Split (1)

train · 498k rows

meta dict	text stringlengths 0 55.8k
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6200 }	Medical Text: Admission Date: [2184-12-17] Discharge Date: [2184-12-31] Service: MEDICINE Allergies: Percodan Attending:[First Name3 (LF) 425] Chief Complaint: Not well Major Surgical or Invasive Procedure: Placement of temporary pacer Placement of [Hospital1 ]-ventricular pacer. History of Present Illness: The patient is an 81 year old male with h/o CAD s/p CABG x 3 in [2179], h/o htn, CVA, PVD who presented to the ED in third degree heart block. He was found by his neighbor earlier this evening not looking well who called EMS. EMS records indicate that the patient was found in bed, pale, incontinent of feces, lethargic and complaining of chest pain. The patient was unable to give any history upon arrival to the emergency room. VS in the field BP = 140/38, HR = 24, RR = 18, SaO2 = 90%. Pacer pads were placed in the filed and he was transported to [Hospital1 18] and placed on non-rebreather mask. Patient was then admitted to CCU. Past Medical History: Peripheral Vascular Disease-s/p right axillo [Hospital1 ]-femoral bypass [11/2180](indicated for complete occlusion of infrarenal abdominal aorta) Coronary Artery Disease-s/p NSTEMI -[10/2180] s/p CABG x 3 [11/2180] Hyperlipidemia S/p Coronary artery bypass graftx 3 [11/2180]- LIMA-LAD, SVG-OM, SVG-RAMUS Carotid Stenosis s/p bilateral carotid endarterectomy CVA-with residual right arm hemiparesis H/o bladder cancer H/o hepatitis A s/p inguinal hernia repair H/o presumed pulmonary embolism diagnosed by intermediate probability V/Q scan-[2180-12-12] Social History: Widower, lives alone, has a daughter [Name (NI) ] who is actively involved in his care-([Telephone/Fax (1) 59528] Physical Exam: T=95.7, BP = 95/P, P =20s, RR? Gen: confused agitated HEENT: Dry mucous membranes, PERRL Neck: JVP-flat, supple Chest: Anteriorly clear without crackles. CV: Extremely bradycardic, no m/r/g Abd: nabs, steel tubing appreciated in stomach-bipass, nt Pertinent Results: [2184-12-17] 11:39PM TYPE-ART PO2-259* PCO2-47* PH-7.21* TOTAL CO2-20* BASE XS--9 INTUBATED-INTUBATED [2184-12-17] 11:39PM LACTATE-4.6* K+-5.2 [2184-12-17] 11:39PM O2 SAT-98 [2184-12-17] 10:49PM URINE COLOR-LtAmb APPEAR-SlCldy SP [Last Name (un) 155]-1.030 [2184-12-17] 10:49PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [2184-12-17] 10:49PM URINE RBC-9* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 [2184-12-17] 10:35PM TYPE-ART PO2-36* PCO2-64* PH-7.19* TOTAL CO2-26 BASE XS--5 [2184-12-17] 10:35PM LACTATE-6.4* [2184-12-17] 10:23PM GLUCOSE-106* UREA N-62* CREAT-4.7* SODIUM-144 POTASSIUM-6.8* CHLORIDE-105 TOTAL CO2-20* ANION GAP-26* [2184-12-17] 10:23PM ALT(SGPT)-24 AST(SGOT)-50* LD(LDH)-379* CK(CPK)-259* ALK PHOS-80 TOT BILI-0.4 [2184-12-17] 10:23PM CK-MB-4 cTropnT-0.15* [2184-12-17] 10:23PM CALCIUM-8.3* PHOSPHATE-6.1* MAGNESIUM-2.3 [2184-12-17] 10:23PM TSH-2.8 [2184-12-17] 10:23PM WBC-11.0 RBC-3.54* HGB-10.7* HCT-33.2* MCV-94 MCH-30.3 MCHC-32.3 RDW-14.6 [2184-12-17] 10:23PM PLT COUNT-187 [2184-12-17] 10:23PM PT-18.6* PTT-29.8 INR(PT)-2.2 [2184-12-17] 10:23PM PT-18.6* PTT-29.8 INR(PT)-2.2 [2184-12-17] 09:03PM GLUCOSE-96 LACTATE-3.7* NA+-142 K+-5.6* CL--107 TCO2-21 [2184-12-17] 09:03PM HGB-12.5* calcHCT-38 O2 SAT-31 CARBOXYHB-0.8 MET HGB-0.9 [2184-12-17] 09:03PM freeCa-1.08* [2184-12-17] 08:50PM GLUCOSE-95 UREA N-58* CREAT-4.7* SODIUM-144 POTASSIUM-5.6* CHLORIDE-107 TOTAL CO2-22 ANION GAP-21* [2184-12-17] 08:50PM AMYLASE-57 [2184-12-17] 08:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2184-12-17] 08:50PM WBC-13.0* RBC-3.86* HGB-11.8* HCT-36.0* MCV-94 MCH-30.5 MCHC-32.7 RDW-14.7 [2184-12-17] 08:50PM PLT COUNT-234 [2184-12-17] 08:50PM PT-19.9* PTT-32.6 INR(PT)-2.5 [2184-12-17] 08:50PM FIBRINOGE-460* ECG: [Hospital1 112] report [2184-1-3] - no image sent: NSR with ? LA enlargement RBB- Echo: post CABG- [2180-11-29]- EF = 55-60%, Mild concentric LVH Brief Hospital Course: Plan: 1. CVS: CHB: Etiology of complete heart block remains unclear. The differential diagnosis included medications, ischemia, fibrosis and sclerosis, along with hyperkalemia. The pateint's troponin was elevated at 0.15 upon admission but this was difficult to interpret in light of his acute renal insufficiency. He was also on a small dose of beta blocker and this was thought to be too small to lead to complete heart block. We thought that that it was highly likely that the patient had a diseased conduction system at baseline as evidenced by his baseline right bundle branch which may have pre-disposed him to have complete heart block in the face of a secondary insult such as small electrolyte imbalance or brewing infection. A temporary pacer wire was placed which was removed two days later secondary to concerns of a potential infection. See ID. He resumed normal sinus rhthym without incident and once his infection was adequately treated with antibiotics a permanent [Hospital1 ]-ventricular pacer was placed. . Coronary Artery Disease: His complete heart block was concerning for potential ischemia. We trended his cardiac enzymes which peaked at a troponin of 0.3 with a CKMBI of 7. WE thought that his cardiac ischemia was secondary to his poor cardaic output in light of his severe bradycardia and not acute coronary syndrome. His cardiac ischemia was managed by improving his cardiac output by placing a temporary pacer. His enzymes trended down and he was continued on atorvastatin and aspirin. . Htn: His beta-blocker was held until his pacer was placed and then he was re-started on his home regimen. . 2. CVA: -During his hospital course the patient was found with left lower extremity hemiparesis and a head MRI demonstrated new R embolic strokes. The patient was continued on heparin and his SBP was maintained >140 for one week. He recovered use of his left leg and left arm but he continued to have a waxing and [Doctor Last Name 688] exam which was most notable for left sided neglect. . 3. UTI: During the course of his hospitalization the patient began spiking temperatures. He was fond to have a levaquin resistant E. Coli UTI along with pulmonary infiltrates concerning for possible aspiration pneumonia. He was started on zosyn and completed a 7 day course. . 4. H/o CVA, PE and fem-[Doctor Last Name ] graft: His coumadin was held and he was continued on a IV heparin while in hospital. His coumadin was restarted upon discharge with lovenox as a bridge. . 5.Acute renal insufficiency: We thought this is elevated creatinine was secondary pre-renal in etiology as demonstrated by its decrease with fludis to 2.0 upon discharge. . 6.Ventilation: The patient was intubated electively for agitation,confusion and out of concern for airway protection. He was successfully extubated and weaned off his O2 with lasix and antibiotics until upon the day of discharge he was sating well on room air. 6. COPD/Shortness of Breath: The patient experienced episodes of SOB with exertion while in hospital which resolved with nebulizers and serial chest X rays and ECGs were unchanged. He was thus started on a rapid prednisone taper with good effect. . 7. Guaic positive stools: The patient was found to have guaic positive stool during this admission. His hematocrit remained stable and thus we suggest an outpatient GI work up. . 8.Pocket Hematoma: The patient developed a pocket hematoma after his pacer was placed. He was started on kelfext complete a 7 day course to prevent an infection. 9.FEN: He was continued on a low Na, renal diet. 10. Hyperkalemia: During the last two days of his hospital stay the patient was found to have elevated potassium. Serial EKGs were checked and the patient remained asymptomatic. We then realized that the patient has a penchant for bananas. In light of his elevated creatinine we suggest that he be conitinued on renal cardiac diet. 11. In light of his continued improvement he was discharged to stroke rehab to recuperate from his hospital stay. Medications on Admission: Coumadin 2.5 mg qd Gemfibrozil 600 mg po bid Terazosin 2 mg qs Metoprolol 25 mg qd Folate 1 mg qd Lasix 20 mg M/W/F Lipitor 20 mg qhs Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary: Complete heart block Pneumonia Urinary Tract Infection Secondary: Peripheral Vascular Disease Coronary Artery Disease-s/p NSTEMI -[10/2180] Hyperlipidemia S/p Coronary artery bypass graft x 3 Carotid Stenosis s/p bilateral carotid endarterectomy CVA-with residual right arm hemiparesis H/o bladder cancer H/o hepatitis A s/p inguinal hernia repair H/o presumed pulmonary embolism Discharge Condition: Good. Still requiring oxygen, which he uses at home at his baseline - he has been on [1-21] L via NC. Has COPD, therefore keeping sats 91-94%. Alert, conversant. Discharge Instructions: Please return to the emergency room if you experience shortness of breath, sudden weakness, slurred speech, light headedness, chest pain, black stools or bright red blood per rectum. Please cut back on your banana intake!! They cause your potassium levels in your blood to be too high. Please take all medications as prescribed. You have been re-started on your home regimen of medications. