stable
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Ro
Followup Instructions:
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.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2200-1-24**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6119
} | Medical Text: Admission Date: [**2168-2-11**] Discharge Date: [**2168-3-5**]
Date of Birth: [**2106-1-30**] Sex: F
Service: MEDICINE
Allergies:
Zestril / Coumadin
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Dyspnea on exertion and lower extremity edema
Major Surgical or Invasive Procedure:
medical intensive care unit (MICU) monitoring
History of Present Illness:
This is a 62 year old female with history of pulmonary embolus
in [**2160**] treated with heparin/coumadin complicated by large
retroperitoneal bleed from a supratherapeutic INR, diastolic
congestive heart failure, diabetes [**Year (4 digits) **], obstructive sleep
apnea on Bipap who presents with increased dyspnea on exertion.
One day prior to admission, she had increase in weight of 2 lbs
and increasing lower extremity edema to mid leg bilaterally. On
day of admission she had a 10 lb increase in weight and today
her dypsnea on exertion became severe, her balance was off, she
felt lightheaded/dizzy with standing. Patient denies chest pain
or fever. She admits to a chronic cough with increased sputum
production and phlegm over the past several weeks. She also
notes right scapula pain with inspiration over the past several
weeks. She sleeps with bed elevated and has cpap machine at
home. She has urinary incontinence and thinks she has had
worsened symptoms recently.
Past Medical History:
1. Pulmonary emboli ([**2160**]) status post IVC filter secondary to
retroperitoneal bleed on coumadin; Sadddle embolus ([**2168**])
2. Thoracic osteomyelitis status post 6 week treatment with
vancomycin. Also concern for underlying tumor that is being
worked up.
3. Insulin dependent diabtes complicated by neuropathy and
retinopathy.
4. Congestive heart failure recently diagnosed per patient.
Echocardiagram during this admission does not demonstrate any
heart failure.
5. Chronic lower extremity edema
6. Obesity
7. Right foot ulcers
8. Fibromyalgia
9. Osteoarthritis, left knee status post "injection" and prior
knee surgery
[**72**]. multiple surgeries: appendectomy, cholecystectomy (ex lap),
partial hysterectomy
11. Obstructive sleep apnea on BIPAP at night
13. L4-5 herniated disc, status post steroid injections
Social History:
She quit smoking 23 years ago - she started at age 13 with 1
pack per day and then increased to 2-3 packs per day until she
quit. She denies alcohol. She lives at home with a [**Doctor Last Name **]
child who is 20 years old. She has cleaning lady. She walks
independantly.
Family History:
Her brother had a stroke at age 65. There is a family history
of diabetes, hypertension, and Multiple sclerosis.
Physical Exam:
Vitals: Temperature:98.9 Pulse:79 Blood pressure:107/53
Respiratory rate:18 Oxygen Saturation:95% on room air.
GENERAL: pleasant morbidly obese female in no acute distress,
breathing comfortably
HEENT: Extraoccular movements intact, pupils equal and reactive,
moist mucous membranes.
NECK: unable to appreciate JVP given body habitus, no bruits.
CARDIAC: distant heart sounds, regular rate and rhythm, no
appreciable murmurs, rubs, or gallops.
PULMONARY: Clear to ausculatation bilaterally, no respiratory
distress, no accessory muscle use.
BACK: midline lower surgical scar appreciated
ABDOMEN: obese, soft, normoactive bowel sounds, nontender,
nondistended surgical scar transverse from left lower costal
edge towards right hepatic area, right lower quadrant surgical
scar at McBurney's point.
EXTREMITIES: Edema, trace-1+ pitting to knee bilaterally,
Dorsalis pedis 1+ bilaterally, ulcer on dorsal surface of right
first digit
NEURO: alert and oriented times 3. Gait not observed. Cranial
nerves II-XII grossly intact.
Pertinent Results:
Hematology:
WBC-9.3 HGB-13.6 HCT-39.9 PLT COUNT-193
NEUTS-69.2 BANDS-0 LYMPHS-22.0 MONOS-3.8 EOS-3.5 BASOS-1.5
.
Chemistries:
SODIUM-143 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-29 UREA N-36
CREAT-1.0 GLUCOSE-163
CALCIUM-9.2 PHOSPHATE-2.3 MAGNESIUM-2.2
.
Cardiac:
CK(CPK)-42 CK-MB-NotDone cTropnT-0.06
proBNP-50
.
Coagulation:
PT-11.5 PTT-18.5 INR(PT)-0.9
D-DIMER-4006
.
Urinalysis: negative.
.
EKG: sinus tachycardia, normal intervals, no ST changes.
.
Imaging:
1. Chest x-ray: No radiographic evidence of failure.
2. Chest CTA: Large saddle embolus involving the right and left
main pulmonary arteries extending to the middle and lower lobes
bilaterally. The CT obstruction index is about 50%. Stable
appearance of right upper lobe lung nodule.
Brief Hospital Course:
This is a 62 year-old female who presented with dyspnea on
exertion and lower extremity edema who was found to have saddle
pulmonary emboli.
.
1. Pulmonary emboli: Her CTA was notable for a saddle embolus
involving the right and left main pulmonary arteries extending
to the middle and lower lobes bilaterally with an obstruction
index of about 50%. She was started on heparin as a bridge to
Coumadin. Her Coumadin dose was increased until a therapeutic
level was achieved. This is her second pulmonary emboli and
therefore she will likely need anticoagulation for life. She
will need a hypercoagulable work-up as an outpatient. She was
discharged on 7.5 mg daily of Coumadin.
.
2. Hematomas: While on anticoagulation, she developed 2
hematomas in her left flank and left groin. She had no evidence
of compartment syndrome. Her pain was controlled with Tylenol
and oxycodone. She did require red cell transfusions for blood
loss anemia.
.
3. Hypotension: Early on during this admission, she developed
hypotension to 85/41. Her blood pressure responded to a fluid
challenge. An EKG had no signs of ischemia and a echocardiogram
had no sign of right ventricular dysfunction. Her hematocrit at
that time was stable and there was no sign of acute bleed. She
appeared intravascularly dry with an low Fe Urea. Therefore,
her hypotension was attributed to overdiuresis. Her blood
pressure improved with hydration.
.
4. Lower extremity edema: On admission, she had increased lower
extremity edema above her baseline. There was no evidence of
heart failure on echocardiogram. She was initially overdiuresed
resulting in hypotension, as above. Once her blood pressure had
stabilized, she was restarted on her outpatient Lasix dose with
decrease in lower extremity edema. She appeared to be
overdiuresed on her previous outpatient dose of Lasix;
therefore, she was discharged on a lower dose (20 mg daily).
.
5. Urinary tract infection: She was noted to have cloudy urine
and a urine culture was positive for klebsiella. She was
treated with a 7-day course of ceftriaxone.
.
6. Diabetes: She had been on 36 units of Lantus as an
outpatient. Her sugars were under poor control (A1c = 9.3), so
her Lantus was increased to 42 units. This regimen yielded good
glucose control.
.
7. Obstructive sleep apnea: She was maintained on CPAP at night.
.
8. Right toe ulcer: She had been seen by [**Doctor Last Name **] for
debridement of her ulcer. She was maintained on wet-to-dry
saline dressing changes daily.
.
9. Back pain: She was maintained on her outpatient gabapentin
and baclofen.
.
10. FEN: Low sodium cardiac diabetic diet. She had hyperkalemia
on admission that was treated. She had no further episodes of
hyperkalemia.
.
11. Prophylaxis: Anticoagulation with heparin/Coumadin,
Colace/senna, PPI, ambulation.
.
12. Access: Peripheral IV
.
13. FULL CODE
.
14. DISPO: She was discharged to home once she was therapeutic
on Coumadin for 48 hours. She will follow-up in clinic 4 days
post-discharge for an INR and hematocrit check.
Medications on Admission:
1. spectravite
2. gabapentin 800mg qid
3. baclofen 10mg ([**2082-11-1**])
4. spironolactone 25mg'
5. diovan 40mg'
6. lasix 80mg'
7. protonix 40mg'
8. mirapex 0.5mg'
9. ranitidine 300mg'
10. aspirin 81mg'
11. lipitor 10mg'
12. citalopram 40mg'
13. bethenachol 25mg qid
14. tramadol 100mg qid
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
4. Baclofen 10 mg Tablet Sig: ASDIR Tablet PO TID (3 times a
day): Take 10 mg (1 tablet) in the morning, 10 mg in the
afternoon, and 20 mg (2 tablets) at bedtime.
5. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO QD ().
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
10. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): Take while still taking oxycodone.
Disp:*60 Capsule(s)* Refills:*2*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Continue while taking
oxycodone.
Disp:*30 Tablet(s)* Refills:*0*
13. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
14. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3-4H (Every 3 to
4 Hours) as needed: Take until leg pain resolves.
Disp:*45 Tablet(s)* Refills:*0*
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours): until left leg pain resolves.
Disp:*100 Tablet(s)* Refills:*2*
17. Insulin Glargine 100 unit/mL Solution Sig: Forty Two (42)
units Subcutaneous at bedtime.
18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
saddle pulmonary embolism
Discharge Condition:
Stable. She has large left medial thigh hematoma that is stable
in size. Her left leg pain is stable if not slightly improved.
her respiratory status is stable.
Discharge Instructions:
Please take all medications as prescribed and keep all follow-up
appointments.
.
Call your doctor or go to emergency room if you develop sudden
worsening shortness of breath, fever/chills, lightheadedness,
chest pain, palpitations, bleeding that doesn't stop or anything
else that you find worrisome.
Followup Instructions:
You have the following appointment to have your INR checked:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 5808**]
Date/Time:[**2168-3-9**] 1:40
.
You also have the following appointments:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2168-4-4**]
10:00
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2168-4-4**] 11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2168-3-7**]
ICD9 Codes: 2851, 5990, 2875, 2767, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6120
} | Medical Text: Admission Date: [**2110-10-25**] Discharge Date: [**2110-10-27**]
Date of Birth: [**2060-5-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Shortness of breath, Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 y/o F with metastatic adenoid cystic carcinoma, GERD, PE,
recent esophageal stent placement presents with increasing
cough. She presented intially to her PCP 2 days back with cough
and was given levoflox. However continued to have worsening
cough with phlegm and difficulty swallowing. Of note, she had
esophageal stents placed twice in the last month.
.
ED: Initial vitals were 99.3, 156, 122/81, 18, 100%/2L. Imaging
showed aspiration PNA and did not show any PE or significant
pericardial effusion. Started on Ceftriaxone, Zithro, Flagyl.
She remained tachycardiac to 120s non-responsive to fluids. She
was admitted to the ICU given her low pulm reserve and likely
semi-urgent esophageal stent placement.
Past Medical History:
1. Adenoid cystic carcinoma, diagnosed [**3-/2103**], details below
2. Left vocal cord paralysis
3. GERD
4. History of PE, [**2099**], [**2107**]
5. Cerebral vein thrombosis
6. Depression? (found in ED note)
7. CVA? (found in ED note)
8. Esophogeal stent [**2110-9-30**]
.
Onc Hx:
[**2102**]: diag after work-up 8 months of cough, L pneumonectomy and
carinal resection and postop radiation.
[**2105**]: Recurrent dz in pleural space.
[**2106**]: palliative radiation with concurrent low-dose Taxotere.
[**2107**]: Hepatic involvement --> 4 cycles of cisplatin and
Adriamycin.
[**2107**]: CT showed progression in lungs/liver. 2 cycles of
carboplatin and Taxol given, still with pulm progression. Tx
complicated by thrombocytopenia and PE on CT, started on
Lovenox.
[**2108**]: Brachial plexus MRI showed tumor L paraspinal region from
T2-T5
[**2108**]: 4 cycles of dose-reduced cisplatin, Navelbine
[**2108**]: CT showed renal hepatic progression.
[**2108**]: started on gemcitabine, held sev times for
myelosuppression.
[**2108**]: MRI showed leptomeningeal enhancement L frontal lobe.
[**2109**]: seizure, vein of Trolard thrombosis.
[**2109**]: weekly epirubicin, received 3 cycles, but multiple doses
were held because of poor performance status.
[**2109**]: onc team and pt decided upon symptom managment as CT scan
showed progression, she received single [**Doctor Last Name 360**] cisplatin.
Social History:
She does not smoke cigarettes or drink alcohol. She moved from
[**Country 3594**] to [**State 350**] in [**2091**]. She has a daughter who lives
in [**Location 17065**]. She also has a brother and sister who live in
the Greater [**Name (NI) 86**] area. She denies tobacco or alcohol use and
is currently not working. In the past, she has worked in a
bakery.
Family History:
Her mother is alive and healthy. Her father died at age 80 from
a stroke and heart attack. She has 5 sisters and 2 brothers, and
some of them have hypertension, hypercholesterolemia, and
diabetes. She has 6 daughters and a
son; they are all healthy.
Physical Exam:
PE: T 99, BP 105/80, HR 130, RR 18, 100% 2L
Gen: cachectic, chronically ill-appearing F in moderate
discomfort [**12-27**] neck pain; mostly Spanish speaking.
HEENT: EOMI. dry mucous membranes, clear oropharynx without
thrush.
Neck: flat JVP, tenderness diffusely along right paracervical
muscles without associated LAD, erythema or discrete mass
palpated. full ROM on neck. mild distension of neck veins on
right.
Lungs: good air movement R, decreased left, w/o focal
ronchi,rales, or wheeze
Cardiac: tachycardic, RRR, S1, S2, no murmurs
Abd: SNTND, +bs
Extr: thin, warm, well perfused. no clubbing/cyanosis/edema.
Skin: no rashes or other lesions. port on right chest c/d/i, no
erythema, tenderness to palpation.
Neuro: A&O, CNs grossly intact, no focal deficits
Affect: appropriate
Pertinent Results:
Labs on Admission:
[**2110-10-25**] WBC-11.8* RBC-3.43* Hgb-9.7* Hct-29.1* MCV-85 MCH-28.3
MCHC-33.3 RDW-15.2 Plt Ct-398 Neuts-92.2* Bands-0 Lymphs-4.2*
Monos-3.4 Eos-0.1 Baso-0.1 Hypochr-2+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Target-1+ Plt Smr-NORMAL Plt Ct-398
[**2110-10-26**] PT-17.3* PTT-60.6* INR(PT)-1.6*
[**2110-10-25**] Glucose-95 UreaN-5* Creat-0.4 Na-139 K-3.5 Cl-98
HCO3-31 AnGap-14 Calcium-7.9* Phos-3.4 Mg-1.0*
[**2110-10-26**] 12:20AM BLOOD Type-ART pO2-84* pCO2-55* pH-7.32*
calTCO2-30 Base XS-0 Intubat-NOT INTUBA
[**2110-10-26**] Lactate-2.2*
Imaging:
[**2110-10-25**] CXR FINDINGS: Single bedside AP examination labeled
"erect, 16:45 hours" is compared with the recent study dated
[**10-23**], as well as previous study, dated [**2110-10-9**]. There has been
progressive opacification of the right hemithorax over the
series of studies, which may represent confluent aspiration
pneumonitis. The patient is s/p left pneumonectomy and tubular-
appearing, presumably pleural, calcifications in the medial left
hemithorax are unchanged. Again demonstrated are esophageal
stent in situ, with slight narrowing at its mid-portion, as
before, as well as right subclavian venous access device with
tip likely at the cavo-atrial junction or high right atrium.
[**2110-10-25**] CTA
IMPRESSION:
1. No PE and no significant pericardial effusion.
2. Patchy airspace disease in the right lower lobe consistent
with aspiration pneumonitis.
3. Study is otherwise overall unchanged since the recent study
dated [**2110-9-25**].
Brief Hospital Course:
50 y/o F w/ h/o adenoid cystic carcinoma, GERD, PE, presented
with aspiration pneumonitis in the setting of likely obstructed
esophageal stent.
# Aspiration PNA: Aspiration from obstructed esophageal stent in
the setting of widely metastatic adenoid cystic carcinoma.
Patient was maintained NPO and started on Ceftriaxone,
Azithromycin, Flagyl for aspiration pneumonia. Given end-stage
carcinoma and high likelihood of repeated aspiration events in
the setting of esophageal obstruction and stent failure, goals
of care were changed to comfort measures only after discussion
with family on day 2 of admission. Patient received morphine
for respiratory distress.
# adenoid cystic carcinoma: Patient with known widely metastatic
disease on admission; was home hospice but family reversed it 2
days prior to admission as the service was not helping the
patient to be comfortable. Extensively discussed with patient
and family about goals of care: they would like comfort care and
minimal intervention to help make her comfortable. Patient was
given morphine for pain and comfort.
.
# Code: DNR/DNI on admission, made comfort measures only on day
2 of admission. The patient died the following day from
respiratory failure.
.
# FEN: The patient was maintained NPO during this hospital
admission.
.
# Dispo: The patient died one day after decision to continue
comfort measure care.
Medications on Admission:
Levoquin
Codeine,couh suppresant
Neurontin
Fentanyl patch
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspiration Pneumonitis
Esophageal Stent Occlusion
Adenoid cystic carcinoma, metastatic
Respiratory Failure
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6121
} | Medical Text: Admission Date: [**2178-12-9**] Discharge Date: [**2178-12-15**]
Date of Birth: [**2105-4-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Ventricular tachycardia
Major Surgical or Invasive Procedure:
VT-ablation
Arterial line placement and removal
History of Present Illness:
73 yo M with nonischemic cardiomyopathy, ventricular tachycardia
s/p VT ablation and AICD, who was admitted to [**Hospital 794**] Hospital
for multiple AICD shocks on [**2178-12-6**], now transferred for repeat
VT-ablation.
.
At [**Hospital 794**] Hospital, he was started on amiodarone and lidocaine
drip, which decreased his heart rate. He then underwent a
right-sided catheterization, which showed muliple vessel disease
and had PCI to the LAD/LCx. The procedure was uncomplicated.
This morning, patient again went into sustained monomorphic
ventricular tachycardia. He was thus transferred to [**Hospital1 18**] for
repeat VT-ablation.
.
Patient reports that when he has VT, he experiences
palpitations, diaphoresis, and weakness. Recently, he had these
symptoms at the end of [**Month (only) **] and was hospitalized at [**Hospital **]
Hospital from [**10-19**] - 11/31, when he was treated with potassium
and plan was to consider upgrading his ICD to biventricular
pacing. He was discharged home and then had repeated symptoms on
[**10-6**].
.
Of note, patient had his ICD placed approximately 8 years ago,
but had recurrent VTs. He underwent VT ablation by Dr. [**Last Name (STitle) **]
in [**2172**] but continued to have VTs. He was then succesfully
medically managed with amiodarone for 3 years, but had to stop
due to hepatic toxicity. Since then, he has been shocked "more
than 50 times", including one episode where he had an induced
ICD firing, presumably for slow VT.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
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, or syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2179-10-7**] with 3 stents
placed to LAD and LCx.
- PACING/ICD: VT storm s/p AICD and ablation [**2179**] in [**Location (un) 86**]
- Cardiomyopathy, EF 20%
- Myocardial infarction in [**2154**]
3. OTHER PAST MEDICAL HISTORY:
- COPD
- Hypothyroidism
- Abdominal aortic aneurysm repair with stent
- Eczema
- Multiple hemorrhoidectomies
Social History:
Patient lives alone. He is independent for all ADLs, continues
to drive.
- Tobacco history: ~75 pack year history, quit 7 years ago
- ETOH: Occasional beer but used to drink heavily.
- Illicit drugs: None
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Extensive history of cancers.
Physical Exam:
Physical exam on discharge:
VS: <<<<<<<<<< >>>>>>>>>
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 6 cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Soft heart sounds, RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4. ICD in left chest.
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.
EXTREMITIES: No c/c/e. No femoral bruits. Right post-cath side
no hematoma, no bruits.
SKIN: eczematous changes in finger nails and elbows
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
1. Labs on admission:
[**2178-12-9**] 01:13AM BLOOD WBC-8.6 RBC-4.06* Hgb-12.3* Hct-35.5*
MCV-88 MCH-30.2 MCHC-34.6 RDW-13.5 Plt Ct-262
[**2178-12-9**] 01:13AM BLOOD PT-12.6 PTT-26.3 INR(PT)-1.1
[**2178-12-9**] 01:13AM BLOOD Glucose-104* UreaN-23* Creat-0.9 Na-135
K-4.2 Cl-101 HCO3-23 AnGap-15
[**2178-12-9**] 01:13AM BLOOD ALT-12 AST-22 LD(LDH)-224 AlkPhos-98
TotBili-0.5
[**2178-12-9**] 01:13AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.3 Mg-2.1
[**2178-12-9**] 01:13AM BLOOD TSH-0.11*
[**2178-12-9**] 01:13AM BLOOD Free T4-1.4
.
2. Labs on discharge:
<<<<<<<<<<<< >>>>>>>>>>
.
3. Imaging/diagnostics:
- Echocardiogram ([**2178-12-9**]): The left atrium is mildly dilated.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is moderate to
severe regional left ventricular systolic dysfunction with
near-akinesis of the distal [**11-23**] of the left ventricle and global
hypokinesis in the remaining segments. A left ventricular
mass/thrombus cannot be excluded. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion.
IMPRESSION: Dilated left ventricular cardiomyopathy with
near-akinesis of the distal [**11-23**] of the left ventricle and global
hypokinesis in the remaining segments. Mild mitral
regurgitation.
.
- CXR ([**2178-12-9**]):
Heart is moderately enlarged, but there is no pulmonary edema or
even vascular congestion and the hila are normal size. No
pleural effusion or evidence of central adenopathy. Lungs clear.
Transvenous right atrial pacer lead follows the expected course.
A transvenous right ventricular pacer defibrillator lead ends
closer to the midline than we generally see but cannot be more
carefully localized without a lateral view.
.
- CXR ([**2178-12-10**]):
ICD leads remain in standard position. Cardiomediastinal
contours are unchanged. Lungs and pleural surfaces are clear.
.
Brief Hospital Course:
73 yo M with recurrent ventricular tachycardia despite ablation
and AICD, cardiomyopathy, CAD s/p PCI, COPD, hypothyroidism,
treated with dofetilide and repeat VT-ablation.
.
# Ventricular tachycardia: Pt admitted for initiation of
dofetilide ggt which was maintained for 3 days eventually being
decreased to 250mcg q12h. However, on HOD 2 he developed VT
into the 140s, with sBP in the 110s-120s. Received lidocaine
bolus, placed on gtt, and ativan. Broke after 5 minutes and did
not require firing of ICD. He subsequently went for ventricular
substrate ablation the following day (see report). After the
procedure his antiarrhythmic therapy was changed to mexilitine
150mg q8h and quinidine was started at 324mg TID. Dofetalide
was d/c'd. Of note When arterial sheath was being pulled, he
became transiently hypotensive to 60s, got 1 amp of atropine and
recovered. He remained hemodynamically stable for the remainder
of admission, but was noted to have occasional runs of 20-40
beats of vtach during which he remained asymptomatic. He was
discharged on mexilitine 150 TID and quinidine 324mg TID.
.
# Fever: Febrile to 102 on admission. Influenza swabs sent, came
back positive. Patient remianed on droplet precautions. He
remained afebrile throughout admission.
.
# Cardiomyopathy: Repeat echocardiogram here confirmed EF of
25-30%, with severe regional left ventricular systolic
dysfunction, near-akinesis of distal [**11-23**] of the LV and global
hypokinesis. He diuresed well and remained euvolemic on home
dose 20 mg PO Lasix.
.
# CAD s/p stent: History of MI in [**2154**] with anteriolateral
distribution on EKG, consistent with catheterization finding of
LAD, LCX stenosis. Patient has been asymptomatic and cardiac
enzymes at OSH were not elevated. Underwent uncomplicated
catheterization with three stents placed in the LAD and LCX.
Discharged on aspirin and plavix.
.
# Hypothyroid: TSH low at 0.11 (0.14 at OSH) and T4 appropriate
at 1.4. Just started on new lower dose of levothyroxine 50 mcg
three days ago so do not expect TSH to change dramatically. Kept
on same dose.
.
# HTN: Currently normotensive on Carvedilol and Losartan.
Increased carvedilol to 6.25 [**Hospital1 **].
.
# HLD: Lipid panel at OSH showed good control on home medication
of Cholestipol. Held during admission as was non-formulary. To
be continued at discharge.
Medications on Admission:
-Synthroid 88mcg qd
-Carvedilol 3.125 mg [**Hospital1 **]
-Aspirin 325 mg qd
-Losartan 25 mg qd
-MAgnesium oxide 400mg [**Hospital1 **]
-Klonopin 1.0 mg qd
-Colestipol 1 mg [**Hospital1 **]
-Lasix 20 mg po daily
-Vitamin D
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
5. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
10. quinidine gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. cholestipol Sig: One (1) tab once a day.
13. Outpatient Lab Work
Check Chem-10 for [**2178-12-22**]. Please fax results to:
Dr. [**First Name (STitle) **] [**First Name (STitle) 49514**]: [**Telephone/Fax (1) 89952**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ventricular Arrythmia
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital because of a persistent fast
rhythm called ventricular tachycardia and because your ICD went
off multiple times. You had a procedure called an ablation and
the settings on your ICD/pacemaker were adjusted. You also had
new stents placed in the arteries supplying blood to your heart.
Because of this, YOU NEED TO TAKE PLAVIX EVERY DAY. DO NOT
STOP PLAVIX FOR ANY REASON UNTIL YOU SPEAK WITH YOUR
CARDIOLOGIST FIRST.
.
We made the following changes to your medications:
STARTED Plavix 75 mg once a day
STARTED Quinidine 324 mg 3 times a day
STARTED Mexiletine 150 mg three times a day
INCREASED Carvedilol to 6.25 mg [**Hospital1 **]
Please note your follow up appointments below with Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) 49514**]. We have also include a prescription for
bloodwork to be done [**2178-12-22**] with the results to be faxed to Dr.
[**Last Name (STitle) 49514**].
It was a pleasure taking care you during your hospital stay.
Followup Instructions:
Please make an appointment to see your PCP in the next [**11-22**]
weeks.
Cardiology appointment with Dr. [**First Name (STitle) **] [**First Name (STitle) 49514**]
[**2178-12-31**] at 2:15 PM
[**Street Address(2) 85853**], [**Location (un) 796**], RI
([**Telephone/Fax (1) 85855**]
Department: CARDIAC SERVICES
When: FRIDAY [**2179-1-1**] at 1 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4271, 4254, 2724, 4019, 412, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6122
} | Medical Text: Admission Date: [**2193-10-18**] Discharge Date: [**2193-10-22**]
Date of Birth: [**2112-3-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Hypoxia, nausea, vomiting, increased abdominal distention
Major Surgical or Invasive Procedure:
[**10-18**] Endotracheal intubation
History of Present Illness:
Mr. [**Known lastname 97639**] is a 81 year old male transferred to [**Hospital1 18**]-ED on
[**10-18**] from his residence of [**Hospital3 2558**] via ambulance. While
eating breakfast that morning he aspirated, desaturated to the
80's, and he was noted to have increased abdominal distention.
Upon arrival to the ED he was intubated, sedated, a nasogasatric
tube was placed with gastric contents which were dark red,
guaiac positive. He has a past medical history of seizures,
dementia, and depression. He was transferred to the intensive
care unit and admitted to the surgical service for further
management.
Past Medical History:
Past Medical History:
Dementia
Seizure disorder
Depression
Osteoarthritis
IBS
Vitamin B12 deficiency
Past Surgical History:
[**1-27**] ORIF
Social History:
Full time residence at Cooledge house facility; [**Location (un) 86**], MA
Family History:
Non-contributory
Physical Exam:
Upon admission:
100.6 109 144/55 30 91% on NRB
Gen: Elderly male, tachypneic
Eyes: Anicteric
Neck: Supple
Chest: Diffuse crackles and rhonchi
CV: S1 S2, tachycardic
Abd: Obsese, distended
Rectal: Brown stool, guaiac positive
MSK: No clubbing, cyanosis, or edema
Skin: Warm, dry
Neuro: Alert
Pertinent Results:
Admission:
[**2193-10-18**] 10:50AM BLOOD WBC-24.7*# RBC-4.65 Hgb-15.6 Hct-47.4
MCV-102* MCH-33.5* MCHC-32.9 RDW-13.6 Plt Ct-306#
[**2193-10-18**] 10:50AM BLOOD Neuts-70 Bands-19* Lymphs-8* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2193-10-18**] 10:50AM BLOOD Plt Ct-306#
[**2193-10-18**] 12:33PM BLOOD PT-14.0* PTT-23.7 INR(PT)-1.2*
[**2193-10-18**] 10:50AM BLOOD Glucose-269* UreaN-38* Creat-1.6* Na-144
K-4.9 Cl-101 HCO3-16* AnGap-32*
[**2193-10-18**] 10:50AM BLOOD ALT-24 AST-31 CK(CPK)-47 AlkPhos-137*
Amylase-103* TotBili-0.2
[**2193-10-18**] 10:50AM BLOOD Lipase-22
[**2193-10-18**] 10:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2193-10-18**] 10:50AM BLOOD Albumin-4.1 Calcium-9.0 Phos-4.8* Mg-2.2
[**2193-10-18**] 03:46PM BLOOD Phenoba-18.9
[**2193-10-18**] 01:13PM BLOOD Type-ART pO2-275* pCO2-47* pH-7.23*
calTCO2-21 Base XS--7 Intubat-INTUBATED Vent-CONTROLLED
[**2193-10-18**] 03:55PM BLOOD freeCa-1.06*
Discharge:
[**2193-10-22**] 07:05AM BLOOD WBC-12.0* RBC-3.30* Hgb-10.4* Hct-32.2*
MCV-98 MCH-31.6 MCHC-32.4 RDW-13.4 Plt Ct-154
[**2193-10-22**] 07:05AM BLOOD Plt Ct-154
[**2193-10-22**] 07:05AM BLOOD Glucose-121* UreaN-10 Creat-1.2 Na-143
K-3.3 Cl-105 HCO3-25 AnGap-16
[**2193-10-22**] 07:05AM BLOOD Calcium-7.5* Phos-3.9 Mg-1.9
[**2193-10-20**] 03:22PM BLOOD Phenoba-18.7
[**2193-10-19**] 11:55AM BLOOD freeCa-1.14
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2193-10-18**] 8:13 PM
CHEST PORT. LINE PLACEMENT
Reason: line placemnt
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with resp distress
REASON FOR THIS EXAMINATION:
line placemnt
HISTORY: Line placement.
One portable view at 20:55. Comparison with the previous study
done earlier the same day. There is slight interval worsening of
interstitial edema. The heart and mediastinal structures are
unchanged. An endotracheal tube and nasogastric tube remain in
place. A right subclavian catheter has been inserted and
terminates at the level of the junction of the superior vena
cava and right atrium. There is no other significant change.
IMPRESSION: Interval worsening of interstitial edema. Right
subclavian line placement as described.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: SUN [**2193-10-20**] 2:19 PM
RADIOLOGY Final Report
CT PELVIS W/O CONTRAST [**2193-10-18**] 12:05 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: DARK BROWN MATERIAL FROM OGT, ASPIRATED, PROB UGIB, EVAL
FOR MESENTERIC ISCHEMIA
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with dark brown material from OGT, aspirated,
prob UGIB, ? mesenteic ischemia w/ lactate 9.6.
REASON FOR THIS EXAMINATION:
eval for mesenteric ischemia
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 81-year-old male with dark brown material from OGT,
aspiration. Question mesenteric ischemia.
TECHNIQUE: Contiguous axial CT images of the abdomen and the
pelvis were obtained without the administration of intravenous
or oral contrast.
COMPARISON: Abdominal radiograph taken approximately one hour
earlier on the same day.
FINDINGS: The evaluation of abdominal organs and major vessels
are extremely limited due to lack of intravenous contrast [**Doctor Last Name 360**].
There is no evidence of free air or free fluid. Note is made of
mildly dilated small bowel in the midabdomen with air-fluid
level, measuring up to 3.1 cm. Transverse colon is somewhat
prominent, measuring up to 7 cm, however, gas is seen down to
the rectum. The limited evaluation of the abdominal organs
demonstrates no focal liver lesion. The patient is status post
cholecystectomy. Spleen, pancreas, and left adrenal gland are
within normal limits. There is right adrenal mass with 6HU,
representing adenoma. Kidneys are somewhat atrophic with large
left renal cyst. There is no significant lymphadenopathy.
PELVIS: There is no evidence of ascites. No free fluid or free
air.
In the visualized portion of the lung bases, note is made of
bibasilar consolidations with small amount of effusion. There is
no suspicious lytic or blastic lesion in skeletal structures. SI
joints are fused due to degeneration.
Multiplanar reformation images confirmed the above finding.
IMPRESSION:
1. CT study for the evaluation of mesenteric vessels and
abdominal organs for mesenteric ischemia without intravenous
contrast.
2. Mildly dilated small bowel in the midabdomen measuring up to
3.5 cm with air-fluid level.
3. Bilateral renal cysts. Some of the small low density lesions
on the right kidney are too small to characterize.
4. Right aderenal adenoma.
5. Bibasilar consolidations with small effusion.
The wet read was provided to ED dashboard, and discussed with
Dr. [**Last Name (STitle) **] in person immediately after the completion of the
study.
RADIOLOGY Final Report
PORTABLE ABDOMEN [**2193-10-18**] 11:01 AM
PORTABLE ABDOMEN
Reason: evalf or acute process
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with resp distress
REASON FOR THIS EXAMINATION:
evalf or acute process
INDICATION: 81-year-old man with respiratory distress. Evaluate
for acute process.
COMPARISON: None.
FINDINGS: Single portable supine plain radiograph of the abdomen
and pelvis was obtained. Air-filled dilated small and large
bowel is identified. The small bowel measures up to
approximately 3.9 cm in diameter. The large bowel measures
approximately 8.4 cm in diameter. Air is seen to the mid
descending colon. However, air is not definitively identified
within the rectum. There is no evidence of free intraperitoneal
air; however, the diaphragms are not visualized on this
radiograph. An orthopedic screw is identified in the right
femur.
IMPRESSION: Moderately dilated air-filled small and large bowel
without air definitively seen in the rectum. This may represent
an ileus versus a low obstruction. Recommend CT for further
evaluation.
These findings were related to the ED via the wet read-board at
approximately 12:20 p.m. on [**2193-10-18**].
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2193-10-19**] 6:15 AM
CHEST (PORTABLE AP)
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with resp distress
REASON FOR THIS EXAMINATION:
interval change
PORTABLE CHEST.
History of respiratory distress. There are persistent bilateral
pulmonary infiltrates, which most likely represent edema. The
heart and mediastinal structures are unchanged. An endotracheal
tube, nasogastric tube, and right subclavian catheter remain in
place.
Compared with the previous study, there is slight interval
worsening at the bases.
IMPRESSION: Bilateral pulmonary infiltrates consistent with
edema. Slight interval worsening.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: SAT [**2193-10-19**] 2:42 PM
[**2193-10-18**] 6:19 pm MRSA SCREEN Site: RECTAL
Source: Rectal swab.
**FINAL REPORT [**2193-10-20**]**
MRSA SCREEN (Final [**2193-10-20**]): NO STAPHYLOCOCCUS AUREUS
ISOLATED.
[**2193-10-18**] 11:30 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2193-10-20**]**
GRAM STAIN (Final [**2193-10-18**]):
THIS IS A CORRECTED REPORT [**2193-10-19**].
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): YEAST(S).
PREVIOUSLY REPORTED AS [**2193-10-18**].
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2193-10-20**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
[**2193-10-18**] 10:45 am BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2193-10-18**] 10:50 am BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2193-10-18**] 11:25 am URINE Site: CATHETER
**FINAL REPORT [**2193-10-19**]**
URINE CULTURE (Final [**2193-10-19**]): NO GROWTH.
[**2193-10-18**] 6:20 pm MRSA SCREEN Site: NARIS (NARE)
Source: Nasal swab.
**FINAL REPORT [**2193-10-21**]**
MRSA SCREEN (Final [**2193-10-21**]):
No MRSA isolated.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin sensitivity performed by agar screen.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
OXACILLIN------------- S
Brief Hospital Course:
Upon admission to the intensive care unit he was intubated,
sedated, received intravenous hydration and bolussing for
hypotension, intravenous proton pump inhibitor was started;
nasogastric tube and foley catheter were placed. A central
venous catheter was placed for optimal intravenous access. A CT
scan demonstrated mildly dilated small bowel with air-fluid
level, no free air, and bibasilar consolidations with small
effusion. His white blood cell count was elevated to 24.7k, he
was treated with broad spectrum antibiotics. He has a history of
seizures and is stable on Phenobarbital, his level was
therapeutic and his current dose was continued intravenously.
His hematocrit on admission was 47.4, serial hematocrits were
initiated with a downward trend, the lowest was his 26.9; his
stools were guaiac positive, however he remained hemodynamically
stable and did not require transfusions. On HD 2 his white blood
cell count had decreased to 12.2k, he was successfully
extubated, and he was without abdominal pain. On HD 3 he was
oxygenating well on nasal cannula and remained afebrile. On HD 4
he was transferred to an in-patient nursing unit, his
nasogastric tube was removed, and his diet was advanced. His
antibiotics were discontinued secondary to his cultures being
mixed oropharyngeal flora; blood cultures were pending at the
time of discharge. He received a dose of Lasix after a chest
x-ray demonstrated pulmonary congestion; his mental status was
back to baseline being oriented to person and time. On HD 5 he
remained afebrile, his white blood cell count was stable at
12.2k, his hematocrit was also stable at 32.2, he was tolerating
a regular diet, and had regular bowel movements with flatus. On
HD 5 he received another dose of Lasix and Potassium
replacement; he was started back on his home medications with
Potassium daily. His foley catheter remained in secondary to
diuresis with Lasix. He still had bilateral lower extremitiy
edema with improvement. He was requiring 2 liters nasal cannula
to maintain his saturations above 94% with no respiratory
distress. He was transferred back to his place of residence at
the Cooledge house in good condition. He will continue on the
proton pump inhibitor and will be followed by his PCP.
Medications on Admission:
Phenobarbitol
Vitamin B12
Celexa
MVI
Imodium
Bisocodyl
Zyprexa
Mirtazapine
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
Injection twice a day: Until patient ambulating and/or mobile.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Phenobarbital 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY
(Daily).
8. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day) as needed for diarrhea.
10. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration
Discharge Condition:
Good
Discharge Instructions:
Notify MD/NP/PA/RN at rehabilitation facility patient
experience's:
*Increased or persistent pain
*Fever > 101.5 or chills
*Nausea, vomiting, diarrhea, or increased abdominal distention
*Inability to pass gas, stool, or urine
*Change in mental status
*Bright red blood from rectum
*Shortness of breath or labored breathing
*Any other symptoms concerning to you
Followup Instructions:
Follow-up with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] within 1-2 weeks of discharge from
hospital, call [**Telephone/Fax (1) 10492**] for an appointment
Completed by:[**2193-10-22**]
ICD9 Codes: 5070, 5789, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6123
} | Medical Text: Admission Date: [**2139-12-19**] Discharge Date: [**2140-1-19**]
Date of Birth: [**2139-12-19**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: This is a 32 and [**2-14**] week
gestation twin I admitted for prematurity.
Maternal history was significant for being a 36-year-old
gravida 1, para 0, woman with insulin-dependent diabetes
mellitus for 12 years (currently on an insulin pump).
Hemoglobin A1c during pregnancy was 5.8%. Mother also has
[**Name (NI) 25670**] disease.
Prenatal screens were O positive, antibody negative,
hepatitis negative, Rubella immune, rapid plasma reagin was
nonreactive, and group B strep status unknown.
PREGNANCY HISTORY: In [**Last Name (un) 5153**] fertilization pregnancy with
estimated date of delivery of [**2140-2-11**] for an estimated
gestational age of 32 and 2/7 weeks. Dichorionic-diamniotic
twin gestation with concordant growth and normal fetal
surveys. The pregnancy was complicated by preterm
contractions since [**64**] weeks, not requiring therapy or bed
rest. Today, rupture of membranes 21 hours prior to
delivery. Question of meconium stained amniotic fluid in
twin I. Started on antibiotics for prophylactic antibiotic
therapy. Betamethasone complete. Proceeded to cesarean
section for decelerations in twin I.
PRENATAL COURSE: Infant vigorous at delivery. Orally and
nasally bulb suctioned and free-flow oxygen provided.
Subsequently pink with mild retractions with free-flow
oxygen. Apgar scores were 8 at one minute of age and 8 at
five minutes of age. Transferred to the Neonatal Intensive
Care Unit uneventfully.
PHYSICAL EXAMINATION ON PRESENTATION: This was a
well-appearing infant in no respiratory distress. Heart rate
was 150, respiratory rate was 46, temperature was 98.1,
oxygen saturation was 97% on room air. Blood pressure was
58/30, with a mean of 43. Birth weight was 1795 grams (50th
percentile). Head circumference was 29 cm (25th percentile.
Length was 45.5 cm (75th percentile). Head, eyes, ears,
nose, and throat examination was normal with AFSF, nondysmorphic,
palate was intact, neck and mouth were normal. No nasal flaring.
Chest with mild retractions currently. Good bilateral breath
sounds. No crackles. Cardiovascular was well perfused. A
regular rate and rhythm. Femoral pulses were normal. Normal
first heart sounds and second heart sounds. No murmurs.
Abdominal examination revealed the abdomen was soft and
nontender. No organomegaly. No masses. Bowel sounds were
active. The anus was patent. Genitourinary revealed normal
preterm male genitalia. Testes undescended bilaterally.
Active, alert, and responsive to stimulation, tone normal.
Moved all extremities symmetrically. Musculoskeletal examination
revealed normal spine, limbs, hips, and clavicle. Dipstick was
48.
IMPRESSION: This was a 32 and [**2-14**] week gestational twin I
baby boy with sepsis risk factors based on preterm labor,
prolonged rupture of membranes, unknown maternal group B
strep status colonization status that was partially
attenuated with intrapartum antibiotic therapy 20 hours prior
to delivery, risk for hypoglycemia based on maternal
insulin-dependent diabetes mellitus. The parent was followed
in the maturity of respiratory drive, maintained vigilance
for patent ductus arteriosus, followed dipsticks, and sepsis
workup.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: From a respiratory standpoint, the
baby remained stable without any need for intubation or
mechanical ventilation. On [**12-21**], however, there was
noted some significant spells overnight, and caffeine was
started to stabilize the respiratory drive. The baby
remained on room air without any further significant spells.
The caffeine was discontinued on [**1-1**], following which
there was no significant apneic episodes.
2. CARDIOVASCULAR ISSUES: The patient's cardiovascular
course was stable with no evidence of a murmur early in his
Neonatal Intensive Care Unit course. There was no evidence
of a hemodynamically significant patent ductus arteriosus in
his early Neonatal Intensive Care Unit course. He continued
to do well with good blood pressures and equal pulses
throughout.
3. GASTROINTESTINAL ISSUES: The baby was started on initial
total fluids of 80 cc/kg per day. Feedings were begun on day
of life two with PE-20 and breast milk by PG. Feedings were
advanced, and the infant was on full volume feeds within one
week. The maximum calories on the feedings were up to 26
calories per ounce. This was weaned down to 24 calories per
ounce. This was weaned to breast milk 24 calories per ounce
as the baby continued to gain good weight and tolerate his
oral intake. By the time of discharge, the infant had
tolerated all his feeds by mouth for approximately 48 hours
to 72 hours.
4. INFECTIOUS DISEASE ISSUES: An initial sepsis workup was
unremarkable. Ampicillin and gentamicin were started and
continued for 48 hours. The infant was started on a
phototherapy for a brief period of hyperbilirubinemia.
5. DISCHARGE PLANNING ISSUES: (a) Hearing
screens passed and car seat test passed. (b) Immunizations:
Hepatitis given on [**1-2**].
6. SOCIAL ISSUES: The parents demonstrated an excellent
understanding of the baby's care and were ready to receive
the baby at home on the day of discharge.
7. PRIMARY PEDIATRICIAN: Name of primary pediatrician is
Dr. [**Last Name (STitle) 53119**] (telephone number [**Telephone/Fax (1) 43573**]).
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Mild respiratory distress.
3. Ruled out sepsis.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Name8 (MD) 47147**]
MEDQUIST36
D: [**2140-1-19**] 07:28
T: [**2140-1-19**] 07:39
JOB#: [**Job Number 53120**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6124
} | Medical Text: Admission Date: [**2165-8-26**] Discharge Date: [**2165-9-3**]
Date of Birth: [**2085-11-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain, abnormal Stress
Major Surgical or Invasive Procedure:
[**2165-8-28**] Cardiac Cath
[**2165-8-29**] Intra-aortic balloon pump insertion
[**2165-8-29**] Coronary bypass grafting x 3 on intra-aortic balloon
pump, urgent, with left internal mammary artery left anterior
descending coronary; reverse saphenous vein single graft from
aorta to first diagonal coronary artery; reverse saphenous vein
single graft from aorta to posterior descending coronary artery
History of Present Illness:
79 year old male with history of Hypertension, Diabetes (on
insulin), Hyperlipidemia, reports acute Shortness of breath on
exertion while down on [**Hospital3 **]. He woke up the next morning
with tightness across the middle of his chest, without
radiation, that lasted minutes and then resolved. He denies a
history of angina or SOB but has noticed an increase in fatigue
and lower extremity edema. Mr.[**Known lastname **] went to his PCP, [**Name10 (NameIs) 1023**] did an
EKG and found normal sinus rhythm at 60 beats per minute,
prolonged PR interval of 248 consistent with first-degree AV
block, a right bundle-branch block and T-wave inversions
primarily in leads III, T-wave flattening in aVF, T-wave
inversions in V1 through V3 (not markedly changed from his prior
EKG in [**2164-2-7**]). He was referred to the ED. In the ED he
had 3 negative sets of CE, and was ordered for stress test given
his ECG. MIBI grossly abnormal= 4 [**Last Name (LF) 1364**], [**First Name3 (LF) **] depressions, 1mm ST
elevation, also had nuclear-- moderate reversible inferolateral
wall with an inappropriate BP drop. Patient was sent to cath lab
which revealed mutivessel coronary artery disease with
significant Left Main stenosis. Dr.[**Last Name (STitle) 914**] was consulted for
coronary revascularization.
Past Medical History:
Hypertension
Type 2 diabetes mellitus
Prostate cancer
Spinal stenosis for which he received steroid injections
Gout
Past Surgical History: s/p Left Knee
Social History:
-Tobacco history: Denies any tobacco use
-ETOH: Denies alcohol
-Illicit drugs: None
Family History:
Father who passed away from MI at 60, otherwise noncontributory.
Physical Exam:
Pulse:SB-53 Resp: 16 O2 sat: 94% R/A
B/P Right:147/61 Left:
Height: Weight:
General:A&Ox3
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM x[]
Chest: Lungs clear bilaterally [CTA]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit :none Right: 2+ Left:2+
Pertinent Results:
[**2165-8-28**] Cardiac Cath: 1. Coronary angiography in this right
dominant system demonstrated three vessel disease. The LMCA was
calcified and had a 90% distal stenosis, which extended into the
LAD, resulting in a 80% proximal stenosis. The Ramus intermedius
had an 80% stenosis surrounded by aneurysmal dilatation. The LCx
had a 90% stenosis at its origin. The OM2 was occluded. The RCA
had a 70% distal stenosis. 2. Limited resting hemodynamics
revealed mild systemic hypertension with an SBP of 143 mmHg and
DBP 68 mmHg.
[**2165-8-29**] Echo: PRE-BYPASS: The left atrium is moderately dilated.
No spontaneous echo contrast is seen in the left atrial
appendage. Left ventricular wall thicknesses are normal. 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. The descending
thoracic aorta is mildly dilated. There are three aortic valve
leaflets. The aortic valve leaflets (3) are mildly thickened. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion. POST-BYPASS: For the post-bypass study,
the patient was receiving vasoactive infusions including
phenylephrine and was being A paced. 1. Biventricular function
is normal 2. Aortic contours appear intact post decannulation.
3. Other findings are unchanged
[**2165-8-29**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
<40%.
[**2165-9-3**] 03:04AM BLOOD WBC-6.7 RBC-3.15* Hgb-10.3* Hct-29.2*
MCV-93 MCH-32.6* MCHC-35.2* RDW-16.2* Plt Ct-165#
[**2165-8-26**] 03:50PM BLOOD WBC-5.3 RBC-3.53* Hgb-12.1* Hct-34.1*
MCV-97 MCH-34.2* MCHC-35.4* RDW-14.3 Plt Ct-155
[**2165-8-30**] 04:45AM BLOOD PT-13.4 PTT-29.2 INR(PT)-1.1
[**2165-8-26**] 03:50PM BLOOD PT-13.5* PTT-27.5 INR(PT)-1.2*
[**2165-9-3**] 03:04AM BLOOD Glucose-99 UreaN-41* Creat-1.7* Na-140
K-3.7 Cl-100 HCO3-30 AnGap-14
[**2165-8-26**] 03:50PM BLOOD Glucose-111* UreaN-32* Creat-1.5* Na-137
K-4.1 Cl-102 HCO3-24 AnGap-15
Brief Hospital Course:
On [**8-28**], during the night after his cardiac cath, Mr.[**Known lastname **]
developed recurrent chest pain and ECG changes:*- new ST
depressions in V2 - V4 which resolved when his chest pressure
was relieved with SL Nitro and morphine. He was transferred to
the CCU where he had an intra-aortic balloon pump placed as a
bridge to surgery. On [**2165-8-29**], he was taken urgently to the
operating room where he underwent coronary artery bypass graft x
3(Left internal Mammary artery grafted to Left anterior
Descending/Saphenous vein grafted to Ramus/Posterior Descending
Artery).Cross Clamp time= 51 minutes.Cardiopulmonary Bypass
Time= 70 minutes. Please see Dr[**Last Name (STitle) 5305**] operative report for
further details. Mr.[**Known lastname **] [**Last Name (Titles) 8337**] the procedure well and was
transferred in critical but stable condition to the CVICU. The
Intraortic balloon pump was removed on post-op day one. POD#2 he
was weaned from sedation, awoke neurologically intact and
extubated. Of note, his rhythm went into atrial fibrillation,
treated medically optimizing Beta-Blocker, and it converted to
sinus rhythm. All lines and drains were discontinued in a timely
fashion. Mr.[**Known lastname **] continued to progress and was transferred to
the telemetry floor for further care. Physical therapy
consulted and evaluated him for strength and mobility. The
remainder of his postoperative course was essentially
uneventful. He was cleared by Dr.[**Last Name (STitle) 914**] for discharge to rehab
on POD# 5, where he will have therapy to increase strength,
enduranance, and activities of daily living. All follow up
appointments were advised.
Medications on Admission:
Atenolol 50mg daily, Hydrochlorothiazide 12.5mg daily, Lantus
80-100 units daily, Humalog 30 units three times a day,
Lisinoprol 80mg daily, Flomax 0.4mg daily, Aspirin 81mg daily,
Multivitamin daily, Omego 3 fatty acids
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temp.
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous As directed.
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Hypertension
Type 2 diabetes mellitus
Prostate cancer
Spinal stenosis for which he received steroid injections
Past Surgical History: s/p Left Knee
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
[**Hospital Ward Name 121**] 6 in 2 weeks for wound check
Dr. [**Last Name (STitle) 914**] in 4 weeks, [**Telephone/Fax (1) **], please call for an
appointment
Dr. [**First Name (STitle) 216**] in [**2-8**] weeks
Cardiologist in [**3-12**] weeks
Completed by:[**2165-9-3**]
ICD9 Codes: 2724, 2749, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6125
} | Medical Text: Admission Date: [**2103-12-16**] Discharge Date: [**2103-12-21**]
Date of Birth: [**2047-1-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 yo M with PMH of alcohol abuse and alcohol withdrawal
seizures who presents s/p seizures at home. Patient is Spanish
speaking only so most of history obtained from his wife and some
from patient as well.
.
Patient says he drinks vodka but says he last drink was Monday
(6 days prior to presentation). His wife confirms she believes
this is true. She reports that she came home from work yesterday
and the patient had a black eye on the right which he told her
was from a fall. He also may have vomited yesterday although
this history is not clear. Then today she and her daughter
witnessed him seizing. Whole body shaking with all limbs moving.
No loss of bowel or bladder continence. Lasted about one min
then stopped. Then started again for another min. She reports he
was confused and did not know who she was afterwards. She called
EMS to bring him to the ED. She reports he had this about 6
months ago and was told it was from alcohol use. She also
reports that he has not been eating well secondary to his
esophageal stricture which was recently dilated by GI here.
.
In the ED, his initial vital signs were T 98.7, BP 131/80, HR
86, RR 18, O2sat 100% RA. He was given potassium, magnesium,
banana bag and ativan per CIWA scale (about 6-8mg total).
Neurology was consulted in the ED as well. He had a trauma work
up for CT c-spine, head and maxillary/mandible all of which were
negative for fracture. CXR was unchanged with no acute process.
He was sent to the ICU for further care.
Past Medical History:
-ETOH abuse c/b withdrawal seizures
-Chronic liver disease c/b pancytopenia-f/up unclear
-esophageal stricture recently dilated by Dr. [**Last Name (STitle) 174**]
[**Name (STitle) 31040**] c/b pneumothoraces in [**2094**]. He completed antibiotic regimen
per notes.
Social History:
The patient immigrated from [**Country 7192**] in [**2078**]. Married with
daughters. Smokes cigars. Drinks at vodka per him and his wife,
at least a pint a day. Prior notes comment on rum as well.
Family History:
unknown
Physical Exam:
General: thin, malnurished male in NAD, but tremulous. Not
diaphoretic.
HEENT: Has hematoma and ecchymosis over right eye which is shut.
PERRL, anicteric sclera. non-injected conjunctiva. OP clear but
dry MM
CV: RRR soft 1/6 SEM but distant heart sounds
Lungs: CTAB no w/r/r
Abdomen: +BS, soft, NTND
Ext: no e/c/c
Neuro: difficult to assess given language difficulty. Strength
seems full throughout. no neck tenderness with FROM. +asterixis.
Toes mute. Reflexes in tact.
Pertinent Results:
[**2103-12-16**] 10:09AM BLOOD WBC-6.9 RBC-3.71* Hgb-12.7* Hct-36.2*
MCV-97 MCH-34.1* MCHC-35.0 RDW-12.7 Plt Ct-114*
[**2103-12-16**] 10:09AM BLOOD Neuts-70.8* Lymphs-22.9 Monos-5.6 Eos-0.2
Baso-0.5
[**2103-12-18**] 03:21AM BLOOD PT-13.4 PTT-48.8* INR(PT)-1.2*
[**2103-12-16**] 10:09AM BLOOD Glucose-169* UreaN-9 Creat-0.6 Na-137
K-2.7* Cl-89* HCO3-35* AnGap-16
[**2103-12-16**] 10:09AM BLOOD ALT-21 AST-70* LD(LDH)-329* CK(CPK)-219*
AlkPhos-124* TotBili-2.2*
[**2103-12-16**] 10:09AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Head CT [**2103-12-16**]: The study is limited due to motion artifact.
There is no intracranial mass lesion, hydrocephalus, shift of
normally midline structures, major vascular territorial infarct,
or intracranial hemorrhage. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. The study is limited due to motion
artifact for the evaluation of the orbits; however, no displaced
fracture is identified. There is a large right periorbital
hematoma. The ocular globes appear intact.
.
CT Mandible, Sinus [**2103-12-16**]: The cribriform plate appears
intact. The nasal septum is mildly deviated to the right. There
is a small air-fluid level in the right maxillary sinus. No
acute fracture is identified. Right periorbital soft tissue
hematoma is seen.
.
CT C-Spine [**2103-12-16**]: There is no prevertebral soft tissue
swelling. The
alignment is maintained without spondylolisthesis. No acute
fracture is
identified. The odontoid process is intact. Multilevel
degenerative changes, worse at the level of C5-6 and C6-7. The
visualized lung apices demonstrate a left apical bleb. Bilateral
apical pleural thickening. The visualized paranasal sinuses
demonstrate minimal opacification of the right maxillary sinus.
Soft tissue density in both external auditory canals may
represent cerumen. Clinical correlation is recommended.
.
Chest X-ray [**2103-12-16**]: 1. Small nodular opacities within the left
mid lung field, which were present on the previous chest CT, may
be slightly improved. Findings may represent small airways
infection or aspiration.
2. Post-surgical changes, right lung.
.
Barium Swallow [**2103-12-21**] (preliminary read): No esophageal
diverticulum seen. Narrowing of distal esophagus with holdup of
13 mm barium tablet, without holdup of barium. No dysmotility or
reflux seen.
.
Pending studies at the time of discharge:
Final read of Barium swallow study
Brief Hospital Course:
1. SEIZURES
Mr. [**Known lastname **] was admitted to the MICU after having 2 witnessed
seizures in the setting of alcohol withdrawal. He said that it
had been 6 days since his last drink and had a history of
seizures 6 months prior in the setting of alcohol withdrawal.
His ETOH level was negative on tox screen. Neurology was
consulted in the ED and recommended and outpatient EEG. He was
put on a CIWA protocol and given Diazepam PO to treat his
withdrawal. He required IV Ativan initially to control his
symptoms but then was given PO Diazepam. His withdrawal
sytmptoms were controlled and he had no witness seizures during
this hospital stay. He was given thiamine, folate and a
multivitamin and was put on a PPI. He was transferred to the
medicine floor on [**2103-12-19**]. He continued to have no seizures
for the remainder of his hospital course. He was scheduled for
outpatient neurology follow-up and will be called by the EEG lab
regarding scheduling of an outpatient EEG.
.
2. ALCOHOL ABUSE
Mr. [**Known lastname **] was given IV Ativan initially for withdrawal and this
was later changed to PO Diazepam. He required no further
benzodiazepines after [**2103-12-19**]. He was seen by the addiction
social worker who suggested inpatient rehab program but he
preferred to seek help at outpatient treatment centers and was
given a list of programs prior to discharge. He was advised not
to drink alcohol. His liver function tests were normal through
his hospital course.
.
3. DYSPHAGIA
Mr. [**Known lastname **] had a history of dysphagia and prior EGDs with
dilation. Several prior biopsies had shown no evidence of
cancer. On admission he stated that he had dysphagia to thick
meats such as steak. He was evaluated by a barium swallow study
which showed hold-up of a 13mm barium tablet but no hold-up of
the liquid barium and no diverticulum. His outpatient
gastroenterologist, Dr. [**Last Name (STitle) 174**] was contact[**Name (NI) **] and suggested
outpatient follow-up for this problem with another EGD and
possibe sugerical referral in the future. Mr. [**Known lastname **] was given
an appointment to see Dr. [**Last Name (STitle) 174**] in [**Month (only) 404**]. He was evaluated by
speech and swallow who stated that he had no difficulty in
swallowing above the epiglottis. He was advised not to eat
steak and to seek medical attension if he had pain with
swallowing or the feeling of food getting stuck in his throat.
He was advised to seek medical attention if he could not
maintain his weight properly with foods.
.
4. PROPHYLAXIS
Mr. [**Known lastname **] was put on SC heparin for DVT prophylaxis, a PPI and a
bowel regimen during his hospital course. He was given a
prescription for a PPI as an outpatient.
.
Prior to discharge, Mr. [**Known lastname **] was evaluated by PT who
recommended outpatient PT for [**2-25**] more days and ambulation with
a cane, as the patient was not entirely steady on his feet.
Medications on Admission:
none
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Outpatient Physical Therapy
Diagnosis: Alcohol Withdrawal, ambulate with LRAD, 1-2 visits
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Alcohol Withdrawal Seizures
.
Secondary Diagnoses:
2. Dysphagia
3. Alcohol Abuse
4. Fatty Liver Disease
Discharge Condition:
afebrile, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital with seizures in the setting
of alcohol withdrawal. You were given benzodiazepines to treat
your withdrawal symptoms. Your symptoms improved and you did
not require benzodiazepines any longer prior to discharge. You
were evaluated by neurology for your seizures who felt that they
were due to alcohol withdrawal and you should have outpatient
follow-up. You had an x-ray to evaluate your esophagus during
this admission.
.
You were started on a multivitamin, thiamine and folate during
this admission. You should continue to take these at home and
can buy them over-the-counter. You should take also take a
proton-pump inhibitor.
.
You had an esophageal barium swallow study to evaluate your
dysphagia. You should follow-up with Dr. [**Last Name (STitle) 174**] for this as
described below.
.
You should follow-up with Neurology with an EEG and appointment
with Dr. [**Last Name (STitle) 2340**] as described below. The EEG will be scheduled
by Neurology and they will contact you on monday to schedule
this. You should follow-up with your primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] regarding treatment for your alcoholism and further
care. You were provided with phone numbers for outpatient
substance abuse treatment centers on discharge.
.
You should call your doctor or come to the emergency room for
any fevers > 100.4, chills, night sweats, seizures, weakness or
numbness in any parts of your body, severe headache, vision
changes, vomiting, abdominal pain or any other symptoms that
concern you. Please call Dr.[**Name (NI) 31041**] office if you have any
difficulty swallowing or feeling of food getting stuck in your
throat.
Followup Instructions:
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2103-12-31**] 10:30
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) 8618**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2104-1-16**] 2:00
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 174**] (Gastroenterology) [**2103-1-27**] at 1:45pm. Rhabb
building [**Location (un) 453**]. [**Telephone/Fax (1) 463**]
ICD9 Codes: 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6126
} | Medical Text: Admission Date: [**2128-10-30**] Discharge Date: [**2128-11-16**]
Date of Birth: [**2076-2-29**] Sex: F
Service: Surgery, Purple Team
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
female, status post right cephalic vein port placement and
laparoscopic-assisted jejunostomy tube placement on
[**2128-10-29**].
The patient presented on [**2128-10-30**] with nausea,
vomiting, and abdominal pain. The pain was described as
being in the midabdomen and occurs in waves. The pain began
last night. It was only somewhat relieved by Roxicet.
PAST MEDICAL HISTORY: Past medical history is significant
for esophageal cancer which was diagnosed approximately two
weeks prior.
PAST SURGICAL HISTORY: Past surgical history as described
above.
MEDICATIONS ON DISCHARGE: Medications included Prevacid,
Roxicet, multivitamin, and calcium.
FAMILY HISTORY: Family history is significant for a mom with
ovarian cancer.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, the
patient was noted to have a temperature of 98.9, pulse
was 76, blood pressure was 148/70, respiratory rate was 16,
and was saturating 98% on room air. She appeared to be in
discomfort and nauseated. Her head, eyes, ears, nose, and
throat examination was significant for extraocular movements
which were intact. Pupils were equal, round, and reactive to
light and accommodation. There was no icterus demonstrated.
The oropharynx demonstrated mucous membranes were dry. She
was clear to auscultation bilaterally. Heart rate was
regular in rate and rhythm without any associated murmurs,
rubs, or heart sounds. Her abdomen was distended,
tympanitic, with percussion tenderness near the incision.
Bowel sounds were hypoactive. Extremities had trace edema
bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
obtained at the time indicated white blood cell count
was 8.5, hematocrit was 51.3, platelets were 508. Her
Chemistry-7 demonstrated sodium was 138, potassium was 4.2,
chloride was 98, bicarbonate was 29, blood urea nitrogen
was 13, creatinine was 0.6, and blood glucose was 112. Her
liver function tests were normal.
RADIOLOGY/IMAGING: A KUB obtained in the Emergency Room
indicated free air consistent with her laparoscopic
operation. It also demonstrated gastric dilatation and one
small air/fluid level in the midabdomen.
HOSPITAL COURSE: The patient was admitted to the Purple
Surgery Service and treated with antiemetics, and medication,
as well as intravenous hydration for possible postoperative
ileus.
On hospital day two, she was noted to have increasing amounts
of gastric dilatation and increasing amounts of discomfort,
starting at approximately 11 o'clock that afternoon.
She was subsequently taken to the operating room for
re-exploration and revision of her jejunostomy tube
placement. Please see the Operative Note per Dr. [**First Name8 (NamePattern2) 333**]
[**Last Name (NamePattern1) **] for details of this operation.
Notably, during the course of this operation her course was
complicated by a aspiration upon anesthesia induction.
Approximately 2 liters of gastric content was estimated to
have entered the lungs and was rapidly suctioned out;
however, attempts at extubation failed, and the patient was
ultimately transferred to the Intensive Care Unit with a
presumed diagnosis of acute respiratory distress syndrome
secondary to her aspiration.
On [**2128-10-31**], the patient was maintained intubated in
the Intensive Care Unit. On postoperative day one, the
patient was converted to a prone position in the Intensive
Care Unit to help improve her respiratory status. This
gradually improved. The patient was returned to a supine
position on postoperative day two. She was gradually weaned
from the ventilator over the next several days until she was
extubated on postoperative day eight.
On postoperative day seven, Pseudomonas pneumonia was grown
from her tracheal tube. She was started on ceftazidime and
Zosyn that was ultimately converted from Zosyn to
ciprofloxacin. Tube feeds were started on postoperative day
eight and were brought to goal by postoperative day thirteen.
The patient was transferred to the floor on [**2128-11-12**].
Just prior to discharge to the floor, it was noted that she
had swelling in her right arm. An ultrasound was undertaken
to rule out deep venous thrombosis. A thrombus was seen
within the distal jugular vein; consistent with deep venous
thrombosis from the right brachial vein to the subclavian.
The patient was started on a heparin drip at that time, and
over the next several days was converted toward Coumadin. At
the time of discharge, however, she was not therapeutic on
the Coumadin; potentially from interference from the
antibiotics she was on, so the patient was ultimately
discharged on Lovenox.
On the final day of the patient's admission, her port was
accessed. She was discharged home on tube feeds at 120 cc
per hour times 15 hours. She was given oxygen therapy;
predominately because of anxiety that she was dealing with
over feelings of air hunger. She was also given Lovenox
injections. All of this was accomplished through the aid of
a visiting nurse who was going to help the patient with
delivery of medications, the Lovenox injections, and the tube
feeds, as well as assisting with monitoring Coumadin in
concert with the local physician.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Esophageal cancer.
2. Status post jejunostomy tube placement and port placement
complicated by small-bowel obstruction requiring
re-exploration and jejunostomy tube revision, complicated by
acute respiratory distress syndrome subsequent to aspiration.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Enoxaparin sodium 60 mg subcutaneously q.12h.
2. Warfarin 5 mg q.d. (crushed and given per jejunostomy
tube)
3. Roxicet elixir 5 cc to 10 cc per jejunostomy tube q.4-6h.
as needed.
4. Ranitidine 150 mg per jejunostomy tube (as an elixir).
5. Sertraline HCl 50 mg per jejunostomy tube q.d.
6. Colace elixir 100 mg per jejunostomy tube b.i.d.
7. Albuterol 4 puffs inhaled q.4-6h. as needed.
8. Tube feeds were also given with Impact full strength with
fiber at 120 cc per hour.
DISCHARGE DISPOSITION/INSTRUCTIONS: Dressing changes were
to be done every day on the jejunostomy tube site per
[**Hospital6 407**]. An oxygen tank was also to be
provided to the patient. At the time of discharge, the
patient was again receiving tube feeds at the above-mentioned
rates over the above-mentioned times and was tolerating this
without problems. She was also taking full liquids at the
time of discharge.
DISCHARGE FOLLOWUP: Follow-up plans included seeing
Dr. [**Last Name (STitle) **] in approximately one to two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 1752**]
MEDQUIST36
D: [**2128-11-16**] 16:49
T: [**2128-11-16**] 15:41
JOB#: [**Job Number 22150**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6127
} | Medical Text: Admission Date: [**2122-1-16**] Discharge Date:
Date of Birth: [**2122-1-16**] Sex: M
Service: NEONATALOG
HISTORY OF PRESENT ILLNESS: [**First Name5 (NamePattern1) 3613**] [**Last Name (NamePattern1) 52868**] is the former 3.785
kilogram product of a 41 week gestation pregnancy born to a
35-year-old G1, P0, now P1 mother. Prenatal screens were
unremarkable except for a positive group beta-strep status.
Antepartum course was unremarkable. There was an echogenic
focus seen on a prenatal ultrasound in the cardiac region and
alpha fetal protein was within normal limits. Rupture of
membranes occurred on the day of delivery. The mother was
taken to cesarean section for a nonreassuring fetal heart
rate tracing. The infant emerged vigorous with Apgars of 9
at 1 minute and 9 at 5 minutes. He was admitted to the
Neonatal Intensive Care Unit for a sepsis evaluation with
less than four hours of treatment prior to delivery.
PHYSICAL EXAM ON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 3.785 cubic grams, length 21 inches, head
circumference 35.5 cm. General: Non-dysmorphic infant with
mild respiratory distress. Oxygen saturation less than 90%
in room air. Head, eyes, ears, nose and throat: Anterior
fontanel open and flat, symmetric facial features, palate
intact, nares grossly patent, neck supple. Lungs: Clear
and equal bilaterally. Good chest excursion.
Cardiovascular: Grade 2/6 systolic ejection murmur, audible
along left sternal border. Pulses equal throughout.
Abdomen: Soft, nontender, nondistended, no masses.
Genitourinary: Descended testes bilaterally, normal male
genitalia. Anus patent. Spine straight. Normal sacrum.
Extremities: Moving all, hips stable.
HOSPITAL COURSE: By systems including pertinent laboratory
data:
1. Respiratory: [**Doctor First Name 3613**] required nasal cannula O2 through the
first 36 hours of life. He has been on room air since 9 p.m.
on [**2122-1-17**]. His tachypnea resolved. At the time of
transfer, he is breathing comfortably in the 30s and 40s with
oxygen saturation greater than 94%.
2. Cardiovascular: Due to the murmur and the prenatally
identified echogenic cardiac focus, [**Doctor First Name 3613**] had a cardiac
evaluation. Four limb blood pressures were within normal
limits. He passed a hyperoxia test. An electrocardiogram
was normal. The murmur resolved within 24 hours and is not
audible at the time of transfer.
3. Fluid, electrolytes and nutrition: Due to his
respiratory distress, [**Doctor First Name 3613**] was initially NPO. Enteral feeds
were started on day of life one and he has been ad lib,
feeding and breast feeding. Weight on the day of transfer is
3.68 kilograms.
4. Infectious Disease: Due to the unknown etiology of the
respiratory distress, and the less than four hour antepartum
prophylaxis for group beta strep, [**Doctor First Name 3613**] was evaluated for
sepsis. A white blood cell count was 13,500 with a
differential of 46% polys, 4% bands. Intravenous ampicillin
and gentamicin were started. Cultures were no growth at 47
hours with the intention to discontinue the antibiotics at 48
hours if the culture remained negative.
5. Hematology: Hematocrit at birth was 48.8%.
6. Neurology: [**Doctor First Name 3613**] has maintained a normal neurological
exam and there were no neurological concerns at the time of
transfer.
7. Sensory/audiology: Hearing screening has not yet been
performed.
CONDITION OF DISCHARGE: Good.
DISCHARGE STATUS: Transfer to the Newborn Nursery. The
primary pediatrician is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital3 43346**], [**Location 4288**], [**Numeric Identifier 52869**]. Phone number is
[**Telephone/Fax (1) 40499**].
CARE RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding ad lib, breast feeding.
2. No medications with expected discontinuation of the
ampicillin and gentamicin within the hour.
3. State newborn screen: Not as yet sent and no
immunizations administered thus far.
4. Hearing screen prior to discharge to home.
DISCHARGE DIAGNOSES:
1. Respiratory distress, secondary to retained fetal lung
fluid and resulting transient tachypnea of the newborn.
2. Suspicion for sepsis ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (un) 52870**]
MEDQUIST36
D: [**2122-1-18**] 01:27
T: [**2122-1-18**] 13:42
JOB#: [**Job Number 52871**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6128
} | Medical Text: Admission Date: [**2131-1-11**] Discharge Date: [**2131-1-23**]
Date of Birth: [**2079-2-3**] Sex: M
Service: [**Hospital1 3253**]
CHIEF COMPLAINT: Hematemesis.
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old
male with hep C cirrhosis, HIV, former IV drug user, who
presents with one week of nausea, fatigue, progressive
lightheadedness, culminating in progressively frequent black
tarry stools. Over the last eight hours prior to admission
had multiple episodes of emesis with clots, bright red blood,
bilious material. Denies overt retching, but states he
filled a quart container with dark blood, followed by an
episode of bilious emesis. Increased lethargy, dark stools.
Came to the emergency department for evaluation. In the E.D.
his vitals were temperature 98, blood pressure 101/48,
respiratory rate 12. He received two units of packed red
blood cells and 3 liters of normal saline. In the emergency
department he continued to vomit times three, filling urinal
basins with blood. NG lavage did not clear after 250 cc of
saline.
PAST MEDICAL HISTORY: Hepatitis C. Portal hypertension
gastropathy. Last EGD in [**2130-6-7**]. History of GI bleed in
the past likely secondary to portal gastropathy and
[**Doctor First Name **]-[**Doctor Last Name **] tear. HIV diagnosed in [**2120**]. Was on HAART.
Last CD4 count was 300, viral load 1000. RPR positive. Type
2 diabetes mellitus.
MEDICATIONS ON ADMISSION: Combivir 50 mg p.o. b.i.d.,
Kaletra 3 mg p.o. b.i.d., Aldactone 50 mg p.o. q.day,
glyburide, lactulose 30 cc p.o. t.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is married with two children. Prior
heroin and cocaine IV drug use. Remote tobacco use. No
alcohol.
PHYSICAL EXAMINATION: On admission temperature 96.4, pulse
98, blood pressure 126/64, respiratory rate 20, O2 sat 100%
in room air. In general, drowsy, arousable. HEENT exam:
pupils equal, round and reactive to light and accommodation.
Mucous membranes moist. Neck flat JVP, supple.
Cardiovascular exam regular rate and rhythm, normal S1, S2,
2/6 systolic ejection murmur left upper sternal border.
Lungs clear to auscultation bilaterally. Abdomen soft,
nondistended, nontender. Some mild epigastric fullness.
Extremities trace pedal edema, dry and cool. Neurological
exam cranial nerves II-XII intact, alert and oriented times
three times three. Skin no palmar erythema, no visible open
lesions.
LABORATORY DATA: On admission [**Known lastname **] blood count 6.9,
hematocrit 19, platelets 84. Sodium 122, potassium 6.8, BUN
33, creatinine 1.2, chloride 97, bicarbonate 21, glucose 87.
PT 24, INR 3.7. Blood gas pH 7.42, bicarb 26, PO2 104. EKG
normal sinus rhythm at 96, normal axis and intervals, [**Street Address(2) 4793**]
depressions in 2, 3 and aVF, 1/[**Street Address(2) 1766**] depressions in V4
through V6, 1/[**Street Address(2) 1766**] elevation in aVR. Chest x-ray no
infiltrates, no effusion. Right subclavian sitting in left
brachycephalic vein. Small right apical pneumothorax.
IMPRESSION: The patient is a 51 year old male with hep C
cirrhosis who presents with upper GI bleed.
HOSPITAL COURSE:
1. GI. Patient was typed and crossed for four units and was
transfused in the MICU, given octreotide and Protonix IV.
Was given FFP and vitamin K. Esophagogastroduodenoscopy was
performed by the gastroenterology service which showed three
lesions (1) [**Doctor First Name **]-[**Doctor Last Name **] tear; (2) esophageal ulcers
secondary to candidiasis; (3) portal gastropathy. Patient
was kept NPO for three days and no further evidence of
bleeding with no intervention done on EGD. Clear liquids
were started and were advanced slowly to a house diet with
low protein. Patient's hematocrit gradually climbed to the
33 to 35 range where it remained stable. One further episode
of melena occurred one day after discharge from the medical
intensive care unit. However, hematocrit was stable and
there was no further melena and only small amounts of trace
bright red blood from the rectum with bowel movements.
2. Liver. Patient initially had asterixis on admission.
Was given lactulose to titrate to bowel movements three to
four per day and had improvement in his mental status as well
as his asterixis. On discharge patient is continuing on two
to three times a day of lactulose and no longer has any
asterixis and his mental status has improved significantly.
3. Infectious disease. HIV was initially on HAART. Will be
holding this while an inpatient secondary to GI irritation.
However, he will be restarted on these medications prior to
discharge. There was evidence also of a urinary tract
infection secondary to the Foley catheter. The organisms
that grew out were Enterococcus, staph aureus. Patient was
started on Levaquin and dicloxacillin. Chest x-ray showed
some evidence of atelectasis versus pneumonia and patient was
continued on Levaquin for this as well.
4. Pulmonary. During central line placement there was a
small pneumothorax for which a Heimlich valve was placed,
reducing the pneumothorax. However, there was a significant
amount of output initially from the Heimlich valve. The
fluid was sent for gram stain and culture as well as labs
which showed that this was likely an exudative pleural
effusion and there was no evidence of infection. The
Heimlich valve was pulled and the pneumothorax completely
resolved and there was no evidence of reaccumulating pleural
effusion or further infection.
5. Cardiovascular. In the setting of the hematocrit drop
down to 19, there was a small troponin leak to 2.2,
indicating likely subendocardial ischemia or possibly small
infarct. However, this was a peak of the troponin and there
was no further evidence of acute ischemia. Echocardiogram
was performed and showed normal EF and no focal wall motion
abnormalities. Patient was started on Lopressor 12.5 mg p.o.
b.i.d. for beta blockade peri-MI.
6. Heme. Patient's hematocrit continued to hold stable in
the low to mid-30s. Platelets remained in the range of 30 to
40. Likely the thrombocytopenia is due to HIV, however,
there is likely some component of cirrhosis related
thrombocytopenia as well as low grade DIC. There was no
further evidence of bleeding and no platelets were
transfused.
DISCHARGE DIAGNOSES:
1. Upper GI bleed secondary to [**Doctor First Name **]-[**Doctor Last Name **] tear,
esophageal ulcerations, portal gastropathy.
2. HIV.
3. Hep C.
4. Subendocardial MI.
5. Pneumothorax secondary to line placement.
6. Thrombocytopenia.
CONDITION ON DISCHARGE: Fair. Patient has been seen by
physical therapy and walked, however, it seems there is a
significant amount of deconditioning secondary to the
hospital stay and patient would benefit from a short stay in
acute rehab for improvement of mobility.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg p.o. b.i.d.
2. Bumex 1 mg p.o. q.day.
3. Lopressor 12.5 mg p.o. b.i.d.
4. Levaquin 500 mg p.o. q.day. Course to finish on [**2131-1-24**].
5. Dicloxacillin 250 mg p.o. q.six hours. Course to finish
on [**2131-1-28**].
6. Simethicone 80 mg p.o. q.i.d. p.r.n.
7. Oxycodone 5 mg p.o. q.four to six hours p.r.n.
8. Ursodiol 300 mg p.o. b.i.d.
9. Lactulose 30 cc p.o. q.i.d., titrate to three to four
bowel movements per day.
10. Guaifenesin 5 to 10 cc p.o. q.six hours p.r.n.
11. Fluconazole 200 mg p.o. q.day.
12. Nystatin oral suspension 5 cc p.o. q.i.d.
13. Insulin sliding scale.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10621**], M.D. [**MD Number(1) 10622**]
Dictated By:[**Doctor Last Name 9869**]
MEDQUIST36
D: [**2131-1-21**] 09:38
T: [**2131-1-21**] 09:29
JOB#: [**Job Number **]
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6129
} | Medical Text: Admission Date: [**2171-3-15**] Discharge Date: [**2171-3-22**]
Service: GENERAL
HISTORY OF THE PRESENT ILLNESS: The patient is a 74-year-old
female with a history of type 2 diabetes mellitus,
hypothyroidism, and asthma. The patient was transferred from
[**Hospital3 2558**] for evaluation of right-sided abdominal pain.
On [**2171-3-13**], the patient had a fever of 101.8. At that time
she complained of right upper quadrant abdominal pain for a
couple of days. She stated that the pain was only when she
moved, not at rest and it was a dull, aching, constant pain,
which was nonradiating. There was no relieving or
aggravating factors besides movement. The patient also
complained of nausea the day prior to admission. This was
followed by one bout of emesis after which the nausea
resolved. She had a large loose bowel movement the day prior
to admission when she was at [**Hospital3 2558**], which was
reported as C. difficile negative.
PAST MEDICAL HISTORY:
1. Methicillin resistant Staphylococcus aureus of the right
foot status post treatment with Vancomycin.
2. Type 2 diabetes mellitus times 20 years.
3. Hypothyroidism.
4. Asthma.
5. No known cardiac history.
6. Schizophrenia.
PAST SURGICAL HISTORY: Question as to whether the patient
has had an appendectomy. She does have a midline
infraumbilical scar. She is also status post metatarsal
resections.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Insulin NPH 28 units q.a.m.; 14 units q.p.m.
2. Levoxyl 25 mg q.d.
3. Risperdal 1 mg p.o.q.h.s.
4. Multivitamin, one tablet p.o.q.d.
5. Peri Colace.
SOCIAL HISTORY: The patient currently is living in [**Hospital3 7511**], otherwise, she lives at home with her daughter. She
has a 100 pack per year tobacco history.
PHYSICAL EXAMINATION: Examination on admission was notable
for the following: VITAL SIGNS: Temperature 102.1, heart
rate 107, blood pressure 120/44, breathing at a rate of 14,
97% on room air. GENERAL: The patient was awake and
appropriately responding. CARDIOVASCULAR: Regular rate and
rhythm, normal S1 and S2. PULMONARY: Clear to auscultation
bilaterally with no wheezes, decreased breath sounds at the
bases. ABDOMEN: Examination was notable for a distended,
but soft abdomen with right upper quadrant tenderness to
palpation with a positive [**Doctor Last Name **] sign. She had some
voluntary guarding and decreased bowel sounds. RECTAL:
Rectal examination was guaiac negative per the emergency
department examination.
LABS ON ADMISSION: Labs were notable for a white count of
15.3, hematocrit of 33.8, platelets 259; 87 neutrophils, 5
bands, 5 lymphs. The Chem 7 was within normal limits except
for a potassium of 6.9 on the hemolyzed sample, which was
repeated and the potassium was 3.6, ALT was 25, AST 58,
amylase 121, lipase 10, alkaline phosphatase 110, total
bilirubin .4, albumin 2.8.
Right upper quadrant ultrasound revealed a thickened
gallbladder wall, pericholecystic fluid, no stones, sludge in
the gallbladder, no common bile duct dilatation, positive
ultrasonographic [**Doctor Last Name 515**].
HOSPITAL COURSE: The patient was admitted to the Surgical
Service with a diagnosis of diabetes with acalculus
cholecystitis,. After discussion with the family, the plan
was to place a cholecystostomy tube by radiology. The
patient tolerated the procedure well and had no
complications. Post procedure, the patient was on the floor,
but noticed to be making decreased urine output. At this
point, the patient was transferred to the Surgical Intensive
Care Unit for hemodynamic monitoring. The patient's urine
output responded to fluid boluses. On hospital day 3 of 2,
the patient was felt to be stable to be transferred to the
floor.
At this time, the patient had been started on Ampicillin,
Ceftriaxone, Flagyl, upon admission and these were continued
upon her transfer to the floor. On hospital day #3, the
patient's diet was advanced to clear diet. Abdominal pain
was resolving and the white blood cell count decreased to
within normal limits. She also received two units of packed
red blood cells for hematocrit of 26.6.
Examination was notable on [**3-19**] for increased wheezing. This
was felt to either be attributed to asthma or mild fluid
overload and, therefore the patient received Lasix with good
response. The patient's mild respiratory distress and
wheezing then resolved.
On hospital day #6, the patient's diet was advanced to a
regular diet. The patient was tolerating a regular diet
well. The antibiotics were changed on hospital day #7 to
Amoxicillin and p.o. Levofloxacin. These were to cover the
Enterococcus and sparse gram-negative rods, which were
cultured from her initial drainage of the cholecystostomy
tube.
On [**2171-3-22**], hospital day #8, the patient was felt to be
well enough to return to [**Hospital3 2558**]. She was still
complaining of right upper quadrant soreness, but she was
reporting that her abdomen was overall improving and that she
was feeling much better. The patient will be discharged to
[**Hospital3 2558**] to finish a 14-day course of Amoxicillin and
Levofloxacin p.o. She is to have her cholecystotomy tube
flushed with 10 cc normal saline q.8h. and have her inputs
and outputs recorded. She is instructed to return to see
Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] in one week. She is to call his office if
she should have issues which arise prior to then.
DISCHARGE MEDICATIONS:
1. Insulin NPH 28 units q.a.m., NPH 14 units q.p.m.
2. Levoxyl 25 mg p.o.q.d.
3. Risperdal 1 mg p.o.q.h.s.
4. Multivitamin one per day.
5. Peri-Colace.
6. Amoxicillin 500 mg p.o.t.i.d.
7. Levofloxacin 500 mg p.o.q.d. for a total of 14-day
course.
DISCHARGE STATUS: The patient is discharged back to [**Hospital3 7511**].