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 59] Date/Time:[2185-1-5] 11:30 Please call your PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 24943] at [Telephone/Fax (1) 8506] for follow up within one week. He will need frequent INR checks (every other day) until INR is stable between 2 and 3, as we have just restarted his coumadin. ICD9 Codes: 5990, 5849, 5070, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6201 }	Medical Text: Admission Date: [2150-5-16] Discharge Date: [2150-5-22] Date of Birth: [2093-6-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None. History of Present Illness: 56 with history of tonsillar cancer (post XRT in [2140], post trach/PEG, recurrent aspiration PNA) presents from [Hospital1 1099] rehab with hypotension. Of note, he was just recently admitted to [Hospital1 18] for septic shock in [2-21] and to [Hospital1 2177] in [5-3] for the same problem. Over the past 6 months he has had recurrent aspiration and has been ventilator dependent. . He presented to the ED with hypotension. He was transferred for BP in 70-80. He was given fluid bolus at [Hospital3 672] with no response and hence transferred here. He was also reported had change in mental status. His initial vitals were T101.8 P120 BP84/50. He was given 1L NS, flagyl, levaquin, 1L LR and 1u PRBC. He refused central line twice in the ED. Sepsis protocol was thus not initiated. He was also found to be profoundly anemic, with leuckocytosis and severe diarrhea with is guiac positive. Past Medical History: Head and Neck Ca s/p XRT 96 (PEG/Trach) history of recurrent aspiration pneumonias. Recent discharge from [Hospital1 2177] IDDM, Hep C, hz IVDU, Anxiety, PTSD history of pericarditis ([12-24] hospitalization) history of MRSA pneumonia history of pseudomonas Social History: has 2 daughters [Name (NI) ] has been in hospitalized setting since [2149-10-20], prior to this he was living at home with aunt. [Name (NI) ] was a former drug abuse counsellor Family History: noncontributory Physical Exam: bp117/76 p110 on AC, 400x12 40% FiO2, PEEP=5, 99% Gen: severe cachexia HEENT: dry MM, pallor Abd: diffusely tender Lungs: diminished BS bilaterally CV: RRR, nl s1/s2, no m/r/g Extr: Left thigh swollen and tender Pertinent Results: Admission Labs: [2150-5-16] 07:40PM WBC-44.5# RBC-1.65# HGB-5.0# HCT-15.7# MCV-95 MCH-30.0 MCHC-31.5 RDW-16.7* [2150-5-16] 07:40PM NEUTS-68 BANDS-18* LYMPHS-4* MONOS-5 EOS-0 BASOS-0 ATYPS-1* METAS-3* MYELOS-1* [2150-5-16] 07:40PM PLT SMR-NORMAL PLT COUNT-315# [2150-5-16] 07:40PM PT-12.9 PTT-33.2 INR(PT)-1.1 [2150-5-16] 07:40PM GLUCOSE-66* UREA N-21* CREAT-0.9 SODIUM-142 POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-26 ANION GAP-12 [2150-5-16] 07:40PM ALT(SGPT)-22 AST(SGOT)-44* CK(CPK)-68 TOT BILI-0.5 . CT LOW EXT W&W/O C BILAT [2150-5-17] 12:59 PM CT LOWER EXTREMITY: The left adductor magnus muscle is expanded to 7.3 x 7.1 cm, with high-density fluid consistent with blood. The right adductor muscle, at the same level measures 2.5 x 3.0 cm. The hematoma extends to the level of the pubic symphysis superiorly, and to the distal femur/knee inferiorly. Additionally, high-density fluid fills the gluteus maximus muscle posteriorly. Fat stranding is seen throughout the imaged left leg. On post-contrast imaging, there was no evidence of arterial active bleed. There are diffuse vascular calcifications. Air is seen within the bladder, without a visualized Foley catheter in place. BONE WINDOWS: Mild degenerative changes are seen. There is no visible disruption of the cortex, periosteal reaction, or sinus tract within the left femur to indicate osteomyelitis. Degenerative changes are seen along the pubic symphysis, bilateral hips. There are diffuse vascular calcifications. IMPRESSION: 1) Large left hematoma, without CT evidence of active bleeding. If arterial source is clinically suspected this should be evaluated with conventional angiography. 2) No bony changes to suggest the presence of an abscess, or osteomyelitis. 3) Air within the bladder, without presence of Foley catheter. Reasons for this could include recent instrumentation, recent removal of Foley catheter, versus infectious etiology. CHEST (PORTABLE AP) [2150-5-16] 5:37 PM PORTABLE AP CHEST RADIOGRAPH: The study is extremely limited secondary to difficulty with patient positioning. There is an opacity in the left lower lobe, which may represent pneumonia. There is a small left pleural effusion. The remainder of the lung fields is unchanged from prior study. A tracheostomy tube is seen with the tube tip approximately 6 cm above the carina. The soft tissue and osseous structures are unchanged from prior study. IMPRESSION: Limited study. There appears to be an opacity in the left lower lobe, which may represent pneumonia. Additionally, there appears to be a small left pleural effusion. Recommend repeat evaluation with PA and lateral chest radiographs. PORTABLE ABDOMEN [2150-5-16] 11:13 PM There is paucity of the air throughout the abdomen. Air is probably noted in the ascending and transverse colon and rectosigmoid. No evidence of obstruction. No evidence of toxic megacolon. There is probably a small bilateral pleural effusion. Patchy opacity is seen in the left lower lobe. If clinically indicated, please evaluate with chest x-rays. The free air is not well examined on this supine abdominal film. IMPRESSION: No evidence of obstruction. Brief Hospital Course: 56yo M with tonsillar cancer, recurrent aspiration penumonia, ventilator dependent, diabetes who presented with sepsis and acute hematocrit drop with goal of care comfort measures only #ID:The patient initially presented with leukocytosis, fever, 18% bandemia but with lactate 1.9 with possible sources including cdiff, LLL PNA, and UTI. Initial CXR was clear. His stool cultures were pending but he had diarrhea in the setting of recent antibiotics and thus flagyl for possible Cdiff was started. The pt and his family subsequently requested comfort measures only and specified that all antibiotics, additional IVs, blood draws etc be discontinued for comfort. After this decision was made, pt's sputum culture was found to have klebsiella sensitive to only imipenum and meropenum and pansensitive pseudomonas resistant only to ciprofloxacin. Stool cultures and Cdiff were negative. No antibiotics were continued on discharge (patient was made CMO after discussion with patient and family), and he was discharged to hospice. . #anemia- The patient was found to be anemic believed to be secondary to a hematoma in the left medial thigh. The etiology remains unclear but it may have been related to a femoral stick at an outside hospital. His initial hct in the ED was 15. He was transfused 2 units pRBC's with an increase to 24. A CT scan of his left thigh showed a hematoma with suspected ongoing bleed based on appearance. A source was not localized. His repeat Hct was 21. A pressure gauze was placed on his left leg and he was transfused an additional 2 units for suspected ongoing bleed. Vascular surgery was consulted as well for potential surgical intervention, however family wished for no invasive procedures, only supportive care. . #respiratory : The patient was initially continued on outpatient ventilatory settings. He was treated prn with anti-anxiety medications. On [5-18], a family meeting was held with the patient's daughter ([Name (NI) 12230]) and an aunt who agreed that the patient would want the ventilator to be discontinued as well. He tolerated this well and was placed on a trach maskl. He maintained o2 sats in the high 90-100 range. . #FEN: Pt was initial kept NPO. Pt expressed that he was a hungry and a desire to eat/drink. He was started on bolus tube feeds through his J tube. #code-DNR/DNI/CMO. Had family meeting on [5-17] and [5-18] where daughter and aunt agreed that the patient would not aggressive measures at this time. This includes intubation, pressors, IVs, lab draws, antibiotics. They are agreeable to IV only for pain meds in the case he loses IV access. The patient cannot take PO MSO4 (including liquid form). After transfer to the floor, palliative care was consulted. He was ultimately discharged to hospice care. #Communication -aunt very involved with his care although daughters are official healthcare proxy. daughter [Name (NI) 12231] [Known lastname 12232] [Telephone/Fax (1) 12233] [Name2 (NI) ]ter [First Name8 (NamePattern2) 12234] [Last Name (NamePattern1) ] [Telephone/Fax (1) 12235] Medications on Admission: On admission: Zosyn SQ heparin Fentanyl TP Vancomycin MVI Vitamin C Zyprexa Protonix Fe supplements Discharge Medications: 1. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Ativan 2 mg/mL Solution Sig: 1-5mg Injection every 4-6 hours as needed for aggitation. 3. Haldol 5 mg/mL Solution Sig: 0.5-1 Injection every 4-6 hours as needed for aggitation. 4. Morphine Sulfate 2 mg/mL Solution Sig: 2-10mg Injection q3h as needed for pain. Discharge Disposition: Extended Care Discharge Diagnosis: Tonsillar cancer Aspiration pneumonia (klebsiella and pseudomonas) Discharge Condition: Maintaining o2 sat from 95-100% Discharge Instructions: Pt is comfort measures only. -no IVF, lab draws, antibiotics. He is DNR/DNI. Followup Instructions: None ICD9 Codes: 0389, 5070, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6202 }	Medical Text: Admission Date: [2150-5-23] Discharge Date: [2150-5-24] Date of Birth: [2084-7-29] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[First Name3 (LF) 28994] Chief Complaint: Fevers, tachycardia, tachypnea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 28983] is a 65 year old man with a history of CLL and pulmonary embolus. He has been off of treatment for his CLL secondary to complications from the chemotherapy. He has required frequent transfusions for his anemia (last transfusion of 2 units of pRBC's on [5-21]). He is neutropenic and has been on valacyclovir, pentamidine, and voriconazole. . He reports a dry cough starting about one month ago. Two weeks ago he began having a cough slightly productive of whitish sputum. The cough was at night and would occasionally wake him up. He did not take any medication for the cough and it was not made better or worse by anything that he noticed. At his oncology appointment on [5-21] he reported worsening of this cough. A chest xray showed a right sided infiltrate with concern for a fungal process. He was started on Augmentin and azithromycin. He felt febrile last evening, but did not have a thermometer. He took Motrin and drove back from [Location (un) ] to his regular home. His temperature this AM was 98.7. By noon his temperature was 102.5. He called his oncologist and was sent to the ED for further evaluation and workup of his fevers. . In the ED, initial vs were: 102.5 130 113/58 26 100 on 4L. He was given a total of 2 L of normal saline and 1000 mg of acetaminophen. His blood pressures were in the low 90's during most of his stay in the ED. His respiratory rate increased to the 30's, but improved after treatment with a nebulizer. His heart rate improved to the 110's after fluids. He also received 100 mg of hydrocortisone. After discussion with the onc fellow, the patient was started on vancomycin and cefepime. His antifungal coverage was not increased. . Vital signs on transfer were: 102.8 98/43 112 22 99 on 4L. Initially on presentation to the [Hospital Unit Name 153], he reported being relatively comfortable, but tachypneic. Afterwards he developed on ongoing cough that was improved with guafenesin and a nebulizer. He stated that his breathing felt more comfortable than yesterday. . Review of sytems: Reports recent constipation, but now having regular bowel movements. He reports having a few episodes at home where he will not be able to get to the bathroom quick enough. He had some incontinence of urine last night, but denied dysuria or hematuria. He reports last night using the urinal and having a bowel movement at the same time on the floor. He reports being able to sense the bowel movement, but not being able to get to the toilet quick enough. Reports little appetite over the last day. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Denied arthralgias or myalgias. Past Medical History: Oncology History: SUMMARY OF CLL HISTORY: 1) He developed herpes zoster of the right cheek in [2143], treated with Valtrex. In [2143], he had recurrence of a cutaneous eruption involving the right cheek, but evaluation was felt inconsistent with recurrent herpes zoster and biopsies supported a clonal low-grade B-cell lymphoproliferation, perhaps "marginal zone B-cell lymphoma," reviewed by dermatologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 28984] at [Hospital1 112]. (2) This right face cutaneous eruption waxed and waned in early [2144], extending to involve the right nostril and skin to the left of midline underneath the nose. In follow-up evaluation a CBC showed leukocytosis (WBC = 22.7K), but differential was not obtained. He saw Dr. [Last Name (STitle) 28984] in follow-up who performed skin lesional punch biopsy of the superior nasolabial crease on [2145-4-7]. This showed skin involvement by CLL, without evidence of transformation. (3) Subsequently, he saw Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Company 2860], and flow cytometry of peripheral blood on [2145-4-28] confirmed a lymphocyte predominance by CLL; 3% of cells were positive for CD38. On [2145-4-28], torso CT scan at [Hospital1 112] showed extensive lymphadenopathy at multiple sites throughout the upper neck, chest, abdomen and pelvis, as summarized in my [2146-2-25] note. (4) Repeat CBCs in [5-11] again showed leukocytosis with lymphocyte predominance on differential. He saw hematologist Dr. [First Name4 (NamePattern1) 401] [Last Name (NamePattern1) 410] for a second opinion. At [Hospital1 18], WBCs = 13.6 and 17.9K with 76% and 66% lymphocytes on [2145-5-26] and [2145-5-31], respectively. Flow cytometry at [Hospital1 18] again confirmed CLL; however, 50% of B cells were CD38 positive. (5) In [5-11], he developed fevers and constitutional symptoms with marked fatigue and weight loss. On evaluation by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Company 2860], concern was raised regarding transformation of his CLL, and repeat torso CT scan was obtained on [2145-6-3], showing interval increase in some but not all areas of lymphadenopathy, as summarized in my [2146-2-25] note. However, subsequent evaluation by infectious disease specialist Dr. [First Name8 (NamePattern2) 1059] [Last Name (NamePattern1) 1057] at [Hospital1 18] disclosed erlichiosis, and therapy with doxycycline was begun. By [2146], he had noted marked improvement in his constitutional symptoms with resolution of fevers and stabilization of his weight, having had a 15-pound weight loss during his summer illness. (6) In [12-12], he developed bilateral otitis media, worse on the right, complicated by tympanic membrane perforation. Throughtout [Month (only) 404] and [2146-1-6] he noted progressive DOE. He saw Dr. [Last Name (STitle) ] at [Company 2860] on [2146-1-13] who noted 2 cm submandibular and inguinal lymph nodes, in addition to small anterior and posterior cervical and bilateral axillary lymph nodes. Chest exam was clear. WBC was now 60K, representing a tripling in WBC over 4 months. Peripheral blood FISH analysis on CLL cells was obtained showing abnormalities for the D13S319 13q14.3 and P53 17p13.1 probes in 4/100 and 70/100 nuclei, respectively. (7) In [2-9], he met pulmonologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2168] and cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171], who diagnosed and managed CHF. On lasix, he felt improved shortness of breath. However, on [2146-3-28] and [2146-4-11] he experienced "crashing" fevers and sweats. With progressive dyspnea, he was found to have markedly increased left pleural effusion and posterior pericardial effusion with RV collapse. Admitted to hospital on [2146-4-27], he ultimately underwent placement of a pericardial window, with drainage of left pleural and pericardial fluid, both showing CLL cells. However, evaluation of pericardial tissue showed organizing fibrinous material with entrapped mixed inflammatory cells, including numerous small lymphocytes consistent with CLL cells. However, there was no evidence of [Doctor Last Name 6261] transformation or otherwise, and CLL cells were regarded as "bystanders." The overall findings were those of an "organizing pericarditis, the cause of which is unclear." Of note, multiple specimens for various infectious diseases (see OMR) were negative except for [Location (un) ] B4 and B5 antibodies which were "8" rather than "less than 8." (8) On [2146-5-12], he was admitted to hospital from [6-2] to [2146-6-9] with progressive dyspnea related to worsening bilateral pleural effusions. Left thorascopic pleural biospy and talc pleurodesis were performed on [2146-6-6]. Pleural biopsy showed: "Extensive granulation tissue along with mesothelial proliferation and hemosiderin-laden macrophages are seen, consistent with the chronicity of the effusive process is present. No morphological evidence of large cell transformation or infection is seen. The morphology, supported by the concurrent flow cytometry immunophenotyping ([-6/2615]: CD20 dim, CD5-positive, CD23-positive, lambda light chain expression) is consistent with a diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma." Again, CLL was felt to be a "bystander" and not the cause of the pleural effusion. Of note, convalescent serum samples subsequently returned showing a rise in [Location (un) ] B5 antibody to a level of 32. Molecular analyses for Erlichia were negative on pleural tissue. He felt improved after talc pleurodesis. (9) With progressive symptomatic anemia and thrombocytopenia, he began his first chemotherapy for CLL on [2146-9-21], receiving cycle #1 of fludarabine/Cytoxan (without rituximab). On [2146-10-24], when peripheral blood lymphocytes declined below 50K, he received his first dose of Rituxin, given over 2 days. Further therapy with Fludara/Cytoxan was held due to persistent thrombocytopenia. On [2146-11-1], with persistent thrombocytopenia, he began weekly Rituxin X 4 with vincristine and prednisone 100 mg daily x5 added to Rituxin on [2146-11-8], followed by prednisone taper for presumed ITP. With subsequent improvement in platelet counts, he received R-CVP from [2146-11-23] to [2146-11-25]. On [2146-12-20], with substantial recovery in all blood counts, he received FCR, with FC administered on days 1 and 2, not day 3. Full-dose cycle 3 FCR was administered on days 1 through 3 beginning [2147-1-17]. (10)Due to worsening anemia and thrombocytopenia thought to be secondary to ITP as well as bone marrow involvement with CLL, he received a pulse of high-dose dexamethasone at the beginning of [9-12] with 4 doses of weekly rituximab and weekly vincristine on weeks 2 through 4 ([2147-9-14] through [2147-10-5]). On [2147-9-21], he began daily prednisone instead of dexamethasone pulsing. Thrombocytopenia improved but anemia persisted. (11) On [2147-10-16], he began Campath subcutaneously in an attempt to further unload CLL from bone marrow. On [2147-10-27], after five Campath doses, Campath was held secondary to WBC 0.4 with ANC 297 and increased anemia and thrombocytopenia. He received one week of weekly rituximab on [2147-10-23]. (12) Hospitalized [2147-12-27] to [2148-1-2] with febrile neutropenia attributed to viral infection. Blood cultures, urine culture, CMV viral load, adenovirus PCR, EBV PCR, Parvo 19 DNA negative and HHV-8 PCR and respiratory viral screen and cultures were all negative. Received Cefime and Neupogen with resolution of fever. (13) On [2148-10-10], with worsened severe thrombocytopenia attributed to ITP complicating progressive CLL, he resumed prednisone 1 mg/kg = 80 mg daily. 