CONDITION ON DISCHARGE: Acalculus cholecystitis status post
placement of cholecystostomy tube.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 9704**]
MEDQUIST36
D: [**2171-3-22**] 09:49
T: [**2171-3-22**] 09:54
JOB#: [**Job Number **]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6130
} | Medical Text: Admission Date: [**2201-11-17**] Discharge Date: [**2201-11-27**]
Date of Birth: [**2133-7-8**] Sex: F
Service: SURGERY
Allergies:
Demerol
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68F with long history of Crohn's disease and multiple operations
recently discharged from [**Hospital1 18**] [**2201-11-6**] to [**Last Name (un) 16844**] Acute
Rehabilitation Center after long hospitalization for
sepsis/enterocutaneous fistulae/enterovesicular fistula. Returns
to [**Hospital1 18**] on [**2201-11-17**] for hypotension, abdominal pain, and
elevated WBC count at 60K.
Past Medical History:
1.Crohn's disease s/p proctocolectomy and s/p total abdominal
colectomy, proctectomy, and end ileostomy in [**2187**].
2.Incarcerated parastomal hernia s/p repair with mesh in [**2198**].
3.Stenosis of an ileostomy in [**2200**] s/p multiple operations
4.Multiple enterocutaneous fistulas
5.Diabetes Mellitus II
6.Hypertension
7.Depression
Social History:
Married. No ETOH. Tobacco- stopped 20 years ago
Family History:
Non-contributory
Physical Exam:
Initial Physical Exam - [**2201-11-17**]
96.6 100 84/50 18 100% 4LNC
Gen: NAD
Car: rapid rate, regular rhythm
Lungs: CTAB
Discharge Physical Exam -
99.2 91 117/67 16 100%RA
Gen: NAD
Card: RRR
Lungs: CTAB
Abd: soft, appropriately tender. Ostomy and drainage devices in
place. No leak.
Neuro: AxOx3
Pertinent Results:
Admission Labs
-------------------
[**2201-11-17**] 02:15AM BLOOD WBC-69.2*# RBC-3.72* Hgb-11.6* Hct-33.0*
MCV-89 MCH-31.1 MCHC-35.1* RDW-16.4* Plt Ct-516*
[**2201-11-17**] 02:15AM BLOOD Neuts-78* Bands-14* Lymphs-2* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2201-11-17**] 05:50AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2201-11-17**] 02:15AM BLOOD PT-15.5* PTT-44.7* INR(PT)-1.4*
[**2201-11-17**] 02:15AM BLOOD Glucose-143* UreaN-79* Creat-1.3* Na-132*
K-5.2* Cl-101 HCO3-17* AnGap-19
[**2201-11-17**] 02:15AM BLOOD ALT-40 AlkPhos-549* Amylase-97
TotBili-0.4
[**2201-11-17**] 02:15AM BLOOD Lipase-31
[**2201-11-17**] 09:21AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2201-11-17**] 02:15AM BLOOD Calcium-6.9* Phos-5.1*# Mg-2.3
[**2201-11-23**] 05:30AM BLOOD calTIBC-191* Ferritn-926* TRF-147*
Discharge Labs
[**2201-11-24**] 05:44AM BLOOD WBC-6.7 RBC-3.34* Hgb-10.5* Hct-29.9*
MCV-89 MCH-31.5 MCHC-35.3* RDW-16.0* Plt Ct-174
[**2201-11-24**] 05:44AM BLOOD Plt Ct-174
[**2201-11-27**] 05:37AM BLOOD Glucose-103 UreaN-15 Creat-0.5 Na-133
K-4.4 Cl-104 HCO3-22 AnGap-11
[**2201-11-27**] 05:37AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9
Abdominal/Pelvic CT
CT ABDOMEN WITH CONTRAST: There is a small bibasilar
atelectasis. The visualized heart is unremarkable. The liver
enhances homogeneously. The gallbladder appears normal. The
pancreas is atrophied. The spleen, stomach appear normal.
Percutaneous GJ-tube unchanged. All small bowel loops are
diffusely abnormal with multiple sections of small bowel
dilation measuring up to 4 cm, but there is no definite evidence
for obstruction. Bowel loops are diffusely abnormal and
inflamed, and adjacent fat stranding and fluid has increased
from [**2201-9-24**]. There is an area of possible rim enhancing
fluid collection anteriorly on the right (2:55 that may
represent an abscess, but this is difficult to differentiate
from the poorly opacified bowel loops. Multiple cutaneous
fistulas are again identified. There is no free intra- abdominal
air.
CT PELVIS WITH CONTRAST: There is air trapped up underneath the
gluteal folds. Patient is status post colectomy. The Foley is
present within an empty bladder.
BONE WINDOWS: The osseous structures are unchanged. No
suspicious lesions are identified.
IMPRESSION:
Diffusely inflammed small bowel loops with increase in adjacent
inflammatory stranding and fluid with completx 5 cm right
anterior interloop abscess. Multiple enterocutaneous fistulas.
No free intra- abdominal air. Repeat imaging with improved
contrast opacification of bowel loops would like better
characterize abscess if [**Year (4 digits) 10015**] necessary.
Brief Hospital Course:
[**Known firstname 2048**] [**Known lastname 67256**] was transferred to [**Hospital1 18**] emergency department
on [**2201-11-17**] after initial treatment from [**Hospital 487**] Hospital for
hypotension, abdominal pain, and elevated WBC count. In the
emergency department a left femoral central line was placed
after three unsuccessful attempts at the left subclavian. A
non-contrast abdominal/pelvic CT scan showed diffusely inflammed
small bowel loops; a 5 cm right anterior interloop abscess;
multiple enterocutaneous fistulas; and no free intra- abdominal
air (see pertinent results for full report). Urinalysis showed
6-10 WBCs, trace leukocytes, and moderate yeast. Her WBC count
was 69; BUN 79; Creat 1.3. Cortisol stem test was negative.
Chest xray was negative.
She was admitted to the surgery service under the care of Dr.
[**Last Name (STitle) 957**] and was taken to the ICU. IV fluids and Levophed were
continued from OSH, and Linezolid/Imipenem/Flagyl were started
for empiric coverage. Her PICC line was removed and sent for
culture. Stool cultures were sent for c. difficile. She was
placed NPO and her G/J tubes were to gravity. Wound nurses were
consulted for ostomy/tube care. She was given Lovenox, SCDs,
and prevacid for prophylaxis.
At HD 2 her blood pressure, WBC count, and renal function were
improving. PRBCs were given for a Hct of 20.6
At HD 3 TPN w/ nephramine was started. Her Hct was stable after
2 units PRBCs. Her stool culture was negative for c. difficile
and her PICC line tip culture was negative. The femoral central
line was removed after placement of a right IJ catheter.
At HD 4 she was much improved. Tube feeds were started and TPN
was continued. Her diet was advanced to full liquids at
60ml/hr. Later in the evening she was transferred to the floor.
At HD 5 her tube feeds were increased and her TPN was changed to
standard amino acids. Urine culture was positive for yeast and
she was started on fluconazole. Her linezolid was stopped.
At HD 7 she was advanced to a full liquid diet with no volume
restrictions, which she tolerated well. Her g-tube remained to
gravity. Imipenem was stopped and her flagyl and fluconazole
were switched from IV to PO. Levofloxacin was started. WBC count
was at 9.8; BUN 19; Creat 0.4.
At HD 10 her TPN was discontinued, she was on a soft diet which
she enjoyed and was tolerating well. Her tube feeds were
advanced and cycled overnight for 12 hours. Her G-tube was
clamped. Calorie counts revealed that she was taking in 1894
kcal and 66g protein.
At HD 11 she was discharged to [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 67259**] in [**Location (un) 976**], MA in
good condition. She was discharged on a soft diabetic diet and
her G-tube was clamped. Her central line was pulled prior to
discharge. She was taking 8U Lantus at bedtime and was to be
monitored and covered via insulin sliding scale. Her tube feeds
were [**2-9**] Impact with Fiber at 60ml/hr cycled at 12 hours. She
was to continue her Flagyl and Fluconazole x 1 week and was to
remain on the Levofloxacin. She was written to have a Chemistry
panel drawn each Monday and faxed. She will follow up with Dr.
[**Last Name (STitle) 957**] in 3 weeks. An appointment was made for [**12-18**]
at 1:45pm.
Medications on Admission:
Sulfasalazine 2G tube feeds
Lantus 8U
SSI
Fentanyl 50mcg patch
Enoxaparin 40mg
Metooprolol 50mg [**Hospital1 **]
Lansoprazole 30mg
Tylenol 650mg TID
Reglan
Fludrocortisone 0.1mg
Calcium + D
Neutraphos
Hydromorphone 1mg PRN
Discharge Medications:
1. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily): J-tube.
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours).
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
6. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours.
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Loperamide 1 mg/5 mL Liquid Sig: Two (2) mg PO BID (2 times
a day): Non-generic Imodium.
11. Lantus 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
12. Humulin R 100 unit/mL Solution Sig: Per sliding scale
Injection Per sliding scale: Insulin SC Sliding Scale-
Breakfast, Lunch, Dinner, Bedtime:
Regular
Glucose Insulin Dose
0-60 mg/dL [**2-9**] amp D50
61-160 mg/dL 0 Units
161-200 mg/dL 3 Units
201-240 mg/dL 6 Units
241-280 mg/dL 9 Units
281-320 mg/dL 12 Units
> 320 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 46542**] Center for Rehabilitation and Nursing
Discharge Diagnosis:
Urinary Sepsis
Discharge Condition:
Stable
Discharge Instructions:
Please contact or return if you experience:
* Persistent nausea or vomiting
* Fever 101 F or greater
* Abdominal pain
* Removal or misplacement of tubes
* Any other concerns
Please take medications as prescribed. There will be a dressing
at your right neck where you central line was removed on
[**2201-11-27**] at 10:30am. This can be removed in 24 hours.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**] on [**2201-12-18**] at 1:45pm .
Please call
([**Telephone/Fax (1) 376**] to verify or change your appointment.
Completed by:[**2201-12-1**]
ICD9 Codes: 0389, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6131
} | Medical Text: Admission Date: [**2191-12-20**] Discharge Date: [**2191-12-25**]
Date of Birth: [**2118-11-15**] Sex: F
Service:
ADMITTING DIAGNOSIS: Hilar carcinoma of the lung.
DISCHARGE DIAGNOSIS: Hilar carcinoma of the lung, pending
pathology, status post right pneumonectomy.
CHIEF COMPLAINT: Cough and a cold.
HISTORY OF PRESENT ILLNESS: This is a 73 year old African
American female who presented to the Emergency Department in
early [**Month (only) **] due to cough and some shortness of breath.
She had previously been admitted to the hospital for
shortness of breath in [**2189**], at which time a chest x-ray was
done and said to be normal, and the patient was discharged
home on an Albuterol inhaler. She had remained asymptomatic
until the aforementioned visit to the Emergency Department,
at which time a repeat chest x-ray showed the presence of a
large right hilar mass which was associated with volume loss
in the right hemithorax, and suggestive of a neoplasm of the
lung. She denied having any history of fever, chills, chest
pain, nausea, vomiting, constipation or diarrhea. She also
denied any history of lower extremity edema. She stated that
her appetite had been good, however, she had experienced an
approximately ten pound weight loss over the previous two
months. A biopsy was performed of her hilar mass which was
consistent with a nonsmall cell lung carcinoma. She also
underwent a bone scan in a workup for metastases but this did
not reveal any such disease. She underwent further imaging
with CAT scan of the hilar mass and it was staged as a T3,
NO, MO lesion, and was believed to be amenable to primary
resection.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Status post benign breast biopsy in [**2188**], and a
lumpectomy in [**2177**].
4. Cataract disease.
MEDICATIONS ON ADMISSION:
1. Diltiazem 180 mg p.o. twice a day.
2. Albuterol meter dose inhaler.
3. Lipitor.
4. Steroid meter dose inhaler.
5. Multivitamin.
ALLERGIES: The patient reports an allergy to Penicillin
which she states causes swelling, itching, and rash.
SOCIAL HISTORY: The patient lives at home alone. She quit
smoking one month prior to presentation at the Emergency
Department. She does have an extensive tobacco history
having smoked two packs per week for forty years. She also
drinks alcohol on which she states to be a regular basis.
FAMILY HISTORY: Significant for breast cancer and diabetes
mellitus in her mother. There is no family history of
coronary artery disease.
PHYSICAL EXAMINATION: On initial physical examination, she
was found to be afebrile with a heart rate of 90 and sinus
rhythm and a blood pressure of 110/70. Her height was five
feet and her weight was 110 pounds. She was a pleasant 73
year old woman in no acute distress. Her pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements were intact. The neck was supple with no jugular
venous distention. Her carotid arteries were 2+ palpable
with no audible bruits. She had no lymphadenopathy. Her
heart showed a regular rate and rhythm with normal S1 and S2
heart sounds and no murmurs. The lungs were clear to
auscultation bilaterally with good air entry and movement,
however, she did have bilateral expiratory wheezing which was
quite significant. Examination of her breasts revealed no
masses on palpation with no nipple discharge or tenderness.
Her abdomen was soft, nontender, nondistended with no
hepatosplenomegaly or other palpable masses. Neurologically,
she was alert and oriented to person, place and time and
motor and sensory systems were grossly intact. Her
extremities were warm and dry with palpable pedal pulses and
no lower extremities edema.
LABORATORY DATA: Her complete blood count done just prior to
admission showed a white blood cell count of 7.0 with a
hematocrit of 40.4 and platelet count of 469,000. Her
chemistries done just prior to admission were significant for
a sodium of 138, potassium 2.8. She was also found to have a
slightly elevated cortisol level at 24.
Preadmission radiologic studies of significance was a chest
x-ray performed on [**2191-11-1**], which showed a new right hilar
mass. This was further confirmed by CAT scan which showed a
large [**Location (un) 21851**] in the right hilum resulting in
obstruction of the right upper lobe bronchus and severe
compression of the intermediate bronchus. It also showed
multiple ill-defined areas of opacity within the right upper
lobe. The patient further underwent a bone scan which showed
no evidence of bony metastases and a CAT scan of the head
which showed no abnormalities. Ventilation perfusion scan
was also performed which showed right lung perfusion to be
25% of the total.
HOSPITAL COURSE: The patient was admitted to the operating
room on [**2191-12-20**], where she underwent a pneumonectomy of the
right lung as well as bronchoscopy and a pericardial flap.
Please see the operative note for full details of this
procedure. The right lung as well as hilar lymph nodes were
sent to pathology for further examination. Two chest tubes
were placed at the time of surgery, and the patient was
transferred to the Post Anesthesia Care Unit in stable
condition. The patient was subsequently transferred to the
Cardiac Surgery Recovery Unit following continued intubation
and a need for Neo-Synephrine to maintain her blood pressure.
She was at this time on continuous epidural at 4 cc/hour for
pain control. The patient self extubated herself at
approximately 6:30 p.m. on postoperative day number zero.
She appeared to tolerate this well as she was alert and
oriented and breathing fairly comfortably. Her oxygen
saturation at the time remained greater than 90%. On
postoperative day number one, she was alert and oriented to
person, place and time. She was maintaining her heart rate
in the 60s to 70s with her Neo-Synephrine drip being titrated
to maintain a systolic blood pressure greater than 100. The
Neo-Synephrine drip had been able to be shut off for several
hours during the night. She began to experience some greater
incisional discomfort, at which time her epidural rate was
increased to 5 cc/hour. She was encouraged to perform
aggressive pulmonary toilet and incentive spirometry with
which her oxygen saturations and level of pain improved. She
was able to be weaned off her Neo-Synephrine drip completely
towards the end of postoperative day number one. Her pain
was excellently controlled with her epidural running at a
rate of 5 cc/hour. Her relative hypoxia and respiratory
acidosis were slowly being corrected through aggressive
pulmonary toilet. On postoperative day number two, she was
found to be alert and oriented to person, place and time.
She was in sinus rhythm. One of her chest tubes was removed
at this time which she tolerated without difficulty. She was
subsequently transferred to the floor later on postoperative
day number two. During the mid afternoon on postoperative
day number two, the patient went from a sinus rhythm into
rapid atrial fibrillation with a heart rate into the 140s and
a systolic blood pressure between 80 and 90. She was given a
slow 500 cc bolus of normal saline, and proceeded to convert
in and out of atrial fibrillation and sinus rhythm throughout
much of the afternoon. She then went into a sustained rapid
atrial fibrillation, and an Amiodarone intravenous bolus of
150 mg was given over ten minutes and then infusion of
Amiodarone at 1 mg/minute was started. She continued on this
overnight and converted her rhythm back to sinus rhythm
during the night which she sustained. She was started on
oral Amiodarone the following morning, postoperative day
number three, at 400 mg twice a day. Her systolic blood
pressure slowly improved and came into the 120 to 130 range.
She continued to improve remaining in sinus rhythm, and due
to her improving blood pressure was restarted on her
Diltiazem which she had been on prior to admission. She had
excellent pain control and her epidural was quickly weaned.
On postoperative day number four, following chest x-ray which
showed evidence of only a very slight pneumothorax, her
second chest tube was removed. She subsequently had her
dural and Foley catheters removed, all of which she tolerated
extremely well. During the next day and one half, the
patient did very well on the floor, increasing her level of
activity with the assistance of physical therapy and the
nursing staff. On postoperative day number four, it was felt
that the patient was ready for discharge from the hospital.
It was felt at this time that due to the extensive number of
stairs in her home and the fact that she lived alone that she
would benefit from a short stay at a skilled care nursing
facility. She was stable and ready for discharge on
postoperative day number five, at which time she found a
skilled nursing care facility bed. At that time, her
physical examination was significant for a temperature of
99.2, heart rate 100 and sinus rhythm, blood pressure 118/70,
respiratory rate 18 with an oxygen saturation 99% on two
liters of nasal cannula. Her most complete blood count from
[**2191-12-24**], showed a white blood cell count of 8.8, hematocrit
33.8 and a platelet count of 469,000. Her electrolytes on
[**2191-12-24**], showed a sodium of 136, potassium 4.5, chloride 95,
bicarbonate 31, blood urea nitrogen 11, creatinine 0.5, with
a blood glucose of 135. Magnesium at the time was 1.9. On
physical examination, she was alert and oriented to person,
place and time, moving all extremities and following all
commands. Her heart showed a regular rate and rhythm with
normal S1 and S2, and no murmurs. She had good air entry and
movement over the left lung field which was clear to
auscultation. Her abdomen was soft, nontender, and
nondistended. Her sternotomy incision was healing nicely and
her sternum was stable. Her incisions were open to air,
clean and dry. Her extremities were warm and well perfused
with no evidence of pedal edema.
MEDICATIONS ON DISCHARGE:
1. Diltiazem 180 mg p.o. twice a day.
2. Amiodarone 400 mg p.o. twice a day.
3. Acetaminophen 1000 mg p.o. q6hours as needed for pain.
4. Albuterol-Ipratropium inhaler one to two puffs every six
hours as needed.
DIET: At discharge, her diet was as tolerated.
ACTIVITY: Her activity was also as tolerated with probable
benefit from some additional skilled care to increase
strength and mobility particularly in climbing stairs.
DISPOSITION: To the [**Hospital3 537**].
FOLLOW-UP: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**].
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2191-12-25**] 11:31
T: [**2191-12-25**] 12:03
JOB#: [**Job Number 22485**]
ICD9 Codes: 2762, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6132
} | Medical Text: Admission Date: [**2161-2-14**] Discharge Date: [**2161-2-20**]
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old male
who was in his usual state of health until 10 days ago when
he fell on the left frontal area on a beach and believes with
no loss of consciousness. Since then he has had constant
headache, diffuse with no change in character. This A.M. the
slow ambulation. He had no incontinence, no visual changes,
no nausea or vomiting.
They took him to the emergency room at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16558**]
Hospital where a head CT scan was done which showed a 1 cm
frontal parietal left subdural hematoma with an area of
hemorrhage within the subdural hematoma and mild line shift.
[**Hospital1 69**] for further management.
PHYSICAL EXAMINATION: Blood pressure 165/71, heart rate 69,
respiratory rate 16, sat 98% on room air. The patient was
awake, alert, in no acute distress. Chest is clear to
auscultation bilaterally. Cardiovascular - regular rate and
rhythm. Abdomen - nontender, nondistended, positive bowel
sounds, neurologically alert, oriented to [**Hospital3 **]
[**2161-2-10**]. Speech slightly slurred, follows three step
commands. Pupils are equal, round and reactive to light, 3
down to 2.5 mm. EOMs are full. Visual fields are full to
confrontation. Face is symmetric. Palate rises
symmetrically. Motor strength is normal bulk and tone, right
upper extremity with a positive drift. Deltoids [**5-10**], biceps
4+/5, reflexes absent in the lower extremities, 1+ in the
upper extremities and toes downgoing bilaterally.
LABORATORY DATA: On admission white count was 6.2, creatinine
40, platelet count 277,000, sodium 132, potassium 4.0,
chloride 96, CO2 24, BUN 13, creatinine 0.7, glucose 102.
HOSPITAL COURSE: The patient went to the operating room on
[**2161-2-13**] for left posterior frontal craniotomy for
evacuation of his subdural hematoma. In postop the patient
was monitored in the surgical Intensive Care Unit. His vital
signs were stable. He was afebrile. He was easily aroused but
confused. He denied being in the hospital, requiring frequent
stimulation to follow commands. His pupils are equal, round
and reactive to light.
On postoperative day two his mental status improved. He had
the drain in place times two days. Repeat head CT scan
showed good evacuation. The patient's drain was removed and
he was transferred to the regular floor. He was somewhat
confused for two to three days on sitters. Sitters were
discontinued on [**2161-2-19**] and the patient has been off sitters
and oriented times 24 hours. His vital signs have remained
stable. His dressings are clean, dry and intact. His is
stable. His staples should be removed on postoperative day
10. He was operated on [**2161-2-13**]. He was seen by Physical
Therapy and Occupational Therapy and found to require rehab
prior to discharge to home.
DISCHARGE MEDICATIONS:
1. Dilantin 200 milligrams po tid.
2. Zantac 150 milligrams po bid.
3. Lopressor 25 milligrams po bid.
4. Folate 1 milligram po q day.
5. Thiamine 100 milligrams po q day.
6. Trazodone 25 milligrams po q HS prn.
7. Hydralazine 20 milligrams po q six hours hold for
systolic blood pressure less than 110. Hydralazine can be
weaned as tolerated keeping blood pressure less than 160.
DISCHARGE STATUS: His vital signs remained stable. The
patient is afebrile. He will follow up with Dr. [**Last Name (STitle) 1132**] in two
to three weeks times with repeat head CT scan at that time.
DISCHARGE CONDITION: His condition was stable at the time of
discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2161-2-20**] 11:21
T: [**2161-2-20**] 11:25
JOB#: [**Job Number 16559**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6133
} | Medical Text: Admission Date: [**2103-11-21**] Discharge Date: [**2103-11-22**]
Date of Birth: [**2042-2-1**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / House Dust / pollen / silk tape
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for coiling
Major Surgical or Invasive Procedure:
[**2103-11-21**]: Cerebral angiogram with coiling to ophthalmic artery
aneurysm and placement of a stent to the cavernous carotid
aneurysm
History of Present Illness:
Elective admission for cerebral angiogram for coiling of the
ophthalmic artery aneurysm and stent placement for the cavernous
carotid aneurysm.
Past Medical History:
Hypercholesterolemia, HTN
Social History:
Lawyer, 1 drink in two weeks, denies tobacco
Family History:
Sister died of brain aneurysm at age 38
Physical Exam:
On admission:
nonfocal exam
On Discharge:
Patient is neurologically intact. She displays some hoarsness
when speaking which we attributed to her intubation and was
noted to have considerable bruising on the the right side of her
toungue.
Pertinent Results:
[**2103-11-22**] Cerebral Angiogram
IMPRESSION:
Preliminary Report1. [**Known firstname 25415**] [**Known lastname 106479**] underwent successful
re-coiling for short-interval Preliminary Reportre-canalization
of the the right PICA aneurysm (likely related to the
Preliminary Reportorientation of the aneurysm neck towards the
PICA branching angle and high
Preliminary Reportdynamic stress on the coil-pack).
Preliminary Report2. Coil-embolization of the left ophthalmic
segment was performed and was Preliminary Reportuneventful.
Preliminary Report3. Treatment of the left cavernous segment
broad-based aneurysm was initiated Preliminary Reportby placing
a stent that will serve to protect the parent vessel in future
coil
Preliminary Reportattempts.
Preliminary Report4. Note is made of an outpouching from the
right distal ophthalmic segment, Preliminary Reportlikely
corresponding to an additional aneurysm.
Brief Hospital Course:
61F admitted for an elective coiling of the ophthalmic artery
aneurysm and stent placement for the cavernous carotid aneurysm.
She was placed on Plavix pre-op. Post procedure she was on a
heparin drip until 7am on [**2103-11-22**].
Post procedure and prior to discharge she remained
neurologically intact. She was however experiencing some voice
hoarsness and a hematoma on the right side of her tongue likely
form the intubation. She was seen by our anesthesiologist who
did not notice any lesions or cuts and will follow up with a
phone call to make sure the patient does not develop airway
compromise.
Medications on Admission:
Plavix, lisinopril, ibuprofen, HCTZ, lorazepam, nortriptyline,
simvastatin, and Zantac
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*5*
3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**11-19**]
Tablets PO Q6H (every 6 hours) as needed for Headache.
Disp:*30 Tablet(s)* Refills:*0*
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Ophthalmic artery aneurysm (unruptured)
Cavernous carotid aneurysm (unruptured)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 6 months with an MRI/MRA of
the brain. When you call for your appointment this study will be
arranged for you.
Completed by:[**2103-11-22**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6134
} | Medical Text: Admission Date: [**2174-3-2**] Discharge Date: [**2174-3-3**]
Date of Birth: [**2094-11-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
SOB, VT
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
History of Present Illness:
79F w/CHF EF 15% and BiV ICD, COPD, DM presented to OSH from [**Hospital1 1501**]
w/dyspnea and hypotension. PT was hospitalized [**1-17**] for
dysphagia workup, at that time diuresed for CHF and had episode
of VT felt to be provoked by albuterol treatement. Exam, CXR c/w
?CHF exacerbation, no UOP to multiple doses of IV lasix. Also
tachycardic w/?VT vs SVT w/aberrancy HR in 130s. Also
hyperkalemic to 6.0 at OSH. Decompensated and developed
cardiogenic shock - hypotensive to 80s systolic requiring max
dobutamine via CVL but still hypotensive with lactate of 8. Got
lasix 40mg x2, solumedrol, xanax, nebs and was started on
dobutamine prior to transfer. On arrival to [**Hospital1 18**] ER still
hypotensive and tachycardic.
In ED: ECG showed VT vs afib/svt with aberrancy. Given lidocaine
bolus/gtt (avoid amio given ?CHF exacerbation and beta blockade
activity of amiodarone) Pt converted to Afib with PVCs after
electric cardioversion now in BiV pacing rhythm. HR went down to
100s-110s and BP up to 90s systolic. Pt was started on levophed
for continued hypotension, also received 200cc IVF with 100ccs
of urine out. Triple lumen IJ was placed and she was intubated
in ED with etomidate, rocuonium, for looking "downhill" after 3
attempts requiring bougie for difficult airway. Was able to
nswer questions but cold extremities. Transferred to CCU on
levophed 0.16, dobutamine 4, lido 2.75, midaz 4, fent boluses
prn. Vent settings: AC 400/18 5/60%. Vs prior to transfer -
HR:110 O2: 100% BP: 98/73 map 79.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: systolic CHF with EF 15%, valvular heart
disease - unclear specifics
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD: BiV ICD
Episode of VT presumed secondary to albuterol
3. OTHER PAST MEDICAL HISTORY:
Thalassemia Minor
dysphagia
arthritic deformities (mobility issues), right club foot
h/o hypothyroidism
?COPD
Social History:
- Tobacco history: prior but quit 25 yrs ago
- ETOH: none
- Illicit drugs: none
other : husband died a few years ago lives alone.
Family History:
nc, pt intubated/sedated
Physical Exam:
Expired
Pertinent Results:
[**2174-3-2**] 03:41AM BLOOD WBC-16.3* RBC-5.47* Hgb-11.6* Hct-39.4
MCV-72* MCH-21.2* MCHC-29.4* RDW-17.2* Plt Ct-277
[**2174-3-2**] 03:41AM BLOOD Neuts-90.6* Lymphs-6.4* Monos-2.2 Eos-0.4
Baso-0.4
[**2174-3-2**] 03:41AM BLOOD PT-23.6* PTT-29.4 INR(PT)-2.3*
[**2174-3-2**] 11:57AM BLOOD Glucose-172* UreaN-72* Creat-1.6* Na-125*
K-5.6* Cl-89* HCO3-21* AnGap-21*
[**2174-3-2**] 04:10AM BLOOD Glucose-86 UreaN-69* Creat-1.5* Na-127*
K-5.9* Cl-91* HCO3-20* AnGap-22*
[**2174-3-2**] 03:41AM BLOOD Glucose-76 UreaN-68* Creat-1.6* Na-125*
K-5.7* Cl-90* HCO3-17* AnGap-24
[**2174-3-2**] 03:41AM BLOOD cTropnT-0.01 proBNP->[**Numeric Identifier **]
[**2174-3-2**] 04:10AM BLOOD cTropnT-0.02*
[**2174-3-2**] 04:12AM BLOOD Type-[**Last Name (un) **] Rates-16/ Tidal V-400 PEEP-5
pO2-55* pCO2-43 pH-7.32* calTCO2-23 Base XS--3 -ASSIST/CON
Intubat-INTUBATED
[**2174-3-2**] 03:46AM BLOOD Lactate-6.3*
ECHO [**2174-3-2**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is dilated. There is severe
global left ventricular hypokinesis (LVEF = 15%). Marked left
ventricular mechanical dyssynchrony is present. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with severe global free wall hypokinesis. The
aortic valve is not well seen. Significant aortic stenosis is
present (not quantified). The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Severe (4+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. [In the
setting of at least moderate to severe tricuspid regurgitation,
the estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.
Brief Hospital Course:
In brief, the patient was transferred to [**Hospital1 18**] for further
management of cardiogenic shock. She was intubated in the ED
for airway protection. Upon arrival to the CCU, she was
ventilating well but requiring high doses of dobutamine and
levophed for pressor support. Echocardiogram demonstrated
worsening biventricular dilation and global hypokinesis with
wide open mitral and tricuspid regurgitation. Cardiac enzymes
were relatively flat, suggesting no acute ischemic cause for her
cardiogenic shock. Her lactate continued to rise, and in the
setting of cardiogenic shock requiring high dose pressor support
with an ECHO demonstrating very poor global systolic function
with extreme valvular disease, the decision was made in
conjunction with the family to make the patient comfort measures
only.
She passed on [**2174-3-3**] at approximately 3am after terminal
extubation with weaning of pressor support.
Medications on Admission:
allopurinol 100 mg po daily
asa 81mg daily
atorva 10 mg po daily
spironolactone 12.5 mg po daily
folic acid 1mg po daily
tramadol 25mg po TID
flaxseed oil 1 tab daily
glipizide 2.5mg daily
protonix 20mg daily
levothyroxine 75mcg po daily
metoprolol 12.5 mg po daily
lovenox 30mg sq daily
xopenex neb QID prn
proair MDI 2 puffs q 2 hours prn
bumex 1 mg po daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 4271, 2761, 2762, 496, 4240, 2449, 2767, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6135
} | Medical Text: Admission Date: [**2145-2-14**] Discharge Date: [**2145-3-4**]
Date of Birth: [**2080-7-21**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64M with a hx of ETOH abuse, depression, multiple falls who
called 911 this morning with vague complaints. Patient initially
gave 911 the incorrect address (he gave his childhood address).
When EMS arrived to patient's home, he was
ambulatory,intoxicated. Per report the patient was combative at
the outside hospital and was sedated and intubated in order to
obtain a Head CT for a suspected head bleed.
Past Medical History:
Depression
Diverticular bleed in [**2135-10-1**]
Social History:
Unemployed. Lives alone. Daughter lives nearby. Per daughter,
patient has been struggling with depression and ETOH abuse since
being unemployed. He was in detox/rehab about a year ago. He has
the hx of mixing his antidepressants w/ETOH and hx of falls.
Family History:
NC
Physical Exam:
Gen: L eye ecchymosis, facial scratches, intubated, sedated
Initial Neuro Exam:
No EO, no commands. PERRL 3-2mm, R corneal. BUE attempts to
localize, BLE triple flexion.
Repeat Neuro Exam off sedation:
EO to loud voice, MAE- LUE purposeful, squeezes hands
bilaterally, BLE withdraws.
Exam at time of Discharge:
Nonfocal, neurologically intact.
Alert and Oriented to person, place and date.
Following commands, Fluent speech.
Full strength in all 4 extremities.
Upon discharge:
alert, oriented x 3,understands reason for hopsital stay, motor
full, ambulating in halls
Pertinent Results:
CT HEAD W/O CONTRAST [**2145-2-14**]
Stable right temporal intraparenchymal hemorrhage and subdural
hematoma. Slight increase in intraventricular hemorrhage. No
significant
midline shift. No fracture identified.
CT HEAD W/O CONTRAST [**2145-2-15**]
Stable appearance of right temporal intraparenchymal hemorrhage
as well as
intraventricular hemorrhage. Interval decrease in prominence of
right
cerebellar tentorium density.
Brief Hospital Course:
64 y/o M +ETOH and question of fall was taken to OSH where he
was combative and aggressive. Patient was intubated and sedated
to obtain head CT. Head CT revealed R temporal IPH and patient
was transferred to [**Hospital1 18**] for further neurosurgical intervention.
On examination without sedation, patient EO to voice, PERRL, BUE
purposeful, and w/d BLE. He was admitted to the ICU for
monitoring. He was extubated and exam remained stable. On [**2-15**],
repeat head CT was stable and cipro was started for a UTI. In
afternoon, patient became aggitated and pulled out his foley. He
was given ativan and on CIWA scale for possible DTs. Dilantin
level corrected was 6, he was given a 500mg bolus of dilantin.
His level the following morning improved to 13.7 and he remained
on 100mg TID for 10days and then discontinued. He was
transferred from the ICU to the stepdown unit and he continued
to require ativan per the CIWA scale for his DT's. His
neurological exam at this time was eyes open, following commands
intermittently, agitated and trying to get OOB. For patient
safety, he remained in restraints. On [**2-19**] he was more alert- he
was oriented to hospital, city and month but not the year. His
hand and wrist restraints were DC'd but he did require a posey
as he was continually getting OOB without the help of nursing
and was increased fall risk. He was started on PO seroquel on
[**2-19**] and this was titrated to 50mg twice daily. His mental
status continued to improve and on [**2-22**] he was more awake and
oriented to self and year but not to place. Despite up
titration of Seroquel, he continued to require restraints for
agitated behavior and so Geriatric medicine consult was called
for recommendations on [**2-25**]. They recommended to wean the ativan
to off over 3 days as well as wean seroquel to off over 2 days.
A full lab workup was obtained including B12, TSH, LFTs and
these values were all within normal limits. A U/A was consistent
with infection and he was started on a 10 day course of
ciprofloxacin to finish [**2145-3-6**].
Patient's mental status continued to clear and by [**3-1**] the
restraints were no longer needed to maintain patient safety. He
was seen in consultation by psychiatry who were very helpful
with medication adjustment. He was started on celexa 20 qd
(usual dose 60mg qd) but as he was without it for extended
period of time this was introdeced at lower dose. Per his
daughter he had also been on neurontin 600 [**Hospital1 **], doxepin 100 at
bedtime and ativan 0.5mg [**Hospital1 **] - these have not yet been resumed.
Multiple attempts were made to contact his psychiatrist but
calls have not been returned. (Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 36815**])
Patient was oriented and expressing desire for to focus on
addiction issues. Psychiatry recommended psychiatric consult at
rehab.
PT and OT evaluated the patient and found him appropriate for
rehab for cognitive needs. He had follow up head CT on [**2145-3-4**]
prior to discharge that showed resolution of all hemorrhage.
Medications on Admission:
Celexa60 qd, Ativan 0.5mg [**Hospital1 **], neurontin 600 [**Hospital1 **], doxepin 100
hs
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours): last dose [**2145-3-6**].
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right Intraparenchymal Hemorrhage
Delerium Tremens
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
.Take medicine as prescribed.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 2726**] Dr. [**Last Name (STitle) 548**] office as needed for any
questions but no formal follow up or CTs are needed.
Completed by:[**2145-3-4**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6136
} | Medical Text: Admission Date: [**2160-6-18**] Discharge Date: [**2160-6-22**]
Date of Birth: [**2087-2-9**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
female who was otherwise healthy who started complaining of
numbness and weakness of the right arm and leg. It lasted
about two weeks. It was discovered that she had a left
middle cerebral artery aneurysm and was admitted status post
the coiling of the left middle cerebral artery aneurysm on
[**2160-6-18**]. She was admitted to the trauma sick unit post
coiling. During the procedure it was noted that a small non-
occlusive thrombus had formed on an M2 division at its origin
near the coil mass and this was treated with intravenous
Integrilin with resolution. There were no post-
operative neurological deficits noted.
PAST MEDICAL HISTORY: Coronary artery disease.
MEDICATIONS:
1. Dilantin.
2. Aspirin.
3. Calcitrate.
PAST SURGICAL HISTORY: Appendectomy.
PHYSICAL EXAMINATION: Alert and oriented times three; blood
pressure 126/61; heart rate 60. Chest: Clear to
auscultation. Cardiovascular: Regular rate and rhythm.
Abdomen: Soft, non-tender, non-distended with positive bowel
sounds. Postprocedure: Groin site was clean, dry, and
intact with no oozing. Extremities: Positive femoral and
pedal pulses with no hematoma. Vital signs: Stable, blood
pressure was kept to 100 to 130 and she was stable
postprocedure, awake, alert, and oriented times three with no
drift, moving all extremities with good strength, smile was
symmetric.
HOSPITAL COURSE: She was transferred to the regular floor on
[**2160-6-20**]. She was in stable condition. On [**2160-6-21**] she was
awake, alert, and oriented times three. Her face was
symmetric. Her repetition was intact. Her EOMs were full.
She had antigravity strength in all extremities. She had no
drift.
DISCHARGE STATUS: She was discharged to home on [**2160-6-22**] with
Aspirin and Plavix.
FOLLOW-UP PLAN: She will follow-up with Dr. [**Last Name (STitle) 1132**] in two
weeks time.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg by mouth once daily.
2. Aspirin 325 by mouth once daily.
3. Dilantin 200 mg by mouth q12 hours.
4. Colace 100 mg by mouth twice a day.
5. Famotidine 20 mg by mouth twice a day.
DISCHARGE CONDITION: Stable at time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2160-9-15**] 11:20
T: [**2160-9-16**] 17:54
JOB#: [**Job Number 48049**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6137
} | Medical Text: Unit No: [**Numeric Identifier 66120**]
Admission Date: [**2132-3-8**]
Discharge Date: [**2132-3-20**]
Date of Birth: [**2132-3-8**]
Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Name2 (NI) 1549**]-[**Known lastname 66121**] is the 2.335 kg product of
a 33-week gestation born to a 38-year-old G2, P0 now 1
mother. Prenatal screens: B+, direct COOMBS negative.
Hepatitis surface antigen negative. RPR Nonreactive. Rubella
immune, GBS unknown.
PAST OB HISTORY: Notable for spontaneous abortion in [**2129**]
and infertility.
PAST MEDICAL HISTORY: Notable for depression on Bupropion
and hypothyroidism on levothyroxine.
ANTENATAL COURSE: IVF pregnancy, embryo transfer, full fetal
survey normal. Pregnancy complicated by pre-term contractions
at 30 weeks, responsive to hydration. Experienced premature
rupture of membranes on [**2132-3-5**] followed by recurrence
of pre-term contractions. Receive a full course of
betamethasone and was treated with magnesium sulfate,
progressed to labor and eventually to cesarean section for
non-reassuring fetal heart rate. There was an intrapartum
maternal fever of 103 despite maternal antibiotic prophylaxis
from time of premature rupture of membrane.
NEONATAL COURSE: The infant was vigorous at delivery, orally
and nasally suctioned. Viscus yellow secretions. Dried,
subsequent pink and in no distress on room air. Apgar's are 8
and 9 at 1 and 5 minutes respectively.
PHYSICAL EXAMINATION: Birth weight 2.335 kg, head
circumference 30 cm, leg 46.5 cm. Anterior fontanel soft and
flat, nondysmorphic, palate intact. Neck and mouth normal. No
nasal flaring. Chest: No retractions. Good breath sounds
bilaterally. No adventitious sounds. Cardiovascular: Well
perfused, regular rate and rhythm. Femoral pulses normal. S1
and S2 normal, no murmur. Abdomen soft, nondistended. Liver 1
cm below right costal margin, no splenomegaly, no masses,
bowel sounds active, anus patent. Genitourinary normal penis.
Testes descended bilaterally. Central nervous system: Active,
alert and responds to stim. Tone normal and symmetric, moves
all extremities. Suck, root, gag intact. Grasp symmetric.
Integumentary normal. Musculoskeletal: Normal spine, limbs,
clavicles, left hip click noted.
HOSPITAL COURSE: Respiratory: [**Doctor First Name **] has been stable on room
air since admission. He has not required methylxanthine
therapy.
Cardiovascular: [**Doctor First Name **] has been hemodynamically stable throughout
admission without need for cardiovascular support.
Fluid and Electrolytes: His birth weight was 2.335 kg. His
discharge weight is 2315 gm. Infant was initially maintained on
IVF, and advanced on enteral feeds without difficulty. By the
time of discharge, infant was taking E24 ad lib with
breast-feeding.
GI: Infant experienced hyperbilirubinemia requiring several days
of phototherapy, with peak bilirubin was day of life #3 of
10.7/0.3.
Hematology: Hematocrit on admission was 51.
Infectious Disease: CBC and blood culture obtained on
admission. CBC was benign and blood culture remained
negative. In light of maternal risk factors suggestive of
presumed chorioamnionitis, infant was treated for total of 7 days
with ampicillin and gentamicin for presumed sepsis.
Lumbar results were within normal limits. Initial CBC was
unremarkable, and blood cx was negative. Lumbar puncture
performed on antibiotics was unremarkable.
Neuro: Infant had been appropriate for gestational age. Hearing
screen was performed and passed prior to discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **]. Telephone number
is [**Telephone/Fax (1) 43330**].
FEEDS AT DISCHARGE: E24 ad lib in addition to breast feeding.
MEDICATIONS: Not applicable.
Car seat position screening was performed and passed. State
newborn screens have been sent per protocol and have been
within normal limits. Infant received hepatitis B vaccine prior
to discharge.
DISCHARGE DIAGNOSIS:
1. Premature infant born at 33 weeks.
2. Presumed sepsis.
3. Hypoglycemia resolved.
4. Hyperbilirubinemia.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
MEDQUIST36
D: [**2132-3-14**] 06:58:40
T: [**2132-3-14**] 07:39:53
Job#: [**Job Number 66122**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6138
} | Medical Text: Admission Date: [**2200-9-11**] Discharge Date: [**2200-9-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
Hypoxemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 74787**] is an 87 yo woman with paroxysmal atrial
fibrillation, h/o stroke with persistent hemiparesis and
frequent UTIs [**3-15**] indwelling Foley (placed b/c of sacral
decubitus & immobility) who presented today with hypoxemia.
.
She was recently treated for bronchitis and reported to nursing
staff at her NH that she was not feeling well. She reports that
she has been having a productive cough for the past 3 days. She
remianed afebrile during this course. There was a possible
aspiration 3 nights prior per nursing and had coarse rhochi the
following day. The day prior to admission her O2 sat on RA was
noted to be 82% and she was transferred to the [**Hospital1 18**] ED.
.
In the ED, her initial VSs were 97.9 86 140/64 24 94%
nonrebreather. She received cefepime, vancomycin and
levofloxacin.
Past Medical History:
Paroxysmal A-FIB
Stroke [**2198**] with persistent hemiparesis
recurrent UTI
GIB [**2195**], attributed to ASA.
recurrent osteomyelitis of ischium and heel
Social History:
Pt was previously at [**Hospital 599**] Rehab.
Pt her sister lives in [**Hospital3 **]
Pt was a former secratary
Family History:
NC
Physical Exam:
PE:
VSs: Tc & Tm: 98.4, 104-111/40-57, 75-95, 24, 96% facemask 70%
Gen: Chronically ill-appearing, very thin, fatigued, contracture
on left upper and lower ext.
HEENT: Clear OP, ppor dentition MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. distant S1, S2. No appreciable murmurs, rubs or
gallops
LUNGS: diffusely ronchorous bilaterally, poor inspiratory
effort, prolonged expiratory phase, mildly tachypneic, use of
acessory muscles
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
contracture in flexsion on left upper ext and lower ext.
Back: 2 stage IV sacral decubitus ulcers
NEURO: A&Ox1. left sided facial droop, appears fatigued.
Left-sided hemiparesis3/4 relexes in upper ext. Unable to elict
lower relfexes
Pertinent Results:
[**2200-9-11**] WBC-16.2* Hgb-9.1* Hct-29.9* MCV-85 Plt Ct-539*
Neuts-82* Bands-0 Lymphs-13* Monos-3 Eos-0 Baso-0 Atyps-2*
Metas-0 Myelos-0
[**2200-9-19**] WBC-11.3* Hgb-9.9* Hct-31.9* MCV-83 Plt Ct-532*
[**2200-9-11**] PT-15.1* PTT-28.5 INR(PT)-1.3*
[**2200-9-19**] PT-19.3* PTT-31.5 INR(PT)-1.8*
[**2200-9-11**] Glucose-115* UreaN-26* Creat-0.6 Na-144 K-5.9* Cl-107
HCO3-32
[**2200-9-19**] Glucose-90 UreaN-8 Creat-0.5 Na-139 K-4.3 Cl-104
HCO3-31
[**2200-9-19**] Calcium-8.8 Phos-2.8 Mg-2.0
[**2200-9-17**] 6:32 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2200-9-17**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
? OROPHARYNGEAL FLORA.
YEAST. MODERATE GROWTH.
[**2200-9-13**] 11:18 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2200-9-13**]**
GRAM STAIN (Final [**2200-9-13**]):
[**12-6**] PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2200-9-13**]):
TEST CANCELLED, PATIENT CREDITED.
[**2200-9-11**] 7:20 pm BLOOD CULTURE
**FINAL REPORT [**2200-9-17**]**
Blood Culture, Routine (Final [**2200-9-17**]): NO GROWTH.
[**2200-9-11**] 7:10 pm BLOOD CULTURE SOURCE: VENIPUNCTURE.
**FINAL REPORT [**2200-9-17**]**
Blood Culture, Routine (Final [**2200-9-17**]): NO GROWTH.
Urine Legionella antigen: negative
CXR: [**2200-9-11**]
IMPRESSION:
1. Opacity in the left mid and lower chest, worrisome for
pneumonia.
2. Mild interstitial edema.
CXR [**2200-9-16**]
IMPRESSION:
1. Mild cephalization of the pulmonary vasculature without
evidence for
pulmonary edema.
2. Increased right basilar atelectasis, with decreased left
basilar and mid lung atelectasis.
U/S R Upper Ext [**2200-9-18**]
IMPRESSION: Thrombus material seen in the two superficial veins
of the right arm which are the right basilic and the right
cephalic veins. No evidence of a clot in the deep veins of the
right arm.
Brief Hospital Course:
She was admitted for presumed apiration pneumonia and started on
antibiotics. Pt had one witness aspiration event. Her oral
meds were held. She then went into A-FIB with rapid ventricular
responce. She was transferred to the CCU and started on an
amiodarone drip. She went back into sinus rhythm and was
transfered back to the floor. There was a concern on the floor
for her pressure ulcer that it might have progressed to
osteomylitis. A Bone scan was performed which ruled out
osteomylitis of the sacrum. Local wound care was provided.
However there was still a concern for infection of the pressure
ulcer and given the fact that she had an episode of hypotension
and fever (100.4) she was started on IV vancomycin and IV
cefepime. She remained stable on these antiobiotics. A PICC
line was inserted on [**9-26**] for IV antibiotics. Pt. had another
episode of aspiration on [**2200-9-26**]. At the time if aspiration her
sats dropped to the 80s. Food was immediately suctioned out and
deep suctioning was performed. Her diet was changed from soft
to puree. Flagyl was added to her antibiotics and it was
decided to keep her on a ten day course of antibiotics for her
aspiration event. Her Vancomycin, cefepime and flagyl course
will be completed on [**2200-10-6**]. Her code status was DNR/DNI. On
[**2200-9-27**] she was discharged to [**Hospital 100**] Rehab.
Problems:
.
# Pneumonia: Pt arrived with cough, fevers, and O2 saturations
in the 90's on 70% shovel mask. The patient was tachypneic and
fatigued, but able to moderately communicate. The CXR showed L
mid/lower opacity concernig for pneumona. She was started on
broad spectrum antibiotcis: Vancomycin, Cefepime and
Ciprofloxacin. The patient had an elevated WBC on admission
(16.2) that decreased to 9.6 after antibiotics. The patient
continued to have intermittent productive cough and rhonchi, but
improved from admission. There was a concern for anaerobes from
aspiration and the patient antibiotcs were changed to
vancomycin, cefepime and flagyl. Her The patient was also
symptomatically managed with nebs Q6 and respiratory care. The
blood cultures were pending and the Legionella antigen was
negative. She should be monitored and started on treatment if
symptoms continue. She comlpeted a course of Levoquin and
Flagyl in the hospital. However she aspirated again on [**2200-9-26**],
flagyl was added to her antibiotics and it was decided to
continue a ten day course of flagyl, vancomycin and cefepime.
.
# Paroxysmal atrial fibrillation: The patient was found to be in
sinus rhythm at admission. Her INR was subtherapeutic on
admission (1.4) and her coumadin dose was increased from 1mg
daily to 2mg. Her Digoxin and diltiazem was held on admission
because she was NPO due to lethargy and aspiration risk, but was
restarted the following day. On [**2200-9-14**] her meds were again held
because of aspiration risk, but she remained in sinus rhythm.
On [**2200-9-15**] at 8:15am she went into A-fib w/ RVR (HR 140-180)and
hypotensive 60-70/doppler. She was given 5mg diltazem x 2 and
IV fluids. Her pressures remained low and desated into the low
90's. Cardiology was consulted and amiodarone 150mg over
10minutes was started. She remained in a-fib w/ RVR (HR
120-140) and was transferred to the CCU. The family was
notified of the transfer and patient status. Pt started on
amiodarone drip, given calcium and converted to sinus around
noon on [**9-15**]. She was converted to PO amiodarone 100mg and
started on PO diltiezem. She remained in sinus and was
trasnferred out of the CCU on [**2200-9-17**]. She remained on telemetry
and was stable.
.
# Bacteriuria: The admission UA showed bacteria in her urine,
but minimal WBC and no symptoms with a chronic foley. This was
most likely due to contamination and the patient was not started
additional antibiotics. However, urine culture was sent and the
foley was changed.
.
# Decubitus ulcers: The patient has two Stage III-IV decubitus
ulcers. Local wound care was provided and Wound Care Specialist
were consulted for treatment. There was some concern that she
had osteomylitis or infection of pressure ulcer resulting in
early sepsis as she had one episode of hypotension with a temp
pf 100.4. She was started on cefepime and Vancomycin. Bone
scan on [**9-24**] showed no evidence on increase bone turnover in the
sacral area, no evidence of infection. A PICC was placed on
[**2200-9-26**] so that she could finish her course of antibiotics (to
be completed on [**2200-9-29**]).
Medications on Admission:
Oxycodone 2.5 mg prn
Vitamin C 500 mg daily
Albuterol prn
Ipratropium prn
Senna 2 tabs qhs
Warfarin 1 mg daily
Vitamin B12
Diltiazem 30 mg qid
Docusate daily
Furosemide 20 mg qMWF
Digoxin 0.0625 mg daily
Megestrol 400 mg [**Hospital1 **]
MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Megestrol 400 mg/10 mL Suspension [**Hospital1 **]: One (1) PO BID (2
times a day).
4. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 500 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO QMOWEFR
(Monday -Wednesday-Friday).
7. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: 1-10 MLs
Miscellaneous Q2H (every 2 hours) as needed for secreations.
8. Amiodarone 200 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Neb Inhalation Q6H (every 6 hours) as
needed.
10. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Neb
Inhalation Q6H (every 6 hours) as needed.
11. Levofloxacin 250 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Q24H
(every 24 hours).
12. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO TID (3 times a day) for 2 days.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q 8H
(Every 8 Hours).
15. Ascorbic Acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily) for 10 days.
16. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily) for 10 days.
17. Vitamin A 10,000 unit Capsule [**Last Name (STitle) **]: Two (2) Capsule PO DAILY
(Daily) for 10 days.
18. Diltiazem HCl 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
19. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM.
20. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours).
21. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed: please swab mouth.
22. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day): please cont while INR is
subtherapeutic.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia
Atrial fibrillation w/ RVR
h/o stroke with hemiparesis ([**2198**])
h/o GIB
Recurrent UTI
Discharge Condition:
stable, O2 saturations >90% on 40% shovel mask, normotensive,
non-ambulating, awake and alert.
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted because you had pneumonia and
required supplemental O2. You were treated with antibiotics and
improved. You still required 2L of oxygen, but you felt much
better then before.
Your heart rate also increased and your blood pressure was low
so you were sent to the Cardiac Care Unit for close monitoring.
You were given medications to slow your heart and fixed your
irregular heart rate. You were stablized and your heart rate
went back to normal.
Please follow the medications shown below.
Please follow the appointments shown below.
You will return back to your rehab facility and will be followed
by your doctors [**Name5 (PTitle) **].
Followup Instructions:
You will be discharged to [**Hospital 100**] Rehab, and will be followed by
Dr. [**Last Name (STitle) **] and your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74788**].
ICD9 Codes: 5070, 0389, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6139
} | Medical Text: Admission Date: [**2162-5-1**] Discharge Date: [**2162-5-5**]
Date of Birth: [**2106-12-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
hypotension, hematemesis
Major Surgical or Invasive Procedure:
EGD on [**5-1**] and repeated [**5-3**]
History of Present Illness:
55 M c EtOH cirrhosis, h/o variceal bleed presents with
hematemesis x 1 day. After vomiting second time, pt had
transient LOC, awoke, and went to sleep. His wife found him pale
and called EMS. Presented to OSH where SBP 90's and tachycardic,
Hct 22. Transfused 1 units PRBC and IVF, started on octreotide
gtt, 80mg IV protonix, then transferred here. SBP on arrival 88
systolic with Hct only 24. Pt c/o lightheadedness but no CP/SOB.
In ED, coffee ground emesis. He was given 2 more PRBC, 2U FFP,
2U platelets, erythromycin 250mg, and decreased octreotide gtt
to 40. Access is 2 peripheral IV and no central line. NS 1300cc.
Continues to vomit dark red blood. No melena.
Had EGD in MICU which showed mid-esophageal ulcer, no signs
of variceal bleed. Very small varices were seen in the lower
esophagus. The pt was continued on octreotide gtt and protonix
IV bid, he remained HD stable overnight in the ICU, no further
bleeding.
Past Medical History:
EtOH cirrhosis: Prior variceal bleed in [**2161-5-10**]. In [**1-15**] had
upper GIB from ? portal hypertensive gastropathy and not
variceal bleed.
psoriasis
HTN
Pancytopenia - suspected EtoH marrow suppression, cirrhosis
Inguinal hernia repair '[**59**]
Social History:
EtOh: 12 beers/day
No tobacco
Lives with wife in [**Name (NI) **], worked as a meat cutter 32yrs.
states sober for 6 wks after his last variceal bleed but started
drinking after this because of the stress of his job and caring
for his mother and father-in-law
Family History:
n/c
Physical Exam:
vs: Tm 100.7 bp 127/55(102-135/36-65) p 64(64-125) rr17,
90-99% 3L
Gen: somewhat tired appearing NAD
Heent: pale conjunctiva, OP clear,
Chest: ctab
CV: rrr, no m/r/g
Abd: soft, NT, no ascites, no caput medusa. +BS
Ext: No c/c/e
Neuro: No asterixis
Pertinent Results:
[**2162-5-1**] 07:59PM HGB-9.2* calcHCT-28
[**2162-5-1**] 07:59PM LACTATE-4.2*
[**2162-5-1**] 08:02PM PT-18.7* PTT-31.0 INR(PT)-1.8*
[**2162-5-1**] 08:02PM PLT COUNT-30*
[**2162-5-1**] 08:02PM MACROCYT-1+
[**2162-5-1**] 08:02PM NEUTS-69.4 LYMPHS-24.9 MONOS-5.6 EOS-0.1
BASOS-0.1
[**2162-5-1**] 08:02PM WBC-3.4* RBC-2.51* HGB-8.8* HCT-24.8*
MCV-99*# MCH-34.9* MCHC-35.4* RDW-15.1
[**2162-5-1**] 08:02PM AFP-15.4*
[**2162-5-1**] 08:02PM AFP-15.4*
[**2162-5-1**] 08:02PM OSMOLAL-345*
[**2162-5-1**] 08:02PM TOT PROT-5.3* ALBUMIN-2.7* GLOBULIN-2.6
PHOSPHATE-4.5 MAGNESIUM-1.4*
[**2162-5-1**] 08:02PM CK-MB-8 cTropnT-<0.01
[**2162-5-1**] 08:02PM LIPASE-51
[**2162-5-1**] 08:02PM ALT(SGPT)-57* AST(SGOT)-117* LD(LDH)-362*
CK(CPK)-533* AMYLASE-88 TOT BILI-1.0
.
[**2162-5-5**] 05:07AM BLOOD WBC-3.1* RBC-3.34* Hgb-10.6* Hct-31.2*
MCV-93 MCH-31.8 MCHC-34.0 RDW-17.7* Plt Ct-36*
[**2162-5-1**] 08:02PM BLOOD Neuts-69.4 Lymphs-24.9 Monos-5.6 Eos-0.1
Baso-0.1
[**2162-5-1**] 08:02PM BLOOD Macrocy-1+
[**2162-5-5**] 05:07AM BLOOD Plt Ct-36*
[**2162-5-5**] 05:07AM BLOOD Glucose-121* UreaN-7 Creat-0.7 Na-136
K-3.3 Cl-102 HCO3-28 AnGap-9
[**2162-5-2**] 05:00AM BLOOD ALT-50* AST-91* CK(CPK)-400* TotBili-1.3
[**2162-5-2**] 05:00AM BLOOD Lipase-21
[**2162-5-2**] 05:00AM BLOOD CK-MB-6 cTropnT-<0.01
[**2162-5-5**] 05:07AM BLOOD Mg-1.9
[**2162-5-2**] 05:00AM BLOOD Osmolal-318*
[**2162-5-1**] 08:02PM BLOOD AFP-15.4*
[**2162-5-1**] 08:02PM BLOOD ASA-NEG Ethanol-157* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2162-5-1**] 08:00PM BLOOD RedHold-HOLD
[**2162-5-1**] 07:59PM BLOOD Lactate-4.2*
[**2162-5-1**] 07:59PM BLOOD Hgb-9.2* calcHCT-28
.
Liver US:
IMPRESSION:
1. Nodular cirrhotic liver with small amount of ascites.
2. Normal Doppler waveforms.
.
EGD [**2162-5-1**]:
Impression: Localized ulceation and an adherent clot were seen
in the mid esophagus, at 30 cm, likely the source of bleeding.
The etiology was likely esophagitis and ulceration. Decompressed
varices can not be excluded, although this is an unusual
location for variceal bleeding.
Very small varices at the lower third of the esophagus
Erythema and congestion in the whole stomach compatible with
moderate portal gastropathy
Old, blood in the fundus
Otherwise normal EGD to second part of the duodenum
Recommendations: Protonix, octreotide, levofloxacin as per chart
recommendations.
NPO except medications.
No NG tube
Most likely with repeat EGD monday, if stable.
.
EGD [**2162-5-3**]:
Impression: Giraffe skin appearance in the fundus and stomach
body compatible with portal gastropathy
Grade 3 esophagitis in the middle third of the esophagus
Recommendations: Protonix 40mg IV BID
carafate slurry 1 gram QID
continue serial hct.
History: alcoholic cirrhosis, history of variceal bleed
Brief Hospital Course:
A/P:
55 M c EtOH cirrhosis, h/o variceal bleed presents with
hematemesis likely [**2-11**] esophageal ulcer rather than varices, per
EGD on [**5-1**].
.
1. UGIB:
The pt was admitted initially to the ICU given the hematemesis
in the setting of cirrhosis. He was monitored in the ICU
overnight and remained hemodynamically stable. He did receive 4
units pRBCs and underwent EGD which showed small varices, though
suggested an esophageal ulcer as the source of the bleed rather
than variceal bleed. The hct was followed several times per day.
He had several large bore peripheral IVs. He was continued on
protonix 40 IV bid which was changed to oral. Octreotide gtt was
stopped after he stabilized his hct. A Repeat EGD on Monday
showed no evidence of new bleeding source. His hct had remained
stable for 48 hours. He was discharged home in stable condition.
Nadolol therapy was started for variceal bleed prevention.
Discussions were held with the patient and with his family
members present regarding the importance of complete alcohol
abstinence. Alcoholics anonymous and family support were
encouraged. The patient was also advised to take all of his
medicines as directed and to maintain good follow up with his
physicians. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the pcp, [**Name10 (NameIs) **] [**Name (NI) 653**] by phone and
was updated. He will follow up with the patient next week.
.
2. Cirrhosis:
The patient has a known history of alcoholic cirrhosis.
Levofloxacin was initially given to cover for possible SBP,
although this was stopped when it was clear that there was no
ongoing infection. Liver US was performed which showed nodular
liver with no evidence of vascular compromise.
.
3. EtOH:
The patient has not been able to remain abstinent. He states
that he was 6 drinks daily. The EtOH level was 157 on [**5-1**]. He
was administered valium per CIWA and required only several doses
of 5 mg IV over the first couple of days.
.
4. FEN: His diet was advanced to full as tolerated after the
EGD.
.
5. Psychosocial:
The patient recieved new that his father passed away during the
inpatient stay. He was very saddened and was notably tearful.
Social work consult was called. The patient had several family
members come visit and provide support. He will follow-up with
his pcp.
.
#Ppx: PPI, vitamins, no hep sc
#Code: FULL
#Comm: wife
#Dispo: pending resolution of acute medical issues.
Medications on Admission:
nadolol
effexor
thiamine
protonix
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*qs 1 month Cap(s)* Refills:*2*
2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs 1 month Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs 1 month Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs 1 month Tablet(s)* Refills:*2*
6. Pantoprazole 40 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. Effexor 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
Disp:*qs 1 month qs 1 month* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
referral to be made for pyschosocial services
Discharge Diagnosis:
1. UGIB
2. Esophageal Ulcer
3. Grade III esophagitis
4. EtOH cirrhosis
5. Anxiety
6. Hypertension
7. Pancytopenia
8. Psoriasis
9. Alcoholism
Discharge Condition:
Stable hct x 48 hours, tolerating full diet. Ambulating with an
02 saturation of 98%.
Discharge Instructions:
Please follow-up with your PCP for any problems with chest pain,
shortness of breath, black stools, bloody stools, abdominal
pain, or any other concerns.
Followup Instructions:
Wednesday, [**6-23**] at 3:10 with Dr. [**Last Name (STitle) **] in the liver
clinic on [**Hospital Ward Name 517**] on [**Location (un) **].
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2162-6-23**] 3:10
Arrange follow-up appointment with you ophthalmologist for
futher evaluation of left eye.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6140
} | Medical Text: Admission Date: [**2125-11-9**] Discharge Date: [**2125-11-24**]
Date of Birth: [**2050-1-26**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Codeine
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
chest tube placement
intubation
History of Present Illness:
Mrs. [**Known lastname **] is a 75 year old woman with a history of Afib s/p
ablation,HTN,DM, spinal stenosis, with recent hospitalization
for osteomyelitis who presents with altered mental status and
worsening tremor. She had been discharged from [**Hospital1 **] following
hospitalization from presumed sepsis and hypotension on [**2125-11-5**]
to rehab. On the evening of [**11-9**] a moonlighter was called for
increasing agitation. It is unclear at what point she received
0.5mg of ativan. The patient was confused (oriented x1) with a
question of increasing tremor and possibly slurred speech and
was transferred to [**Hospital1 **] for concern of seizures v. sepsis with
AMS.
.
In ED tachy to 110s, SBP 110s and required a 0.7L fluid bolus
with resolution of BP to 130s, but remained tachy to low 100s. A
CT ab/pelvis revealed a fluid collection on her left flank. No
PE was noted. She continued to receive Vanc/flagyl and got a
dose of zosyn, with admission for further work up.
.
ROS was negative for chest pain, syncope or presyncope,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. Patient did not have any other complaints. She reported
that her tremor has been present since she was in her 20s,
related to a medication effect.
.
This am on the floor she was intermittently oriented to place
and month but sometimes thinking she was stranded without her
car and needing help. She did complain of anxiety once, calling
for help, and was verbally calmed down then noted to be
tachycardic to the 140s. Cardiology was consulted, with carotid
massage x 2 performed, with return to normal sinus rythm.
[**Name (NI) **] son notes that her speech is significantly more
garbled in the last two to three days than previously. She began
to have difficulty speaking status post extubation during the
previous ICU stay, but her speech has become progressively
worse. He confirms that the patient has had a baseline tremor,
thought to be due to a medication effect 20 years ago. By the
time the son visited the patient in the late morning, her tremor
had improved, though it did intermittently worsen when the
patient became more anxious. Son also noted that pt had
intermittently stared off into space and been less responsive
for a few minutes, then would return to conversation.
Past Medical History:
PAST MEDICAL HISTORY:
Atrial fibrillation s/p ablation, not on coumadin
Iron-deficiency anemia
Gastritis per EGD, [**2124**]
Insulin-dependent diabetes mellitus c/b neuropathy, retinopathy
Lumbar stenosis, s/p L5-S1 laminectomy (age 40)
Hypertension
Hyperlipidemia
DJD
Tremor
Steatohepatitis
Depression
PAST SURGICAL HISTORY:
Cataract surgery
Carpal tunnel release bilaterally
Tonsillectomy
Appendectomy
Cholecystectomy
Social History:
Patient currently lives in a house in [**Location (un) **], Mass. She lives
with her husband. She is now retired but formerly worked in
medical records at [**Hospital **] Hospital. She denies EtOH, tobacco,
and other drugs. Mrs. [**Known lastname **] reports attempting to maintain a
diabetic diet, but admits to not being as good about it as she
should be. She reports exercising by doing chores around the
house.
Family History:
Diabetes II
Physical Exam:
On admission
VS - 97.5 (98.8 rectally), 120/60, 110, 24, 100 % 2L
Gen: Tremor worse with movement.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
CV: S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: Decreased BS, worse on L.
Abd: Soft, NTND. No HSM or tenderness.
Ext: + edema b/l, pitting.
Skin: midline surgical scar on back. At the bottom of scar,
small opening, small amount of bleeding when instpected with
Q-tip, no tracking noted.
Neuro: CNII-XII intact. Strength diffusly [**2-25**]. Sensation intact.
She is awake, alert, oriented to self only. Responds to
questions and some long term memory intact. Patient able to
recal 1 object at 5 minutes. Difficulty with finger to nose b/l.
Changes at discharge:
1+ bilateral foot edema, trace bilateral lower extremity edema,
alert and oriented x 3, answering questions appropriately
Pertinent Results:
============
Radiology
============
CT Torso [**11-9**]
1. No pulmonary embolus or acute aortic abnormality.
2. 2.2 x 2.0 cm fluid and air collection in the subcutaneous
tissues of the
left lateral abdominal wall that could reflect post-operative
seroma, but
abscess cannot be excluded.
3. No evidence large fluid collection surrounding spinal
fixation hardware in the lumbar spine, although artifact
obscures fine detail and evaluation is suboptimal.
4. Cirrhotic liver with ascites.
5. Bilateral pleural effusions, moderate on the left and small
on the right
with adjacent atelectasis.
6. Atherosclerotic disease.
CT Head [**11-10**]
IMPRESSION: Limited study due to patient motion. Within this
limitation, no
acute intracranial abnormalities identified.
Repeat study [**11-10**]
Several rounded areas of hypodensity are seen within the left
frontal region seen on axial images only that are likely areas
of volume averaging, however, peripheral areas of infarction
cannot be entirely excluded, and if of clinical concern, a
repeat examination or MR can be
performed. No evidence of hemorrhage.
MR [**Name13 (STitle) 430**] [**11-11**]
IMPRESSION:
1. No definite acute infarction.
2. Mild-to-moderate dilatation of the lateral ventricles, with
features as described above and slightly out of proportion to
the prominence of the cerebral sulci; while this can relate to
volume loss, associated communicating hydrocephalus/NPH cannot
be completely excluded. To correlate clinically
============
Neurology
============
EEG [**11-13**]
This is a normal routine EEG in the waking and drowsy states.
Note is made by technician of intermittent left leg shaking
without obvious epileptiform discharges or EEG correlate seen
during that time. Due to technical difficulties, video was
unavailable for review. No focal, lateralized, or epileptiform
features were noted during this recording. Note is made of a
tachycardia of 108 bpm in a single EKG channel.
24 hour EEG [**11-18**]
This 24 hour video EEG telemetry capture no electrographic
seizures. There were no clear focal or lateralizing epileptiform
features. The background showed a slightly disorganized alpha
theta rhythm which would be normal for advanced age.
===========
Cytology
============
Pleural fluids [**11-14**]
NEGATIVE FOR MALIGNANT CELLS.
============
Cardiology
============
Stress test [**11-12**]
No anginal symptoms or ischemic ST segment changes to
pharmacologic stress. Appropriate blood pressure response with
flat
heart rate response to Persantine infusion. Nuclear report sent
separately.
TTE [**11-14**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with focal hypokinesis of
the basal half of the inferior wall and mid-inferior septum and
inferolateral walls. The remaining segments contract normally
(LVEF = 50 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild to moderate
([**11-24**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
Compared with the prior study (images reviewed) of [**2125-11-5**],
regional left ventricular systolic function is now improved. The
estimated pulmonary artery systolic pressure is now higher.
===========
Micro
===========
[**2125-11-13**] 7:38 pm MRSA SCREEN: No MRSA isolated.
[**2125-11-24**] Urine culture: YEAST. 10,000-100,000 ORGANISMS/ML
==============
Labs
==============
Admission Labs
[**2125-11-9**] 06:00PM BLOOD WBC-8.5 RBC-3.35* Hgb-9.3* Hct-30.2*
MCV-90 MCH-27.9 MCHC-30.9* RDW-18.7* Plt Ct-366
[**2125-11-9**] 06:00PM BLOOD Neuts-83.5* Lymphs-9.4* Monos-6.4 Eos-0.5
Baso-0.2
[**2125-11-9**] 06:00PM BLOOD PT-16.0* PTT-31.4 INR(PT)-1.4*
[**2125-11-9**] 06:00PM BLOOD Glucose-109* UreaN-13 Creat-1.2* Na-145
K-3.7 Cl-108 HCO3-29 AnGap-12
[**2125-11-9**] 06:00PM BLOOD ALT-20 AST-32 CK(CPK)-54 TotBili-0.5
[**2125-11-9**] 06:00PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2125-11-9**] 06:00PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2125-11-9**] 06:00PM BLOOD Albumin-3.1* Calcium-8.3* Mg-1.3*
Discharge labs:
WBC-7.2 RBC-3.59* Hgb-10.6* Hct-33.2* MCV-93 MCH-29.4 MCHC-31.8
RDW-18.0* Plt Ct-324
Glucose-179* UreaN-17 Creat-1.1 Na-141 K-4.3 Cl-99 HCO3-33*
AnGap-13
Calcium-8.9 Phos-3.7 Mg-1.8
Brief Hospital Course:
75 year old woman with a history of Afib s/p ablation, HTN, DM,
spinal stenosis, with recent hospitalization for osteomyelitis
who presents with altered mental status and worsening tremor.
She had been discharged from [**Hospital1 **] following hospitalization from
presumed sepsis and hypotension on [**2125-11-5**] to rehab. On the
evening of [**11-9**] a moonlighter was called for increasing
agitation. It is unclear at what point she received 0.5mg of
ativan. The patient was confused (oriented x1) with a question
of increasing tremor and possibly slurred speech and was
transferred to [**Hospital1 **] for concern of seizures v. sepsis with AMS. On
the day of admission, patient was transferred to the MICU for an
episode of unresponsiveness on the floor. The patient rapidly
improved in regards to her mental status upon admission to the
MICU. CT head and MRI were negative, and Neuro felt this event
was likely toxic/metabolic in nature. She was called out to the
floor where an EEG was performed and negative. She underwent
diagnosistc thoracentesis which was transudative in nature on
[**11-12**]. Post-thoracentesis CXR detected a left hemidiaphagm and
repeat film several hours later was performed while the patient
was having another episode of shaking. She became unresponsive
and was noted to have shallow breathing. The xray technicians at
the patient's side were unable to palpate a pulse so CPR was
initiated and a code was called. Code team immediately noted
that patient was in A fib, and CPR was stopped. Patient at this
time was awake but delirious. Her oxygen saturation began to
plummet and decreased breath sounds were noted on the left side.
CXR revealed a large hydrothorax, and patient was transferred
back to the MICU. A chest tube was placed and blood tinged
sanguinous fluid returned. Patient was intubated for airway
protection.
Patient remained in the MICU from [**11-12**] through [**11-18**]. While in
the MICU she was extubated on [**11-14**]. She required pressors from
[**11-12**] through [**11-15**]. Her hypotension was felt to be due to
hypovolemia secondary to dramatic chest tube fluid output. Chest
tube drained between 2 and 4 L per day of ascitic fluid from
presumed hepatic hydrothorax. Cardiac enzymes were slightly
elevated, but consistent with her level of renal dysfunction and
was felt not to have ACS. She had several TTEs which showed
improving systolic function from EF 35 to 50%. The patient
required 2 untis of PRBC transfusion in the unit and multiple
albumin bags for resuscitation. Thoracic surgery was consulted
on [**11-16**] for assistance on hydrothorax management, and they
advised no surgical intervention. Instead the chest tube was
placed to waterseal on [**11-17**] and diuresis was initiated with
lasix drip per thoracic surgery recommendations. A diaphragmatic
defect was not felt to be responsible. The patient was able to
maintain her pressures, and she tolerated diuresis with these
maneuvers. Her course in the MICU was also complicated by
intermittent episodes of sinus tachycardia to has high as 140s
bpm which responded transiently to carotid massage. Her sinus
tach was felt to be due to [**Last Name (un) 3041**] shifts and anxiety. She was
transferred out of the MICU on [**11-18**]. No clear cause for her
change in mental status was found while in the MICU. A repeat
EEG was again negative, and Neurology once again felt that this
was likely multifactorial toxic/metabolic insults in the setting
of acute on chronic renal failure, liver disease, chf, dm and
hypoxia from chronic pleural effusions.
Back on the medical floor, she continued to improve.
# Altered mental status: Her altered mental status was likely
related to medication side effects or hepatic encephalopathy.
Her Elavil was decreased for possible anticholinergic side
effects. If her mental status worsens, suggest changing patient
over to nortripytline and checking levels.
# Tachycardia: Her sinus tachycardia improved after adding
metoprolol back to her medication regimen.
# Anemia: She had a hematocrit drop while in the MICU without
clear source and was guaiac negative. After 2 units pRBCs on
[**11-15**], her hematocrit was stable.
# Osteomyelitis: Patient is on long term vanco/metronidazole
since previous hospitalization for L2 osteo and is followed by
ID as an outpatient. She is to continue vancomycin until [**2125-12-16**]
and flagyl until [**2125-12-20**].
# Mild systolic congestive heart failure: She was diuresed as
above. Patient's most recent EF 50%.
# NASH Cirrhosis: She was seen by hepatology during this
admission. She had a low MELD. Patient was started on
aldactone and diuresed as above. She is to follow-up with the
liver center as an outpatient.
# Inverted nipple noted on exam: Patient will need follow up
with PCP for this issue.
# DM: She was continued on an insulin sliding scale.
# Communication: daughter [**Name (NI) **] [**Telephone/Fax (1) 40153**], son [**Name (NI) **]
[**Telephone/Fax (1) 40152**], [**Name2 (NI) **] [**Telephone/Fax (1) 40154**]
Full code
Medications on Admission:
Per last D/C sum:
Acetaminophen 325 mg prn q6
Amitriptyline 75mg qHS
Bisacodyl 10 mg dailr prn
Docusate Sodium 100 mg [**Hospital1 **] prn
Ferrous Sulfate 325 mg (65 mg Iron) daily
Furosemide 40 mg daily
Heparin SC 5,000 Units TID
Lidocaine 5 %(700 mg/patch) daily prn
Megestrol 40 mg TID
Metoprolol Tartrate 25 mg [**Hospital1 **]
Metronidazole 500 mg q8
Miconazole Nitrate 2 % Powder [**Hospital1 **]
Pantoprazole 40 mg Daily
Sennosides [**Hospital1 **] prn
Simvastatin 40 mg daily
Trifluoperazine 2 mg daily
Vancomycin 500 mg IV Q 24H
Insulin SS
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on and 12 hours off.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP<100, HR<60 .
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Hold for > 4 BM per day .
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for skin irritation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours): Continue until [**2125-12-20**].
11. Vancomycin 750 mg Recon Soln Sig: One (1) dose Intravenous
once a day: Until [**2125-12-16**].
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Trifluoperazine 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for SBP<100 .
16. Furosemide 10 mg/mL Solution Sig: Sixty (60) milligrams
Injection [**Hospital1 **] (2 times a day).
17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Do not exceed 2grams daily.
19. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
20. Insulin
Please continue humalog insulin sliding scale as attached.
21. Heparin (Porcine) 5,000 unit/mL Syringe Sig: 5000 (5000)
units Injection three times a day.
22. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day:
last day [**2125-12-8**]
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Altered mental status
Urinary tract infection
Hydrothorax
Osteomyelitis
Cirrhosis
Discharge Condition:
Level of Consciousness:Alert and interactive (but intermittent
as patient may wx and wane)
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Mental Status:Confused - sometimes (waxes and wanes but alert
and oriented currently) Questionable hospitalization delirium
Discharge Instructions:
You were admitted to the hospital for confusion. During your
hospital stay, you had 2 episodes of decreased responsiveness
prompting stays in the intensive care unit. We suspect your
first episode was from medications causing sedation and that
your second episode was from difficulty breathing because you
had fluid accumulating around your left lung. You improved
after draining the fluid with a cathether and taking medications
to clear the fluid from your body. You were stable to be
discharged to a rehab facility to work on regaining your
strength. Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 40075**].
The following changes were made to your medications:
Decreased Elavil from 75mg to 25mg as it may have worsened your
confusion
Increased lasix to 60mg IV twice a day. This will be tapered to
meet your goal Ins and Outs
Increased vancomycin to 750mg for therapeutic level
Decreased metoprolol from 25mg [**Hospital1 **] to 12.5mg [**Hospital1 **]
Started fluconazole 200 mg daily for fungus in your urine for 14
days (last day [**2125-12-8**])
Started Lactulose 30mg TID and aldactone to help control your
liver cirrhosis.
Started full dose aspirin for your atrial fibrillation
Stopped megace
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 40075**]. You can call
[**Telephone/Fax (1) 40076**] to schedule an appointment.
Please follow-up with Dr. [**Last Name (STitle) 497**] in the liver center. You will
be called about appointment scheduling but if you do not hear
from them, please call ([**Telephone/Fax (1) 1582**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
ICD9 Codes: 5849, 5990, 5180, 2760, 5715, 4280, 4168, 4240, 3572, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6141
} | Medical Text: Admission Date: [**2197-9-16**] Discharge Date: [**2197-12-27**]
Date of Birth: [**2197-9-16**] Sex: M
Service: Neonatology
HISTORY: Baby boy [**Known lastname 68869**], twin No. 1, was born weighing 718
grams, the product of a 24 and 6/7 weeks gestation pregnancy.
He was born to a 34-year-old G2, P0, now 2 mother. Maternal
history was notable for short cervix with cerclage placement
prenatally.
Prenatal screens - blood type O positive, antibody negative,
HbSAg negative, RPR nonreactive, rubella immune, GBS unknown.
This infant was born by cesarean section after unstoppable
preterm labor. The infant emerged with a weak cry, was brought
to the warmer, given some positive pressure ventilation and
intubated in the delivery room.
PHYSICAL EXAMINATION: Anterior fontanel open and flat.
Coarse breath sounds bilaterally with good breaths
bilaterally. Positive red reflexes bilaterally. No
murmur. normal S1S2. Normal pulses. Soft, nondistended, no
masses. Moved all extremities equally. Pink and well
perfused. Three-vessel cord, patent anus.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The infant had respiratory distress syndrome on
admission to the NICU and was intubated and received surfactant
therapy x2. He remained ventilated with conventional ventilation
until [**2197-10-11**], which is day of life 25 when he required
high frequency ventilation at that time for sepsis issues.
Within 24 hours he returned to conventional ventilation. In the
setting of his chronic lung disease, he was started on Lasix on
DOL #42 ([**10-28**]), receiving Lasix every Monday, Wednesday and
Friday. He extubated to CPAP on [**2197-11-7**], day of life 52,
successfully weaned to nasal cannula on [**2197-11-27**],
which is day of life 73. He weaned to room air on [**2197-12-17**], and has remained stable on room air since that
time. He has had no apnea or bradycardia issues for well over
a week. He was given caffeine citrate from [**2197-11-19**],
through till [**2197-10-17**], at which time caffeine was
discontinued due to increased heart rate. Caffeine was never
restarted thereafter.
Currently, he is receiving Lasix every Monday, Wednesday and
Friday. He had been receiving KCl as well but this was
discontinued on [**12-20**] and his most recent Cl on [**12-26**] was 106
with a K of 5.5. The infant will be followed for chronic
lung disease by Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 37305**] at [**Hospital3 1810**] and has
a follow- up appointment on [**1-5**].
CARDIOVASCULAR: The infant presented with symptoms of PDA on
[**2197-9-17**], at which time indomethacin was given. A
post-indomethacin echocardiogram on [**2197-9-19**] showed
that that the ductus was closed. Followup echocardiogram was done
on [**2197-10-3**], due to re-presentation, which showed a small
1 mm PDA. No indomethacin was given at that time. Two further
echocardiograms have been done, both in [**Month (only) 359**] (23 and 26th)
due to persistent murmurs. Both of those showed a very tiny PDA,
neither of which was treated with Indocin. The infant has
been hemodynamically stable and at this time does not have a
murmur and has normal heart rate and blood pressure. No
further issues. He does not have a murmur at the time of
discharge.
The infant did present with a brief period of supraventricular
tachycardia on [**2197-10-17**], at which time caffeine citrate
was discontinued and no urther episodes have been observed.
FLUIDS, ELECTROLYTES AND NUTRITION: IV fluids were initiated
on admission to the NICU and changed to total parental nutrition
over the next few days. An umbilical arterial catheter was placed
and a double lumen umbilical venous line was also placed on
admission. The infant was started on enteral feedings on
[**2197-9-21**], with a slow feeding advance and achieved full
enteral feedings. A PICC line was placed on [**2197-9-23**].
The double lumen UVC was discontinued at that time. Enteral
feedings were advanced and the infant achieved full enteral
feedings by [**2197-9-30**]. Enteral feedings were then
further concentrated to caloric density of breast milk 30 calorie
per ounce with Beneprotein.
The infant had an episode of abdominal distention with an
abnormal KUB and was treated for 14 days for medical necrotizing
enterocolitis which was started on [**2197-10-10**]. The KUB
subsequently normalized and the infant was restarted on enteral
feedings on [**2197-10-27**]. Feedings advanced without an
incident.
Currently, he is feeding PO ad lib of 26 calorie breast milk
mixed as breast milk with 4 calories of Similac powder per ounce
and 2 calories of corn oil per ounce. The infant's most recent
weight is 2810 grams. He is gaining well. He is taking
approximately 3 ounces every 4 hours enterally. Most recent set
of electrolytes were done on [**2197-12-26**], and the results
are Na=138, K=5.5, Cl=106, HCO3=23. His most recent head
circumference is 34 cm, most recent length is 48 cm, both done on
[**2197-12-26**]; at present he is 10 to 25th percentile for
weight, 50 to 75th percentile for head circumference, and 25th to
50th percentile for length. He is on daily multivitamins, 1 ml
per day.
Renal: On [**2197-12-26**], renal ultrasound was performed
which showed bilateral calcifications in both kidneys, consistent
with chronic lasix use.
GASTROINTESTINAL: The infant did have a period of medical
necrotizing enterocolitis that was discussed under fluid,
electrolytes and nutrition as above, treatment from [**2197-10-10**], through [**2197-10-27**]. The infant did have
hyperbilirubinemia with a peak bilirubin level of 3.8/ 0.3
and did receive a total of 8 days of phototherapy.
HEMATOLOGY: The patient's blood type is A positive, DAT
negative. The infant has received numerous blood product
transfusions, and in total has received 5 transfusions of
packed red blood cells with the most recent transfusion being
on [**2197-10-28**]. The infant is on elemental iron, ferrous
sulfate at 0.5 ml PO daily. Most recent hematocrit was 36 on
[**2197-12-12**], with a reticulocyte count of 8.1%.
INFECTIOUS DISEASE: CBC and blood culture were screened on
admission to the NICU. The infant had a white blood cell
count of 5.1 with 29 polys, yielding an ANC of 1479. There
was no left shift. The infant received 48 hours of ampicillin
and gentamycin initially which were subsequently discontinued
when the blood culture remained negative at that time. The
infant had a sepsis evaluation done on [**2197-9-29**], at
13 days of life due to clinical instability. CBC at that time
was normal but the blood culture grew staph epidermidis
bacteremia. The infant was started on vancomycin and
gentamycin and given a 7-day course of antibiotics at that
time. At the end of that course of antibiotics, the infant
presented with medical necrotizing enterocolitis and that was
on [**2197-10-10**]. The antibiotic therapy was switched to
Zosyn to treat for medical necrotizing enterocolitis at that
time. The infant received 12 days of Zosyn therapy which was
changed on [**2197-10-21**], to vancomycin, gentamycin and
clindamycin when a blood culture grew positive at that time
for gram positive cocci. CBC at that time was not shifted on
[**2197-10-10**]. The infant received an additional 7 days of
antibiotics which were subsequently discontinued on [**2197-10-27**]. The infant had a yeast diaper rash and was treated
with miconazole powder from [**2197-10-21**], through till
[**2197-10-29**]. There have been no further infectious
disease issues.
NEUROLOGY: The infant has had numerous cranial ultrasounds
done on [**2197-9-18**], [**2197-9-25**], [**2197-10-16**], [**2197-12-21**], all within normal limits.
SENSORY: Hearing screen was performed and the infant passed
in both ears.
OPHTHALMOLOGY: The infant has had numerous ophthalmological
examinations. The initial examination was done on [**2197-10-30**], and the most recent ophthalmologic examination was
[**2197-10-26**]. The infant did have mild ROP but has
progressed to mature eyes on [**2197-10-26**], and the plan
is for follow up with ophthalmology in 9 months after
discharge.
PSYCHOSOCIAL: [**Hospital1 18**] social worker has been involved with the
family. If there are any concerns, she can be reached at [**Telephone/Fax (1) 56048**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
[**Location (un) **].
CARE RECOMMENDATIONS:
1. Ad lib PO feedings of breast milk 26 calorie per ounce
made as breast milk with 4 calorie per ounce of Similac
powder and 2 calories per ounce of corn oil.
2. Medications: Elemental iron 0.5 ml per day. Daily
multivitamin drops 1 ml per day, Lasix 5.5 mg which
equals 0.6 ml once daily on Mondays, Wednesdays and
Fridays.
3. Car seat positioning. The infant was tested in the infant
car seat and did not pass in an upright position. It was
recommended that the infant be discharged in an infant
car bed in a supine position.
4. State newborn screens: Numerous state newborn screens
have been sent and the most recent screen is normal.
5. Immunizations received: The infant received Pediarix
vaccine on [**2197-11-19**], pneumococcal vaccine on
[**2197-11-20**], Synagis on [**2197-12-25**].
6. Immunizations Recommended:
Synagis RSV prophylaxis should be continued monthly through
[**Month (only) 958**].
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 appointment is recommended with the pediatrician
on [**2187-12-29**]. Also followup appointment on [**1-5**] at 1 p.m.
with Dr. [**Last Name (STitle) 37305**], from pediatric pulmonology at [**Hospital3 18242**]. VNA referral after discharge. Early intervention follow
up and Infant [**Hospital **] Clinic at [**Hospital3 1810**].
DISCHARGE DIAGNOSES:
1. Prematurity born at 24 and 6/7 weeks gestation.
2. Twin No. 1, respiratory distress syndrome, resolved
3. Rule out sepsis.
4. Patent ductus arteriosus, resolved
5. Necrotizing enterocolitis, resolved
6. Staph epidermidis bacteremia, resolved
7. Chronic lung disease.
8. Hyperbilirubinemia, resolved
9. Anemia of prematurity.
10. Retinopathy of prematurity, resolved.
11. Left hydrocele.
12. Bilateral renal calcifications Lasix-induced
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Name8 (MD) 68870**]
MEDQUIST36
D: [**2197-12-26**] 22:22:26
T: [**2197-12-27**] 02:27:30
Job#: [**Job Number 68871**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6142
} | Medical Text: Admission Date: [**2167-11-9**] Discharge Date: [**2167-11-18**]
Date of Birth: [**2114-5-14**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
HCV cirrhosis
Major Surgical or Invasive Procedure:
Liver transplant [**2167-11-9**]
History of Present Illness:
53-y.o. female with HCV cirrhosis s/p TIPS is called in for
potential liver transplantation. Patient was recently
hospitalized [**Date range (1) 87949**] for hepatic encephalopathy and treated
with PO and PR lactulose. Per daughter, Pt has been at baseline
since being discharged two days ago: able to converse and
perform
daily activities of living. Although her mental status was
normal yesterday, pt complained of weakness and "not feeling
well." This morning, she woke up confused and unoriented.
Denies fever, chills, nausea, vomiting, cough, dysuria, SOB or
CP. Most of history is obtained through her daughter and HCP as
pt is minimally conversant.
Past Medical History:
- HCV: Dx [**2166**]; she is infected with G3A genotype. She has no
history of UGIB or varicies. She has no history of IDU or
transfusions.
- DM-2
- Asthma: never required hospitalization or intubation
- Migraine headaches
- history of Gallstones
- ? peripheral vascular disease
- Cirrhosis
- Diuretic refractory ascites s/p TIPS [**2167-3-25**]
- HCC s/p RFA ablation
Social History:
She has 2 children and 2 grandchildren ages 15 and 18. They have
no pets, she does not garden or keep indoor plants. She has
worked in a local store as a stockperson. Not working. From
[**Male First Name (un) **] and moved here 40 yrs ago.
.
She was born in [**Male First Name (un) 1056**]. While there, she worked in assembly
lines, stores, and other manual labor jobs; She left [**Male First Name (un) 1056**]
over 40 years ago, and lived first in [**Location (un) 7349**] then NJ with her
present husband. They moved to [**State 87856**] over 1 year
ago.
Family History:
There is no known family history of liver disease or liver
cancer. She has 6 brothers and 5 sisters; her father died when
she was 17 (ETOH abuse) and her mother is alive and living in
[**Name (NI) 108**] now.
Physical Exam:
T: 97.3 P: 82 BP: 127/43 RR: 18 O2sat: 96% on RA
General: awake, alert, follows commands, NAD, oriented to
person,
oriented to place after much encouragement
HEENT: NCAT, EOMI, icteric sclera
Heart: RRR
Lungs: normal excursion, no respiratory distress
Abdomen: obese, soft, NT, ND, no fluid wave
Extremities: WWP, 2+ pedal edema
Skin: multiple ecchymotic areas on both arms
Neuro: moves all extremities
Studies:
Serum electrolytes:
pending
CBC:
pending
CT head [**2167-11-2**] showed:
No acute intracranial process.
Brief Hospital Course:
53-y.o. female HCV cirrhosis admitted for liver transplantation.
Upon admission, she was lethargic and was given
lactulose/rifaximin. Ammonia level was 128. She underwent liver
transplant and ventral hernia repair on [**2167-11-9**]. Surgeon was
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for details. 3
JPs were placed (posterior to liver, under hilum and
subcutaneous at hernia repair). Drains were non-bilious. She was
sent to the SICU postop and was extubated the next day.
LFTs increased postop day 1. Liver duplex was wnl. Mental status
was improved from preop. LFTs continued to trend down. She was
sent out of SICU on postop day 2. Diet was slowly advanced and
tolerated. Insulin was given for hyperglycemia due to steroids.
[**Last Name (un) **] was consulted and ordered 75/25 pen. Vital signs remained
stable.
Lasix was given for low urine output and edema. Creatinine
increased on postop day 2, up to 1.5 from 2 then improved daily.
Immunosuppression consisted of Cellcept which was well
tolerated, steroid taper and Prograf that was started on postop
day 1. Doses were adjusted per trough. She did well with
medication teaching and self administration of insulin with
assist of family members.
VNA Greater RI 1-[**Telephone/Fax (1) 87950**] was arranged to assist with JP
drain care (in hernia bed). Nsg anf PT services were requested.
Medications on Admission:
Ciprofloxacin 250 mg daily, clotrimazole 10 mg troche 5x daily,
metformin 500 mg [**Hospital1 **], glimepiride 1 mg daily, rifaximin 550 mg
[**Hospital1 **], esomeprazole 40 mg daily, furosemide 20 mg daily,
spironolactone 50 mg daily, lactulose 10 g/15 mL x 30 mL TID,
tramadol 50 mg Q6H PRN pain, ropinirole 0.5 mg daily, ferrous
sulfate 300 mg daily, docusate sodium 100 mg [**Hospital1 **], polyethylene
glycol 17 g PO BID PRN constipation, fleet enema PRN
constipation, vitamin D-2 50,000 unit Qweek.
Allergies:
NKDA.
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
follow taper schedule.
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
8. Humalog Mix 75-25 KwikPen 100 unit/mL (75-25) Insulin Pen
Sig: Forty (40) units Subcutaneous once a day.
Disp:*30 pens* Refills:*4*
9. Humalog Mix 75-25 KwikPen 100 unit/mL (75-25) Insulin Pen
Sig: Twenty Five (25) units Subcutaneous at bedtime: take at
dinner.
10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Breeze 2 Test Strips Strip Sig: One (1) Miscellaneous
four times a day.
Disp:*1 box* Refills:*2*
15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
16. Kayexalate Powder Sig: Fifteen (15) grams PO 15 gm(s) by
mouth As directed Only take if directed by transplant team .
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
visiting nurse services of greater RI
Discharge Diagnosis:
HCV cirrhosis
Asthma
DM II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Visiting Nurses services of Greater [**Doctor Last Name 792**]have been
arranged
-Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the following: fever (101 or greater), shaking chills,
nausea, vomiting, inability to take any of your medications,
jaundice, increased abdominal/incision pain, incision
redness/bleeding/drainage or diarrhea/constipation.
-You will need to have blood drawn every Monday and Thursday for
lab monitoring at Quest lab or Lab provider recommended by [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 23170**], RN
-Please empty and record abdominal drain output. Bring record of
drain output to next Transplant appointment
-Do not lift anything heavier than 10 pounds. No straining
-You may shower
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-11-26**] 3:40
Completed by:[**2167-11-19**]
ICD9 Codes: 5849, 5715, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6143
} | Medical Text: Admission Date: [**2144-10-11**] Discharge Date: [**2144-10-26**]
Date of Birth: [**2126-11-21**] Sex: M
Service: TRA
HISTORY OF PRESENT ILLNESS: The patient is a 17 year old
male with gunshot wound to the chest and back. Initially, he
was seen at an outside hospital. The patient had bilateral
chest tubes placed at that time. He was initially alert and
oriented times three but now complaining of bilateral lower
extremity paralysis. He is not withdrawing to pain. The
patient was found to have five bullet wounds. He had four
units of packed red blood cells prior to his transfer and was
intubated at the outside hospital. The patient was
hemodynamically stable upon transfer.
PAST MEDICAL HISTORY: None.
MEDICATIONS AT HOME: None.
ALLERGIES: None.
SOCIAL HISTORY: Unknown. The patient lives at home with two
sisters.
PHYSICAL EXAMINATION: The patient has a temperature of 96.6;
heart rate of 110; blood pressure 96/70; respiratory rate of
20; saturating 94 percent on room air. Physical examination:
The patient is sedated and paralyzed. Heart is regular rate
and rhythm. Chest is coarse bilaterally. The patient has
one sternal bullet wound; one in the left posterior axillary
line; two in the right posterior axillary line and one in the
left thigh posteriorly. Abdomen is distended. His
extremities are warm. He has bilateral late palpable pulses.
His back has no step-off.
HOSPITAL COURSE: The patient was taken directly to the
operating room for exploration, at which time an exploratory
laparotomy was performed. A splenectomy was performed. The
patient also had a repair of a left diaphragmatic injury and
repair of a liver laceration. This was performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient was
admitted at that time and sent to the Intensive Care Unit for
observation. The patient was placed on a Solu-Medrol
protocol. He was also seen by the orthopedic spine service.
The orthopedic spine service had intention to perform
surgical intervention on his back; however, it was deemed
important to make sure that the patient was stable from a
hemodynamic standpoint and held on surgery. The patient did
receive perioperative Cefotetan. He was also left intubated
for a prolonged period of time. It became evident early in
the patient's stay that the patient's white blood cell count
began to increase. The patient was pan cultured as well as
his lines removed and changed. The only thing found was a
hemophilus pneumonia which was treated for seven days with
Levofloxacin. Meanwhile, his white blood count continued to
increase, which has presumably been secondary to splenectomy
as no other source has been identified nor is there is any
source apparent on physical examination or complaint of the
patient. The patient did receive a bronchoscopy which showed
blood and clots in the right middle lobe of the bronchus of
his lung, although no clear injury was found. The patient
required a thoracic consult as the patient had a prolonged
air leak in one of his right chest tubes. It was believed
that once the patient was off positive pressure ventilation,
that this air leak would resolve. The patient was finally
taken back to the operating room and had a decompression and
T10 to L2 fusion of his vertebra by the ortho spine service.
The patient tolerated that procedure well as well. After
that procedure, the patient began his vent weaning and, as
expected, once he had been weaned down adequately, the
patient's air leak began to decrease. The patient was
started on tube feeds while intubated. He was also given
diuretics to help him down load his edema, as he had quite a
bit of fluid on board from the multiple surgeries and the
resuscitation. Over the course of the next few days, the
patient was successfully extubated. His nasogastric tube was
removed and he was started on a regular diet. This was a
prolonged course increasing his p.o. intake, as the patient
did not have much interest in food. During all of the
patient's critical care management, multiple family visits
were made by his team of physicians to discuss different
aspects of the patient's care and it was evident that the
mother is in denial of the patient's likely permanence of
paraplegia, however, is on board with the patient going to
rehabilitation. Prior to leaving the Intensive Care Unit,
the patient had his left chest tube and one of his right
tubes removed. While on the floor, the final chest tube was
removed as pneumothorax was seen as stable on his chest x-ray
and believed to be scarred into place. No air leak was
evident at that time.
While on the floor, the patient was seen by physical therapy.
He was also plugged into case management for placement
issues. At that time, it was decided that the patient was
appropriate for transfer to rehabilitation. At that time,
the patient again spiked a temperature and was worked up
thoroughly. His blood and urine were cultured. Chest x-ray
was performed. Urinalysis was performed. The patient was
looked over thoroughly for sources of an infection, although
no source was found. His chest x-ray looked better than it
ever had. His urinalysis was negative and nothing grew on
culture. It is believed that his high white count is
secondary to splenectomy and will resolve on its own. The
patient did tolerate p.o. and is passing stool and gas
freely. It is now [**2144-10-26**] and the patient is being
discharged in good condition to a rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Tylenol prn.
2. Dulcolax prn.
3. Colace 100 mg p.o. twice a day.
4. Ativan 1/2 mg q. 4 hours prn anxiety.
5. Reglan 10 mg p.o. q 8 hours.
6. Milk of Magnesia 30 mg p.o. q. Six hours prn.
7. Percocet as pain.
8. Pepcid 20 mg p.o. twice a day.
9. Heparin 5000 units subcutaneous three times a day.
10. Ambien 5 mg p.o. q h.s. prn.
DISCHARGE DIAGNOSES:
1. T11 burst fracture of the spine, status post vertebral
fusion.
2. Bilateral pneumothoraces, status post chest tube
placement.
3. Liver laceration, status post repair.
4. Splenic laceration, status post splenectomy.
5. Diaphragm injury, status post repair.
6. Exploratory laparotomy.
7. Hemophilus influenza pneumonia.
8. Left thigh gun shot wound.
9. Multiple chest gunshot wounds.
10. Blood loss anemia.
11. Hypocalcemia.
12. Hypomagnesemia.
13. Paraplegia.
14. Anxiety.
DISCHARGE DIET: House diet as tolerated. The patient should
be given Boost for breakfast, lunch and dinner.
The patient was given hemophilus influenza pneumococcal and
meningococcal vaccines prior to discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Last Name (NamePattern1) 3956**]
MEDQUIST36
D: [**2144-10-26**] 12:09:07
T: [**2144-10-26**] 12:44:05
Job#: [**Job Number 60159**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6144
} | Medical Text: Admission Date: [**2133-9-22**] Discharge Date: [**2133-9-26**]
Date of Birth: [**2072-6-13**] Sex: F
Service: MEDICINE
Allergies:
Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
DKA, UTI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61F w/ PMH DM, CKD (Cr 1.5-1.8), HTN, with recent
hospitalization for DKA/UTI now presenting to ED from PCP with
persistent dysuria, nausea and chills. She was discharged on
cefuroxime based on prior history of pan-sensitive
proteus/ecoli. During that hospitalization, she was noted to
have elevated blood glucose, increased anion gap, and ketones in
urine reflective of DKA thought to be precipitated by the UTI.
She initially received IV insulin and was transitioned to a SC
regimen.
She was discharged on [**9-18**] and notes that that the nausea and
chills returned the following day despite taking cefuroxime [**Hospital1 **]
as directed. She experiences dysuria and myalgias. No hematuria.
No back pain. No recorded fevers. Poor po intake x3 days.
In the ED, initial VS were 96 91 146/100 20 97% ra. She
received 2L NS, 4mg IV zofran, and ciprofloxacin 400mg IV x1 for
UTI (59 wbc, lg leuks, 300 protein, 1000 glu on UA) . She was
noted to have AG of 17 and glucose in the 300s, so was given 10U
regular insulin and started on insulin ggt at 2u/hr. Lactate
was 2.8. K+ was elevated to 6.3 but hemolyzed, and was 4.5 on
green top. WBC was elevated to 12.6 from 7.7 on last d/c.
Pt admitted to MICU for insulin ggt requirement. Access is 2
PIVs. Of note, ED reports that she appears more
somnelent/lethargic on transfer.
Past Medical History:
1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction
Social History:
The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs.
Family History:
Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.5, 188/95, 98, 14, 96% RA
General: obese female lying in bed, somnelent, but [**Last Name (un) **]/oriented
and answering questions
HEENT: dry MM, OP clear, EOM intact, rosy face
Neck: supple, JVP not elevated, no LAD
CV: distant heart sounds but regular, no murmurs
Lungs: distant breath sounds, but clear bilaterally
Abdomen: obese, NT/ND, BS+
GU: foley
Ext: warm, well perfused, 1+ pulses, chronic venous stasis
changes and bilateral erythema of the shins with open ulcers,
multiple toe-amputations
Neuro: moving all extremities, A/O x2 (didn't have date right),
but lethargic
DISCHARGE PHYSICAL EXAM
VS: T97.6 BP 156/60 HR 75 RR 18 O2 sat 98% (RA)
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear, poor dentition
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft obese NT ND normoactive bowel sounds, no r/g
EXT warm, well perfused, 1+ distal pulses, chronic venous stasis
changes and bilateral erythema of lower extremities, multiple
toe-amputations
NEURO CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
[**2133-9-22**] 07:00PM BLOOD WBC-12.6*# RBC-5.18 Hgb-16.1*# Hct-48.8*
MCV-94 MCH-31.0 MCHC-32.9 RDW-13.6 Plt Ct-289
[**2133-9-22**] 07:00PM BLOOD Neuts-89.7* Lymphs-6.5* Monos-2.8 Eos-0.3
Baso-0.6
[**2133-9-22**] 07:00PM BLOOD Glucose-354* UreaN-29* Creat-1.3* Na-133
K-5.9* Cl-97 HCO3-19* AnGap-23*
[**2133-9-22**] 07:00PM BLOOD ALT-18 AST-46* AlkPhos-113* TotBili-0.7
[**2133-9-22**] 07:00PM BLOOD Lipase-16
[**2133-9-22**] 07:00PM BLOOD Albumin-4.2 Calcium-9.8 Phos-5.0*# Mg-1.8
[**2133-9-22**] 08:05PM BLOOD Osmolal-313*
[**2133-9-23**] 01:37AM BLOOD Type-[**Last Name (un) **] pO2-93 pCO2-44 pH-7.36
calTCO2-26 Base XS-0 Comment-GREEN TOP
[**2133-9-22**] 07:11PM BLOOD Glucose-347* Na-133 K-9.9* Cl-101
calHCO3-22
[**2133-9-22**] 07:00PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2133-9-22**] 07:00PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2133-9-22**] 07:00PM URINE RBC-5* WBC-59* Bacteri-FEW Yeast-RARE
Epi-1 TransE-<1
[**2133-9-23**] 06:32PM URINE CastHy-15*
Discharge:
[**2133-9-26**] 08:33AM BLOOD WBC-8.9 RBC-3.88* Hgb-12.0 Hct-36.3
MCV-94 MCH-31.1 MCHC-33.2 RDW-14.0 Plt Ct-259
[**2133-9-26**] 08:33AM BLOOD Glucose-141* UreaN-31* Creat-1.5* Na-143
K-4.1 Cl-106 HCO3-26 AnGap-15
[**2133-9-25**] 07:35AM BLOOD ALT-13 AST-17 AlkPhos-89 TotBili-0.3
[**2133-9-25**] 07:35AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.7
[**2133-9-24**] 08:00AM BLOOD CK-MB-5 cTropnT-0.01
[**2133-9-23**] 04:00PM BLOOD CK-MB-4 cTropnT-0.02*
MICRO:
URINE CULTURE [**9-22**]
URINE CULTURE (Final [**2133-9-23**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
URINE CULTURE (Final [**2133-9-25**]):
YEAST. >100,000 ORGANISMS/ML..
IMAGING:
[**9-23**] FINDINGS: In comparison with the study of [**9-16**], there is
again enlargement of the cardiac silhouette. There is better
penetration of the image, so that there is no evidence of
pulmonary vascular congestion at this time. The lateral view is
limited due to extensive scattered radiation related to the size
of the patient. No acute focal pneumonia.
Brief Hospital Course:
Brief Course:
Ms. [**Known lastname 35127**] is a 61 year old female admitted with diabetic
ketoacidosis (DKA) likely exacerbated by gastroparesis and UTI.
Active Issues:
# DKA: Patient presented with blood sugars in the 300s along
with anion gap metabolic acidosis and ketones in the urine. She
was maintained on an insulin drip and transitioned to
subcutaneous insulin when her anion gap closed. She tolerated
this well and was able to eat. Her precipitant was initially
thought to be due to cellulitis of the left lower leg. Her
outpatient provider reported that her leg looked much more
infected than previously in clinic 1 week prior. We consulted
podiatry about her leg to try to debride the chronic ulcers and
get culture data, but they did not think that the ulcers
warranted debridement. We felt the her leg exam was more
consistent with venous stasis changes than cellulitis. She
endorsed dysuria, however repeated urinalyses and urine cultures
showed contaminated from normal flora and yeast. We treated the
patient with 4 days of 1V ceftriaxone, based on prior culture
date. Her CXR was negative and her EKG was at baseline. She
did have a severe candidiasis of the intertriginous region of
her groin which may have contributed to her DKA. We treated her
with miconazole and a dose of fluconazole. [**Last Name (un) **] was consulted
to help transition to outpatient insulin regimen.
# Nausea and vomiting: Has been chronic for several months and
has prompted several admissions to the hospital for symptomatic
management. Likely also contributes to her DKA. She was
started on metoclopromide empirically and phenergan prn. She
has never had a work-up for gastroparesis but her symptoms would
fit with this and would help explain her difficult to control
blood sugars. She was discharged on metoclopramide and should
follow up with her PCP about continuing this medication. A
gastric emptying study can be considered as an outpatient.
# HTN: Patient hypertensive to the 170s-180s even after
restarting her home losartan and hydrochlorothiazide. Thus, she
was started on labetalol 200 mg [**Hospital1 **]. She will follow up with her
PCP about further HTN management.
# Lower extremity ulcers: Chronic appearing, likely secondary
to peripheral vascular disease and diabetes. Has element of
chronic venous stasis which can be confused with cellulitis but
she did not have evidence on exam of real cellulitis.
# Flattened affect: Had a recent head CT which was negative,
her neurologic exam was non-focal. She is slow to answer
questions and has a flattened affect which is likely her
baseline. Her nortriptyline was held initially but restarted on
discharge.
# Yeast infection: Likely in setting of poor glycemic control.
Was given miconazole powder and treated with 1 dose of
fluconazole.
# Chronic kidney disease: Stable. On admission Cr 1.3, within
recent baseline. Medications were renally dosed.
Transitional Issues:
1. Codes Status: DNR/DNO
2. Communication: patient
3. Medication Changes:
-CHANGE your Humalog sliding scale according to the attached
sheet
-START Labetolol for your high blood pressure
-START Metoclopramide for your gastroparesis. But please follow
up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**] to see if you should continue this
medicine long term.
4. Pending studies: fungal urine culture
5. Follow up: PCP, [**Name10 (NameIs) **], Podiatry
Medications on Admission:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Nortriptyline 150 mg PO HS
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Vitamin D 50,000 UNIT PO MONTHLY
7. cefUROXime 500 mg [**Hospital1 **]
8. Detemir 70 Units Bedtime
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Rosuvastatin Calcium 20 mg PO DAILY
4. Nortriptyline 150 mg PO HS
5. Pantoprazole 40 mg PO Q24H
6. Vitamin D 50,000 UNIT PO MONTHLY
7. Detemir 70 Units Bedtime
8. Labetalol 200 mg PO BID
hold for systolic blood pressure < 130
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
9. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth QIDACHS Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary:
DKA
UTI
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. [**Known lastname 35127**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
because you weren't feeling well and your glucose level was
found to be very high, and you were in DKA. We were able to
control your blood sugar and we made some adjustments to your
insulin regimen. You also were found to have a UTI which may
have been the same infection as your last admission that never
fully resolved. You were treated with antibiotics through your
veins.
Please make the following changes to your medications:
-CHANGE your Humalog sliding scale according to the attached
sheet
-START Labetolol for your high blood pressure
-START Metoclopramide for your gastroparesis. But please follow
up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**] to see if you should continue this
medicine long term.
Please call [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3146**] [**Location (un) 4628**] Services at [**Telephone/Fax (1) 35130**] to
arrange a home health aid that can help with bathing and wound
care.
Followup Instructions:
Please follow up with the following appointment:
Department: PODIATRY
When: MONDAY [**2133-9-28**] at 8:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Last Name (LF) **], [**First Name3 (LF) **]. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appointment Monday [**2133-9-28**] 10:00am
Department: ADULT MEDICINE
When: THURSDAY [**2133-10-1**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], MD [**Telephone/Fax (1) 6662**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2133-9-27**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6145
} | Medical Text: Service: CARDIAC S. Date: [**2181-11-22**]
Surgeon: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
HISTORY OF THE PRESENT ILLNESS: This is a 77-year-old
retired anesthesiologist visiting the family from [**State 531**],
who was admitted to [**Hospital1 36651**]
after the patient noted rales in his chest with chest
pressure. In the ER the patient was found to be in acute
pulmonary edema. The patient was treated with Morphine,
sublingual nitroglycerin, Lasix, and aspirin, with subsequent
bradycardia and hypotension. Hemodynamic stability returned
after IV fluids. The EKG in the ER showed 2-mm to 3-mm ST
depression in leads V4 through V6, as well lead 2.
Subsequent EKGs showed 5-mm ST depression in leads V2 through
V6 and leads 2, 3, and AVF. The patient was admitted to the
hospital for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
4. Benign prostatic hypertrophy.
5. Status post cataract surgery.
PREOPERATIVE MEDICATIONS:
1. Toprol XL 100 mg p.o.q.d.
2. Accupril 20 mg p.o.q.d.
3. Aspirin 325 mg p.o.q.d.
4. Pravachol 10 mg p.o.q.d.
5. Cardura 8 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Initial physical examination revealed
the pulse 85; blood pressure 104/64; oxygen saturation 94% on
four liters nasal cannula. GENERAL: The patient's general
appearance is comfortable. NECK: Elevated JVP at 9-cm.
CHEST: Crackles bilaterally 2/3rds of the way up, right
greater than left. CARDIOVASCULAR: Normal S1 and S2; 2/6
systolic murmur at the apex. EXTREMITIES: Dorsalis pedis
pulses are 2+ bilaterally. Extremities are without edema.;
ABDOMEN: Positive bowel sounds, soft, and nontender.
LABORATORY DATA: Data revealed the following: White blood
cell count 8.0; hematocrit 38.3; platelet count 130; Chem 7
sodium 139; potassium 3.8; chloride 101; bicarbonate 29; BUN
25, creatinine 1.1; blood sugar 151; PT 12.9; PTT 30.2.
Chest x-ray showed severe pulmonary edema, asymmetrical,
right greater than left.
HOSPITAL COURSE: The patient was taken to the Cardiac
Catheterization Laboratory on [**2181-11-16**]. Cardiac
catheterization showed EF of 45% with anterior-wall
hypokinesis, 70% LAD lesion, 100% old left circumflex lesion,
80% PDA lesion, 1+ MR. The patient underwent echocardiogram
on [**2181-11-16**], which showed a mildly dilated left atrium,
depressed left ventricular function with global left
ventricular hypokinesis, 1+ AR, 1+ MR.
The patient remained in the Coronary Care Unit for diuresis
and monitoring. The patient was taken the operating room on
[**2181-11-19**] with Dr. [**Last Name (STitle) **]. The patient underwent a CABG
times three, LIMA to the LAD, SVG to RCA, SVG to OM. The
patient was transferred to the Intensive Care Unit in stable
condition on Dopamine infusion at 5 mcg/kg per minute.
Please see operative note for further details. The patient
was weaned and extubated from mechanical ventilation on his
first postoperative evening. Dobutamine infusion was weaned
off with the cardiac index greater than three. The patient
was transferred from the Intensive Care Unit to the floor on
postoperative #1. The patient's chest tubes were removed on
postoperative day #1. The patient began working with
physical therapy. On postoperative day #2, the patient was
able to ambulate 500 feet and climb one flight of stairs
without any assistance. The patient was cleared for
discharge by the Physical Therapy Department. On
postoperative day #3, the patient was cleared for discharge
to home with his daughter.
On postoperative day #3, the patient was noted to be mildly
tachycardiac with rates in the 90s to 100s, sinus rhythm.
The patient's hematocrit, at that time, was 23.4. This was
discussed with Dr. [**Last Name (STitle) **]. The patient was hemodynamically
stable and not symptomatic from his anemia. It was decided
to discharge the patient on his current dose of Lopressor.
The patient is to followup in one week for adjustment of
medications, as necessary.
CONDITION ON DISCHARGE: Temperature maximum 99; temperature
current 99.1; pulse 93 sinus rhythm with occasional PVCs;
blood pressure 126/76; room air oxygen saturation 97%. The
patient's weight on [**2181-11-22**] was 73.5 kg. The patient's
preoperative weight was 69 kg. The patient is neurologically
intact. Cardiovascular: Regular rate and rhythm, positive
rubs, no audible murmur. Respiratory rate: Breath sounds
are clear bilaterally. GI: The patient has positive bowel
sounds. Abdomen: Soft, nontender, nondistended. The
patient is tolerating a regular diet. The patient has trace
lower extremity edema. Sternal incision staples are intact.
The wound is clean, dry, and intact. There is no erythema or
drainage noted. The patient's appendectomy site is clean and
dry without erythema or drainage noted.
LABORATORY DATA: Data revealed the following: White blood
cell count 8.8; hematocrit 23.4; platelet count 129. The
Chem 7 revealed sodium 140, potassium 4.2, chloride 103,
bicarbonate 31, BUN 15, creatinine 0.8.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft.
2. Hypertension.
3. Hypercholesterolemia.
4. Benign prostatic hypertrophy.
5. Status post cataract surgery.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o.b.i.d.
2. Pravachol 10 mg p.o.q.h.s.
3. Niferex 150 mg p.o.q.d.
4. Colace 100 mg p.o.b.i.d.
5. Lasix 20 mg p.o.q.d. times two weeks.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o.q.d. times two weeks.
7. Aspirin 325 mg p.o.q.d.
8. Ibuprofen 400 to 600 mg p.o., q.4-6h., p.r.n.
The patient inquired about restarting his Cardura, which he
was on preoperatively for benign prostatic hypertrophy. The
patient was told that he should wait several days before
resuming the medication to ensure that his blood pressure and
hemodynamics remained stable on his current medication
regimen.
The patient is to followup with Dr. [**Last Name (STitle) **] in three to four
weeks. The patient is to return to the Clinic in two weeks
for wound check and staple removal. The patient is to
followup with his cardiologist in three to four weeks at
home.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2181-11-22**] 10:51
T: [**2181-11-22**] 10:51
JOB#: [**Job Number 36652**]
ICD9 Codes: 4280, 4240, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6146
} | Medical Text: Admission Date: [**2189-7-15**] Discharge Date: [**2189-7-17**]
Date of Birth: [**2130-5-18**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
[**2189-7-15**] Right craniotomy resection of right temporal tumor
History of Present Illness:
[**Known firstname 553**] [**Known lastname 100149**] is a pleasant 59-year-old right-handed female who
presents with a brain tumor, which was diagnosed last Wednesday.
She had a significant
headache and imbalance since [**6-30**] and an MRI scan of the brain
showed the right temporal lobe lesion and a right occipital lobe
mass. She also had a chest x-ray which showed a right upper
lobe mass.
At this point, her MRI scan of the brain shows a fairly large
brain tumor located in the right temporal lobe which measures at
least 4 cm with mass effect and right uncal herniation. At this
point, this scan is already a week old and I feel that she would
have progressed. I did schedule her for surgery tomorrow and I
advised her that surgery should be done at the earliest. She,
however, would like a second opinion from [**Hospital1 4601**] and will
get back to us after her second opinion. At this point, I have
also started her on Keppra given the risk of seizures and as a
preoperative adjunct therapy.
Past Medical History:
Past medical history is significant for bipolar disorder.
Social History:
Social History: She is divorced and lives alone. Her father
died at age 82. She works part-time as a waitress and she has
been smoking for the past 40 years. Her mother has a history of
meningioma and uncle had a brain tumor.
Family History:
NC
Physical Exam:
On examination, her blood pressure was 140/80, heart rate was 80
per minute. She is awake, alert, excitable, oriented x3. Her
pupils are equal and reacting to light. Extraocular movements
are full. Facial sensation and movement is symmetric. Her
palate elevation is symmetric. Shoulder shrug with good
strength
bilaterally. Tongue is in the midline. Her motor strength is
[**3-21**] in all 4 extremities. Reflexes were [**12-20**]. Her gait and
coordination was normal.
PHYSICAL EXAM UPON DISCHARGE:
non focal
incision- sutures c/d/i
Pertinent Results:
[**7-15**] MRI BRAIN: IMPRESSION: Right temporal hyperintense mass
and unchanged from prior study. Examination performed for
surgical planning.
[**7-15**] CT Head: IMPRESSION:
1. Immediately status post right frontotemporal craniotomy and
resection of the relatively large right temporal lobar mass,
with expected post-surgical changes in the region.
2. Small amount of intra- and extra-axial blood in the
resection bed, without organized collection or significant mass
effect.
3. Superimposed on the preexistent vasogenic edema, there is a
rounded
low-attenuation region, immediately deep to the resection
cavity; while
re-expansion of the subjacent temporal [**Doctor Last Name 534**] is likely, a
contribution of small post-operative infarct at this site is an
additional consideration.
[**7-16**] MRI Brain:
Brief Hospital Course:
Patient was admitted to Neurosurgery on [**2189-7-15**] and underwent
the above stated procedure. Please review dictated operative
report for details. Patient was extubated without incident. She
was transfered to the SICU. CT head showed no hemorrhage. She
was neurologically stable on [**7-16**] and was transfered to the
floor. MRI imaging showed good resection.
She was seen by physical therapy for discharge planning. They
recommended discharge home.
Now DOD, patient is afebrile, VSS, and neurologically stable.
Patient's pain is well-controlled and the patient is tolerating
a good oral diet. Pt's incision is clean, dry and intact
without evidence of infection. Patient is ambulating without
issues. She is set for discharge home in stable condition and
will follow-up accordingly.
Medications on Admission:
Medications currently are bupropion, dexamethasone,
ergocalciferol, paroxetine, penicillin, triamcinolone, coenzyme
Q10, flaxseed oil, and multivitamin.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain, headache
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Famotidine 20 mg PO BID
RX *famotidine [Acid Controller] 20 mg 1 tablet(s) by mouth
twice a day Disp #*14 Tablet Refills:*0
5. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth q4hrs prn Disp
#*60 Tablet Refills:*0
8. Paxil CR *NF* (PARoxetine HCl) 12.5 mg Oral daily
* Patient Taking Own Meds *
9. Wellbutrin XL *NF* (buPROPion HCl) 150 mg ORAL QAM
* Patient Taking Own Meds *
10. Cephalexin 1000 mg PO Q12H Duration: 5 Days
RX *cephalexin 500 mg 2 capsule(s) by mouth twice a day Disp
#*10 Capsule Refills:*0
11. Dexamethasone 2 mg po q6h Duration: 1 Days
RX *dexamethasone 1 mg taper tablet(s) by mouth taper Disp #*22
Tablet Refills:*0
12. Dexamethasone 2 mg po q12 Duration: 2 Days Start: After 2 mg
tapered dose.
13. Dexamethasone 1 mg po q12 Duration: 2 Days Start: After 2 mg
tapered dose.
14. Dexamethasone 1 mg po q24 Duration: 2 Days Start: After 1 mg
tapered dose.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
right temporal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? 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 discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to the office in [**5-26**] days(from your date of
surgery) for removal of your 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 [**2189-8-10**]
@ 4pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2189-7-17**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6147
} | Medical Text: Admission Date: [**2119-9-8**] Discharge Date: [**2119-9-17**]
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
gentleman with a history of chronic obstructive pulmonary
disease, also with a history of hypertension and chronic
obstructive pulmonary disease, who had the sudden onset of
shortness of breath at approximately 4 p.m. today that was
refractory to his usual inhalers.
Per Emergency Medical Service notes, no chest pain or recent
illnesses. His systolic blood pressure was 240/120,
respiratory rate was 30, and his oxygen saturation was 92% on
a nonrebreather. En route to [**Hospital 882**] Hospital the patient
was given, nitroglycerin, Ativan, and supplemental oxygen.
At [**Hospital 882**] Hospital the patient was noted to be diaphoretic
but could communicate. Improved breathing to 100% on
nonrebreather. Initial arterial blood gas was 7.18/100/499 on
100% nonrebreather and was electively intubated despite the
clinical improvement.
Vital signs revealed the patient's blood pressure was
220/100, his respiratory rate was 32 to 40, and his oxygen
saturation was 92% on nonrebreather. The patient's white
blood cell count was 18 with 2 bands. His hematocrit was 45.
His bicarbonate was 37. Creatine phosphokinase and troponin
levels were negative. Electrocardiogram there showed sinus
tachycardia. No ST changes. Orogastric tube and Foley
catheter were placed and showed poor urine output. The
patient was given intravenous Lasix. A chest x-ray was
consistent with chronic obstructive pulmonary disease. The
patient had blood cultures, urine cultures, and sputum
cultures sent. The patient was given intravenous Levaquin
500 mg, intravenous Solu-Medrol 125 mg total, Ativan 7 mg,
and approximately 7 liters of normal saline. A repeat
arterial blood gas was 7.28/73/118.
The patient was transferred to [**Hospital1 188**] Emergency Department where he arrived intubated and
sedated He was afebrile. The patient's blood pressure was
91/65, tachycardic to 120, his heart rate was 97, his
respiratory rate was 14, and his oxygen saturation was 94% on
an FIO2 of 0.4. His chest x-ray showed no acute infiltrates.
The patient was given 500 mg intravenous Flagyl and 2 mg of
Ativan, and his ventilator was set synchronized intermittent
mandatory ventilation pressure support 5, positive
end-expiratory pressure 5, volume 600, rate 14, and FIO2 of
0.4. Arterial blood gas was 7.32/58/112. Thick tan
secretions were obtained.
Of note, the patient is normally cared for at the [**Hospital6 50626**] Center, and his medical records there
are more detailed.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Hypertension.
3. Diastolic heart failure.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide.
2. Colace.
3. Tylenol.
4. Atrovent.
5. Albuterol.
6. Prednisone.
7. Theophylline.
8. Potassium.
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives [**Location (un) 6409**] with his wife
of many years. An extensive history of smoking. The patient
has not drank alcohol in many years.
PHYSICAL EXAMINATION ON PRESENTATION: In general, the
patient was intubated and sedated. The patient's temperature
was 95.8 degrees Fahrenheit, his heart rate was 102, his
blood pressure was 108/71, his respiratory rate was 14, and
his oxygen saturation was 100%. Head, eyes, ears, nose, and
throat examination revealed pupils 2 mm and equally reactive.
Neck examination revealed no lymphadenopathy. Cardiovascular
examination revealed a regular rate and rhythm. First heart
sounds and second heart sounds were very distant. No
murmurs, rubs, or gallops. Pulmonary examination revealed
clear to auscultation anteriorly and laterally. No wheezes.
Abdominal examination revealed the abdomen was obese,
moderately distended, with midline surgical scars. Extremity
examination revealed the extremities were warm. There was
trace bilateral edema. No clubbing. Neurologic examination
revealed the patient was intubated and sedated. Skin
examination revealed no lesions or rashes.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed the patient's white blood cell count was
18.2, his hematocrit was 45.7, and his platelets were 512.
Differential revealed neutrophils of 82, lymphocytes of 10,
bands of 3. His INR was 1.7. His partial thromboplastin
time was 29.7. Sodium was 141, potassium was 4.2, chloride
was 97, bicarbonate was 37, blood urea nitrogen was 20,
creatinine was 0.6, and his blood glucose was 202. Total
protein was 7.3. His albumin was 4. His total bilirubin was
0.3, his alkaline phosphatase was 71, his AST was 30, and his
ALT was 33. Creatine kinase was 95. Troponin T was less
than 0.01.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed
endotracheal tube was in place, biapical bolus, diaphragmatic
flattening, bibasilar atelectasis, small bilateral pleural
effusions.
Electrocardiogram revealed sinus tachycardia at 120 beats per
minute. Normal axis. Early repolarization. Normal
intervals. Inferolateral T wave flattening.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is an 83-year-old gentleman with hypercarbic
respiratory failure in the setting of a chronic obstructive
pulmonary disease exacerbation complicated by diastolic heart
failure, hypertension, and a pneumonia.
1. RESPIRATORY FAILURE ISSUES: The patient was intubated
for respiratory acidosis and hypoxemia for retained
secretions most likely due to a chronic obstructive pulmonary
disease exacerbation.
Several trials have been made to optimize his blood pressure
and heart rate which were unsuccessful and then being able to
extubate him upon awakening. The patient had very labile
hypertension where his systolic blood pressures would go from
the 120s to 130s and all the way up to the 200s.
The patient was started on Lopressor and removed all of his
diltiazem to control his heart rate, and the patient was
started on captopril to control his blood pressure. Trials
using diltiazem drips and nitroglycerin to control his blood
pressure and heart rates were unsuccessful.
On [**9-16**], the patient became profoundly hypotensive, so
at this time the cardiac medications were being held. The
patient has been receiving fluid boluses with target central
venous pressures of 12.
2. PNEUMONIA ISSUES: The patient grew out Staphylococcus
aureus (coagulase-positive) from two sputum cultures which at
this time is being treated with a course of oxacillin for 14
days. The patient is currently on day four.
3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE/BRONCHITIS ISSUES:
the patient was continued on Solu-Medrol, Atrovent, and
albuterol for his chronic obstructive pulmonary disease and
bronchitis flare. He received a 7-day course also of
Levaquin, but no pathogens were grown out except the
Staphylococcus aureus from his sputum, for which he was
placed on oxacillin.
4. MILD CONGESTIVE HEART FAILURE ISSUES: The patient had an
echocardiogram which showed the left ventricular cavity size
was normal and regional left ventricular wall motion was
normal. His overall ejection fraction was greater than 55%.
The aortic root was moderately dilated. The tricuspid and
aortic valves were structurally normal. Trivial mitral
regurgitation.
Therefore, the patient was felt to be in diastolic heart
failure and optimizing of his blood pressure and heart rate
were attempted to be obtained before extubation so that he
would try to prevent flash pulmonary edema which we thought
might be leading to him having wheezes rather than just his
chronic obstructive pulmonary disease exacerbation.
5. HYPOTENSION ISSUES: On [**9-16**], the patient became
profoundly hypotensive. It was felt to be unclear whether he
was volume depleted or had been septic. Blood cultures were
sent and were still pending. The patient received several
fluid boluses with goals of obtaining a central venous
pressure of 12, and his hypertensive medications were held.
CONDITION AT DISCHARGE: The patient was still intubated and
in the Medical Intensive Care Unit. This is an interval
Discharge Summary. The patient is currently hypotensive from
an unclear etiology.
DISCHARGE STATUS: The patient is still in the Medical
Intensive Care Unit at [**Hospital1 69**].
MEDICATIONS ON DISCHARGE: Deferred.
DISCHARGE INSTRUCTIONS/FOLLOWUP: Deferred.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Name8 (MD) 26705**]
MEDQUIST36
D: [**2119-9-16**] 13:34
T: [**2119-9-16**] 14:21
JOB#: [**Job Number 50627**]
ICD9 Codes: 4280, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6148
} | Medical Text: Admission Date: [**2184-7-28**] Discharge Date: [**2184-8-10**]
Date of Birth: [**2119-1-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain, SOB
Major Surgical or Invasive Procedure:
AVR(#21mm CE Magna)/MVR(#29mm St.[**Male First Name (un) 923**] Epic)/TV repair (#28mm CE
MC3ring)/Coronary Artery Bypass Grafting x 4(Left internal
mammary artery grafted to left anterior descending/Saphenous
vein grafted to Diag/OM2/PDA)-[**2184-8-2**]
History of Present Illness:
Mr. [**Known lastname 24481**] is an Italian-speaking 65 yo male with HTN and
50+ pack-year smoking history who has not been seen by a
physician [**Name Initial (PRE) **] 1.5 years, presented to the ED with 1 day of SOB,
diaphoresis and CP. He began to feel diaphoretic and short of
breath while at work as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. When the symptoms did not
resolve with rest, he left work early and went home. There, he
describes feeling CP that he describes as "squeezing," [**8-13**],
non-radiating and not relieved with rest, which led him to take
an ambulance to the ED.
He reports frequent SOB and occasional CP on exertion at
baseline for at least the past year, which he says normally
resolves with rest, although he does endorse occasional SOB at
rest. He attributes these symptoms to his age and smoking. He
also notes a chronic cough over the past year, which he
attributes to his smoking, and denies any recent worsening of
the cough.
EKG showed inferior Q waves, TWI and ST depressions. CXR showed
pulmonary edema anmd and CEs were elevated with troponin 3.13.
He was loaded with plavix 600mg, received one full dose ASA and
started on heparin gtt.
He was sent to the cath lab for angiography which showed severe
LM/3VD. A Swan-Ganz catheter was placed and showed low cardiac
index (1.4). A TTE was performed in the cath lab which revealed
inferior and inferoseptal hypokinesis, normal RV function,
significant AS, 4+ MR, 3+TR, LVEF 35% and moderate pulmonary
HTN. An IABP was placed. Dr.[**Last Name (STitle) 914**] was consulted for coronary
revascularization and valvular replacement.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, Dyslipidemia, +tobacco
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
-Patient denies any other PMH but per OMR, h/o PUD.
HTN
Erectile Dysfunction
no medical care for many years
Social History:
He is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in [**Location (un) 4310**] and lives with his wife in [**Location (un) 686**].
-Tobacco history: 1-1.5ppd for 30+ years, still smoking
-ETOH: social
Family History:
-Mother with a "large heart" from a young age, died of heart
disease at 66
-Father diagnosed with DM2 in his 50s, died at 74
-Brother with CVA, liver disease diagnosed in his 50s
Physical Exam:
VS: T= 99.8 BP= 114/63 HR= 87 RR= 23 O2 sat= 96% 2L NC
GENERAL: WDWN Male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with 5cm JVP, but with bed flat due to IABP.
CARDIAC: RR, with mechanical sounds.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ PT 2+ DP by doppler
Left: Carotid 2+ PT 2+ DP by doppler
Pertinent Results:
CXR [**2184-7-28**]: Single AP chest radiograph without comparison shows
moderate interstitial pulmonary edema. The heart size is
probably top normal. There is no pneumothorax or large pleural
effusions.
IMPRESSION: Moderate interstitial pulmonary edema.
.
EKG [**2184-7-28**], 10:48:24: sinus tachycardia at 110 bpm with some
LAD, normal intervals, notable for Q waves in II, III, aVF; deep
TWI in II, III, aVF; 1mm STD in I, aVL.
.
2D-ECHOCARDIOGRAM:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with near akinesis of the
inferior and inferoseptal walls. The remaining segments contract
normally (LVEF = 35 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] The aortic valve leaflets are
moderately thickened. Significant aortic stenosis is present
(not quantified - ? Mild-moderate)). Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Severe
(4+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD. Severe mitral regurgitation.
Moderate pulmonary artery systolic hypertension. Moderate to
severe tricuspid regurgitation. If clinically indicated, a TEE
would be able to better identify a potential mechanical problem
with the mitral valve (I.e., flail leaflet or partial papillary
muscle rupture as the cause of the mitral regurgitation).
CAROTID U/S ([**7-29**]): Impression: Right ICA stenosis <40%.
Left ICA stenosis <40%.
[**2184-8-10**] 05:30AM BLOOD WBC-11.1* RBC-3.68* Hgb-10.2* Hct-31.2*
MCV-85 MCH-27.8 MCHC-32.8 RDW-15.4 Plt Ct-320
[**2184-7-28**] 10:28AM BLOOD WBC-13.8* RBC-4.80 Hgb-12.5* Hct-38.2*
MCV-80* MCH-26.1* MCHC-32.7 RDW-14.0 Plt Ct-266
[**2184-8-10**] 05:30AM BLOOD PT-19.1* INR(PT)-1.7*
[**2184-7-28**] 10:28AM BLOOD PT-15.2* PTT-25.6 INR(PT)-1.3*
[**2184-8-9**] 05:25AM BLOOD Glucose-100 UreaN-27* Creat-0.9 Na-138
K-4.3 Cl-100 HCO3-30 AnGap-12
[**2184-7-28**] 10:28AM BLOOD Glucose-134* UreaN-22* Creat-1.1 Na-134
K-4.6 Cl-98 HCO3-22 AnGap-19
Brief Hospital Course:
65yo Italian-speaking male was taken to the operating room and
underwent AVR(#21mm CE Magna)/MVR(#29mm St.[**Male First Name (un) 923**] Epic)/TV repair
(#28mm CE MC3ring)/Coronary Artery Bypass Grafting x 4(Left
internal mammary artery grafted to left anterior
descending/Saphenous vein grafted to Diag/OM2/PDA)-[**2184-8-2**].
Cross clamp time= 192 minutes. Cardiopulmonary bypass time=230
minutes. Please refer to Dr[**Last Name (STitle) 5305**] operative report for
further details. He tolerated the procedure well and was
transferred to the CVICU in critical but stable condition
requiring multiple pressors and Milrinone to optimize cardiac
output.The intra-aortic balloon pump, placed preop, was
discontinued on POD#1.He awoke neurologically intact and was
extubated on POD#2. Drips were weaned off. Lines and tubes were
discontinued in a timely fashion.Beta-blocker and diuresis was
initiated. He continued to progress and was transferred to the
step down unit for further monitoring on POD#5. Dental was
consulted regarding Mr.[**Known lastname 24482**] ill-maintained lower teeth.
Amoxicillin was empirically initiated and recommended to
continue until dental extraction is completed as an outpatient.
Coumadin was started for low dose anticoagulation secondary to
the double tissue valves and tricupsid ring. On day of
discharge, Coumadin was held and the patient's daughter was
instructed that Mr.[**Known lastname 24481**] should hold off taking Coumadin
until the dental procedure is complete. Once Coumadin is
restarted, it is to be continued for 2 months. Dr.[**Last Name (STitle) **],
Cardiology, will follow the INR/Coumadin dosing. The remainder
of his postoperative course was essentially uneventful. On POD#
8, Mr.[**Known lastname 24481**] was cleared by Dr.[**Last Name (STitle) 914**] for discharge to home
with VNA. All follow up appointments were advised.
Medications on Admission:
Medications at home:
Enalapril 10 mg daily
Viagra 50mg PRN
Discharge Medications:
1. Aspirin 81 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Last Name (STitle) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atorvastatin 80 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY
(Daily).
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
4. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
Disp:*60 Packet(s)* Refills:*2*
5. Warfarin 1 mg [**Last Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM: **Do not resume until Dental procedure completed. Than x
2months.
Disp:*90 [**Last Name (Titles) 8426**](s)* Refills:*2*
6. Ranitidine HCl 150 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2
times a day): x 2 months (while on Coumadin).
Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg [**Last Name (Titles) 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 [**Last Name (Titles) 8426**](s)* Refills:*0*
8. Furosemide 80 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO DAILY (Daily).
Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2*
9. Carvedilol 12.5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times
a day).
Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2*
10. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours): Continue until Dental procedure completed.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
MR
[**First Name (Titles) **]
[**Last Name (Titles) **]
s/p CABG/AVR/MVR/TVr
HTN
Erectile Dysfunction
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
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:
***Your chest CT scan showed some small nodules. This should be
followed up with a repeat scan in 6 weeks to ensure that the
nodules have improved. You can arrange this through your primary
care doctor or when you follow-up with your cardiologist.***
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], please call for appointment
([**Telephone/Fax (1) 7976**]in 1 week
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-9**] weeks ([**Telephone/Fax (1) 62**]) please call for
appointment
**Please have dental extractions done as soon as can be arranged
**Dr.[**Last Name (STitle) **] to follow INR/Coumadin dosing (once resumed after
dental extractions)x 2months, than Coumadin to be discontinued
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2184-8-10**]
ICD9 Codes: 4280, 5859, 2859, 412, 4168, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6149
} | Medical Text: Admission Date: [**2111-3-9**] Discharge Date: [**2111-3-16**]
Date of Birth: [**2034-3-11**] Sex: M
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old
male with a history of insulin dependent diabetes who was
admitted to outside hospital on [**2111-3-6**] following a
cardiac catheterization showing a ______ and three vessel
coronary artery disease. The patient has been
hemodynamically stable and chest pain free since the
catheterization. Chest x-ray on admission showed a left
lower lobe mass versus atelectasis. CT scan on [**3-7**]
showed superficial opacity at the left lung base measuring
2.5 cm at maximum diameter. The patient was seen by
pulmonary and infectious disease who felt that the patient's
coronary artery disease should be addressed primarily and
follow up CT scan in one month. The patient is now
transferred to [**Hospital1 69**] for
evaluation of coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. Noninsulin dependent diabetes mellitus.
2. Status post colectomy for colon cancer in the year [**2107**].
3. Irritable bowel syndrome.
4. Hiatal hernia status post right inguinal hernia repair.
5. Status post right hydrocele removal.
SOCIAL HISTORY: Lives with wife. Retired electrician. The
patient smokes one to two cigars per week for the past four
or five years. Quit 24 years ago. The patient denies use of
alcohol.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Asacol 800 mg po t.i.d.
2. Lopressor 12.5 mg po b.i.d.
3. Enteric coated aspirin 325 mg po q day.
4. Glucotrol 20 mg po q.d.
5. Regular insulin sliding scale.
6. Metformin at home.
REVIEW OF SYSTEMS: The patient denies chest pain, fevers or
chills, nausea, vomiting, abdominal pain, melena, denies
hematochezia, denies dysuria.
PHYSICAL EXAMINATION: Temperature 97. Blood pressure
120/70. Heart rate 80. Respiratory rate 18. Satting 96% on
room air. The patient is alert and oriented and in no acute
distress. Extraocular movements intact. Pupils are equal,
round and reactive to light. The patient had no lesions in
the mouth. The patient's head was normocephalic, atraumatic.
Examination of the neck revealed no lymphadenopathy. No JVD.
No bruits. Chest was clear to auscultation bilaterally.
Heart revealed a regular rate and rhythm without any murmurs,
rubs or gallops. Examination of the abdomen revealed soft,
nontender, nondistended abdomen. No hepatosplenomegaly. No
splenomegaly. The patient had a surgical scar in the right
lower quadrant. The patient's extremities had no clubbing,
cyanosis or edema. The patient had 2+ pulses bilaterally,
femoral, popliteal, dorsalis pedis and posterior tibial.
Cranial nerves II through [**Doctor First Name 81**] were grossly intact.
Extremities sensory and motor were intact.
LABORATORY: White blood cell count on admission was 10.9,
hematocrit 37.3, platelets 521, INR 1.1, sodium 139,
potassium 4.3, chloride 101, bicarb 29, BUN 26, creatinine 1,
glucose 192.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Surgery Service and underwent coronary artery bypass graft
times three. The patient had a left internal mammary
coronary artery to the left anterior descending coronary
artery, saphenous vein graft to obtuse marginal, saphenous
vein graft to posterior descending coronary artery. On
postoperative day number one the patient was extubated and
remained afebrile with stable vital signs. On postoperative
Vancomycin and on insulin drip to control the glucose.
Otherwise the patient was doing well. On postoperative day
number two the patient continued to do well. The patient was
completely weaned off all drips. The patient was put back on
home regimen for glucose control. He remained afebrile with
stable vital signs. The patient continued to do well and was
transferred to the floor. Overnight the patient had a bout
of delirium. The patient had a sitter and was put on low
dose Haldol. On postoperative day number three the patient
continued to do well. The patient was on Lopressor 50 mg
b.i.d. and remained afebrile with stable vital signs. The
patient had good urine output. The patient's wire was
removed and the patient was continued with a sitter for
confusion. On postoperative day number four the patient
continued to have bouts of confusion, although improved.
Urinalysis was negative. The patient remained afebrile with
stable vital signs. Physical therapy worked with the
patient. A standing dose of Haldol was stopped and put on
Captopril and obtained a PA and lateral chest x-ray, which
revealed small pleural effusion. No pneumo. On
postoperative day number five the patient continued to do
well. The patient had eight beats of ventricular tachycardia
overnight, which was asymptomatic. EP was consulted who
recommended to replete the electrolytes and to do regular
follow up with patient's cardiolgoist since the patient has
no history of myocardial infarction or signs of ischemia on
electrocardiogram. The patient continued to do well.
On postoperative day number six the patient had no
complaints. Remained afebrile with a blood pressure of
149/76 and a pulse of 80. The patient's Metoprolol was
increased to 75 b.i.d. The patient was taking good po and
making good urine. The patient was discharged to home.
CONDITION ON DISCHARGE: Good.
DISPOSITION: Discharged to home.
FINAL DIAGNOSES:
1. Status post coronary artery bypass graft.
2. Coronary artery disease.
3. Status post colectomy for colon cancer in [**2107**].
4. Noninsulin dependent diabetes mellitus.
5. Irritable bowel syndrome.
6. Hiatal hernia status post right inguinal hernia repair.
7. Status post right hydrocele removal.
8. Lung nodule on x-ray.
FO[**Last Name (STitle) 996**]P PLANS: Please follow up with Dr. [**Last Name (Prefixes) **] in
four weeks. Please follow up with primary care physician and
Dr. [**Last Name (STitle) 1655**] in one to two weeks.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q.d.
2. Colace 100 mg po b.i.d.
3. Asacol 800 mg po t.i.d.
4. Glipizide 20 mg po q day.
5. Metformin 1000 mg po q.a.m., 500 mg po q.p.m.
6. Captopril 6.725 mg po t.i.d.
7. Percocet one to two tabs po q 4 to 6 hours.
8. Lopressor 75 mg po b.i.d.
9. Sliding scale insulin.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3118**]
MEDQUIST36
D: [**2111-3-16**] 09:06
T: [**2111-3-16**] 09:22
JOB#: [**Job Number 52591**]
ICD9 Codes: 9971, 4271, 2930, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6150
} | Medical Text: Admission Date: [**2130-4-25**] Discharge Date: [**2130-4-29**]
Date of Birth: [**2055-11-16**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Crestor / Lipitor / Fosamax
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Nausea, diaphoresis
Major Surgical or Invasive Procedure:
Cardiac catheterization
PCI to RCA
History of Present Illness:
74F with hx of recent right TKR on Lovenox presents with STEMI.
She states that around 4:30am, she had been up watching TV and
didn't feel herself. She walked to the bathroom and found
herself very pale and diaphoretic. She started feeling dizzy and
nauseous. BP checked by the nurses and found to be 60/40 with a
heart rate of 40. EMS was called and on arrival, did EKG that
showed 2mm ST elevations in II, III, aVF. She was given ASA
325mg and NTG x 1 and transferred to [**Hospital1 18**]. On arrival to the
ER, she received 600mg plavix and was started on integrillin and
heparin gtts. Vitals were stable at 12/69 with heart rate of 98,
satting 96% on 2L. Of note, pt only notes slight chest pressure
on the way the hospital. In the ER, she was noted to have
transient Wenckebach, with heart rate of 42.
.
Pt was take to the cath lab, arriving at 6:15am. There she was
found to have a totally occluded RCA and a cypher stent was
placed. LVgram showed an EF of 55%. right heart cath showed RA
mean of 17mmHg, RV 47/11 with end diastolic of 20mmHg, PAP 46/18
(33) and wedge of 23; CO 3.11 (CI 1.74)
.
On arrival to the CCU, pt felt well, no chest pain, shortness of
breath, pain.
.
On ROS, pt denies PND, orthopnea, lower ext swelling. She
normally exercises daily, swimming one mile per day (but not
since [**Month (only) 404**] due to her knee). She wears O2 at night due to
sleep apnea and chronic hypoxia due to her hernia (lung did not
expand following her hernia surgery). Also with recent pain in
right ankle, treated as cellulitis with keflex and then
ceftriaxone when it failed to improve. now much better
Past Medical History:
1. Asthma
2. sleep apnea, on CPAP at home
3. Morgagni hernia s/p repair [**2128-9-7**].
4. HTN
5. s/p TIA 10 years ago
6. recurrent R ear herpes, R Bell's palsy
7. s/p TAH
8. bladder diverticula
9. s/p Right Total Knee Arthroplasty (Replacement) [**2130-4-11**]
10. PVC's (followed by Dr. [**Last Name (STitle) 911**], on lopressor)
Social History:
Currently at [**Hospital **] rehab s/p knee replacement. Retired nurse.
Husband retired family pratice physician. [**Name10 (NameIs) **] tobacco, ethanol,
or IVDU.
Family History:
Father had first MI at age 39, died of MI at age 68
Physical Exam:
temp 97.5, BP 118/57, HR 78, R 18, O2 100% on 3L
Gen: 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 10cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. distant sounds, no murmurs
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits. Pressure dressing in place in
left groin
Ext: left lower ext cool with palp pulses; right lower ext warm,
1+ edema, palp pulses; no erythema; TKR scar c/d/i
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
Initial EKG (at 5:30a) demonstrated NSR at 65 bpm, normal axis,
prolonged PR, ST elevations in II, III, and aVF (4mm in III, 3mm
in II and aVF) with 1mm ST elevation in V1, ST depressions in I,
aVL. Right sided EKG showed 2mm ST elevation in V4
.
EKG following cath showed NSR at 80, nl axis, small Q waves in
III, aVF
.
2D-ECHOCARDIOGRAM performed on [**12/2129**] demonstrated:
LA is normal in size. No ASD or patent foramen ovale is seen by
2D, color Doppler or saline contrast with maneuvers. Mild
symmetric LVH with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal.
Tissue Doppler imaging suggests a normal left ventricular
filling pressure
(PCWP<12mmHg). AV leaflets (3) are mildly thickened but aortic
stenosis is not present. No AR. MV appears structurally normal
with trivial MR. [**Name13 (STitle) **] mitral valve prolapse. Mod PA systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
.
CARDIAC CATH performed on [**2130-4-25**] demonstrated:
LVgram: EF 55%, mild MR
[**Name13 (STitle) **] normal with modest calcification
LAD: modest calcification with mild luminal irregularities
LCx: non-dominant vessel with mid-segment 80% lesion in AVG
RCA: dominant vessel with mid-segment 99% lesion with noted
thrombus s/p 3.0 x 18 cypher stent; final residual was 0% with
normal flow
.
L groin US [**4-25**]:
Communicating with the left common femoral artery, there is a
2.1 x 2.2 x 1.2 cm pseudoaneurysm that contains two-third of
thrombosed clot with a one- third residual lumen with flow. A
0.3 cm neck is visualized communicating with the common femoral
artery.
.
L groin US [**4-27**]:
Scans through the left groin now show a residual hematoma
measuring 2.4 x 2.8 x 1.1 cm. There is no flow within the
hematoma, and there has been complete thrombosis of the
previously shown pseudoaneurysm.
.
RLE US [**4-25**]:
1. No evidence of deep venous thrombosis in the right lower
extremity
2. [**Hospital Ward Name 4675**] cyst within the right popliteal fossa.
.
TTE [**2130-4-29**]:
There is mild regional left ventricular systolic dysfunction
with basal
inferior hypokinesis (EF 50-55%). The other segments appear to
contract well, although they are only visualized in the
short-axis view. The right
ventricular cavity is mildly dilated. There is focal hypokinesis
of the apical free wall of the right ventricle. IMPRESSION:
Mild regional left and right systolic dysfunction, c/w CAD.
Technically limited study. Compared with the prior study (images
reviewed) of [**2130-1-9**], left and right ventricular regional
systolic dysfunction are new.
Brief Hospital Course:
74F with hx of HTN who presents with dizziness, diaphoresis and
nausea found to have acute inferior STEMI due to totally
occluded RCA now s/p cypher stent. Course c/b groin hematoma.
.
1) CAD/STEMI: The patient initially had symptoms of dizziness,
diaphoresis, nausea, she was found to be hypotensive and EMS was
called. The initial EKG demonstrated ST elevations in inferior
leads II, III, an aVF. A right sided EKG showed ST elevations
on V4r indicating a likely RV infarct. She was given ASA,
plavix, heparin and integrillin and taken urgently to the cath
lab. She was found to have 2VD with a 90% lesion in the distal
LAD and a 95% occlusion of the mRCA. A cypher stent was deployed
to the mRCA lesion. She was monitored in the CCU given risk of
hypotension and bradycardia following RV infarct. She was
asymptomatic following catheterization. She remained
hemodynamically stable. She was continued on ASA and plavix
which she will need for 1 year. Her integrillin was stopped due
to a groin hematoma as discussed below. Once her groin hematoma
stablized she was restarted on lovenox. The patient has a know
allergy to lipitor and crestor, therefore, she was started on
pravastatin as this statin has a lower occurence of side
effects. She tolerated this well. Initially her
antihypertensives were held in light of her low cardiac output
and recent wenckebach. When her cardiac profile improved, she
was restarted on her beta-blocker, aspirin, and plavix. She has
an outpatient appointment with her cardiologist to follow up.
.
2) Groin hematoma: Post-cath the patient was noted to have a
left groin hematoma so her integrillin was stopped. A stat
groin US showed a small 2x2cm pseudoaneurysm that was [**1-14**]
thrombosed. A pressure dressing was applied and her hematoma
remained stable. Her hematocrit was stable at 24 (down from
baseline of 35), the patient refused transfusion. A second groin
US showed no flow in the pseudoaneurysm and complete thrombosis.
A residual hematoma was noted and stable.
.
3) Rhythm: In the [**Last Name (LF) **], [**First Name3 (LF) **] EKG was significant for Wenckebach.
This resolved, she remained in NSR on telemetry.
.
4) Pump: During her cardiac catheterization she was noted to
have depressed cardiac function in the setting of her MI. The
LVgram showed a EF 55%, CO 3.11, and wedge of 23. A repeat echo
showed new, mild regional left and right systolic dysfunction
and an EF of 50-55%. However, the study was technically limited
and an outpatient Echo with contrast has been ordered.
.
5) HTN: At home the pt was on cozaar, hctz and lopressor. During
her inpatient stay her medications were adjusted, she as
discharged on lower doses of her beta blocker and cozaar and her
HCTZ was discontinued since her blood pressure was well
controlled without it. Her BP meds should be uptitrated or
restarted as needed as an outpatient.
.
6) Elevated blood glucose: The patient's blood glucose was noted
to be elevated. A HbA1c was high normal at 5.7. Her elevated
glucose could be stress induced. However, this could also
indicate new glucose intolerance. This should be followed as an
outpatient. She was maintained in house on a RISS.
.
7) Cellulitis: Mrs. [**Known lastname **] had evidence of cellulitis of the RLE.
She was started on ceftrioxone with good results and completed
her course of antibiotics prior to discharge. An US of the lower
extremities was done and showed no DVT.
.
8) Leukocytosis: On presentation to the CCU, the patient had a
WBC count of 14, this was likely due to cellulitis or
inflammation from her MI. She completed her course of
ceftrioxone during her stay and her WBC count continued to trend
down. She had a low grade fever of 100, CXR was performed that
was negative for an acute process and UA showed increased WBC
but no bacteria. Her fever was attributed to likely atelectasis.
.
9) FEN: cardiac diet
.
10) PPX: SQ heparin, bowel reg
.
11) Access: PIV
.
12) Code: full
.
13) Comm: daughter [**Name (NI) **] [**Name (NI) 96045**] [**Telephone/Fax (1) 96046**]
Medications on Admission:
* Lovenox 40mg qd
* Keflex 500mg tid x 10 days (d/c'd [**4-22**])
* ceftriaxone 1gram qd (first day [**4-22**], last day [**4-26**])
* oxybutynin 2.5mg [**Hospital1 **]
* metoprolol 75mg [**Hospital1 **]
* colace/senna
* fluticasone 1spray to nostrils daily
* advair 100/50 [**Hospital1 **]
* HCTZ 25mg qd
* Cozaar 100mg qd
* MVI
* omeprazole 40mg qd
* tylenol as needed
* oxycodone 10mg q4hrs prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily) for 4 days.
Disp:*4 injection* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Oxybutynin Chloride 5 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Discharge Worksheet-Discharge
Diagnosis-Finalized:[**Last Name (LF) **],[**Name8 (MD) **], MD on [**2130-4-29**] @ 1536
Primary:
myocardial infarction
groin hematoma
right total knee replacement
asthma
hypertension
PVC's
secondary:
sleep apnea on CPAP at home
Morgagni hernia s/p repair [**2128-9-7**]
recurrent R ear herpes, R Bell's palsy
TAH
bladder diverticula
Discharge Condition:
Tolerating POs. Hemodynamically stable. Chest pain free.
Discharge Instructions:
You had a myocardial infarction and were emergently taken to the
cardiac catheterization lab. There you were found to have a
blocked coronary artery. A drug eluting stent was placed in the
artery. You will need to take plavix every day for at least 1
year (to be discussed with your cardiologist). Do not miss one
dose.
.
You also developed a pseudoaneurysm at your catheter site, this
is now resolved.
.
ACTIVITY: 50% partial weight bearing only to operative leg.
Unlocked [**Doctor Last Name **] Brace to right leg whenever out of bed. CPM
machine
advance as tolerated. Brace not needed for CPM use and must be
kept off in bed to prevent skin breakdown. No strenuous exercise
or heavy lifting.
.
Your diuretic HCTZ has been held and you are on a lower dose of
your Cozaar and beta blocker since your blood pressure has been
well controlled. Your PCP [**Name Initial (PRE) **]/or cardiologist should increase
and restart your blood pressure medications as needed.
.
You have prescribed the oral pain medicine dilaudid to be taken
only if you experience severe pain since you developed itching
to your previous pain medication oxycodone. Please avoid
excessive use of this strong pain medicine.
.
If you experience any fevers, chills, chest pain, shortness of
breath or other worrisome symptoms please seek medical
attention.
Followup Instructions:
Your ultrasound study of the heart (echocardiogram) was limited.
Thus, you should have an echocardiogram with contrast (called
Definity) done within 1-2 weeks after discharge before you will
see your cardiologist Dr. [**Last Name (STitle) 911**]. An order has been placed for
this study. Please make an appointment by calling the echo lab
at ([**Telephone/Fax (1) 19380**] on Monday. Please call Dr.[**Name (NI) 5786**] office at
[**Telephone/Fax (1) 920**] if there are any problems with scheduling this
important study.
.
Please follow up with:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2130-10-23**] 1:40
note: Dr.[**Name (NI) 5786**] office will contact you for an earlier
appointment (you should follow up with him within 2 weeks from
now).
.
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-13**] weeks.
[**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 3393**]
- During your stay, your blood glucose was slightly elevated,
you may be developing glucose intolerance. This should be
followed by your primary care physician.
.
Please also follow up with orthopedic surgeon Dr. [**Last Name (STitle) **] (his
office number is ([**Telephone/Fax (1) 5238**]) on [**5-5**] at 12.45PM, [**Location (un) **]
[**Hospital Ward Name 23**] Bldg, [**Hospital Ward Name **].
.
Please also follow up with:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2130-5-5**]
12:45
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6151
} | Medical Text: Admission Date: [**2121-12-12**] Discharge Date: [**2121-12-14**]
Date of Birth: [**2043-10-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy with placement of endoclips on [**2121-12-12**]
Transfused 3 units pRBCs.
History of Present Illness:
78 yr old gentelman with h/o HTN, DM, hypercholesterolemia, CRI
(baseline creatinine [**1-28**]), arthritis, Zenker's diverticulum,
gout who presents with complaint of bright red blood per rectum.
The patient underwent colosnoscopy with polypectomy on [**2121-12-4**].
He was doing well after the procedure until the day of
admission, [**2121-12-12**], when he began to have BRBPR. He had a total
of [**6-2**] episodes of painless bright red rectal bleeding. He was
otherwise asymptomatic. He denied CP, palpitations, SOB,
tachycardia, pre-syncopy, LH, nausea, vomiting, diaphoresis. He
has been taking aspirin 325 mg po qd and Plavix. In the ED the
patient was found to be hypotensive: BP 70/30, but responded
quickly to NS boluses. Hct was 29.8 on admission but decreased
to 26.9 two hours later (baseline 37). The patient was initially
admitted to ICU for close hemodynamic monitoring. He was made
NPO, anti-platelet agens and BP meds were held and he was
briefly on DDAVP. He was transfused 3 units of pRBCs.
Colonoscopy on [**2121-12-12**] identified a site of bleeding in the
transverse colon at the previous polypectomy site and this was
managed with endoclips. The patient was then transferred to the
regular medicine floor.
At the time of transfer to the floor he was asymptomatic. Denied
fever/chills, N/V, CP, SOB, dizziness/LH. Had not had a BM since
colonoscopy. He was tolerating clears well.
Past Medical History:
1. Type II DM
2. HTN
3. CRI (baseline creatinine [**1-28**])
4. Hemorrhoids
5. Zenker's diverticulum
6. Bilateral carotic stenosis, s/p unilateral CEA
7. PVD
8. OA
9. ? Gout
10. Basal cell skin ca
[**27**]. Hypercholesterolemia
Social History:
Retired history professor [**First Name (Titles) **] [**Last Name (Titles) **]. Tob: 65 pack-year, quit 20
years ago. Regular EtOH.
Family History:
Non-contributory
Physical Exam:
96.1 69 161/47 16 100% RA
General: pleasant, hard of hearing, appears his stated age, NAD,
alert and oriented x3
HEENT: NC, AT, sclera non-icteric, conjunctiva pale, EOM intact,
PERRL, mmm, OP clear
NECK: no LAD, no thyromegaly, supple
PULM: CTA bilaterally
CV: regular, nl S1S2, no m/g/r
Abd: +BS, soft, NT, ND
Extr: no c/c/e
Neuro: no focal deficits
Pertinent Results:
Labs on admission:
[**2121-12-12**] 12:25PM BLOOD WBC-6.9 RBC-3.13* Hgb-10.0* Hct-29.8*
MCV-95 MCH-32.0 MCHC-33.6 RDW-15.3 Plt Ct-203
[**2121-12-12**] 12:25PM BLOOD Neuts-54.7 Lymphs-39.3 Monos-4.3 Eos-1.2
Baso-0.5
[**2121-12-12**] 12:25PM BLOOD Glucose-222* UreaN-78* Creat-2.8* Na-137
K-4.9 Cl-107 HCO3-17* AnGap-18
[**2121-12-13**] 02:23AM BLOOD ALT-8 AST-11 AlkPhos-52 TotBili-0.6
[**2121-12-13**] 02:23AM BLOOD Calcium-7.9* Phos-5.3* Mg-2.1
Labs at discharge:
[**2121-12-14**] 06:25AM BLOOD WBC-4.7 RBC-3.33* Hgb-10.3* Hct-30.6*
MCV-92 MCH-31.0 MCHC-33.8 RDW-16.4* Plt Ct-174
[**2121-12-14**] 06:25AM BLOOD Glucose-170* UreaN-50* Creat-2.1* Na-139
K-4.7 Cl-112* HCO3-18* AnGap-14
[**2121-12-14**] 06:25AM BLOOD Calcium-8.3* Phos-3.5# Mg-2.2
Brief Hospital Course:
1. GI bleed secondary to polypectomy while on aspirin and
Plavix. The patient was admitted to the intensive care unit. The
patient was made NPO and was initially supported with pRBCs
transfusions (total of 3 units over hospital stay) and DDAVP.
ASA and Plavix (for carotid artery stenosis) were held. GI and
surgery were consulted. The patient underwent colonoscopy on
[**2121-12-12**] which identified active bleeding in transverse colon at
the site of previous polypectomy. Endo clips were placed with
good hemostasis. The patient was then gradually restarted on
clear and then on low residue diet. At the time of discharge, he
had a stable HCT, was asymptomatic, and was tolerating low
residue diet without difficulties. He was instructed to avoid
NSAIDs, aspirin and Plavix for one week after the intervention.
He will continue with low residue diet for one week. The patient
was instructed to follow up in the clinic for BP check after the
discharge prior to resuming HCTZ and Lasix. He will also have
his CBC checked to confirm stable HCT. This plan was also
discussed with the patient's daughter.
2. Diabetes: Glycemic control was maintained with FS checks and
ISS. The patient was resumed on his outpatient regimen of oral
hypoglycemics on the day of discharge.
3. CRI (baseline creatinine [**1-28**]: Creatinine has remained at
baseline during hospitalization.
4. HTN: BP medications were held initially given active
hemorrhage. The patient was restarted on his BP medications on
the day of discharge except for HCTZ and Lasix. His SBP was low
normal on the day of discharge. He was instructed not to resume
HCTZ and Lasix until he consults his primary care physician
after BP check in the clinic next week.
5. Meningioma: The patient was unaware of meningioma found on a
recent head MRI. The patient will f/u with neurosurgery Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as an outpatient.
6. Carotid stenosis: The patient will f/u with US in 3 months
with vascular ([**Numeric Identifier **]).
7. Prophylaxis: PPI, pneumonitis
8. FEN: Patient was initially NPO. He was then restarted on
clears which was then advanced to low residue diet. He tolerated
regular consistency diet without difficulty.
9. Code: full
Medications on Admission:
List of current medications reviewed with the patient:
Plavix 75 mg po qd
ASA 325 mg po qd
Lasix 40 mg po bid (dose he is currently taking per patient)
Accupril 10 mg po qd
Allopurinol 100 mg po qd (does not take)
Pravachol 30 mg po qd
Valium 5 mg q8h prn
Zantac 150 mg po qd
Salsalate 500 mg po bid
Inderal 80mg po bid
Sodium bicarbonate tabs
Glipizide 5 mg po qd
HCTZ 25 mg po qd
Ambien prn
Tylenol prn
Discharge Medications:
1. Pravastatin Sodium 10 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): PLease do not take until you are seen by a health care
provider.
4. Propranolol HCl 80 mg Capsule, Sustained Action 24HR Sig: One
(1) Capsule, Sustained Action 24HR PO BID (2 times a day).
5. Glipizide 5 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO DAILY (Daily).
6. Quinapril HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: Please
do not start until [**2121-12-19**]. .
9. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: Please do not
start until [**2121-12-19**].
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: Do
not start until seen by a health care provider in the clinic
next week for BP check.
11. HCTZ Sig: 25 mg once a day: Do not start until seen by a
health care provider in the clinic next week for BP check.
12. Outpatient Lab Work
CBC please have done on [**2121-12-16**]. Please have the results called
to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1921**]. Please follow up on the results
with Dr. [**Last Name (STitle) **].
13. Salsalate 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Lower gastrointestinal bleed from polypectomy
2. Hypotension secondary to gastrointestinal hemorrhage
3. Diabetes
4. Chronic renal insufficiency
Discharge Condition:
Stable. Patient asymptomatic. Ambulating without difficulties.
Tolerating regular consistency diet. Hematocrit stable.
Discharge Instructions:
Please avoid medications that affect your platelets (aspirin,
alleve, motrin, and other NSAIDs) and Plavix for 7 days after
your colonoscopy. You then may resume taking aspirin and Plavix
on [**2121-12-19**] as before.
Please do not take Lasix and HCTZ until you are seen in the
clinic early next week, have your blood pressure checked and are
told by a primary care physician to restart diuretics.
Please eat low residue (low fiber) diet for 7 days.
Please call you doctor immediately or return to the hospital if
you start having blood in stool, become dizzy, lightheaded, or
have other worrisome symtpoms.
Please have CBC drawn in the lab on [**2121-12-16**]. Follow up with Dr.
[**Last Name (STitle) **] or another health care provider regarding the results.
Followup Instructions:
1. Please call ([**Telephone/Fax (1) 1300**] to schedule an appointment with
your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] early next week.
2. Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1113**] Date/Time:[**2122-1-6**] 11:30
3. Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2122-3-24**]
10:40
4. Please call ([**Telephone/Fax (1) 108593**] and schedule an appointment with
Dr. [**First Name (STitle) **] in neurosurgery regarding meningioma that was found on CT
scan.
5. Please call ([**Telephone/Fax (1) 88**] to schedule appointment with Dr.
[**First Name (STitle) **] to follow up on the management of meningioma.
Completed by:[**2122-1-3**]
ICD9 Codes: 5789, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6152
} | Medical Text: Admission Date: [**2150-6-22**] Discharge Date: [**2150-7-2**]
Date of Birth: [**2080-8-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Asymptomatic ascending Aneurysm
Major Surgical or Invasive Procedure:
[**2150-6-25**]
Redo sternotomy, replacement of ascending aorta
and hemiarch using deep hypothermic circulatory arrest with a
30-mm Vascutek Dacron tube graft.
History of Present Illness:
This is a 69-year-old gentleman with history of rheumatic heart
disease status post mechanical AVR and MVR in [**2137**], who
currently
presents for evaluation of stable ascending thoracic aortic
aneurysm, estimated on recent MRA as measuring 6.2 cm in its
maximal dimension. This has been stable on serial
echocardiograms measurements as well as compared to prior MRA
obtained in [**2149-9-7**]. He remains asymptomatic.
Past Medical History:
Ascending Aortic Aneurysm
PMH:
- Chronic Systolic Congestive Heart Failure
- History of Rheumatic heart disease
- Hypertension
- Atrial fibrillation
- Colonic adenomas
- ?Osteoporosis
- BPH
- Remote CVA was noted on brain CT and MRI [**2132**] (R thalamic)
Past Surgical History
- s/p mechanical AVR (#29 Carbomedics) and MVR (#31 carbomedics)
in [**2137**]
- Laparoscopic right colectomy complicated by anastomotic bleed
requiring exploratory laparoscopy [**2149-9-7**]
- Appendectomy
- Bilateral Shoulder
- Left Foot Bunion
Social History:
Lives with: Wife
Occupation: Retired construction worker
Tobacco: 5 cigars per month
ETOH: nightly Glass of wine with dinner
Family History:
Father had valvular heart disease. Mother had
[**Name2 (NI) 499**] CA
Physical Exam:
Pulse: 87 Resp: 16 O2 sat: 99%
B/P Right: 105/73 Left: 117/73
Height: 69 inches Weight: 200 lbs
General: WDWN male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur - crisp mechanical clicks
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
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2150-6-25**] Intra-op TEE
Conclusions
PRE-CPB:
The left atrium is moderately dilated. The pt is in atrial
fibrillation. No thrombus is seen in the left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The LV
chamber is severely dilated. Overall left ventricular systolic
function is severely depressed (LVEF= 25-30%) with the inferior
wall appearing more hypokinetic than other wall segments. Right
ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level. The
ascending aorta is severely dilated. While the entire visualized
ascending aorta appears dilated, there appears to be a focal
outpouching at the level just below the RPA. There are simple
atheroma in the descending thoracic aorta. No thoracic aortic
dissection is seen.
A bileaflet mechanical aortic valve prosthesis is present. There
appear to be three small paravalvular leaks, two in the area
near the interatrial septum, and one next to the area by the
pulmonary valve. The prosthetic valve appears to be well-seated
with normal leaflet motion.
A bileaflet mitral valve prosthesis is present. The normal
washing jets of this mechanical prosthesis is seen. The valve
appears to be well-seated. Occasionally, one leaflet is slower
than the other to close, possibly due to poor LV contractility.
POST-CPB:
The patient is now on Epi, Phenylephrine, and Milrinone
infusions. The LV EF appears improved on inotropic support,
estimated EF is 40-50%. The inferior wall still appears to be
more hypokinetic than other wall segments.
The bioprothetic valves continue to show appropriate function.