14) From [10-18] to [2148-10-20], he recieved cycle 1 cyclophosphamide plus 7 days dexamethasone (in lieu of prednisone). Cycle 1 was complicated by H1N1 infection with presumed superimposed aspergillosis, and he was in hospital with prolonged neutropenia. With persistent neutropenia, he received 4 weekly doses of rituximab in [11/2148] and again in [12/2148], ending on [2149-1-1]. Prednisone was resumed for ITP following hi-dose pulsed dexamethasone, and prednisone dosing has been tapered slowly. On [2149-2-18], we administered IVIg for hypogammaglobulinemia in the setting of his infection. On [2149-3-3], repeat chest CT showed marked improvement with near complete resolution of ground glass lung opacities, prompting infectious disease specialist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] to discontinue voriconazole therapy for aspergillosis. (15) Began RCD chemotherapy on [2149-4-29] for progressive thrombocytopenia, anemia, lymphadenopathy and neutropenia. (16) After four cycles of RCD chemotherapy, anemia and thrombocytopenia improved, and lymphadenopathy resolved. Decision made to hold off on further cycles due to prolonged leukopenia and increasing fatigue. . OTHER PMH: (1) History of basal cell carcinoma of skin. (2) Osteoarthritis of hands. (3) Urinary frequency with BPH. (4) Hyperplastic colonic polyp resected in [2-4] colonoscopy. (5) Ankle fracture in early [2128] complicated by DVT requiring coumadin anticoagulationx Social History: Retired banking lawyer. Lives on the [Hospital3 ], but spends the summers on [Hospital3 ]. Rare alcohol. Denies tobacco/illicits. Family History: Father had bladder cancer Physical Exam: Admission Exam: General: Alert, oriented HEENT: sclera anicteric, MMM Neck: supple, JVP not elevated Lungs: crackles at bases, rhonchorous breath sounds over right middle and upper lobes CV: Tachycardic Abdomen: soft, non-tender, slightly-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 2+ DP/PT pulses, 2+ LE edema. Neuro: sensation intact around perirectal area, appears to have good tone Discharge Exam: Deceased Pertinent Results: Admission Labs: [2150-5-23] 09:34PM TYPE-ART PO2-50* PCO2-22* PH-7.56* TOTAL CO2-20* BASE XS-0 [2150-5-23] 09:34PM LACTATE-1.5 [2150-5-23] 09:34PM O2 SAT-86 [2150-5-23] 05:35PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2150-5-23] 05:35PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG [2150-5-23] 05:35PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-<1 [2150-5-23] 05:35PM URINE MUCOUS-RARE [2150-5-23] 02:30PM LACTATE-1.7 [2150-5-23] 02:30PM HGB-8.5* calcHCT-26 [2150-5-23] 02:20PM GLUCOSE-127* UREA N-21* CREAT-0.8 SODIUM-131* POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-22 ANION GAP-15 [2150-5-23] 02:20PM estGFR-Using this [2150-5-23] 02:20PM ALT(SGPT)-52* AST(SGOT)-40 ALK PHOS-146* TOT BILI-0.7 [2150-5-23] 02:20PM LIPASE-13 [2150-5-23] 02:20PM cTropnT-0.03* [2150-5-23] 02:20PM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.8 [2150-5-23] 02:20PM WBC-5.4 RBC-2.51* HGB-8.2* HCT-25.3* MCV-101* MCH-32.8* MCHC-32.6 RDW-21.3* [2150-5-23] 02:20PM NEUTS-2* BANDS-0 LYMPHS-96* MONOS-0 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 OTHER-1* [2150-5-23] 02:20PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-2+ TEARDROP-OCCASIONAL BITE-1+ [2150-5-23] 02:20PM PLT SMR-RARE PLT COUNT-20* [2150-5-23] 02:20PM PT-12.8 PTT-31.0 INR(PT)-1.1 Blood cultures [2150-5-23] [2150-5-23] 2:20 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [2150-5-24]): GRAM NEGATIVE ROD(S). Reported to and read back by [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 28089] AT 14:40PM ON [2150-5-24]. Urine Culture [2150-5-23]: pending Imaging: CXR [2150-5-24]:Large opacity is identified within the right upper to mid lung zone, corresponding to the region of abnormality on prior chest radiograph, though significantly increased in size/severity compared to prior. The left lung is clear. There is no pneumothorax. No significant vascular congestion or pulmonary edema is identified. Mild blunting of the right costophrenic angle is unchanged from prior and likely represents a stable small effusion. A trace left effusion may also be present. Cardiomediastinal and hilar contours are within normal limits. IMPRESSION: 1. Large consolidation within the right upper lung zone, significantly increased in size since prior, probable pneumonia given the clinical history and increase in severity compared to prior. 2. Stable small right pleural effusion. Possible trace left pleural effusion. Brief Hospital Course: Mr. [Known lastname 28983] is a 65 year old man with advanced CLL which left him neutropenic for an extended period of time. He met SIRS criteria on admission with tachycardia, fevers and leukopenia. His CXR revealed a RUL consolidation concerning for pneumonia. He was broadly covered for bacterial pathogens with vancomycin and cefepime. He had been on voriconazole prophylaxis prior to admission which was expanded to ambisome for fungal coverage. He had a history of erlichia and was started empirically on doxycycline as he had spent time on [Hospital3 ] this season. His blood and urine was cultured, and beta glucan and galactomanan were assayed. Blood cultures would later show GNR. Despite treatment, he had persistent respiratory distress with increased work of breathing and hypoxia. He was clear that he did not want to be intubated and maintained a DNR/DNI order. He briefly tried non-invasive BiPAP mask ventilation for comfort the morning after his arrival, though this measure was poorly tolerated. After discussing with his family, he elected to focus his goals of care on comfort only. His antibiotics were discontinued. He was placed on a morphine drip and his respiratory distress was alleviated. He died several hours later at 14:30 on [2150-5-24] in the company of his family. An autopsy was declined. Medications on Admission: ENOXAPARIN 80 mg [Hospital1 ] LORAZEPAM - 0.5-1 mg Tablet QHS prn sleepiness METOPROLOL SUCCINATE - 25 mg PANTOPRAZOLE - 40 mg PENTAMIDINE [NEBUPENT] 300 mg(s) inhaled via nebulizer every 4 weeks PREDNISONE - 5 mg Tablet qAM, 2.5 mg qPM TAMSULOSIN - 0.4 mg Capsule VALACYCLOVIR - 500 mg Tablet [Hospital1 ] VORICONAZOLE [VFEND] - 200 mg Tablet [Hospital1 ] DIPHENHYDRAMINE HCL [BENADRYL] 25 mg QHS prn MULTIVITAMIN Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired ICD9 Codes: 486, 5119, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6203 }	Medical Text: Admission Date: [2197-6-24] Discharge Date: Service: MED CHIEF COMPLAINT: Coffee ground emesis. HISTORY OF PRESENT ILLNESS: This is an 87 year old man with a history of ETOH abuse, significant for drinking six or seven scotches per night, history of dilated cardiomyopathy, ejection fraction of 30 percent. He awoke two nights prior to admission, had four episodes of brownish ground coffee emesis. The patient was admitted on [2197-6-23]. No complaints of abdominal pain or retching. He also noted bright red blood, some dizziness, no shortness of breath and no weakness. He went to his primary care physician who sent the patient to the Emergency Department. In the Emergency Department, he had two more episodes of coffee ground emesis. Nasogastric lavage attempted but it was aborted secondary to a nosebleed. The patient's hematocrit had dropped from 44.0 percent to 35.0 percent. The patient was therefore admitted to the unit for evaluation of upper gastrointestinal bleed. PAST MEDICAL HISTORY: ETOH history. Hypertension. Chronic atrial tachycardia with a baseline heart rate of 100 to 110. Gout. Questionable atypical seizure disorder. Dementia. ALLERGIES: Aspirin sensitivity, nosebleeds. MEDICATIONS ON ADMISSION: 1. Toprol XL 12.5 mg p.o. once daily. 2. Digoxin 0.125 mg p.o. once daily. 3. Hydrochlorothiazide 25 mg once daily. 4. Allopurinol 300 mg once daily. 5. Mysoline 250 mg once daily. 6. Multivitamin. SOCIAL HISTORY: The patient lives with wife, retired, history of multiple jobs. History of drinking six or seven scotches per day. Nonsmoker. PHYSICAL EXAMINATION: The patient's vital signs are unremarkable except for heart rate of 108. Physical examination is notable for positive Dupuytren's contracture. No evidence of hepatosplenomegaly on examination. HOSPITAL COURSE: The patient was admitted for observation. Hematocrit was stable in the mid 30s overnight. He underwent esophagogastroduodenoscopy which was negative for any source of acute bleed. It was positive for what appeared to be friable esophageal mucosa consistent with Barrett's esophagitis as well as a C line which was displaced proximally. No biopsies were taken. At this point, the patient was treated with Protonix and discharged home on p.o. Protonix with follow-up with his primary care physician in one to two weeks with plans for referral for an outpatient esophagogastroduodenoscopy for biopsies to confirm the visual appearance of Barrett's esophagitis. The patient is to follow-up in six to eight weeks. MEDICATIONS ON DISCHARGE: The patient will be discharged on all his original outpatient medications in stable condition with addition of Protonix 40 mg once daily. 1. Toprol XL 12.5 mg p.o. once daily. 2. Digoxin 0.125 mg p.o. once daily. 3. Hydrochlorothiazide 25 mg once daily. 4. Allopurinol 300 mg once daily. 5. Mysoline 250 mg once daily. 6. Multivitamin. 7. Protonix 40 mg p.o. once daily. DISCHARGE DIAGNOSIS: Barrett's esophagitis. MAJOR PROCEDURES: Esophagogastroduodenoscopy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 18138] Dictated By:[Doctor Last Name 12733] MEDQUIST36 D: [2197-6-25] 11:18:25 T: [2197-6-25] 12:02:22 Job#: [Job Number 110950] ICD9 Codes: 4254, 4280, 5849, 2749, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6204 }	Medical Text: Admission Date: [2154-8-13] Discharge Date: [2154-8-19] Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1835] Chief Complaint: consulted for Subdural hematomas Major Surgical or Invasive Procedure: none History of Present Illness: 87M with a history of Parkinson's disease and atrial fibrilliation on coumadin, who presented to OSH after he was found down in his yard by a neighbor. The patient was able to describe that he was getting his mail and tripped and fell, hitting his head but no loss of concsciousness, although he does not recall exactly what happened. Per EMS, he had perserveration, but denied headache, neck pain, extremity pain or parasthesias. He was A+Ox 3 at OSH and upon arrival to [Hospital1 18] ED this afternoon. CT scan at OSH demonstrated bilateral subdural hematomas, L frontal hematoma 13mm and R frontal hematoma 4mm, with subarachnoid hemorrage extending into parietal convexities, without midline shift. INR 1.9. Received 2u FFP and Vit k prior to transfer. Of note, patient was offered surgery for his valvular disease a few months ago, but decided against it and made himself DNR status. Past Medical History: AFIB, parkinsons, CHF, aortic valvular disease Social History: lives alone. Occasionally smokes, no ETOH. Family History: non-contributory Physical Exam: PHYSICAL EXAM upon admission: T: 97.6 BP: 149/70 HR: 98 AF R 19 O2Sats 99% 4LNC Gen: WD/WN, comfortable, NAD. HEENT: MM dry, no teeth. Abrasion to central occiput, no hematoma. face is atraumatic Pupils: equal reactive to light 3->2mm Neck: Supple, non tender Lungs: course B/L, decreased bases. Cardiac: irregularly irregular Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake but drowsy, cooperative with exam, normal affect. Orientation: Oriented to person only. Was A+O x 3 earlier, now cannot name date or place Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 2mm bilaterally. 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. Strength full power [6-3] throughout. No pronator drift Sensation: Intact to light touch. Toes downgoing bilaterally Pertinent Results: CHEST RADIOGRAPH [2154-8-15] INDICATION: Intraparenchymal hemorrhage. COMPARISON: [2154-8-13]. FINDINGS: There is no relevant change. Moderate cardiomegaly, mild distension of the pulmonary vasculature. No evidence of pleural effusion, no focal parenchymal opacities suggestive of pneumonia. Head CT [2154-8-14]: FINDINGS: There is no significant change in multi-compartmental blood 13 hours after the most recent scan. There is slightly more intraventricular blood, but no evidence of obstruction. No new hemorrhage is seen. No evidence of herniation or other short interval change is seen. IMPRESSION: 1. No significant change in multi-compartmental blood 13 hours after the most recent scan. 2. Slight increase in intraventricular blood, but no evidence of obstructive hydrocephalus. Head CT [2154-8-13]: Final Report INDICATION: Fall and subdural hematoma, transferred from outside hospital. COMPARISON: Outside hospital study obtained at approximately 10 a.m. on [2154-8-13] Hospital. TECHNIQUE: Non-contrast head CT with additional bone algorithm reconstructions. FINDINGS: There is marked interval worsening of bifrontal subdural, subarachnoid, and intraparenchymal hemorrhage. A large focus of intraparenchymal hemorrhage in the left inferior frontal lobe measuring 2.3 x 3 cm was not noted on the prior study. There is also increased hemorrhagic component layering along the interhemispheric fissure and falx cerebri. Multiple bilateral foci of subarachnoid hemorrhage involving left inferior temporal, bilateral frontal, posterior frontoparietal are noted. There is mild perihemorrhagic edema most prominently noted in the left inferior frontal lobes without significant mass effect or shift of normally midline structures. There is no intraventricular hemorrhage, entrapment or hydrocephalus. Bilateral basal ganglia and insular cortex demonstrates old lacunar infarct. The basilar cisterns are preserved without evidence of downward transtentorial herniation. There is posterior soft tissue thickening with scalp hematoma noted superiorly. Air-fluid levels and mucosal thickening is noted in the left sphenoid and right maxillary antrum. There is also mucosal thickening in bilateral anterior and posterior ethmoid air cells, left maxillary sinus and middle sphenoid sinus. Small amount of air is noted in the cavernous sinus which could be iatrogenic. Additionally, there is also minimal opacification of bilateral mastoid air cells. Impacted right upper molar is noted in the right maxillary antrum. Osseous structures demonstrate nondisplaced midline frontal bone fracture. IMPRESSION: 1. Mild interval worsening of bifrontal subdural, subarachnoid and intraparenchymal hemorrhage. Additional foci of subarachnoid hemorrhage are also noted bilaterally involving the frontoparietal and inferior temporal regions. There is no intraventricular hemorrhage on the current study. 2. Small amount of air in the cavernous sinus could be iatrogenic. 3. Nondisplaced midline frontal bone fracture. 4. Mucosal thickening in multiple paranasal sinuses, and bilateral mastoid air cell opacification as described above. Brief Hospital Course: The patient was admitted on [8-13] to the ICU. He received FFP and factor IX to reverse his INR as well as vitamin K. He was put on mannitol to decrease swelling in the brain. He was also put on dilantin. The patient was DNR/DNI when he arrived to the hospital. Cardiology was consulted who agreed with giving him additional lasix due to his CHF history after receiving FFP. On [8-14] there was a family meeting and they decided to all him to be intubated if necessary for short-term. The patient's exam remained stable. He received FFP again on [8-15] and [8-16] for elevated INR. On [8-16] he was transferred to the stepdown unit. Over the weekend the patient's neuro exam became worse. The family decided to make him DNR/DNI again and to make him comfort measures only. Geriatrics was also consulted to help with his management. He was unresponsive on [8-19] in the morning but his pupils were reactive. He did have a grasp bilaterally and withdrew with the lower extremities. Palliative care was consulted and they recommended adding a morphine bolus in addition to the morphine drip. During the afternoon of [8-19] the patient's respirations were increasing and he received a morphine bolus. He expired at 3:45 on [8-19] and both his sons were notified shortly afterwards. Medications on Admission: coumadin 3mg daily, carbidopa/levo 25/250 QID, furosimide 40mg daily, lopressor 25mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: SDH Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[2154-8-19] ICD9 Codes: 4280, 4241, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6205 }	Medical Text: Admission Date: [2159-8-30] Discharge Date: [2159-9-6] Date of Birth: [2078-5-19] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2777] Chief Complaint: Lt groin pain Major Surgical or Invasive Procedure: [8-31]: OPERATIONS PERFORMED: Excision of left limb of aortofemoral bypass graft, and vein patch angioplasty of left superficial femoral artery at distal anastomosis with distal right greater saphenous vein. [9-4]: PROCEDURE: Debridement and delayed primary closure of left flank and left groin incision. History of Present Illness: 81M who presents w left groin pain for approx 24 hours. He is s/p aorto bifem in [2148]. In [2152] I and D