The aortic valve paravalvular leaks remain unchanged from
pre-op. The peak gradient across the aortic valve is 20mmHg, and
the mean gradient is 9mmHg with a CO of 7.
There is no evidence of aortic dissection.
Dr. [**Last Name (STitle) 914**] was notified in person of the results at the time of
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2150-6-25**] 18:44
Radiology Report CHEST (PA & LAT) Study Date of [**2150-6-30**] 7:24 PM
Final Report: PA and lateral upright chest radiographs were
reviewed in comparison to [**2150-6-28**] and several prior studies
dating back to [**2148**].
The cardiomegaly is unchanged, including both left and right
ventricle. Two replaced valves are noted, unchanged since the
prior examination. The small amount of right pleural effusion is
unchanged. Anterior mediastinal air with small air-fluid level
noted on the lateral view are redemonstrated with the air-fluid
level potentially representing small loculated anterior
pneumothorax in combination with post-surgery air in the
mediastinum. Small amount of pneumopericardium cannot be
excluded laterally, although it might represent summation of
shadows. Continued followup is recommended.
Post-sternotomy wires appear intact.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 17414**] [**Name (STitle) 17415**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Discharge Labs:
[**2150-7-1**] 04:10AM BLOOD WBC-5.1 RBC-2.91* Hgb-9.7* Hct-27.7*
MCV-95 MCH-33.4* MCHC-35.1* RDW-14.2 Plt Ct-201
[**2150-7-1**] 04:10AM BLOOD Plt Ct-201
[**2150-7-1**] 04:10AM BLOOD UreaN-16 Creat-0.8 Na-133 K-4.1 Cl-98
Admission labs:
[**2150-6-22**] 04:47PM PT-15.6* PTT-27.7 INR(PT)-1.4*
[**2150-6-22**] 04:47PM PLT COUNT-139*
[**2150-6-22**] 04:47PM WBC-4.1 RBC-3.78* HGB-13.0* HCT-36.5* MCV-97
MCH-34.4* MCHC-35.6* RDW-13.3
[**2150-6-22**] 04:47PM %HbA1c-5.7 eAG-117
[**2150-6-22**] 04:47PM ALBUMIN-4.3 MAGNESIUM-2.0
[**2150-6-22**] 04:47PM ALT(SGPT)-16 AST(SGOT)-23 LD(LDH)-322* ALK
PHOS-47 TOT BILI-0.5
[**2150-6-22**] 04:47PM GLUCOSE-95 UREA N-24* CREAT-0.8 SODIUM-139
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-29 ANION GAP-10
Brief Hospital Course:
The patient was a direct admission to the operating room on
[**2150-6-25**] where the patient underwent replacement of ascending
aorta and aortic hemiarch. Please see the operative report for
details. In summary he had:
Redo sternotomy, replacement of ascending aorta and hemiarch
using deep hypothermic circulatory arrest with a 30-mm Vascutek
Dacron tube graft, catalog number [**Serial Number 102644**], lot number [**Serial Number 102645**],
serial number [**Serial Number 102646**]. His CARDIOPULMONARY BYPASS TIME was 119
minutes, with a CROSSCLAMP TIME of 75 minutes, and CIRCULATORY
ARREST TIME of 18 minutes.
He 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. Heparin was initiated as a bridge to coumadin for
his mechanical valves. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #7 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged on to home
with VNA services, in good condition with appropriate follow up
instructions advised.
Medications on Admission:
Warfarin 6 mg Daily (last dose [**2150-6-19**])
Alendronate 70 mg Daily; Carvedilol 6.25 mg [**Hospital1 **]; Eplerenone 50
mg
Daily; Flomax 0.4 mg Daily; Benicar daily; Calcium + Vit D
Daily;
Magnesium
Discharge Medications:
1. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 5 days.
Disp:*5 Packet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2*
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*2*
5. carvedilol 12.5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
6. alendronate 70 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO 1X/WEEK (ONCE
PER WEEK).
Disp:*30 [**Hospital1 8426**](s)* Refills:*2*
7. oxycodone 5 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*50 [**Hospital1 8426**](s)* Refills:*0*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. warfarin 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO ONCE (Once) for
1 doses.
Disp:*1 [**Hospital1 8426**](s)* Refills:*0*
10. furosemide 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*5 [**Hospital1 8426**](s)* Refills:*0*
11. warfarin 2.5 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day: INR
goal= 3-3.5 for double mechanical valves.
Disp:*180 [**Last Name (Titles) 8426**](s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Ascending Aortic Aneurysm
PMH:
- Chronic Systolic Congestive Heart Failure
- History of Rheumatic heart disease
- Hypertension
- Atrial fibrillation
- Colonic adenomas
- ?Osteoporosis
- BPH
- Remote CVA was noted on brain CT and MRI [**2132**] (R thalamic)
Past Surgical History
- s/p mechanical AVR (#29 Carbomedics) and MVR (#31 carbomedics)
in [**2137**]
- Laparoscopic right colectomy complicated by anastomotic bleed
requiring exploratory laparoscopy [**2149-9-7**]
- Appendectomy
- Bilateral Shoulder
- Left Foot Bunion
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:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2150-7-8**]
10:15
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**], [**2150-7-21**] 1:30
Cardiologist Dr. [**Name (NI) **], [**Telephone/Fax (1) 62**], [**2150-7-30**] 11:00
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 7726**],[**First Name3 (LF) 177**] A. [**Telephone/Fax (1) 7728**] in [**5-12**] 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
Coumadin for mechanical AVR and MVR
Goal INR 3-3.5
First draw day after discharge:[**2150-7-3**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**First Name (STitle) **]
Results to fax- [**Telephone/Fax (1) 3341**]
Completed by:[**2150-7-2**]
ICD9 Codes: 4168, 4019, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6153
} | Medical Text: Admission Date: [**2187-4-12**] Discharge Date: [**2187-5-3**]
Date of Birth: [**2133-11-27**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Acute Renal Failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 53 year old man with HCV cirrhosis, complicated by
recurrent ascites, SBP, encephalopathy, and portal hypertensive
gastropathy who is being sent in by the liver center after
yesterday's labs showed an elevated creatinine. Unfortuantely,
the lab work is not available in our system.
.
He has had multiple admissions in the past six months for acute
on chronic renal failure. His urine lytes are usually c/w with
pre-renal azotemia. Renal U/S have showed no hydronephrosis. He
typically improves with fluids, midodrine and octreotide. With
renal failure, he has also had several episodes of hyperkalemia.
.
His most recent admission was from [**Date range (1) 84789**] for ARF,
hyperkalemia, and refractory ascites. He had 9 L paracentesis on
[**2187-4-5**]. Pt has no complaints since his discharge on Friday. He
denies any change in urine output, dysuria. He has not been
taking any medications other than prescribed--no NSAIDS. His
wife only noticed his tremors worsened today.
.
ROS:
(+) Diarrhea with lactulose
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria.
Past Medical History:
Hepatitis C diagnosed [**2177**]
- viral load 335k [**11/2186**]
- recurrent/refractory ascites requiring frequent paracenteses
- history of hepatic encephalopathy
- portal gastropathy without esophageal varices
HepB coreAb positive, surface Ag negative [**11/2186**]
Low back pain s/p disc surgery [**2178**], [**2180**]
Radial right wrist fx at the end of [**11-10**] after fall
Hemachromatosis, HETEROZYGOUS FOR THE C282Y MUTATION
Spur cell hemolytic anemia
-[**2187-4-19**] piggyback liver transplant
Social History:
He is married and lives with his wife. [**Name (NI) **] is not working
currently. Stopped smoking 6-7 months ago. Smoked 1 PPD since
age 15. No alcohol in 2 years. Multiple tattoos. His wife
organizes his medications.
Family History:
His father had ETOH cirrhosis. No history of kidney problems.
Physical Exam:
Vitals: T: 98.1, P: 87, BP: 119/75, R: 18, SaO2: 100RA
General: Awake, alert and oriented x3, refused to do MOYB but
did them forwards, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: supple, no LAD
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M noted
Abdomen: positive bowel sounds, soft, nontender, distended but
not tense.
Extremities: 1+ pedal edema to knees bilaterally
Skin: spider angiomas on chest, maculopapular rash on abdomen
Neurologic: sl asterixis
Pertinent Results:
[**2187-5-3**] 06:30AM BLOOD WBC-9.0 RBC-3.19* Hgb-9.8* Hct-30.1*
MCV-95 MCH-30.7 MCHC-32.5 RDW-16.4* Plt Ct-232
[**2187-4-28**] 06:30AM BLOOD PT-11.7 PTT-26.7 INR(PT)-1.0
[**2187-5-3**] 06:30AM BLOOD Glucose-79 UreaN-42* Creat-2.0* Na-137
K-5.4* Cl-111* HCO3-19* AnGap-12
[**2187-5-3**] 06:30AM BLOOD ALT-30 AST-21 AlkPhos-346* TotBili-2.4*
[**2187-5-3**] 06:30AM BLOOD Calcium-9.3 Phos-4.6* Mg-1.6
Brief Hospital Course:
53 y.o. man with HCV cirrhosis, complicated by recurrent
ascites, SBP, encephalopathy, and portal hypertensive
gastropathy was admitted with recurrent acute on chronic renal
failure that was managed with albumin, midodrine, and octreotide
after paracentesis. Cr slightly improved to 2.6. Lactulose and
rifaxamin were continued. Cipro was continued for sbp
prophylaxis.
On [**2187-4-19**], a liver donor became available and he underwent
piggyback liver transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Induction
immunosuppression was given (solumedrola and cellcept). Five
liters of ascites were removed. There was a size mismatch
between the donor (smaller)and recipient bile duct. This was
adjusted for by cutting a slit on top of the donor liver, using
interrupted 5-0 PDS to accomplish a biliary anastomosis. Two
drains were placed in the usual locations (posterior to liver
and hilar area). Postop, he was transferred to the SICU for
management. VRE rectal screen was positive. He experienced a lot
of pain on top of his chronic back pain and required large
amounts of narcotics. On postop day 1, he was extubated and
resumed his home doses of oxycontin. Re-intubation for
pulmonary edema was required on postop day 4. He was also found
to have myocardial stunning from the stress of surgery. BNP was
39,512. Cardiology was consulted. Cardiac enzymes were negative.
Diuresis and metoprolol were given. No cardiac event occurred
and he was eventually extubated. Chest CT was negative for PE
and notation was made of bilateral pleural effusions. Hepatic
vasculature was patent. On [**4-23**], TTE demonstrated EF of 30%.
There was moderate regional left ventricular systolic
dysfunction with infero-lateral and apical akinesis, trace MR
and borderline pulmonary artery systolic HTN. He was extubated
on [**4-25**].
Of note, JP drains had large bilious outputs requiring albumin
and fluid replacement. LFTs increased initially with t.
bilirubin peaking at 12 then decreasing. Liver duplex
demonstrated patent hepatic vasculature, but suboptimal
visualization of the inferior vena cava, no intrahepatic biliary
ductal dilation and a small amount of ascites. On [**4-26**], ERCP was
performed noting extravasation of contrast from the biliary
anastomosis was seen, with contrast tracking along the JP drain.
A 10cm 8 French stent was placed. LFTs then continued to improve
with JP drain outputs dropping and appearing non-bilious.
He was transferred out of the SICU on [**4-28**] to the Med-[**Doctor First Name **] unit
where he continued to do well. Diet was advanced and tolerated.
Glucoses were elevated requiring NPH daily with intermittent
sliding scale regular insulin. Lateral JP was removed on [**5-2**].
Lateral JP creatinine was 2.3 with serum bili of 2.7. The medial
JP remained in place.
PT worked with him noting impulsivity and need for a rolling
walker. He was cleared for home with home PT thru VNA.
Medication teaching was done and he did fairly well with
reinforcement. Insulin administration and glucoses checks were
reviewed. He required assist from his wife for management of
this. This plan was for VNA services to provide
monitoring/instruction.
Immunosuppression consisted of cellcept 1 gram [**Hospital1 **] that was well
tolerated. Steroids were tapered to 20mg daily per protocol and
Prograf which was started on postop day 0 was adjusted per
trough levels. On the day of discharge, Prograf trough was 10.9.
Prograf was decreased to 4mg [**Hospital1 **].
Creatinine increased postop to 3.6 after CT, but gradually
decreased to 1.8. On the day of discharge, creatinine was 2.0
and potassium was 5.4. He was instructed to follow a
carbohydrate consistent, 2gram potassium diet.
He was discharged to home with VNA of Southeastern MA
([**Telephone/Fax (1) 80441**]). He had resumed his home dose of oxycontin 80mg
tid with prn oxycodone 10mg approximately 3-4 times a day for
breakthru pain.
Medications on Admission:
Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H as needed for
pain.
Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO TID
Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID
Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID
Magnesium Oxide 400 mg Tablet daily
Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID
Pantoprazole 40 mg Tablet, Delayed Release daily daily
Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Thiamine 100 daily
Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (SA).
Clotrimazole 10 mg 5 times a day
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
follow taper.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
5. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*42 Tablet(s)* Refills:*0*
9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
13. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous once a day.
Disp:*1 bottle* Refills:*2*
14. Insulin Regular Human 100 unit/mL Solution Sig: follow
printed scale Injection four times a day.
Disp:*1 bottle* Refills:*2*
15. Outpatient Lab Work
STAT Labs: cbc, chem 10, alt, ast, alk phos, t.bili, trough
prograf
Fax results to [**Hospital1 18**] [**Telephone/Fax (1) 697**] attention [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 8147**] RN
16. insulin syringes
NPH qd and prn sliding scale regular
Low dose syringe with 25-26 gauge needle
supply: 1 box
refill: 1
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
HCV cirrhosis
s/p liver transplant [**2187-4-19**]
pulmonary edema, resolved
myocardial stunning, resolved
hyperglycemia on steroids
Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)-impulsive with activities/walking
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the warning signs listed below
You will need to get labs drawn every Monday and Thursday
Empty and write down drain output. Bring record of drain outputs
to next transplant office appointment
Apply dry gauze to your drain daily
Check your blood sugars prior to meals and give insulin as
directed on sliding scale
No driving while taking pain medication
You may shower
No heavy [**Last Name (un) 37604**]/straining
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-5-7**]
8:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-5-14**]
10:30
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-5-24**]
10:00
Completed by:[**2187-5-3**]
ICD9 Codes: 5845, 9971, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6154
} | Medical Text: Admission Date: [**2182-3-9**] Discharge Date: [**2182-4-5**]
Service: MEDICINE
Allergies:
Allopurinol
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Respiratory failure and hypotension; transferred from OSH
Major Surgical or Invasive Procedure:
CVL from OSH [**2182-3-8**]
PICC line placement
Tracheostomy placement
Intubation - [**2182-3-9**]; reintubation on [**2182-3-13**]; reintubation on
[**2182-3-30**]
Bronchoscopy [**2182-3-13**]
Arterial line placement
History of Present Illness:
86 yo M w/history of CVA, right hemiparesis, obtunded at
baseline, bilateral AKA presents with respiratory failure and
hypotension. The patient was sent to [**Hospital1 882**] after an apparent
aspiration even last night, with SaO2 87% on RA and coarse
breath sounds bilaterally. The patient had sats 87-94% on 4L and
was treated with Levo/Flagyl and nebs. At 4:30 pm the patient
was found with decreased responsiveness, diaphoretic with vitals
of 96.4, 110, 28, 63/41. The patient was placed on a NRB and
sent to the [**Hospital1 882**] for further evaluation. A chest x-ray
showed a multilobar pneumonia, for which he was given one dose
of Zosyn and Vancomycin. His pressure was noted be as low as
50/30, and a right subclavian line was placed. He wsa started on
levophed and dopamine and additionally received one 0.5mg dose
of Atropine for bradycardia. He was transferred to [**Hospital1 18**] for
further managment.
In the [**Hospital1 18**] ED, his pressures were maintained on both pressors
initially, but dopamine was discontinued due to HR 100-110. He
was found to have a multilobar pneumonia, and an initial lactate
of 4.5 (improved to 3.5 with IVF). WBC 28.6, 29% Bands. Blood
cultures were sent and vancomycin 1 g IV was given. Levaquin was
not used due to QTc 0.450. An EKG revealed ST elevations
laterally. Interventional cardiology was consulted, but the
patient was not felt to be an appropriate catheterization
candidate. The patient was also found to be strongly guaiac
positive, with a Hct 25.0 and therefore, no heparin was given.
He was transfused 1 unit PRBC. His urinalysis was grossly
positive. Additonal abnormal labs included: Na: 130, Cr: 1.5,
ALT: 55, AST: 97, LDH: 305, AP: 208, Tbili: 2.7, Albumin: 2.0,
INR 1.3.
Upon arrival to the ICU the patient is maintained on Levophed
only with MAP > 60. An a-line was placed in the patient's right
arm.
Past Medical History:
#. Aspiration pneumnonia
#. C. Diff complicated by sepsis [**2181-11-21**]
#. Multiple admissions for sepsis related to
UTI/pneumonia/sacral decubitus ulcers
#. s/p CVA with R hemiparesis (arms contracted)
#. PVD s/p bilateral AKA
#. Seizure Disorder
#. Dementia
#. Diabetes II
#. Anemia
#. MRSA colonization
#. Hypernatremia
#. cataracts
#. contracted hips
#. Stage IV Sacral decubitus ulcers
#. Fistula
#. ETOH
Social History:
Unobtainable
Family History:
Unobtainable
Physical Exam:
General: Patient is intubated, appears chronically ill.
Patient's lower extremities surgically missing, hips severely
flexed
HEENT: NCAT, EOMI, +ETT
Neck: right subclavian line
Chest: Lung sounds relatively [**Name2 (NI) **] with few course expiratory
breath sounds
Cor: Tachycardic, regular
Abdomen: thin, firm but not rigid. Patient flexes with deep
palpation of abdomen. + BS, hyperactive
Back: stage IV decubitus ulcer at sacrum/coccyx level, stage II
decubitus ulcer with several necrotic foci on right buttock,
Extremities: bilateral AKA
Pertinent Results:
[**2182-3-9**] 08:53PM
WBC-28.6* HGB-8.3* HCT-25.0* MCV-100* MCH-33.4* MCHC-33.3
RDW-14.9
NEUTS-62 BANDS-29* LYMPHS-5* MONOS-4 EOS-0 BASOS-0 ATYPS-0
METAS-0
MYELOS-0
PLT SMR-NORMAL PLT COUNT-248
PT-15.2* PTT-42.4* INR(PT)-1.3*
GLUCOSE-99 UREA N-61* CREAT-1.5* SODIUM-130* POTASSIUM-4.9
CHLORIDE-101 TOTAL CO2-15* ANION GAP-19
ALBUMIN-2.0* CALCIUM-7.1* PHOSPHATE-4.3 MAGNESIUM-2.1
ACETONE-NEG
cTropnT-0.37* CK-MB-25* MB INDX-3.0
LIPASE-17 ALT(SGPT)-55* AST(SGOT)-97* LD(LDH)-305* CK(CPK)-836*
ALK PHOS-
208* TOT BILI-2.7*
URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-
SM UROBILNGN-1 PH-5.0 LEUK-MOD
URINE RBC->50 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0
LACTATE-4.6*
TYPE-ART PO2-404* PCO2-37 PH-7.27* TOTAL CO2-18* BASE XS--8
INTUBATED-INTUBATED
CXR: 1. Bibasilar opacities likely representing a combination of
small effusions and passive atelectasis and/or pneumonia. 2.
Moderate central pulmonary arterial enlargement suggestive of
underlying pulmonary hypertension.
ECG: Sinus tachycardia with premature atrial contractions. ST
segment elevation in leads V3-V5 is non-specific. Clinical
correlation is suggested. Low QRS voltage in the limb leads. No
previous tracing available for comparison.
[**2182-3-30**]: CT chest
IMPRESSION:
1. Bilateral large layering nonhemorrhagic pleural effusion with
associated compressive atelectasis.
2. Diffuse patchy opacities involving both upper lobes could
represent infectious or inflammatory process.
3. Calcified pleural plaques.
4. Small liver hypodensity, too small to be fully characterized.
5. No evidence of cavitary lesion.
[**2182-4-3**]: Xray to confirm PICC line (prelim read):
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
single-lumen Vaxcel PICC line placement via the left brachial
venous approach. Final internal length is 44 cm, with the tip
positioned in SVC. The line is ready to use.
ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50%). The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
A/P: 86 year old Male with history of aspiration pneumonia who
presents with respiratory failure and hypotension.
.
#. Hypoxic Respiratory failure: His respiratory failure was
thought most likely secondary to aspiration/hospital acquired
pneumonia. He received Zosyn at the OSH prior to transfer to
[**Hospital1 18**], in the [**Hospital1 **] ER he received vanc. Coverage was broadened
for potential multiple sources. Over his course of stay, he was
treated with Linezolid (VRE/MRSA), Cefepime (Pseudomonas), Cipro
(gram negative), Azithro, PO Vanc/IV Flagyl; as well as
transiently with Tobramycin for GNR based on sensitivities.
However, per ID recs, tailored down to course of Meropenem &
oral vancomycin (for history of C.diff). During his course, his
sputum grew GNRs and MSSA and blood cultures grew Klebsiella
pneumoniae. Legionella antigen was negative. He was extubated
on [**3-12**] and reintubated on [**3-13**] with increased work of
breathing. He continued antibiotic treatment and was diuresed
once blood pressure allowed. This allowed for successful
extubation on [**3-27**]. Patient was made DNR during this admission,
though per his HCP (niece) he was to be reintubated which he was
on [**2182-3-30**] for respiratory distress and increased work of
breathing. The patient also grew out multidrug resistant
Klebsiella from his sputum during his hospitalization. His
antibiotics were discontinued with the exception of his oral
vancomycin, which he should continue until [**2182-4-18**]
prophylactically for a history of C. Difficle sepsis.
.
#. Hypotension: Pt has multiple reasons for hypotension
requiring pressors. His hypotension was felt most likely
distributive secondary to sepsis given his elevated WBC and
bandemia with multiple potential sources including aspiration
pneumonia, UTI, sacral decubitus ulcer, C. Diff. Patient may
have also had contribution of cardiogenic shock given evolving
MI and was at risk for hypovolemia given guaiac+ stool with low
Hct. He was monitored with arterial line and pressors were
continued. He received aggressive fluid/pressor resuscitation
to maintain pressures. He had a total of 6 units of RBCs
throughout hospital course to maintain oxygen delivery. He
improved with treatment of sepsis and pressors were
discontinued.
.
#. STEMI: The patient was noted to have ST elevations in V3-V5.
He was seen by cardiology in ED, and thought not to be a cardiac
cath candidate. Given guaiac positive stool, a heparin gtt not
started. He has received ASA daily. Throughout his hospital
course, he has been transfused to maintain hematocrit in the
upper 20's. Troponin trended down from admit level of 0.37.
Echo was slightly poor quality, but with EF 50%, possible WMA,
1+ MR. Beta blocker started once hypotension improved.
.
#. Anemia: The patient was found to be guaiac positive in ED and
was originally transfused 1 unit of PRBC for his anemia. His
source is most likely GI, however given acute illness, overall
prognosis, and general stability he did not have endoscopy or
colonoscopy during this admission. His hematocrit was monitored
and he required a total of 6 units this admission with
appropriate bumps. At this point, the patient has transfusion
dependent anemia. He was transfused PRN throughout his course
to maintain a hematocrit greater than 24. B12 and folate levels
were checked, which were both within normal limits. Please
continue to monitor his hematocrit Q three days and transfuse as
needed.
.
#. Acute renal failure: The patient developed acute renal
failure in setting of acute illness, possible ATN. His
creatinine peaked at 2.4 and has prgressively trended down to
normal. His renal function improved with treatment of
underlying illness.
.
#. Decubitus ulcers with fistulization: Wound care was
consulted and recommendations followed for extensive wounds.
Please continue wound care recs per the page one.
.
#. s/p CVA with R hemiparesis (arms contracted): The patient
was continued on aspirin for stroke prevention.
.
#. Seizure Disorder: The patient was continued on his original
anti-epileptic medications. Please continue these medications
as prescribed.
.
#. Dementia: The patient is demented at baseline. His mental
status did not appear to change during his hospital course.
.
#. Diabetes II: The patient was continued on a sliding scale.
Please continue his sliding scale per the included sheet.
Medications on Admission:
Meds (on discharge from last hospitalization [**2181-11-23**])
1. omeprazole 40 mg po qd
2. folate 1 mg po qd
3. vitamin C 1 tab po bid
4. zinc 220 mg po qd
5. vitamin A 5000 units po qd
6. Magnesium oxide 400 mg po bid
7. Neurontin 200 mg po bid
8. Multivitamin 5 mL po qd
9. Neutra-phos one packet po bid
10. KCl 20 mEq po qd
11. Dilantin suspension 75 po tid
12. vancomycin 250 mg po qid x10 days (now discontinued)
13. chlorhexadine rinse 0.12% [**Hospital1 **]
-------
Meds from med list from Nursing Home
1. omeprazole 20 mg via g-tube qd
liquid antacid q6h prn GI upset
MOM 30 ml via g-tube for constipation
acetaminophen 325 2 tabs via g-tube q4hours
.
Allergies: Allopurinol
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): While pt is on mechanical
ventilation.
3. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. 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.
6. Morphine Sulfate 2 mg IV Q4H:PRN pain
for dressing changes
7. Furosemide 40 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
9. Phenytoin 100 mg/4 mL Suspension [**Last Name (STitle) **]: Seventy Five (75) mg PO
TID (3 times a day).
10. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**12-19**]
Drops Ophthalmic PRN (as needed).
12. Insulin Regular Human 100 unit/mL Solution [**Month/Day (2) **]: Pls see
attached sheet Injection ASDIR (AS DIRECTED).
13. Vancomycin
Vancomycin Oral Liquid 125 mg PO Q6H until [**2182-4-18**], then
discontinue
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
Multilobar pneumonia with respiratory failure requiring
tracheostomy
ST elevation myocardial infarction
Chronic anemia
Secondary:
s/p CVA with right sided hemiparesis
Stage IV sacral decubitus ulcers
Peripheral vascular disease s/p bilateral AKA
Seizure disorder NOS
Dementia
Type II Diabetes
Bilateral cataracts
Contracted hips
Fistula
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with respiratory failure and
low blood pressure. While you were in the hospital, you
required intubation to help you breath. Because you were unable
to be weaned off the ventilator, a tracheostomy was performed.
You were also treated with antibiotics for a pneumonia.
.
While you were in the hospital, you also had a heart attack.
Cardiology felt medical management was most appropriate so you
were treated with medications which were continued during your
hospitalization.
Followup Instructions:
You will be followed by physicians at the rehabilitation
facility.
You can also follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 5351**] at [**Telephone/Fax (1) 608**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5070, 5990, 5849, 2761, 5789, 2859, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6155
} | Medical Text: Admission Date: [**2190-9-1**] Discharge Date: [**2190-9-15**]
Service: MEDICINE
Allergies:
Codeine / Pneumovax 23 / Lescol
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
abd pain, chills
Major Surgical or Invasive Procedure:
ERCP
Laprascopic Cholecystectomy
History of Present Illness:
Pt is a [**Age over 90 **]yoW who presented from [**Hospital3 **] facility with
chills/fever and ruq abd pain for 2 days. Denies diarrhea, but
has had nausea w/o vomitting. Denies
CP/SOB/HA/rash/dysuria/myalgias/ back pain.
.
She was taken to [**Hospital1 18**] [**Location (un) 620**] where she was febrile to 103.2,
found to have elevated LFTs, CT with likely cholangitis.
.
She was transferred to [**Hospital1 18**] ED and taken to ERCP, where
sphincterotomy performed, several stones extracted from CBD,
stent placed. Several stones where noted to remain, exiting from
the cystic duct. In the ERCP suite she was treated with
ampicillin and gentamycin.
Past Medical History:
HTN
COPD
Hypothyroid
hx of gallstones
Stress incontinence
Anxiety
Social History:
Married and lives at [**Hospital3 **] with her husband. Was able
to ambulate with a walker prior to admission. Was not on any
home oxygen. Denies current tobacco/alcohol/IVDA. Has a ~15
pack year history of smoking (5 cig/day from teens to [**2157**]).
Family History:
nc
Physical Exam:
Vital Signs: T:97BP:120/68 HR:62 RR:14 O2 Sat:99%2L
.
GEN: no jaundice
.
HEENT
-Head/Neck: Anicteric sclera. Head is symmetric and atraumatic.
Neck has full
range of motion and cervical, occipital, and supraclavicular
lymph nodes are nonpalpable and nontender.
-Eyes: PERRL, EOM are intact
.
Respiratory: CTA bl.
.
Cardiovascular: RRR nl s1s2 no mrg
.
Abdominal: soft, mild RUQ tenderness, hypoactive bs
.
Neurologic: CN 2-12 intact
.
Extremities: bl legs markedly tender to palpation, no edema, no
erythema
.
Back: no cva tenderness, no spinal or paraspinal point
tenderness
Pertinent Results:
[**2190-9-1**] 10:03AM LACTATE-2.9*
[**2190-9-1**] 09:40AM GLUCOSE-140* UREA N-14 CREAT-1.1 SODIUM-141
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13
[**2190-9-1**] 09:40AM ALT(SGPT)-271* AST(SGOT)-220* ALK PHOS-216*
AMYLASE-44 TOT BILI-1.9*
[**2190-9-1**] 09:40AM LIPASE-29
[**2190-9-1**] 09:40AM ALBUMIN-3.6 CALCIUM-8.5 PHOSPHATE-2.3*
MAGNESIUM-2.1
[**2190-9-1**] 09:40AM WBC-7.9 RBC-4.16* HGB-12.5 HCT-36.1 MCV-87
MCH-30.1 MCHC-34.7 RDW-13.6
[**2190-9-1**] 09:40AM NEUTS-91.4* BANDS-0 LYMPHS-5.9* MONOS-2.4
EOS-0.1 BASOS-0.2
[**2190-9-1**] 09:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2190-9-1**] 09:40AM PLT SMR-LOW PLT COUNT-148*
[**2190-9-15**]
06:20a
138 104 12 102 AGap=10
4.0 28 1.0
Ca: 8.2 Mg: 1.9 P: 2.5
ALT: AP: Tbili: Alb:
AST: LDH: 214 Dbili: TProt:
[**Doctor First Name **]: Lip:
Other Blood Chemistry:
Hapto: Pnd
87
8.6 9.0 543
26.3
[**2190-9-13**]
3:00p
Free-T4:1.2
Other Blood Chemistry:
CRP: 186.8
New Reference Ranges As Of [**2189-6-26**];Low Risk <1.0, Average Risk
1.0-3.0, High Risk >3.0 (But <10.0)
SED-Rate: 93
[**2190-9-13**]
10:31a
Color
Straw Appear
Clear SpecGr
1.010 pH
8.0 Urobil
Neg Bili
Neg
Leuk
Neg Bld
Neg Nitr
Neg Prot
Tr Glu
Neg Ket
Neg
RBC
0 WBC
0 Bact
None Yeast
None Epi
0
[**2190-9-10**]
06:00a
TSH:11
[**2190-9-6**]
08:21a
ALT: AP: Tbili: Alb:
AST: LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 19
[**2190-9-4**]
12:50a
TNT,CP,CPMB ADDED 135AM,[**2190-9-4**]
MB: 5 Trop-*T*: 0.02
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Other Blood Chemistry:
proBNP: 7662
Reference Values Vary With Age, Sex, And Renal Function;At 35%
Prevalence, Ntprobnp Values; < 450 Have 99% Neg Pred Value;
>1000 Have 78% Pos Pred Value;See Online Lab Manual For More
Detailed Information
[**2190-9-2**]
05:36a
Other Urine Chemistry:
Osmolal:627
[**2190-9-1**]
09:40a
N:91.4 Band:0 L:5.9 M:2.4 E:0.1 Bas:0.2
.
[**9-1**] ERCP
ERCP: Ten ERCP images were obtained by Dr. [**Last Name (STitle) 6745**].
Cholangiogram demonstrates a dilated common duct with numerous
filling defects. By report a sphincterotomy was performed and
stones were extracted. Residual impacted stones were observed
and a biliary stent was placed.
.
[**9-7**] CXR: AP single view of the chest obtained with the patient
in semi-erect position is analyzed in direct comparison with a
similar study obtained [**9-6**]. The bilateral pleural
effusions remain practically unchanged. Heart size as before. No
new parenchymal infiltrates are seen, and the accessible lung
fields demonstrate unchanged pulmonary vasculature.
.
[**9-6**] ECHO:
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
EKG [**9-8**]: NSR 68, nl intervals, TWI in II/III, no ST changes.
.
[**9-8**] CXR
HISTORY: [**Age over 90 **]-year-old woman with low oxygenation.
IMPRESSION: AP and lateral chest compared to [**9-6**] and
12:
Moderate bilateral pleural effusion, right greater than left,
has increased slightly on the right. Mild-to-moderate
enlargement of the cardiac silhouette is more pronounced. There
could be a component of pericardial effusion. Aside from
relaxation atelectasis at the lung bases, there is no focal
pulmonary abnormality, though there is pulmonary vascular
engorgement.
.
[**9-12**] CXR
Compared with [**2190-9-11**], no significant change is detected. Again
seen are small bilateral pleural effusions, with underlying
collapse and/or consolidation. There is cardiomegaly, with an
unfolded aorta. No CHF is identified. Aside from the bases, no
focal infiltrate is identified.
IMPRESSION: No significant change compared with one day earlier.
Bilateral pleural effusions with underlying collapse and/or
consolidation. Lungs otherwise grossly clear. Background COPD
noted.
.
[**9-13**]
CT OF THE ABDOMEN WITH IV CONTRAST: There are bibasilar
effusions with adjacent areas of compressive atelectasis. The
right effusion is moderate in size.
There is a stent in the common bile duct, with associated
pneumobilia centrally, but there is no intra- or extrahepatic
biliary ductal dilatation. No focal liver lesions are
identified. The patient is status post cholecystectomy. The
spleen, pancreas, and adrenal glands are within normal limits.
There is a 3.6 cm diameter hypoattenuating lesion in the lower
pole of the left kidney with relatively high density. This may
represent a cyst with hemorrhage, but is not fully characterized
here.
There is a large hiatal hernia. Apparent wall thickening of the
distal colon is probably due to underdistension. The stomach,
small and large, bowel, are unremarkable. There is no evidence
of obstruction. There is no lymphadenopathy or free air or
fluid.
There is a partly saccular infrarenal abdominal aortic aneurysm
with maximal diameter of the aorta of 3.2 cm. There are
extensive vascular calcifications as well. There are fairly
large calcifications in the mesentery in the pelvis. These may
represent unusual phleboliths. There is no free fluid.
BONE WINDOWS: There is marked leftward convex scoliosis of the
mid lumbar spine with degenerative change but no suspicious
lytic or blastic lesions.
IMPRESSION:
1. Bilateral effusions, right greater than left.
2. Bibasilar opacities which are more suggestive of atelectasis
than pneumonia.
3. Stent in the common bile duct with associated pneumobilia.
Cholangitis cannot be excluded by this study but there is no
parenchymal abnormality in the liver or evidence of biliary
ductal dilatation or enhancement to raise the possibility based
on the CT.
4. Large left-sided renal cystic lesion. This may represent a
renal cyst with hemorrhage but an ultrasound could be performed
to confirm.
5. Abdominal aortic aneurysm.
6. Status post cholecystectomy.
.
[**9-14**] CT Chest
FINDINGS: There are bilateral pleural effusions, moderate on the
right, small on the left. There is associated bilateral
compressive basal atelectasis. There is centrilobular emphysema
predominantly in both upper lobes. Fine detail is obscured by
motion artifact. Adjacent to the area of centrilobular emphysema
in the right upper lobe, there is a focal area of bronchiectasis
and bronchial thickening. No mass is appreciated, but small
lesions may be below the detection threshold given the motion
artifact. Emphysematous changes are also seen in the lower lobes
but partially obscured by the pleural effusion. Pleural effusion
extends into the right major fissure.
There is mild cardiomegaly. No pericardial effusion is seen.
Atherosclerotic calcifications are seen within the coronary
arteries, aorta, and the origin of great vessels. The airways
appear patent to the level of the subsegmental bronchi.
Non-contrast images through the upper abdomen demonstrate a
stent in the common bile duct with associated pneumobilia. A
hypoattenuating exophytic lesion arising from the left kidney is
incompletely visualized. Significant motion artifact obscures
details in the right kidney. There is a moderate to large hiatal
hernia.
BONE WINDOWS: No suspicious lytic or blastic lesions are seen.
Thoracic scoliosis with significant associated degenerative
changes is noted.
IMPRESSION:
1. Centrilobular emphysema, with predominance in both upper
lobes.
2. Focal area of bronchial thickening and bronchiectasis
posteriorly in the right upper lobe. An infectious process
including tuberculosis cannot be excluded.
3. Bilateral pleural effusions, right greater than left with
associated compressive atelectasis at the lung bases.
4. Mild cardiomegaly with severe coronary artery atherosclerotic
calcifications.
5. Large hiatal hernia.
6. Hypoattenuating lesion arising from the left kidney, better
visualized on the CT of [**9-13**].
7. Partial visualization of common bile duct stent and
pneumobilia better visualized on CT of [**2190-9-13**].
8. Moderate to severe thoracic scoliosis and degenerative
changes.
Brief Hospital Course:
[**Age over 90 **] yo F with HTN, hypothyrodisim, and COPD who presented to [**Hospital1 **]
[**Location (un) 620**] with fevers, elevated LFTs, and CT abd concerning for
cholangitis. She was transferred to [**Hospital1 18**] for ERCP with
sphincerotomy and stent placement ([**9-1**]). She was then taken for
a lap ccy ([**9-3**]). Post op she was noted to be increasingly
somnolent in the setting of pain control post op with lack of
spontaneous breathing. Given narcan. Transfered to the [**Hospital Unit Name 153**]. She
was placed on unasyn for abx coverage post op in the [**Hospital Unit Name 153**]. [**Hospital Unit Name 153**]
course notable for improvement in mental status. She was
transferred to the SICU for hypotension and low UOP. She was
called out of the SICU to the floor but then returned to the
SICU for resp distress, satting 91% on 6L. An ABG showed
7.51/73/30, concerning for resp alkalosis. A CXR on [**9-6**] showed
? new infiltrate. She was placed on levoquin 250mg and flagyl.
She returned to the floor with a fever to 101.2 on [**9-7**], sats
remained in the low 90's on [**1-29**] L NC. She desatted to 93% on 4L
with activity with PT.
.
She was transferred to the medicine service on [**9-9**] for further
management before discharge to [**Hospital1 1501**]. Hospital course on medicine
as follows:
.
# Hypoxia: Likely a mixed picture due to PNA/ COPD exacerbation
vs CHF (diastolic dysf w/ nl EF). Pt had a fever to 101.1
([**9-6**]-->[**9-7**]) with a prod cough and CXR suggestive of an
infiltrate. In addition, her prior exam suggested vol overload.
In someone with exisiting COPD, these two additional ailments
would compromise her pulmonary status. By discharge, she had a
minimal O2 req (2L) and was afebrile >24 hrs with decreased SOB.
a. for PNA: likely nosocomial as this happened in-house.
--switched from levoquin to piperacillin/taz as she spiked
through the Levo. Will continue a 7 day course.
.
b. for CHF: in mild decompensated CHF. Likley [**1-28**] vol overlaod
during surgery as well as from hypoixa causing HTN/increased
afterload and susequent pulm edema. She was diuresed > 4 L and
her respiratory status improved.
-- her Is=Os X several days so no standing furosemide was
continued, she will be dishcarged on 10 mg fuosemide prn if
weight increases or I > O
.
#) L ankle pain: She complained of L ankle pain on ambulation.
It continues to be edematous (L >R) mildly TTP on lateral aspect
of L ankle with minimal erythema. XR did not show an acute
fracture. Rheum consult did not feel that her ankle was the
source of her fever and there was not an effusion to be tapped.
.
#) Urinary retention: foley was replaced [**1-28**] urine output.
Likely [**1-28**] retention or urethral inflammation.
- continue foley for now; recommend attempts at d/c in NH
.
#) Mouth pain: [**1-28**] dry mouth/cracked lips.
- magic mouthwash, tylenol prn
.
#) Normocytic Anemia: likely 2/2 blood loss from surgery and
serial phlebotomy. Her hematocrit was 36 on admission and 26 on
discharge. There was no evidence for hemolysis. She did not
receive any transfusions during her hospital course.
.
#) Hypothyroidism: TSH was found to be elevated at 11, so her
levothyroxine dose was increased to 75 mcg q day.
- her TSH should be re-checked in 3 weeks.
.
#) HTN: continued metoprolol. BP well-controlled during hospital
stay.
.
#) FEN: low-sodium diet, replete lytes prn
.
#) Prophylaxis: sc heparin, PT consult
.
#) Code Statue: Full, confirmed with patient on [**9-9**]
.
#) Contact: [**Name (NI) **] [**Name (NI) **] [**Name (NI) 68317**] ([**Telephone/Fax (1) 68318**]
.
#) Dispo: d/c to The Crossing with IV antibiotics and continuous
O2
- she will need re-evaluation of her AAA in 6 months
- f/u with PCP [**Last Name (NamePattern4) **] 2 weeks.
.
Medications on Admission:
levoxyl 50 mcg qd
oxazepam 15 mg tid
prevacid 30 mg qd
metoprolol 25 mg [**Hospital1 **]
Carafate
Vit C
Calcium
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
q4-6h prn as needed for shortness of breath or wheezing.
5. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO tid prn as
needed for anxiety or insomnia.
6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO BID PRN () as
needed for anxiety.
9. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 4 days.
10. Levothyroxine Oral
11. Outpatient Lab Work
Please check CBC on Monday, [**9-20**].
12. Outpatient Lab Work
Please check TSH in 3 weeks
13. Furosemide 20 mg Tablet Sig: [**12-28**] Tablet PO q day prn as
needed for Intake > Output or increasing daily weight.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Ascending Cholangitis
Cholelithiasis
Pneumonia
COPD
HTN
Hypothyroidism
Stress incontinence
Urinary retention
Discharge Condition:
Hemodynamically Stable
Discharge Instructions:
Please take all medications as instructed. There were several
changes made to your current medications regimen.
If you experience any nausea, vomiting, lightheadedness, chest
pain, shortness of breath, or any other concerning symptoms
please seek medical attention immediately.
Followup Instructions:
Please follow-up with your primary care doctor within 2 weeks of
discharge.
.
Please re-check TSH in 3 weeks.
.
Please check daily weights. If I > O in 24 hrs, please give
furosemide 10 mg po.
.
Please make a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Surgeon)
within the next 3 weeks. Tel ([**Telephone/Fax (1) 9000**].
.
She will need repeat imaging in 6 months to follow her AAA.
ICD9 Codes: 486, 496, 4280, 5185, 5119, 2851, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6156
} | Medical Text: Admission Date: [**2155-4-25**] Discharge Date: [**2155-4-27**]
Date of Birth: [**2079-8-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
groin hematoma
Major Surgical or Invasive Procedure:
Cardiac catheterization with 2 Cypher stents to RCA and LAD
History of Present Illness:
75F with HTN, ex smoker who developed substernal chest pressure
and discomfort and burping. Patient went to [**Hospital3 **]
hospital where an EKG noted TWI on EKG, serial Troponins of
0.05, 0.43, 0.28, and ECHO showed an EF of 40%. Patient was
transferred to [**Hospital1 18**] for catheterization for symptoms of
unstable angina & MI.
.
Patient underwent catheterization this am with the following
intervention: Cypher stent to the RCA and Cypher stent to the
LAD.
.
Post cath the patient felt nauseous, lightheaded, was found to
have SBP in 70's. Patient was bleeding from the groin, pressure
was held for 45 minutes. Hct @ 11:00 am was 28, baseline Hct is
34.
Past Medical History:
Other Past History:
HTN
Dyslipidemia
Rheumatoid Arthritis
s/p CCY
s/p cataract removal
Osteoporosis
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. .
Family History:
There is no family history of premature coronary artery disease
or sudden death
Physical Exam:
Blood pressure was 108/48 mm Hg while seated. Pulse was 79
beats/min and regular, respiratory rate was 18 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma, there were pale conjunctiva. There was
no pallor or cyanosis of the oral mucosa. The neck was supple
with JVP of 1cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to auscultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed large R-sided groin hematoma extending proximally
to the umbilical ligamet and distally to the upper thigh. There
was no stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1 PT 1
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+
Pertinent Results:
Imaging:
CT PELVIS W/O CONTRAST [**2155-4-25**] 1:39 PM
IMPRESSION: Extensive superficial soft tissue stranding
consistent with blood dissecting around the fat planes and
muscles in the right inguinal region extending mid way down the
right thigh without discrete collection identified. No
retroperitoneum hematoma.
.
FEMORAL VASCULAR US [**2155-4-25**] 1:37 PM
IMPRESSION:
1. Infiltration of the subcutaneous soft tissues of the right
groin consistent with hematoma formation.
2. No evidence of pseudoaneurysm or arteriovenous fistula.
.
C.CATH Study Date of [**2155-4-25**]
COMMENTS:
1. Coronary angiography of this right dominant system
demonstrated 2
vessel coronary artery disease. The LMCA and LCx had no
angiographically apparent flow-limiting disease. The LAD had a
90%
eccentric stenosis after S1. The RCA had a subtotal occlusion
of the
mid-vessel.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressure with a BP of 121/65 mmHg.
3. Successful PCI/stent to mid LAD with a 2.5x13mm Cypher stent
deployed
to 14atms. Normal flow and no residual stenosis.
4. Successful PCI/stent to mid RCA with a 2.5x13mm Cypher stent
postdilated with a 2.5mm Quantum Maverick balloon. Normal flow
with no
residual stenosis.
5. Delayed failure of Angioseal closure device with development
of large
groin haematoma which was stabilized with manual compression.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PCI/stent to mid LAD with a Cypher stent.
3. Successful PCI/stent to mid RCA with a Cypher stent.
4. Delayed failure of Angioseal closure device stablized with
manual
compression.
.
ECHO Study Date of [**2155-4-26**]
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the mid-
and distal anterior septum (in the distribution of the LAD).
The apex is probably hypokinetic, but is not fully visualized.
The other segments contract normally. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
consistent with coronary artery disease. Mild pulmonary
hypertension.
.
Micro:
None
.
Labs:
[**2155-4-25**] 11:06AM BLOOD Hct-28.2*
[**2155-4-25**] 12:54PM BLOOD Hct-34.5*
[**2155-4-26**] 04:21AM BLOOD WBC-8.7 RBC-3.74* Hgb-11.3* Hct-33.6*
MCV-90 MCH-30.2 MCHC-33.6 RDW-17.4* Plt Ct-171
[**2155-4-27**] 04:04AM BLOOD WBC-9.5 RBC-3.46* Hgb-10.6* Hct-31.3*
MCV-90 MCH-30.6 MCHC-33.9 RDW-17.4* Plt Ct-177
[**2155-4-25**] 12:51PM BLOOD Glucose-135* UreaN-15 Creat-0.8 Na-139
K-3.6 Cl-108 HCO3-24 AnGap-11
[**2155-4-25**] 09:16PM BLOOD CK(CPK)-950*
[**2155-4-26**] 04:21AM BLOOD CK(CPK)-884*
[**2155-4-25**] 09:16PM BLOOD CK-MB-18* MB Indx-1.9 cTropnT-0.10*
[**2155-4-26**] 04:21AM BLOOD CK-MB-15* MB Indx-1.7 cTropnT-0.09*
[**2155-4-25**] 12:51PM BLOOD Calcium-7.1* Phos-2.7 Mg-1.6
[**2155-4-26**] 04:21AM BLOOD Albumin-3.3* Calcium-7.0* Phos-2.8 Mg-2.4
[**2155-4-27**] 04:04AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.2
[**2155-4-26**] 04:21AM BLOOD Cortsol-19.8
Brief Hospital Course:
75F with NSTEMI at OSH, admitted to CCU with R groin hematoma
with hypotension s/p catheterization.
.
#. Right Groin Hematoma - Patient with groin hematoma not
susceptible to compression. Patient also hypotensive, thus was
started on Dopamine gtt and given a total of 3U of pRBC for
intravascular support. Patient remained on the dopamine for <24
hours as her BP stabilized. With imaging, (official results
above) patient did not have an RP bleed, or
pseudoaneurysm/fistulazation femoral vessels. Vascular Surgery
assessed the patient and with the imaging, was not deemed to be
a surgical candidate. Clinically the patient stabilized quickly
and her Hct remained stable upon discharge.
.
#. CAD - Patient was continue plavix/ASA, and a statin was
started. cardiac enzymes were cycled and objectively the
patient did not have myocardial ischemia.
#. Pump - Patient was restarted on Atenolol 50' prior to
discharge without event.
#. Rhythm - Patient monitored on telemetry without event.
.
#. Rheumatoid Arthritis - Patient restarted on Prednisone 2.5'
prior to discharge.
.
.
After discussion with the patient and the medical staff, all
were in agreement that [**Known firstname **] [**Known lastname **] was a suitable candidate
for discharge.
Medications on Admission:
Plavix 75 qd
ASA 325 mg qd
HCTZ 25 [**Hospital1 **]
Inderal 80 mg [**Hospital1 **]
PPI 40 qd
Hydroxychloroquine 200 qd
Lisinopril 20 qd
Norvasc 10 qd
Prednisone 2.5 mg qd
Folate
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
8. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week.
9. Methotrexate Sodium 5 mg Tablet Sig: One (1) Tablet PO once a
week.
10. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Glucosamine 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ST elevation MI c/b groin hematoma
Discharge Condition:
Stable to be discharged home.
Discharge Instructions:
Please take all medications as indicated below. Your
hydrochlorothiazide(HCTZ), and Lisinopril are being held.
Please do not take these medications until instructed by your
cardiologist.
We have started a new medication called Atenolol 50mg to replace
your Inderal. This is to be taken once daily. We have also
started a new medication called Lipitor (Atorvastatin) at a dose
of 80mg, which is also to be taken once daily. Continue to take
all of your other medications as you were previously doing.
You had two stents placed in your heart. You must take Aspirin
everyday for the rest of your life and Clopidegrel (Plavix)
everyday for at least the next 9 months. If you are not able to
take this medication for any reason, you must contact your
cardiologist immediately.
If you develop chest pain, shortness of breath, lightheadedness,
fainting or passing out, fever, pain in your groin, or any other
concerning symptoms, please call your doctor or report to the
nearest ER.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 5686**] (your cardiologist) at [**Telephone/Fax (1) 11554**]
on Tuesday to schedule follow up in the next week so that your
blood pressure can be checked and your Lisinopril can be
restarted.
Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 23873**] 1-2 weeks after discharge. Call [**Telephone/Fax (1) 23874**] to schedule
that appointment.
Completed by:[**2155-4-30**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6157
} | Medical Text: Admission Date: [**2139-5-26**] Discharge Date: [**2139-6-4**]
Date of Birth: [**2090-7-7**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 48 year-old man
with a history of CREST syndrome times 25 years and a more
recent history of dyspnea on exertion worsening over the past
several months. The patient was admitted to the hospital in
late [**2139-2-21**] and diagnosed with severe pulmonary
hypertension by echocardiogram and right heart
catheterization, which showed a pulmonary artery pressure of
86 and a pulmonary capillary wedge pressure of 19. The
patient was discharged on [**3-31**] on Bosentan 62.5 mg twice
a day as well as Lasix. He took the Bosentan for a month
without relief, then stopped for ten days due to loss of
insurance and then restarted at 125 mg twice a day. The
patient notes that he did not fill his Lasix prescription
following the [**Month (only) 958**] discharge and did not check his daily
weights. Over several days after restarting the Bosentan the
patient noted increasing dyspnea on exertion, shortness of
breath, bilateral peripheral lower extremity edema,
paroxysmal nocturnal dyspnea, and increasing orthopnea. He
was referred to the Emergency Department where he was
admitted for the initiation of continuous infusion Flolan
treatment, which had previously been planned for a week after
the time of his deterioration.
REVIEW OF SYSTEMS: At the time of admission revealed severe
right digital pain in the right upper extremity secondary to
Raynaud's. The patient denies fevers or chills, nausea and
vomiting, chest pain, abdominal pain, change in bowel habits,
melena or bright red blood per rectum.
PAST MEDICAL HISTORY:
1. CREST syndrome diagnosed 25 years ago. The patient has a
history of digital ulcers secondary to Raynaud's phenomenon
and is status post right laparoscopic sympathectomy in
[**2138-9-21**] without symptomatic relief.
2. Gastroesophageal reflux disease with esophageal
stricture.
3. Pulmonary hypertension first noted on echocardiogram in
[**2135**] and recently diagnosed as described in the history of
present illness. The patient is on 4 liters of home O2.
4. Mild restrictive lung disease with a decreased DLCO.
5. History of upper gastrointestinal bleed.
6. Status post left hernia repair.
ALLERGIES: The patient notes nausea and vomiting with
morphine and codeine and itching with Percocet.
PHYSICAL EXAMINATION ON ADMISSION TO THE FLOOR: Vital signs
temperature 98.9. Pulse 73. Blood pressure 108/48.
Respirations 15. O2 sat 92% on room air. The patient was
alert and oriented times three and complaining of digital
pain. He was in no acute distress. The pupils are equal,
round and reactive to light. Extraocular movements intact.
His mucous membranes are moist with telangiectasias. There
was no cervical lymphadenopathy. The patient did have
jugulovenous distention to about 16 cm. Lung examination
revealed diffuse mild crackles throughout bilaterally with
resonant percussion. Heart examination showed a regular rate
and rhythm with a normal S1 and a split S2 with a loud P2.
There was also a 2 out of 6 systolic ejection murmur heard
best at the left upper sternal border. Extremity examination
revealed no clubbing or cyanosis. The patient did have 1+
edema in the lower extremities bilaterally to the mid calf
level. The calves were discolored with multiple brownish red
indurated nodular lesions, which were nontender. The upper
extremities had significant digital ulceration on digits one
through four of the right hand. Neurological examination was
notable for intact cranial nerves and intact strength and
sensation in the upper and lower extremities bilaterally.
LABORATORY DATA ON ADMISSION: White blood cell count 6.7,
hematocrit 34.9, platelet count 211. Electrolytes sodium
139, potassium 4.0, chloride 103, bicarbonate 25, BUN 18 and
creatinine 1.2 with a glucose of 94.
Admission electrocardiogram showed normal sinus rhythm, T
wave inversion in 1, 2, and 3 with poor R wave progression
and T wave inversion in V1 through V5. There were also new T
wave inversions in 2, 3 and AVF.
HOSPITAL COURSE: The patient was admitted to the MICU on [**5-26**]. He was ruled out for myocardial infarction and diuresed
with Lasix. A Swan-Ganz catheter was placed and the Flolan
was started on [**5-27**]. A Hickman catheter was placed by
general surgery on [**5-29**] and the patient was called out of
the MICU to the medical floor. The Flolan was titrated to 9
nanograms per kilogram per minute with moderate flushing,
headache and nausea. These side effects were treated with
Compazine and Vicodin. A Flolan dose of 10 nanograms per
kilogram per minute was attempted on [**6-1**], but was
decreased back to 9 nanograms per kilogram per minute due to
hypotension to 90/45. The patient did note improvement in
his dyspnea on exertion in the days following the Flolan
initiation. An outside agency provided Flolan teaching for
the patient's sister who will prepare the Flolan at home. A
Flolan nurse will visit the home daily in the week following
discharge.
Also during this admission pain service was consulted
regarding the patient's digital ulcer pain. The pain was
treated with Oxycontin with Vicodin for breakthrough.
Oxycontin was increased from 30 b.i.d. to 30 t.i.d. on [**6-1**], but was changed to 40 b.i.d. on [**6-4**] secondary to
increased sedation. In addition, on [**6-3**] the patient
complained of severe throat pain and pharyngeal edema and
exudate were noted on examination. A culture was sent and
Amoxicillin was started for a presumed strep throat. The
patient was discharged to home in stable condition.
DISCHARGE STATUS: Good.
DISCHARGE DIAGNOSES:
1. CREST syndrome.
2. Pulmonary hypertension.
DISCHARGE MEDICATIONS:
1. Flolan 9 nanograms per kilogram per minute intravenous
infusion.
2. Oxygen 4L by NC
3. Furosemide 60 mg po q.d.
4. Coumadin 1 mg po q.h.s.
5. Oxycontin 40 mg po b.i.d.
6. Vicodin one to two tablets po q 6 hours as needed for
pain.
7. Lorazepam 0.5 mg po t.i.d.
8. Prazosin 1 mg po t.i.d.
9. Diltiazem SR 480 mg po q.d.
10. Compazine 10 mg po q six hours prn nausea.
11. Pantoprazole 40 mg po b.i.d.
12. Sucralfate 1 gram po q.i.d.
13. Ferrous sulfate 325 mg po q.d.
FOLLOW UP PLANS: The patient is to follow up within the next
two weeks with Dr. [**Last Name (STitle) **] in Pulmonology, Dr. [**Last Name (STitle) **] his
primary care physician, [**Name10 (NameIs) **] Dr. [**Last Name (STitle) **] his rheumatologist.
These appointments have been scheduled for him.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 103528**]
Dictated By:[**First Name3 (LF) 103529**]
MEDQUIST36
D: [**2139-6-4**] 03:49
T: [**2139-6-10**] 09:27
JOB#: [**Job Number 103530**]
ICD9 Codes: 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6158
} | Medical Text: Admission Date: [**2200-1-8**] Discharge Date: [**2200-1-24**]
Date of Birth: [**2200-1-8**] Sex: F
HISTORY OF PRESENT ILLNESS: [**Location (un) 16284**] is a 33 5/7 weeks
gestation triplet #2 delivered pre-term due to progressive
pregnancy-induced hypertension. The mother is a 34 year old
gravida 2, para 3. Prenatal screens: blood type 0 positive,
B surface antigen negative and Group Beta Streptococcus
status unknown. In [**Last Name (un) 5153**] fertilization conception with
triamniotic trichorionic triplets, estimated date of confinement
[**2200-2-21**]. This pregnancy was complicated by pre-term labor
at 24 weeks gestation treated with a complete course of
Betamethasone at that time and magnesium sulfate for one month.
The mother developed pregnancy-induced hypertension, headache and
delivered by cesarean section under general anesthesia
(due to inadequate epidural analgeisa) on [**2200-1-8**] at 33
5/7 weeks gestation. This triplet emerged with spontaneous cry
and required only blow-by oxygen for resuscitation. Apgar scores
were 8 at one minute and 8 at five minutes. The infant was
transferred to the Newborn Intensive Care Unit secondary to
prematurity.
PHYSICAL EXAMINATION: Vital signs revealed temperature 98.1
rectally, heartrate 140, respiratory rate 64, blood pressure
57/25 with a mean arterial pressure of 38, oxygen saturation
of 97%. Birthweight was 1525 gm, (15th percentile), length
was 43 cm, (30th percentile) and head circumference 29 cm
(15th percentile). Overall appearance is consistent with
known gestational age, nondysmorphic. Anterior fontanelle is
soft, open and flat. Red reflex present bilaterally.
Palates intact. Breathsounds clear and equal. Heart is
regular rate and rhythm without murmur. Abdomen is benign
without hepatosplenomegaly. No masses. Three vessel
umbilical cord. Normal female genitalia for gestational age,
back and extremities normal. Skin pink and well perfused.
Alert and comfortable with appropriate tone and strength for
gestational age.
HOSPITAL COURSE:
Respiratory - [**Location (un) 16284**] has been room air since her
delivery. She has had no issues with apnea of prematurity
and no Methylxanthines were required.
Cardiovascular - [**Location (un) 37871**] blood pressure has been stable
since her admission to the Newborn Intensive Care Unit. No
fluid boluses or support with vasopressors were required.
Fluid, electrolytes and nutrition - Enteral feedings were
started on day of life 1 of premature Enfamil 20 calorie with
iron. The volume was advanced to 150 cc/kg/day by day of
life #6 without incident and caloric density was advanced to
a maximum of 26 cal/oz. Her blood glucoses remained stable
throughout her hospitalization. Discharge weight is 1685 grams .
Discharge length 43 cm. Discharge head circumference 30 cm
cm.
Gastrointestinal - Peak bilirubin on day of life #3 was 8.6
with a direct of 0.3. She was started on single phototherapy
at that time. Phototherapy was discontinued on day of life
#7 and rebound bilirubin on day of life 9 was 5.7.
Hematology - [**Location (un) 16284**] did not require any transfusions with
blood products throughout her hospitalization.
Infectious disease - Complete blood count with differential
and blood culture was not drawn upon admission to the Newborn
Intensive Care Unit as there were no sepsis risk factors and
delivery was strictly for maternal reasons. The infant has
been well and has not shown any signs of infection.
Neurology - Head ultrasound was not indicated for this 33 [**4-15**]
weeker.
Sensory - Hearing screen was performed with automated
auditory brain stem responses on [**1-13**] and she passed in
both ears. Ophthalmologic screening was not performed given her
gestational age.
Psychosocial - [**Hospital6 256**] social
work has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **].
CONDITION AT DISCHARGE: [**Location (un) 16284**] is stable, tolerating full ad
lib feedings. Temperature stable, in open crib and no apnea
of prematurity.
DISCHARGE DISPOSITION: To home with parents.
PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) **] of [**Hospital 620**] Pediatrics,
phone [**Telephone/Fax (1) 37814**].
CARE RECOMMENDATIONS:
Feeds at discharge - The infant is being discharged on ad lib
demand feedings of 26 calorie Enfamil enriched to 26 calories by
concentration and 2 calories of corn oil per oz.
Medications - Ferinsol 0.15 ml PO once daily.
State newborn screening status - The last newborn screen was
sent on [**1-22**] and no abnormal results have been
reported.
Immunizations - [**Location (un) 16284**] has not received any immunizations at this
time. Synagis respiratory syncytial virus prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of
the following three criteria: 1. Born at less than 32 weeks; 2.
Born between 32 and 35 weeks with plans for daycare during
respiratory syncytial virus season, with a smoker in the
household or with preschool siblings; or 3. With chronic lung
disease. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
Follow up - A follow up appointment with Dr. [**Last Name (STitle) **] has been
scheduled for [**1-24**].
DISCHARGE DIAGNOSIS:
1. Prematurity at 33 5/7 weeks
2. Hyperbilirubinemia
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Name8 (MD) 37391**]
MEDQUIST36
D: [**2200-1-23**] 16:33
T: [**2200-1-23**] 16:43
JOB#: [**Job Number 37872**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6159
} | Medical Text: Admission Date: [**2178-7-8**] Discharge Date: [**2178-7-11**]
Service: NMED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Left-sided weakness
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
History of Present Illness:
Patient is an 82 year-old Russian-speaking woman with a history
of coronary artery disease and hypertension who presents with
sudden onset left-sided weakness.
Pt went to bed at 11pm the night prior to admission and was
normal at that time. This morning at 6am, husband woke up and
found patient had been incontinent of stool. He reports she was
"not making any sense" when speaking, unclear if the difficulty
was due to slurring of words vs inappropriate word usage. She
was able to sit up, but then fell out of bed, with inability to
use her left side. EMS was called, and the patient was brought
to the [**Hospital1 18**] ED. On arrival in the ED, SBP was ~190, and she was
seen to have spontaneous movement on the right but not the left.
She had no gag reflex and son[**Name (NI) 7884**] respirations, and she was
paralyzed and intubated for airway protection. Head CT was
consistent with early R MCA ischemic stroke, and pt was admitted
to the neurology ICU service.
ROS: Per patient's family, she does have occasional dyspnea on
exertion, unable to characterize further.
Past Medical History:
1. Coronary artery disease, s/p myocardial infarction ~5 yrs
ago. Has not ever had cardaic cath.
2. Hypertension
3. High cholesterol
Social History:
Lives with husband. [**Name (NI) **] one son and daughter-in-law, both of
whom speak English. Per family, patient was fully independent.
No history of tobacco or EtOH use.
Family History:
Unclear, though son doesn't think there is history of stroke
Physical Exam:
T 96.0 BP 169-175/39-45 HR 70-81
Vent: SIMV/PS 450x16, PEEP 5, FiO2 0.4
General: Appears stated age, intubated, seems calm
HEENT: NC/AT Sclera anicteric.
Lungs: Clear to auscultation anterolaterally on right, decreased
and coarse breath sounds on left
CV: RRR, nl S1, S2, no murmur. 2+ carotids without bruit
Abd: Soft, nontender, normoactive bowel sounds
Extr: No edema
Neurologic Examination:
Mental Status: Intubated, awake, follows some commands in
Russian (see below)
Cranial Nerves: Does not open eyes to command. Does not blink to
confrontation. Pupils small (~1mm), but equal, round and briskly
reactive to light, bilaterally. Unable to do fundoscopic exam
due to small size of pupils. Does not move eyes to command.
Difficult to assess facial symmetry given ETT. Does not open
mouth or protrude tongue to command.
Motor:
Normal bulk bilaterally. Tone decreased in left upper extremity,
increased in left lower extremity, normal on right. No
fasiculations, no tremor.
Moves right arm and leg spontaneously and to command; can show
thumb, squeeze hand and let go, move foot. Strength roughly
intact on right. Does not move left side spontaneously nor to
command.
Sensation was intact to light touch on right. Does grimace, move
right side and slightly withdraw on left to painful stimuli on
left.
Toes were downgoing on right, upgoing on left
Pertinent Results:
Labs on admission:
WBC-11.5* HGB-12.8 HCT-39.6 MCV-96 PLT COUNT-222
PT-12.6 PTT-26.1 INR(PT)-1.1
GLUCOSE-143* UREA N-30* CREAT-1.1 SODIUM-143 POTASSIUM-5.3*
CHLORIDE-105 TOTAL CO2-26
CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.1 CHOLEST-154
TRIGLYCER-106 HDL CHOL-47 CHOL/HDL-3.3 LDL(CALC)-86
Cardiac enzymes were normal. UA was normal.
NON-CONTRAST HEAD CT [**7-8**]: No acute intra or extra-axial
hemorrhage or hydrocephalus. There is a dense MCA sign on the
right, particularly in the region of the bifurcation.
Furthermore, there is narrowing of the right cerebral
hemispheric sulci and there is loss of [**Doctor Last Name 352**]-white matter
differentiation in the insular and frontal and temporal cortex
on the right. The findings are consistent with an early right
MCA distribution infarction. Remaining brain shows evidence of
volume loss and chronic microvascular infarction.
MRI/MRA [**7-9**]: Large right MCA infarction with no definite
involvement of the basal ganglia. Susceptibility artifact is
present in infarct, indicating interval hemorrhage into the
area. There is edema which flattens the right lateral ventricle.
There is minimal shift of midline structures to the left.
Additionally, there are patchy areas of increased FLAIR and T2
signal in the left cerebral hemisphere. This may reflect chronic
microvascular infarction.
MRA of the circle of [**Location (un) 431**] is limited, but there is diminished
or no flow in the right Sylvian middle cerebral branches and
there also appears to be diminished left anterior cerebral
arterial flow. The vertebral arteries are only partially in
view.
Brief Hospital Course:
Assessment:
82F with histroy of HTN, hypercholesterolemia, presents with
acute onset left hemiparesis, with possible aphasia versus
dysarthria. Based on her initial physical exam, cranial nerves
seemed relatively intact, though cannot gauge extraocular
movements, making a brainstem localization less likely.
Therefore, lesion is likely cerbral peduncles or higher.
Inability to open eyes to command, when she can move right arm
and leg to command, raises possibility of oculomotor apraxia,
which would suggest involvement of right parietal lobe.
Unfortunately, because patient was intubated on arrival in ED,
language function, as well as attention could not be fully
assessed, and ability to follow commands has to be taken in the
context of sedatives as well. It was unclear if she has any
neglect.
Given her stool incontinence, initial differential diagnosis was
stroke, likely in the right MCA distribution, vs [**Doctor Last Name 555**]
paralysis secondary to seizure, though patient has no known
seizure disorder. Given findings on CT however, R MCA ischemic
infarct is the most likely diagnosis.
Hospital Course:
Pt was admitted to the neuro service with acute right MCA
infarct. She was not a candidate for TPA because she was outside
the 3-hour window. She was initally managed with continued ASA,
and maintenance of her systolic blood pressure between 140 and
200. MRI imaging the next day revealed the very large size of
the infarct, with involvement of nearly all of the cortical
territory of the MCA. As she had been taking ASA at home,
aggrenox was added. Initially, patient did well and was able to
be extubated on [**7-9**]. She continued to follow commands. On [**7-9**]
she also developed fever with chest x-ray with possible
infiltrate and she was started on levofloxacin.
Unfortunately, the very large size of the infarct resulted in
significant and severe cerebral edema, and by [**7-10**] her mental
status worsened. She developed a right, fixed, midposition pupil
secondary to the edema affecting her brainstem. Given the
severity of the infarct, it was unlikely that she would have a
meaningful neurological recovery. A family meeting was held on
[**7-10**], and it was decided to make the patient comfort measures
only.
Patient died at 6:45am on [**7-11**]. Family declined post-mortem
examination.
Medications on Admission:
Lipitor 10, atenolol 50, ASA, clonazepam 0.5
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
Funeral home
Discharge Diagnosis:
Large right middle cerebral artery infarction, complicated by
cerebral edema and herniation
Likely aspiration pneumonia
Airway compromise, requiring intubation, resolved
Discharge Condition:
Deceased
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 5070, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6160
} | Medical Text: Admission Date: [**2108-10-26**] Discharge Date: [**2108-10-29**]
Date of Birth: [**2031-9-28**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
gentleman with an extensive history of coronary artery
disease (status post multiple myocardial infarctions) who was
transferred from an outside hospital for cardiac
catheterization.
The following history is per the patient's daughter; as the
patient only speaks Portuguese. She reports that the patient
had increasing shortness of breath with exertion over the
week prior to admission. At 1 o'clock a.m. on the morning of
admission, the patient awoke from sleep with acute shortness
of breath. He decided to present to an outside hospital. At
approximately 7 o'clock a.m., while driving to the hospital,
the patient developed chest pain.
At the outside hospital, the patient was pain free after
receiving oxygen. He was found to have a troponin of 76.3, a
creatine kinase of 501, and a CK/MB of 20.8. The patient was
given a heparin bolus, and the decision was made to transfer
the patient to [**Hospital1 69**] for
cardiac catheterization. At that time, the heparin was
discontinued and the patient was started on Integrilin.
Other laboratories from the outside hospital included a
potassium of 3.9, creatinine of 1.4, and a hematocrit of 39.
His arterial blood gas at the outside hospital was 7.46/38/69
on 3 liters nasal cannula. Electrocardiogram revealed sinus
tachycardia at approximately 110 beats per minute. Axis was
approximately was 30 degrees. The patient had poor R wave
progression. There were a few changes from previous studies.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Type 2 diabetes mellitus.
3. Hypercholesterolemia.
4. Status post myocardial infarction times two;
(a) In [**2102-5-16**], the patient had a posterior/inferior
myocardial infarction with a cardiac catheterization showing
70% left anterior descending artery, 98% left circumflex, and
diffuse right coronary artery disease. The patient had
stenting of the left circumflex and the right coronary
artery.
(b) In [**2103-4-15**], the patient had an inferoseptal
myocardial infarction with cardiac catheterization showing
70% stenosis in the middle of the left anterior descending
artery, 40% stenosis in the second diagonal, and 70% in-stent
restenosis in the left circumflex which was intervened on.
(c) A redo catheterization in [**2103-5-16**] showed diffuse
proximal and mid disease in the left anterior descending
artery which was stented.
(d) the patient subsequently underwent redo catheterization
in [**2104-2-15**] when he was found to have left anterior
descending artery 50% narrowing prior to the stent, the left
circumflex stent was widely patent, and the right coronary
artery stent was widely patent.
5. Peripheral vascular disease.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lopressor 50 mg by mouth twice per day.
2. Pepcid 40 mg by mouth once per day.
3. Neurontin 100 mg by mouth three times per day.
4. Lasix 40 mg by mouth once per day.
5. Lipitor 10 mg by mouth once per day.
6. Moexipril 15 mg by mouth once per day
7. Xanax 0.5 mg by mouth twice per day.
8. Glyburide 5 mg by mouth twice per day.
SOCIAL HISTORY: The patient is a pleasant
Portuguese-speaking gentleman who is married and lives with
his wife. [**Name (NI) **] is a retired box maker. The patient has an
extensive tobacco history of one pack per day for
approximately 60 years. He quit smoking in [**2102**]. No history
of alcohol or drug abuse.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed his temperature was 99 degrees
Fahrenheit, his blood pressure was 103/59, his heart rate was
78, his respiratory rate was 22, and his oxygen saturation
was 96% on 4 liters nasal cannula. In general, the patient
was a mildly obese male in no acute distress with labored
breathing. Head, eyes, ears, nose, and throat examination
revealed pupils were equal, round, and reactive to light.
Extraocular movements were intact. The mucous membranes were
moist. Neck examination revealed increased jugular venous
pulsation at approximately 12 mm to 14 cm at 30 degrees.
Positive right carotid bruit. Cardiovascular examination
revealed normal first heart sounds and second heart sounds.
A regular rate. There was a [**3-22**] crescendo-decrescendo murmur
with radiation to the axilla. The lungs were clear to
auscultation anteriorly. There were bibasilar crackles. No
wheezes. The abdomen was soft, nontender, and nondistended.
Positive bowel sounds. No hepatosplenomegaly. Extremity
examination revealed 1 to 2+ pitting edema to the patellas
bilaterally. Dorsalis pedis pulses were 2+ bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed his white blood cell count was 10.9,
his hematocrit was 35.6, and his platelets were 197. His
prothrombin time was 13.4, his partial thromboplastin time
was 39.3, and his INR was 1.2. His sodium was 137, potassium
was 4.3, chloride was 101, bicarbonate was 27, blood urea
nitrogen was 22, creatinine was 1.4, and his blood glucose
was 285. His calcium was 9, his magnesium was 1.5, and his
phosphorous was 3.4. Creatine kinase was 370. CK/MB was 14.
Troponin was 3.72.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR ISSUES: Cardiac catheterization revealed
two patent left anterior descending artery overlapping
stents. The left circumflex was patent with very distal
upper branch disease and a large first obtuse marginal. The
right coronary artery and the AV groove was patent including
proximal stents. There was an eccentric 40% mid right
coronary artery lesions. The left anterior descending artery
was stented with a 3.25 X 18 cypher, and the right coronary
artery was stented with a 3 X 13-mm Hepacoat stent.
The patient received 20 mg of intravenous Lasix in the
Catheterization Laboratory with approximately 700 cc of urine
output.
Following the catheterization, the patient completed an
18-hour course of Integrilin. Throughout the admission, he
was also continued on an aspirin, Plavix, an ACE inhibitor, a
beta blocker, and a statin.
(a) Rhythm: The patient was in a sinus rhythm throughout
the admission. He was monitored continuously on telemetry.
(b) Myocardium: The patient had a congestive heart failure
exacerbation on admission to the hospital with increasing
shortness of breath, lower extremity edema, and exercise
intolerance over the week prior to admission. He had a good
diuresis in the Catheterization Laboratory following 40 cc of
intravenous Lasix. The patient continued to have a good
diuresis over the first one day of admission. His shortness
of breath resolved, and he felt much better.
The patient had previously had a poor left ventricular
ejection fraction of 20% to 30% on previous echocardiograms.
Therefore, a repeat echocardiogram was performed on [**2108-10-29**]. This revealed a mildly dilated left atrium. The
right atrium was normal in size. The left ventricular cavity
was severely dilated. There were multiple left ventricular
wall motion abnormalities including; mid anterior/akinetic,
mid anterior septal/akinetic, mid inferoseptal/akinetic, mid
inferior/akinetic, mid inferolateral/akinetic, anterior
apex/akinetic, septal apex/akinetic, inferior apex/akinetic,
lateral apex/akinetic, and apex/dyskinetic. The right
ventricular chamber size and free wall motion were normal.
The aortic root was mildly dilated as was the ascending
aorta. There was no aortic valve stenosis. There was trace
aortic regurgitation. Mild-to-moderate 1 to 2+ mitral
regurgitation was seen. There was borderline pulmonary
artery systolic hypertension. The estimated left ventricular
ejection fraction was less than 20%.
Given the patient's history of multiple myocardial
infarctions and very decreased left ventricular ejection
fraction, pacemaker placement was discussed. It was
determined that this would not be done as an inpatient, but
the patient was to follow up with Electrophysiology.
2. TYPE 2 DIABETES MELLITUS ISSUES: The patient was
continued on an insulin sliding-scale throughout his
admission with good blood sugar control.
3. RENAL ISSUES: The patient's creatinine was slightly
elevated at 1.4 prior to catheterization. Following
catheterization, he received intravenous hydration and
Mucomyst times two. Subsequently, his creatinine decreased
and was 1.3 at the time of discharge.
4. HYPERCHOLESTEROLEMIA ISSUES: The patient was continued
on a statin throughout his admission.
5. HYPERTENSION ISSUES: The patient was continued on his
ACE inhibitor and beta blocker. He had good blood pressure
control throughout the admission.
6. PULMONARY ISSUES: Following diuresis on admission, the
patient's shortness of breath greatly improved. On the day
of discharge, he was saturating in the mid 90% range on room
air. In addition, he was able to walk around the unit
without becoming short of breath.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSES:
1. Type 2 diabetes mellitus.
2. Hypercholesterolemia.
3. Hypertension.
4. Peptic ulcer disease.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Plavix 75 mg by mouth once per day.
3. Famotidine 40 mg by mouth once per day.
4. Gabapentin 100 mg by mouth three times per day.
5. Atorvastatin 10 mg by mouth once per day.
6. Alprazolam 0.5 mg by mouth twice per day.
7. Moexipril 15 mg by mouth once per day
8. Toprol-XL 50 mg by mouth once per day.
9. Glyburide 5 mg by mouth twice per day.
10. Lasix 40 mg by mouth once per day.
11. Nitroglycerin 0.3 mg sublingually one tablet as needed
(for chest pain).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with primary care
physician (Dr. [**Last Name (STitle) **] who also manages the patient's cardiac
issues in approximately one week.
2. The patient was instructed to follow up Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2108-10-28**] at 1 o'clock p.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**]
Dictated By:[**Name8 (MD) 18812**]
MEDQUIST36
D: [**2108-10-31**] 14:58
T: [**2108-11-3**] 06:56
JOB#: [**Job Number 18813**]
ICD9 Codes: 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6161
} | Medical Text: Unit No: [**Numeric Identifier 58391**]
Admission Date: [**2176-6-28**] Discharge Date: [**2176-7-5**]
Date of Birth: [**2176-6-28**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname **] twin II is a 2.5 kilogram product
of a 34 [**3-13**] week gestation born to a 42 year old gravida V,
para I mom. This pregnancy was a dichorionic diamniotic
twins gestation.
Prenatal screens: A positive, antibody
negative, RPR nonreactive, rubella immune, hepatitis B
negative and GBS unknown. This pregnancy was complicated by
unstoppable preterm labor. This infant was born by cesarean
section for failure to progress, emerged with Apgar scores of
8 and 8, was given positive pressure ventilation in the
delivery room.
EXAMINATION ON ADMISSION: Weight was 2.5 kilograms, 75th
percentile, head circumference 33 cm, 75th percentile, length
49 cm, 98th percentile. Normocephalic, atraumatic, anterior
fontanelle open and flat. Palate intact. Red reflex present
bilaterally. Neck supple Chest symmetric, intercostal
retractions with intermittent grunting. Lungs clear
bilaterally. Cardiovascular: Regular rate and rhythm, no
murmur, femoral pulses 2+ bilaterally. Abdomen soft with
active bowel sounds, no masses or distention. GU
demonstrates normal male testes bilaterally palpable. Spine
midline, no sacral dimple. Anus patent. Hips stable.
Clavicles intact. Neurologic appropriate for gestational
age.
HOSPITAL COURSE BY SYSTEMS: Respiratory: Initially required
nasal CPAP for mild respiratory distress syndrome. Was
transitioned to room air on day of life one and has been
stable on room air since then. Has had no episodes of apnea,
bradycardia of prematurity.
Cardiovascular: Baby was cardiovascularly stable throughout
hospital course.
Fluids and electrolytes: Birth weight was 2.5 kilograms. He
was initially started on 80 cc per kilogram per day of D10W.
His discharge weight was 2.340 kilograms. He is ad lib
feeding special care formula.
Gastrointestinal: Peak bilirubin was on [**7-3**] of 15.6/0.3.
Photo therapy was initiated. Photo therapy was discontinued
on [**7-5**] at 6 A.M. and his bilirubin level was 8.7 at that
time and it is currently 8.3/0.2 ten hours after photo
therapy was discontinued.
Hematology: Hematocrit on admission was 55.5. Has not
required any blood transfusions during this hospital course.
Infectious disease: CBC and blood culture were obtained on
admission. CBC was benign. Antibiotics were discontinued at
48 hours with negative blood culture.
Neurologic: Appropriate for gestational age.
Audiology: Hearing screen was performed and infant passed
both ears.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home to parents. Name of primary
pediatrician is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], telephone number is [**Telephone/Fax (1) 58389**].
FU bilirubin to be performed tomorrow at [**Hospital1 18**].
FEEDS AT DISCHARGE: Continue ad lib feeding of mother's milk
or [**Doctor Last Name **] 20.
MEDICATIONS: Ferinsol, Vidaylin
Car seat position screening was performed and the infant
passed. State Newborn screens have been sent per protocol
and have been within normal limits. Infant has not received
hepatitis B vaccine.
DISCHARGE DIAGNOSES: Preterm twin number II born at 34 4/7
weeks gestation.
Mild respiratory distress syndrome.
Hyperbilirubinemia.
Status post rule out sepsis with antibiotics.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2176-7-5**] 16:59:45
T: [**2176-7-5**] 17:32:35
Job#: [**Job Number **]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6162
} | Medical Text: Admission Date: [**2127-1-9**] Discharge Date: [**2127-1-29**]
Date of Birth: [**2082-8-14**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin / Ciprofloxacin
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
44 yo male with hx of asthma, EtOH and tobacco who presented
with SOB and fever to OSH found to have RML PNA requiring
intubation now complicated by pancreatitis, drug rash and acure
renal failure. Pt was admitted [**12-29**] for cough, anorexia, fever
and hemoptysis. CXR on admission showed RML PNA and was started
empirically on azithromycin and ceftriaxone. He was also noted
to be in ARF and was hydrated with improvement to creatinine
1.1. He became more hypoxic and tachycardic on [**12-30**] and was
intubated. He was started on solumedrol due to severe wheeze.
Over the past 5-6 days his creatinine has continued to climb and
then stabilized at 4.2. During this period his hematocrit has
also dropped to 25.2 from 39.7. He was started on tube feeds but
these were discontinued after an episode of high residuals and
emesis on [**1-3**]. Amylase and lipase were found to be elevated at
212 and 310 with RUQ U/S revealing gallbladder wall thickening
with sludge and and hypoechoic areas of the pancreas concerning
for pancreatitis. On [**1-8**] sputum cx revealed MSSA with influenza
negative so antibiotics were changed to nafcillin which resulted
in diffuse rash so this was changed again to vancomycin. Due to
continued clinical decline pt was transferred for further
management. Of note pt did receive Zosyn per ID consulation at
OSH but not noted on DC summary.
Past Medical History:
Asthma
EtOH
Smoking
amputation of left 5th distal phalanx
hemmorhoidectomy
Social History:
Lives with brother. Used to work dispatching oil truck but
currently unemployed. Drinks 1 sick pack/day of beer with no hx
of withdrawal seizures or DT's. 15 pack year smoking history.
Family History:
Unable to obtain
Physical Exam:
Vent AC at 700/18 Fio2 50% PEEP 5 satting 98% with PIPS 42
Gen-diaphoretic
HEENT-PERRL, MMM, no elev JVP
Hrt-tachy RR, nS1S2 no MRG
Lungs-diffuse rhonchi with poor air movement throughout
Abd-soft, NT, mod distended, liver 3cm below costal margin,
hypoactive BS
Extrem-2+ rad and dp pulsed, 2+ edema to knees bilat
Neuro-sedated, hyperreflexic biceps and patellae bilat, legs
flaccid
Skin-diffuse maculopapular rash
Pertinent Results:
[**2127-1-9**] 10:12PM TYPE-ART TEMP-36.9 RATES-20/6 TIDAL VOL-500
PEEP-10 O2-50 PO2-78* PCO2-60* PH-7.30* TOTAL CO2-31* BASE XS-1
-ASSIST/CON INTUBATED-INTUBATED
[**2127-1-9**] 10:06PM URINE HOURS-RANDOM UREA N-759 CREAT-50
SODIUM-35
[**2127-1-9**] 10:06PM URINE OSMOLAL-397
[**2127-1-9**] 10:06PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2127-1-9**] 10:06PM URINE RBC-226* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
[**2127-1-9**] 10:06PM URINE EOS-NEGATIVE
[**2127-1-9**] 08:25PM TYPE-ART TEMP-36.9 RATES-14/2 TIDAL VOL-500
PEEP-10 O2-60 PO2-123* PCO2-71* PH-7.25* TOTAL CO2-33* BASE XS-1
-ASSIST/CON INTUBATED-INTUBATED
[**2127-1-9**] 08:25PM O2 SAT-98
[**2127-1-9**] 06:19PM estGFR-Using this
[**2127-1-9**] 06:19PM ALT(SGPT)-25 AST(SGOT)-20 LD(LDH)-342* ALK
PHOS-53 AMYLASE-79 TOT BILI-0.3
[**2127-1-9**] 06:19PM LIPASE-97*
[**2127-1-9**] 06:19PM CALCIUM-8.4 PHOSPHATE-5.1* MAGNESIUM-2.4
[**2127-1-9**] 06:19PM TRIGLYCER-168*
[**2127-1-9**] 06:19PM VANCO-17.9
[**2127-1-9**] 06:19PM WBC-12.6* RBC-2.78* HGB-8.4* HCT-25.4* MCV-92
MCH-30.4 MCHC-33.2 RDW-14.4
[**2127-1-9**] 06:19PM PLT COUNT-479*
[**2127-1-9**] 06:19PM PT-13.5* PTT-36.4* INR(PT)-1.2*
.
C DIFF NEGATIVE X 3
.
SPUTUM GRAM STAIN (Final [**2127-1-23**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2127-1-25**]):
HEAVY GROWTH OROPHARYNGEAL FLORA.
.
BLOOD CX: NO GROWTH
.
PLEURAL FLUID CULTURE:
GRAM STAIN (Final [**2127-1-11**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2127-1-14**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2127-1-17**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2127-1-13**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
.
BAL:
GRAM STAIN (Final [**2127-1-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2127-1-12**]):
OROPHARYNGEAL FLORA ABSENT.
ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
LEGIONELLA CULTURE (Final [**2127-1-16**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2127-1-10**]):
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).
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2127-1-10**]):
PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Final [**2127-1-23**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2127-1-10**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
.
INFLUENZA, [**Last Name (un) **] LEGIONELLA: NEGATIVE
Admission CXR
Severe cavitary pneumonia of the right middle and upper lobes.
.
Renal Ultrasound
The right kidney measures 12.6 cm. The left kidney measures 12.2
cm. There is no evidence of hydronephrosis, nephrolithiasis, or
renal mass. Cortical medullary differentiation is well
preserved. The bladder is decompressed secondary to a Foley
catheter.
.
CT CHEST W/O CONTRAST [**2127-1-21**]:
FINDINGS: The conglomerate of large cavities in the right upper
lobe is
smaller, 12.7 x 6.6 cm today, previously 13.7 x 8.2 cm, and
contains less
debris/soft tissue. Adjacent loculated pneumothorax has
decreased in size. Peripheral consolidation located anterior to
the right major fissure measures 20 x 13 mm, was 35 x 31 mm.
Cavitary lesion in the left apex measuring 18 x 13 mm was 23 x
16 mm, now fluid filled. Peribronchial inflammation throughout
remaining of both lobes is new, for instance in the left lower
lobe (3, 50). Impaction and/or narrowing of the right upper
lobe, bronchus intermedius, right middle lobe, and right lower
lobe bronchus has resolved. There are no endobronchial lesions.
Small right pleural effusion has decreased in size. There is no
left pleural effusion. Trace of pericardial effusion is stable.
Paratracheal, subcarinal, and carinal lymph nodes have decreased
in size, for
instance a 14- mm carinal lymph node was 16 mm. Cardiac size is
normal.
Moderate atherosclerotic calcification is present in the LAD.
There are no bone findings of malignancy.
The upper abdomen is unremarkable.
IMPRESSION: Clearing necrotizing right upper lung pneumonia,
resolved right bronchial obstruction, decreasing small,
loculated right pneumothorax and small to moderate right pleural
effusion, . New or increased mild peribronchial infiltration in
both lungs may be due aspiration of purulent material.
.
MRI EXAM OF THE BRAIN AND MRA OF THE CIRCLE OF [**Location (un) **] (for
flaccid paralysis):
IMPRESSION: Partly degraded MRI exam due to repeated motion
artifact and also partly related to the patient's intubated
status. No acute territorial infarcts could be demonstrated on
diffusion images. Scattered T2 hyperintense foci along the
cerebral white matter seen only on FLAIR images. Bilateral
mastoiditis of uncertain chronicity. Followup is suggested
based on clinical grounds.
MRA OF THE CIRCLE OF [**Location (un) **]:
IMPRESSION: Unremarkable MRA exam of the circle of [**Location (un) 431**].
.
MR C SPINE (for flaccid paralysis):
IMPRESSION: Moderately degraded exam due to motion artifact and
the patient's intubated status. Left paracentral herniation
seen at C6-C7 level encroaching over the left exiting C7 nerve
root.
Mild-to-moderate foraminal stenosis at C5-C6 level. Right-sided
facet
effusion at C3-C4 level.
Questionable T2 hyperintense signal involving the cervical cord
at C4-C5
level, possibly artifactual in nature. Repeat T2-weighted
sagittal images would be helpful for further evaluation of cord
signal.
.
RIGHT UPPER EXTREMITY ULTRASOUND (for right UE swelling):
IMPRESSION:
1. No son[**Name (NI) 493**] evidence of DVT in the right upper extremity.
The most distal aspect of the right subclavian vein as it
enters into the
brachiocephalic vein was not visualized.
2. Small-caliber, but patent right internal jugular vein.
.
CT TORSO W/O CONTRAST [**2127-1-10**]:
CT OF THE CHEST:
There is a large multiloculated relatively thin walled cavitary
lesion
involving the right upper lobe measuring roughly 13.7 x 8.2 cm.
There are what appears to be air- fluid levels within it. It is
difficult to determine whether there is pleural invasion. An
adjacent region of consolidative in the right upper lobe (3:27)
measures 3.5 x 3.1 cm. Debris is seen within the right main
stem bronchus. The trachea and left segmental bronchi are clear.
A smaller cavitary lesion is seen in the left upper lobe,
measuring 2.3 x 1.6 cm. Multiple small ground- glass opacities
are also seen, particularly in the left upper lobe in a
tree-in-[**Male First Name (un) 239**] pattern. There are additional consolidative nodular
opacities, for example, in the left lower lobe (3:38) measuring
16 x 12 mm and in the right upper lobe measuring 8 mm in
diameter. Multiple small paratracheal lymph nodes are seen,
which do not meet criteria for pathologic enlargement. No
axillary lymphadenopathy is appreciated. There
is no cardiomegaly. There is a trace amount of pericardial
fluid. There is a left-sided moderate pleural effusion of simple
fluid attenuation.
A left-sided central venous catheter tip terminates in the
central
brachiocephalic vein. A nasogastric tube tip is in the antrum
of the stomach. An endotracheal tube tip is in the region of the
thoracic inlet.
CT OF THE ABDOMEN: On this non-contrast study, the liver,
gallbladder,
adrenal glands, spleen, pancreas, kidneys, and loops of bowel
appear
unremarkable. Multiple small retroperitoneal lymph nodes do not
meet criteria for pathologic enlargement. There is no ascites.
Nonspecific perinephric stranding is seen bilaterally.
CT OF THE PELVIS: A Foley catheter is within the bladder lumen.
The
prostate, seminal vesicles, rectum, and pelvic loops of bowel
appear
unremarkable. There is no pathologic pelvic or inguinal
lymphadenopathy.
There is no free fluid in the pelvis. There is dependent
superficial subcutaneous edema consistent with anasarca.
OSSEOUS STRUCTURES: No concerning lytic or sclerotic lesions
are identified.
IMPRESSION:
1. Large cavitary right upper lobe lesion and smaller left
upper lobe
cavitary lesion with additional foci of ground glass as well as
consolidative opacities in both lungs consistent with multifocal
pneumonia. Moderate right- sided pleural effusion. Debris in
the right-sided bronchi.
2. No drainable fluid collections or areas concerning for
inflammation in the abdomen or pelvis.
Brief Hospital Course:
# Leukocytosis:
Patient's initial leukocytosis resolved with treatment of his
pneumonia. He then developed diarrhea and abdominal cramping
with a rising wbc, concerning for c diff versus viral
gastroenteritis. C diff negative x 3 and his symptoms are
improving. He is tolerating po without precipitating
pain/cramps. He will follow-up with his PCP [**Last Name (NamePattern4) **] 2 days to
reassess his symptoms and recheck his wbc. If still
symptomatic, would treat empirically with flagyl +/- send c diff
toxin B. Of note, urinalysis negative and no other new
signs/symptoms of infection. White blood cell count prior to
discharge ranged from 12 to 13.
.
#. Cavitating MSSA pneumonia with also enterobacter in sputum:
Patient was initially intubated at an outside hospital on [**12-30**].
He was successfully extubated on [**1-14**]. On BAL, while intubated,
he was found to have pan-sensitive enterobacter cloacae and had
MSSA in sputums from the outside hospital. ID was consulted and
followed throughout his hospital stay. He was treated with 10
days of gram negative coverage (cefepime, then FQ) for the
enterobacter and will complete 4 weeks of IV vancomycin,
followed by an yet-to-be-determined course of po clindamycin for
the MSSA. He is scheduled for a follow-up chest CT and ID
follow-up to determine the course of his clindamycin. He was
weaned off the steroids started at the outside hospital. He
received nebs and will continue inhalers at home. Of note,
interval CT during his hospital stay showed some improvement.
His blood cultures remained negative. He underwent a
thoracentesis which appeared exudative but was not consistent
with an empyema. Additional work-up included, urine legionella
antigen, influenze DFA, PPD, and AFB smear, all of which were
negative. He also had a negative HIV antibody test in house.
Please note, patient is due for a trough on [**2127-1-30**] and
vancomycin dose will be adjusted prn based on this level.
.
# Anasarca:
Patient developed swelling in his feet, ankles, hands, and
sacral area in the setting of a urine protein/creatinine ratio
of 0.4 and likely protein wasting enteropathy in the setting of
his GI symptoms. His albumin was 2.3 on the day of discharge.
He is on ensure supplements to aid. Will need PCP [**Name9 (PRE) 702**] to
confirm proteinuria resolves.
.
# Drug Rash:
Patient was transferred with history of drug rash to nafcillin.
He then developed a rash at [**Hospital1 18**] to ciprofloxacin. Dermatology
was consulted. The rash resolved without mucousal involvement
with discontinuation of the cipro.
.
#. Acute renal failure:
On admission, patient had creatinine of 4. Urine sediment
suggested acute tubular necrosis. He was also noted to have
positive urine eos and likely had a component of acute
interstitial nephritis related to his drug reactions. His
creatinine on the day of discharge was down to 1.6. He is
making good urine and his lytes have been stable.
.
# Delerium:
Suspect multifactorial: steroids, icu psychosis, resolving
prolonged infection, benzo withdrawal. This resolved after
steroids were weaned and patient began to improve. MRI head
showed no evidence of stroke. At discharge he is back to
baseline mental status.
.
# Flaccid weakness: The patient had flaccid paralysis noted
bilaterally upper and lower extremitites on [**2127-1-13**]. Head and
C-spine MRI were unremarkable. This resolved off steroids and
with weaning of sedatives. He is now ambulatory again and was
cleared by PT for discharge to home with continued PT to improve
his strength.
.
#. Hypertension:
Antihypertensives adjusted for improved blood pressure control
(see discharge medications).
.
#. Pancreatitis: Resolved soon after admission. Suspect
possibly due to high doses of propofol. Triglycerides were 168.
Right upper quadrant ultrasound [**2127-1-17**] was unremarkable. CT
abdomen did not show any evidence of fluid collections.
.
# Anemia: Suspect due to chronic disease. Ferritin 1149.
Folate/B12/hapto were normal. Patient received 3 units of blood
while in house. Patient did have one guaic positive stool in
the setting of his diarrhea. Per patient he is due for his
follow-up c-scope and will discuss this with his PCP.
.
# Access: PICC in place
.
# Code: Full
.
# Dispo: Patient discharged to home (staying with his parents)
with services.
Medications on Admission:
Albuterol
Flovent
Norvasc
Benazepril/HCTZ 20/12.5
Discharge Medications:
1. Outpatient Lab Work
Please draw CBC with differential, potassium, BUN, creatinine,
and magnesium on [**2127-1-31**] and call results to Dr. [**First Name (STitle) **],[**First Name3 (LF) **] L.,
phone: [**Telephone/Fax (1) 71298**]
2. Outpatient Lab Work
Please draw vancomycin trough on [**2127-1-30**] and call results to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**], phone: ([**Telephone/Fax (1) 4170**]
3. VANCOMYCIN
750 mg IV q24h
Dispense: 9000 mg
Refills: none
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
Disp:*360 Tablet(s)* Refills:*2*
9. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
12. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
Disp:*1 inhaler* Refills:*0*
13. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 1 months: START THIS AFTER YOU HAVE COMPLETED
THE COURSE OF VANCOMYCIN.
Disp:*120 Capsule(s)* Refills:*0*
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 1 months.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
15. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
INH Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapy
Discharge Diagnosis:
primary:
MSSA cavitating pneumonia
viral gastroenteritis
drug rash
acute renal failure
acute pancreatitis
secondary:
history of hypertension
Discharge Condition:
good: afebrile, tolerating po
Discharge Instructions:
Please call your doctor or go to the emergency room if you
experience temperature > 101, worsening shortness of breath or
cough, vomiting or worsening diarrhea, or other concerning
symptoms.
Please take an ensure supplement two to three times per day for
the next 2 weeks.
You are allergic to penicillins and fluoroquinolones
(levofloxacin, ciprofloxacin).
Please avoid ibuprofen as this can affect your kidneys.
Followup Instructions:
Please call to schedule a follow-up chest CT on [**2127-2-21**]. Phone:
[**Telephone/Fax (1) 327**]
Please follow-up with the infectious disease doctor below:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2127-2-25**]
11:30
Location: [**Hospital1 18**], [**Hospital Unit Name **] ([**Last Name (NamePattern1) 71299**]
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5395**] (works with your primary
care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) on Friday, [**2127-1-31**] at
10:45 AM to have your infection cell count checked, to have your
kidney function checked, to discuss scheduling a colonoscopy,
and for a routine follow-up. Phone: [**Telephone/Fax (1) 71298**].
ICD9 Codes: 5119, 5845, 3051, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6163
} | Medical Text: Admission Date: [**2169-8-25**] Discharge Date: [**2169-9-14**]
Date of Birth: [**2169-8-25**] Sex: M
Service: NEONATOLOG
HISTORY OF PRESENT ILLNESS: This interim summary covers the
dates of [**2169-8-25**], through [**2169-9-14**].
Baby [**Name (NI) **] [**Known lastname **] is a now 20-day-old ex-33-3/7 week 2.105
kilogram baby who was born to a 33-year-old G3, P2, Mom via
cesarean section. Mom's prenatal screens include B positive,
Rubella immune, RPR nonreactive, hepatitis B surface antigen
positive and unknown GBS status. Her pregnancy was
unremarkable until preterm labor. Mom had had prior cesarean
section and, therefore, had repeat surgery. There was no
maternal fever documented and as such Mom did not receive
antibiotic prior to delivery.
Cesarean section notable for slightly difficult extraction of
shoulder in the DR. [**Last Name (STitle) 51600**] fluid was also noted to be
bloody at the time of delivery with question of malabruption.
Resuscitation unremarkable with spontaneous cry. Apgars were
8 and 8 at one and five minutes respectively.
PHYSICAL EXAMINATION: 98.3, 150, 50's, blood pressure 56/38.
Accu-Chek 73. Birth weight 2105 grams. Head circumference
31 cm. Length 45 cm. HEENT: Facial bruising,
nondysmorphic, no cleft lip or palate. Cardiovascular:
Regular rate and rhythm, no murmur. Pulses equal. Lungs:
Occasional grunting. Air exchange adequate bilaterally.
Abdomen soft, non-tender, no masses palpable. Liver 1 cm
below costal margin. Genitourinary: Normal external male
genitalia with testes descended bilaterally. Neuro: Normal
tone. Moro present and equal. Suck present.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Patient originally had mild respiratory
distress requiring CPAP for approximately 24 hours. After
that time he was easily weaned to room air and has not had
additional issues from a respiratory standpoint. This
includes an absent apnea or bradycardias. However, of recent
(in the last 24 hours) patient was noted to have some
duskiness with feed. He had originally been taken off of
oximetry but this has been resumed to further follow
symptoms.
2. Cardiovascular: [**Known lastname 915**] has remained stable from a
cardiovascular standpoint without concerns of murmur.
3. Fluids, Electrolytes and Nutrition: Patient originally
was supported on total parenteral nutrition with gradual
advancement of feeds. He originally started gastric feeds on
day of life four. Feeds were gradually advanced with
achievement of full feeds on day of life eight. We have
currently been feeding [**Known lastname 915**] with breast milk 24 Kcals, both
p.o. and p.g. However, at this point he takes only about 50%
of his feeds orally. [**Known lastname 915**] has been demonstrating good
weight gain on this feeding regimen with most recent weight
on day of life 20 ([**9-14**]) of 2.43 kilograms.
4. Gastrointestinal: As briefly mentioned above, there have
been some concerns for dusky spells with feeding in the past
24 hours. However, nobody has ever described that [**Known lastname 915**]
chokes, gags or sputters with feeds. From a bilirubin
standpoint, [**Known lastname 915**] had a prolonged course of
hyperbilirubinemia with phototherapy originally initiated on
day of life two. [**Known lastname 12340**] peak bilirubin was reached on day
of life five at 14.0. He gradually declined but ultimately
required phototherapy through day of life ten. A rebound
bilirubin on day of life 12 was 11.0. At time of dictation
patient still appears moderately jaundiced.
. With his prolonged course of
hyperbilirubinemia, a repeat bilirubin will be obtained
tomorrow morning.
5. Infectious Disease: [**Known lastname 915**] had a 48 hour rule out sepsis
with ampicillin and gentamicin. Blood culture remained
negative for this period of time. [**Known lastname 12340**] [**Last Name (NamePattern1) 21206**] is known to be
hepatitis B surface antigen positive. For this reason he was
given both a hepatitis B vaccine as well as HBIG after
delivery. No additional issues from an infectious disease
standpoint.
6. Neurology: The patient does not meet criteria for
screening head ultrasound.
7. Sensory: Patient will still need hearing screen prior to
discharge. He does not fit criteria for ophthalmology
examination.
PRIMARY PEDIATRICIAN: [**Hospital3 **] Health Center, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2262**], M.D.
CARE/RECOMMENDATIONS:
A. Feeds at interim: Breast milk 24 Kcal at 150 cc/kg/day
p.o. or p.g.
B. Medications: None.
C. Car seat positioning: Pending.
D. State Newborn Screen: Sent.
E. Immunizations Received: Hepatitis B on day of life zero
([**2169-8-25**]).
INTERIM DIAGNOSES:
1. Prematurity at 33-3/7 weeks.
2. Respiratory distress, resolved.
3. Rule out sepsis, resolved.
4. Maternal hepatitis B infection.
DR.[**Last Name (STitle) **],[**Doctor Last Name **],[**Doctor Last Name **] 50-470
Dictated By:[**Last Name (NamePattern1) 51601**]
MEDQUIST36
D: [**2169-9-14**] 16:34
T: [**2169-9-14**] 16:30
JOB#: [**Job Number 51602**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6164
} | Medical Text: Admission Date: [**2154-7-15**] Discharge Date: [**2154-7-19**]
Date of Birth: [**2092-10-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
mental status and vision changes
Major Surgical or Invasive Procedure:
cardiac catheterization on [**7-16**]
History of Present Illness:
61 yo F with CAD s/p MI, DM, PVD, RCA stenosis, and CRI who was
admitted for elective cardiac catheterization and transferred
post-cath for mental status and vision changes. The patient was
referred for cardiac catheterization after abnormal stress
testing prior to planned carotid endarterectomy. She was
admitted yesterday for post-cath hydration. She received [**Month/Year (2) **],
plavix, heparin bolus, and integrillin during the procedure.
Cardiac cath showed CO 4.67, CI 2.50, PCW 12, PA 24/13, RV 25/5.
Cath showed 80% occlusion of LAD, s/p stent in LIMA - LAD.
.
Post cath she was noted to be confused and complained of new
loss of vision. The Stroke service was urgently consulted.
Integrillin gtt was stopped. Head CT showed a lesion concerning
for R occipital CVA. She underwent MRI/MRA demonstrating
patency of the arterial circulation.
.
On exam she denies vision changes (diplopia, eye pain,
photophobia). She has no memory of the morning's events (cath,
CT or MRI, vision problems). She reports nausea and frontal
headache. She denies chest pain, SOB, abdominal pain.
Past Medical History:
PMH:
HTN,
CAD,
s/p MI '[**34**],
NIDDM,
hypothyroidism
PSH:
CABG with harvest B saphenous veins
Social History:
previous smoker / quit 10 years ago
no alcohol
lives with husband
Family History:
Father, brother died of MI at age 47
Mother MI in 70s
Sister died of MI at age 39.
Physical Exam:
Vitals: 98.6F HR 75 BP 149/79 RR 10 97 RA weight 84 kg
Gen: awake, oriented x 2, pleasant, c/o mild headache. exam
limited due to patient laying flat post-cath
HEENT: PERRL/EOMI, anicteric sclera. OP clear, MMM
Neck: supple, 2+ carotid pulses, no carotid bruits appreciated.
unable to assess JVD.
CV: RRR, distant S1, S2.
Pulm: clear anteriorly
Abd: +BS, soft, ND/NT
Ext: warm, 1+ DP/PT b/t. L toes with erythema, no skin breaks,
mild tenderness to palpation. no edema b/t, no calf tenderness.
R groin without hematoma, 1+ femoral pulse.
Neuro: A & O x 2, CN II-XII grossly intact, except for inferior
field defect to Left eye. mild agnosia. 4+ strength in UE/LE.
3+reflexes in LUE, nl in RUE and LLE (unable to assess RLE due
to post-cath monitoring). sensation intact. neg Romberg.
down-going Babinskis b/t.
Pertinent Results:
[**2154-7-15**] 09:21PM PT-11.3 PTT-26.9 INR(PT)-1.0
[**2154-7-15**] 09:21PM PLT COUNT-226
[**2154-7-15**] 09:21PM WBC-7.9 RBC-4.02* HGB-12.7 HCT-35.9* MCV-89
MCH-31.6 MCHC-35.3* RDW-13.1
[**2154-7-15**] 09:21PM CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-2.3
[**2154-7-15**] 09:21PM GLUCOSE-135* UREA N-31* CREAT-1.5* SODIUM-142
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
EKG: NSR, rate 80. nl intervals. Q waves in III, aVF, slight L
axis. Poor R-wave progression
.
Cardiac Cath [**7-16**]: CO 4.67, CI 2.50, PCW 12, PA 24/13, RV 25/5.
80% occlusion of LAD, s/p stent in LIMA -> LAD.
.
CT Head [**7-16**]: Findings suggestive of ischemic event involving
the right occipital lobe with perfusion in that area. There is
also possibly involvement of the left occipital lobe. old
lacune disease.
.
echo: per report, moderate depression of LV fx, distal septal
inferior hypokinesis.
.
Brief Hospital Course:
A/P: 61 yo F with CAD s/p MI, DM, PVD, RCA stenosis, and CRI who
was transferred post-elective cath for mental status and vision
changes, now s/p R post occipital stroke. The following issues
were investigated during this hospitalization:
.
# CVA: Likely thromboembolic in setting of cardiac
catheterization and not thought to be due to ICA stenosis. Since
she had already received [**Last Name (LF) 13860**], [**First Name3 (LF) **], Plavix during her
catheterization, tPA administration was thought to be too risky
(and perhaps not needed). Integrillin was stopped on transfer to
the CCU and the stroke/neurology team continued to follow her
progress. Initially, she was disoriented and had a left inferior
field vision cut. Otherwise, her vision was intact. She was also
febrile to 101.9. Blood and urine cultures show no growth to
date and CXR was unremarkable. She was given Tylenol and started
on empiric treatment with Levaquin, mostly for PNA and UTI
organisms, since fever can worsen a stroke. She continued to be
afebrile 2 days after her initial fever and since cultures
showed no growth, Levaquin was d/c'd. A SBP goal of 140-180 was
set by the stroke team to provide adequate perfusion of the
brain in the setting of a stroke. However, despite fluid boluses
and holding anti-hypertensive medications, her SBP never went
above 130. Pt was only able to tolerate Trendelenberg for a few
hours before becoming nauseous and vomiting. No other
interventions were made. An EEG showed no seizure activity. Pt's
orientation and memory slowly improved and she was d/c'd with
Aspirin and Plavix. Per PT and OT consults, patient will need 24
hour supervision at home, which her husband is able and willing
to provide.
.
# CVS: Patient had an abnormal outpatient stress Echo and was
referred to [**Hospital1 18**] for a cardiac catheterization which revealed
an 80% occlusion of LAD. She received a stent in LIMA -> LAD.
While in the unit, she had an echo which showed a normal EF.
She was discharged on [**Hospital1 **], Plavix and Lipitor. Her beta-blocker
and ace-inhibitor were held since her blood pressure seemed to
be well-controlled and since the recommendations of the stroke
team was to allow for better perfusion of her brain with a
higher BP. She was d/c'd on her outpatient beta-blocker dose.
.
# PVD:`Pt. has a history of 80-90% RCA stenosis for which she
has already been evaluated as an outpatient. [**Hospital1 **] surgery
was aware that the patient was in-house. They recommend that the
patient continue with the current plan of follow-up as an
outpatient and eventual carotid endarterectomy.
.
# DM: During this hospitalization, patient's Metformin was held
because of concern for lacic acidosis in the setting of CRI and
being post-cath. Her FS were well-controlled on a regular
insulin finger stick. HbA1C is 7. On discharge, she was sent out
on her outpatient doses of Glipizide and Glucophage.
.
# CRI: Patient's creatinine was maintained at baseline during
this hospitalization and was not an active issue.
.
# Hypothyroidism: Pt. was maintained on outpatient dose of
Synthroid
Medications on Admission:
Clopidogrel 75 mg qday
ecAspirin 325 mg qday
Coreg 3.125 [**Hospital1 **]
Fosinopril 10 mg qday
Glucophage 1,000 mg po bid
Synthroid 125 mcg PO qday
Glipizide 10 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Fosinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Occipital Stroke
Coronary Artery Disease
Diabetes Mellitus
Carotid stenosis
Peripheral [**Hospital1 **] disease
Discharge Condition:
Stable
Discharge Instructions:
Please call your physician or call 911 if you experience a
change in vision, severe headache, slurred speech or sudden
weakness, chest pain, shortness of breath, fevers, numbness,
weakness, leg pain, leg/foot ulcers or other concerning
symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 17562**], [**Name11 (NameIs) 487**] MD Date/Time: [**2154-7-29**] 9:30 AM. You
will need to get a referral from Dr. [**Last Name (STitle) 17562**] for your appointment
with neurology on [**8-13**].
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:
[**2154-7-31**] 1:45
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2154-7-31**] 3:40
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 2394**] [**2154-7-31**] AT 1:00 PM
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **], MD Neurology Phone: ([**Telephone/Fax (1) 7394**]
Time/Date: [**2154-8-13**] at 1:30 PM on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building, [**Hospital Ward Name 516**] of [**Hospital1 69**]
ICD9 Codes: 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6165
} | Medical Text: Admission Date: [**2187-8-8**] Discharge Date: [**2187-8-17**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Increased shortness of breath and malaise
Major Surgical or Invasive Procedure:
Cardiac catherization and stent in RCA, LMCA, and LAD
History of Present Illness:
Pt is an 80 y/o M with a h/o metastatic poorly differentiated
squamous cell CA, GERD who presented to [**Hospital **] hospital with
2-3 days of increasing SOB and fatigue, saying he was "gasping"
for air by the time he got to the hospital. Over the days prior
to admission, he complained of exacerbations of his "reflux"
that seemed to be worse with urination/defecation, not worse
with eating or supine position. At [**Hospital1 **], had elevate CK,
MB, TnI and a CXR indicating possible pneumonia and mild CHF and
was started on B-blocker, nitro drip, ASA, lasix,
ceftazidime/azithromycin. His OSH echo showed 35-40% EF,
septal/apical/inf wall hypokinesis, mild MR, trace TR. A CT of
his torso showed mediastinal LAD, hilar LAD, B/L pleural
effusions, multiple pleural calcifications c/w prior asbestos
exposure, B/L LL infiltrates, RUL infiltrate, and a R inguinal
fluid collection. A cath two days after admission showed 80%
left main disease, extensie three vessel disease, prompting a
transfer to [**Hospital1 18**]. At [**Hospital1 18**], pt had a cath with cypher and
hepacoat stenting of RCA, PTCA to LAD and LCx with hepacoat in
LAD and distal LM, hepacoat to ostium of LM.
Pt's post cath course was complicated by two episodes of fever
up to 101-102 with new diarrhea, RUL and RLL opacities. Also,
pt has bilateral pleural effusions, L>R, s/p left thoracentesis
that does not support empyema, though with pleural fluid
appearing transudative in nature.
Past Medical History:
1.)Metastatic poorly differentiated squamous cell carcinoma
2.)GERD
3.)Arthritis
4.)BPH
Social History:
The patient is a retired bartender who lives alone, has a 40
pack year history, and quit smoking in [**2175**].
Family History:
non-contributory
Physical Exam:
tm 101.0/tc 98.6, bp 78/45->94/60, hr 67 63-68, rr 18, spo2 96%
ra
gen- awake, a&o M, healthy appearing, looks own age, NAD
HEENT- no scleral icterus/injection, op clear, poor dentition (1
tooth), dry mucosa
neck- supple, v-wave jugular pulsation, no lad, no thyromegaly
cv- rrr, s1s2, 2/6 systolic murmur loudest over ao region
pul- good bilat air movement, rales in both bases L>>R,
bronchial breath sounds in RUL
abd- soft, NT, nabs, no organomegaly
extrm- no c/c/e, warm, well perfused, r groin with 3x4cm firm
painless mass with 1x1cm ulceration, nontender, no pus
expressed, no erythema, left groin at cath site, no hematoma, no
erythema
neuro- a&ox3, fluent coherent speech, approriate affect, cn
II-XII intact, motor [**4-25**] all extrm
Pertinent Results:
[**2187-8-8**] 12:50PM PT-13.3 PTT-34.2 INR(PT)-1.1
[**2187-8-8**] 12:50PM PLT COUNT-320
[**2187-8-8**] 12:50PM WBC-11.3* HGB-11.2* HCT-33.1* MCV-81*
[**2187-8-8**] 12:50PM ALBUMIN-3.1* CALCIUM-8.7 PHOSPHATE-3.6
MAGNESIUM-2.2
[**2187-8-8**] 12:50PM ALT(SGPT)-18 AST(SGOT)-24 LD(LDH)-324*
CK(CPK)-70 ALK PHOS-77 TOT BILI-0.8
[**2187-8-8**] 12:50PM GLUCOSE-90 UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
[**2187-8-8**] CK 70 Trop 0.8
[**2187-8-16**] 11:18AM BLOOD WBC-10.8 RBC-4.35* Hgb-11.6* Hct-36.1*
MCV-83 MCH-26.7* MCHC-32.2 RDW-13.9 Plt Ct-530*
[**2187-8-16**] 11:18AM BLOOD Glucose-153* UreaN-13 Creat-0.9 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
[**2187-8-15**] 06:50AM BLOOD calTIBC-191* Ferritn-473* TRF-147*
[**2187-8-15**] 06:50AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.2 Iron-11*
[**2187-8-8**] 12:50PM BLOOD CK-MB-NotDone cTropnT-2.3*
[**2187-8-9**] 04:55PM BLOOD CK-MB-NotDone cTropnT-3.12*
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA
[**2187-8-13**] 2:55 pm PLEURAL FLUID
GRAM STAIN (Final [**2187-8-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2187-8-16**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Blood cultures -- No growth to date
Brief Hospital Course:
1.)CAD -- Pt was admitted with three vessel disease and severe
left main disease. Pt was considered to not be a surgical
canidate given functional status and metasatic squamous cell CA.
A cath was performed on [**8-9**]: LM 60-80% ostial, 80% distal; LAD
99% ostial, o/w diffuse; LCx 50% ostial, 80% mid; RCA 80%
ostial, prox, & mid; Cypher & hepacoat x3 to mid RCA w/20%
residual; hepacoat x2 to LM/LAD w/no residual. Pt tolerated
procedure well. He was started on routine post-cath
medications, including ASA, metoprolol, ACEI, statin, and
Plavix. Once the patient was on the floor, he was noted to be
mildly hypotensive with systolics in the 80's (mentating well,
producing urine) with a Cr of 1.2, so his ACE-I was held, with
plans to restart as an outpatient. His sbp responded quickly to
250cc of normal saline, coming up to 110-120, where it remained
for the rest of his stay. Pt had no chest pain or SOB for the
rest of the admission, no abnormalities on telemetry, and was
considered stable for discharge.
2.)CHF -- Pt initially diuresed with lasix and ACEI started for
afterload reduction. Pt had echo at OSH which showed EF of
35-40%. However, given hypotension and Cr of 1.2, his ACE-I was
held, and he was kept 0.5-1.0 liters positive for two days with
no compromise of respiratory status, as it was felt he was
hypovolemic. Following this, his fluids were kept even. He had
bilateral pleural effusions that were tapped, and the analysis
was most consistent with a transudate, no empyema, no malignant
cells seen on cytologic exam.
3.)Azotemia -- His Cr bumped to 1.2 with a BUN of 29 and a FeNa
of 0.2%. Given the clinical findings and lab values, he was
felt to be dry and the azotemia secondary to a prerenal
etiology. His Cr trended down with fluids to 1.0.
4.)Fever -- Pt spiked a fever two days after cath. Diagnostic
possibilities included pneumonia, infected pleural effusion, R.
groin abscess secondary to a metastatic nodal site, and
diarrhea/C difficile. His blood and pleural fluid cultures were
negative, his pleural fluid analysis had a pH of 7.46 making
empyema unlikely, and his R. groin swelling had no pain,
erythema, or pus. An ultrasound of the right groin showed a
fluid collection that could represent a hematoma or an abscess;
surgery evaluated the right groin lesion and felt that it was
unlikely to be infected. His C. diff assay came back positive.
He was treated for the two most likely items on this
differential, the pneumonia and C. diff diarrhea, with
levofloxacin for the pneumonia and metronidazole for the
diarrhea. By discharge, he'd been afebrile for greater than 48
hours.
5.)Squamous cell carcinoma -- Initially diagnosed [**2187-6-21**] by
excisional bx at [**Hospital **] hospital, CT torso at [**Hospital1 **]
showed necrotic mass in right groin. Pt has had little work-up,
but wants to be followed at [**Hospital1 18**]. He was seen by Onc while an
inpatient and will be followed by Dr. [**Last Name (STitle) **]. A CT w/ constrast
showed bilateral pleural effusions with consolidation in the
right lower lobe, representing a pneumonia, an ill-defined
nodular lesion in the medial portion of the left upper lobe
measuring 2 cm in diameter, associated with extensive
mediastinal and hilar lymphadenopathy, multiple ill-defined
patchy opacities with possible cavitations in left upper lobe,
with underlying bilateral pulmonary edema(these ill-defined
opacities can be a part of pneumonia, or pulmonary edema, or can
be septic emboli, or metastases), multiple calcified pleural
plaques suggesting asbesto exposure, and GB stones. [**Hospital1 **]
will be contact[**Name (NI) **] to send over pathology slides and films.
6.)Anemia -- Lab results came back with low Fe and TIBC and
elevated ferritin, making chronic disease/inflammation anemia
the most likely possibility. This is probably related to his
squamous cell carcinoma.
Medications on Admission:
Flomax
Xanax
Protonix
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 12 days.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 12 days.
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
1. NSTEMI
2. LMCA and three vessel coronary artery disease.
3. Stenting of the LMCA/LAD - Stenting of the RCA - PTCA of the
LCX. (see comments below).
4. Systolic CHF, EF ~ 40%.
5. RUL and LLL Pneumonia.
6. Squamous Cell Cancer of the penis with right inguinal
metastasis.
7. Right groin complex mass measuring approximately 6.8 cm x 4
cm x 7 cm, with echogenic material and septations.
8. Diarrhea.
9. Pre-renal azotemia.
10. Microcytic Anemia.
11. Bilateral density calcified pleural plaques, suggesting
asbestos
exposure.
12. Right sided pleural effusion - transudate.
13. COPD.
PCI: Right Dominant circulation, severe LMCA and three vessel
coronary disease, LMCA had a 60% ostial and 80% distal stenosis.
The LAD had a 99% ostial lesion and had diffuse moderate
disease throughout. The LCX had a 50% ostial lesion and an 80%
mid lesion in the AVG LCX. The RCA had serial ostial, proximal
and mid lesions up to 80%. Stenting of the LMCA/LAD was
performed with overlapping 4.0 x 8 mm and 3.0 x 18 mm Hepacoat
stents. Kissing PTCA of the LMCA/LAD/LCX was performed with two
3.0 mm balloons. PTCA of the mid LCX was performed with a 2.5 mm
balloon. Stenting of the RCA was peformed with a 3.0 x 33 mm
Cypher (mid) and a 3.5 x 23 mm Hepacoat (ostial).
Discharge Condition:
Fair
Discharge Instructions:
Pleasw return to the emergency department for chest pain,
shortness of breath, fever/chills, changes in mental status.
Take medications as prescribed. You have two medications that
it is crucial to take: aspirin and Plavix (clopidogrel) --
please take these medications every day as directed. Do not
stop them unless explicitly directed to by your cardiologist.
Follow-up as below.
Please check your weight every day to see if you are retaining
fluids. If your weight increases by two pounds, take 40mg of
Lasix. If by five pounds, take 40mg of lasix, once in the
morning and once in the evening.
Followup Instructions:
Please call your PCP to arrange an appointment to be seen with
one to two weeks of discharge from the hospital.
You have an appointment with Dr. [**Last Name (STitle) **], your oncologist, on
[**Month (only) **] the seventh at 1:00pm in the [**Hospital 23**] clinic building
on the ninth floor. For questions, call [**Telephone/Fax (1) 6161**].
You have an appointment with a cardiologist, Dr. [**First Name (STitle) 437**], on
[**Month (only) **] the eight at 9:30am in the [**Hospital 23**] Clinic building on
the seventh floor. For questions, please call [**Telephone/Fax (1) 62**].
ICD9 Codes: 4280, 5119, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6166
} | Medical Text: Admission Date: [**2170-1-18**] Discharge Date: [**2170-2-2**]
Date of Birth: [**2129-6-22**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Hydralazine / Pyridium / Bactrim / Nitrofurantoin /
Dapsone / Quinine / Quinidine / Methylene Blue
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
fatigue, poor PO intake, abdominal discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 1557**] is a 40-year-old man with medical history of [**First Name8 (NamePattern2) **]
[**Last Name (Prefixes) 93502**] disease (glycogen storage disease) who presented with
fatigue, poor PO intake, and abdominal pain. Per his father,
[**Name (NI) **] has not been doing well since he completed alpha
interferon at the end of [**10/2169**] for treatment of his liver
adenomas. He has been more exhausted and his PO intake has been
extremely poor. He denies any fevers, chills, chest pain,
shortness of breath, or diarrhea. The patient does admit to
increasing bilateral lower extremity edema over the past 2
weeks. His BS's have been difficult to control at home since he
is not always compliant with his cornstarch due to fatigue.
Given his constellation of symptoms he was recommended to go to
the ED by his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16258**].
Initial vitals in the ED were T 98.1, BP 118/65, HR 107, RR 27,
O2 sat 100% RA. Initial labs revealed a leukocytosis of 25 and
lactate of 13. Patient was initially started on D10W with close
monitoring of his blood sugars which was then changed to 1/2 NS
given his lactic acidosis. He was also given Zosyn 3.375gm IV
and Ceftriaxone 1gm IV. Repeat labs showed an increase in WBC to
45.3 and lactate of 16. He was transferred to MICU for closer
monitoring. His Hct was noted to be 18.
.
Mr. [**Known lastname 1557**] also underwent a CT scan abd/pelvis in ED which
showed a possible ruptured adenoma. Patient's family did not
want any further procedures to be done. Of note, the patient was
recently admitted in mid-[**Month (only) 404**] for anemia and was admitted for
blood transfusions.
Past Medical History:
1)[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] disease
2)s/p porto-caval shunt
3)Anemia
Social History:
Lives independently in [**Location (un) 745**]. No current tobacco, alcohol, or
IVDA.
Family History:
Brother passed away from complications of [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**] diease.
Physical Exam:
ADMISSION EXAM:
T 97.0 BP 129/67 HR 116 RR 25 O2 sat 100% RA
Gen: Patient appears acutely ill, severely cachectic, older than
stated age
HEENT: MMM
Heart: Sinus tachycardia, no audible m,r,g
Lungs: CTAB, no crackles
Abdomen: Markedly distended, hard to palpation, visible veins.
Extremities: [**1-30**]+ bilateral pitting edema, 1+ DP/PT pulses
Pertinent Results:
ADMISSION LABS:
WBC-25.0*# RBC-2.43*# HGB-5.4*# HCT-20.4* MCV-84
NEUTS-78* BANDS-2 LYMPHS-8* MONOS-11 EOS-0 BASOS-0
PT-17.6* PTT-37.2* INR(PT)-1.6*
GLUCOSE-19* UREA N-39* CREAT-0.6 SODIUM-142 POTASSIUM-4.3
CHLORIDE-93* CO2-12*
ALT(SGPT)-73* AST(SGOT)-514* ALK PHOS-4623* TOT BILI-3.0*
LIPASE-702*
CALCIUM-10.4* PHOSPHATE-2.5* MAGNESIUM-2.5
TRIGLYCER-364*
LACTATE-13.0*
.
IMAGING STUDIES:
1)Cxray ([**1-18**]): No evidence of pneumonia. No acute
cardiopulmonary
abnormalities.
2)CT abd/pelvis ([**1-18**]): 1. Massively enlarged liver with
innumerable heterogenous masses most consistent with adenomas.
Extraluminal pooling of contrast are concerning for active
intra- tumoral hemorrhage in the most inferiorly located tumor
mass in the right hepatic lobe. Minimal normal appearing liver
parenchyma remains. A targeted ultrasound of this area is
recommended for further evaluation of possible intra- tumoral
hemorrhage vs. venous lakes. 2. Marked tumor neovascularity
within the liver, especially the left lobe which is near
completely replaced with tumor. Hepatocellular carcinoma within
these areas cannot be excluded.
3)RUQ U/S ([**1-18**]): Well-defined, focal hypoechoic areas which
show slow internal flow within the most inferior right-sided
hepatic mass most likely represent internal venous lakes
Brief Hospital Course:
Mr. [**Known lastname 1557**] is a 40-year-old man with history of glycogen storage
disease who presented with worsening fatigue, poor PO intake,
and abdominal discomfort.
.
* Glycogen storage disease: AG metabolic acidosis on
presentation, secondary to hypoglycemia. Patient was admitted to
the MICU. Infusion of D10W then D10 1/2NS was started, and as
hypoglycemia resolved, his lactate acidosis improved. The
regimen was discussed with his specialist, Dr. [**Last Name (STitle) **]. Goal
blood sugar is between 70-100. As he started the cornstarch the
D10 gtt was weaned off. When patient was hypoglycemic he was
encouraged to eat small meals. By discharge lactate had
decreased from a peak of 15 to 6.6. Due to loose stools, the
patient could not tolerate cornstarch for several days, but by
discharge diarrhea had resolved, and the patient had been taking
cornstarch for 2 days, with stable fingersticks.
.
* Leukocytosis: Patient initially presented with WBC of 25. No
apparent source of infection was identified. CXR and urinalysis
were unremarkable. Abdominal CT revealed no abscess. Blood and
urine cultures were negative. He was empirically started on
Zosyn on admission which was stopped after 48 hours because of
no evidence for an active infection. When he developed loose
stools later in the hospital course, metronidazole was started
for presumed C. diff and completed by discharge. C. diff came
back negative. The WBC trended down but remained elevated at 15
by discharge. Patient was afebrile during hospitalization.
.
* Recent diarrhea: with persistent leukocytosis. He was
empirically treated with a short course of metronidazole. C.
diff came back negative. Stool studies were unremarkable, and no
clear cause was found. The diarrhea gradually improved, allowing
the patient to better absorb the cornstarch by discharge.
.
* Anemia: Mr. [**Known lastname 1557**] had extensive workup in the past. Concern
for anemia of chronic disease, in setting of hepatic adenomas.
The patient's Hct was 18 on admission, and he subsequently
received pRBCs to increase Hct to high 20s.
.
* Hepatic adenomas: known multiple adenomas per CT scan report.
Family declined further work-up at this time.
.
* Elevated LFTs/coagulopathy: presented with elevated
ALT/AST/alk phos, likely in setting of extensive hepatic
adenomas. INR remained elevated around 1.6-1.7, suggesting
underlying synthetic dysfunction.
.
* LE and scrotal edema: likely from low albumin, and with
infusion of IVF during hospital stay.
.
* Code: Full
Medications on Admission:
Allopurinol 300mg PO daily
Cornstarch
Discharge Medications:
1. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet
Sig: One (1) Powder in Packet PO TID (3 times a day).
Disp:*90 Powder in Packet(s)* Refills:*2*
2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Dextrose (Diabetic Use) 300 mg Tablet Sig: 2-4 Tablets PO PRN
(as needed) as needed for FS < 60.
9. Corn Starch (Bulk) Powder Sig: see comment Miscellaneous
q4 (): 45 gm at 6am, 10am, 2pm, 6pm; 55 g at 10pm, 2am .
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis: lactic acidosis
Secondary diagnosis: glycogen storage disease
Discharge Condition:
Stable
Discharge Instructions:
You presented to [**Hospital1 18**] with fatigue, abdominal discomfort, and
poor appetite. You were found to have hypoglycemia (low blood
sugar) and lactic acidosis, consistent with your glycogen
storage disease. You refused infusion of D10 1/2NS for glucose
control. Cornstarch was started then stopped due to diarrhea.
Work-up for the diarrhea revealed no apparent cause. You were
empirically treated with an antibiotic called metronidazole.
Your diarrhea improved, and the cornstarch was restarted, the
dextrose infusion was discontinued, and your blood sugar
remained stable.
Please take your medications as instructed. If you develop any
fevers, chills, shortness of breath, chest pain, recurrent
diarrhea, or any other symptoms that concern you, please call
your doctor or go to the nearest Emergency Room.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16258**],
[**Telephone/Fax (1) 19196**], for a follow-up appointment within two weeks.
ICD9 Codes: 2762, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6167
} | Medical Text: Admission Date: [**2165-11-25**] Discharge Date: [**2165-12-9**]
Date of Birth: [**2109-2-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base / Penicillins / Claritin / Lipitor / Latex
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
paroxysmal atrial fibrillation
Major Surgical or Invasive Procedure:
Bilateral thoracoscopic mini-Mazes, left atrial appendage
ligation [**11-27**]
History of Present Illness:
This 56 year old white female has a several year history of
paroxysmal atrial fibrillation. She has continued this despite
multiple medication trials. She self referred for evaluation of
surgical ablation and was admitted for surgery.
Past Medical History:
paroxysmal atrial fibrillation
s/p DCCV
seizure disorder
hypertension
chronic hyponatremia
hyperlipidemia
glaucoma
obesity
s/p R knee surgery
s/p L elbow surgery
s/p bladder resusupension
Social History:
The patient is a special education teacher.
non smoker, denies ETOH use
Family History:
noncontributory
Physical Exam:
Admission:
Alert and oriented, exam nonfocal.
lungs- clear
Cor- AF at 95 BPM, w/o murmur
Extremeties- well perfused, palplable pulses, trace edema.
Abd- obese, benign.
discharge:
General: well appearing obese female in NAD
VS: 97.9, 114/69, 80SR, 18, 99% on roomair
Chest: CTAB
Incisions: bilateral thoracotomy incisions both c/d/i without
erythema or drainage
COR: RRR, no murmur or rub
ABD: large, round, soft, NT, ND, +BS
Extrem: warm and well perfused, no edema
Pertinent Results:
Indication: Left ventricular function. Right ventricular
function. Acidosis post Maze procedure
ICD-9 Codes: 424.0, 424.2
Test Information
Date/Time: [**2165-11-28**] at 14:55 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2009W000-0:00 Machine: Vivid i-5
Sedation: (See comments below for other sedation.)
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Findings
40 mg of Propofol was given.
LEFT ATRIUM: No spontaneous echo contrast in the body of the LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present.
LEFT VENTRICLE: Overall normal LVEF (>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal descending aorta diameter. No atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No masses or
vegetations on aortic valve. No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral valve. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was under general
anesthesia throughout the procedure. No TEE related
complications.
Conclusions
No spontaneous echo contrast is seen in the body of the left
atrium. A patent foramen ovale is present. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Normal biventricular systolic function. Stretched
patent foramen ovale is present.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2165-11-28**] 18:03
[**2165-12-9**] 07:10AM BLOOD WBC-9.7 RBC-3.74* Hgb-11.7* Hct-32.8*
MCV-88 MCH-31.5 MCHC-35.9* RDW-13.2 Plt Ct-425
[**2165-12-7**] 08:00AM BLOOD PT-41.9* INR(PT)-4.6*
[**2165-12-8**] 11:00AM BLOOD PT-23.2* INR(PT)-2.2*
[**2165-12-9**] 07:10AM BLOOD PT-17.0* INR(PT)-1.5*
[**2165-12-6**] 04:52AM BLOOD PT-35.1* INR(PT)-3.7*
[**2165-12-9**] 07:10AM BLOOD Glucose-109* UreaN-13 Creat-0.6 Na-135
K-3.9 Cl-97 HCO3-26 AnGap-16
Brief Hospital Course:
She was admitted 2 days prior to surgery for heparinization off
coumadin. She was taken to the operating room on [**11-27**] where
bilateral thoracoscopic mini-Mazes with left atrial appendage
ligation was performed. She tolerated the procedure well and
was transferred to the ICU in stable condition.
She weaned from the ventilator and was extubated on POD 2 after
her metabolic acidosis/respiratory failure cleared. A TEE was
performed on POD 1 to demonstrate no cardiac pathology.
Paravertebral blocks were administered on [**11-28**] for pain control
with good results. She was kept in the ICU for pulmonary care
and ready for transfer to the floor on POD 5 ([**12-2**]). Amiodarone,
beta blockers and antiinflammatory medications were administered
to maintain sinus rhythm and control post operative inflammatory
response. However on POD# 6 pt developed Afib, flutter which was
rate controlled. Coumadin was resumed at home dose of 5 mg but
INR rose to 5.6- coumadin was held and d/c was post-poned. That
evening she went into atrial flutter and her lopressor was
increased. On post-operative day 9 she was electively
cardioverted to sinus rhythm. INR normalized and the patient was
maintained on lower doses of coumadin than previously due to
concommitant amiodarone administration.
She continued to progress and she was ready for discharge to
rehab on POD # 12 where she will undergo further conditioning to
increase strength, endurance and activities of daily living. All
follow up appointments were advised.
Medications on Admission:
Keppra 1500mg [**Hospital1 **]
Tegretol XR 400mg [**Hospital1 **]
Diltiazem SR 180mg/D
Ativan 0.5 mg/D
ASA 325mg/D
Lopressor 150mg TID
Coumadin 5mg/D
Xalantan 0.05% ophth. 1 gtt OU qHS
Pantoprazole 40mg/D
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Carbamazepine 100 mg Tablet Sustained Release 12 hr Sig: Four
(4) Tablet Sustained Release 12 hr PO BID (2 times a day).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week,
then 200mg/day until further instructed.
Disp:*120 Tablet(s)* Refills:*0*
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*qs * Refills:*0*
12. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed. Tablet(s)
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-15**]
Puffs Inhalation Q6H (every 6 hours) as needed.
16. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
17. Warfarin 1 mg Tablet Sig: .5 Tablet PO once a day: .5mg
alternating with 0mg for goal INR 2-2.5 (atrial fibrillation).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
paroxysmal strail fibrillation
s/p bilateral thoracoscopic mini-Mazes, left atrial appendage
ligation
hypertension
obesity
seizure disorder
hyperlipidemia
glaucoma
endometriosis
s/p bladder resuspension
s/p R knee surgery
s/p L elbow surgery
s/p appendectomy
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
wound clinic in 2 weeks
Dr. [**Last Name (STitle) 73**] in 2 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**11-15**] weeks ([**Telephone/Fax (1) 608**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (ENT) as an outpatient to evaluate mass on left
vocal cord
please call for appointments
Completed by:[**2165-12-9**]
ICD9 Codes: 5185, 5180, 2761, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6168
} | Medical Text: Admission Date: [**2158-9-11**] Discharge Date: [**2158-9-15**]
Service: [**Last Name (un) **]
Allergies:
Coumadin / Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
1. Casting of Left forearm for Colles fracture
2. Hinge casting of bilateral lower extremities for spiral
fracture of the right distal femoral diaphysis extending to the
supracondylar region and oblique fracture of the distal left
femur metaphysis
3. Placement of percutaneous left nephrostomy tube
4. Transfusion of 2U PRBC
History of Present Illness:
82 y.o. female nursing home resident who fell during transfer
from bed to wheelchair on [**2158-9-9**]. The patient landed on her
knees bilaterally and struck her nose on the bed. After this
event, she complained of bilaterally leg pain. On [**2158-9-10**] X-rays
were taken at the nursing home, showing bilateral femur
fractures. She was then transferred to [**Hospital1 18**] for treatment.
Past Medical History:
A fib
HTN
Depression
Non-insulin dependent DM
Chronic venous stasis w/ hx of foot ulcers
Bilateral hip fractures s/p bilateral hip replacement
Osteoporosis
Arthritis
Degenerative joint disease
Chronic UTI
Social History:
lives at [**Location 58139**] [**First Name9 (NamePattern2) 58140**] [**Doctor First Name 533**] center for extended care
has two goddaughters who both have POA: [**Name (NI) 58141**] [**Name (NI) 58142**] and
[**Last Name (un) **] [**Name (NI) 58143**]
Family History:
non-contributory
Physical Exam:
on arrival to the ED
vitals: Temp 101.6 rectal HR 138 BP 153/52 RR 23 Sats 100% on
NRB FSBG 280
GEN: awake, alert, able to answer yes and no to questions,
follows commands NAD
HEENT: PERRL, EOMI, right perorbital ecchymosis, midface stable,
no oral pharyngeal trauma
NECK: c-collar in place, trachea midline
CHEST: equal BS bilaterally
CV: irregularly irregular, no M/R/G
ABD: SNTND
PELVIS: stable to AP and lateral compression
RECTAL: normal tone, no gross blood, heme neg
BACK: no palpable step-offs, no visible abrasions
EXT: left wrist swelling and ecchymosis, Right leg in flexion,
no grossly apparent deformities of bilateral LE
Skin: warm, dry, intact
NEURO: CN II-XII intact, able to move all 4 ext, no apparent
motor or sensory deficits
Pertinent Results:
[**2158-9-10**] 10:11 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
IMPRESSION:
1) No evidence of acute traumatic intraabdominal injury.
2) 9 mm obstructing stone in the proximal left ureter with
moderate hydronephrosis. CT evidence of bilateral pyelonephritis
[**2158-9-10**] 10:11 PM CT C-SPINE W/O CONTRAST; CT
RECONSTRUCTIONIMPRESSION: Severe degenerative changes and
demineralization. No definite acute fracture seen.
[**2158-9-10**] 10:10 PM CT HEAD W/O CONTRAST IMPRESSION: Likely remote
right MCA distribution infarct. Subacute to chronic right PCA
distribution infarct, but exact timing is indeterminate without
a prior study. MRI could be performed for further evaluation, if
the patient is a candidate for MRI
[**2158-9-10**] 9:36 PM ELBOW (AP, LAT & OBLIQUE) LEFT; WRIST(3 +
VIEWS) LEFTIMPRESSION:
1. Suspicion for fracture of the radial head.
2. Colles' fracture.
[**2158-9-11**] 3:57 PM L-SPINE (AP & LAT); T-SPINE IMPRESSION:
1. Loss of height in multiple midthoracic vertebral bodies and
in the L1 vertebral body. These are of uncertain chronicity.
2. Grade I anterolisthesis of L4 on L5.
3. Diffuse demineralization. No acute fracture can be
identified, noting that evaluation is limited in the presence of
diffuse demineralization.
[**2158-9-11**] 12:52 AM FEMUR (AP & LAT) BILAT
There is a spiral fracture of the right distal femoral diaphysis
extending to the supracondylar region. There is an oblique
fracture of the distal left femur metaphysis. Neither of these
fractures appear to extend intraarticularly. There is posterior
displacement of the distal fracture fragments bilaterally. There
is diffuse demineralization. Degenerative changes are seen in
both knees. There is a dynamic compression screw in the proximal
right femur with extensive foreshortening of the femoral neck
region and associated heterotopic bone formation. A bipolar left
hip prosthesis is present without evidence of fracture.
[**2158-9-10**] 09:10PM BLOOD WBC-21.3* RBC-3.16* Hgb-9.9* Hct-29.0*
MCV-92 MCH-31.5 MCHC-34.3 RDW-13.9 Plt Ct-360
[**2158-9-11**] 08:50AM BLOOD WBC-17.6* RBC-2.44* Hgb-7.7* Hct-23.4*
MCV-96 MCH-31.7 MCHC-33.1 RDW-13.7 Plt Ct-329
[**2158-9-11**] 10:35PM BLOOD Hct-27.6*
[**2158-9-12**] 01:59AM BLOOD WBC-15.6* RBC-3.24*# Hgb-10.2*# Hct-29.4*
MCV-91 MCH-31.4 MCHC-34.5 RDW-15.3 Plt Ct-270
[**2158-9-12**] 03:47PM BLOOD WBC-14.0* RBC-3.22* Hgb-10.3* Hct-28.5*
MCV-89 MCH-32.1* MCHC-36.3* RDW-15.6* Plt Ct-250
[**2158-9-13**] 05:27AM BLOOD WBC-11.7* RBC-3.21* Hgb-10.3* Hct-28.9*
MCV-90 MCH-32.0 MCHC-35.5* RDW-15.2 Plt Ct-267
Brief Hospital Course:
[**2158-9-10**]: X-ray studies revealed bilateral femur fx and left
Colles' fx. CT of Abd/Pelvis also revealed obstructing 9mm
ureteral stone on left with bilateral hydronephrosis. The pt was
empirically started on Levofloxacin for treatment of presumed
pyelonephritis. The pt was initially admitted to the TSICU
because she was requiring Diltiazem IV for management of her
rapid a fib. Vascular and Ortho services were also consulted for
evaluation of the pt's injuries. Based on clinical exam, the
pt's fractures did not compromise blood flow to the lower
extremities. A confirmatory angiogram was deferred secondary to
the risks of the procedures and the [**Hospital **] medical comorbidities.
Close neurovascular surveillence of the pt's LE was continued
throughout her hospital course and no changes were noted.
Orthopedics performed a closed reduction of the pt's left
Colles' fracture with good success. Her left forearm was then
placed in a hard cast. Urology was also consulted for the pt's
obstructing ureteral stone. Their decision to place a diverting
percutaneous nephrostomy tube would be determined based on the
pt's urine culture.
[**2158-9-11**] to [**2158-9-15**]: The pt's C-spine was cleared after flex-ex
films were obtained. T/L spine films revealed old compression
fx. The pt's HCT dropped to 23 and she was transfused 2U PRBC.
After clearance of the pt's C-spine, she was switched to PO meds
and transferred to the hospital floor. Options for treatment of
the pt's bilateral femur fx were discussed and the POA's decided
on non-surgical management with casting under fluoroscopy. This
was performed by orthopedics and the pt tolerated the procedure
well. The pt's initial urine ctx came back with diffuse
contamination. Urology decided to place a percutaneous
nephrostomy tube due to the high likelihood of infxn. This was
performed by interventional radiology on [**2158-9-14**]. After the
procedure, the pt's foley remained in place and will be removed
at the nursing care facility at the request of the pt's health
care POA. She had no difficulty urinating and clear urine was
draining from the tube. She was tolerating PO without difficulty
and placed back on all of her home meds. The bilateral hinged
casts on her LE fit well with no evidence of pain, swelling, or
erythema of the skin or her toes. Physical therapy worked with
the pt in house to facilitate her rehab. On [**2158-9-15**] the pt was
discharged home to her previous rehab facility. She will be
continued on PO antibiotics for five days after discharge.
Medications on Admission:
1. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO at bedtime.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Effexor 37.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
7. Isordil Titradose 40 mg Tablet Sig: 1.5 Tablets PO once a
day.
Disp:*45 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO at bedtime.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Effexor 37.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
7. Isordil Titradose 40 mg Tablet Sig: 1.5 Tablets PO once a
day.
Disp:*45 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) injection
Subcutaneous QD (once a day) for 6 weeks.
Disp:*30 injection* Refills:*2*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
1. Pyelonephritis
2. A fib
3. GERD
4. Degenerative joint disease
5. Bilateral hip replacement
6. Left Colles' fracture requiring reduction and casting
7. Spiral fracture of the right distal femoral diaphysis
requiring reduction and casting
8. Oblique fracture of the distal left femur metaphysis
requiring reduction and casting
9. HTN
10. Depression
11. Non-insulin dependent DM
12. Chronic venous stasis w/ hx of foot ulcers
13. Osteoporosis
14. Blood loss anemia requiring transfusion 2U PRBC
15. Obstructive nephrolithiasis requiring placement of
percutaneous nephrostomy tube in the left ureter
Discharge Condition:
Stable
Discharge Instructions:
You may resume your regular diet. Continue physical therapy as
tolerated to help improve your movement with the leg casts. Your
weight bearing status is: non-weight bearing on bilateral lower
extremities and non-weight bearing on left upper extremity. You
will be on the Lovenox injections for anticoagulation for a
total of six weeks. Please leave the foley catheter in place
until arrival at the health care facility, then it may be
removed.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) **] in the [**Hospital **] clinic
located in the [**Hospital Ward Name 23**] building on the [**Location (un) 1773**]. An
appointment has been scheduled for you on [**10-20**] @ 9:10
AM. Please call ([**Telephone/Fax (1) 58144**] if you have any questions or need
to change the appointment. Prior to this appointment, please
obtain AP and Lateral x-rays of bilateral femurs and an x-ray of
the pt's left wrist. Please have these transported with the pt
on the day of the clinic appointment so Dr. [**Last Name (STitle) **] may see the
films.
Follow up with Dr. [**Last Name (STitle) 770**] of Urology in 4 weeks. Call ([**Telephone/Fax (1) 58145**] to schedule an appt. The clinic is located in the
[**Hospital Ward Name 23**] building. If possible, you may want to schedule the appt
for the same day as your orthopedic visit.
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6169
} | Medical Text: Admission Date: [**2159-6-27**] Discharge Date: [**2159-7-24**]
Date of Birth: [**2134-1-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
Exploratory Laparotomy [**2159-6-27**]
Bialteral chest tubes
Bronchoscopy [**2159-6-29**] [**2159-7-11**]
Percutaneous tracheostomy [**2159-7-11**]
History of Present Illness:
24 yo male helmeted driver, s/p motorcycle crash; ? LOC.
Transported to [**Hospital1 18**] for continued trauma care.
Past Medical History:
Seizure Disorder
Family History:
Noncontributory
Physical Exam:
VS upon admission to trauma bay:
HR 150's BP 60's RR 30
GCS 14
Gen: color ashened
HEENT: EOMI, PERRL 3->2; TM's clear
Neck: c-collar
Chest: CTA bilat
Cor: reg tachy
Abd: soft, NT, ND FAST positive for fluid around liver
Rectum: nl tone
Back: no stepoffs
Pertinent Results:
[**2159-6-27**] 10:49PM TYPE-ART PO2-98 PCO2-75* PH-7.07* TOTAL
CO2-23 BASE XS--10
[**2159-6-27**] 10:49PM GLUCOSE--251* LACTATE-7.8* NA+-138 K+-5.3
CL--103
[**2159-6-27**] 10:49PM HGB-13.2* calcHCT-40 O2 SAT-95 CARBOXYHB-1
MET HGB-1
[**2159-6-27**] 10:00PM PT-19.1* PTT-57.6* INR(PT)-1.8*
CHEST (PORTABLE AP) [**2159-7-16**] 10:31 AM
CHEST (PORTABLE AP)
Reason: eval: R CT placement
[**Hospital 93**] MEDICAL CONDITION:
25 year old man s/p R CT placement
REASON FOR THIS EXAMINATION:
eval: R CT placement
EXAMINATION: AP CHEST 10:45 A.M., [**7-16**].
HISTORY: Chest tube placement.
IMPRESSION: AP chest compared to [**7-10**] and 7:
New right apical pleural tube. No pneumothorax. Decrease
moderate size right pleural effusion. Left lung clear aside from
mild vascular congestion. Heart is normal size. Widening of the
upper mediastinum due to fat deposition and vascular
engorgement. Nasogastric tube ends in the stomach.
CT ABDOMEN W/CONTRAST [**2159-7-15**] 11:29 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: eval for abcess, loculated fluid collection
Field of view: 48 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
25 year old man with s/p motorcycle accident, h/o chest tubes,
s/p ex lap for liver lac, now with fevers
REASON FOR THIS EXAMINATION:
eval for abcess, loculated fluid collection
CONTRAINDICATIONS for IV CONTRAST: None.
25-year-old male status post motorcycle accident with multiple
fractures and hepatic lacerations, now with fever and concern
for intra-abdominal abscess.
COMPARISON: [**2159-7-3**].
TECHNIQUE: MDCT continuously acquired axial images of the chest,
abdomen and pelvis were obtained after 130 mL Optiray IV as well
as oral contrast.
CT OF THE CHEST WITH IV CONTRAST: The tracheostomy remains in
appropriate position. There has been interval removal of a right
chest tube. A nasogastric tube terminates in the stomach. The
heart and pericardium as well as aorta are unremarkable. There
is no pathologic mediastinal, hilar or axillary lymphadenopathy.
There has been interval worsening in a now very large right
pleural effusion with associated total atelectasis of the right
middle and lower lobes. There has been improvement in left
basilar consolidation with residual patchy nodular opacities
more peripherally, possibly representing areas of contusion.
CT OF THE ABDOMEN WITH IV CONTRAST: Again demonstrated is
extensive laceration of the right hepatic lobe, primarily
segments V, VI and VII. This is not significantly changed. The
gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach,
duodenum, and intra-abdominal loops of large and small bowel are
unremarkable. The kidneys enhance and excrete contrast
symmetrically, and the ureters are of normal caliber. There has
been interval resolution of the small bowel obstruction, and
there is free passage of oral contrast through to the ascending
colon. There is a small amount of fluid along the inferior edge
of the liver. There has been resolution of ascites seen
previously to track into the pelvis. No intra-abdominal fluid
collection or abscess is identified.
CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter
within the decompressed urinary bladder. The rectum, prostate
gland, seminal vesicles and intrapelvic loops of bowel are
unremarkable. There is no significant free pelvic fluid or
lymphadenopathy.
BONE WINDOWS: Again demonstrated are multiple bilateral
posterior rib fractures as well as fractures of the posterior
spinous processes from T2 through T5 as well as the right
scapula.
IMPRESSION:
1. Interval worsening in now large right pleural effusion with
associated total atelectasis of the right middle and lower
lobes.
2. Improvement in left basilar consolidation with residual
patchy nodular peripheral left lung opacities, probably
representing contusion.
3. No significant change in right hepatic laceration.
4. Multiple fractures as previously described.
5. Near resolution of intra-abdominal free fluid with only a
small amount of residual fluid along the inferior edge of the
liver.
PATIENT/TEST INFORMATION:
Indication: Left ventricular function.
Height: (in) 68
Weight (lb): 228
BSA (m2): 2.16 m2
BP (mm Hg): 106/67
HR (bpm): 116
Status: Inpatient
Date/Time: [**2159-6-28**] at 15:36
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W014-1:08
Test Location: West SICU/CTIC/VICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 2.6 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 160 msec
TR Gradient (+ RA = PASP): 25 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded. Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Aortic valve not well seen. No AS. No AR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal
tricuspid valve supporting structures. Normal PA systolic
pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - poor parasternal views. Suboptimal image quality
- poor apical
views. Suboptimal image quality - poor subcostal views.
Suboptimal image
quality - bandages, defibrillator pads or electrodes. Suboptimal
image quality
as the patient was difficult to position. Suboptimal image
quality -
ventilator.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded.
Overall left ventricular systolic function appears grossly
normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic
valve is not well seen. There is no aortic valve stenosis. No
aortic
regurgitation is seen. The estimated pulmonary artery systolic
pressure is
normal. There is no pericardial effusion.
CT T-SPINE W/O CONTRAST [**2159-6-28**] 5:02 PM
CT T-SPINE W/O CONTRAST
Reason: trauma
[**Hospital 93**] MEDICAL CONDITION:
25 year old man with
REASON FOR THIS EXAMINATION:
trauma
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 25-year-old man with trauma.
TECHNIQUE: T-spine CT without contrast.
No comparison.
FINDINGS: There is no evidence of subluxation. The prevertebral
soft tissue is unremarkable. Note is made of minimally displaced
fracture of the spinous processes from T2-T5. Note is made of
rib fractures bilaterally at T1, on the righta t T3-8, and
possibly on the left at T8. Note is made of opacities in the
lungs, which was described in detail in torso CT report.
IMPRESSION: No subluxation. Minimally displaced fractures of the
spinous processes of T2-T5. Multiple rib fractures. Please also
refer to the official report of the CT torso study.
Brief Hospital Course:
Patient admitted to the trauma service. FAST exam positive in
the emergency department; he was intubated and immediately taken
to the operating room for exploratory lap, repair of liver
laceration and placement of bilateral chest tubes for pulmonary
contusions. His chest tubes were eventually removed; follow up
chest xray after removal of right chest tube reveals tiny apical
pneumothorax. Neurosurgery was consulted for ICP bolt
placement given his mechanism of injury and decreased mental
status; initial pressures were 28. The bolt was eventually
removed several days later.
Orthopedic spine surgery was consulted because of minimally
displaced fractures of spinous processes T2-T5. he was treated
non operatively for these injuries and was fitted for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36323**]
brace to be worn while out of bed.
Infectious disease was consulted for persistent fevers; he was
cultured; central line tip cultured as well; blood cultures grew
out staph caog negative; catheter tip grew Acinetobacter and
Klebsiella; sputum grew Klebsiella. He was treated with
Vancomycin, which completed on [**7-23**]; Meropenem and Gentamicin,
which will continue through [**7-31**] & Bactrim po, which will also
continue through [**7-31**].
Speech and Swallow was consulted to evaluate swallowing and
Passy Muir valve. He was eventually able to tolerate the PMV;
his diet was upgraded to regular solids with thin liquids. His
tracheostomy was downsized on HD #28 with the plan to follow up
in Trauma Clinic in 1 week to decannulated.
Physical and Occupational therapy have worked with patient
throughout his hospital course; at time of discharge he is
independent with ambulation and ADL's; will require some
assistance for donning his [**Location (un) 36323**] brace.
Medications on Admission:
"Antiseizure" meds
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Gentamicin 40 mg/mL Solution Sig: One (1) Injection Q 12 for
7 days: 250 mg.
Disp:*24 * Refills:*0*
3. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 7 days.
Disp:*28 Recon Soln(s)* Refills:*0*
4. Bactrim 400-80 mg Tablet Sig: 1.5 Tablets PO three times a
day for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: Two (2) Tablet
PO every 6-8 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. PICC
PICC line care per protocol
9. Carbamazepine 100 mg Tablet, Chewable Sig: 1.5 Tablet,
Chewables PO four times a day.
Disp:*180 Tablet, Chewable(s)* Refills:*2*
10. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
s/p Motorcycle crash
Liver laceration
Lung contusions
Respiratory failure
Right scapula fracture
Spinous process fractures T2-T5
Bacteremia
Multiple rib fractures
Discharge Condition:
Good
Discharge Instructions:
Return to the emergency department if you develop fevers,
chills, headache, dizziness, increased shortness of breath,
nausea, vomiting, diarrhea and/or any other symptoms that are
concerning to you.
You must continue to wear your brace when out of bed.
Your antibiotics will continue until [**7-31**].
Followup Instructions:
Follow up in Trauma Clinic in 2 weeks. Call [**Telephone/Fax (1) 6439**] for an
appointment.
Follow up with Dr. [**Last Name (STitle) 363**], Orthopedic Spine Surgery in 4 weeks,
call [**Telephone/Fax (1) 3573**] for an appointment. Inform the office that you
may need a repeat MRI scan for this appointment.
Follow up with Dr. [**Last Name (STitle) **], Neurosurgery in 3 months, call
[**Telephone/Fax (1) 1669**] for an appointment.
Completed by:[**2159-7-31**]
ICD9 Codes: 5185, 2851, 7907, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6170
} | Medical Text: Admission Date: [**2146-8-24**] Discharge Date: [**2146-8-30**]
Service: [**Hospital 878**]
HOSPITAL COURSE: This is an 88-year-old right-handed woman
with past medical history of myocardial infarction,
hypertension, atrial fibrillation, and poor medicine
compliance, who was admitted on [**8-24**] after falling off her
chair when trying to get up. She notes she had weakness on
She was brought to the Emergency Room and was noted to have
slurred speech with language intact. She had a right gaze
preference, but no gaze paresis. She did not respond to
visual threat on the left and had a flattened left nasolabial
fold. She was inattentive to said stimuli. Upper and lower
extremity strength was normal on the right and was 3+ to 4-
and had an upgoing toe also on the left.
Diffusion-weighted imaging at the time showed increased
signal intensity in the left cerebellum and right hemisphere
at MCH distribution, involving the basal ganglia, insula, and
parotid lobe.
She was treated with intra-arterial TPA by Dr. [**Last Name (STitle) 17302**], and
Interventional Radiology team, and there was successful
partial revascularization of the distal right MCA branch
(M-II).
She did well postoperatively, and began to regain strength on
the left side. On the evening of [**8-25**], she developed
a large groin hematoma that extended to her abdominal wall.
Her hematocrit remained stable at 28.0 to 28.4, and CT scan
of the abdomen and pelvis showed no retroperitoneal bleed.
She was then transferred out of the Intensive Care Unit and
onto the Neurology Service.
Since transfer, she continued to recover function
neurologically. She had been progressing well with physical
therapy. She initially complained of bilateral leg pain that
has since resolved. On Tele monitoring, she has been noted
to have episodes of intermittent rapid atrial fibrillation.
She is currently on metoprolol 25 mg [**Hospital1 **] for this. In regard
there is anticoagulation for atrial fibrillation, Vascular
Surgery recommended to wait one week prior to starting
Coumadin.
Her hematocrit was stable at 30.1 on the day of discharge.
She will follow up with Dr. [**First Name (STitle) 1001**] in the Stroke/[**Hospital 878**]
Clinic at [**Hospital1 69**] on [**9-13**] at 4 pm. Phone number [**Telephone/Fax (1) 17303**] at the [**Hospital Ward Name 23**]
Clinical Center.
MEDICATIONS: Protonix 40 mg po q day, aspirin 325 mg po q
day, metoprolol 25 mg po bid, Tylenol 650 mg q4-6 hours prn
for pain, Heparin 5,000 units subQ q12, Lasix 20 mg po q day,
and Colace 100 mg po bid.
DISCHARGE DIAGNOSES:
1. Right middle cerebral artery stroke.
2. Atrial fibrillation.
3. Right groin hematoma.
4. Hypertension.
DISPOSITION: Rehab.
Diet is cardiac. Condition is stable. Rehabilitation
potential excellent.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17304**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2146-10-12**] 11:27
T: [**2146-10-15**] 07:36
JOB#: [**Job Number 17305**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6171
} | Medical Text: Admission Date: [**2176-2-27**] Discharge Date: [**2176-5-15**]
Date of Birth: [**2115-11-10**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins / Latex / Red Dye / Darvon /
Percodan / Aspirin / Aspartame / Fentanyl
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
10% blasts on routine differential
Major Surgical or Invasive Procedure:
Ommaya Placement with Intrathecal Chemotherapy
Cycle 1 of hyperCVAD
Right femeral a-line
Right central line
History of Present Illness:
60-year-old woman with a history of ALL status post allogeneic
transplant with subsequent disease recurrence status post DLI
with subsequent achievement of a complete remission p/w several
non-spicific pain-related complaints and dizziness and 10%
blasts on peripheral smear. Patient endorses dizziness,
generalized pain with sharp, stabbing pain in her right mid-back
and neck. Also endorses shortness of breath. She is unsure if it
is exertional.
.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
ONCOLOGIC HISTORY:
The patient was diagnosed with acute lymphoblastic leukemia in
[**2166**] after bone marrow biopsy was performed secondary to iron
deficiency anemia workup. She was treated with standard dose
chemotherapy and had a good response. She completed induction
and consolidation chemotherapy and achieved a complete
remission. Her course was complicated by severe bilateral
avascular necroses of the hips due to steroid use. She also had
multiple dental issues requiring extractions. [**Known firstname **] remained in
remission for several months but
ultimately showed signs of disease recurrence in her marrow. She
underwent reinduction and achieved once again a complete
remission. She did well until the summer of [**2168**] when she
developed evidence of relapse. She received induction
chemotherapy once again and achieved remission. This course was
complicated by neutropenic fever, development of a coagulative
negative staph bacteremia, left upper extremity DVT, aseptic
necrosis of the bilateral hips, and septic emboli of the
liver. [**Known firstname **] then underwent a nonmyeloablative allogeneic stem
cell transplant from matched unrelated donor with Campath
conditioning in [**2169-11-29**]. She did well and subsequently
achieved remission. Her posttransplant course was complicated by
the development of a sore throat and question of low level EBV
infection. There was some concern at that time by involvement
with a lymphoproliferative disease. Her EBV titer disappeared
upon withdrawal of her cyclosporine. She was followed by
quantitative EBV levels, which remained undetectable, and she
had
fully recovered from this. She had no definite evidence for
GVHD.
She remained in remission until her relapse in 10/[**2170**].
.
Since her relapse in [**8-/2171**], [**Known firstname **]
received treatment with hyper-CVAD in [**9-/2171**] and a donor
lymphocyte infusion on [**2171-11-5**]. She was again noted for
relapse of her ALL in [**12/2171**] and was admitted to the hospital
from [**2172-1-7**] to [**2172-2-26**]. She had persistent pain in the
perirectal area with incontinence and was found to have CNS
involvement of the cauda equina and received radiation therapy
to
her lower spine in 02/[**2171**]. She then received another cycle of
hyper-CVAD in [**1-/2172**] following the completion of her radiation
therapy. Her day 14 bone marrow showed no residual leukemia and
she received another DLI on [**2172-2-18**]. She also received two
doses of intrathecal methotrexate on [**2172-2-25**] and [**2172-3-19**].
Unfortunately, by the end of [**2-/2172**], she was noted for
decreasing
counts and was admitted with concern for relapsed disease, which
was confirmed on bone marrow aspirate and biopsy. Because of
her
debilitated state, [**Known firstname **] was not given any further treatment and
she was sent home with increased support and to follow up with
her local oncologist with a concern that her disease would
relapse or progress further. However, since her discharge from
the hospital in [**3-/2172**], [**Known firstname **] improved with normalization of her
counts and no further evidence for disease recurrence. She has
required no further treatment, but has had many chronic
complications. She developed increasing problems with [**Name2 (NI) 7809**]
with
constipation and intermittent diarrhea, as well as increasing
pain in the rectal area, as well as increasing pelvic and hip
pain. There have been no changes with MRI of the lower spine.
The
feeling was that she developed issues with anal stricture after
her cauda equina syndrome and radiation therapy along with a
neurogenic rectum that did not empty fully. After approximately
two years of significant stress with her bowel regimen and
attempts at anal dilatation, she underwent a diverting sigmoid
colostomy in [**11/2173**] under the direction of Dr. [**Last Name (STitle) 1120**] at [**Hospital1 18**].
She also has had issues of chronic hip pain due to osteonecrosis
of the hip and she is status post left hip replacement. In
[**Month (only) 958**]/[**2175-2-28**], [**Known firstname **] was noted for increasing shortness of
breath. She underwent an echocardiogram, which was noted for a
drop in her ejection fraction to 35-40%. She has been started
on
captopril. She underwent an adenosine stress test, which did
not
show any evidence for coronary artery disease. It was felt that
this may have been related to a viral illness. She did undergo
a
repeat echocardiogram on [**2175-6-12**], which showed improvement to
about 40%.
[**Known firstname **] has been followed with continued normal counts until more
recently when labs from an outside hospital have shown increased
lymphocytes with atypical lymphocytes and decreasing neutrophils
with ANC of 700. There were no immature cells noted and white
count, hematocrit and platelet count were normal. She had been
recovering from two upper respiratory infections. Given the
persistent change in her counts, [**Known firstname **] was seen today for
further
evaluation and was noted for 10% circulating blasts. She
underwent bone marrow aspirate and biopsy and is being admitted
for further evaluation and probable treatment.
.
PAST MEDICAL HISTORY:
ALL, juvenile rheumatoid arthritis, h/o paroxysmal
supraventricular tachucardia and paroxysmal atrial tachycardia,
h/o of laryngeal spasm, irritable bowel syndrome w colostomy
placed for chronic constipation,avascular necrosis of the hips
in the left shoulder and s/p left hip replacement, left upper
extremity clot, Sjogren's, Shingles (Spring [**2174**]), systolic CHF
(EF in the 30s per patient)
Social History:
Mrs. [**Known lastname 11513**] lives alone in her own home. She has a personal
home care assistant that helps with her cooking, cleaning, and
personal hygiene. She also is followed closely by the Visiting
Nurses Association and Physical Therapy. She denies alcohol or
tobacco use. She reportedly has a remote history of marijuana
use. She has three children.
Family History:
[**Name (NI) 1094**] mother died [**2172-3-7**] of lung cancer with brain mets at 80y/o.
Also had gallstones and hypothyroidism. The patient's father
had prostate cancer, hypertension, and diabetes. At least one of
her paternal aunts had breast cancer, and another had multiple
myeloma. One of the patient's paternal cousins has leukemia. The
patient's aunt has scleroderma.
Physical Exam:
Vital Signs: T: 98.4 BP: 124/78 HR: 86 RR: 16 O2 sat: 95% RA
Weight: 137.9 lbs Height: 60.5 in
General: Alert, oriented, no acute distress, chronically ill
appearing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, 1cm nontender, mobile L
maxillary LN
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 grossly intact. Unsteady gait.
Pertinent Results:
[**2176-2-27**] 12:10PM RET AUT-0.2* PLT SMR-NORMAL PLT COUNT-224
[**2176-2-27**] 12:10PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL HOW-JOL-1+
NEUTS-25* BANDS-0 LYMPHS-58* MONOS-4 EOS-0 BASOS-0 ATYPS-3*
METAS-0 MYELOS-0 OTHER-10* WBC-3.7*# RBC-4.17* HGB-13.4 HCT-39.3
MCV-94 MCH-32.1* MCHC-34.1 RDW-15.8*
[**2176-2-27**] 12:10PM T4-9.4 TSH-11*
[**2176-2-27**] 12:10PM ALT(SGPT)-44* AST(SGOT)-42* LD(LDH)-209 ALK
PHOS-109 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1 ALBUMIN-4.3
CALCIUM-9.3 PHOSPHATE-4.4 MAGNESIUM-2.0 UREA N-22* CREAT-0.8
SODIUM-137 POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-32 ANION GAP-10
GLUCOSE-86
[**2176-2-27**] 03:12PM BONE MARROW IPT-D CD34-D CD3-D CD4-D CD8-D
CD33-D CD41-D CD56-D CD64-D CD71-D CD117-D CD45-D HLA-DR[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 31151**]
A-D KAPPA-D CD2-D CD7-D CD10-D CD11C-D CD13-D CD14-D CD15-D
CD19-D CD20-D LAMBDA-D CD5-D
IMAGING AND DIAGNOSTICS:
Bone Marrow [**2-27**]:
ACUTE LEUKEMIA, RECURRENT.
By immunostaining most immature (blasts) cells appear
immunoreactive for CD34 and c-kit. A subset is in addition
positive for nuclear TDT. Myeloperoxidase stains only
approximately 20% of the cells.
Immunophenotypic findings consistent with relapsed acute
leukemia.
KARYOTYPE: 46,XX[17]//46,XY[3]
INTERPRETATION:
A chimerism result was obtained from this unstimulated
specimen. Three cells were 46,XY and represent the male
bone marrow donor. The remaining 17 cells were 46,XX and
represent the female patient.
nuc ish(DXZ1x2)[89]//(DXZ1,DYZ3)x1[111]
FISH was performed on interphase nuclei with probes ([**Doctor Last Name 7594**]
Molecular) for DXZ1 (chromosome X alpha satellite DNA) at
Xp11.1-q11.1 and DYZ3 (chromosome Y alpha satellite DNA) at
Yp11.1-q11.1 probes. A chimeric XX/XY hybridization pattern
was observed, in which 89 cells were XX and 111 cells were
XY.
These XY cells represent that of the male donor and not the
female recipient.
MR [**Name13 (STitle) 430**] [**2-28**]:
1. No masses, edema or infarct.
2. Nonspecific heterogeneous marrow which may represent
hyperplasia or
infiltration.