of his left groin for infection and he underwent exploration of the left groin, detachment of left the limb from the common femoral artery, vein patch angioplasty of common femoral artery, excision of left limb, and reconstruction with interposition new graft segment for proximal left aortobifemoral graft to superficial femoral artery with rifampin impregnated 8 mm Dacron graft. He had a duplex at local hospital showing fluid around left limb of ABF graft approx 1 month ago. Now w the new left groin pain there is concern that the graft could be infected. He denies fevers/chills, rash, SOB, CP, abd pain, changes in bowel habits, N/V, or other complaints. Past Medical History: PMH: Hypercholesterolemia, PVD, hypothydroidism, BPH . PSH: appendectomy and hernia repair, aorto bifem ([2148]), [2152] - I and D of his left groin for infection w exploration of the left groin, detachment of left the limb from the common femoral artery, vein patch angioplasty of common femoral artery, excision of left limb, and reconstruction with interposition new graft segment for proximal left aortobifemoral graft to superficial femoral artery with rifampin impregnated 8 mm Dacron graft Social History: smokes 10 cigs/day for decades. Social drinker. Lives with wife at home Family History: n/c Physical Exam: PHYSICAL EXAM: VS: T 97.0, HR 75, BP 139/57, RR 19, 95%3L NC General: pleasant elderly man, NAD HEENT: PERRL, EOEMI, sclerae anicteric OP: MMM, no ulcers/lesions/thrush Neck: supple, no LAD, no thyromegaly Cardiovascular: RRR, normal S1, S2, no M/G/R Respiratory: CTA bilat w/o wheezes/rhonchi/rales Abdomen: surrounding area clean, dry, nonerythematous, minimally tender, not swollen Musculoskeletal: moving all extremities Ext: Warm and well perfused, no edema. L thigh wound closed, nonerythematous, slightlytender Lymph: no cervical, axillary, inguinal lymphadenopathy Skin: no rashes, no jaundice Neurological: aaox3 Psychiatric: non-anxious, normal affect Pertinent Results: [2159-9-6] 06:00AM BLOOD WBC-8.8 RBC-3.22* Hgb-10.0* Hct-29.6* MCV-92 MCH-31.1 MCHC-33.9 RDW-14.5 Plt Ct-270 [2159-9-6] 06:00AM BLOOD Plt Ct-270 [2159-9-6] 06:00AM BLOOD Glucose-108* UreaN-26* Creat-1.6* Na-139 K-3.8 Cl-110* HCO3-21* AnGap-12 [2159-9-6] 06:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.3 [2159-9-6] 06:00AM BLOOD Vanco-19.9 [2159-8-30] 09:30AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.018 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2159-8-31] 11:45 am SWAB PERI GRAFT H ILIAC. GRAM STAIN (Final [2159-8-31]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2159-9-2]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [2159-8-30] 9:30 am URINE Site: CLEAN CATCH URINE CULTURE (Final [2159-8-31]): <10,000 organisms/ml. [2159-8-31] 2:17 pm MRSA SCREEN Site: NARIS (NARE) MRSA SCREEN (Final [2159-9-3]): No MRSA isolated. [2159-8-31] 12:10 pm FOREIGN BODY LEFT FEMORAL GRAFT. WOUND CULTURE (Final [2159-9-5]): NO GROWTH. FINDINGS: New right PICC terminates within the mid to lower superior vena cava. Cardiomediastinal contours are within normal limits. Left retrocardiac opacity probably reflects atelectasis, but developing pneumonia should also be considered in the appropriate clinical setting. The study and the report were reviewed by the staff radiologist. US: Ultrasonography of the left upper extremity is negative for DVT but the entire cephalic vein is occluded around the PICC site ECHO: Conclusions The left atrium and right atrium are normal in cavity size. A patent foramen ovale is present. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (mobile) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are complex (>4mm) atheroma in the abdominal aorta. The aortic valve leaflets (3) are mildly thickened. The study is inadequate to exclude significant aortic valve stenosis. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild mitral regurgitation is seen. Brief Hospital Course: On admission: Pt did have elevated creatinine. He was hydrated before CTA. Was given PO mucomyst and IV Bicarb. Also Gentle hydration. On DC creatinine is stable. I CTA IMPRESSION: 1. Large 7.7 x 5.8 x 27.1-cm fluid collection surrounding the left aortofemoral graft with inferior components of higher attenuation that is most compatible with hematoma. In addition, on post-contrast images, some evidence of active extravasation. Overall, these findings have characteristics compatible with pseudoaneurysm. Superinfection cannot be excluded. Recommend clinical correlation. 2. 17 x 10-mm hypoattenuating lesion within the uncinate process of the pancreas incompletely characterized, could either represent pancreatic cystic neoplasm or side branch IPMN, with interval growth since [1-9]. Recommend MRCP on non- urgent basis for further evaluation. Mr. [Known lastname ], [Known firstname 1955] was then admitted on [8-30] with Infected aortobifemoral artery bypass graft. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. Broad spectrum Antibiotics given. ID consult obtained. Pt to have 6 weeks ov Vancomycin, PO Cipro, PO Flagyl. He does have follow-up in [Hospital ] clinic. He will probably need long term PO suppression therapy. It was decided that she would undergo a: O7/24. PERATIONS PERFORMED: Excision of left limb of aortofemoral bypass graft, and vein patch angioplasty of left superficial femoral artery at distal anastomosis with distal right greater saphenous vein. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. He was then transferred to the CVICU for further recovery. While in the CVICU he recieved monitered care. He had a VAC placd. JP bulbs to suction. Extubated POD # 2. Pt did have post op anemia secondary to blood loss. Transfused 2 units PRBC. On DC HCT is stable. He was transfered to the VICU for further care. He was delined. His diet was advanced. A PT consult was obtained. PICC line placed. Wound Vac taken down, it was then decided to primary close the wound. Pt pre-op'd. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. [9-4]: PROCEDURE: Debridement and delayed primary closure of left flank and left groin incision. He tolerated the proceure well without complications. He was then transfered to the PACU for further care. Once recovered from anesthesia. He was transfered to the VICU. for further care. [Last Name (un) ] in the VICU, it was noticed that he had swelling in his LUE. An US revealed cephalic vein thrombois. His PICC was Dc'd. Another PICC was placed in his RUE. A CXR revealed tip in the SVC. Once stabl from the VICU setting, he was transfered to the Floor. On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged to a rehabilitation facility in stable condition. He has an appointmentwith ID in 5 weeks and Vascular in 2 weeks Medications on Admission: synthroid 0.15mg/daily flomax 0.4mg/daily simvastatin 20mg QD, fludrocortisone0.1mg/daily Discharge Medications: 1. PICC LINE Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 2. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 5 weeks: Follow trough and creatinine. 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 weeks. 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 5. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO four times a day: prn. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): DC when ambulatory. 10. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 weeks. 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Outpatient Lab Work Please draw weekly LFT, CBC with Diff, Vanco trough, BUN and creatinine. Fax the results to [Telephone/Fax (1) 432]. Dr [Last Name (STitle) 23383] Office. Discharge Disposition: Extended Care Facility: [Hospital 392] Rehabilitation & Nursing Center - [Hospital1 392] Discharge Diagnosis: Infected aortobifemoral artery bypass graft Hypercholesterolemia, PVD, hypothydroidism, BPH Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [3-13] 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 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2159-9-20] 4:10. This is in the [Last Name (un) ] building. [Doctor First Name ]. [Location (un) 442] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13896], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2159-10-16] 11:30. This is in the [Last Name (un) ] building. [Doctor First Name ]. Basement Completed by:[2159-9-6] ICD9 Codes: 5849, 2851, 2720, 2449, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6206 }	Medical Text: Admission Date: [2147-4-12] Discharge Date: [2147-4-18] Date of Birth: [2147-4-12] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: [First Name8 (NamePattern2) ] [Known lastname ] is the former 3.025 kg product of a 37 week gestation pregnancy [Known lastname ] to a 36 year old gravida 5, para 2 to 3 woman, prenatal screens of blood type A positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative, Group B Streptococcus negative. PAST MEDICAL HISTORY: Notable for chronic hypertension. Her prenatal course was unremarkable except for continued hypertension. She was admitted for elective induction of labor, rupture of membranes occurred three hours prior to delivery. There was no maternal fever. Second stage of labor was 18 minutes. The baby was [Name2 (NI) ] by spontaneous vaginal delivery with Apgars of 8 at one minute and 8 at five minutes. A nuchal cord was noted at the time of delivery. The baby was admitted to the [Name (NI) ] Nursery. She exhibited symptoms of grunting, flaring and retracting. These persisted and she was admitted to the Neonatal Intensive Care Unit for further observation and treatment. PHYSICAL EXAMINATION: Physical examination upon admission to the Neonatal Intensive Care Unit, weight was 3.025 kg, length 48 cm, head circumference 34.5 cm. General: Pink infant in nasal cannula oxygen, skin pink, no lesions. Head, eyes, ears, nose and throat: Soft anterior fontanelles, normal facies, intact palate. Chest: Mild grunting and retraction, fair air entry. Cardiovascular: No murmur. Femoral pulses present. Abdomen: Soft, nontender, no hepatosplenomegaly. Genitourinary: Normal external genitalia, patent anus. Musculoskeletal: Stable hips, small ecchymosis on the dorsal aspect of the right forearm, normal perfusion. Neurologic: Normal tone and activity. HOSPITAL COURSE: (By systems including pertinent laboratory data). 