CSF [**2-29**]:
Immunophenotypic findings consistent with involvement by acute
leukemia.
CSF [**3-7**]:
There is a minor population of CD34+ cells, which in conjunction
with the morphology on the cytospin, are consistent with the
patient's known leukemia.
CSF [**3-9**]:
ATYPICAL.
CSF [**3-12**]:
Cell marker analysis was performed, but was non-diagnostic in
this case due to insufficient numbers of cells/insufficient
amount of tissue for analysis and due to poor viability;
however, morphologic assessment of the cytospin showed numerous
blasts consistent with patient's known leukemia.
TTE [**3-1**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild global
left ventricular hypokinesis (LVEF = 50%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Right ventricular chamber
size and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Moderate (2+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild global left ventricular systolic dysfunction.
Moderate mitral regurgitation.
Compared with the report of the prior study (images unavailable
for review) of [**2172-4-1**], left ventricular systolic function is
probably similar. Mitral regurgitation may have slightly
increased.
MR C/T/L spine [**3-1**]:
1. Diffuse leptomeningeal and cauda equina root enhancement, in
this setting
strongly suspicious for leptomeningeal involvement by the
patient's known ALL.
2. No discrete enhancing epidural or other paraspinal soft
tissue mass.
3. Diffusely abnormal bone marrow signal, consistent with
extensive
replacement by known recurrent ALL.
4. No spinal canal stenosis.
MICRO:
CMV Viral Load (Final [**2176-2-28**]):
CMV DNA not detected.
CSF GRAM STAIN (Final [**2176-3-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2176-3-11**]):
SPECIMEN NO GROWTH ON REPLANT.
CLOSTRIDIUM PERFRINGENS.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
*****This was thought to be a contaminated
specimen.************
Brief Hospital Course:
60 YO F with recurrent ALL status-post non-myeloablative
allogeneic matched transplant from an unrelated donor in [**11/2169**]
with relapse treated w chemo and DLI in [**8-/2171**] and 03/[**2171**].
#. ALL: The patient was found to have recurrent bone marrow as
well as CNS disease after presenting with dizziness. After C/T/L
spine imaging, the patient's CSF was sampled and she was given
IT MTX through an Ommaya biweekly for 2 weeks after her CSF
cleared on [**2176-4-1**]. The was then treated on a weekly basis
starting on XXXX. The patient was unable to tolerate AraC due
to severe nausea and vomiting. After one treatment with Ara-C,
the patient instead recevied intra-thecal methotrexate
approximately twice per week. Her CSF remained positive for
blasts until tap on [**2176-4-1**]. She also received a cycle of
HyperCVAD. She received part A as well as dexamethasone on
D11-14 but vincristine was not given on D11 due to poor ostomy
output and concern for further ileus. Peripheral blood smears
showed resolution of peripheral blasts after 1-2 days of
systemic chemotherapy. Her course was complicated by mucositis,
poorly healing aphthous ulcers and poor po intake secondary to
pain, which complicated healing and cause electrolyte
abnormalities requiring significant repletion. She was changed
from oral pain medication to a low dose morphine PCA with good
effect. She was also started on TPN for nutrition and her
electrolytes abnormalities resolved.
#. History of anthracycline-induced cardiomyopathy: Repeat TTE
showed improvement in EF from 35% in the past to 50% on [**3-1**].
The patient became quite hypervolemic during hyperCVAD part A
and required aggressive diuresis. Her home captopril was
switched to lisinopril. She was started on low dose maintenance
lasix. An attempt was made to start the patient on a low dose
beta-blocker as well but she developed an episode of
fluid-responsive hypotension most likely due to the addition of
multiple anti-hypertensive medications so beta-blockade could
not be initiated. She was intermittently able to tolerate low
dose lisinopril and lasix 20mg PO with maintenance of euvolemia,
they were occasionally held in setting of low blood pressures.
She was intermittently hypotensive in the setting of poor po
intake as above. Repeat echo on [**2176-3-27**] showed ER 40-45%,
essentially unchanged from prior.
#. Hypothyroidism. Patient was maintained on home dose
levothyroxine which she intermittently agreed to take. TSH was
elevated upon admission although free T4 was within normal
limits. The patient was encouraged to continue to take her
medications in order to prevent symptomatic hypothyroidism.
==================================
#. MICU course #1 ([**Date range (1) 31152**]):
Overnight [**4-13**], Ms. [**Known lastname 11513**] became increasingly tachypneic and
tachycardic and was transferred to the [**Hospital Unit Name 153**]. Her Omaya port was
tapped and she was found to have infection in her CSF which
later speciated as VRE. Her antibiotics were changed to
linezolid and vancomycin for improved CSF penetration.
#. Code blue event: On [**4-14**], Ms. [**Known lastname 11513**] developed a
supraventricular tachycardia at ~170-180 bpm, with tenuous blood
pressures. ECG was performed, and no obvious p-waves were noted.
She was noted to have a history of SVT/atrial tachycardia in the
past. 5mg IV metoprolol were given without change in rate; the
metoprolol was repeated x 1, again with no change in rate. Given
her tenuous clinical status, respiratory alkalosis, and
tachypnea, 15mg diltiazem was given x 1 with resulting
improvement in her rate to the 70's. Her blood pressure at that
time was in the 70's systolic, and normal saline was hung wide
open. There was difficulty obtaining [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] on the
non-invasive blood pressure [**Last Name (LF) **], [**First Name3 (LF) **] phenylephrine was initiated
to bring up the blood pressure.
.
Given the difficulty in obtaining an accurate blood pressure,
several ([**6-5**]) attempts were made to place a radial arterial line
to obtain arterial blood pressure. During these attempts, her
blood pressure ranged from 70-170 systolic (depending on the
rate of phenylephrine infusion). She continued to be tachypneic,
breathing at a rate of 40-50 breaths per minute.
At 0121, her heart rate was noted to decline, and asystole was
subsequently noted. A code was called. Within approximately 15
seconds, chest compressions were initiated. 1mg atropine was
given, followed by 1mg epinephrine. After one cycle of CPR, she
remained pulseless. She was successfully intubated by
anesthesia. ABG during code was 6.82/37/315/7. CPR was
continued. She received another 1mg epinephrine, followed by 1mg
atropine. She was subsequently given 1 amp of CaCl2, 20 units of
vasopressin, and another amp of CaCl2, with return of
spontaneous circulation. Please see code sheet for further
details.
The theory behind her cardiac arrest is calcium channel blocker
poisoning from diltiazem given in the setting of hypocalcemia
and alkalemia; thus she regained her pulse after admininstering
calcium chloride. She was given 2 amps of calcium chloride after
return of circulation and 4 grams of calcium gluconate. She was
given 5mg glucagon for possible beta blocker toxicity and to
increase cyclic AMP in the setting of calcium channel toxicity.
She had no further episodes of bradycardia.
Several physicians attempted to place an arterial line after the
code without success. A repeat ABG was 7.09/27/87/9 on FiO2
100%, PEEP 10, rate ~30, Tv 560.
Further MICU #1 ([**Date range (1) 31152**]) course:
# VRE in CNS: Blood cx negative since [**4-11**], but now
enterococcus in CSF, presumably the same bacteria. Omaya port
which was seeded has now been removed. Daptomycin was
switched to linezolid for better CSF penetration, although
linezolid will cause BM suppression. Gentamicin for synergy
initially, later stopped. TTE was negative for vegetation [**4-15**],
but given new finding of likely VRE in CSF, suspicion is high
for endocarditis. Would need 8 weeks of abx if vegetation
present vs 4 week if only CNS infection s/p source removal.
Meropenem was discontinued given low suspicion for gram negative
process. TEE would not affect immediate mgt and was thus not
pursued in [**Hospital Unit Name 153**] as she had just been extubated. ID consult is
following.
.
# HYPOTENSION: Patient had an episode of SBP 80s, did not
respond to 750 cc bolus so far. Lactate also elevated, likely
secondary to poor perfusion. Differential includes sepsis, and
her new leukocytosis would go along with this (although she is
not neutropenic, on very broad abx coverage, and blood cx
repeatedly negative). Also on the differential are cardiogenic
shock (EF recently 20% in the post-arrest period), volume
depletion, adrenal insufficiency, CNS etiology, PE (but not
hypoxic nor impressively more tachycardic). She required
levophed for 1 day. [**Last Name (un) **] stim did not show evidence of adrenal
insufficiency and infectious work-up was negative. BP improved.
# ALTERED MENTAL STATUS: Mental status changes likely
multifactorial including recent SDH, prolonged asystolic arrest,
CNS infection, possible recurrent CNS lymphoma. Improved over
4 days from not alert at all despite no sedation to alert and
interactive. She was extubated when neuro status had improved.
.
# ALL: Neupogen was continued initially and thought o be
responsible for her bump in WBC. s/p hyper-CVAD. She is also
s/p intrathecal MTX and DLI this admission. Per BMT, will need
further treatment for CNS lymphoma in the future.
.
# RESPIRATORY FAILURE: Intubated in the setting of cardiac
arrest, with ongoing primary metabolic alkalosis. Cause is most
likely intracranial process (ongoing infection, recent surgery).
PE was on the differential but LENIs negative; unable to do CTA
[**1-1**] contrast allergy. There is some concern for the risk of
seizure with alkalemia, but we are not able to give opiates to
depress her respiratory drive because of hypotension.
Respiratory alkalosis improved. Her neurologic status also
improved such that she was extubated without difficulty 4 days
after the arrest event.
# LEUKOCYTOSIS: Most likely secondary to counts recovering
after chemo (many immature forms), however very sharp bump today
is also concerning for an infectious etiology. She has been
afebrile since her evacuation procedure and is on very broad
coverage as above. Will work-up for infectious cause as above.
.
# RASH: Concerning for a drug allergy. After discussion with
ID, meropenem is a likely culprit. Although it has been on for a
month, it is possible to develop a new rash after this time.
Would also be concerned that linezolid could be contributing,
since this was recently started, although this drug is much less
likely to cause rash. Rash improved after stopping meropenem.
.
# ELEVATED LIVER ENZYMES: consistent with shock liver. Now
downtrending. INR climbing, which may be secondary to synthetic
dysfunction after hepatic injury.
.
# S/P ASYSTOLIC ARREST: likely was secondary to CCB in the
setting of a heart compromised by prior cardiotoxic
chemotherapy. Recent echo showed significant interval worsening
of EF (40%-->20%) over the past 2 weeks without any focal wall
motion abnormalities. Nodal agents were avoided and
electrolytes repleted with particular attention to calcium. She
will need a repeat echo in [**3-4**] weeks.
.
# Isolated elevation in PTT: Repeating, this is likely a
spurious value, but if it remains high, would pursue mixing
studies to eval for acquired coagulopathy.
.
# MICU Course #2 ([**Date range (1) 31153**]):
.
# RESPIRATORY DISTRESS: Unclear etiology - ? [**1-1**] flash pulmonary
edema from cardiogenic shock given elevated troponins. On [**4-25**],
her BMT intern found her to be in respiratory distress,
tachypneic and hypoxic. She was able to maintain adequate O2
saturation on a non-rebreather but was working hard and looked
to likely be tiring. She was transferred to the [**Hospital Unit Name 153**] and
intubated. She required dobutamine and norepinephrine support
for possible cardiogenic shock. Pt diuresed and eventually
weaned off mechanical ventilation. On transfer to the floor, pt
is comfortable at 100% on 3L by NC. Speech and swallow
evaluation recommended dysphagic diet, 1:1 observation.
.
# HYPONATREMIA: Until [**4-23**] the patient had serum sodiums in
the range of 135-137. Her sodium declined to 125-127 until [**4-27**] when it began to further deline now to a nadir of 115. Urine
osms suggested SIADH, thought to be secondary to her recent
known intracranial empyema vs pulmonary processes. A medication
effect from rarely (<1%) micafungin or atovaquone (7-10%) is
also possible. She also likely has a component of heart failure
and lasix-associated exacerbation which are also contributing.
She received hypertonic saline w correction of Na to 125. On
transfer to the floor pt is started on salt tabs.
.
# VRE infection w CNS involvement, s/p Omaya removal: ID
continued to follow her, linezolid was continued. There were no
further positive cultures. Micafungin stopped on transfer to
floor per ID.
.
# ANEMIA: received 2pRBCs w lasix in between to transfuse to Hct
> 25.
Transferred temporarily to MICU on [**5-4**] after episode of vtach
likely in the setting of baseline heart disease and low K, Mg.
Vtach resulted in decreased peripheral perfusion w elevated
lactate and demand ischemia. Temporarily on amiodarone drip, but
became bradycardic, so stopped. Treated temporarily w abx for
possible septic infxn, but discontinued as no evidence of active
infection. Did continue linezolid for prior VRE bacteremia. Pt
improved to baseline by morning and transferred back to BMT.
.
FLOOR:
Since arriving back on the floor, pt has required 500 cc bolus
of IVFs for hypotension and then this afternoon found to be more
tachypneic. Initial ABG 7.26/12/86/6 and written for ativan prn
for anxiety. However, upon reeval, pt still tachypneic and
appeared to be tiring. Respiratory code called, pt intubated by
anesthesia and transferred to [**Hospital Unit Name 153**].
Pt transferred for acute respiratory failure (s/p intubation on
[**5-6**]), thought to be [**1-1**] shock - cardiogenic vs septic vs
combination. Cardiogenic shock [**1-1**] acute on chronic CHF from
chemo (repeat TTE showed LVEF 25%). Sepsis [**1-1**] prior VRE
infection (L femoral TLC still in on transfer, as pt has
difficult access) vs Klebsiella PNA (based on sputum cx). L
femoral TLC d/c'd on [**5-7**], new L femoral aline and R femoral
venous TLC placed. Elevated lactate to 14 on transfer [**1-1**]
hypoperfusion from shock, though ddx included linezolid side
effect vs nutritional (thiamine deficiency), so linezolid
switched to daptomycin and thiamine administered. Continued
broad antimicrobial coverage: meropenem x 7 days ([**5-6**] -
[**2176-5-12**]), daptomycin x 7days ([**5-7**] -[**2176-5-13**]), ciprofloxacin (5
days total), atovaqone, acyclovir. Monitored CO, CI and
hemodynamics w vigileo system. Patient extubated on [**5-10**].
Diuresed as tolerated by blood pressure with lasix 40mg IV x 1
daily (required one dose albumin for support). Blood, urine and
sputum culture negative. She was transitioned to tube feeds.
Video swallow study was deferred as patient was too weak and
sleepy to cooperate. Transferred to floor on [**5-15**] in AM.
Patient had been called out to the floor earlier in the AM, but
respiratory status declined over a period of hours within
arriving to the floor. Code blue was called for increased work
of breathing. Patient intubated and immediately required
initiation of pressors. Upon arrival to the [**Hospital Unit Name 153**], SBPs in 60-70s
in spite of being maxed out on 1 pressor and she was noted to be
very cold in her extremities. Stat labs notable for worsening
anion gap metabolic acidosis. Patient given stress dose
steroids, broad spectrum antibiotics, started and quickly maxed
out on 3 pressors, bedside TTE revealed no significant
pericardial effusion, and pt given several amps of HCO3. During
this time, the pt's pulse was maintained and chest compressions
were not required. Stat aline was placed in sterile conditions
in R femoral and ABG obtained revealed 7.05/33/34/10 with
lactate 8.5. Given profound hypoxemia, SBPs in 60s in spite of
being maxed out on 3 pressors, pt's son was called who agreed
with withdrawing care. Pressors were turned off and pt's BPs
decreased to 30/10s; however, she did not expire until ETT was
removed several hours later. Son declined autopsy.
Medications on Admission:
ativan 1mg q6 PO prn
captopril 6.25 po BID
synthroid 100mcg daily
oxycodone 5-10mg QID prn
benadryl topical ointment for pruritis
artificial tears
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Primary:
Recurrent Acute Lymphoblastic Leukemia with CNS involvement
Cardiopulmonary Arrest
Secondary:
Acute on Chronic Systolic Anthracycline-Induced Congestive Heart
Failure
Hypertension
Discharge Condition:
Expired.
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2176-5-18**]
ICD9 Codes: 2761, 4275, 4280, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6172
} | Medical Text: Admission Date: [**2121-3-28**] Discharge Date: [**2121-3-30**]
Date of Birth: [**2069-1-17**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
new onset seizure
Major Surgical or Invasive Procedure:
L craniotomy for resection of meningioma
History of Present Illness:
She is a 52-year-old right-handed woman with multiple medical
problems who last week suffered her first ever seizures. Both
of these lasted relatively short periods of
time. The first of these episodes sounds as if it was
psychomotor in nature but during the second episode, the patient
states she was fully awake but unable to speak. The patient was
brought to an outside hospital where her Lamictal was increased.
She has been previously taking Lamictal (to stabilize her mood),
the patient was sent for imaging which reveals a left-sided
meningoma along the convexity in the region of the primary motor
cortex. The patient presents today to be evaluated for this
lesion. Aside from these two seizures, the patient denies new
weakness, nausea or vomiting. The patient has a history of
chronic headache but she does not feel her headaches have
changed
in any way. She has had no further seizures since the two
episodes that occurred last week.
Past Medical History:
headache, bipolar disease, hypothyroism, LBP
Social History:
The patient received an associate's degree.
She is married and has two children. She does not smoke and she
drinks alcohol rarely.
Family History:
NC
Physical Exam:
On ADmission:
The patient is a normally developed woman who appears her stated
age. She is alert and oriented toall spheres. Her expressive
and receptive language functions arenormal. Pupils are equal
and reactive to light. Her extraocular
movements are full. Her face is symmetric. Her tongue and
palate are midline. Her motor tone and bulk are normal. Her
strength is [**4-19**] throughout. There is no upper extremity drift.
The patient ambulates on a narrow base. She can turn on a dime.
Romberg is negative. Sensory exam is grossly intact.
Coordination is normal and toes are downgoing. The patient has
perhaps brisk knee reflexes on the right compared to the left.
On discharge:
Pertinent Results:
Review of the patient's MRI does indeed reveal a
contrast enhancing mass along the convexity in the region of the
primary motor cortex. This lesion is consistent with a
meningoma. There is underlying cerebral edema associated with
this lesion. There is some modest local mass affect but no
shift
of midline. Lesion comes close to but does not seem to invade
the superior sagittal sinus
Brief Hospital Course:
52 y/o F with new onset of seizures presents with L frontal
meningioma. She was taken to the OR on [**3-28**] for elective L
craniotomy for resection of meningioma. OR course was
uncomplicated and she was transferred to the ICU for monitoring.
She remained neurologically and hemodynamically stable. She had
post-op MRI which showed no residual tumor. Activity and diet
were advanced. She transferred to the floor. On POD #2 she was
tolerating a regular diet, ambulating without difficulty. Her
dressing was removed and her incision was clean and dry. She has
requested to be discharged home, she will follow up in the brain
tumor clinic to have sutures removed.
Medications on Admission:
aspirin, lithium, Caltrate, meloxicam, Synthroid, Topamax,
Lamictal, Percocet and OxyContin
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Use while on Oxycodone.
Disp:*40 Capsule(s)* Refills:*0*
2. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lithium carbonate 150 mg Capsule Sig: Four (4) Capsule PO QAM
(once a day (in the morning)).
6. lithium carbonate 150 mg Capsule Sig: Three (3) Capsule PO
QPM (once a day (in the evening)).
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Use while on decadron.
Disp:*8 Tablet(s)* Refills:*0*
9. topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
10. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for breakthrough pain.
Disp:*40 Tablet(s)* Refills:*0*
12. dexamethasone 1 mg Tablet Sig: 2mg tid X 24 hour; 1mg tid X
24 hours; 1mg [**Hospital1 **] X24 hours; then 1mg PO X1 then stop Tablets PO
per wean for 4 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
L frontal meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? 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.
?????? ?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2121-4-7**] @
10:30AM . The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2121-3-30**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6173
} | Medical Text: Admission Date: [**2151-4-14**] Discharge Date: [**2151-4-18**]
Service: SICU
CHIEF COMPLAINT: Transferred from outside hospital for a
bronchoscopy by family wishes.
HISTORY OF THE PRESENT ILLNESS: The patient is an
81-year-old man with a past medical history significant for
hypertension, COPD, status post multiple hospitalizations for
this in the recent few months, new onset atrial fibrillation,
alcohol abuse, moderate aortic stenosis, who presented to
[**Hospital3 **] on [**2151-3-23**] with a COPD flare after
being discharged two weeks prior with a COPD flare. At that
time, the patient's symptoms were cough, productive yellow
sputum, fever, chills, and difficulty breathing. In the
Emergency Room, at the outside hospital, chest x-ray showed
acute infiltrate superimposed on chronic right middle lobe
infiltrate. One month prior to admission, a right pleural
based mass was seen. He had a repeat CAT scan on admission
at [**Hospital3 **] with an increase in size of mass. The
patient was initially treated with Levaquin for
community-acquired pneumonia as well as steroids for a COPD
exacerbation; however, he grew MRSA in his sputum culture on
[**2151-4-12**]. He was started on vancomycin at that time.
In addition, he had new onset atrial fibrillation with rapid
ventricular response that was treated with Diltiazem and then
loaded with Amiodarone. This led to a likely rate-induced
ischemia with peak troponin I to 0.54.
The patient was given Lovenox to a Coumadin bridge. Of note,
he had Guaiac positive diarrhea two days after admission
prior to starting anticoagulation. He was treated with 2
units of packed red blood cells on [**2151-4-10**] for a
hematocrit of 26.6 down from 36 on [**2151-4-6**]. There
were no further Guaiac stools at that time.
On [**2151-4-12**], he had an episode of hypoxia with P02
66.8, PC02 58, saturating 92% on a nonrebreather mask. He
was then transferred to the [**Hospital1 18**] for further evaluation of
his hypoxia and questionable lung mass.
PAST MEDICAL HISTORY:
1. Hypertension.
2. COPD, status post multiple hospitalizations and flares.
3. Alcohol abuse.
4. Moderate aortic stenosis with a reported valve area of
0.9.
5. New onset atrial fibrillation.
6. MRSA pneumonia, as described in HPI.
7. Questionable right lower lobe mass versus round
atelectasis.
8. Questionable IBD.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER:
1. Coumadin 5 mg q.h.s.
2. Amiodarone 200 mg p.o. b.i.d.
3. Zantac 150 mg p.o. b.i.d.
4. Multivitamin.
5. Rifampin 600 mg q.d.
6. Vancomycin 1 gram IV q.d., day number one is
approximately [**2151-4-12**].
7. Zovirax 400 mg p.o. t.i.d.
8. Lovenox 60 mg subcutaneously b.i.d.
SOCIAL HISTORY: The patient smoked for 45 years, two packs
per day. He also has a history of asbestos exposure.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
100.3, pulse 73, blood pressure 180/60, respirations 21, 93%
on a 50% face mask. General: The patient was in no acute
distress, speaking in full sentences. HEENT: Significant
for a lesion in the middle of his upper lip that had
irregular borders, nontender. Cardiovascular: Regular rate
and rhythm with a III/VI holosystolic murmur at the left
sternal border heard throughout the precordium. Pulmonary:
Poor inspiratory effort, wheezes bilaterally, crackles
one-third of the way up bilaterally. Abdomen: Soft,
nontender with active bowel sounds, right lower quadrant scar
from appendectomy. Extremities: No cyanosis or clubbing,
[**2-23**]+ edema to the mid thigh bilaterally, small weeping ulcer
on left lower extremity. Neurologic: Intact.
LABORATORY/RADIOLOGIC DATA: On admission, white blood cell
count 8.1, hematocrit 33.8, platelets 224,000, MCV 87.
Chemistries within normal limits. INR 1.6.
Chest x-ray showed a right middle lobe and right lower lobe
opacity.
HOSPITAL COURSE: 1. HYPOXIA: The patient's hypoxia was
felt to be multifactorial given the patient's history of
congestive heart failure, COPD, recent rapid atrial
fibrillation, and multilobar MRSA pneumonia. For the
patient's COPD, he was continued on nebulizer treatments. He
had completed a full course of steroids at [**Hospital3 **]
prior to transfer and thus the patient was not started on IV
steroid therapy. It was felt that he was not in acute flare
during his ICU course.
For the patient's congestive heart failure, he was gently
diuresed in the setting of his aortic stenosis. An
echocardiogram was obtained which showed an ejection fraction
of greater than 55%, pulmonary artery pressure of 20 mmHg,
mild symmetric left ventricular hypertrophy, mild 1+ aortic
regurgitation, and moderate aortic stenosis with mild
dilation of the ascending aorta. The patient's oxygen
requirement decreased with continued diuresis. The patient
was very responsive to small doses of IV Lasix and was
negative daily. The patient was also continued on treatment
of his multilobar pneumonia with IV vancomycin at 1 gram q.
12. The patient also had a CAT scan to follow-up on history
of lung mass and asbestos exposure. CAT scan showed no
pleural mass but loculated fluid in the minor fissure that is
somewhat mass-like in appearance. There were emphysematous
changes. There was also bilateral air space opacities in the
mid lower lungs, right greater than left with some nodular
appearance. There were multiple sites of mediastinal
lymphadenopathy and bilateral calcified plaques consistent
with asbestos exposure. A follow-up CAT scan in three months
is recommended. An abdominal aortic aneurysm was also noted
infrarenally at 3.7 cm.
The patient's hypoxia continued to improve and on the day of
transfer to the floor, he was on [**4-27**] liters of nasal cannula
with saturations greater than 93%.
2. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS PNEUMONIA:
The patient began vancomycin therapy at approximately [**2151-4-12**], however, it is difficult to decipher in the
transfer summary from [**Hospital3 **]. It was decided that
the patient would have a 14 day course of IV antibiotics and
thus a request for a PICC line was placed prior to transfer
to the floor. The patient remained afebrile during this
admission and his white count was within normal limits as
well. His sputum cultures were repeatedly contaminated and
his blood cultures are no growth to date.
3. QUESTIONABLE RIGHT LOWER LOBE MASS: There was no mass
seen on chest CT here, however, there was lymphadenopathy
that could be consistent with infectious reaction. However,
it was felt that lymphadenopathy should be followed-up in
three months with a CAT scan.
4. PAROXYSMAL ATRIAL FIBRILLATION: The patient's weight was
well controlled during his admission until [**2151-4-17**]
when he went into atrial fibrillation with rapid ventricular
response to the 120s. His hypoxia slightly worsened at this
time and thus a Diltiazem drip was started. The patient had
a good response to this and was transitioned quickly to p.o.
Diltiazem with slow titration upwards. At the time of floor
transfer, he is currently on Diltiazem 60 mg p.o. q.i.d. It
was thought that a calcium channel blocker would be a better
choice in this patient with COPD as opposed to metoprolol.
The patient was Coumadin loaded at [**Hospital3 **]. However,
this was stopped upon admission to the [**Hospital1 18**] in case
procedures were necessary.
The patient was started on a heparin drip and Coumadin was
held during his ICU course with exception of one dose on the
evening prior to transfer. The patient was loaded with
Amiodarone at the outside hospital and his dose was decreased
in the Intensive Care Unit to 200 mg q.d. The patient's
rhythm oscillated between normal sinus as well as
rate-controlled atrial fibrillation on day prior to floor
transfer. It is uncertain at this time whether Amiodarone
will still be indicated in this patient. These issues will
be addressed in the patient's floor course.
The patient's echocardiogram showed an ejection fraction of
greater than 55% with no marked left atrial dilation. Please
see above for more details on echocardiogram report.
5. QUESTIONABLE HYPOTHYROIDISM: The patient's TSH was
elevated during his Intensive Care Unit course; however, his
free T4 was normal. It was thought that this would be hard
to interpret in the acutely ill ICU setting and should be
followed up as an outpatient. No therapy was started.
6. SKIN LESION: The patient's skin lesion superior to his
lip looked worrisome for malignancy and thus a dermatology
consult was obtained. Dermatology felt quite certain that
the patient's lesion was a squamous cell carcinoma. However,
they were unable to biopsy this lesion in-house as
microsurgery is indicated and cannot be done in the inpatient
setting. They recommended biopsy within ten days at the
[**Hospital 2652**] Clinic and the Dermatology Service should be
contact[**Name (NI) **] for close follow-up upon discharge.
7. METABOLIC ALKALOSIS: The patient suffered a metabolic
alkalosis during his ICU course. It was felt that this was
likely due to diuresis. He received three days of
acetazolamide and [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] repletion. His respiratory status
continued to improve. However, he did have a mild
respiratory acidosis as well. This is likely chronic given
the patient's history of COPD. His bicarbonate upon
admission was also 37.
8. HYPERTENSION: The patient's blood pressure was well
controlled during this admission. He was titrated up on
Captopril. Diltiazem was also started in the setting of his
rapid atrial fibrillation. There were no acute issues.
9. ANEMIA: During the inpatient hospital course at [**Hospital1 **]
it was noted that he had Guaiac positive stools with the need
of 2 units of packed red blood cells. The patient's
hematocrit was stable during his ICU course requiring no
transfusions. He was Guaiac positive here. Iron studies
showed an anemia of chronic disease picture, however, it is
hard to interpret in the setting of recent transfusions. The
patient will likely need outpatient follow-up with
colonoscopy as he has never been evaluated for this.
10. PROPHYLAXIS: The patient was continued on pantoprazole
as well as heparin drip, as above. Communication was with
the patient's daughter. Of note, the patient is a DNR/DNI
according to multiple discussions with the patient and his
daughter. The patient will be transferred to the floor on
[**2151-4-18**] to continue his evaluation and treatment.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-986
Dictated By:[**Last Name (NamePattern1) 9244**]
MEDQUIST36
D: [**2151-4-18**] 06:44
T: [**2151-4-18**] 18:55
JOB#: [**Job Number 54934**]
ICD9 Codes: 4280, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6174
} | Medical Text: Admission Date: [**2173-4-9**] Discharge Date: [**2173-5-5**]
Date of Birth: [**2104-4-12**] Sex: F
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: This is a 68-year-old Cambodian
female who has no significant past medical history. She was
found unresponsive at home on [**2173-4-6**]. She was
found to be hypertensive and intubated at the scene and
resuscitated with IV fluid boluses. Prior to this, the
patient had neck swelling for 2 days which occurred in
conjunction with administration of Actos for newly diagnosed
diabetes. Laryngoscopy was performed revealing airway edema.
A CT scan of the chest and neck revealed a goiter with airway
compression. TSH was elevated at 7.13. Neurology workup
including EEG and CT was negative. She was transferred here
for a planned sternotomy with mass resection.
HOSPITAL COURSE: On admission, the patient was stable and
intubated. Endocrine was consulted given the patient's
diabetes and hypothyroid state. It was recommended that total
thyroidectomy be performed as well as thyroid hormone
replacement initiated. She was preopped for surgery on [**2173-4-12**]. On [**2173-4-12**], the patient underwent bronchoscopy
and partial sternotomy with right total and left subtotal
thyroidectomy. See operative report for details. The patient
tolerated the procedure well from a hemodynamic standpoint.
However, attempts to re-intubate her at the end with
assistance of tube changer were unsuccessful using 8.0, 7.5,
7.0 and even a 6.5 endotracheal tube and it was presumed that
the patient had an extrinsic mass or perhaps extrinsic
pathology to the trachea. She was returned to the OR on [**2173-4-14**] for rigid bronchoscopy and tumor debridement as well
as dilation of tracheal stenosis. At this time, it was noted
that she had diffusely abnormal mucosa of her subglottic
space and significantly narrow tracheal lumen down to the
distal trachea. Biopsies and therapeutic aspiration were
performed. At this time, a 6.5 ET tube was placed without
difficulty. She was transferred back to the ICU for further
management. The pathology showed the patient to have
papillary carcinoma of the thyroid with extrathyroidal
invasion and nodal involvement. At this time, the patient was
found to have nosocomial pneumonia with sputum cultures
positive for Acinetobacter, pan-resistant, as well as
Enterobacter cloacae, pansensitive. ID was consulted and the
patient was started on imipenem and tobramycin at this time.
The patient remained stable and on [**2173-4-16**], returned
to the OR for bronchoscopy with tracheal dilation (balloon
and rigid) with tracheostomy. Postoperatively, chest x-ray
showed that the patient had developed a right pneumothorax,
displacing the right hemidiaphragm and the mediastinum,
collapsing the right lung secondary to barotrauma versus the
tracheal dilation procedure. A right chest tube was placed as
well as her central line was changed over wire and post chest
tube chest x-ray showed marked improvement of the large right
pneumothorax. At this time, it was also noted that the
patient had gram negative rods, specifically Acinetobacter in
her blood cultures, and she was also placed on amikacin. On
[**4-17**], chest x-ray showed near resolution of her right
pneumothorax. Unfortunately, the patient went into atrial
flutter which responded to IV Lopressor. Given her high grade
of bacteremia, a CT sinus was recommended by Infectious
Disease. This showed mucosal thickening of both maxillary
sinuses and opacification of the ethmoid and sphenoid air
cells. No fluid levels were noted. Additionally, there is
opacification of the mastoid air cells bilaterally. At this
time, given her stable, resolved pneumothorax, the chest tube
was placed to water seal. On [**2173-4-18**], her vent was
weaned to CPAP and pressure support which the patient
tolerated well. Her A line sites were changed as well. Over
the following day, the patient was diuresed and tolerated
tracheostomy mask trials for 2-3 hour periods per day.
Endocrine was following and corrected the patient's
hypocalcemia with Calcitriol as well as calcium carbonate.
Her blood sugars were stable and the patient was off the
insulin drip at this point. She was started on NPH and
sliding scale insulin. On [**2173-4-20**], a chest CT was
performed to evaluate for consolidation. Multifocal opacities
in the left lower lobe, right lower lobe and right upper lobe
were concerning for pneumonia. A small right-sided
pneumothorax persisted with the right chest tube in place. On
[**2173-4-22**], the patient remained stable. Her chest tube
was removed and post pull chest x-ray showed no evidence of
pneumothorax. At this point, the patient had been receiving
tube feeds at goal via NG tube. On [**2173-4-23**], a PICC
line was placed and the central line was removed. She was
tolerating tracheostomy mask for 6 hours. Over the next few
days, the [**Hospital 228**] hospital course was uneventful save for a
fever spike in which blood cultures were negative, sputum
cultures showed persistent Acinetobacter infection and urine
cultures showed yeast. The Foley was changed. On [**2173-4-27**], a bedside swallow was performed to evaluate for the
patient's ability to tolerate p.o. intake. Unfortunately, she
aspirated at this time and failed the swallow exam. ENT was
consulted for evaluation of possible vocal cord paralysis. On
fiberoptic exam, it was noted that the patient had
significant edema and pooling of secretions above her vocal
cords. ENT felt that her ET tube was too big/long to phonate
and cognitive issues were also preventing her from fully
cooperating with the exam. They recommended downsizing her
tracheostomy. Discussions with interventional pulmonology
were initiated regarding having a custom-made T tube made. On
[**2173-4-28**], a Dobhoff tube was placed and plans were made
for a PEG to be placed the following week given the patient's
failure to pass the swallow exam. Over the next few days, the
patient was stable and remained afebrile on Unasyn and
amikacin. She completed her antibiotic course on [**2173-5-1**]. She continued to tolerate her Dobhoff tube feeds. On
[**2173-5-3**], the patient returned to the OR for a flexible
bronchoscopy for tracheal measurements as well as flexible
EGD with insertion of a percutaneous endoscopic gastrostomy
tube. The patient tolerated the procedure well and returned
to the recovery room in stable condition. On [**5-4**], her
tube feeds were resumed and increased to a goal of 50 cc per
hour with fiber at full strength. She tolerated her tube
feeds well. On [**2173-5-5**], a rehab facility accepted the
patient and she was discharged to rehab in stable condition.
Of note, I had no interaction with this patient's care. This
hospital course was dictated from the patient's records only.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Papillary cancer with positive nodes
status post sternotomy and partial right and total left
thyroidectomy on [**2173-4-12**], status post rigid
bronchoscopy and tumor debridement on [**2173-4-14**], status
post open tracheostomy on [**2173-4-16**], status post
bronchoscopy and percutaneous endoscopic gastrostomy tube
placement on [**2173-5-3**].
DISCHARGE MEDICATIONS: Heparin subcutaneously 5,000
units/ml, 1 injection b.i.d., albuterol sulfate 0.083%
solution, 1 puff q.6h. as needed, ipratropium bromide 0.02%
solution, 1 puff q.6h. as needed, Percocet 5/325 mg per 5 ml
solution, [**6-16**] ml p.o. q.4-6h. p.r.n., metoprolol 37.5 mg
p.o. t.i.d., lansoprazole 30 mg suspension, delayed release,
1 p.o. daily, liothyronine 25 mcg 0.5 tablets p.o. b.i.d.,
calcium carbonate 500 mg per 5 ml suspension, 5 ml p.o.
t.i.d., Heparin Lock Flush 100 units per ml, 2 ml IV daily as
needed, followed by 10 cc of normal saline, insulin NPH human
recombinant 100 units per ml suspension, 20 units
subcutaneously 3 times a day, adjust to achieve euglycemia.
FOLLOW-UP PLANS: Interventional Pulmonology has ordered a
custom T tube for the patient. Later, she will be contact[**Name (NI) **]
to arrange for overnight admission for placement. She has an
appointment with Dr. [**Last Name (STitle) 10759**] from Endocrine, [**Telephone/Fax (1) 62877**]
on [**2173-6-1**] at 2:30 p.m. in the [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) **].
[**Name6 (MD) 4667**] [**Name8 (MD) **], M.D. [**MD Number(2) 39921**]
Dictated By:[**Name8 (MD) 37607**]
MEDQUIST36
D: [**2173-5-5**] 11:27:34
T: [**2173-5-5**] 12:59:02
Job#: [**Job Number 65843**]
cc:[**Name8 (MD) 65844**]
ICD9 Codes: 496, 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6175
} | Medical Text: Admission Date: [**2159-8-5**] Discharge Date: [**2159-8-9**]
Date of Birth: [**2112-11-11**] Sex: F
Service:
Dictating for: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D.
CHIEF COMPLAINT: Chest pressure.
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
female with cardiac risk factors of a positive family history
and tobacco use who was in her usual state of health until 7
a.m. on the day prior to admission when she noted the sudden
onset of chest pain which was intermittent throughout the day
and radiated to her left arm. This chest pain was associated
with nausea, shortness of breath, and diaphoresis.
She presented to the [**Hospital1 69**]
Emergency Department and was found to have inferior ST
elevations. While in the Emergency Department she was
started on aspirin, heparin, and Integrilin. She was
hypotensive upon arrival and was then started on dopamine.
While in the Emergency Department she had an episode of
ventricular fibrillation arrest requiring shock therapy times
one at 200 joules.
She was then taken to the Catheterization Laboratory
emergently and found to have a 100% mid right coronary artery
lesion which was treated by stent placement. While in the
Catheterization Laboratory she required a temporary wire
placement for complete heart block as well as shock therapy
times two, and an amiodarone intravenously drip was started
for current ventricular fibrillation. She had an
intra-aortic balloon pump placed and was sent to the Coronary
Care Unit in stable condition.
Of note, her hemodynamic revealed a mean arterial pressure of
37 and a mean pulmonary capillary wedge pressure of 31. Her
echocardiogram showed no tamponade or effusions.
PAST MEDICAL HISTORY: None.
MEDICATIONS ON ADMISSION: No medications at home.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Positive tobacco smoking history for
approximately 20 years or so.
FAMILY HISTORY: Family history of coronary artery disease
in her mother.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs with a weight of 59 kilograms, heart
rate was 71, her blood pressure was 99/64, and her oxygen
saturation was 100%. The patient was ventilated on assist
control with a tidal volume of 300, respiratory rate of 24,
FIO2 of 100%, positive end-expiratory pressure of 5, and she
was saturating 100%. In general, a middle-aged female,
intubated and sedated. Head, eyes, ears, nose, and throat
examination revealed pupils were 5 mm and reactive.
Normocephalic and atraumatic. The neck was supple. No
lymphadenopathy, and no bruits appreciated. Chest
examination revealed the lungs were clear to auscultation
anteriorly. No wheezes. Cardiovascular examination revealed
heart was regular, intra-aortic balloon pump sounds, no rubs
or gallops. The abdomen was soft, nontender, and
nondistended. Positive bowel sounds. Extremity examination
revealed no edema. Dopplerable pulses. Extremities were
cool to touch. Neurologic examination revealed the patient
was sedated.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed her white blood cell count was 22.9 and her
hematocrit was 35.7. Her blood sugar/glucose was 375.
Creatinine was 0.8. INR was 1. Initial creatine kinase was
57. Troponin was less than 0.01. Next creatine kinase was
1109. Troponin was 0.56. Lactate was 6.5.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed
complete heart block with ST elevations in leads II, III, and
aVF, and V3. Early R wave progression. ST depressions in
leads I and aVL.
A chest x-ray revealed no pneumonia and appropriate placement
of intra-aortic balloon pump.
An echocardiogram revealed no effusions. Poor echo windows.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR ISSUES: (a) Ischemia: The patient was
maintained on aspirin, Plavix, a heparin drip, and an
Integrilin drip times 18 hours status post catheterization.
The patient's beta blocker was initially held due to a
decrease in blood pressure and intra-aortic balloon pump.
The patient was maintained on dopamine in house which was
subsequently weaned off. The patient's ACE inhibitor
initially held. A statin was started with a goal low-density
lipoprotein of less than 100. The patient was counseled
significantly on smoking cessation.
On hospital day two, the patient's intra-aortic balloon pump
was removed without any complications. Her creatine kinase
had peaked to a level of [**2181**]. She was extubated without
complications. Initially tolerated 4 liters, down to 2
liters. On the day of discharge, she was saturating 94% on
room air. The patient's dopamine was subsequently weaned off
with an elevation in her blood pressure, and the patient was
started on Lopressor and captopril titrated doses to a
discharge dose for Toprol-XL of 100 mg and captopril changed
to lisinopril 20 mg by mouth once per day. The patient
initially had a heparin drip, but this was discontinued after
the removal of the intra-aortic balloon pump.
(b) Pump: The patient had initially presented in
cardiogenic shock and received 4 liters of intravenous fluids
in the Emergency Department. The patient was maintained and
volume resuscitated during her course in the Coronary Care
Unit. The patient was initially started on dopamine which
was eventually weaned off; we continued to keep her mean
arterial pressures of greater than 16 and was subsequently
eventually weaned off. The intra-aortic balloon pump was
also weaned off after extubation of the patient on hospital
day two.
An echocardiogram was done on hospital day three which showed
an ejection fraction of greater than 55%, mild regional left
ventricular systolic function, with hypokinesis in the basal
inferoseptal and basal inferior regions, 1+ mitral
regurgitation, and 1+ tricuspid regurgitation. No further
anticoagulation was given.
(c) Rhythm: The patient is currently in sinus rhythm, but
had recurrent ventricular fibrillation arrest both during
catheterization. The patient was maintained initially on an
amiodarone drip and temporary pacing wires in place which
were discontinued on hospital day two. The amiodarone drip
was also stopped. She had no further episodes of ventricular
tachycardia or any abnormal rhythms during the remainder of
her hospitalization. The patient did not require any further
workup, and she was maintained on telemetry until the day of
discharge.
On hospital day three, the patient had two episodes of
recurrent chest pain which showed no electrocardiogram
changes and responded to one sublingual nitroglycerin tablet
with full relief. The patient was subsequently started
Isordil while in house and was to be discharged with Imdur
for continued angina. This was unlikely to be acute coronary
syndrome given the fact that she had received catheterization
prior.
2. PULMONARY ISSUES: The patient initially presented with
severe shortness of breath, and she was ventilated initially
on assist control which was done. The patient was
subsequently weaned off on hospital day two and extubated
without complications.
3. GASTROINTESTINAL ISSUES: The patient has a history of
coffee-grounds emesis upon arrival to the Coronary Care Unit,
but this subsequently resolved. She was maintained on
intravenous Protonix twice per day. Serial examinations
showed no further episodes, and her hematocrit remained
stable. The patient was to be discharged on a proton pump
inhibitor.
4. HEMATOLOGIC ISSUES: The patient's hematocrit remained
stable throughout her hospitalization. On the day prior to
discharge, she had a slight drop in her hematocrit which was
likely due to the fact that she initiated a full diet and
started to take lots of oral intake. [**Month (only) 116**] have been
dilutional. The patient was transfused with a hematocrit of
32 on the day of discharge.
5. INFECTIOUS DISEASE ISSUES: On hospital day three, the
patient had a temperature spike of 102.1 degrees Fahrenheit.
Blood cultures and urine cultures which were no growth to
date up to the day of discharge. A STAT chest x-ray was
obtained which showed some consolidations in the right lower
lobe and possibly involving the left lower lobe. The patient
was initially started on Zithromax, but upon repeat
examination of the chest x-ray showed worsening
consolidation. The patient was changed to levofloxacin on
the day of discharge which was to be continued for 10 days
for ventilator-associated pneumonia. The patient had been
afebrile for 72 hours on the day of discharge, and no growth
on the blood cultures. The patient was maintained on
Robitussin with codeine and Tessalon Perles and Cepacol
lozenges for her cough.
6. PROPHYLAXIS ISSUES: The patient was maintained on a
Protonix for gastrointestinal prophylaxis and subcutaneous
heparin for deep venous thrombosis prophylaxis.
7. CODE STATUS: The patient was a full code.
8. ENDOCRINE ISSUES: The patient initially presented with
elevations in her blood sugars; likely due to stress given
her significance illness from the ventricular fibrillation
arrest. The patient initially had fingersticks four times
per day and was initially placed on an insulin drip with
improvement of her blood sugars. The insulin drip was
discontinued on hospital day two. The patient had no further
episodes of hyperglycemia during this hospitalization.
DISCHARGE DISPOSITION: The patient had a stable blood
pressure in the 110s, heart rate goal to 60s, return of her
hematocrit after a blood transfusion, with no further
abnormal heart rhythms, her cough was improving, and she had
been afebrile for 72 hours on the day of discharge, and was
covered broadly with antibiotics for ventilator-associated
pneumonia. It would be reasonable to obtain a chest x-ray to
follow up the pneumonia in a few weeks to see resolution of
her symptoms.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with her primary
care physician (Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**]) at [**Hospital 92821**] Health Care,
[**Street Address(2) 92822**], [**Location (un) 538**] on [**2159-8-22**] at 10
a.m. (telephone number [**Telephone/Fax (1) 1792**]).
2. The patient was instructed to follow up with Dr. [**First Name11 (Name Pattern1) **]
[**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (cardiologist) at [**Hospital1 188**], on [**2159-9-5**] at 11 a.m. (telephone number
[**Telephone/Fax (1) 25135**]).
MEDICATIONS ON DISCHARGE:
1. Enteric-coated aspirin 325 mg by mouth every day.
2. Clopidogrel 75 mg by mouth once per day.
3. Atorvastatin 10 mg by mouth once per day.
4. Percocet 5/325 one to two tablets by mouth q.4-6h. as
needed (for pain); dispensed eight tablets.
5. Pantoprazole 20 mg by mouth once per day.
6. Nicotine patch 21 mg one patch transdermally once per
day.
7. Bupropion sustained release 150 mg by mouth twice per day
(for 60 days; until [**2159-8-11**]).
8. Robitussin with codeine.
9. Lisinopril 20 mg by mouth once per day.
10. Toprol-XL 100 mg by mouth once per day.
11. Imdur 30 mg by mouth once per day.
12. Levofloxacin 500 mg by mouth once per day (times 10
days; first dose on [**2159-8-9**]).
CONDITION AT DISCHARGE: Condition on discharge was stable.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-953
Dictated By:[**Last Name (NamePattern1) 92823**]
MEDQUIST36
D: [**2159-8-9**] 11:42
T: [**2159-8-9**] 11:58
JOB#: [**Job Number 92824**]
ICD9 Codes: 4275, 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6176
} | Medical Text: Admission Date: [**2194-10-23**] Discharge Date: [**2194-10-31**]
Date of Birth: [**2118-10-15**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
female transferred from [**Hospital6 33**] with suspected
subarachnoid hemorrhage. The patient reports that the night
before admission, while watching a Sox game, he had a sudden
onset of whole headache. The headache, the patient states,
radiated down the posterior aspect of the neck bilaterally
into the shoulders and arms, but further states left-sided,
and some numbness in the hands. The patient was unable to
move the entire left side x 45 minutes. The patient was
transferred to [**Hospital6 33**] where a head CT was
negative. She had an LP, which showed stable amount of blood
in all 4 tubes. The patient further states that now she just
has posterior neck discomfort bilaterally. Denies current
nausea, visual changes, shortness of breath, fever, headache
or stiff neck.
PAST MEDICAL HISTORY: Giant cell arteritis.
Polymyalgia rheumatica.
Breast cancer with right lumpectomy.
Hypothyroidism.
Left cochlear implant.
ALLERGIES:
1. MORPHINE.
2. SULFA.
3. AMOXICILLIN.
4. CODEINE.
PHYSICAL EXAMINATION: She is awake, alert and oriented x 3.
Vital signs are stable. Visual fields are intact
bilaterally. Cardiovascular: Regular rate and rhythm. No
murmurs, rubs or gallops. Lungs are clear to auscultation.
Neck: Nontender to palpation. Abdomen: Soft, nontender,
nondistended. Positive bowel sounds. Neurologic: Moving
all extremities with good strength 5/5. Sensation is intact
to light touch. Proprioception is intact. She has no drift.
Naming is intact. Repetition intact. Cranial nerves II
through XII grossly intact. Her face is symmetric. Lips are
full bilateral. Tongue midline. Deep tendon reflexes are
full and symmetric. Toes are downgoing.
Again, head CT was negative. LP showed 630 white cells and
[**Pager number **],000 red cells.
HOSPITAL COURSE: The patient was admitted to the ICU for
close neurologic observation. She underwent an angiogram,
which showed a 1.5-mm right PCOmm infundibulum, which required
no intervention and most likely is not the source of her
subarachnoid hemorrhage. She remained neurologically stable,
was transferred to the regular floor, had a CT myelogram to
rule out spinal AVM, which was ruled out. Was seen by
Physical Therapy and Occupational Therapy and was felt to be
safe for discharge to home with follow-up with Dr. [**Last Name (STitle) 1132**] in 2
weeks. The patient's condition was stable at the time of
discharge.
MEDICATIONS ON DISCHARGE:
1. Levothyroxine 88 mcg p.o. q.d.
2. Divalproex sodium 250 mg 1 p.o. q.8h.
3. Hydrochlorothiazide 50 q.d.
4. Valsartan 100 mg p.o. q.d.
5. Alendronate sodium 70 p.o. q.Sunday.
6. Prednisone 15 mg p.o. q.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: She will follow up with Dr. [**Last Name (STitle) 1132**] in 2 weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2194-10-31**] 12:26:26
T: [**2194-11-1**] 02:29:08
Job#: [**Job Number 111000**]
ICD9 Codes: 4019, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6177
} | Medical Text: Admission Date: [**2126-5-19**] Discharge Date: [**2126-5-22**]
Date of Birth: [**2069-5-13**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization, 2 stents to LAD and LCX
History of Present Illness:
Ms [**Name13 (STitle) 85175**] is a 57 year old woman with HLD, GERD, ? HTN who
presented via EMS status post cardiac arrest to [**Location (un) 620**] and
transferred to [**Hospital1 18**] for cardiac catheterization.
.
Per ED records, patient called EMS for substernal chest pain and
shortness of breath. On EMS arrival, patient was conscious but
then she passed out. She arrested infront of EMS and received 2
shocks by AED. She regained consciousness with reported normal
mental status. Enroute, she arrested again and was shocked
again. She got 300mg of amio by EMS. Rhythm strips reportedly
showed torsades. At [**Location (un) 620**], she was again, awake, but
intubated for airway protection. She received aspirin 325mg,
plavix 600mg, heparin gtt, amiodarone gtt and integrillin. An
ECG showed heart rate 63, STD in v1-3 with concern for posterior
STEMI.
.
She was transferred to [**Hospital1 18**] for cath lab. In cath lab, her she
had proximal 95% LAD and mid 95% LCx oclusion that were stented.
She was also noted to have markedly elevated filling pressures
and received lasix.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, + Dyslipidemia, ?
Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
HLD
HTN
GERD
Social History:
+ smoking history
Family History:
family history of CAD
Physical Exam:
ADMISSION PHYSICAL EXAM
GENERAL: Intubated, sedated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP elevated to mandible.
CARDIAC: Distant heart sounds, regular rate, no
murmurs/rubs/gallops appreciated.
LUNGS: Anterior breath sounds clear.
ABDOMEN: Obese. 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+
Pertinent Results:
Admission labs:
[**2126-5-19**] 02:08AM BLOOD WBC-14.4* RBC-3.86* Hgb-11.6* Hct-36.1
MCV-94 MCH-30.0 MCHC-32.1 RDW-13.0 Plt Ct-391
[**2126-5-19**] 02:08AM BLOOD Neuts-89.3* Lymphs-7.7* Monos-2.7 Eos-0.2
Baso-0.1
[**2126-5-19**] 02:08AM BLOOD PT-13.1 PTT-65.7* INR(PT)-1.1
[**2126-5-19**] 02:08AM BLOOD Glucose-194* UreaN-10 Creat-0.7 Na-141
K-4.1 Cl-108 HCO3-23 AnGap-14
[**2126-5-19**] 02:08AM BLOOD ALT-38 AST-46* LD(LDH)-272* AlkPhos-76
TotBili-0.4
[**2126-5-19**] 02:08AM BLOOD Albumin-3.8 Calcium-7.9* Phos-2.9 Mg-2.2
Cholest-159
[**2126-5-19**] 02:08AM BLOOD %HbA1c-6.0* eAG-126*
[**2126-5-19**] 02:08AM BLOOD Triglyc-110 HDL-32 CHOL/HD-5.0
LDLcalc-105 LDLmeas-112
[**2126-5-19**] 02:08AM BLOOD TSH-1.4
.
Cardiac enzymes:
[**2126-5-19**] 02:08AM BLOOD CK-MB-16* MB Indx-7.8* cTropnT-0.23*
[**2126-5-19**] 02:08AM BLOOD ALT-38 AST-46* LD(LDH)-272* CK(CPK)-204*
AlkPhos-76 TotBili-0.4
[**2126-5-19**] 05:28AM BLOOD CK-MB-29* MB Indx-9.5*
[**2126-5-19**] 05:28AM BLOOD CK(CPK)-305*
[**2126-5-19**] 05:26PM BLOOD CK-MB-20* MB Indx-5.5 cTropnT-0.40*
[**2126-5-19**] 05:26PM BLOOD CK(CPK)-364*
[**2126-5-20**] 05:04AM BLOOD CK-MB-6
[**2126-5-20**] 05:04AM BLOOD CK(CPK)-204*
.
Discharge labs
[**2126-5-22**] 07:20AM BLOOD WBC-7.0 RBC-3.97* Hgb-11.6* Hct-36.1
MCV-91 MCH-29.3 MCHC-32.2 RDW-12.7 Plt Ct-541*
[**2126-5-22**] 07:20AM BLOOD Glucose-89 UreaN-12 Creat-0.7 Na-141
K-4.4 Cl-103 HCO3-33* AnGap-9
[**2126-5-22**] 07:20AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0
CATH REPORT [**2126-5-19**]
COMMENTS:
1. Coronary angiography in this right-dominant system
demonstrated
two-vessel disease. The LMCA had no angiographically apparent
disease.
The LAd had a proximal 95% stenosis. The LCx had a 99% hazy
stenosis
just prior to the second obtuse marginal branch. The RCA had
mild
disease.
2. Resting hemodynamics revealed elevated right- and left-sided
filling
pressures, with an RVEDP of 22 mm Hg and a PCWP of 25 mm Hg.
There was
mild pulmonary arterial systolic hypertension with a PASP of 41
mm Hg.
The cardiac index was high at 8.9 L/min/m2.
3. Successful PTCA and stenting of the mid LCx with a 2.5 x 18mm
Promus
drug eluting stent which was postdilated to 3.0mm. Final
angiography
revealed no residual stenosis, no dissection, and TIMI 3 flow.
(see PTCA
comments for details)
4. Successful POBA of the jailed OM with a 1.5mm Apex Flex
balloon.
5. Successful PTCA and stenting of the proximal LAD with a 2.5 x
15mm
Promus drug eluting stent which was postdilated to 3.0 mm. Final
angiography revealed no residual stenosis, no dissection, and
TIMI 3
flow. (see PTCA comments for details)
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Elevated right- and left-sided filling pressures.
3. Successful PTCA and stenting of the mid LCx.
4. Successful POBA of the jailed OM.
5. Successful PTCA and stenting of the proximal LAD.
ECHO - TTE [**2126-5-20**]
The left atrium is normal in size. The estimated right atrial
pressure is 10-15mmHg. Left ventricular wall thicknesses and
cavity size are 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
estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
Brief Hospital Course:
57 year old woman with HLD and family history of CAD transferred
to [**Hospital1 18**] for cardiac catheterization. She was shocked x3 by EMS
for reported torsades.
.
# Coronary Artery Disease: Patient is status post cardiac
catheterization on [**2126-5-19**] with two stents placed to proximal
LAD and mid LCx. She is status post cardiac arrest, shocked
three times by EMS, likely ischemic in etiology. She received
integrillin and discharged on aspirin 325 mg PO daily, plavix
150 mg PO daily x 2 weeks and 75 mg PO daily thereafter,
simvastatin 40 mg PO QHS, and Toprol XL 50 mg PO QD. The plavix
dose was increased for the first two weeks given her
thrombocytosis in house. Pharmacy called and stated
atorvastatin was not covered by pt's insurance, and so she was
D/C'ed on simvastatin. An echo prior to discharge showed normal
global left ventricular systolic function with an EF of >55%.
Patient was discharged with follow up to see cardiology at
[**Location (un) **] to be arranged by PCP.
.
# Rhythm: Currently, patient is in sinus. Per report she had
event of torsades, status post shock by EMS in the field. Event
was thought to be ischemic in nature. Patient's electrolytes
and tele were closely monitored. No further intervention was
done, and patient was started on metoprolol.
.
# Respiratory distress: Intubated at OSH for airway protection.
Successfully extubated at [**Hospital1 18**] without any compications.
.
# GERD: Switched PPI to H2 blocker.
.
# Smoking cessation: Discussed with patient importance of
smoking cessation and risk of MI with continued tobacco use.
Patient aware, will follow up with PCP regarding this.
Medications on Admission:
simvastatin
prilosec
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily):
Take two pills at once for the next two weeks (150 mg through
[**2126-6-5**]). Then take one pill a day after this.
Disp:*45 Tablet(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*0*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
NOTE: Pharmacy called a couple hours after pt's discharge.
Fluticasone-Salmeterol and atorvastatin were unavailable on
formulary, so she was changed to Flovent and simvastatin.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ST elevation Myocardial Infarction
Discharge Condition:
A&OX3
Self ambulatory
Discharge Instructions:
You were transferred to [**Hospital1 18**] because you had a heart attack and
cardiac arrest. Your cardiac arrest was because of your heart
attack. At [**Hospital1 18**] you underwent cardiac catheterization and had
two stents placed to two coronary arteries. We started you on
several new medications. We have started you on aspirin and
plavix.
IT IS VERY IMPORTANT THAT YOU TAKE ASPIRIN AND PLAVIX DAILY. Do
not skip these medications. They are blood thinners and will
prevent clot formation in your stents.
IT IS VERY IMPORTANT THAT YOU STOP SMOKING. Cigarettes can
accelerate atherosclerosis and increases your risk of a heart
attack. You should talk to your doctor about quitting smoking.
We have made the following changes to your medications:
1. Start Plavix. You should take plavix every day. DO NOT MISS
THIS [**Hospital1 **]. You should take this [**Hospital1 4085**] for at least 1
year. Your cardiologist will tell you how long to take this
for. For the next two weeks only through [**2126-6-5**], take two
plavix at once. This will be a total of 150 mg once a day.
Then, after two weeks beginning on [**2126-6-5**], take only one pill a
day. This will be 75 mg daily.
2. Start Aspirin. You should take aspirin every day. DO NOT
MISS [**First Name (Titles) **] [**Last Name (Titles) **].
3. Start Metoprolol.
4. Switched Simvastatin to Lipitor.
5. Switched Omeprazole to Ranitidine.
6. Start Fluticasone/Salmeterol inhaler
Followup Instructions:
Please follow up with:
1. PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 70012**] on Thursday, [**2126-5-23**] at 11:00 am. His
telephone number is [**0-0-**].
He will schedule an appointment for you to see Cardiology at
[**Location (un) 912**] cardiology.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2126-5-22**]
ICD9 Codes: 3051, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6178
} | Medical Text: Admission Date: [**2134-5-17**] Discharge Date: [**2134-5-30**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath with known Aneurysm
Major Surgical or Invasive Procedure:
[**2134-5-17**] Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to
PDA), Asc. Aorta Replacement (26mm gelweave graft), Mitral Valve
Replacement (31mm CE mosaic tissue valve)
[**2134-5-21**] Flexible bronchoscopy
[**2134-5-28**] PICC line placement
History of Present Illness:
86 y/o male with known asc. aortic aneurysm x 3yrs. He has
developed increased shortness of breath and fatigue. Aneurysm
has slightly increased in size. Recent cardiac cath revealed
coronary artery disease along with moderate mitral
regurgitation. He is being admitted for elective surgery.
Past Medical History:
Coronary Artery Disease, Ascending Aortic Aneurysm, Mitral
Regurgitation, Diabetes Mellitus, Hypertension, Benign Prostatic
Hypertrophy, Obesity, Hiatal hernia, s/p pacemaker in [**2129**], s/p
left knee surgery
Social History:
Denies tobacco use. Admits to rare ETOH use.
Family History:
Non-contributory
Physical Exam:
On admission:
VS: 60 14 112/60 5'8" 210#
Gen: WD/WN male in NAD
Skin: W/D -lesions
HEENT: NC/AT EOMI, PERRL, OP benign
Neck: Supple, FROM, -JVD, -carotid bruits
Chest: CTAB -w/r/r
Heart: CTAB -w/r/r
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses
throughout
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
Echo [**2134-5-17**]: PRE-BYPASS: The probe could not be advanced beyond
the mid-esophagus. Even at that level, windows and views were
very limited. Therefore it was not possible to assess
ventricular fxn or the tricuspid valve. No atrial septal defect
is seen by 2D or color Doppler. The aortic root is mildly
dilated at the sinus level. The ascending aorta is markedly
dilated The aortic arch is mildly dilated. The descending
thoracic aorta is mildly dilated. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
mild mitral valve prolapse. There is severe mitral annular
calcification. There is mild mitral stenosis (area 1.5-2.0cm2).
The mitral regurgitation jet is eccentric. There is no
pericardial effusion. POST-BYPASS: Limited views of the
prosthetic mitral valve were seen. From what was visible, the
valve seemed well-seated without perivalvular leak or MR. Could
not assess LV or RV fxn. Aortic valve appeared unchanged. Dr.
[**First Name (STitle) 6507**] assisted on exam. We recommended esophagoscopy and
transthoracic echo on this patient.
Echo [**5-24**]: 1. No atrial septal defect is seen by 2D or color
Doppler. 2. Left ventricular wall thicknesses and cavity size
are normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is mildly depressed. 3. Right
ventricular chamber size is normal. Right ventricular systolic
function is borderline normal. 4. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic valve stenosis. Trace aortic regurgitation is seen.
5. A bioprosthetic mitral valve prosthesis is present. The
motion of the mitral valve prosthetic leaflets appears normal.
The transmitral gradient is normal for this prosthesis. A small
perivalvular mitral prosthesis leak is seen in the anteromedial
aspect of the valve. 6. There is no pericardial effusion.
UE U/S [**5-26**]:Ultrasound evaluation of the left upper extremity
deep venous system using grayscale, color, pulse wave Doppler
reveals the left internal jugular, subclavian, axillary,
brachial, basilic veins to be fully compressible with normal
Doppler waveforms, augmentation, and respiratory variation in
flow. The left cephalic vein is not compressible with
hyperechogenic within the lumen consistent with thrombosis.
CXR [**5-27**]: The right internal jugular catheter was withdrawn in
meantime interval. The pacemaker leads terminate in right atrium
and right ventricle, unchanged. The heart size is markedly
enlarged but stable. There is worsening of the left lower lobe
and right lower lobe atelectasis. Right pleural effusion is
small to moderate. Left pleural effusion cannot be assessed due
to the fact that the left costophrenic angle was not included in
the field of view. There is slight worsening of the perihilar
haziness and upper zone pulmonary vasculature redistribution
suggesting mild pulmonary edema. The distended azygos vein
contributes to the diagnosis suggesting for overload.
[**2134-5-17**] 02:40PM BLOOD WBC-12.0*# RBC-3.26*# Hgb-10.4*#
Hct-29.2*# MCV-90 MCH-31.8 MCHC-35.5* RDW-15.0 Plt Ct-69*#
[**2134-5-21**] 03:01PM BLOOD WBC-8.6 RBC-3.17* Hgb-9.9* Hct-29.4*
MCV-93 MCH-31.2 MCHC-33.7 RDW-15.5 Plt Ct-103*
[**2134-5-28**] 06:35AM BLOOD WBC-8.1 RBC-3.97* Hgb-12.1* Hct-36.8*
MCV-93 MCH-30.4 MCHC-32.8 RDW-15.1 Plt Ct-310
[**2134-5-17**] 02:40PM BLOOD PT-19.2* PTT-65.9* INR(PT)-1.8*
[**2134-5-25**] 03:34AM BLOOD PT-14.3* PTT-30.6 INR(PT)-1.3*
[**2134-5-17**] 04:33PM BLOOD UreaN-14 Creat-0.8 Cl-120* HCO3-22
[**2134-5-28**] 06:35AM BLOOD Glucose-147* UreaN-25* Creat-1.4* Na-137
K-4.1 Cl-99 HCO3-32 AnGap-10
[**2134-5-27**] 06:00AM BLOOD Calcium-8.5 Mg-2.5
[**2134-5-28**] 06:35AM BLOOD Mg-2.6
Brief Hospital Course:
Mr. [**Known lastname 14410**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On day of admission he
was brought to the operating room where he underwent Coronary
Artery Bypass Graft x 2, Asc. Aorta Replacement, and Mitral
Valve Replacement. Please see operative report for details.
Following surgery he was transferred to the CSRU for invasive
monitoring in stable condition. Over the next two days he
remained intubated secondary to hemodynamic instability
requiring multiple Inotropes. on post-op day two he was weaned
from sedation, awoke neurologically intact and extubated. He
required aggressive pulmonary toilet via multiple inhalers and
diuresis. He was gently diuresed towards his pre-op weight. On
post-op day four he underwent a bronchoscopy for left lung
atelectasis and a mucous plug was removed. Gram stain from
bronchoscopy revealed gram negative rods and antibiotics were
started. On post-op day five he was transfused one unit pRBC.
Chest tubes and epicardial pacing wires were removed per
protocol. Despite aggressive pulmonary toilet, diuresis for CHF
and antibiotics for pneumonia, patient was having worsening
shortness of breath on post-op day six and eventually had
respiratory decompensation that required re-intubation. He was
eventually weaned from sedation on post-op day eight and
extubated without incident. On post-op day nine he underwent an
upper ext. U/S which revealed a thrombosis of the left cephalic
vein. He began ambulating well with PT and on post-op day ten he
was transferred to the telemetry floor for further care. Over
the next two days there were no further complications. On
post-op day eleven he required a PICC line placement d/t poor
venous access. He continued to work with physical therapy for
strength and mobility. He appeared stable on post-op day twelve,
but still required additional physical therapy. He was therefore
discharged to rehab facility with the appropriate follow-up
appointments and medications.Prior to d/c a UA was sent after
UOP cloudy. Results were negative for UTI.
Medications on Admission:
Zocor 40mg qd, Felodipine 10mg qd, Terazosin 5mg qd, Atenolol
50mg qd, Aspirin 325mg qd, Proscar 5mg qd, Novolog 70/30 5qAM,
8qPM
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks.
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
14. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Five (5) units Subcutaneous qAM: Please also have Insulin
Sliding Scale (see attached).
15. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: 8 (eight) units Subcutaneous qPM: Please also have Insulin
Sliding Scale (see attached).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease/Ascending Aortic Aneurysm/Mitral
Regurgitation s/p Coronary Artery Bypass Graft x 2, Asc. Aorta
Replacement, Mitral Valve Replacement
Pneumonia
Congestive Heart Failure
Deep Vein Thrombosis
PMH: Diabetes Mellitus, Hypertension, Benign Prostatic
Hypertrophy, Obesity, Hiatal hernia, s/p pacemaker in [**2129**], s/p
left knee surgery
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) **] in [**2-6**] weeks
Dr. [**Last Name (STitle) 2204**] in [**1-5**] weeks
Completed by:[**2134-5-30**]
ICD9 Codes: 486, 5180, 4280, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6179
} | Medical Text: Admission Date: [**2182-12-3**] Discharge Date: [**2182-12-8**]
Date of Birth: [**2115-4-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2182-12-3**] Aortic Valve Replacement (21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue)
History of Present Illness:
This is a 67 year old female with known history of aortic
stenosis that is followed by serial echocardiograms. She
complains of progressively worsening dyspnea on exertion.
Cardiac cath revealed no coronary artery disease.
She is now scheduled for aortic valve replacement this month.
Overall she feels well and has no major change in symptoms from
[**2182-8-1**].
Past Medical History:
Past Medical History:
Aotic Stenosis
Hypercholesterolemia
Hypertension
Hyperthyroidism with thyroid nodule
Nonspecific Thrombocytopenia ( mild)
Obesity
Depression
Meralgia paresthetica
Asthma
GERD
Dysglycemia
Thoracic back pain/sciatica
SVT ( episode during stress test)
remote esopagitis
Past Surgical History:
s/p Tonsillectomy
Social History:
Race:Caucasian
Dental: clearance letter obtained
Lives with: Daughter
Contact: [**Name (NI) **] [**Name (NI) 88836**], [**First Name3 (LF) **] Phone #[**Telephone/Fax (1) 88837**]
[**Name2 (NI) 27057**]tion: Runs coat checking business (has summer off)
Cigarettes: Smoked no [] yes [X] last cigarette [**2147**] Hx: 1.5 ppd
Other Tobacco use: no
ETOH: < 1 drink/week [] [**1-7**] drinks/week [X] >8 drinks/week []
Illicit drug use: Denies
Family History:
Family History: Denies premature coronary artery disease
Physical Exam:
VS:
B/P Right: 118/66 Left: 116/60
Height: 5'7 [**12-2**]" Weight: 190 lbs
General: WDWN female in NAD
Skin: Dry []x intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade ___3/6 systolic
radiates throughout chest to carotids___
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] no
HSM
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: R lat thigh
Neuro: Grossly intact [x];nonfocal exam;MAE [**4-5**] strengths
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]:NP Left:NP
Radial Right:2+ Left:2+
Carotid Bruit -murmur radiates to carotids
Pertinent Results:
Admission labs:
[**2182-12-3**] 10:31AM WBC-8.5# RBC-2.67*# HGB-7.8*# HCT-23.7*#
MCV-89 MCH-29.0 MCHC-32.7 RDW-13.7
[**2182-12-3**] 12:15PM PT-11.6 PTT-30.5 INR(PT)-1.1
[**2182-12-3**] 12:15PM WBC-7.0 RBC-3.02* HGB-9.0* HCT-27.0* MCV-90
MCH-29.9 MCHC-33.3 RDW-13.8
[**2182-12-3**] 12:15PM UREA N-12 CREAT-0.6 SODIUM-143 POTASSIUM-4.0
CHLORIDE-114* TOTAL CO2-24 ANION GAP-9
Discharge labs:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *81 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No mass/thrombus in
the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. No
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV
chamber size. Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. No masses or
vegetations on aortic valve. Severe AS (area 0.8-1.0cm2).
Moderate (2+) AR.
MITRAL VALVE: Moderate mitral annular calcification. No MS.
Moderate (2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: The patient was under general anesthesia
throughout the procedure. The patient received antibiotic
prophylaxis. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Results were personally reviewed with the MD
caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-CPB: 1.The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No mass/thrombus is seen in the left
atrium or left atrial appendage. No thrombus is seen in the left
atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is severe symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. The right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with normal free wall
contractility.
5. There are simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. There was minimal
movement of the NCC and RCC. The aortic valve leaflets are
severely thickened/deformed. No masses or vegetations are seen
on the aortic valve. There is severe aortic valve stenosis
(valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is
seen.
7. Moderate (2+) mitral regurgitation is seen.
8. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
Post-CPB: On infusion of phenylephrine, AV-pacing for slow CHB
(initially). Well-seated bioprosthetic valve in aortic position
with trivial valvular AI, transvalvular gradient measured at
15mmHg. Preserved biventricular systolic function, 1+ MR, aortic
contour normal post-decannulation.
Brief Hospital Course:
Ms [**Known lastname 88836**] was a same day admission to the operating room for a
scheduled aortic valve replacement. Please see the operative
report for details,in summary she had:
Aortic valve replacement with a 21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve. Her
cardiopulmonary bypass time was 57 minutes with a crossclamp
time of 42 minutes.
She tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition
with minimal vasopressor support.
She remained hemodynamically stable in the immediate post-op
period, her anesthesia was reversed, she woke neurologically
intact and was extubated.
On POD1 she was transferred from the cardiac surgery ICU too the
stepdown floor for continued post-op care. All tubes lines and
drains were removed per cardiac surgery protocol. She was
transfused one unit PRBC for post-op anemia. She reports
postoperative intermittent visual changes, lasting only seconds.
No focal defecit appreciated. As discussed with Dr.[**Last Name (STitle) **],
Ms.[**Known lastname 88836**] will alert the cardiac surgery service if these
symptoms persist. Dr[**Last Name (STitle) **] office will also follow up in 1
week after discharge to ascertain whether Ms.[**Known lastname 88836**] will require
an outpatient eval by Neuro and/or Opthamologist.
The remainder of her hospital course was uneventful. She worked
with nursing and physical therapy to increase her strength and
endurance. By POD# 5 she was ready for discharge home with
visiting nurses. She is to follow up with Dr [**Last Name (STitle) **] in 1week at
wound clinic and at 1 month in cardiac surgery clinic.
Medications on Admission:
METHIMAZOLE - 15 mg once a day
METOPROLOL SUCCINATE -50 mg Extended Release once a day
ROSUVASTATIN 5 mg once a day
CALCIUM CARBONATE - 500 mg calcium (1,250 mg) - 1 Tablet once a
day
CHOLECALCIFEROL 1,000 unit once a day
LYSINE -500 mg once a day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 5 days.
Disp:*20 Tablet Extended Release(s)* Refills:*0*
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
8. methimazole 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis s/p AVR
PMH:
Hypercholesterolemia
Hypertension
Hyperthyroidism with thyroid nodule
Nonspecific Thrombocytopenia ( mild)
Obesity
Depression
Meralgia paresthetica
Asthma
GERD
Dysglycemia
Thoracic back pain/sciatica
SVT ( episode during stress test)
remote esopagitis
PSH:
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions: Sternal - healing well, no erythema or drainage
Leg 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:
Wound Check on [**12-12**] at 11:00am [**Hospital **] Medical Office Building
[**Hospital Unit Name **] [**Telephone/Fax (1) 1504**]
Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] on [**1-8**] at 1:15pm [**Hospital **] Medical Office
Building [**Hospital Unit Name **] [**Telephone/Fax (1) 1504**]
Cardiologist:Dr [**First Name8 (NamePattern2) 88838**] [**Last Name (NamePattern1) 1923**] on [**12-31**] at 2:30pm
Please call to schedule appointment with:
Primary Care: Dr [**Last Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 88839**] in [**3-6**] 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:[**2182-12-8**]
ICD9 Codes: 4241, 5119, 2724, 4019, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6180
} | Medical Text: Admission Date: [**2172-4-30**] Discharge Date: [**2172-5-12**]
Date of Birth: [**2117-1-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
abdominal pain, dyspnea
Major Surgical or Invasive Procedure:
intra-aortic balloon bump
central line
PA catheter
arterial line
intubation
History of Present Illness:
This is a 55 YOM with PMHX significant for CAD, HTN, smoking,
hyperlipidemia who presents in shock. He was well until 5 days
PTA. Per his family he had onset of abdominal pain/indigestion
(similar to 1st ACS presentation). They are unaware of the
nature of the pain or if he had any other symptoms including
fevers, chest pain, dyspnea, nausea, vomiting, or dysuria. He
was taken by his girldriend to [**Hospital1 **] [**Location (un) 620**] ED for evaluation
[**2172-4-29**]. At their ED his intial vitals were, T 98.7 HR 110 BP
116/83 RR 18 and 99% on RA. PEr their ED records he complained
of orthopnea, denied N/V, chest pain, palps, fevers. The
abdominal pain was characterized as gradual onset, constent,
[**4-30**], and diffuse in location. Their exam noted mild tenderness
in LLQ and normal cardipulmonary exam aside from tachycardia.He
was found to have an elevated WBC count and treated with
levo/flagyl empirically for presumed diverticulitis. EKG
revealed afib with rate of 171. nl axis. TWI in V5 V6. He was
given a total of 25 mg IV diltiazem, 30 mg po, atenolol 50 mg
po. His pulse then dropped to 70 and SBP to 40. He was then
intubated and started on dopamine. Dopamine titrated up to 20
mcg with SBP still in the 50s. He then also started on levophed
and given a total of 8L of NS. Pressures then to 113 systolic.
.
Upon arrival to the [**Hospital1 18**] ED, his vitals were HR 116, BP 113/96.
He was not making urine. A right IJ triple lumen was placed. He
was given 1g of vancomycin. Dopamine switched to dobutamine with
out significant improvement in urine output. He was also given 1
amp of bicarb for pH of 7.11.
.
REVIEW OF SYSTEMS:
Unobtainable
Past Medical History:
hypertension
coronary artery disease
hyperlipidemia
ethanol abuse
smoking
Social History:
significant for current tobacco use. There is history of daily
alcohol use.
Family History:
Brother and father with CAD in 50s
Physical Exam:
VS: T 97.8 BP111/78 HR103 RR 23 O2 100%
VENT" AC Vt 600 RR 20 FiO2 60% Peep 10
Gen: Intubated/sedated
HEENT: NCAT. Sclera anicteric. PERRL, . Conjunctiva were pink
with periorbital edema.No pallor or cyanosis of the oral mucosa.
No xanthalesma.
Neck: R IJ cordis in place
CV: irregular, normal S1, S2. Distant heart sounds No m/r/g. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB (anterior, no
crackles, wheezes or rhonchi.
Abd: Soft, NT, distended. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Percutaneous coronary intervention, in [**2-23**] anatomy as follows:
1. Selective coronary angiography revealed a right-dominant
system with single-vessel coronary disease. The LMCA had no
angiographically
apparent disease. The LAD had no angiographically apparent
disease.
The LCx had a proximal 30% ulcerated plaque and the large first
OM was occluded proximally. The RCA had minor diffuse plaquing
and the posterolateral branch had a distal 60% stenosis.
2. Limited resting hemodynamics revealed a moderately elevated
left-sided filling pressure of 28 mmHg. There was no gradient
across
the aortic valve on pullback of the catheter from the left
ventricle.
3. Left ventriculography revealed no significant mitral
regurgitation, normal wall motion, and a calculated ejection
fraction of 60%.
4. Successful PTCA and stenting of the totally occluded OM1
with a 2.5x 8 mm Cypher DES. Final angiography revealed no
residual stenosis, no apparent dissection, and normal flow in
the vessel .
.
EKG demonstrated afib,rate 79 bpm. nl axis. narrow qrs. ST
depressions in v5 v6
.
TELEMETRY demonstrated: afib
.
2D-ECHOCARDIOGRAM performed in ED demonstrated: Global
hypokinesis
.
HEMODYNAMICS:
CVP 20
RV 47-53/17
PA 50/38
PCWP 23
CO 3.6
SVR 1467
.
CXR: There is a new right central venous catheter terminating in
the superior vena cava. The nasogastric tube projects only
immediately beyond the hemidiaphragms and a side hole is within
the distal esophagus. Advancing the tube is recommended into
the stomach. Patient remains intubated. There is distention of
the azygos vein and vascular pedicle, as well as marked
cardiomegaly and a small effusion.
.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are bibasilar
atelectases and effusions. There is fatty infiltration of the
liver. There is dense material throughout the gallbladder,
which is nondistended, which may represent sludge, and less
intravenous contrast was administered recently, which could
suggest vicarious excretion. The spleen is normal in size. The
pancreas is somewhat atrophic. The kidneys show a small 2-mm
calcification on the right, which may be vascular or tiny
nonobstructing stone. The adrenal glands are within normal
limits. The bowel is not dilated, and there is a full
thickening of the small bowel, as well as stranding in the
retroperitoneum and ascites, all of this could be explained by
fluid overload.
There is fatty infiltration of the wall of the ascending colon,
which is suggestive of chronic inflammation.
There is stranding focussed in the central mesentery.
Although nondistended jejunal folds appear thickened, and more
distally the bowel is collapsed.
There is marked diverticulosis, but no evidence of
diverticulitis.
.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is a Foley catheter
in the bladder. Rectum appears normal. Severe diverticulosis
is noted. There is fairly extensive fatty hypertrophy of the
perirectal fat.
.
RUQ U/S WET READ No gallstones or gallbladder distension. Wall
edema may be due to anasarca. Fatty liver.
.
[**2172-4-30**] Echo:
Conclusions: No spontaneous echo contrast or thrombus is seen
in the body of the left atrium/left atrial appendage or the body
of the right atrium/right atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No
spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. There is severe global left
ventricular hypokinesis. Overall left ventricular systolic
function is severely depressed. Right ventricular systolic
function appears depressed. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild to moderate
([**12-24**]+) mitral regurgitation is seen. There is no pericardial
effusion.
Impression: No [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA thrombus. Severely depressed LV
function. Mild to moderate mitral regurgitation.
[**2172-5-7**] CT head: No acute intracranial hemorrhage, shift of
normally midline structures, or major vascular territorial
infarct. [**Doctor Last Name **]-white matter differentiation is preserved. There
is no hydrocephalus. Osseous structures and soft tissues are
unremarkable. IMPRESSION: no hemorrhage or major vascular
territorial infarct.
.
TTE [**2172-5-7**]: EF 30%. The left atrium is mildly dilated. The
right atrium is moderately dilated. The estimated right atrial
pressure is 11-15mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is moderate to severe global left
ventricular hypokinesis (ejection fraction 30 percent). Right
ventricular chamber size is normal. Right ventricular systolic
function appears depressed. The ascending aorta is mildly
dilated. 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. Mild to moderate ([**12-24**]+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
[**2172-4-30**] 12:28AM WBC-12.5* RBC-3.80* HGB-13.2* HCT-40.1
MCV-106* MCH-34.8* MCHC-33.0 RDW-14.4
[**2172-4-30**] 12:28AM cTropnT-0.09*
[**2172-4-30**] 12:28AM CK-MB-8
[**2172-4-30**] 12:28AM ALT(SGPT)-491* AST(SGOT)-705* LD(LDH)-692*
CK(CPK)-118 ALK PHOS-56 AMYLASE-45 TOT BILI-2.9* DIR BILI-2.1*
INDIR BIL-0.8
[**2172-4-30**] 12:28AM GLUCOSE-183* UREA N-38* CREAT-1.8* SODIUM-136
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-13* ANION GAP-23*
Brief Hospital Course:
Hospital course: This is a 55 year old male who presented from
an OSH intubated in atrial fibrillation with RVR and cardiogenic
shock. He initially required multiple pressors to support his
blood pressure. His hemodynamics were monitored with a PA
catheter and he required an intra-aortic balloon pump to be
placed. Soon after the IABP was placed his cardiac indices
improved and he was weaned off of pressor support and the IABP
was removed. He was aggressively diuresed and extubated.
.
1) Shock: The differential of the etiology of shock in this
patient was cardiogenic vs septic. He had initially presented
with complaints of abdominal pain to the OSH. Per the OSH ED
record, the patient had a leukocytosis and some LLQ tenderness
to palpation concerning for a possible abdominal infection.
However, there were no conclusive findings on abd. CT or U/S.
Seen on CT was some stranding and thickening of the small bowel
(could be explained by fluid overload). On admission, he was
started empirically on vanc/levo/flagyl for presumed sepsis.
More likely was cardiogenic shock in the setting of atrial
fibrillation with RVR and many nodal blocking agents given at
OSH. Given his significant alcohol history it was felt that he
may have had an underlying cardiomyopathy that in setting of his
arrhythmia and drugs tipped him over into cardiogenic shock
requiring intubation. TTE here showed global hypokinesis
consistent with this. A right-heart catheter was placed.
Hemodynamics were also consistent with cardiogenic shock
(elevated filling pressures, elevated SVR, low CO and CI). He
required pressors to maintain MAPs >65. He was placed on
levophed and dobutamine drips transiently. Elevated lactate was
consistent with decreased tissue perfusion. An IABP was placed
due to worsening cardiac status. He eventually improved on the
IABP which allowed weaning off the pressors. His IABP was
removed again and the patient remained hemodynamically stable
off pressors and mechanical support and could be extubated. His
Afib was managed as described below. His CHF and BP were also
medically managed and optimized towards the end of his hospital
stay. He was discharged on ASA 81, BB, Lasix, Spironolactone
and Dig (also for Afib, see below). He has an outpatient
appointment with his PCP, [**Name10 (NameIs) 2085**] and electrophysiologist.
He was off oxygen requirement, hemodynamically stable and with
minimal LE edema upon discharge. He should weigh himself daily
and follow a sodium restricted diet.
.
2) ID: As above, there was concern for initial sepsis with
possible abdominal source. He was started on vanco/levo/flagyl
empirically. Cultures were negative. He completed a 7 day
course of antibiotics. His leukocytosis trended down and he
remained afebrile.
.
3) Respiratory failure: Hypoxic secondry to pulmonary edema in
the setting of afib and RVR. In addition, the patient had been
given 8 liters of fluid at the OSH. Patient was intubated at
OSH and remained intubated in the CCU. Once his hemodynamics
improved and he was maintaining his BP without pharmacologic
support he was given boluses of IV lasix for diuresis. His
respiratory status improved with diuresis and he was
successfully extubated. He was off any oxygen requirement upon
discharge.
.
4) CAD: Stent to OM in [**2168**]. No CP. No significant cardiac
enzyme elevations.
.
5) Rhythm: AFib with RVR. DC cardiovesion was attempted several
times without success in addition to medical management
including frequent IV metoprolol doses. Medical conversion was
also attempted with Amiodarone. However, the patient remained
in Afib although he was rate controlled later during his
hospital stay. He was eventually stabilized on a regimen of
Amiodarone, metoprolol, and Digoxin. Anticoagulation was
initiated transiently with a heparin drip and with coumadin 5mg
qHS towards his discharge. His INR prior to discharge was 1.8.
An appointment with his PCP was scheduled two days after
discharge in order to check another INR with a goal of [**1-25**].
.
6) Pump: Global hypokinesis. Unclear cause. Myocarditis vs
depression in setting of sepsis vs other. Likely underlying
alcohol-induced cardiomyopathy given his history of ethanol
abuse until recently. See above with regards to his
CHF/cardiogenic shock management.
.
7) Acidosis: metabolic with inadequate respiratory response
initially. High lactate. No osmolar gap. Gap eventually closed
after having stabilized his cardiogenic shock. Lactate trended
down. Acidosis resolved.
.
8) Renal failure: In setting of likely poor PO intake. Pre-renal
vs ATN from cardiogenic shock. No hydro seen. Renal function
improved slowly throughout the course of his hospital stay. His
renal function returned to [**Location 213**] prior to discharge.
.
9) Acute Liver failure: History of daily alcohol use. Fatty
liver on U/S. No stones or ductal dilation. Transaminases
elevated and direct hyperbilirubinemia. Likely shock liver due
to cardiogenic shock. Hepatitis serologies were negative LFTs
were slowly trending down throughout his hospital stay.
.
10) Coagulopathy: [**1-24**] liver failure. Improved with improving
liver function. Towards the end of his hospital stay, coumadin
was started for anticoagulation for Afib.
.
11) Alcohol use: H/o [**12-24**] bottle of whiskey until recently. No
history of DTs. MCV was high. Patient received
B12/thiamine/folate.
.
12) Hyperlipidemia: Normal cholesterol and TGs. Chol/HDL was
2.0.
.
13) DM: No history. Sugars transiently elevated. Covered with
SSI. HbA1c was 5.7.
.
14) FEN: cardiac, heart healthy diet after extubation.
.
15) PPX: Pneumoboots, PPI, later coumadin.
.
16) Access: A-line, R IJ, initially femoral line
.
17) Code: Full
.
Medications on Admission:
Atenolol
Lipitor
Lisinopril
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO every twelve
(12) hours for 3 days: twice daily for 3days, then daily after
that until you see your cardiologist.
Disp:*12 Tablet(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Start daily doses after 3 days of twice daily doses after
discharge. .
Disp:*60 Tablet(s)* Refills:*2*
12. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day: Start on
[**2172-5-13**].
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Outpatient Lab Work
INR check on [**2172-5-14**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Cardiomyopathy with cardiogenic shock and CHF (EF initially
15%, then up to 30%), status post intubation and inotropic
pressure support and intraaortic balloon pump
2. Systolic and diastolic CHF, EF 15% (now 30%)
3. Hypertension
4. Hyperlipidemia
5. Atrial fibrillation with rapid ventricular response requiring
DC cardioversion, on coumadin
6. Questionable sepsis, completed 7 day course of
vanc/levo/flagyl empirically
7. CAD s/p stent in [**2168**]
8. Acute renal failure secondary to poor forward flow from CHF
9. Acute liver failure in setting of cardiogenic shock
10. Fatty liver, h/o Etoh abuse
.
Secondary Diagnosis:
1. H/o Ethanol abuse
2. Obesity
Discharge Condition:
Stable. Afebrile. Tolerating PO. Ambulating without difficulty.
Discharge Instructions:
You have been treated for a heart condition called
cardiomyopathy with congestive heart failure. You have been
intubated and sedated and received intravenous medications to
keep your blood pressure and circulation stable. You have
partially recovered from this condition. You have been started
on several new oral medications: Amiodarone, Digoxin and
Coumadin (a blood thinner) for anticoagulation and rate control
for a heart rhythm condition called atrial fibrillation; blood
pressure and heart failure medications (lisinopril,
spironolactone, toprol XL, lasix). Please take all medications
as prescribed and discontinue your previous oral medications.
.
You should weigh yourself daily and call your PCP if you gain
more weight than 3 pounds. You should follow a low sodium diet
and restrict your fluid intake to 1.5 liters per day.
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, leg swelling,
nausea/vomiting, spontaneous bleeding or any other concerning
symptoms.
.
Please take all your medications as directed.
.
Please keep you follow up appointments as below.
Followup Instructions:
You should have a lung function test (called PFTs) as an
outpatient because you have been started on a drug called
amiodarone to control your heart rate and rhythm. This
medication can sometimes compromise lung function and therefore
you should have a baseline test to be scheduled by your PCP.
.
You should follow up with an electrophysiologist regarding your
atrial fibrillation and arrythmias. You have an appointment
scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for [**5-25**] at 9:20am in the
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. Call ([**Telephone/Fax (1) 5862**] with
any questions.
.
Please also follow up with your cardiologist at [**Hospital1 18**] [**Location (un) 620**]
(Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], phone: ([**Telephone/Fax (1) 8937**]. An appointment has
been scheduled for [**6-29**], Monday, at 3pm. The office will
contact you if an earlier appointment is going to be available
as you should follow up earlier than that with him, if possible.
.
You have an appointment with your primary care physician, [**Last Name (NamePattern4) **].
[**First Name (STitle) 1022**], on [**2172-5-20**] at 3:30pm. [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 15818**]
.
You should go to your Dr.[**Name (NI) 2989**] office on [**2172-5-14**] for lab work.
The so called INR should be checked which is a lab test to
determine if your anticoagulation (blood thinning) on coumadin
is accurate. Your last INR on discharge was 1.8.
ICD9 Codes: 4254, 4280, 5849, 0389, 2762, 2761, 4019, 2930, 2724, 3051, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6181
} | Medical Text: Admission Date: [**2103-5-17**] Discharge Date: [**2103-5-23**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Coronary Artery Byapss Graft x 1 (LIMA to LAD) and Aortic Valve
Replacement (21mm CE pericardial tissue valve) [**2103-5-17**]
History of Present Illness:
82 y/o female with worsening shortness or breath. Referred for
cardiac cath which revealed coronary artery disease and aortic
stenosis.
Past Medical History:
Hypertension, Hypercholesterolemia, Seizure disorder,
Hypothyroidism, Myeloproliferative disorder with mild anemia,
h/o Atrial Fibrillation h/o cellulitis, s/p Hysterectomy
Social History:
Retired waitress. Denies tobacco use. Denies ETOH use, but
admits to alcoholism and quit in [**2087**].
Family History:
Father died of MI at age 47.
Physical Exam:
VS: 60 15 168/70 5' 68.5kg
General: WD/WN elderly female in NAD
HEENT: EOMI, PERRLA, OP benign
Neck: Supple, FROM, -JVD, -carotid bruits
Chest: CTAB -w/r/r
Heart: Irreg-regular with 3.6 murmur
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, trace edema, -varicosities
Neuro: A&O x 3, non-focal, MAE
Pertinent Results:
Echo [**5-17**]: Pre-cpb: The left atrium is moderately dilated. The
left atrial appendage emptying velocity is depressed (<0.2m/s).
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is moderate symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular systolic function is
normal. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are focal calcifications in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis. Mild
(1+ aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Moderate (2+) mitral regurgitation is seen.
POST-CPB-Well seated bioprosthetic valve in the aortic posotion.
No AI Peak gradient 23, mean 12 mm Hg. Preserved [**Hospital1 **]-ventricular
systolic fxn, MR 2+, unchanged from pre-bypass.
CXR [**5-22**]: Small bilateral pleural effusions and left lower lobe
atelectasis unchanged. Stable postoperative appearance of the
heart and mediastinum.
[**2103-5-17**] 11:27AM BLOOD WBC-21.4*# RBC-1.99*# Hgb-6.8*#
Hct-20.3*# MCV-102* MCH-34.2* MCHC-33.5 RDW-21.6* Plt Ct-197
[**2103-5-17**] 06:02PM BLOOD Hct-28.8*#
[**2103-5-23**] 07:05AM BLOOD Hct-30.2*
[**2103-5-22**] 06:40AM BLOOD WBC-11.2* RBC-2.98* Hgb-9.5* Hct-28.2*
MCV-95 MCH-31.8 MCHC-33.6 RDW-20.3* Plt Ct-129*
[**2103-5-17**] 12:19PM BLOOD PT-17.5* PTT-36.3* INR(PT)-1.6*
[**2103-5-20**] 03:00PM BLOOD PT-67.3* PTT-36.1* INR(PT)-8.5*
[**2103-5-21**] 08:50AM BLOOD PT-28.2* INR(PT)-2.9*
[**2103-5-23**] 07:05AM BLOOD PT-13.3* INR(PT)-1.2*
[**2103-5-17**] 12:19PM BLOOD Glucose-164* UreaN-18 Creat-0.5 Na-141
K-3.3 Cl-111* HCO3-23 AnGap-10
[**2103-5-22**] 06:40AM BLOOD Glucose-99 UreaN-29* Creat-1.0 Na-137
K-3.4 Cl-98 HCO3-29 AnGap-13
[**2103-5-23**] 07:05AM BLOOD K-4.4
[**2103-5-21**] 02:30AM BLOOD Calcium-8.8 Phos-2.1* Mg-2.1
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname 487**] was found to have severe
AS and coronary artery disease. She had all pre-operative
work-up done as an outpatient and was electively admitted on
[**2103-5-17**] for surgery. She was brought to the operating room on
this day where she underwent an aortic valve replacement and
coronary artery bypass graft. Please see operative report for
surgical details. Amiodarone was started in the OR for AFIB. She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition. Later on op day she was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one her chest tubes were removed and she was
started on beta blockers and diuretics. She was gently diuresed
during post-op course towards her pre-op weight. Coumadin was
started for her Atrial Fibrillation. Over the next several days
she remained stable in the CSRU. Her INR increased dramatically
to over 8 within a couple of days. Coumadin was held and INR
decreased significantly. At time of discharge her INR was 1.2.
Her therapeutic goal is 2-2.5. On post-op day four she was
transferred to the telemetry floor. Epicardial pacing wires were
removed on post-op day five. Physical therapy followed patient
during entire post-op course for strength and mobility. She
appeared to be doing well with stable labs and vital signs, but
still needed PT. She was discharged to rehab facility with the
appropriate follow-up appointments on post-op day 6.
Medications on Admission:
Dilantin 130mg qd, Lopressor 25mg qd, Clonazepam 0.5mg prn,
Synthroid 137mcg qd, Lasix qd, Procrit
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO QAM (once a day (in the morning)).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 2
weeks.
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] for 2 days. Then 400mg qd for 7 days. Then
200mg qd until stopped by cardiologist.
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Titrate for INR goal of [**1-4**].5.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 941**] - [**Location 942**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Byapss Graft x 1
Aortic Stenosis s/p Aortic Valve Replacement
Post-operative Atrial Fibrillation
PMH: Hypertension, Hypercholesterolemia, Seizure disorder,
Hypothyroidism, Myeloproliferative disorder with mild anemia,
h/o Atrial Fibrillation h/o cellulitis, s/p Hysterectomy
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Do not take bath. Do no apply lotions, creams,
ointments or powders to incision.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 2 months.
If you develop a fever or notice redness or drainage from
incision, please contact office immediately.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 29977**] Follow-up
appointment should be in 2 weeks
Dr. [**Last Name (STitle) 8098**] in [**1-5**] weeks
Completed by:[**2103-5-23**]
ICD9 Codes: 4241, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6182
} | Medical Text: Admission Date: [**2149-1-26**] Discharge Date: [**2149-2-5**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Right subdural hematoma
Major Surgical or Invasive Procedure:
s/p burr holes foe evacuation of subdural hematoma
History of Present Illness:
84M who was admitted here early [**Month (only) 404**] falling fall while on
coumadin for afib. At that admisssion had small R acute
convexity SDH. Repeat scans were stable and he was discharged
to
home. He has been off coumadin since that time. Was discharged
on dilantin but level was 1 at OSH today He returns today with
increasing confusion. Head CT at OSH shows 2cm R chronic SDH
with shift and effacement of ventricle.
Past Medical History:
Afib
Htn
MI
Social History:
lives with wife who has dementia. Very supportive family,
children
Family History:
Unknown
Physical Exam:
Gen: WD/WN
HEENT: Pupils:PERRLA EOMs unable to participate
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, confused, unable to cooperate with
exam.
Orientation: Oriented to person only
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4to3
mm bilaterally.
III, IV, VI: Extraocular movements unable to assess
V, VII: Facial strength appears intact.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength antigravity all 4.
Pertinent Results:
Head CT [**1-26**]
Significant increase in size of large right subdural collection
with associated leftward subfalcine herniation, dilation of the
left lateral ventricle, and likely some rightward uncal
herniation.
CXR [**1-26**]
Low position of the endotracheal tube terminating at the
carina. This was discussed with Dr. [**First Name (STitle) **] at 12 noon on
[**2149-1-26**].
Nasogastric tube terminates in the stomach, however side port
is near the GE junction. This was relayed to the emergency board
dashboard at 12 noon and flagged for urgent attention.
EKG [**1-26**]
Atrial fibrillation with a rapid ventricular response and
ventricular premature beat. Diffuse non-specific ST-T wave
abnormalities. Compared to the previous tracing of [**2149-1-10**]
ventricular rate is faster.
Head CT [**1-27**]
Large improvement in the size of the right subdural collection.
Improved leftward subfalcine herniation with mild residua
remaining. The uncal herniation has resolved.
CXR [**1-28**]
Lung volumes are preserved following removal of the endotracheal
tube. Although there is minimal atelectasis at the left lung
base medially, the lungs are otherwise clear. Heart size remains
top normal. There is no pleural effusion or pneumothorax.
Transvenous right ventricular pacer lead in standard placement
Head CT [**1-29**]
Study is compared with the most recent NECT dated [**1-27**], as well
as a series of previous studies dating to [**2149-1-10**]. The overall
appearance is not significantly changed since the most recent
study. As before, the patient is status post placement of two
right frontal burr holes with residual post-operative
pneumocephalus, smaller. The mixed-attenuation subdural
collection layering over the right cerebral convexity is
unchanged and normal in overall size and appearance, and
continues to measure roughly 11 mm in maximal thickness, at the
vertex, with small layering dependent hemorrhage. Additional
small hypoattenuating foci may represent vessels, fibrovascular
strands or additional foci of more acute hemorrhage. There is
persistent mass effect on subjacent gyri and approximately 7 mm
leftward shift of the septum pellucidum, effacement of the
ipsilateral and trapping of the contralateral lateral
ventricles, improved. No new extra- and no intra-axial
hemorrhage is identified. Again demonstrated are some lacunes in
the left basal ganglia.
IMPRESSION: No significant change in the moderately large
subdural collection layering over the right convexity with
similar degree of mass effect and shift of the midline
structures, no new hemorrhage
Brief Hospital Course:
Patient was transferred from outside hospital to [**Hospital1 **] with 2cm
right chronic SDH with shift and effacement of the ventricle.
He went to the operating room to have a burr hole procedure to
evacuate the blood. He spend the night in the PACU intubated
and the patient went in and out of atrial fibrilation requiring
IV diltiazem for control. After restarting his normal home
medications, the situation improved and he defervesced to the
floor. We had the EP team come and evaluate the pacemaker as
the patient fell on the side of his pacemaker before his
admission. The EP team found nothing wrong with the pacemaker.
On POD 2, the patient did very well. PT saw and worked with
him. Later that day, he had a temperature and became
tachycardic. Labs were drawn and fluids were given
aggressively. The rest of his exam at this time was normal. On
POD1, we drew labs to establish a better baseline of where he
started at. There were no bacteria in his urine. On POD2, we
d/c'd his IVF and foley. On [**2149-1-30**] the patient had continued
tachycardia with heart rate up to the 150s which only briefly
reponded to fluid boluses. As a result, a medicine consult was
obtained. After a 5mg dose of lopressor his heart rate came down
to 115. His quinapril and atenolol were discontinued and
metoprolol was added per medicine's recommendations. He
continued to have periods of tachycardia during his
hospitalization an EP consult was also obtained he diltazem and
lopressor were increased to 360 daily and Lopressor 125mg. He
was ruled out for an MI on [**2-3**]. The cardiology and medicine
teams felt he was safe for discharged without telemetry.
Neurologically he intact without any deficits and his sutures
were removed on discharge. He was found to have a Digoxin level
of 3.1 on discharge, we recommend hold his digoxin dose for 2
days then rechecking a level on [**2-7**].
Medications on Admission:
Digoxin, Pravastatin, Allopurinol, Quinapril
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily):
HOLD UNTIL [**2-7**] FOLLOW UP DIG LEVEL.
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
10. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
Right acute subdural hematoma
Discharge Condition:
good
Discharge Instructions:
PLease call the office or come to the emergency room for any
changes in mental status, weakness, seizure, worsening headache
or for any questions/concerns you may have.
Please call the office or come to the emergency room for
excessive redness at incision site, drainage from incision or
fever>101.5
Hold Digoxin for next two days then check level if within normal
limits than may resume.
Followup Instructions:
Follow up with your cardiologist in 1 week
You will also need to make an appointment for follow up with
Dr. [**Last Name (STitle) **] 4 weeks from the time of discharge. Call the same
number to make that appointment. You will need to have a Head
CT at that time.
Please follow dilantin levels;dig levels weekly. Dilantin goal
[**10-25**]
Completed by:[**2149-2-5**]
ICD9 Codes: 5180, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6183
} | Medical Text: Admission Date: [**2104-7-1**] Discharge Date: [**2104-7-15**]
Date of Birth: [**2045-5-4**] Sex: F
Service: SURGERY
Allergies:
Codeine / Penicillins
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59F who is s/p motor vehicle crash. She was in the front seat
when the car ran into a crowd of people and then into a pole.
There was reportedly no LOC. Her c-spine was cleared at the
OSH. Her EtOH level was 122. She had bilateral rib fractures and
a 24Fr R chest tube was placed into the subcutaneous tissue of
the R chest wall at the OSH. She was transferred from an OSH via
med flight.
Past Medical History:
PMH: COPD, bipolar depression, NIIDM, EtOH abuse, ?old R humeral
fx?
PSH: bilateral knee replacement, CCY, VHR
Social History:
H/o EtOH abuse, has had multiple trauma in the past
Family History:
NC
Physical Exam:
Discharge day exam:
99.1 97.7 105 95/61 18 93% trach mask
Gen: NAD, alert, appropriately responsive to yes/no questions
CV: RRR
Pulm: coarse breath sounds, breathing comfortably on trach mask,
most of subcutaneous emphysema resolved, chest tube sites appear
clean
Abd: soft, nontender, nondistended
Ext: WWP
Pertinent Results:
[**2104-7-1**] 05:50PM BLOOD WBC-11.7* RBC-2.96* Hgb-9.8* Hct-30.1*
MCV-102* MCH-33.0* MCHC-32.4 RDW-14.7 Plt Ct-147*
[**2104-7-1**] 07:46PM BLOOD WBC-11.7* RBC-3.41* Hgb-11.1* Hct-34.3*
MCV-101* MCH-32.7* MCHC-32.5 RDW-15.4 Plt Ct-155
[**2104-7-15**] 03:20AM BLOOD WBC-12.7* RBC-3.30* Hgb-10.3* Hct-31.8*
MCV-96 MCH-31.2 MCHC-32.4 RDW-14.8 Plt Ct-336
[**2104-7-1**] 07:46PM BLOOD Glucose-150* UreaN-16 Creat-1.1 Na-139
K-5.1 Cl-111* HCO3-17* AnGap-16
[**2104-7-15**] 03:20AM BLOOD Glucose-151* UreaN-20 Creat-0.9 Na-138
K-4.9 Cl-93* HCO3-37* AnGap-13
[**2104-7-1**] 05:50PM BLOOD ASA-NEG Ethanol-48* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2104-7-1**] CT Abd/Pelv:
IMPRESSION:
1. Extensive subcutaneous emphysema. 2. Right chest tube
within the subcutaneous air and not within the pleural space. 3.
Small right pleural pneumothorax. 4. Trace bilateral
hemothoraces. 5. Trace pneumomediastinum. 6. Trace complex
perihepatic fluid without evidence of injury to the solid
organs. 7. Right third through tenth and left fourth through
eighth rib fractures. Sternal fracture. 8. Small subcutaneous
hematoma overlying the right upper abdomen. 9. Loss of height
of the L4 vertebral body, likely chronic. 10. Complex splenic
cyst. 11. Apparent soft tissue lesion with dense calcifications
in the region of the right anterior mediastinum, not clearly
evaluated on this exam. After the acute findings have resolved,
recommend followup with dedicated chest CT for further
evaluation. 12. Findings suggestive of chronic pancreatitis
with possible obstructing calculus in the distal pancreatic duct
within the pancreatic head. An MRCP can be obtained for further
evaluation.
CT Head:
IMPRESSION:
No acute intracranial abnormality.
[**2104-7-4**] Echo: Left ventricular wall thickness, cavity size, and
overall systolic function are normal (LVEF 65%). Right
ventricular chamber size and free wall motion are normal.
However, in very suboptimal imaging, the basal segment of the
posterior wall may be hypokineticThere is no aortic valve
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is a very small
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
59F s/p MVC partially restrained passenger, front seat, car vs
crowd and then a pole, -[**Hospital 63213**] transferred from OSH via med
flight, neck cleared at OSH. Pt was hypotensive in the CT scan,
triggered was called, pt received 1 U PRBC. CT was found to be
placed in chest wall subcutaneous tissue. She was stable until
arrival in the TICU when she began to have respiratory distress
and was intubated, sedated and is paralyzed. CT scan shows to
have numerous rib fractures, sternal fx, Sub-Q emphysema,
pneumomediastinum, and R PTX. R anterior chest pigtail was
placed initially but it was not resolved her PTX. Bilateral CT
were then placed in the TSICU. On [**7-5**]+ gram negative
diplococci was detected on SCx.Cultures grew w/ Moraxella.
Vanco/Cipro/Cefepime started. Bedside trach was placed on [**7-7**].
On [**7-9**], pt was doing well, +OOB to chair, b/l CT to waterseal.
On [**7-10**]: Left sided chest tube D/c'd. Mental status starts to
improve. [**7-11**]: dobhoff placed. R Chest tube dc'd. On [**7-13**], Pt
was weaned to trach mask and she passed bedside swallow
evaluation. Pt was advanced to regular diet with supplements.
The rest of her hospital course per systems are detailed below:
Neurologic:
Oxycodone/IV dilaudid, zyprexa/seroquel/paxil. TLSO brace when
OOB for T12 Fx
h/o EtOH
on thiamine, folate supplementation
Cardiovascular: Stable, Echo: normal EF, very small effusion, no
tamponade. Cont to monitor for S&S of blunt cardiac injuries
Pulmonary:
On Trach mask, cont to wean as tolerates
Cont pulmonary toilet, breathing treatment (Ipratropium,
Albuterol)
Gastrointestinal:
Regular diet
Hematology:
Stable, cont to monitor
Endocrine:
- DM
Cont GlipiZIDE, Metformin
- Hypothyroidism
continue synthroid
Infectious Disease:
Cont abx for VAP
Prophylaxis: SQ heparin
Medications on Admission:
detrol LA 4 XR', vesicare 10', lorazepam 0.5'', MVI', glipizide
5'', pantoprazole 40', levothyroxine 75', doxepin 100', zyprexa
10', paroxetine 40', folate 1', metformin 500'', spiriva 18',
klor-con 20', albuterol 90 q4h, hydroxyzine 50''' prn,
ranitidine 150'', albuterol nebs prn
Discharge Medications:
1. Bisacodyl 10 mg PR HS:PRN constipation
2. CeftriaXONE 1 gm IV Q24H Duration: 6 Days
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H
5. Doxepin HCl 100 mg PO HS home med
6. GlipiZIDE 5 mg PO BID home med
7. Heparin 5000 UNIT SC TID
8. HydrOXYzine 50 mg PO Q8H:PRN home med- anxiety
9. Levothyroxine Sodium 100 mcg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID home med
11. Paroxetine 40 mg PO DAILY
12. Senna 1 TAB PO BID
13. FoLIC Acid 1 mg PO DAILY
14. Ipratropium Bromide Neb 1 NEB IH Q4H
15. Multivitamins 1 TAB PO DAILY
16. OLANZapine 15 mg PO DAILY
17. Quetiapine Fumarate 25 mg PO BID
18. Furosemide 20 mg PO DAILY:PRN for volume overload
19. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
bilateral rib fractures, sternal fracture, small
pneumomediastinum, small right pneumothorax
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 ACS service after your trauma. Please
follow these directions:
You should resume walking and exercising as you can tolerate.
You have rib fractures and a sternal fracture. If you have pain,
you can take tylenol or motrin. You can also take narcotic
medication if your pain is severe. You can resume a regular
diet.
Followup Instructions:
Please call [**Hospital 2536**] clinic to schedule a follow-up appointment [**12-31**]
weeks after your discharge. The clinic # is [**Telephone/Fax (1) 600**]
ICD9 Codes: 4589, 2851, 496, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6184
} | Medical Text: Admission Date: [**2140-1-27**] Discharge Date: [**2140-2-9**]
Date of Birth: [**2068-10-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Presents for surgery
Major Surgical or Invasive Procedure:
[**1-27**] Laparoscopic esophagogastrectomy with placement of feeding
tube
History of Present Illness:
Mr. [**Known lastname 104432**] is a 71 year old male who presented to [**Hospital1 18**] on [**1-27**]
for scheduled surgical resection of a biopsied confirmed
carcinoma of the esophagus, T2 lesion without evidence of
positive lymph nodes.
Past Medical History:
Past Medical History:
GERD/ Barrett's esophagus
Asthma
Left knee arthritis
Past Surgical History:
Tonsillectomy
Submandibular gland excision
Social History:
Married, works as a dentist; seven drinks per week, non-smoker
Family History:
Father and 2 half sisters with CAD
Pertinent Results:
Operative report [**1-27**]:
Carcinoma of the esophagus. .
PROCEDURES: Minimally invasive total esophagectomy with
laparoscopic feeding jejunostomy.
Chest x-ray [**1-28**]:
There is no pneumothorax or sizable pleural effusions. Right
chest tubes in position. NG tube tip in unchanged position. Left
lower lobe retrocardiac atelectasis is peristent. Improved right
lower lobe and left mid zone atelectasis. There has been no
change in the cardiomediastinal contour in the postoperative
period.
Barrium esophageal swallow [**2-1**]:
IMPRESSION: No evidence of anastomotic leak on barium
esophagram.
Chest x-ray [**2-1**]:
IMPRESSION:
1. Worsening asymmetrical alveolar and interstitial opacities in
the right lung, which may be due to asymmetrical pulmonary
edema, but superimposed aspiration in the perihilar region is
also possible given the clinical suspicion.
2. Interval placement of nasogastric tube with decreased
distention of pull-up.
Abdominal x-ray [**2-4**]:
FINDINGS: Supine and upright films of the abdomen were obtained.
There is persistent left retrocardiac opacity and a left-sided
effusion. A right-sided chest tube is present as well as
partially visualized right lower lung opacities. There has been
progression of contrast through the colon which is now seen
extending to the rectum. Gas distended loops of predominantly
large bowel may be slightly decreased compared to prior study.
There is no evidence for free intraperitoneal air. A linear area
of contrast noted in the right lower quadrant, which likely
represents a normally filled appendix. The osseous structures
are unchanged.
Chest x-ray [**2-5**]:
Heterogeneous opacification in the right lung, particularly the
axillary subsegments is improving, suggesting resolution of
aspiration. The neoesophagus remains severely distended with
fluid. Left lung is clear and the heart is normal size. No
pneumothorax noted. Small right pleural effusion is new since
[**2-3**], small left pleural effusion unchanged
ENT evaluation [**2-6**]:
IMPRESSION/PLAN:
71yM s/p lap esophagogastrectomy now with mild hoarseness and
aspiration. His laryngoscopy is essentially normal with normal
vocal cord function and no evidence that he is unable to
tolerate
his secretions. Recommend [**Hospital1 **] PPI therapy and humidification if
possible. I would expect improvement in his voice an, depending
on what his video swallow shows, eventual improvement in his
swallow coordination.
We will follow up on his video swallow and are available for any
additional questions or concerns.
Speech and swallow therapy [**2-8**]:
RECOMMENDATIONS:
1. PO diet texture of pureed solids and nectar thick liquids.
Po
medications can be given crushed in puree or via J-tube.
2. Aspiration precautions, as follows:
a. Take small bites/sip.
b. Swallow 3 times for each bite & sip.
c. Alternate each bite with a sip.
3. Outside of meals, the pt may be allowed small amounts of thin
liquids (without any other solids) using a chin tuck maneuver.
4.
Repeat video swallow study in the next 10-14 days to monitor for
any further resolution of unilateral pharyngeal paresis in hopes
that the pt's po diet may be upgraded.
Video swallow [**2-8**]:
IMPRESSION: Mild-to-moderate pharyngeal residue due to decreased
laryngeal valve/airway closure and bolus propulsion. This leads
to mild-to-moderate aspiration with thin liquids.
Discharge labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2140-2-5**] 07:55AM 8.0 3.33* 10.3* 30.9* 93 31.0 33.3 12.6
395
Plt Ct INR(PT)
[**2140-2-5**] 07:55AM 395
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2140-2-7**] 10:33AM 137* 12 0.8 134 4.6 100 25 14
Calcium Phos Mg UricAcd Iron
[**2140-2-7**] 10:33AM 8.9 4.0 2.3
Brief Hospital Course:
Mr. [**Known lastname 104432**] had no intra-operative complications,
post-operatively he was NPO with intravenous hydration, Dilaudid
PCA, and intravenous beta-blockade for optimal heart rate and
blood pressure; he had a neck [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] drain, right chest
tube, [**Doctor Last Name **] drain, j-tube, nasogastric tube, and foley catheter;
he was transferred to the SICU for close monitoring.
POD 1: Chest tube removed, Toradol added for optimal pain
control.
POD 2: Tube feeds started, nasogastric tube removed, aggressive
pulmonary toileting, transferred to in-patient nursing unit
POD 4: Desaturation with emesis, improved with oxygen therapy,
transferred back to SICU for aspiration, nasogastric tube
replaced, broad spectrum antibiotics started, temperature with
leukocytosis of 12k.
POD 6: Oxygenating well with nasal cannula, productive cough,
afebrile, antibiotics discontinued, barium esophageal swallow
negative for an anastomotic leak, chest x-ray with opacities in
right lung, transferred back to in-patient nursing unit, all
medications given through jejunostomy tube including oral
beta-blockade and proton pump inhibitor, tube feeds continued,
pain well controlled with Oxycodone elixir and Morphine as
needed; aggressive physical and chest therapy for ambulation,
coughing, and deep breathing continued, ambulating with
assistance.
POD 7: Nasogastric tube and foley catheter removed; foley
replaced secondary to urinary retention, diet advanced,
oxygenating well on room air.
POD 8: Abdominal distention with +flatus, tube feeds held,
abdominal x-ray demonstrated ileus, NPO with intravenous
hydration resumed, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**Doctor Last Name **] drain removed.
POD 9: Speech and swallow therapy evaluation with aspiration of
thin liquids and hoarse voice, abdomen soft, +flatus and bowel
movement.
POD 11: ENT consult with laryngoscopy revealed normal vocal
cords function. Foley catheter removed with patient voiding
without difficulty, tolerating tube feeds.
POD 12: Video swallow confirmed right side unilateral pharyngeal
weakness; diet advanced to regular pureed solids and nectar
thick liquids. He tolerated minimal amount of diet, all
medications either crushed in puree or given through J tube.
Tolerating tube feeds of replete with fiber 2/3 strength to
reach goal of 120mL. Pain well controlled with Roxicet,
oxygenating well on room air, ambulating with assistance, and
chest physical therapy continued with good mobilization of
secretions.
Discharged to [**Hospital3 2558**] rehabilitation center in stable
condition on [**2-9**]. He was to have a repeat video swallow in
[**9-4**] days, and was to follow-up with Dr. [**Last Name (STitle) **] in [**11-24**]
weeks.
Medications on Admission:
Aspirin
Flovent
Prilosec
Voltaren
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day (2) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day): Hold for HR < 60 or SBP < 100
Crush and give with applesauce/pudding
or put through J tube.
3. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical PRN
(as needed).
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain: Can give oral
or through J tube
.
5. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily): Give with
applesauce/pudding or through J tube.
7. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
9. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2
times a day): Hold for loose stool.
10. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. Diphenhydramine HCl 12.5 mg/5 mL Elixir [**Hospital1 **]: Five (5) mL PO
HS (at bedtime) as needed: Crush with applesauce or put through
J tube.
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: 0.5
Tablet,Rapid Dissolve, DR PO BID (2 times a day): Give through J
tube or oral with applesauce/pudding.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Esophageal cancer
Post-operative apsiration
Post-operative urinary retention
Right sided unilateral pharyngeal weakness
Discharge Condition:
Stable
Discharge Instructions:
Notify MD or return to the emergency department if you
experience:
*Increased or persistent pain
*Fever > 101.5
*Nausea, vomiting, diarrhea, or abdominal distention
*Inability to pass gas, stool, or urine
*If incisional sites or feeding tube exit site develop redness
or drainage
*If feeding tube falls out
*Shortness of breath or chest pain
*Any other symptoms concerning to you
You may shower, feeding tube exit site must be covered with an
occlusive dressing
Feeding tube exit site should always have a dry dressing over
exit site and be changed daily
No swimming or tub baths with feeding tube
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**11-24**] weeks, call [**Telephone/Fax (1) 2981**] for
an appointment
Completed by:[**2140-2-9**]
ICD9 Codes: 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6185
} | Medical Text: Admission Date: [**2124-5-3**] Discharge Date: [**2124-5-16**]
Date of Birth: [**2052-1-1**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
Bronchoscopy x2
Tracheostomy
PEG tube placement
History of Present Illness:
The pt is a 72 year-old right-handed woman with a history of
hypertension who presented as a transfer from an OSH with an
ICH.
.
The pt was unable to offer a history at the time of my
encounter. Therefore, the following history is per the medical
record and the pt's husband.
.
The pt had been otherwise in her usual state of health and was
without complaint until approximately 7:30pm on the evening
prior to transfer. At that time, she finished her dinner and
told her husband that her left leg felt "numb." He noticed that
she had some difficulty walking, but was able to do so and went
to rest on the couch in their living room. When her husband
went back to check on her at around 9pm, he noticed that she had
a left facial droop and was slurring her words. He intended to
bring her to a local ED, but the pt was initially reluctant. He
subsequently called 911 and she was taken to an OSH.
.
At the OSH, she was noted to have a flaccid hemiparesis on the
left. She underwent a CT scan which showed a right putaminal
hemorrhage. Reportedly, she became progressively somnolent and
was intubated for airway protection (received etomidate,
succinylcholine, lidocaine for intubation at 2330). She was
subsequently given 4mg of ativan (at 2327 and 2348) and 1g of IV
dilantin (at 2330)- no convulsive activity documented. She was
also given 15mg of IV labetalol at the OSH for BP of 168/108 on
arrival. No subsequent vital signs documented. Per the ED
resident, the pt was given an indeterminate amount of IV ativan
en route from the OSH (no EMS report could be found).
.
The pt was unable to offer a review of systems.
Past Medical History:
-hypertension
-hyperlipidemia
Social History:
Retired but worked in business, mostly for non-profit
organizations. No history of tobacco or illicit drug use.
Occasional alcohol use.
Family History:
Notable for mother with CAD.
Physical Exam:
Vitals: T: 98F P: 50 R: 16 BP: 88/48 SaO2: 100% on CMV with FiO2
100%
General: intubated, lying in bed with eyes closed.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: bradycardic, RR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
bilaterally.
Skin: no rashes or lesions noted.
.
Neurologic (at 0100):
-mental status: Does not respond to verbal command or noxious
stimuli. No verbal output.
.
-cranial nerves: PERRL 1.5mm and sluggishly reactive
bilaterally. Funduscopic exam technically limited due to pupil
size. Right exotropia (old per husband). EOM absent to
oculocephalic maneuver. Corneal reflex weak bilaterally. No
overt facial asymmetry although ET tube in place. Gag and cough
reflex intact.
.
-motor: Normal bulk throughout. Tone flaccid throughout. Does
not withdraw to noxious stimuli in any of the four extremities.
No adventitious movements noted.
.
-sensory: No response to noxious stimuli in all four
extremities.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 2 2 2 1 0
.
Plantar response was extensor bilaterally.
Pertinent Results:
[**2124-5-3**] 07:30PM TYPE-ART PO2-146* PCO2-34* PH-7.39 TOTAL
CO2-21 BASE XS--3
[**2124-5-3**] 07:30PM LACTATE-1.8
[**2124-5-3**] 07:30PM freeCa-1.06*
[**2124-5-3**] 04:54AM TYPE-ART PO2-127* PCO2-44 PH-7.35 TOTAL
CO2-25 BASE XS--1
[**2124-5-3**] 04:54AM LACTATE-1.9
[**2124-5-3**] 04:54AM freeCa-1.07*
[**2124-5-3**] 04:54AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2124-5-3**] 04:54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2124-5-3**] 04:45AM GLUCOSE-328* UREA N-19 CREAT-0.7 SODIUM-140
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14
[**2124-5-3**] 04:45AM ALT(SGPT)-28 AST(SGOT)-23 LD(LDH)-205
CK(CPK)-143* ALK PHOS-67 AMYLASE-51 TOT BILI-0.6
[**2124-5-3**] 04:45AM LIPASE-35
[**2124-5-3**] 04:45AM CK-MB-4 cTropnT-<0.01
[**2124-5-3**] 04:45AM ALBUMIN-3.5 CALCIUM-7.6* PHOSPHATE-3.3
MAGNESIUM-1.8 CHOLEST-139
[**2124-5-3**] 04:45AM VIT B12-421 FOLATE-15.0
[**2124-5-3**] 04:45AM TRIGLYCER-101 HDL CHOL-61 CHOL/HDL-2.3
LDL(CALC)-58
[**2124-5-3**] 04:45AM TSH-3.5
[**2124-5-3**] 04:45AM PHENYTOIN-10.9
[**2124-5-3**] 04:45AM WBC-13.7*# RBC-3.52* HGB-11.1* HCT-32.4*
MCV-92 MCH-31.6 MCHC-34.3 RDW-13.2
[**2124-5-3**] 04:45AM PLT COUNT-198
[**2124-5-3**] 04:45AM PT-11.2 PTT-25.6 INR(PT)-0.9
[**2124-5-3**] 01:04AM TYPE-ART TEMP-35.6 RATES-20/ TIDAL VOL-450
PO2-271* PCO2-38 PH-7.42 TOTAL CO2-25 BASE XS-0 -ASSIST/CON
INTUBATED-INTUBATED
[**2124-5-3**] 12:55AM GLUCOSE-212* UREA N-18 CREAT-0.6 SODIUM-141
POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-19* ANION GAP-16
[**2124-5-3**] 12:55AM WBC-9.0 RBC-3.26* HGB-10.6* HCT-30.0* MCV-92
MCH-32.5* MCHC-35.3* RDW-13.3
[**2124-5-3**] 12:55AM NEUTS-80.0* BANDS-0 LYMPHS-16.0* MONOS-2.3
EOS-1.3 BASOS-0.4
[**2124-5-3**] 12:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2124-5-3**] 12:55AM PLT SMR-NORMAL PLT COUNT-193
[**2124-5-3**] 12:55AM PT-13.4* PTT-23.5 INR(PT)-1.2*
.
.
Radiologic Data
MR CONTRAST GADOLIN [**2124-5-3**] 1:27 PM
IMPRESSION:
1. Right putaminal hemorrhage without underlying mass, with
imaging features strongly favoring a hypertensive etiology.
2. Patent circle of [**Location (un) 431**] and major tributaries.
.
CT HEAD W/O CONTRAST [**2124-5-3**] 12:54 AM
FINDINGS: There is a 4.3 x 4.0 x 2.1 cm parenchymal hemorrhage
involving the right putamen and subinsular white matter. Noted
is a dependent blood-fluid level, dorsally. There is no
significant associated shift of normally midline structures. The
ventricles appear normal in size and are symmetric. No
hemorrhage is identified within the basal cisterns or
ventricles. There is no evidence of hydrocephalus. Osseous and
soft tissue structures are unremarkable. There is fluid within
the right maxillary sinus. The orbits are unremarkable.
IMPRESSION: 4.3 x 4.0 x 2.1 cm parenchymal hemorrhage involving
the right putamen and subinsular white mater. This is a typical
location for hypertensive bleed.
.
CHEST (SINGLE VIEW) [**2124-5-3**] 12:52 AM
IMPRESSION: Endotracheal and nasogastric tubes in appropriate
position. Retrocardiac opacity concerning for pneumonia.
.
EEG [**2124-5-3**]
IMPRESSION: Abnormal EEG, due to a markedly reduced voltage
record with
some rare alpha activity biposteriorly in most delayed portions
of the
record. The precentral beta represents an Ativan effect related
to
medication administered earlier to the patient. The record
overall
suggests a mild to moderate encephalopathy with excessive
drowsiness and
slowed and poorly sustained posterior background rhythm's.
.
CT HEAD W/O CONTRAST [**2124-5-4**] 3:41 PM
CONCLUSION: No change in the appearance of the brain since
[**2124-5-3**]. Right putaminal hemorrhage with surrounding edema. No
evidence of new hemorrhage.
.
CXR [**5-14**]:Left subclavian vein catheter and tracheostomy tube
appear unchanged in position. There is a left retrocardiac
opacity, which appears stable and may represent atelectasis
and/or consolidation. There are atelectatic changes at the right
lung base. There probably is a small pleural effusion on the
left.
.
CXR [**5-5**]:
The endotracheal tube and NG tube remain in satisfactory
position. There are relatively low lung volumes. There is
persistent left lower lobe opacity, which could reflect
aspiration or pneumonia. There is also persistent left-sided
effusion. No other significant changes are identified.
Brief Hospital Course:
Patient was admitted to the neuro ICU, sedated, intubated, and
with a diagnosis of R putaminal hemorrhage. Differential
diagnosis included hypertensive or amyloid hemorrhage, AVM
rupture or intratumoral bleed. She underwent a head MRI which
showed a stable hemorrhage and no underlying mass, strongly
favoring a hypertensive etiology for the hemorrhage due to its
typical location. An EEG suggested mild to moderate
encephalopathy with excessive drowsiness and slowed and poorly
sustained posterior background rhythm's but no epileptiform
activity. Her treatment was focused on strict BP control (<140)
and seizure prophylaxis. On hospitalization day (HD) 2, patient
was still stuporous, likely due to medication effect; a repeat
head CT confirmed the hemorrhage was stable. Plan was to wean
her from the respirator towards extubation, despite a
retrocardiac opacification concerning for pneumonia as seen on
CXR and treated with Levofloxacin (sputum cx [**5-3**]: strep.
pneumoniae; bld cs: neg.) On HD 3, patient was extubated, but
failed to breathe on her own successfully. She continued her
levofloxacin for a 7 day course. She had a bronchoscopy
performed and there was a concern for possible airway collapse
due to tracheomalacia. The interventional pulmonary service saw
the patient and repeated a bronchoscopy. They determined that
tracheomalacia was not playing a role in her difficulty being
extubated. She had 2 more attempts at extubation and failed
each time. At this point, the decision was made to place a
tracheostomy tube and PEG tube. This went well without
complication. She was quickly weaned from the vent to a trach
mask, but contineud to require frequent suctioning. She then
developed a fever and WBC ct elevation again. She had another
sputum culture which grew GPCs, so she was started on vancomycin
due to concerns that this may be MRSA. She defervesed and her
WBC count began to trend down. Repeat CXRs showed stable left
retrocardiac opacity. She will continue on vancomycin at rehab
for 1 week.
She was initially loaded with dilantin but developed no
evidence of seizure. She was therefore stopped after 10 days of
this medication.
The patient's mental status had improved significantly after
4-5 days in the hospital. By the time of her tracheostomy, she
was wide awake, off sedation, following commands and answering
questions/writing well.
Imaging throughout of her head showed a stable hemorrhage.
Her exam remained unchanged as well, with good use of her right
side, but no use of left side(other than minimal use of her toes
and ankle). Her arm is not moving at all. She is able to look
to the left with left eye, but right eye has old exotropia and
does not cross easily to left.
On discharge, the patient's lasix dose was halved due to
dehydration. This may need to be increased at [**Hospital1 **] if she
has trouble with fluid overload.
Medications on Admission:
-triamterene-HCTZ
-lipitor 10mg po daily
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed) as needed for dry eyes.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): HOLD for SBP<100, HR<55 .
5. Acetaminophen 160 mg/5 mL Solution Sig: 320-640 mg PO Q4-6H
(every 4 to 6 hours) as needed.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
10. Bismuth Subg-Balsam-ZnOx-Resor Suppository Sig: One (1)
Suppository Rectal PRN (as needed).
11. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed).
12. Medication
Insulin Sliding Scale as per nurse's spread sheet;
13. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Twenty Eight (28) U Subcutaneous twice a day: Before
breakfast and before dinner!.
14. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day for 7 days.
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**3-16**]
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
ICH
Discharge Condition:
Stable. Pt not moving left arm or leg(except for toes). She is
not speaking due to tracheostomy. She is otherwise answering
questions and following commands.
Discharge Instructions:
Please tell the staff at [**Hospital1 **] if you have any new fever,
headache, new weakness, numbness, or tingling, falls, dizziness,
or lightheadedness.
Followup Instructions:
Please follow-up as the doctors [**First Name (Titles) **] [**Last Name (Titles) **] arrange for you with
your PCP.
-----
You can follow-up in the neurology clinic with Dr [**Last Name (STitle) 4638**] and Dr
[**Last Name (STitle) **] as the staff at rehab arrange. They should call
[**Telephone/Fax (1) 2574**] for an appointment for 1 month after your
discharge.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 431, 5180, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6186
} | Medical Text: Admission Date: [**2141-6-12**] Discharge Date: [**2141-6-16**]
Date of Birth: [**2070-7-11**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
left frontal operculum stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 70 yo woman with hx CAD, high chol, HTN, who presents
at 6:30PM to [**Hospital1 18**] after presenting at 1PM to [**Hospital **] Hospital
with global aphasia since last known well time of NOON, s/p IV
TPA and transferred to [**Hospital1 18**] for further post-TPA care. Hx
provided by son in law, at bedside: pt had been feeling
"slightly
unwell" over wknd, had c/o leg cramps bilaterally. Was last
seen
by husband to be well at noon - husband left house to take a
walk, and returned between 12:20 and 12:30 PM to find wife
staring straight ahead and not talking, not interacting well.
He
feels that she seemed to understand what he was saying to her;
he
asked her to get in the car, and she had no trouble walking to
car, and even locked door on the way out. No obvious weakness
anywhere, or gait problems. [**Name (NI) 4906**] brought pt by car to
[**Hospital **]
Hospital, where initial NIHSS score documented as 7 (2 for LOC
questions, 3 for mute/aphasic, and 2 for dysarthria "speech so
slurred or pt mute" - Dr. [**First Name (STitle) **]/neurology [**Name (NI) 653**], and after
head CT negative for ICH (or early signs of stroke), IV TPA
given
at 14:48 (6mg bolus for wt 150 lbs, followed by infusion of 55mg
over 1 hr, ended at 15:35). BG at time was 121, but unknown
coags. Per family's request (upon arrival of son in law and
daughter), pt was transferred to [**Hospital1 18**] for post-TPA care. Of
note, following TPA administration, nursing note reads "Pt seems
to say 'yes' to all questions." Initially in [**Hospital1 18**] ER, BP was
178/117 but was rechecked as 160/80 after no intervention.
There
is no difference in her exam, though her son in law feels that
she appears very fatigued.
Past Medical History:
PMH:
CAD s/p MI 5 yrs ago s/p stent (unknown details, osh)
High chol
HTN
"occasional headaches"
s/p basal cell ca resection 1 mo ago
GERD
Social History:
Social History:
Lives with husband, very physically active, takes care of 4
horses; no tob, etoh, drugs. Has one son [**Doctor First Name **], one daughter.
Family History:
Family History:
No known early strokes in family.
Physical Exam:
Examination:
Afebrile, hr 60, bp initiall 178/117 upon arrival-> 160s/80s
with
no intervention when rechecked, RR 17, 97% 2L
General appearance: white female, appears younger than stated
age
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
No TTP along spine.
Mental Status: The patient is alert awake; could understand
command to "close eyes" and "open eyes" but did not understand
other verbal commands; could imitate with nonverbal cues, though
not 100% of time; did not make facial expressions, stick out
tongue, or close eyes "tighter." No verbal output (completely
mute). Occasionally closed eyes when not being spoken to, but
appeared alert, with somewhat poor eye contact when being
addressed directly.
Cranial Nerves: +blink to threat bilat. The optic discs are
normal in appearance. Eye movements are normal, with no
nystagmus. Pupils react equally to light, both directly and
consensually. +Corneals bilat. Facial movements are
diminished,
with no volitional mvmt of facial mms, did not protrude tongue -
no obvious asymmetry. Hearing is intact to voice/commands.
Motor System: No obvious abnl bulk/tone, full strength at delt,
[**Hospital1 **], tri, wrist ext, finger ext, finger flex, IPs, hams, quads,
TAs, gastrocs, with no drift, no asterixis
Reflexes: The tendon reflexes are 2+ at [**Hospital1 **], [**Last Name (un) **], tri, knees,
ankles, with downgoing toes bilat
Sensory: W/d slightly to tickling x 4 ext, no obvious asymmetry;
no obvious unilateral neglect.
Coordination: There is no ataxia, with nl RAMs, nl f->n bilat
Gait: deferred for now
Pertinent Results:
[**2141-6-15**] 06:15AM BLOOD WBC-6.2 RBC-3.79* Hgb-12.3 Hct-34.6*
MCV-91 MCH-32.5* MCHC-35.7* RDW-13.1 Plt Ct-222
[**2141-6-14**] 07:05AM BLOOD PT-12.1 PTT-22.1 INR(PT)-1.0
[**2141-6-15**] 06:15AM BLOOD Glucose-118* UreaN-12 Creat-0.7 Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
[**2141-6-12**] 08:10PM BLOOD ALT-22 AST-25 CK(CPK)-181* AlkPhos-92
Amylase-52 TotBili-0.5
[**2141-6-15**] 06:15AM BLOOD ALT-PND AST-PND CK(CPK)-58 Amylase-PND
TotBili-PND
[**2141-6-15**] 06:15AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2
[**2141-6-13**] 03:25AM BLOOD Triglyc-70 HDL-71 CHOL/HD-3.0 LDLcalc-125
[**2141-6-12**] 08:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Studies:
MRI brain/MRA brain: Acute infarct in the superior division of
the left MCA territory.The posterior circulation is patent with
no significant stenosis. In the superior division of the left
MCA is an abrupt cut off of signal on time-of-flight images,
suggesting stenosis from embolus to this vessel. The remaining
branches of the anterior circulation are patent. No evidence of
aneurysm.Loss of signal in the superior division of the left
MCA, likely from embolus to this vessel.
EEG: This is an abnormal EEG in the waking and drowsy states due
to the persistent left posterior quadrant slowing and left
temporal
rhythmic slowing. This suggests left posterior quadrant
subcortical
dysfunction, while rhythmic left temporal slowing suggests a
region of
cortical irritability. No epileptiform features were noted.
Surface echocardiogram:
No PFO/ASD seen. Preserved global and regional biventricular
systolic function. Mild rheumatic mitral stenosis with moderate
mitral
regurgitation. Mild aortic regurgitation. Mild pulmonary
hypertension.
Moderately dilated ascending aorta.
carotid US: Less than 40% stenosis of the proximal internal
carotid arteries bilaterally. This is a baseline examination at
the [**Hospital1 18**].
Brief Hospital Course:
Neurology: Patient admitted for known left frontal operculum
stroke s/p IV TPA likely of cardioembolic etiology. She was in
the ICU x 24 hours on admission for post-IV TPA care. The
patient had an EEG because of first presentation of global
aphasia to rule out seizure (as outside CT scan showed no
evidence of stroke). Her EEg showed no epileptiform activity
that would be concerning for seizure but showed some slowing
over the area of the infarction site. The patient received a
work-up for stroke. Her labs are as following: HgbA1c 6%, LDL
121, HDL 71. Her suface echocardiogram showed the mitral valve
leaflets are mildly thickened, with
characteristic rheumatic deformity. She had mild left atrial
dialtion. No thrombus, vegetations or PFO noted. Family declined
trans-esophageal echocardiogram to visualize aorta. Patient was
kept on telemetry during her hospital stay with no arrhythmias
noted.
In terms of exam, it was clear patient had some dysfunction of
facial muscles from stroke site which limited facial expression
and ability to take oral foods. She initially failed her swallow
study but on follow-up testing with bedside swallow study and
video swallow study, she was cleared for regular diet and thin
fluids. She improved in terms of her ability to produce speech
but speaks with hypophonic voice, and has little spontaneous
speech output. She will work with outpatient speech therapy.
PT/OT cleared her for home discharge.
Upon further discussions with family, it was thought the patient
did take a baby aspirin at home so patient discharged on
Aggrenox. She has history of muscle aches with statins. CK
checked and was 58 and LFTS nml. She was started on Zetia 10 mg
po qday which will be monitored by her primary care doctor.
Medications on Admission:
Atenolol 50 mg [**Hospital1 **]
Zetia 10 mg qd
Nexium 40 mg qd
Wellchol - not taking, per daughter, as bottle full
ASA 81 mg po qday
Discharge Medications:
1. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO twice a day: you may start with one pill
qday x 3 days. If no headache, you may take 1 tab po twice
daily.
Disp:*60 Cap(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Outpatient Speech/Swallowing Therapy
Speech therapy outpatient therapy
Discharge Disposition:
Home
Discharge Diagnosis:
stroke
Discharge Condition:
stable. MS: hypophonic voice, few spontaneous words. Does not
read. Follows midline and appendicular commands. Has mild right
facial droop. Mild right UMN pattern right arm weakness.
Discharge Instructions:
Please follow-up with appointments and take medications as
instructed.
Followup Instructions:
[**Hospital 4038**] Clinic. Neurology. [**Hospital1 18**] [**Hospital Ward Name 23**] [**Location (un) **]. [**Name6 (MD) 3688**] [**Name8 (MD) 72617**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2141-7-18**] 9:30 AM. YOU
MUST CALL TO CONFIRM THIS APPOINTMENT
ICD9 Codes: 2720, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6187
} | Medical Text: Admission Date: [**2124-10-4**] Discharge Date: [**2124-10-9**]
Date of Birth: [**2045-11-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
recurrent mass
Major Surgical or Invasive Procedure:
Craniotomy with resection mass
History of Present Illness:
The patient is a 78-year-old female who is well-
known to neurosurgery service from previous hospitalizations as
well as from
surgery in [**2121**]. The patient had been diagnosed with an
atypical meningioma. The patient was previously irradiated
and underwent a gross total resection, [**Doctor Last Name 18741**] grade 2, in
[**2123-3-20**]. The patient has been followed sequentially with
MRI scans. The patient now re-presents with an enlarging
recurrent tumor on the left side posterior to the resection
bed and abutting the falx. The lesion causes significant mass
effect as well as perifocal edema. The patient has shown
progressive weakening on the right side. The patient was,
therefore, extensively counseled. Since conservative means
are rather exhausted in her case, the family agreed to
proceed with a second resection. The patient was extensively
counseled. The patient was consented. The patient was aware
of the risks and benefits of the procedure. The patient was
then taken electively to the operating room on [**2124-10-4**].
Past Medical History:
Parasagittal meningioma
HTN
Glaucoma
Right wrist fracture
Recent dental tooth extraction
Left rotator cuff repair with LUE weakness
Pelvic prolapse repair
Cataract extraction
Soft diet
.
Past Surgical History:
Pelvic prolapse repair
Cyberknife [**9-22**]
cataract resection
s/p bifrontal craniotomy and resection of parasagittal
meningioma [**2123-4-15**]
Social History:
Originally from [**Location (un) 3156**], lives w/husband (who recently had a
mild stroke) in [**Location (un) **]; one son, no [**Name2 (NI) **]/etoh/drugs. Not
working, no prior career.
Family History:
No illnesses per patient
Physical Exam:
Exam After Patient Medically clear for discharge.
T:97.7 P:96.9 HR:64 BP:96/52 RR:18 SaO2:97%RA
Awake alert oriented x3
Eyes open
Follows commands.
Articulate, intelligent, appropriate.
No dysarthria.
Strength is likely full but the exam is limited by poor effort.
Weakness in the right lower extremity greater than the left but
strength exam is limited by patient effort. Has at least [**12-24**]
strength in the IP, Quad, and hamstring on the right. Strength
is [**3-23**] in the IP and quad on the left.
Senation intact to light touch.
Reflexes symmetrical.
Toes upgoing on the right, mute on the left.
Pertinent Results:
[**2124-10-4**] 03:05PM GLUCOSE-159* UREA N-14 CREAT-0.6 SODIUM-138
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-21* ANION GAP-13
[**2124-10-4**] 11:41AM GLUCOSE-100 LACTATE-1.1 NA+-132* K+-3.7
CL--102
[**2124-10-4**] 10:17AM HGB-11.7* calcHCT-35 O2 SAT-99
[**2124-10-8**] 08:10AM BLOOD WBC-9.9 RBC-3.87* Hgb-11.5* Hct-34.0*
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.6 Plt Ct-265
[**2124-10-8**] 08:10AM BLOOD Glucose-96 UreaN-20 Creat-0.7 Na-140
K-4.3 Cl-103 HCO3-31 AnGap-10
[**2124-10-6**] 05:00AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.8
CT-Head without contrast: [**2124-10-4**]: IMPRESSION: Status post left
frontal craniotomy, with post-procedural changes seen at the
vertex, likely a small amount of hemorrhage at the resection
site. No shift of midline structures identified. Expected
pneumocephalus seen, as noted above.
CXR [**2124-10-4**]: IMPRESSION: Right subclavian line entering the
internal jugular. ET tube at the carina. An NG tube in the
distal esophagus.
MR [**Name13 (STitle) 430**] With Contrast [**2124-10-4**]:
IMPRESSION: Relatively unchanged (or very slightly larger) left
parasagittal enhancing meningioma and postoperative sequela.
MR [**Name13 (STitle) 430**] with and without contrast [**2124-10-5**]:
IMPRESSION: Anticipated post-surgical changes. No definite
abnormal enhancement to indicate residual tumor. Bilateral
parietal T2 hyperintensities, secondary to vasogenic edema, are
unchanged.
Brief Hospital Course:
78 Russian woman with recurrent meningioma admitted for surgical
resection.
PRINCIPAL PROCEDURE PERFORMED on [**2124-10-4**]:
1. Bifrontal redo craniotomy for resection of predominantly left
recurrent meningioma.
2. Intraoperative image guidance.
3. Microscopic dissections.
4. Duraplasty.
5. Central line placement.
Patient was given Dexamethasone post operatively.
Patient started on Cipro for urinary tract infection.
Patient recovered very well after the operation. She complained
of zofran responsive nausea on the day of discharge.
Medications on Admission:
This list was obtained from prior Neuro-oncology note.
AFO --R afo qd while walking pt with r foot drop, please fit new
r afo
ARTHROTEC 50 50 mg-0.2 mg--one tablet(s) by mouth three times a
day as needed for as needed for pain
DARVOCET-N 50 50 mg-325 mg--one tablet(s) by mouth three times a
day as needed for for pain
KEPPRA 250 mg--1 tablet(s) by mouth twice a day increase as
directed to 4 tabs [**Hospital1 **]
MOBIC 7.5 mg--1 tablet(s) by mouth [**Hospital1 **] start at 1 tab [**Last Name (LF) **], [**First Name3 (LF) **]
increase to 2 tabs after one week if not enough effect.
PAMELOR 10 mg--1 capsule(s) by mouth at bedtime increase by 1
tab qweek to a max dose of 4 tabs qhs. hold increase if enough
effect at a lower dose or excess sedation
No medications DC'd on [**2124-9-8**].
Medications prescribed on [**2124-9-8**]:
DEXAMETHASONE 2 mg--2 tablet(s) by mouth twice a day
DILANTIN 100 mg--1 capsule(s) by mouth at bedtime
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Meningioma
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? 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, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN ____________DAYS FOR REMOVAL OF
YOUR STAPLES/SUTURES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN _______WEEKS.
YOU WILL / WILL NOT NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT
CONTRAST
YOU WILL/WILL NOT NEED AN MRI OF THE BRAIN WITH OR WITHOUT
GADOLIDIUM
Completed by:[**2124-10-9**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6188
} | Medical Text: Admission Date: [**2193-3-3**] Discharge Date: [**2193-3-5**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85F h/o HTN, hypothyroidism fell at home yesterday and hit her
head on the radiator. Her step-daughter went to her house today
and noticed that she had mental status changes and brought her
to [**Hospital **] Hospital. Her head CT revealed hemorrhage so she was
loaded with phosphenytoin and was transferred to [**Hospital1 18**] for
further evaluation. The patient reports that she takes a baby
aspirin daily. She reports no headache, dizziness, or visual
changes. She has no SOB or chest pain.
Past Medical History:
HTN, hypothyroidism, [**Last Name (un) 8061**], UTI
Social History:
Lives with husband who she cares for. Has several children and
step-children.
Family History:
non-contributory
Physical Exam:
T:99.3 BP:115/43 HR:78 RR:14 O2Sats:100% 2L NC
Gen: Sleeping when examiner entered the room but woke easily.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple. No tenderness.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date. When asked
again several minutes later, she could not recall the name of
the
hospital.
Recall: Cannot recall any of the 3 objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to 2.0
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: + left facial droop
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-3**] throughout. Slight left
pronator
drift.
Sensation: Intact to light touch bilaterally.
Toes upgoing on the left
Pertinent Results:
[**2193-3-5**] 04:25AM BLOOD WBC-9.5 RBC-3.76* Hgb-10.8* Hct-34.1*
MCV-91 MCH-28.8 MCHC-31.8 RDW-13.4 Plt Ct-209
[**2193-3-3**] 03:00PM BLOOD Neuts-78.0* Lymphs-16.7* Monos-4.9
Eos-0.2 Baso-0.2
[**2193-3-5**] 04:25AM BLOOD Plt Ct-209
[**2193-3-5**] 04:25AM BLOOD Glucose-83 UreaN-29* Creat-1.2* Na-142
K-3.4 Cl-104 HCO3-26 AnGap-15
[**2193-3-3**] 03:00PM BLOOD CK(CPK)-494*
[**2193-3-5**] 04:25AM BLOOD Albumin-3.7 Calcium-8.4 Phos-2.2* Mg-1.8
[**2193-3-5**] 04:25AM BLOOD Phenyto-16.5
Radiology
CT Head: [**2193-3-3**]
IMPRESSION:
Multifocal intraparenchymal hemorrhages as described above with
small amount of subarachnoid hemorrhage and hemorrhage within
the ventricular system with hydrocephalus. Rightward shift of
normally midline structures toward the right by 2 mm. These
findings are stable when compared to prior exam. This
configuration of hemorrhagic findings is unusual given
multifocality and MRI is recommended for further evaluation for
underlying mass lesion or cause.
CT Head [**2193-3-4**]
Impression: Essentially unchanged CT examination of the head
compared to one day prior. There is multifocal intraparenchymal
hemorrhage, with
intraventricular extension, and likely a small focus of
subarachnoid hemorrhage. Associated edema and mass effect is
unchanged. Ventricular size is also stable, with prominent
ventricles, possibly reflecting hydrocephalus, though a
component of underlying atrophy is not excluded. Continued
imaging followup is recommended.
Brief Hospital Course:
Ms [**Known lastname **] was admitted to the neurosurgery service and monitored
in the ICU for the first 24 hours of her hospital stay. A repeat
CT showed no interval increase in left IPH (basal ganglia) and
stable contusion. She was transferred to the surgical floor for
further monitoring and left on telemetry. She was stable and
tolerated a regular diet without problem. [**Name (NI) **] exam showed
improved strength in all her extremities, but continued short
attention span and she could not follow complex commands. She
was evaluated by PT and OT and deemed to be a good candidate for
short term rehab where she will continue her work with PT and
regain her strength. She will be seen in follow up with
neurology and neurosurgy in 4 weeks.
Medications on Admission:
levoxyl (dose unknown)
atenolol (dose unknown)
aspirin 81 mg
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses
6. 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.
7. HydrALAzine 10 mg IV Q6H:PRN SBP > 160
8. 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.
9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Intraparenycmal Hemorrhage
Basal Ganglia Bleed
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? 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, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**]. You
should continue taking this medication and it will be addressed
at your follow up appointment with neurology.
Followup Instructions:
Follow up with Neurology
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2193-4-12**] 10:00
You should call ([**Telephone/Fax (1) 7394**] to arrange an MRI around that
time.
Neurosurgery:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**] to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6189
} | Medical Text: Admission Date: [**2140-1-30**] Discharge Date: [**2140-2-5**]
Service: MEDICINE
Allergies:
Penicillins / Shellfish
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Fever, mental status changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 89 yo woman, NH dependent, w/ h/o HTN, diet controlled
DM who presented initially to [**Hospital **] hospital from NH w/
altered mental status, fevers to 103, hypoxia. Per family, pt
noted to have cough x past 5 days, have worse MS x 1 day, fevers
and hypoxia started today.
On presentation to OSH, pt noted to be hypoxic to 80's on RA,
increased to 100% on NRB, 91% on 3L NC, febrile to 100.8, rectal
temp 102.9, BP stable, HR 125 (sinus tachy). Per report, CXR
showed RLL pna, pt was given moxifloxacin, 500cc IVF and
transferred to [**Hospital1 18**].
On presentation to [**Hospital1 18**], T99.2, HR 130, BP 97/45, RR 18, O2 98%
NRB. Pt given 1 (?2) liters NS, w/ decrease HR to 100-110,
increase BP to 105. She was given vanc, aztreonam, cipro for
nosocomial pna coverage given CXR report from OSH. Labs notable
for ARF (Cr 1.4 from baseline < 1), nl lactate, elevated trop
(in setting of ARF), leukocytosis (WBC 18.2). Given trop, pt
given ASA x 1. U/A markedly positive. Rpt CXR here w/ no pna
per report. Family w/ pt, and pt is DNR/DNI. Would like to
avoid central line if possible, so pt w/ 2 x PIV.
Currently pt awake, not able to answer questions.
Of note, pt w/ recent hospital admission [**Date range (3) 13940**] for
UTI and pneumonia, sputum cxs growing staph and klebsiella, on
discharge she was on Vanc, Levofloxacin, and flagyl.
Past Medical History:
1. breast cancer, status post lumpectomy, radiation therapy, and
Tamoxifen about 10y ago.
2. Depression - also hears voices, s/p ECT years ago.
3. Hypothyroidism.
4. Diet controlled diabetes mellitus.
5. Hypertension.
6. Gout.
7. Cataracts
8. vascular dementia
9. Li toxicity
10. diverticulitis s/p partial colectomy at which time colon
adenoma was found and removed.
11. s/p TAH/BSO
12. s/p full tooth extraction with dentures
13. HOH with hearing aids in both ears
14. GERD
15. ?Aspiration events
16. ?Myasthenia [**Last Name (un) **]
Social History:
Lives at [**Hospital6 13941**] home for years. Used walker until
about 4 m ago when declined to needing wheelchair at all times.
Son [**Name (NI) **] is HCP, daughter [**Name (NI) **] is intimately involved as well. No
Etoh or tobacco. Previously was very active in charity work with
[**Hospital1 **] Family Services, sang in a choir and danced.
In other discussions she has stated that she has lived a full
life and is ready to die without an invasive fight, desiring to
be DNR and opposed to a G-tube.
Family History:
noncontributory
Physical Exam:
Vitals - T 98.6, HR 125, BP 109/42, RR 30, O2 98% NRB
Gen - awake, appears to be following conversation, able to
mumble but otherwise non-verbal, tachypnic, no use of accessory
muscles
HEENT - dry MM
CVS - tachycardia, no noted m/r/g
Lungs - ?mild rhonci anteriorly R middle chest. Could not fully
assess posterior lung fields as pt was moaning
Abd - soft, nt/nd
Ext - 2+ LE edema b/l
At discharge, the patient was afebrile. She is conversant and
able to answer questions clearly. She appears to be comfortable
on one liter nasal cannula. The remainder of her exam was
unchanged with the exception of her resolving tachycardia with
heart rate in the nineties. In addition she was noted to have a
small white head on her labia. Please continue to monitor skin.
Pertinent Results:
CXR ([**2140-2-1**]): There has been interval worsening with increase
in now moderate bilateral pleural effusions, greater on the
right side with associated adjacent atelectasis. Lower lung
volumes accentuate the cardiac silhouette which is top normal.
There is engorgement of the mediastinal vasculature. No overt
pulmonary edema.
EKG: Probable multifocal atrial tachycardia, rate 132. Cannot
exclude sinus tachycardia with frequent atrial premature beats.
Borderline low voltage. Delayed precordial R wave progression.
Possibly normal variant. The overall pattern could be seen in
chronic obstructive pulmonary disease with pneumonia.
[**2140-1-30**] 07:30PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017
[**2140-1-30**] 07:30PM URINE BLOOD-MOD NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2140-1-30**] 07:30PM URINE RBC-21-50* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**2-17**] RENAL EPI-0-2
[**2140-1-30**] 06:59PM LACTATE-1.6
[**2140-1-30**] 06:45PM GLUCOSE-180* UREA N-26* CREAT-1.4*
SODIUM-146* POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-25 ANION
GAP-17
Urine culture grew out E. Coli which was sensitive to Aztreonam.
Brief Hospital Course:
Pt is an 89 yo NH resident w/ PMH DM, HTN p/w sepsis and
respiratory distress who was transferred from an outside
hospital. She was admitted to the intensive care unit for
agressive care with antibiotics, non-rebreather and IVF support.
Per the family, the patient did not receive a central line, nor
other invasive procedures.
.
The patient was admitted with fever, altered MS, ARF, borderline
hypotension, leukocytosis and tachycardia. The etiology of the
infection was likely secondary to a UTI given results of her u/a
and urine cx. She was admitted to the intensive care unit for
management of her sepsis. While in the unit, her blood pressure
and tachycardia were stabilized with IVF but did not require
pressors. She was treated with IV antibiotics, including
aztreonam and clindamycin (to cover a question of aspiration
pneumonitis vs PNA, although review of her admitting CXR showed
no evidence of PNA). The clindamycin was discontinued once the
patient was called out to the floor.
The patient completed a seven day course of aztreonam to treat
the E. Coli infection in her urine. Urine cultures were
sensitive to the medication. Her mental status improved with
treatment of her infections. Given her recent antibiotic use,
if the patient starts having diarrhea, consider checking for a
C. difficle infection and consider starting Flagyl. Please
check a CBC in several days to monitor her white count.
She has been afebrile with stable blood pressure since leaving
the intensive care unit. She was weaned from a non-rebreather
to 4L nasal cannula and maintained her O2 saturation levels
between 96-99% on two liters. She is currently on one liter
nasal cannula and is maintaining her saturation at 94%. She can
continued to be weaned of the oxygen as tolerated. Her home
dose of Lasix was held in the hospital given her hypotension and
acute renal failure. It should be restarted to help decrease
the edema in her legs. Please weigh the patient daily and
assess whether she seems volume overloaded. If she appears dry
or is not taking good PO intake, consider holding her dose of
Lasix. Please check her electrolytes within two to three days
of returning, and if her BUN/cr are elevated or her Na level
begins to rise, also consider holding her Lasix regimen.
The patient appears to have a chronic anemia. Her hematocrit
has been stable throughout this admission.
The patient had mild hypernatremia on admission to the hospital.
Her sodium was 146 on admission, increasing to 147 s/p IVF
hydration. Her free water deficit was calculated at 1.4L. She
was treated with D5W repletion which improved her sodium.
Please check her electrolytes to monitor her sodium in two to
three days. Please encourage oral intake.
For her history of depression/dementia the patient was continued
on her home regimen of risperidone and Effexor.
Given her history of hypothyroidism, the patient's TSH was
checked during this admission which was normal. She was
continued on her home regimen of levothyroxine.
The family reported the patient has a newly dx Myasthenia
[**Last Name (un) 2902**]. Please discuss follow up with Neurology at [**Hospital1 2025**] with the
patient's family. Per report, she saw Neurolgy at [**Hospital1 2025**] on prior
to her admission at [**Hospital1 18**].
The patient takes a pureed diet (as aspiration risk).
In addition, the patient was noted to have a small whitehead on
her labia. It was treated with topical bacitracin as needed.
Please monitor her skin integrity and treat accordingly.
COMM: [**Name (NI) **] [**Name (NI) **] is HCP (h) [**Telephone/Fax (1) 13942**]. (c)[**Telephone/Fax (1) 13943**] DO NOT
CALL CELL ON WEEKENDS OR MON EXCEPT FOR ABSOLUTE EMERGENCY (he
works weekends for MA Pike and will have real trouble if phone
rings at work). Daughter [**Name (NI) **] intimately involved (h)
[**Telephone/Fax (1) 13944**], (w) [**Telephone/Fax (1) 13945**]. Can call her at all times.
CODE: DNR/DNI confirmed with son and daughter, also has DNR ppwk
from [**Name (NI) **].
Medications on Admission:
Docusate Sodium 100 mg PO BID
Risperidone 1 mg PO BID
Senna 8.6 mg 1-2 Tablets PO BID as needed.
Pentoxifylline 400 mg PO BID
Polyvinyl Alcohol 1.4 % 1-2 Drops Ophthalmic TID as needed.
Levothyroxine 50 mcg PO DAILY
Hexavitamin PO DAILY
Colchicine 0.6 mg PO DAILY
Lansoprazole 30 mg PO DAILY
Ipratropium Inhalation Q6H as needed.
Venlafaxine 37.5 mg PO QAM, 112.5mg PO QPM
Lasix 40 mg PO daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Name (NI) **]: One (1) PO BID (2
times a day).
2. Risperidone 1 mg Tablet, Rapid Dissolve [**Name (NI) **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
3. Sodium Chloride 0.65 % Aerosol, Spray [**Name (NI) **]: [**12-16**] Sprays Nasal
QID (4 times a day) as needed.
4. Colchicine 0.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
5. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Lasix 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
8. Venlafaxine 37.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM (once a
day (in the morning)).
9. Venlafaxine 37.5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO HS (at
bedtime).
10. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Bacitracin Zinc 500 unit/g Ointment [**Last Name (STitle) **]: One (1) Appl
Topical QID (4 times a day).
12. Hexavitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
13. Pentoxifylline 400 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1)
Tablet Sustained Release PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
Primary:
#Urosepsis from E.Coli UTI
#Severe Hypoxemia due to Aspiration Pneumonitis
#Mental Status changes now resolved
.
Secondary:
#Hypothyroidism
#Diet controlled diabetes
#GERD
#HTN
#Gout
#Vascular dementia
#?Aspiration
#?Myasthenia [**Last Name (un) 2902**]
Discharge Condition:
Stable, with decreased oxygen requirement and improved mental
status.
Discharge Instructions:
You were admitted to the hospital with a urinary infection,
fevers and difficulty breathing. While you were in the hospital
you were treated with antibiotics for the infection in your
urine and briefly treated for a possible aspiration event in
your chest.
.
We completed your course of antibiotics while you were in the
hospital. We did not change any of your other medications.
Please continue to take your other medications as prescribed.
Followup Instructions:
Please follow up with your primary care doctor in the next seven
to ten days.
.
Please follow up with your Neurologist at [**Hospital1 2025**] for further
work-up of your diagnosis of myasthenia [**Last Name (un) 2902**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
ICD9 Codes: 5070, 5119, 5849, 2762, 5990, 2761, 2859, 311, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6190
} | Medical Text: Admission Date: [**2128-2-4**] Discharge Date: [**2128-2-7**]
Date of Birth: [**2080-5-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Hypoxia, dyspnea, and tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47M with DM1, CKD, recent admission for MRSA PNA requiring
intubation and DKA in late [**Month (only) 1096**] (discharged to rehab [**1-29**]),
was at rehab this morning when he was awoken for routine vitals
and was diaphoretic, dyspneic, and hypoxic to 70% on RA as well
as tachycardic to 130s. O2 up to NRB, given lasix 40mg with
diuresis of 1L and lopressor and transferred to our ED.
In the ED, sat was 68-74% on RA on arrival, able to speak in
full sentences. CXR shows similar multifocal opacities to last
admission, but also new RLL infiltrate as well as some worsening
effusions/congestion. Added zosyn; last dose of vanc was [**2-3**].
Unable to wean down from [**Last Name (LF) 34474**], [**First Name3 (LF) **] admitting to ICU. VS on
transfer: 88, 119/62, 95% on 50% [**First Name3 (LF) 34474**], RR 12.
Past Medical History:
- IDDM c/b peripheral neuropathy
- Medullary sponge kidney
- Nephrolithiasis
- chronic low back pain
- gastritis
- gastroparesis
- depression/anxiety
- HTN
Social History:
Divorced though still in contact with ex-wife. Lived with his
father in [**Name (NI) **], MA, prior to hospitalization in [**Month (only) 1096**].
Smoked [**1-23**] ppd x 20 yrs but no longer smokes. Patient denies
abusing any recreational drugs and denies ETOH abuse, though
recent OMR notes indicate that his ex-wife reported hx of
substance abuse.
Family History:
Mother: Leukemia, currently undergoing chemotherapy
Father: CAD, HTN
Physical Exam:
VS: 98.7 126/63 78 20 97% 50% facemask
GEN: pale middle aged white man, appears older than stated age
HEENT: PERRL 3-2mm, anicteric sclera
RESP: poor airmovement throughout, esp decreased at R base, no
wheezing, no crackles
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft, Distended, NT, + BS
EXT: Mild (2+) peripheral edema, warm, 1+ DP pulses
NEURO: alert and oriented, interactive. moving all four
extremities.
SKIN: scabs over recent R IJ site
Pertinent Results:
[**2128-2-4**] 11:30AM GLUCOSE-214* UREA N-26* CREAT-2.2* SODIUM-136
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-29 ANION GAP-13
[**2128-2-4**] 11:30AM CK(CPK)-15*
[**2128-2-4**] 11:30AM cTropnT-0.06*
[**2128-2-4**] 11:30AM CK-MB-NotDone proBNP-[**Numeric Identifier 34475**]*
[**2128-2-4**] 11:30AM WBC-10.2 RBC-2.74* HGB-8.2* HCT-24.9* MCV-91
MCH-29.9 MCHC-32.9 RDW-17.0*
[**2128-2-4**] 11:30AM NEUTS-74.8* LYMPHS-18.8 MONOS-5.6 EOS-0.2
BASOS-0.7
[**2128-2-4**] 11:30AM PLT COUNT-671*#
[**2128-2-4**] 11:30AM PT-14.6* PTT-31.0 INR(PT)-1.3*
[**2128-2-4**] 11:47AM LACTATE-1.3
IMAGING:
CXR: Acute infective change in the right lower lobe with right
basal effusion superimposed on multifocal pulmonary opacities
consistent with areas of infection.
EKG: SR 94 nml axis, rSr' in V1, 1mm J point elevation in V2. No
significant change compared to [**1-17**].
ECHO ([**7-/2126**]): Global, diffuse HK; EF 35%
TTE [**2128-2-5**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with mild basal
inferior wall hypokinesis. The remaining segments contract
normally (LVEF = 50%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2126-8-6**],
overall biventricular systolic function has substantially
improved, but regionality of LV dysfunction is now appreciated.
The other findings are similar.
2 view CXR [**2128-2-6**]:
PA AND LATERAL CHEST, [**2-6**]
HISTORY: Multifocal pneumonia. Hypoxemia.
IMPRESSION: AP chest compared to [**1-25**] through [**2-4**].
Moderate interstitial pulmonary edema is stable since [**2-4**]. Moderate
right and small left pleural effusion have increased. Right
middle lobe
consolidation most likely pneumonia. Moderate cardiomegaly
stable. Tip of
the left PIC catheter projects over the superior cavoatrial
junction.
Interval improvement in left suprahilar consolidation suggests
that this
second region of pneumonia is improving.
Brief Hospital Course:
AP: 47 yo M with IDDM, recent multifocal, MRSA pneumonia, now
with hypoxia at rehab
#. Hypoxia: The patient had a recent/resolving multifocal, MRSA
pneumonia, and his symptoms (cough, sputum production) have been
resolving, although there does appear to be a new RLL infiltrate
and he has completed > 14 days now of vanc and zosyn. He had no
crackles on exam, but there was mild bilateral ankle edema,
grossly elevated BNP, and pt has history of systolic dysfunction
which could point to heart failure as a cause of his hypoxia.
Also in favor of heart failure is the improvement he had with
diuresis at rehab prior to transfer. Finally, diabetic
gastroparesis may predispose to aspiration as well as his
impaired oropharyngeal swallow seen on recent S & S, which, with
his new RLL infiltrate and acuity of event, seems most likely
explanation.
Patient underwent IV lasix diuresis and was discharged on his
normal lasix 20 mg po qd regimen. The patient may require
further diuresis to optimize his pulmonary status per discretion
of the physicians at [**Hospital1 **].
He was treated with cefepime (day 1 [**2-4**]), renally dosed for an
8-day course days given his likely aspiration; He was continued
on vanc(8 more days)& flagyl.
#. CAD risks: Given the patient's acute hypoxia and cardiac risk
factors such as DM and a low EF. Serial enzymes were checked to
rule out ischemia. He was continued on ASA and a B-blocker. A
TTE showed EF 50%, mild regional left ventricular systolic
dysfunction, c/w CAD, mild mitral regurgitation, mild pulmonary
hypertension.
#. IDDM: He was continued on glargine 12 units at bedtime and
HISS with meals.
#. C diff: The patient was diagnosed recently with C.diff and
was continued to be treated with flagyl x14 past end of other
antibiotics.
#. Thrombocytosis: likely due to his recent, serious infection.
#. Depression: The patient was continued on his outpatient
medication regmien.
#. HTN: Patinet's metoprolol was continued.
#. CKD, Stage 3: current Cr of 2.2 is below recent values of
[**3-25**].
#. Chronic pain syndrome: The patient continued to experience
low back pain. He was continued on fentanyl patches, lidocaine,
neurontin per his outpatient regimen and given break through
pain control with morphine 5mg oral liquid.
#. Anemia: The patient has anemia likely secondary to CKD. He
was continued on epo (formulary exchange for darbepoetin).
#. FEN: The patient's most recent S & S recs were pills whole or
with purees, thin liquids and pureed diet and he was continued
on this regimen.
#. CODE: FULL
Medications on Admission:
MEDS at Rehab
amlodipine 5mg [**Hospital1 **]
aspirin 325mg daily
escitalopram 20mg daily
darbepoetin alfa 100mcg qFriday
colace
fentanyl 150mcg patch q72hrs--last on [**2-4**]
lidocaine patch topical (lumbar region)
lasix 20mg daily
metoprolol 25mg QID
neurontin 300mg tid
heparin 5000 units [**Hospital1 **]
insulin glargine 12 units qhs and lispro sliding scale
omeprazole 20mg [**Hospital1 **]
sucralfate 1gm QID
vancomycin Q48hrs
flagyl 500mg tid
klonopin 0.5mg tid prn
morphine 3mg po q2h prn
compazine 10mg IV q6h prn
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
5. Morphine 10 mg/mL Solution Sig: Two (2) mg Intravenous every
four (4) hours as needed for pain.
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
8. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
QACHS: Administer per sliding scale.
9. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Darbepoetin Alfa In Polysorbat 100 mcg/0.5 mL Pen Injector
Sig: One Hundred (100) mcg Subcutaneous every Friday.
14. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day as needed for heartburn.
15. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for low back pain: on for 12 hours, remove for 12 hours.
18. Vancomycin 1,000 mg Recon Soln Sig: One (1) mg Intravenous
every twenty-four(24) hours for 4 days.
19. Cefepime 2 gram Recon Soln Sig: Two (2) gm Intravenous every
twenty-four(24) hours for 4 days.
20. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 18 days: Continue for 14 days beyond the end of vanc and
cefepime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
MRSA Multifocal Pneumonia
Systolic Heart Failure, Acute
Hypoxemia
ARF on CKD stage 4
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to the ED if you having high fevers, difficulty
breathing, hypotension, confusion, uncontrollable blood sugars
not responding to medical management, severe abdominal pain.
Followup Instructions:
Patient to schedule f/u with his PCP [**Name9 (PRE) 28955**] [**Name9 (PRE) **],[**Name9 (PRE) **]
[**Telephone/Fax (1) **] in [**1-23**] weeks.
ICD9 Codes: 5070, 5849, 4280, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6191
} | Medical Text: Admission Date: [**2183-11-3**] Discharge Date: [**2183-11-20**]
Date of Birth: [**2106-2-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Presented for elective catheterization
Major Surgical or Invasive Procedure:
Coronary catheterization with stenting of the OM2 and LCx
EGD with epinephrine injection and cautery of distal esophagus
EGD with biopsy
History of Present Illness:
This is a 77 year old male with a h/o coronary artery disease,
congestive heart failure (last EF 15%), aflutter s/p ablation,
paroxysmal atrial fibrillation (on coumadin), chronic renal
insufficiency, and schatki's ring dilated in past admitted to
CMI on [**2183-11-3**] for elective cardiac catheterization. Pt had
exercise MIBI (walked 8.5 minutes with resultant drop in BP from
112/60 to 88/60). Imaging showed fixed moderate defect in apex
and distal anterior wall and moderate reversible defect in
septum.
.
Then admitted electively to CMI for cath, which showed R heart:
RA 14, RV 61/8, PA 60/23, PCPW 33
L heart: LMCA norm; LAD 100% prox; LCX 80% mid, 70% prox OM2,
50% distal OM2, distal vessel fills via left to left
collaterals; RCA not visualized; [**Date Range **]-D1-OM1 patent, [**Date Range **]-LAD
patent. Prox OM2 lesion rotablated and stented with minivision
stent (unable to deploy drug-eluting stent); mid LCX stented
with cypher.
.
Pt was started on [**Date Range **], plavix, and also given
bivalirudin during the catheterization. Pt vomitted x 3 with
clotted blood in one episode. Sheath pulled and BP decreased to
88/40 with HR 40's. Pt received atropine 0.6mg IV x1 and 200 cc
NS bolus with BP in 100's/50's and HR 70's. Hct dropped 10
points and pt was tx'd to [**Hospital Unit Name 196**] from CMI. NGT x3 was attempted
unsuccesfully.
.
Of note, pt had abd pain and postprandial abd pain as outpt
leading to 30 lb wt loss. Outpt work up has included an MRA
abdomen to rule out bowel ischemia [**9-15**]. It was a poor study
and results were equivocal. Of note, EGD [**12/2178**] showed schlatki's
ring at GE junction. Also of note, in [**2166**] had CABG using
gastroepiploic artery for bypass. Furthermore, pt is on
coumadin.
.
Past Medical History:
1. Atrial flutter, s/p ablation in [**4-12**]. on coumadin
2. CABG [**2167**] - 5 vessel arterial bypass (using [**Last Name (LF) **], [**First Name3 (LF) **],
gastroepiploic artery)
3. Hypercholesterolemia.
4. Gout
5. Prostate cancer followed by [**Doctor Last Name **] - watchful waiting, last
PSA 2.5, and no signs of progression
6. s/p right hip surgery.
7. CVA, s/p B CEA
8. h/o Deep Venous Thrombosis
9. HTN
10. Left femoral-popliteal bypass.
11. Rectus sheath hematoma.
Social History:
Remote tobacco - smoked at least 1ppd but quit in [**2167**] after
CABG.
No EtOH x 5 years, past "excessive" alcohol intake.
Professor [**Known lastname **] lives at home with wife. [**Name (NI) **] remains very active
with his children and grandchildren and at baseline (until a few
months ago) can walk up many flights of stairs. They have no VNA
or other services but they do have a housekeeper. He is a
retired engineering professor [**First Name (Titles) **] [**Last Name (Titles) **]. He also consulted for an
energy firm until last spring, when he decided to retire after
the CEO of the firm passed away. He holds over 40 patents. He
has 3 children, 5 grandchildren, most of whom he sees often. He
enjoys seeing his grandchildren and spending time in his summer
home.
Family History:
non contributory
Physical Exam:
VSS
gen: nad, interactive, appropriate
heent: NCAT, no LAD, PERRL, EOMI
neck: jvd 2cm sup to clavicle at 30 degrees, cea scars, no
bruits, supple
cv: rrr; 2/6 sem without radiation
lungs: lungs clear
abd: soft, nt, nd, +bs
ext: right groin c/d/i, no oozing, no bruits; good distal pulses
in feet b/l
neuro: aox3; moves all 4 ext, cn grossly intact
.
Pertinent Results:
Labs on Admission
[**2183-11-3**] 10:10PM BLOOD Hct-25.2*# Plt Ct-209
[**2183-11-4**] 06:45AM BLOOD Hct-29.7* Plt Ct-193
[**2183-11-4**] 10:25AM BLOOD WBC-11.6* RBC-3.13* Hgb-9.8* Hct-28.8*
MCV-92 MCH-31.4 MCHC-34.1 RDW-15.6* Plt Ct-205
[**2183-11-3**] 08:35AM BLOOD INR(PT)-1.6
[**2183-11-3**] 05:15PM BLOOD Plt Ct-225
[**2183-11-4**] 03:17AM BLOOD PT-18.0* PTT-31.7 INR(PT)-2.3
[**2183-11-3**] 10:10PM BLOOD K-3.9
[**2183-11-3**] 10:10PM BLOOD CK(CPK)-58
[**2183-11-4**] 06:45AM BLOOD LD(LDH)-164 CK(CPK)-128
[**2183-11-4**] 06:45AM BLOOD CK-MB-12* MB Indx-9.4*
[**2183-11-4**] 06:45AM BLOOD Mg-1.8
[**2183-11-4**] 10:25AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.8
Labs on Discharge
[**2183-11-19**] 6:30A wbc 8.3 rbc 3.27* hgb 9.9* hct 30.0* mcv 92
[**2183-11-19**] 6:30A gluc 158* urea 50* creatinine 1.6* Na 138 K 4.6
Cl 101
HCO3 23
ENZYMES & BILIRUBIN
[**2183-11-11**] 07:50PM
ALT 2197 AST 1842 LDH 1506 ALK phos 293 Amylase 264 t-bili 2.5
.
[**2183-11-17**] 06:20AM
ALT527* AST103* LDH305* ALK phos190* Amlyase 110* t-bili 1.9*
.
EKG [**2183-11-3**]: Sinus rhythm. Prolonged A-V conduction delay. Left
bundle-branch block. Left axis deviation. Rare ventricular
premature beat. Compared to the previous tracing of [**2183-8-8**]
atrial ectopy is no longer present. Left axis deviation has
become more pronounced.
.
Coronary Cath:
1. Selective coronary angiography was performed on the LMCA and
[**Date Range **].
The [**Date Range **] was non-selectively injected and the RCA was not
injected as it
is known to be totally occluded proximally. The LMCA had no
angiographic evidence of CAD. The LAD was proximally 100%
occluded, it
was filled by a patent [**Date Range **]. The [**Date Range **] to D1 with jump to the OM2
was
widely patent with only mild diffuse disease in the proximal
left
subclavian artery. The LCx had a heavily calcified mid-vessel
80%
stenosis just prior to a large OM2. The OM2 had a 70% proximal
stenosis
and a distal 50% stenosis. The distal LCx was occluded and the
distal
vessel including the LPDA filled via left to left collaterals.
The RCA
was non-dominant and was not injected.
2. Hemodynamics revealed severely elevated left and right heart
filling
pressures. There was moderate-severe pulmonary hypertension.
The
cardiac output/index was moderately depressed. There were large
V waves
on the wedge tracing consistent with significant mitral
regurgitation.
3. Left ventriculography was not performed.
4. It proved very difficult to access the left femoral artery
and vein
due to the presence of significant scarring and calcification.
The
artery was progressively dilated with 4, 5 and 6 French dilators
before
the sheath could be introduced. The left femoral artery was
imaged
showing moderate calcification and diffuse disease in the iliac
system.
5. Successful rotational atherectomy, PTCA, and stenting of the
LCX and
OM with a 2.5 x 13 mm Cypher DES, post-dilated with a 3.0 mm
balloon
(LCX) and a 2.0 x 12 mm Minivision (OM).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate mitral regurgitation.
3. Severe diastolic ventricular dysfunction.
4. Moderate systolic ventricular dysfunction.
5. Calcification and scarring of the left femoral artery.
6. Successful PCI of the LCX and OM.
.
EKG post Cath: No significant change compared to pre-cath.
.
Imaging
Liver/Gallbladder U/S [**2183-11-10**]
The gallbladder is markedly distended, contains sludge and has
significant wall thickening. Of note the patient is not locally
tender here. A very limited MRI was performed [**2183-10-27**].
In this study, although a trace amount of pericholecystic fluid
is seen, the gallbladder was not distended on that occasion.
While appearances may represent third spacing with secondary
gallbladder wall thickening, acalculous cholecystitis cannot be
excluded. Correlation with clinical symptoms plus minus HIDA
scan recommended.
.
[**2183-11-12**] Liver or Gallbladder Ultrasound
The liver parenchyma appears unremarkable. Again, there is
evidence of enlargement of the IVC and the intrahepatic and
hepatic veins consistent with congestion, and on Doppler
examination, retrograde flow from reflux can be identified
within these hepatic veins. The main portal vein, anterior and
posterior branches of the right portal vein are all seen and
appear within normal limits. The main hepatic artery is patent.
The patient's gallbladder again is noted to be abnormal,
although it is not as distended as on previous examination and
the degree of edema has lessened when compared to examination
from [**2183-11-10**]. Extensive biliary sludge is again
identified.
CONCLUSION:
The findings are suggestive of right-sided heart dysfunction and
raise possibility of a congestive cause of abnormal LFTs.
Pathology
[**2183-11-28**]
Diagnosis
Stomach ulcer, biopsy:
1. Poorly differentiated adenocarcinoma, signet ring cell type.
There is extension of tumor into the adjacent squamous
epithelium and focal ulcer.
2. Special stains (mucicarmine and PAS-diastase) of the tumor
show rare cells positive for mucin, with satisfactory controls.
Note: The tumor cells have more cytoplasm, compared to the
previous endoscopic biopsy; see addendum to S05-[**Numeric Identifier 92326**]. Dr. [**Last Name (STitle) **].
[**Doctor Last Name **] was provided with a preliminary diagnosis on [**2183-11-20**].
Brief Hospital Course:
The [**Hospital 228**] hospital course was as follows:
.
1. CAD - The patient was admitted to the CMI service for an
elective catheterization after an abnormal stress test. The
catheterization was uncomplicated. The OM2 and LCx were both
found to have critical lesions and were stented with good flow
post stent. The patient received [**Last Name (LF) **], [**First Name3 (LF) **], plavix after
cath. He developed hematemesis x 2 and melenotic stools.
[**First Name3 (LF) 37318**] was stopped but the patient was continued on plavix,
[**First Name3 (LF) **] (just stented); lipitor. Beta-blocker was held.
.
Two days after transfer out of the CCU the patient was started
on lopressor 12.5 because he was having premature atrial
contractions.
.
For the remainder of his course the patient was maintained on
aspirin, statin, plavix and beta-blocker.
.
2. CHF - The patient has an EF of 15%. He received significant
amount of blood transfusions throughout his hospital course and
was in positive fluid balance. For a majority of this hospital
course, the patient complained of SOB and was maintained on O2.
Due to his rising creatinine, he initially received one time
doses of Lasix and was re-assessed. To optimize cardiac
function by reducing afterload, imdur and hydralazine were later
added to the regimen. He was later placed on his home dose of
Lasix. The patient was later weaned off the oxygen and his
dependent edema later improved.
.
3. Rhythm - The patient has a history of paroxysmal atrial
fibrillation but was observed to be in sinus with LBBB on EKG
throughout his hospital course. The patient's Coumadin was held
in the CCU and throughout the rest of his course becuse of his
gastrointestinal bleed.
.
4. Anemia - Post cath, the patient developed hemetemesis and
melena. He was found to have a large HCT drop and was
transferred to the [**Hospital Unit Name 196**] service. He was transfused with 2 units
PRBC and one unit of FFP. His HCT did not show appropriate
response and the patient was transferred to the CCU with
presumed upper GI bleed. Vitals remained stable and the patient
appeared clinically stable. He was started on a PPI IV drip and
HCT was monitored q4. He was seen by the GI service for upper
scope. The scope showed an esophogeal ulcer with associated
friable mucosa with exudate and surrounding erythema. Stomach
cardia showed mass vs blood clot.At that time, GI decided that
given the patient's clinical status and friability of the
lesions, they would biopsy the lesion once the patient was
clinically stable. Pt received another 2 units PRBC in the CCU
with suboptimal HCT response. He received another unit PRBC and
his HCT bumped to over 30 and remained stable. The patient was
transferred to the [**Hospital Unit Name 196**] service with the plan to cont with blood
tx as needed and monitor HCT. At this point, the patient had had
only one melenotic stool over 12 hours and had not had repeat
hemetemesis.
.
Once transferred to the floors, the patient received 1 PRBCs.
For a total of 6 six his admission. His hematocrit hovered in
the low 30s. His melena tapered off.
.
5. UGIB bleed- The patient was seen by GI and had an EGD in the
unit. The EGD showed a small mass ? malignancy and an
ulcerating lesion. Epi and cauterization were used, however a
biopsy was not taken at this time. The patient had a repeat EGD
once he was clinically stable. Per GI Reccs: the patient was
kept on a PPI, Coumadin was held, his diet was advanced and his
HCT was kept above 30.
.
6. Coagulopathy/Shock Liver- In preparation for the repeat
endoscopy by GI, the patient's coags were monitored. Despite
not being on Coumadin or heparin and receiving Vitamin K
multiple times, patient's INR remained elevated. Transaminases
were found to be elevated (AST [**2178**], ALT 1800s). Acetaminophen
was held and a level was checked and was negative. Patient's
coagulopathy was attributed to his shock liver. His shock liver
was attributed to hepatic congestion secondary to congestive
heart failure. On U/S there was enlargement of the IVC,
intrahepatic and hepatic veins consistent with congestion. The
train of thought at this point was that right sided heart
failure had contributed to the congestive changes seen in the
liver. A HIDA scan was done which showed delay kinetics
suggestive of cholecystitis. With continued management of the
patient's congestive heart failure his transaminases improved
and coagulopathy resolved.
.
There was also concern that the patient's use of Acetaminophen
extra strength for several months prior to admission and use of
Acetaminophen during his hospital course to control his GI pain
may have also contributed to his shock liver. But the primary
etiology was thought to be his congestive heart failure.
.
7. Acute on chronic renal insufficiency - Due to patient's
elevating creatinine, renal was consulted. They attributed his
acute renal insufficiency to prerenal physiology due to low EF
and lasix. Per their reccs, Imdur and Hydralazine were added to
reduced afterload and improve forward flow. In the setting of
renal insufficiency, phosphate was also elevated. Renagel was
therefore also given. At the time of discharge, the patient's
creatine was near baseline.
.
8. Adenocarcinoma- Biopsy of the stomach ulcer was consistent
with adenocarcinoma. The patient was seen by Heme/Onc and
followup for further management was scheduled as an outpatient.
.
9. Hypernatremia - While in the CCU, the patient developed mild
hypernatremia for which he was encouraged to take PO
medications.
.
10. Dispo- At the time of discharge the [**Hospital 228**] medical issues
were stable. He had close followup scheduled with his PCP,
[**Name10 (NameIs) 2085**] and with Heme/Onc. The patient was discharged with
the instructions to continue taking his medications as
prescribed, not to take Acetaminophen (he was given a bottle of
and precription for Maalox/ Diphenhydramine/Lidocaine)to return
to the hospital if any worrisome symptoms should arise and to
followup with his physicians.
Medications on Admission:
1. lasix 60 mg PO Qday
2. Losartan 25 mg Qday
3. [**Name10 (NameIs) **] 325 Qday
4. lipitor 10 mg Qday
5. carvedilol 3.125 mg Qday
6. Plavix 75 mg Qday
7. finesteride 5 mg Qday
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Coreg 3.125 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Colace 50 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
10. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO twice
a day: This medication may darken your stools.
Disp:*60 Tablet(s)* Refills:*2*
Of note the patient was also given a prescription for
maalox/diphenhydramine/lidocaine mix. He was also given a
bottle to take home.
Discharge Disposition:
Home
Discharge Diagnosis:
S/P stent placement and Upper GI bleeding
Discharge Condition:
Good
VS T96.8 (oral, HR 63-82, BP 100-106/55-70, R20, 02sat 95-985RA
Discharge Instructions:
You are to return to the hospital immediately if you should
experience any chest pain, shortness of breath or any other
worrisome symptom.
.
Please take your medications as prescribed. Please note that
you were previously taking lipitor but this medication has been
held due to your elevated liver enzymes.
.
You are being discharged on the following medications:
nitroglycerin, aspirin, clopidogrel, folic acid, lasix, coreg,
cozaar, proscar, colace (stool softener), and ferrous gluconate.
Followup Instructions:
Your PET scan is scheduled for [**12-10**] at 10:30AM.
Please see your instruction book for preparation prior to
testing.
.
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY THORACIC UNIT-CC9
Date/Time:[**2183-12-11**] 10:30.
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 5566**] [**Name Initial (NameIs) **]. HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2183-12-11**] 10:30
.
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTISPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Date/Time:[**2183-12-11**] 11:30
Completed by:[**2183-12-21**]
ICD9 Codes: 4240, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6192
} | Medical Text: Admission Date: [**2138-3-29**] Discharge Date: [**2138-4-11**]
Date of Birth: [**2111-9-19**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 3963**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Sinus polyp biopsy, sinus wash and culture
History of Present Illness:
History of Present Illness:
.
26 yo man D +278 after single cord transplant for hypoplastic
MDS with h/o persistent pancytopenia thought to be [**3-20**]
myelosuppression from CMV + antivirals who is now admitted for
sepsis.
.
Patient was first diagnosed with with MDS in Fall [**2136**] when he
presented with pancytopenia. Initial MDS course was complicated
by mucor infection of the tongue with prolonged ICU course for
upper airway obsturuction, followed by pericoronitis as well as
perirectal abcess. Was subsequently managed with a single cord
transplant on [**2137-6-24**] with reduced intensity Flu/MEL/ATG
conditioning. Post transplant course c/b VRE + Coag neg staph
bacteremia [**6-/2137**] (treated with dapsone); CMV viremia [**7-/2137**],
c.diff infection [**10/2137**] (treated with 14 days oral vanc),
admission on [**10/2137**] for low grade temperature attributed to +CMV
viremia with prolonged IV ganciclovir --> oral Valgancyclovir
course; last admission 10/4-6 for neutropenic fever, CT chest
showed non specific minimal peribronchial ground-glass opacity
in the left lower lobe, treated with course of levofloxacine;
Saw ID [**12-12**] Valgancyclovir was stopped as CMV viral loads
remained negative since [**10-22**], was started on valacyclovir for
HSV/VZV PPx. He also continues oral Posiconazole for mucor and
monthly pentamidine nebs for PCP [**Name Initial (PRE) **] (most recent [**12-28**]).
.
Patient had > 97% donor on chimerism on peripheral blood from
[**2137-10-17**]. He has been intermitently leukopenic and neutropenic
throughout his illness with especially low white counts
generally ranging around 1000-3000 during the past 2 months.
This has been attributed to possible BM supression by CMV and/or
antiviral meds. Thrombocytopenia has been continous throughout
his illness and latley stable at ~ 25,000. Hct generally in the
high teens to low twenties. He also had had a stable
transaminitis for months which is attributed to drug effect +/-
hemochromatosis. Finally he is thought to be at low risk for GVH
and thus stopped immunosupressive meds in [**2137-9-16**] (was on
tacrolimus prior). Last neupogen was given on [**2138-3-27**].
.
Over the past several months, he has had recurrent PNAs and has
been followed in pulmonary clinic. In [**Month (only) 404**] he was found to
have fever and neutropenia and worsening tree-in-[**Male First Name (un) 239**] opacities,
particularly in
the left side. He was treated with meropenem, azithromycin and
oseltamivir. Repeat CT chest on [**3-4**] showed some resolution and
he was most recently seen in pulm clinic on [**2138-3-20**]. During this
visit he was in the midst of being treated for another pulm
infection with moxifloxacin.
.
Today pt called clinic because he reported feelings of malaise
and nausea and noted that he had a low grade fever. He went to
clinic and was found to have a fever of 103, Bp in 80's
systolic, HR of 140. He was started on meropenem and vancomycin
and started on maintenance fluids at 150cc/hr. WBC were 4.1
with 80%N.
Past Medical History:
-Hypoplastic MDS (deletion 7q and 13) - single cord transplant
on [**2137-6-24**] with reduced intensity Flu/MEL/ATG.
-Last chemo: Tacrolimus [**2138-10-5**], which was stopped after
clinical suspicion of GVH decreased
- Oral Mucor infection [**2136**]: infiltration into base of the
tongue with bleeding requiring intubation and IR guided ablation
of bleeding lingual artery. s/p excision by ENT. Complicated
hospital course involving multiple ICU stays for post-operative
laryngeal edema following intubation.
- C. difficile infection [**10/2136**]
- pericoronitis s/p extraction 4 teeth [**2137-1-24**]
- peri-rectal abscess s/p drainage [**2137-2-27**]
- Hemochromatosis
- Transaminitis (felt most likely multifactorial; contributions
by medications and hemochromatosis)
Social History:
-Moved from [**Country **] in [**2136**].
-lives with sister, brother-in-law, and their 2 children.
-He has no pet exposures.
-previously worked in warehouse packing boxes, has not worked
since [**35**]/[**2136**]. He has a history of working for an oil company in
[**Country **], though per reports worked mainly in office and had
only occasional exposure to factory environment.
-No significant tobacco history.
-Occasional alcohol use
-No illicit drug.
Family History:
Father died at age 73, per reports had "illness" and progressive
weakness. Mother died of stroke at age 60. No known family
history of cancer or bleeding disorders. Has 6 siblings who are
healthy.
Physical Exam:
Vitals: T:100.6 BP:95/60 P:104 R:20 O2: 98%
General: Alert, oriented, no acute distress, flat affect
HEENT: Sclera anicteric, PERRLA, MMM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, some basilar crackles
which clear with cough, no wheezes or 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
Neuro: no focal deficits, motor [**6-21**] throughout, CNII-XII normal.
Pertinent Results:
[**2138-3-29**] 03:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2138-3-29**] 03:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2138-3-29**] 03:35PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2138-3-29**] 10:15AM GLUCOSE-116* UREA N-14 CREAT-1.0 SODIUM-133
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-22 ANION GAP-14
[**2138-3-29**] 10:15AM estGFR-Using this
[**2138-3-29**] 10:15AM ALT(SGPT)-39 AST(SGOT)-62* LD(LDH)-319* ALK
PHOS-147* TOT BILI-0.6
[**2138-3-29**] 10:15AM ALBUMIN-4.1 CALCIUM-8.5 PHOSPHATE-3.1
MAGNESIUM-2.1
[**2138-3-29**] 10:15AM WBC-4.5# RBC-2.14* HGB-7.7* HCT-22.4*
MCV-104* MCH-35.9* MCHC-34.4 RDW-19.1*
[**2138-3-29**] 10:15AM NEUTS-80* BANDS-1 LYMPHS-14* MONOS-4 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-3*
[**2138-3-29**] 10:15AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
[**2138-3-29**] 10:15AM PLT SMR-VERY LOW PLT COUNT-21*
[**2138-4-3**] 04:08AM BLOOD WBC-2.8* RBC-2.14* Hgb-7.7* Hct-21.1*
MCV-99* MCH-36.2* MCHC-36.7* RDW-20.5* Plt Ct-43*#
[**2138-4-5**] 11:00AM BLOOD WBC-1.2*# RBC-1.98* Hgb-6.6* Hct-19.6*
MCV-99* MCH-33.2* MCHC-33.6 RDW-20.0* Plt Ct-26*
[**2138-4-8**] 11:00AM BLOOD WBC-6.0# RBC-2.76*# Hgb-9.4*# Hct-26.9*#
MCV-97 MCH-33.9* MCHC-34.8 RDW-18.9* Plt Ct-12*#
[**2138-4-11**] 05:32AM BLOOD WBC-2.0*# RBC-2.58* Hgb-8.8* Hct-25.4*
MCV-98 MCH-34.0* MCHC-34.6 RDW-19.1* Plt Ct-17*
[**2138-4-11**] 05:32AM BLOOD Neuts-42* Bands-0 Lymphs-25 Monos-30*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-1*
[**2138-3-30**] 09:20AM BLOOD Gran Ct-1206*
[**2138-3-31**] 03:44PM BLOOD Gran Ct-1533*
[**2138-4-1**] 09:45AM BLOOD Gran Ct-2378
[**2138-4-2**] 04:08PM BLOOD Gran Ct-[**2101**]*
[**2138-4-5**] 11:00AM BLOOD Gran Ct-492*
[**2138-4-8**] 11:00AM BLOOD Gran Ct-4800
[**2138-4-11**] 05:32AM BLOOD Gran Ct-860*
[**2138-4-11**] 05:32AM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-134
K-4.1 Cl-101 HCO3-23 AnGap-14
[**2138-4-3**] 04:08AM BLOOD ALT-36 AST-61* LD(LDH)-294* AlkPhos-136*
TotBili-0.5
[**2138-4-5**] 11:00AM BLOOD ALT-42* AST-76* LD(LDH)-262* AlkPhos-151*
TotBili-0.5
[**2138-4-8**] 11:00AM BLOOD ALT-48* AST-89* LD(LDH)-365* AlkPhos-162*
TotBili-0.6
[**2138-4-11**] 05:32AM BLOOD ALT-43* AST-79* LD(LDH)-296* AlkPhos-149*
TotBili-0.6
[**2138-4-11**] 05:32AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
[**2138-4-8**] 11:00AM BLOOD POSACONAZOLE-PND
[**2138-4-2**] 04:08PM BLOOD ADENOVIRUS PCR-Test Name
.
.
.
Blood cx [**2138-3-29**] - [**2138-4-3**]: No Growth
Sinus Aspirate x4 [**2138-4-2**]: no growth on bacteria/fungal cx
Resp Viral Swab: neg
Stool C.Diff negative x 2
Urine Cx: negative
CMV viral load: not detected
.
MRI Head/Sinus
IMPRESSION:
1. No evidence of intracranial, orbital, or dural extension.
2. Extensive opacification of all the sinuses with mucosal
thickening,
air-fluid levels, loculated air within the fluid collections,
and chronic
inflammatory changes. No bony destruction is visualized.
.
.
CT SINUS
IMPRESSION:
Extensive paranasal sinus disease with active secretions,
suggestive of acute
infection. The above findings appear significantly progressed
from [**2138-2-20**]
exam.
.
DIAGNOSIS:
.
R Middle Inferior Turbinate
Polypoid lesion, right inferior middle turbinate, biopsy:
- Polypoid fragments of sinonasal respiratory mucosa
with focal acute (neutrophilic) and chronic inflammation and
surface erosion.
- No definitive fungal organisms seen; see note.
Note: Special stains (PAS, PAS with Diastase, and GMS stains)
are negative for fungal organisms. Dr. [**Last Name (STitle) **]. Sepehr reviewed
frozen, permanent section, and special stain slides and concurs.
Drs. [**First Name (STitle) **] and [**Name5 (PTitle) **] were notified via emails on [**2138-4-3**]
at 5pm.
Clinical: History of oral mucormycosis, now with sinusitis,
polypoid tissue at inferior right middle turbinate.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known lastname **], [**Known firstname 87416**]" and the medical record number. It consists of
fragments of tan pink soft tissue, measuring 0.9 x 0.8 x 0.2 cm
in aggregate. The specimen is submitted entirely for frozen
section evaluation. The frozen section diagnosis by Dr. [**Last Name (STitle) **].
Sepher is "Angioinvasive fungal elements, highly suspicious for
mucormycosis." The frozen section remnant is entirely submitted
in cassette A.
.
DISCHARGE
[**2138-4-11**] 05:32AM BLOOD WBC-2.0*# RBC-2.58* Hgb-8.8* Hct-25.4*
MCV-98 MCH-34.0* MCHC-34.6 RDW-19.1* Plt Ct-17*
[**2138-4-11**] 05:32AM BLOOD Neuts-42* Bands-0 Lymphs-25 Monos-30*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-1*
[**2138-4-11**] 05:32AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+
Ellipto-1+
[**2138-4-11**] 05:32AM BLOOD Plt Smr-RARE Plt Ct-17*
[**2138-4-11**] 05:32AM BLOOD Gran Ct-860*
[**2138-4-11**] 05:32AM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-134
K-4.1 Cl-101 HCO3-23 AnGap-14
[**2138-4-11**] 05:32AM BLOOD ALT-43* AST-79* LD(LDH)-296* AlkPhos-149*
TotBili-0.6
[**2138-4-11**] 05:32AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
Brief Hospital Course:
26 yo man s/p single cord transplant ([**6-/2137**]) for hypoplastic
MDS c/b mucormycosis, CMV infection, c.diff and VRE bacteremia,
with persistent pancytopenia likely [**3-20**] myelosuppression from
CMV + antivirals, recently with recurrent PNA now admitted from
clinic with sepsis.
.
# Sinusitis/Sepsis: On admission, per SIRS criteria (fever of
103 and HR in 140s in clinic) pt met SIRS criteria. He was
hypotensive initially in clinic, but has been responsive to
fluids with BP stable in 110s systolic at time of admission.
All culture data (including sinus aspirates, blood, urine, NP
swab) was negative. The only obvious source of infection was
sinuses. CT and MR sinuses showed diffuse acute sinusitis. To
gather microbiological source, nasal swab was attained by our
colleagues in ENT, which was negative. Due to pt's history of
invasive mucormycotic infection without negative margins and pt
being on suppressive doses of posaconazole, more invasive
culture/biopsy data was pursued. Due to pt's request for
sedation, repeat ENT was done under conscious sedation in the
[**Hospital Unit Name 153**]. Four sinus aspirates and biopsy of polypoid lesion were
collected during ENT exam. The polypoid lesion was sent for
frozen path, and preliminary read came back positive for
invasive fungal infection. Before pt could be brought to OR for
debridement of this area, the final path report came back
revealing that the invasive fungal read was actually artifact
from frozen section. All fungal markers and stains were
negative, and final path was negative for fungal infection. Pt
was continued on IV broad spectrum antibiotics (dapto and [**Last Name (un) 2830**])
and posaconazole and ultimately transitioned to flagyl and
levaquin. He will continue these medications for a total of 3
weeks from day after ENT biopsy.
.
#Epistaxis: on day after ENT procedure, pt removed packing from
nose despite numerous warnings by staff not to take it out. He
was given afrin and started on amicar drip. ENT re-evaluated
pt, but he would not allow them to repack nose. Over the course
of the day, the bx site clotted and bleeding resolved. Amicar
was stopped.
.
# MDS, s/p BMT. Pt's valcyte dose was decreased to ppx dosing
at 900mg daily given negative CMV viral load. He was transfused
with platelets and PRBCs on numerous occasions during
hospitalization.
.
# transaminitis: stable. thought to be [**3-20**] to med effect or
hemochromatosis.
.
TRANSITIONAL:
- follow up in [**Hospital 3242**] clinic and in BMT [**Hospital **] clinic in 4 weeks
- continue levofloxacin and flagyl for three weeks from [**2138-4-3**]
Medications on Admission:
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
PENTAMIDINE [NEBUPENT] - (Prescribed by Other Provider) - 300 mg
Recon Soln - 300 mg inh once per month diluted in 6mg sterile
water; please give albuterol inhaler, 2 puffs, pre inhalation
POSACONAZOLE [NOXAFIL] - 200 mg/5 mL (40 mg/mL) Suspension - 10
ml Suspension(s) by mouth twice daily for 400 mg twice daily
URSODIOL - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] nam; Dose
adjustment - no new Rx) - 300 mg Capsule - 1 Capsule(s) by mouth
twice a day
VALACYCLOVIR - 1,000 mg Tablet - 1 Tablet(s) by mouth daily
Medications - OTC
MULTIVITAMIN [DAILY MULTIPLE] - Tablet - 1 Tablet(s) by mouth
once a day
Discharge Medications:
1. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
2. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
3. posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: Ten (10)
mL PO Q12H (every 12 hours).
4. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 14 days: until [**2138-4-24**].
Disp:*14 Tablet(s)* Refills:*0*
5. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days: last day [**2138-4-24**].
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Sinusitis
hypoplastic MDS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to hospital for sinusitis. We were concerned
that you might have an invasive fungal infection and had ENT
surgery take a biopsy from your sinus. There was no evidence of
fungal infection on your biopsy. We treated you with IV
antibiotics and transitioned you to oral antibiotic therapy. We
believe that you are now safe to home.
.
The following changes to your medications have been made:
1. Start Flagyl (metronidazole) 500mg by mouth every 8 hours
until [**2138-4-24**]
2. Start Levaquin 500mg by mouth every 24 hours until [**2138-4-24**]
3. change valgancyclovir to 900mg once daily
.
Please continue the rest of your home medications
Followup Instructions:
Department: BMT/ONCOLOGY UNIT
When: TUESDAY [**2138-4-15**] at 1 PM [**Telephone/Fax (1) 447**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2138-4-15**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2138-4-15**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY Infectious disease clinic
When: [**2138-4-30**] 01:30p
With: Dr. [**Last Name (STitle) 724**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 0389, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6193
} | Medical Text: Admission Date: [**2116-12-27**] Discharge Date: [**2117-2-8**]
Date of Birth: [**2049-3-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
woman who has a past history of uncontrolled hypertension who
was babys[**Name (NI) 12854**] her grandchildren on the day of admission
when she started having a headache around 10 PM. At that
time she spoke with her son-in-law and told him that she felt
sick. A family friend was [**Name (NI) 653**] who went over to check
on her, at that point she was found unresponsive. She was
brought to an outside hospital still unresponsive, she was
intubated and was hypertensive with a systolic blood pressure
of 225/102, was given 20 mg of Labetalol and transferred to
[**Hospital1 69**] via [**Location (un) **].
PAST MEDICAL HISTORY: Uncontrolled hypertension.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient speaks French Creole. She was
on a visit from [**Country 2045**] visiting her daughter who lives here.
Her daughter has been her sole source of support for the last
several years. The patient has not worked in over two years.
The patient does not smoke tobacco, use alcohol or use
intravenous drugs.
FAMILY HISTORY: Unknown.
PHYSICAL EXAMINATION: At the time of admission the patient
was intubated with a blood pressure of 166/80, with a heart
rate of 100. Head, eyes, ears, nose and throat exam is
normocephalic, atraumatic. Cardiac exam was regular rate and
rhythm with a systolic ejection murmur. Lungs were clear to
auscultation bilaterally. Abdomen was soft, nontender,
nondistended. Extremities without edema. Neurologically she
was intubated and sedated. Grimacing only to pain. Cranial
nerves: Pupils were 1.5 mm bilateral and reactive. Corneal
reflexes were depressed. She had a left facial droop. On
motor exam she had no spontaneous movement, she withdrew to
pain on the right. Had a flaccid left upper extremity.
Reflexes were decreased on the left and 2+ on the right. She
had bilateral extensor plantar responses.
HISTORY OF HOSPITAL COURSE: The patient is a 67-year-old
Hatian wound with a history of uncontrolled hypertension who
presented after having a headache and was found unresponsive,
sent to [**Hospital1 69**] after
intubation. She had a head CT which showed a large right
thalamic bleed with intraventricular blood and right lateral
ventricle enlargement. Her INR on admission was 1.1. The
patient was on no medications.
She initially went to the Neurological Intensive Care Unit
where she stayed for approximately one month. Her hospital
course there was complicated by uncontrolled blood pressures
which could not be adequately controlled by medication. She
also continued to have low grade fevers. She developed
hydrocephalus and had a ventricular drain placed which was
left in place for approximately three weeks and then removed.
She was on multiple different antibiotics during that time
including Oxacillin and Zosyn for pseudomonas pneumonia and
Oxacillin because of her ventricular drain. She had multiple
blood cultures which showed no evidence of growth. She did
not have any blood cultures drawn prior to the initiation of
antibiotics. She continued to have unexplained fevers and on
exam continued to have a large systolic ejection murmur. She
developed punctate hemorrhages in her nailbeds and had an
echocardiogram which showed evidence of a vegetation on the
mitral valve. She was started on Vancomycin and Ceftriaxone
for endocarditis. She had Infectious Disease consult and
cardiology consult which also felt that her exam and
presentation were consistent with endocarditis.
She was continued on a course of Ceftriaxone and Vancomycin
for six weeks. The patient remained with decreased mental
status however, after extubation she would open her eyes
spontaneously. She had a right gaze preference and her left
upper extremity remained flaccid. She did move her left
lower extremity spontaneously. The patient was able to speak
a few words in French Creole her native language.
After she was transferred to the floor she had a percutaneous
endoscopic gastrostomy tube placed. Several days later she
developed some abdominal tenderness. She had a CT of the
torso which showed no evidence of intraabdominal abscess.
Her tube feeds were restarted and she eventually became
afebrile. The patient remained with waxing and [**Doctor Last Name 688**] mental
status. An EEG was performed which just showed diffuse
slowing consistent with encephalopathy. However, later she
was observed to have some small focal motor seizures of her
left face. She was started on Keppra. Her Keppra was
gradually increased and her mental status improved. She was
also started on Provigil to keep her more alert and able to
participate with Occupational Therapy and Physical therapy.
The patient's exam stabilized over the next month. She
continued to be more alert. Able to deny having pain. Able
to show two fingers and interact slightly with the examiner
however, her left lower extremity remained flaccid. As of
[**2-8**] she remained in this condition. She remained
in the hospital due to her lack of insurance and lack of
citizenship and she will be continued on intravenous
antibiotics for her endocarditis until [**2-18**] at which time
they can be discontinued.
This is a summary of her hospital course to date and a
dictation summary addendum will be added at the time of her
eventual discharge.
DR.[**Last Name (STitle) 726**],[**First Name3 (LF) 725**] 13-268
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2117-2-8**] 16:17
T: [**2117-2-8**] 16:21
JOB#: [**Job Number 14792**]
ICD9 Codes: 431, 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6194
} | Medical Text: Admission Date: [**2183-7-16**] Discharge Date: [**2183-7-19**]
Date of Birth: [**2123-10-19**] Sex: M
Service: MICU/[**Hospital1 212**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old
male with a history of diabetes mellitus type 2, end-stage
renal disease, status post failed renal transplant now on
hemodialysis and hypertension admitted to the MICU for
hypotension and mental status changes. The patient was
scheduled for hemodialysis on the day of admission and he
reportedly was too weak to go to his car and had unclear
speech. He was brought to the Emergency Room by EMS. In the
field, the patient's blood pressure was 102/42, heart rate
100 with a blood sugar in the 190s. On arrival to the [**Hospital3 **], the patient's blood pressure was 58/24, heart rate
90. The patient was afebrile. He was noted to be agitated.
The patient, of note, reports having liquid stools and bouts
of diarrhea increased over the past two weeks with one
episode of vomiting. Initially, the patient had been given 4
liters normal saline and started on dopamine as well as 100
mg of hydrocortisone.
Upon arrival to the MICU, the patient's mental status had
improved and he had been able to give a good history and had
reported these episodes of increased diarrhea, denied any
blood in his stools, although he has had several weeks of
increased diarrhea.
PAST MEDICAL HISTORY:
1. End-stage renal disease, status post renal transplant in
[**2176**], currently on hemodialysis. He had the kidney removed
from the renal transplant in [**2183-4-12**].
2. Diabetes mellitus type 2.
3. Hypertension.
4. Anemia of chronic disease.
5. History of multiple GI bleeds secondary to gastritis,
AVMs, and [**Doctor First Name **]-[**Doctor Last Name **] tear in [**2172**].
6. History of blindness.
7. Gastroparesis.
8. Neuropathy.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Metoprolol.
3. Insulin 20 units of 70/30 in the morning.
4. Procrit.
5. Nephrocaps.
6. Tums t.i.d. with meals.
7. Prednisone 5 mg p.o. q.d.
SOCIAL HISTORY: No tobacco or alcohol. He is a retired
nurse 16 years ago. He lives with his wife.
FAMILY HISTORY: Notable for diabetes.
PHYSICAL EXAMINATION UPON ARRIVAL TO THE MICU: General: The
patient was alert, lethargic appearing. Vital signs:
Temperature 97.6, heart rate 109, blood pressure 139/58,
saturating 100%. HEENT: Normocephalic, atraumatic. The
mucous membranes were slightly dry. The sclerae were
anicteric. Neck: Supple. Lungs: Clear to auscultation
bilaterally. Heart: Regular rate and rhythm, tachycardiac
with a III/VI systolic murmur. Abdomen: With good bowel
sounds, soft, nontender. Surgical site was healed.
Extremities: No edema, no calf tenderness. No open wounds.
Left forearm fistula was with a thrill. No asterixis.
Neurologic: Cranial nerves II through XII were intact.
Strength: [**6-16**] in all extremities except for the left hand
and the patient reports having prior surgery there and this
is an old weakness. The patient was alert to [**Hospital1 18**], [**2183-7-13**], and date, able to spell world backwards.
LABORATORY/RADIOLOGIC DATA: The patient's white count was
17.9, hematocrit 39.8, platelets 235,000. PT 1.1.
Chemistries on admission: Sodium 143, potassium 3.7,
chloride 107, BUN 31, creatinine 7.5, glucose 164. Amylase
90, lipase 26.
HOSPITAL COURSE: The patient is a 59-year-old male with a
history of diabetes mellitus, end-stage renal disease, on
hemodialysis, and a history of multiple GI bleeds presenting
after feeling dizzy and weak, noted to have hypotension.
1. HYPOTENSION: The [**Hospital 228**] hospital course on admission
in the field had been noted for systolic blood pressures in
the 50s to 60s. Upon arrival here, the patient had received
pressors for treatment as well as multiple liters of fluid.
The etiology of the patient's hypotension/shock is most
likely secondary to sepsis versus hypovolemia. With regards
to a sepsis workup, the patient was initially started on
vancomycin and Flagyl. His blood cultures had been negative
upon the time of discharge times 72 hours. During the
hospital course, he had been afebrile.
Other etiologies regarding the patient's hypotension and
shock may have been secondary to hypovolemic shock as the
patient had significant improvement with fluids. The patient
had been initially weaned from pressors after approximately
one day during the hospital MICU stay. Other etiologies of
the patient's shock may have included a history of adrenal
insufficiency. The patient has had a renal transplant in the
past and had been on steroids for suppression. After the
transplant had been removed, he had been tried on a
prednisone taper, although per report had been told to
continue with 5 mg of prednisone for the time being. He
initially had been started on hydrocortisone and Florinef
during the MICU course. The patient's infectious workup had
been negative since the patient had been treated and had been
having multiple days of diarrhea, he had recent stool
cultures. The stool cultures were negative to date. Of
note, the C. dif was also negative.
Other workup for the patient's hypotension included abdominal
CT and chest CT. This showed that there was no evidence of
aortic dissection or pulmonary embolus. No pneumonia. No
intra-abdominal abscess. No evidence of ischemic bowel.
3. NEUROLOGY: The patient initially presented with
confusion per report upon admission. However, upon arrival
to the MICU, the patient had been alert and oriented times
three and had been able to give a good history. He had a
head CT which had been negative for hemorrhage.
4. RENAL: The patient was continued on hemodialysis
throughout this hospital course.
Otherwise with regards to the patient's symptoms, he was
initially started on hydrocortisone in the Emergency Room.
He will be sent home on the steroid taper as the patient is
on baseline 5 mg of prednisone per day. Also of note, during
his hospital course, he reported that he wanted to leave,
although we had recommended keeping the patient in-house for
an extra day or to and the patient signed out against medical
advise. He was recommended to call or return if he has any
symptoms of lightheadedness or dizziness, increased nausea,
vomiting, or diarrhea. He also was sent home on an empiric
course of Flagyl as well as a steroid taper. The empiric
course of Flagyl was possible C. dif.
DISCHARGE DIAGNOSIS:
1. Hypovolemic shock.
2. Chronic renal failure.
3. Diabetes mellitus type 2.
4. History of anemia.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Nephrocaps one p.o. q.d.
3. Calcium carbonate 500 mg p.o. t.i.d. with meals.
4. Metoprolol q.d.
5. Flagyl 500 mg p.o. t.i.d. times 14 days.
6. Prednisone taper starting at 30 mg as directed to be
tapered down to a home dose of 5 mg.
FOLLOW-UP: The patient is to continue to follow-up with
Dialysis on q. Monday, Wednesday, and Friday and he was also
advised if needed to follow-up if his diarrhea persisted,
follow-up with Gastroenterology.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15234**]
Dictated By:[**Last Name (NamePattern1) 25348**]
MEDQUIST36
D: [**2183-7-21**] 02:42
T: [**2183-7-24**] 21:56
JOB#: [**Job Number 26610**]
ICD9 Codes: 2765, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6195
} | Medical Text: Admission Date: [**2160-5-18**] Discharge Date: [**2160-5-29**]
Date of Birth: [**2088-6-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
tibial plateau fracture, [**First Name3 (LF) 8813**] stenosis
Major Surgical or Invasive Procedure:
[**2160-5-23**]
1. [**Month/Day/Year **] valve replacement with a 23-mm Biocor Epic tissue
valve.
2. Coronary artery bypass grafting x2: Left internal
mammary artery graft to left anterior descending;
reverse saphenous vein graft to diagonal branch.
History of Present Illness:
71 year old woman with a medical history of A-fib on coumadin
and sotalol and [**Month/Day/Year 8813**] stenosis. She was told by a doctor
(presumably her cardiologist or cardiac surgeon) that she needed
to have her [**Month/Day/Year 8813**] valve replaced. She
was told this two months ago and because she is scared of the
surgery has not scheduled a date for the surgery. She was
walking and stepped on her left foot oddly, this caused her to
stumble and fall on her left knee. Her daugher who lives with
her was able to help her up and bring her to the ED at [**Hospital 39437**]. She is unable to walk across the room without getting
short of breath. She does not get shortness of breath at rest,
but consistently becomes short of breath with minimal exertion.
She is now being referred to cardiac surgery for evaluation of
an [**Hospital 8813**] vavle repelacment.
Past Medical History:
[**Hospital **] Stenosis
Coronary Artery Disease
PMH:
A-fib
Hypertension
Hyperlipidemia
[**Hospital **] Valve stenosis
Mitral Valve problem
Hypothyroidism
Past Surgical History:
s/p Left ankle fracture 10 years ago repaired with "10 screws
and
a bar"
s/p Surgery for PUD causing gastric outlet obstruction
s/p Tonsillectomy as child
Social History:
No Tob ever
No EtOH
No illicits
Patient lives with daughter and granddaughter
Family History:
Obesity
Heart problems, pt not sure what kind
Half sister had [**Hospital 8813**] valve repalcement at the age of 43
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
Admission:
VS: afebrile 87/62 145 96% RA
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: difficult to assess due to body habitus.
CARDIAC: RR, normal S1, soft S2, 3/6 systolic murmur
crescendo-decrescendo heard throughout precordium, No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles at bases
bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2160-5-28**] 04:13AM BLOOD WBC-8.9 RBC-3.18* Hgb-10.0* Hct-28.9*
MCV-91 MCH-31.4 MCHC-34.7 RDW-17.0* Plt Ct-220
[**2160-5-27**] 07:48AM BLOOD Hct-24.0*
[**2160-5-27**] 04:43AM BLOOD WBC-9.7 RBC-2.57* Hgb-8.4* Hct-23.8*
MCV-93 MCH-32.6* MCHC-35.2* RDW-16.4* Plt Ct-196
[**2160-5-29**] 06:08AM BLOOD PT-26.6* INR(PT)-2.5*
[**2160-5-28**] 04:13AM BLOOD PT-17.9* INR(PT)-1.6*
[**2160-5-27**] 04:43AM BLOOD PT-14.9* INR(PT)-1.3*
[**2160-5-26**] 05:55AM BLOOD PT-14.0* INR(PT)-1.2*
[**2160-5-25**] 12:59PM BLOOD PT-14.2* INR(PT)-1.2*
[**2160-5-24**] 01:36AM BLOOD PT-14.6* PTT-27.1 INR(PT)-1.3*
[**2160-5-23**] 04:00PM BLOOD PT-15.6* PTT-35.2* INR(PT)-1.4*
[**2160-5-23**] 02:05PM BLOOD PT-15.9* PTT-32.7 INR(PT)-1.4*
[**2160-5-23**] 07:05AM BLOOD PT-14.6* PTT-67.7* INR(PT)-1.3*
[**2160-5-22**] 02:50AM BLOOD PT-13.5* PTT-50.5* INR(PT)-1.2*
[**2160-5-21**] 07:30AM BLOOD PT-15.3* PTT-71.6* INR(PT)-1.3*
[**2160-5-28**] 04:13AM BLOOD Glucose-109* UreaN-27* Creat-0.8 Na-133
K-4.2 Cl-95* HCO3-34* AnGap-8
[**2160-5-27**] 04:43AM BLOOD Glucose-124* UreaN-29* Creat-0.8 Na-131*
K-4.4 Cl-94* HCO3-31 AnGap-10
CT L Lower ext [**2160-5-18**]:
FINDINGS: There is a comminuted slightly depressed fracture of
the left
tibial plateau which involves the articular surface. The largest
fracture
fragment involves the medial tibial plateau with 4 mm lateral
displacement of the distal tibia. A large anterior fracture
fragment arising from the lateral tibial plateau also
demonstrates slight displacement. Finally, there is a comminuted
fracture of the lateral aspect of the proximal fibula. There is
no evidence of femoral or patellar fracture. Bones are
demineralized. There is a large lipohemarthrosis in the
suprapatellar region and a small [**Hospital Ward Name 4675**] cyst. There is soft
tissue edema. There is atrophy of the muscles, particularly the
semimembranosis. The remainder of the soft tissues are normal.
IMPRESSION: Comminuted tibial and fibular fractures as above.
TTE [**2160-5-19**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>65%). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The [**Month/Day/Year 8813**] valve leaflets (?#) are moderately
thickened. There is severe [**Month/Day/Year 8813**] valve stenosis. Mild to
moderate ([**2-17**]+) [**Month/Day (2) 8813**] regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is a minimally increased
gradient consistent with trivial mitral stenosis. Moderate to
severe (3+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate to severe
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and normal
regional excellent global systolic function. Severe [**Month/Day (2) 8813**] valve
stenosis. At least moderate to severe mitral regurgitation.
Pulmonary artery systolic hypertension. Dilated ascending aorta.
Cardiac cath [**2160-5-20**]:
1. Selective coronary angiography of this left-dominant system
demonstrated 1 vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting disease. The LAD had
80%
mid-vessel stenosis and there was 70% stenosis at the origin of
a large
diagonal. The LCx had no significant disease. The RCA had 50%
mid-vessel stenosis in a non-dominant vessel.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures.
Intra-op TEE [**2160-5-23**]
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
[**Month/Day/Year 8813**] valve leaflets are severely thickened/deformed. There is
critical [**Month/Day/Year 8813**] valve stenosis (valve area <0.8cm2). Moderate
(2+) [**Month/Day/Year 8813**] regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is no
mitral valve prolapse. There is moderate valvular mitral
stenosis (area 1.0-1.5cm2). Moderate (2+) mitral regurgitation
is seen. There is no pericardial effusion. There is severe
mitral annular calcification. Calcium chunks were also seen on
the atrial aspect of the P2 scallop of anterior mitral leaflelt
probably leading to increased transmitral gradient and mod
mitral stenosis.
Dr. [**Last Name (STitle) **] was notified in person of the results on this
patient before surgical incision.
POST-BYPASS:
Normal biventircular systolic function. LVEF 55%. Post bypass
MVA still shows 1.2 cm2. Mild to Moderate MR. [**First Name (Titles) **] [**Last Name (Titles) 8813**] valve
bioprosthesis is stable, functioning well, no leaks, transaortic
mean gradient of 11 mm of Hg. Intact thoracic aorta.
Minimal TR.
Brief Hospital Course:
Ms.[**Known lastname 1683**] was brought to the operating room on [**2160-5-23**] where the
patient underwent [**Date Range **] valve replacement with a 23-mm Biocor
Epic tissue valve/ Coronary artery bypass grafting x2(Left
internal mammary artery graft to left anterior descending;
reverse saphenous vein graft to diagonal branch) with Dr.
[**Last Name (STitle) **]. Please refer to operative report for further surgical
details. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
She was neurologically intact and hemo- dynamically stable,
weaned from inotropic and vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. Postoperatively, Orthopeadics followed up
on her left tibial plateau fracture immobilization brace.
Coumadin was resumed for atrial fibrillation. Subcutaneous
heparin was administered for DVT prophylaxis. 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. She remained non-weight
bearing on the left lower extremity per ortho recommendations.
By the time of discharge on POD#6 Ms.[**Known lastname 1683**] was cleared by
Dr.[**Last Name (STitle) **] for discharge to [**Hospital1 756**] Manor Nursing and
Rehabilitation for further increase in strength and mobility.
All follow up appointments were advised.
Medications on Admission:
vitamin D 50,000 units once a week
zestoretic daily
levothyroxine 100 mcg daily
lipitor 20 mg daily
coumadin 5 mg daily
sotalol AF 80 mg [**Hospital1 **]
fish oil 1 gm [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever/HA.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
8. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation .
15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]
Discharge Diagnosis:
[**Location (un) **] Stenosis
Coronary Artery Disease
PMH:
A-fib
Hypertension
Hyperlipidemia
[**Location (un) **] Valve stenosis
Mitral Valve problem
Hypothyroidism
Past Surgical History:
s/p Left ankle fracture 10 years ago repaired with "10 screws
and
a bar"
s/p Surgery for PUD causing gastric outlet obstruction
s/p Tonsillectomy as child
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Trace LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for 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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Left lower extremity: Non weight bearing
Left lower extremity brace: [**Doctor Last Name 6587**] lockis 20 degree extension
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **]: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2160-6-19**] at
1:30
Cardiologist Dr. [**Last Name (STitle) 77919**], [**Last Name (un) 83355**] on [**7-11**] at 12:15pm
Please call to schedule the following:
Dr [**Last Name (STitle) 1005**] in 1 week [**Telephone/Fax (1) 9769**]
Primary Care Dr. [**Last Name (STitle) **],[**Last Name (un) 75760**] A. [**Telephone/Fax (1) 75761**] in [**5-20**] 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
Coumadin for a-fib
Goal INR 2-2.5
First draw day after discharge on [**2160-5-30**]
Then please do daily INR checks with Coumadin dosing [**Name8 (MD) **] MD.
Completed by:[**2160-5-29**]
ICD9 Codes: 4241, 4019, 2724, 2449, 2859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6196
} | Medical Text: Admission Date: [**2197-4-10**] Discharge Date: [**2197-4-22**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
ICU to [**Hospital **] transfer from [**Hospital6 204**] for bilateral
thalamic and cerebellar infarcts.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 77747**] is an 83 year old Armenian speaking male with h/o
hypertension, hyperlipidemia, type 2 DM who presents as an
outside hospital transfer with acute bilateral thalamic and
cerebellar infarcts. The pt was well until last Friday around
noon he was at the grocery store and had the sudden onset of
bitemporal headache. He appeared pale and sluggish to his son.
[**Name (NI) **]
was able to slowly walk to the car, but his speech appeared
unusually slow. His son check his blood sugar upon returning
home
and it was 131. EMS was called and pt did not want to go to the
hospital, he was taken to [**Hospital3 **] for evaluation. There
his speech remained slow, but he seemed to improved, "he was 90%
better" according to his family. Head CT reportedly without any
acute changes. On Saturday the pt was still about 90% of
himself.
Able to write his name, sing a song, able to perform addition.
Sunday afternoon the patient was scheduled for an MRI, as he was
being lifted to the gurney he suddenly became pale, closed his
eyes and became flaccid "passing out" per his son who was at the
bedside. The pt has not improved since this time. The Sunday MRI
was cancelled. Hospital records ? whether the patient may have
transiently developed an AV block during this event. About 1-2
hours following this event on Sunday the patient had assymmetric
shaking motions of his extremities. He was loaded on Dilantin
and
given Ativan. The movements persisted for about 2 hours despite
the administration of AED's, but then later resolved. MRI was
performed today [**4-10**] around 4pm at LGH, revealing bilateral
thalamic infarcts, and bilateral cerebellar infarcts. The pt was
transferred to [**Hospital1 18**] for further care.
Prior to last friday family reports pt feeling well at home,
independent of ADL's, still actively writing Armenian novels.
Past Medical History:
HTN
Hyperlipidemia
DM 2
Social History:
Prior to last friday family reports pt feeling well at home,
independent of ADL's, still actively writing Armenian novels.
ROS- reported chronic right leg pain with ambulation.
Family History:
-
Physical Exam:
Vitals: T 98, HR 106, BP 136/66, R 21, Sat 100% 2L NC
Gen- ill appearing, eyes closed, NAD
HEENT- NCAT,
Neck- no carotid or vertebral bruits, no nuchal rigidity
CV- RRR, no MRG
Pulm- transmitted upper airway sounds, expiratory rhonci at RML.
Abd- soft, NT, ND, BS+
Extrem- no CCE, 2+ DP pulses
Neurologic Exam-
MS- no response to voice, eyes closed, does not follow commands,
localizes noxious stimulation with left hand.
CN- right pupil with corneal opacity 3mm fixed and unreactive to
light, left pupil 3mm fixed and unreactive to light, + scatter
of
light with attempt of funduscopic exam, could not visualize L
fundus, intact corneal reflexes bilaterally. Absent
oculacephalic
reflex, grimaces to nasal tickle, intact (weak) gag.
Motor/Sensory- + grasp reflex bilaterally. winces to nailbed
pressure in both arms, withdraws Left arm. No right arm
withdrawal. Feet with triple flexion bilaterally.
Reflexes- absent patellar and ankle jerks. 1+ biceps, triceps,
brachioradialis bilatarally.
Plantar response was triple flexion bilaterally.
Pertinent Results:
[**4-15**] CT/CT head and neck
CT HEAD WITHOUT IV CONTRAST: There is no evidence of acute
hemorrhage, mass,
or shift of normally midline structures. Prominence of the
ventricles and
sulci is consistent with age-related involutional change.
Regions of
hypodensity in the periventricular white matter are consistent
with small
vessel ischemic disease. In addition, there are regions of
hypodensity in the
left greater than the right thalamus, left periventricular white
matter,
bilateral occipital lobes, and bilateral cerebellar hemispheres.
These are
consistent with age-indeterminate regions of
ischemia/infarction.
The paranasal sinuses and the mastoid air cells are clear except
to note a
small mucus retention cyst in the left side of the frontal
sinus. The patient
is status post replacement of the left ocular lens. A right NG
tube is in
place. Vascular calcifications are noted in the intracranial
vertebral
arteries and the cavernous carotid arteries.
CTA HEAD AND NECK: There are calcified plaques along the aorta
at the origin
of the vertebral arteries and within the carotid system,
particularly along
the proximal ICA which is more notable on the left. There is a
7-mm segment
of the left proximal ICA, which demonstrates 60-70% stenosis.
There is a
55-60% stenosis of the right proximal internal carotid artery.
The vertebral
arteries are irregular, with short segments of narrowing,
without occlusion of
flow. Atherosclerotic calcifications are noted at the origins of
the
vertebral arteries, causing moderate stenosis, without flow
limitation. The
basilar artery is patent.
No masses are seen in the lung apices. There is no evidence of
supraclavicular adenopathy. Degenerative changes are noted at
multiple levels
in the cervical spine, with left foraminal narrowing at C3-4
level. However,
these are not adequately assessed on the present study.
IMPRESSION:
1. Hypodense lesions in bilateral thalami, in the left
periventricular white
matter, bilateral occipital lobes and bilateral cerebellar
hemispheres,
consistent with ischemia/infarction of indeterminate age.
Correlation with MR
performed at outside hospital is recommended for better
assessment.
2. Atherosclerotic plaques, soft and calcified, in the proximal
internal
carotid arteries on both sides, more prominent on the left, with
moderate
stenosis of the proximal internal carotid arteries. No flow
limitation.
3. Atherosclerotic calcifications, involving the vertebral
arteries, with
short segments of narrowing as well as at the origin. No flow
limitation
[**4-19**] HCHCT
There is no evidence of an acute intracranial hemorrhage. There
are well-
defined hypodensities involving the cerebral hemispheres
including the
thalami, occipital lobes, and cerebellar hemispheres consistent
with
multifocal infarcts. The ventricular system is stable in size
and
configuration. There is no evidence to suggest hydrocephalus.
The visualized mastoid air cells and sinuses are unremarkable.
IMPRESSION:
Overall stable appearance to the multifocal infarction without
evidence of
intracranial hemorrhage.
Brief Hospital Course:
Patient was admitted to the neurology service. MRI images were
reviewed with the family - we indicated that he had a bad
prognosis given (1) severe bilateral critical stenosis diffusely
in the posterior circulation on multilple levels, most evidently
in the bilateral vertebrals and (2) by that mechanism he had
stroked bilateral occiput, cerebellum, thalamus - he was at high
risk for recurrence or further strokes, including the brainstem.
(3) Also, if he were to not have further strokes, bilateral
thalamic infarcts can give a severe clinical picture resembling
advanced dementia or an abulic state, with hypersomnolence as
well.
The patient had one brief moment of clinical improvement, with
eyes opening to loud voice, acknowledging presence of his
family, answering Y/N questions appropriately. After that, he
became signficantly infected - and [**1-28**] continued negative
cultures he was eventually treated empirically. The treatment
was aimed on optimizing him physically to formerly assess his
neurological status - but after more than a week of empyric
therapy he continued to spike fever with increasing white count.
Neurologically he had deteriorated more than what would be
attributable to infection, he developed a new left hemiparesis
and lost all horizontal eye-movements other than R eye abduction
with head movements. A CT did not demonstrate a bleed, but
clinically he had stroked out his pons now. Multiple
conversations were held with the family, who were very
understanding, and on the [**6-22**] care was withdrawn. He
died shortly thereafter.
Medications on Admission:
metformin, glyburide, lasix, diltiazem, hydroxyzine, doxazocin,
pentoxyfyline. Not taking any antiplatelet agents.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
None (deceased)
Discharge Condition:
Deceased
Discharge Instructions:
None (deceased)
Followup Instructions:
None (deceased)
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2197-4-25**]
ICD9 Codes: 2760, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6197
} | Medical Text: Admission Date: [**2134-12-6**] Discharge Date: [**2134-12-13**]
Date of Birth: [**2134-12-6**] Sex: F
Service: Neonatology
HISTORY: Baby Girl [**Known lastname 52477**] is a 3170 gram female infant born
at estimated gestational age of 35-3/7 weeks to a 34-year-old
G3 P1-2-2 mother.
PRENATAL LABS: Blood type B positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune, group B Strep unknown.
The pregnancy was complicated by maternal diabetes. The
mother presented in spontaneous labor. There was no
prolonged rupture of membranes or maternal fever. Amniotic
fluid was clear. Cesarean section was performed due to
breech position. Apgars were 9 and 9. Infant developed
respiratory distress at approximately two hours of life, with
intermittent grunting and flaring noted. Respiratory
distress persisted, and the baby was admitted to the NICU.
PHYSICAL EXAM ON ADMISSION: Weight 3170 grams. General:
Pink, alert and active, grunting, flaring, and retracting.
HEENT: Anterior fontanel is soft. Palate intact.
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs, normal pulses. Chest: Subcostal retractions, lungs
clear with good air entry. Abdomen is soft, nontender, and
nondistended, no hepatosplenomegaly. GU: Normal female
external genitalia. Extremities are warm and well perfused
with no deformities. Neurologic: Normal tone and reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
A. Respiratory: Initial chest x-ray was suggestive of
transient tachypnea of a newborn. The infant was placed on a
CPAP of 6 with 35% FIO2. By day of life three, she had no
further respiratory distress, and has remained on room air
since that time. She has had no apnea noted.
B. Cardiovascular: Infant has been hemodynamically stable.
She did not have a murmur.
C. Fluids, electrolytes, and nutrition: The infant was
initially NPO due to her respiratory distress, but was
started on feeds on day of life three. She has been
receiving either breast milk or Enfamil 20, and currently on
full volume feedings of 140 cc/kg/day. She does require
gavage feeds. Her oral intake has been improving.
D. GI: The infant had a bilirubin checked at 24 hours of
age, which was 6.2. Peak bilirubin on day of life five was
9.8. The infant is without clinical jaundice.
E. Hematology: Initial CBC was notable for a white count of
10.8 with 82% polys, 0% bands, and 10% lymphocytes.
Hematocrit was 58.6. Platelets were 297.
F. Infectious disease: The infant was initially started on
ampicillin and gentamicin, which was discontinued after 48
hours. She has had no further signs of bacterial infections.
G. Neurology: There has been no active neurologic issues.
H. Sensory: The infant passed her state mandate hearing
screen on [**12-13**].
CONDITION ON DISCHARGE: Fair.
DISCHARGE DISPOSITION: Discharged to [**Hospital3 **].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11060**] in
[**Hospital1 8**], [**State 350**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge: Breast milk or Enfamil 20 140
cc/kg/day p.o./p.g.
2. Medications: None.
3. Car seat position screening should be performed prior to
discharge.
4. The state newborn screen was sent and is pending.
5. Immunizations received: Hepatitis B vaccine was received
on [**2134-12-9**].
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: 1) Born at less than 32
weeks, 2) born between 32 and 35 weeks with two of three of
the following: daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
with school-age siblings, or 3) with chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSES:
1. Prematurity at 35 weeks.
2. Respiratory distress.
3. Rule out sepsis.
4. Immature feeding.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 50798**]
MEDQUIST36
D: [**2134-12-13**] 11:08
T: [**2134-12-13**] 11:07
JOB#: [**Job Number 52478**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6198
} | Medical Text: Admission Date: [**2146-10-5**] Discharge Date:
Date of Birth: [**2146-9-14**] Sex: F
Service: Neonatology
INTERIM DISCHARGE SUMMARY: This summary covers the interim
dates from [**2146-10-4**] to [**2146-10-31**]. Please see
prior History of Present Illness for patient's course over
the prior two months.
SUMMARY OF HOSPITAL COURSE BY SYSTEM: Respiratory: Baby
Girl [**Known lastname 58332**] was on nasal cannula at the beginning of this
interim period for two days but was transitioned quickly to
room air. She has been on room air throughout this month
with mild apnea and bradycardia. She had apneic spells and
was on caffeine until mid month when her caffeine was
discontinued on the [**10-20**]. She has had no
serious apneic spells since then but continues to have mild
bradycardias usually associated with feeds. Her last
bradycardia was overnight, the 27th, and was associated with
feeding.
Cardiovascular: Baby Girl [**Known lastname 58332**] has been cardiovascularly
stable throughout this time period with normal blood
pressures and perfusion. She had an echocardiogram that was
performed when she was at [**Hospital3 1810**] in [**Location (un) 86**] from
the [****] that was negative for any valvular vegetation.
Fluids, Electrolytes and Nutrition: Baby Girl [**Known lastname 58332**]
tolerated her feeding even throughout the beginning part of
this month when her blood cultures were positive with staph
aureus. Upon her return to [**Hospital1 188**] from [**Hospital3 1810**] on the [**10-5**] she
quickly attained full volume enteral feedings by nasogastric
tube.
She was advanced to a maximum calorie density of 28 kilocals
per ounce with ProMod. She had good weight gain and
therefore on the 21st on this month was cut back to 26
calorie formula. She currently is on special care 26 calorie
formula without ProMod at a total volume of 150 cc per kilo
per day. Her discharge weight is 2160 grams. She is
currently beginning to take feedings by [**Known lastname **] and is doing so
very taking approximately half of her bottle volume when
offered the bottle which is about twice per day. Her most
recent set of electrolytes were on the [**10-14**], a
sodium of 140, potassium of 5.8, chloride of 111, CO2 of 20,
BUN of 7, creatinine .2. She also had nutrition laboratories
sent on the [**10-27**] with an alkaline phosphatase of
235, a calcium of 9.2 and a phosphorus of 6.7.
Gastrointestinal: She has tolerated feedings well with no
history of significant aspirate or emesis.
Hematology: Baby Girl [**Known lastname 58332**] most hematocrit is 25.4 from
the [**10-26**]. Her last transfusion was on the [**10-6**] for a hematocrit of 27. She was transfused at
this point secondary to having had multiple blood draws for
blood cultures and drug levels given her prolonged antibiotic
therapy course.
Infectious Disease: Baby Girl [**Known lastname 58332**] was transferred over
to [**Hospital3 1810**], [**Location (un) 86**] on the [**11-3**] for
further work up of what turned out to be osteomyelitis
associated with multiple positive blood cultures with staph
aureus. Her last positive blood culture was from [**Hospital3 18242**], [**Location (un) 86**] on the [****]. She has had blood
cultures negative from the [**10-6**], the [**10-7**], the 4th as well as the [**10-9**] upon her
return here to the [**Hospital1 69**]. All
of the positive blood cultures did show sensitivity to
oxacillin as well as Gentamicin which she was on for the
first week of her therapy for synergy. She has been
Oxacillin throughout and currently on the day of transfer is
on day 27 of 42 of Oxacillin therapy for right tibial
osteomyelitis. She has a Broviac placed in her left chest
which is in the superior vena cava-right atrial junction.
This Broviac was placed on the [**10-12**]. The
remainder of her work up surrounding her positive blood
cultures at [**Hospital3 1810**] consisted of a normal renal
ultrasound on the [****], [**First Name3 (LF) **] MRI of the rest of her
extremities also on the [****] which showed an
osteomyelitis of the right proximal tibia involving the
growth plate with surrounding soft tissue swelling and
myositis. Her hips on that MRI examination were normal as
was her left leg. She had a head CT performed the [**10-5**] which showed an increased density in her left
germinal matrix but no lesions and no abscesses. Baby Girl
[**Known lastname 58332**] has had two 48 hour rule out events secondary to
temperatures of 100.3 to 100.5. During this time a blood
culture was sent both from her Broviac as well as
peripherally and Vancomycin and Gentamicin were started in
addition to the Oxacillin. The first of these episodes was
on [**10-19**] and the second of these episodes started on
[**10-26**]. She also had a C-reactive protein sent during
these times which was less than 0.5. We used this value in
conjunction with a negative blood culture to discontinue her
Vancomycin and Gentamicin each time after 48 hours of blood
negative cultures. Her C-reactive protein had been elevated
above 1 during the initial phase of her positive blood
cultures and osteomyelitis.
Orthopedics: Her right proximal tibial osteomyelitis has
improved, yet there is still a discrepancy in circumference
around her proximal tibia of her right leg compared to the
left. Currently it measures 9 1/2 cm, about 1 cm larger than
her left. There is evidence of bony overgrowth in this area
but there has not been swelling or erythema since the first
week of this month. As stated above, she continues on
Oxacillin and will continue a 42 day course for this. She
has been followed by Dr. [**Last Name (STitle) 18647**], orthopedic fellow at
[**Hospital3 1810**], [**Location (un) 86**] and will need close follow up
when she is discharged from the nursery.
Neurology: Baby Girl [**Known lastname 58332**] had a head ultrasound on the
[**10-17**] that confirmed a left germinal matrix
hemorrhage but no other abnormalities.
Sensory: - Audiology: She has not had hearing screen
performed.
Ophthalmology: She had an eye examination on the [**10-18**] that showed her retinas to be immature. On the day
of transfer, the [**10-31**], she had a repeat
examination that showed her eyes to be immature zone 3. She
will need follow up ophthalmology examination in three weeks
per recommendation.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Level 3 Nursery [**Hospital 10908**].
MEDICATIONS: Include vitamin E and iron as well as
Oxacillin.
DISCHARGE DIAGNOSES: Prematurity.
Presumed sepsis.
Osteomyelitis.
Hyperbilirubinemia.
IMMUNIZATIONS: She received her hepatitis B immunization on
the [**10-24**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Dictated By:[**Last Name (NamePattern1) 56887**]
MEDQUIST36
D: [**2146-10-31**] 17:02:40
T: [**2146-10-31**] 18:02:28
Job#: [**Job Number 58333**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6199
} | Medical Text: Admission Date: [**2196-3-4**] Discharge Date: [**2196-3-13**]
Date of Birth: [**2129-5-16**] Sex: F
The patient is not being discharged; this Summary will cover
up until the date of [**2196-3-13**].
REASON FOR ADMISSION: The patient was admitted for a
history.
HISTORY OF PRESENT ILLNESS: This is a 66 year old female
with a past medical history for diabetes mellitus type 2,
peripheral vascular disease status post left below the knee
amputation and right above the knee amputation in [**2173**],
chronic renal insufficiency, coronary artery disease, status
status post stent, and gout. The patient presented to [**Hospital6 **] with chest pain and shortness of breath.
States that commonly has angina but yesterday had chest pain
radiating to her neck and worsening anginal symptoms with low
exertion. The patient's EKG showed ST changes with ST
depression in I and AVL, a CK at the outside hospital of
1000, MB of 89 with troponin of 24.8.
The patient was transferred for cardiac catheterization which
showed a RA pressure of 9, PA pressure of 34/18, with a mean
of 25 and a wedge pressure of 15. The patient had left main
coronary artery mild disease, left anterior descending
diffuse disease, totally occluded left circumflex,
non-dominant with diffuse disease, right coronary artery
dominant with mid-segment total occlusion. Catheterization
was technically difficulty. No interventions were done.
Cardiothoracic surgery was consulted. The catheterization
was greatly unchanged from a cardiac catheterization in [**2190**]
which showed left main disease with focal area of 80% in left
anterior descending, left circumflex 80% occluded, right
coronary artery with diffuse disease. Evidently, in [**2190**],
the patient was evaluated for coronary artery bypass graft
but it was not done because of being a poor surgical
candidate with co-morbidities.
REVIEW OF SYSTEMS: No history of cerebrovascular accident,
no amaurosis fugax, no claudication in the arms. History of
syncope several years ago but could not recall events
surrounding this. The patient is having worsening of general
symptoms. The patient used to be able to transfer from bed to
wheelchair and would get chest pain after approximately ten feet.
Now patient was getting chest pain strictly on transfer from bed
to wheelchair.
MEDICATIONS ON ADMISSION:
1. Lopressor 100 twice a day.
2. Imdur 60 mg q. day.
3. Insulin 70/30, 56 units twice a day.
4. Lasix 40 mg q. day.
5. Aspirin 81 mg q. day.
6. Allopurinol 100 mg q. day.
7. Pravachol 40 mg q. day.
ALLERGIES: The patient has allergy to ACE inhibitor; she is
intolerant with an increased creatinine.
MEDICATIONS ON TRANSFER FROM CATHETERIZATION:
1. Integrilin drip.
SOCIAL HISTORY: The patient lives in [**Location (un) 5503**] with her
husband. She is independent. She had a 15 pack year history
of smoking which she quit. No alcohol use. She was a former
nurse.
PHYSICAL EXAMINATION: The patient was afebrile on
admission. Heart rate 95 to 100; right arm blood pressure
80, left arm blood pressure 120; 99% on two liters nasal
cannula. Generally, comfortable, obese, lying in bed,
slightly Cushingoid in appearance. HEENT: Showed sclerae
are anicteric. Oropharynx clear. No jugular venous
distention, no bruits. Pupils are equal, round, and reactive
to light and accommodation. Mucous membranes were moist.
Lungs clear to auscultation laterally and occasional
expiratory rhonchi anteriorly. Heart: Regular rate and
rhythm, positive S1, S2, with II/VI holosystolic murmur at
apex. Point of maximal impulse difficult to palpate.
Abdomen with positive bowel sounds, nontender, no ecchymosis.
Groin: Right groin without hematoma. Venous groin sheath in
place. Extremities with left below the knee amputation,
right above the knee amputation. Scar along medial portion
of left below the knee amputation.
LABORATORY: On admission, white blood cell count 9.0.
Hematocrit 26.7, platelets 166, INR 1.7, PT 15.7, PTT 37.2.
Sodium 142, potassium 3.8, chloride 108, bicarbonate 22, BUN
42, creatinine 2.0, glucose 148, magnesium 1.5, calcium 7.8.
CK 2187, MB fraction was 223, MB index 10.2.
EKG on [**3-4**], showed sinus tachycardia, PR interval of 154
with QRS interval of 110 milliseconds, ST depressions in I
and AVL, V5 through V6. RWP was normal. Q's in II and F.
On [**3-4**], status post catheterization, sinus rhythm at 92
beats per minute, LAD, PR interval 166, QRS interval 106, ST
depression in I, AVL and V5 through V6 with 1 millimeter Q's
in III and F. No real change from previous
pre-catheterization EKG.
ASSESSMENT AND PLAN: 66 year old female with type 2 diabetes
mellitus with vascular complications including coronary
artery disease, chronic renal insufficiency and renal artery
stenosis, status post catheterization with extensive coronary
artery disease.
1. Coronary artery disease: Continue Integrilin, restart
heparin without bolus. Cardiothoracic Surgery will be
consulted. CT surgery is not an option. Interventional
could consider stenting right coronary artery, consider
functionality of this. Continue aspirin and beta blocker;
oral nitrates, consider changing them to three times a day
for titration.
Pump: No signs of decompensation. Use Hydralazine with
Nitroglycerin for symptomatic relief. No mortality benefit
per V-Hef trial. Rhythm: Sinus; will monitor.
2. Type 2 diabetes mellitus: Continue NPH and sliding scale
insulin. Check urine protein and creatinine. Continue blood
sugar checks four times a day.
3. Chronic renal insufficiency: Hold on Lasix for now.
Prerenal component. Watch creatinine closely post
catheterization.
4. Hematology: Hematocrit decreased. Baseline creatinine
29.6, microcytic. Possible causes, chronic gastrointestinal
loss or chronic renal insufficiency, guaiac stools. Will
transfuse now. Check on her studies, reticulocyte count,
goal hematocrit is greater than 30.
5. Pulmonary: Stable.
6. Fluids, Electrolytes and Nutrition: Continue with
diabetic diet. Replete electrolytes as needed.
7. Code Status: To discuss with patient. Contact is her
husband, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 42216**].
8. Prophylaxis: The patient getting PPI and heparin.
HOSPITAL COURSE:
1. Cardiovascular: The patient with congestive heart
failure exacerbation status post myocardial infarction with
no intervention. The patient was seen by Cardiothoracic
Surgery and not deemed to be a surgical candidate. The
decision was made that no catheterization intervention was
needed as well and right coronary artery stent was not
placed. The patient was continued on her current medications
as well as the patient's Amiodarone was decreased from 400
twice a day to 400 q. day; Isordil was added. The patient
put on Hydralazine titrated up to 40 four times a day.
The patient had complication status post cardiac
catheterization which turned out to be an extra-peritoneal
bleed with a pseudo-aneurysm. The patient received blood
transfusion for a hematocrit as low as 27.8. The patient
then had thrombin injection/thrombin plug of pseudo-aneurysm,
which was successful. The patient's Plavix, heparin were
both held in light of the retroperitoneal bleed and have not
been restarted. The patient's hematocrit has successfully
stabilized status post thrombin injection of the
pseudo-aneurysm. The patient is stable.
While in Coronary Care Unit the patient also developed severe
abdominal pain. CT scan of the abdomen and pelvis in [**3-8**],
made no mention of gallbladder issues but did mention that
gallbladder was distended with sludge but no edema or
pericholecystic fluid around the gallbladder. Since that
time, the patient did subsequently develop severe abdominal
pain and was sent for an abdominal ultrasound which showed a
grossly distended gallbladder with stones, edematous
gallbladder wall and some pericholecystic free fluid with no
biliary dilatation. The result was a percutaneous
cholecystomy tube under ultrasound guidance; 400 cc. of bile
fluid was removed and drained and the gallbladder was left in
place to gravity bag. The bile fluid showed heavy growth of
Gram negative rods. Subsequent cultures showed Klebsiella
sensitive to Levofloxacin. The patient has been on
Levofloxacin since the gallbladder drainage was placed. The
patient has been afebrile with no real issues with her white
blood cell count which is now slightly elevated.
The patient did have blood cultures drawn for a temperature
spike which, on [**2196-3-8**], was shown to have Staphylococcus
coagulase negative in one bottle; subsequently no growth to
date on other cultures. The patient was started on
Vancomycin 750 mg q. 24 hours due to her renal clearance.
This will be for a seven day course only. The patient was
also put on Metronidazole (Flagyl), 500 mg three times a day,
for further coverage.
The patient's echocardiogram on [**3-6**], showed overall left
ventricular systolic function severely depressed, global
hypokinesis to akinesis in the inferior posterior wall, right
ventricular systolic function was good, two plus mitral
regurgitation. No definite pericardial effusion.
Due to the patient's retroperitoneal bleed, the patient's
Plavix and heparin has not been restarted. The patient does
have a right subclavian line as well as a right PICC line for
long-term antibiotic use.
Since the patient has left the Coronary Care Unit she has
been stable, but the right subclavian line is still in place
on [**2196-3-13**], which will be pulled, and the PICC line will
be left in place. The patient's INR is elevated at 1.9,
therefore, Vitamin K 5 mg subcutaneously was given. INR will
be rechecked before subclavian line is pulled.
The patient will have gallbladder drainage left in place for
approximately up to six weeks while the gallbladder has a
chance to quiesce. Once the gallbladder inflammation has
resolved, the drain will removed per Surgery. The patient
now has restarted p.o./oral medications and eating. The
patient is going well with regards to intake. The patient is
now without abdominal pain, resting comfortably.
Physical Therapy will see the patient to get the patient out
of bed and back to functioning status of transferring to
wheelchair.
DISPOSITION: The patient will be discharged to a
Rehabilitation Center for further intravenous antibiotics and
rehabilitation status post non-Q wave myocardial infarction.
DISCHARGE PLAN: The patient's plan will be to return to
home, not yet with Hospice Care but with continued plan that
she will be titrated up on her medicines for blood pressure
and heart rate control as well as anginal control, and that
she will at some point require Hospice Care for her failing
condition that is not amenable to surgery.
The patient's blood pressure medications will be titrated as
tolerated.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with Surgery regarding
drainage of gallbladder tube and removal of gallbladder tube.
2. The patient will need to be restarted on her
anti-coagulation, heparin and Coumadin, once it is deemed
safe status post her retroperitoneal bleed.
3. The patient will need her subclavian line pulled once INR
is stable.
4. The patient will be continued on her Procrit and her
creatinine has been trending down.
5. The patient will need continued Vancomycin until
[**2196-3-16**].
6. The patient will need Levaquin and Flagyl for a
Klebsiella, Gram negative in her bile which is sensitive to
Levaquin and will be continued to be deemed the course via
Infectious Disease input.
7. The patient will be screened for rehabilitation and sent
to rehabilitation as soon as she is clinically stable.
CODE STATUS: The patient's code status is "DO NOT
RESUSCITATE".
MEDICATIONS AS OF [**2196-3-13**]:
1. Atrovent nebulizers for wheeze.
2. Hydralazine 40 mg p.o. four times a day.
3. Percocet one to two tablets p.o. q. six hours p.r.n.
4. Insulin sliding scale.
5. Lopressor 50 mg p.o. twice a day.
6. Amiodarone 400 mg p.o. q. day.
7. Robitussin AC 10 cc., four times a day p.r.n.
8. Aspirin 325 mg p.o. q. day.
9. Allopurinol 100 mg p.o. q. day.
10. Protonix 40 mg p.o., twice a day.
11. Procrit 3000 Units subcutaneously three times a week.
12. Iron 325 mg p.o. three times a day.
13. Colace 100 mg p.o. three times a day.
14. Isordil 30 mg p.o. three times a day.
15. Lipitor 40 mg p.o. q. day.
16. Levaquin 250 mg intravenously q. 24 hours.
17. Vancomycin 750 mg intravenously q. 24 hours to be
discontinued on [**2196-3-16**].
18. Metronidazole 500 mg intravenously three times a day.
19. NPH is at 40 Units in a.m. and 40 Units in p.m. The
patient's blood sugars have been stable.
CONDITION ON DISCHARGE: Stable and approved.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post non-ST elevation
myocardial infarction and status post cardiac catheterization
with no intervention.
2. Diabetes mellitus type 2.
3. Hypertension.
4. Chronic renal insufficiency.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 4724**]
MEDQUIST36
D: [**2196-3-13**] 16:12
T: [**2196-3-13**] 18:07
JOB#: [**Job Number 42217**]
ICD9 Codes: 4280, 5845 |
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