1. Respiratory - [Doctor First Name ] required nasal cannula oxygen through the first four days of life. She weaned to room air at 9 AM on [2147-4-16]. A chest x-ray was consistent with transient tachypnea of the [Year (4 digits) 19402]. At the time of discharge, she is breathing comfortably in room air with respiratory rates in the 30s to 60s. 2. Cardiovascular - [Doctor First Name ] maintained normal heart rates and blood pressures. No murmurs have been noted. 3. Fluids, electrolytes and nutrition - Breastfeeding was started on day of life #2. Intravenous fluids had been started and were gradually weaned. At the time of discharge she has been exclusively breastfeeding or taking Enfamil p.o. ad lib for three days prior to discharge. Discharge weight is 2.735 kg which is 6 pounds 0.5 ounces, this also represents her low weight since birth. 4. Infectious disease - Due to the unknown etiology of the respiratory distress, [Doctor First Name ] was evaluated for sepsis at the time of admission to the Neonatal Intensive Care Unit. A white blood cell count was 22,000 with a differential of 83% polymorphonuclear cells and 3% band neutrophils. A blood culture was obtained prior to starting intravenous ampicillin and gentamicin. The blood culture showed no growth at 48 hours and the antibiotics were discontinued. 5. Gastrointestinal - Peak serum bilirubin occurred on day of life #4, total of 13/0.3 mg/dl direct with an indirect of 12.7 mg/dl. Repeat on the date of discharge is total of 10.8/0.2 with a new direct of 10.6 mg/dl. 6. Hematology - Hematocrit at birth was 41.2%. [Doctor First Name ] did not receive any transfusions with blood products. 7. Neurology - [Doctor First Name ] has maintained a normal neurological examination during admission. There are no neurological concerns at the time of discharge. 8. Sensory - Audiology, hearing screen was performed with automated auditory brain stem responses, [Doctor First Name ] passed in both ears. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2406], [First Name3 (LF) ] Pediatric Associates, [Last Name (NamePattern1) 38165], [Hospital1 47973] [Numeric Identifier 54550], phone [Telephone/Fax (1) 38162], fax #[Telephone/Fax (1) 38163]. CARE/RECOMMENDATIONS AT DISCHARGE: 1. Feeding - Breastfeeding ad lib. 2. Medications - None. 3. Carseat position screening - Performed, [Doctor First Name ] was observed for 90 minutes in her carseat without episodes of bradycardia or oxygen desaturation. 4. State [Doctor First Name 19402] screen - Sent [2147-4-16] with no notification of abnormal results to date. 5. Immunizations received - Hepatitis B vaccine was administered on [2147-4-16]. 6. Immunizations recommended - I. 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: [Month (only) ] at less than 32 weeks; [Month (only) ] between 32 and 35 weeks with two of the following - Daycare during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities or school-age siblings; or with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW UP APPOINTMENTS: Appointment with Dr. [Last Name (STitle) 2406] within five days of discharge. DISCHARGE DIAGNOSIS: 1. Respiratory distress secondary to transient tachypnea of the [Last Name (STitle) 19402]. 2. Suspicion for sepsis, ruled out. 3. Unconjugated hyperbilirubinemia. Reviewed By: [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36250] Dictated By:[Last Name (Titles) 37548] MEDQUIST36 D: [2147-4-18] 06:36 T: [2147-4-18] 06:40 JOB#: [Job Number 54551] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6207 }	Medical Text: Admission Date: [2112-4-26] Discharge Date: [2112-5-2] Date of Birth: [2064-12-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Asymptomatic with Asc. Aortic Aneurysm Major Surgical or Invasive Procedure: [2112-4-26] Redo-Sternotomy, Asc. Aorta and Hemiarch Replacement with 26mm Gelweave Graft History of Present Illness: 49 y/o male who underwent coarctation repair at age 16 and an AVR in [2103] who underwent an MRI which revealed an ascending aortic aneurysm. He was then referred for surgical management of this aneurysm Past Medical History: Bicuspid Aortic Valve s/p Aortic Valve Replacement [2103], Coarctation of Aorta s/p surgical repair at age 16, Hypertension, s/p foot surgery Social History: Denies tobacco use. Admits to 1 alcoholic beverage/day. Family History: non-contributory Physical Exam: PE: 79, 14, 138/73, 69", 245lbs General: WDWN male in NAD, obese Skin: Well-healed sternotomy and thoracotomy HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM, -JVD, -carotid bruits Chest: CTAB -w/r/r Heart: RRR, soft SEM Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, -varicosoties Neuro: MAE, A&O x 3, Non-focal Discharge Vitals 99.0, 88 SR, 104/60, 18 RA sat 96% wt 114.9kg Neuro A/O x3 nonfocal Pulm CTA except decreased at bases Cardiac RRR no murmur/rub/gallop Sternal inc: No drainage/erythema sternum stable staples intact Abd soft, NT, ND +BS Leg inc Right groin staples no erythema/drainage Pertinent Results: [2112-5-1] 03:55AM BLOOD WBC-12.8* RBC-3.10* Hgb-9.5* Hct-27.4* MCV-88 MCH-30.5 MCHC-34.5 RDW-13.8 Plt Ct-335 [2112-4-26] 12:35PM BLOOD WBC-14.4# RBC-2.78# Hgb-8.7# Hct-24.7# MCV-89 MCH-31.2 MCHC-35.1* RDW-13.8 Plt Ct-161 [2112-5-1] 03:55AM BLOOD Plt Ct-335 [2112-4-28] 02:25AM BLOOD PT-13.2* PTT-26.0 INR(PT)-1.1 [2112-4-26] 12:35PM BLOOD Plt Ct-161 [2112-4-26] 12:35PM BLOOD PT-17.6* PTT-33.4 INR(PT)-1.6* [2112-5-1] 03:55AM BLOOD Glucose-150* UreaN-26* Creat-0.9 Na-136 K-3.8 Cl-95* HCO3-32 AnGap-13 [2112-4-26] 02:17PM BLOOD UreaN-14 Creat-0.7 Cl-114* HCO3-23 [2112-5-1] 03:55AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.5 EKG Sinus rhythm Consider left atrial abnormality Left bundle branch block Since previous tracing of [2112-4-19], no significant change Read by: [Last Name (LF) ],[First Name3 (LF) 177] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 190 148 426/464.42 55 37 121 * Report not finalized * PRELIMINARY REPORT PATIENT/TEST INFORMATION: Indication: Intra-op TEE for Ascending aorta aneurysm repair Height: (in) 69 Weight (lb): 245 BSA (m2): 2.25 m2 BP (mm Hg): 124/68 HR (bpm): 72 Status: Inpatient Date/Time: [2112-4-26] at 09:41 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW209-9:4 Test Location: Anesthesia West OR cardiac Technical Quality: Suboptimal REFERRING DOCTOR: DR. [First Name (STitle) 412] [Last Name (Prefixes) 413] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.7 cm Left Ventricle - Fractional Shortening: 0.27 (nl >= 0.29) Left Ventricle - Ejection Fraction: 55% (nl >=55%) Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm) Aorta - Ascending: 4.5 cm (nl <= 3.4 cm) Aorta - Arch: 2.5 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 2.4 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: 2.3 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 22 mm Hg Aortic Valve - Mean Gradient: 14 mm Hg Aortic Valve - LVOT Peak Vel: 1.17 m/sec Aortic Valve - LVOT VTI: 33 Aortic Valve - LVOT Diam: 1.9 cm INTERPRETATION: Findings: Very poor echo windows throughout RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Moderately dilated ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. Mild coarctation of distal aortic arch. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Normal AVR leaflets. Normal AVR gradient. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. No MS. Trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally post-bypass data Conclusions: PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta is moderately dilated with maximum dimensions of 4.5, the most proximal part of the arch that is seen is 2.5 cm in diameter. There is a mild coarctation of the distal aortic arch, just distal to take off of the Left subclavian artery narrowing down to 1.7cm briefly before enlarging to 2.4 cm. 5. A bioprosthetic aortic valve prosthesis is present. The prosthetic aortic leaflets appear normal The transaortic gradient is normal for this prosthesis. The EOA of this valve is 1.5 cm2 . No aortic regurgitation is seen. 6. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. 7. There is no pericardial effusion. POST-BYPASS: Pt is being A paced and is on an infusion of phenylephrine 1. Biventricular function I spreserved 2. Aorta valve opens well. No AI seen 3. A graft is seen in the ascending aorta 4. Other findings are unchanged [Location (un) ] PHYSICIAN: Reason: CT removal and TLCL change over wire [Hospital 93] MEDICAL CONDITION: 47 year old man s/p Asc. Aorta and Hemi-Arch Replacement. Please page [First Name8 (NamePattern2) ] [Doctor Last Name ] at [Numeric Identifier 8570] with abnormalities. REASON FOR THIS EXAMINATION: CT removal and TLCL change over wire CLINICAL HISTORY: Status post aortic arch replacement with tube removed, evaluate for pneumothorax. The left chest tube has been removed. The right chest tube remains in situ. No pneumothorax is identified. The upper left rib resection is again noted. Some atelectasis and left effusion is now present. IMPRESSION: Left effusion, no pneumothorax. DR. [First Name11 (Name Pattern1) 3347] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 5034] Approved: [Doctor First Name ] [2112-4-28] 4:36 PM Brief Hospital Course: Mr. [Known lastname ] was a same day admit after undergoing all preoperative work-up as an outpatient. On day of admission he was brought to the operating room where he underwent a redo-sternotomy, ascending aorta and hemiarch replacement. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. He remained intubated overnight and post-op day one he was weaned from sedation, awoke neurologically intact and extubated. Beta blocker and diuretics were started and he was gently diuresed towards his pre-op weight. On post-op day two his chest tubes and epicardial pacing wires were removed. Following this he was transferred to the telemtry floor for the remainder of his hospital course. Physical therapy followed patient during his post-op course for strength and mobility. He continued to progress and was ready for discharge home with services POD 6. Medications on Admission: Zocor 20mg qd, Aspirin 81mg qd, Lopressor 50mg [Hospital1 ], Lisinopril 20mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s)* Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 5. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for hiccup for 3 days. Disp:10 Tablet(s) Refills:0 6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:135 Tablet(s) Refills:0 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 10 days. Disp:40 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO BID (2 times a day) for 10 days. Disp:40 Packet(s) Refills:0 Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Ascending Aortic Aneurysm s/p Redo-Sternotomy, Asc. Aorta and Hemiarch Replacement PMH: Bicuspid Aortic Valve s/p Aortic Valve Replacement [2103], Coarctation of Aorta s/p surgical repair at age 16, Hypertension, s/p foot surgery Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use lotions, powders, or creams on wounds. Call our office for temp>101.5, sternal drainage. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) 656] in [2-27] weeks Dr. [Last Name (STitle) 12300] in [1-26] weeks Wound check [Hospital Ward Name 121] 2 friday [2112-5-6] Completed by:[2112-5-4] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6208 }	Medical Text: Admission Date: [2147-2-10] Discharge Date: [2147-3-14] Service: HISTORY OF PRESENT ILLNESS: The patient was transferred from [Hospital 1474] Hospital with a left brain tumor seen on CT scan today. The patient is an 83 year old male with a six week decline in language and motor coordination. Family first noticed some word finding difficulty around [Holiday 1451] but more concerned about confusion of his orientation starting four to six weeks ago. The patient also has headache and gait nystagmus thought to be secondary to his tumor, carotid stenosis and possible transient ischemic attack. He talked with his primary care physician yesterday and told to come to [Hospital 1474] Hospital today for CT scan. Large left hemispheric mass with edema and shift was noted. MRA was done at [Hospital 1474] Hospital. The patient loaded with Dilantin and given 10 mg of Decadron. There is concern of aphasia and the patient is unable to provide history. History is per family. PHYSICAL EXAMINATION: Heart rate in the 60s, blood pressure 162/70, respiratory rate 12, oxygen saturation 98% in room air. In general, the patient was awake and alert and attentive to examination. Speech is fluent yet unintelligible. The patient is able to follow simple two steps commands. The pupils are 3.0 to 2.0 and reacted to light symmetrically. Extraocular movements are intact. He has a right facial droop. Tongue is midline, palate elevates symmetrically. There is increased tone in the lower extremities bilaterally. Strength is [4-24] throughout except right interosseous in hands, [3-25]. There is a question of a slight right sided drift. Reflexes 2+ in the knees and ankles and 3+ in the left upper extremity and 2+ in the right upper extremity. Chest is clear to auscultation bilaterally. Cardiac is regular rate and rhythm, no murmurs. The abdomen is soft, nontender, nondistended. On MR, there is a large 4.0 by 6.0 centimeter mass left parietal temporal frontal lobe, appears to arise from meninges, minimal in appearance by T1, edema on T2 and FLAIR that is enhancing with an irregular shape, no cystic component, midline shift with edema throughout left hemisphere. HOSPITAL COURSE: The patient was admitted to the hospital and started on q1hour neural checks. His blood pressure was maintained less than 160. He was started on Dilantin 100 mg three times a day and Decadron 8 mg q6hours for the edema. Fluid was restricted to one liter. The patient was admitted to the Intensive Care Unit for close attention to all these things and availability of wider range of medicinal means to control blood pressure. Early on while in the Intensive Care Unit, the patient became delirious and concern of ethanol withdrawal was addressed. The patient was given Thiamine and Folate as well as Ativan p.r.n. The patient's operative procedure was initially delayed because there was concern the patient may have severe heart disease and arterial disease. The patient was seen by Cardiology but in the end, angiography and further intervention was held due to the feeling that the meningioma that the patient had was more important. As the patient's surgical procedure approached, the patient had an acute myocardial infarction, being ruled in with cardiac enzymes, which put off his surgery for some time while the patient was treated and allowed to improve post myocardial infarction. It was the impression of the neurosurgical team to transfer the patient to the floor post myocardial infarction for a period of convalescence until such time that he was able to go to surgery. However, the patient developed fever and was determined to have positive blood cultures and positive sputum, sputum positive for gram negative rods, blood for gram positive cocci in pairs and clusters. The patient was started on Vancomycin and Levofloxacin. The patient was then confirmed to have pseudomonas in his sputum. His blood had coagulase negative Staphylococcus and his urine had coagulase negative Staphylococcus. He also had a catheter tip with fifteen colonies of bacteria growing. His antibiotics were changed to Vancomycin, Ciprofloxacin and Ceftazidime. The patient remains in the Intensive Care Unit while on antibiotics and allowed to improve over time with regards to his myocardial infarction and pneumonia. While waiting for the surgery, the patient's mental status continued to decline and the patient appeared to become very depressed. Psychiatry was consulted. The patient was determined not to be an appropriate figure to make his own medical decisions at that time and that responsibility was left to the family. Finally on [2147-3-2], the patient went to the operating room where the left frontotemporal craniotomy was performed and resection of his meningioma was accomplished. The patient tolerated the procedure well and was returned to the Intensive Care Unit postoperatively. The patient had a slow recovery time as he remained very confused and somewhat somnolent postoperatively. The patient did, however, improve somewhat and his activity was advanced and he was able to sit up in a chair and subsequently began to walk with assistance. He has persistently failed swallow studies but at the family's request, he has been allowed to take small amounts of food by mouth. The patient is now transferred to the regular floor. He is receiving physical therapy and is being screened for rehabilitation and the patient will likely go to a rehabilitation facility. He will need to follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1327] in one to two weeks. The patient may shower and observe regular activity. Prior to discharge, he will be evaluated again by speech and swallowing. Decision was to be made whether or not to give him a percutaneous endoscopic gastrostomy tube prior to discharge. Also, postoperatively, the patient suffered from a ventricular tachycardia for which cardiology was consulted. The patient was treated with Diltiazem drip and finally with Amiodarone 800 mg once daily times one week, 400 mg once daily times two months and 200 mg once daily thereafter. [Name6 (MD) 1339] [Last Name (NamePattern4) 1340], M.D. [MD Number(1) 1341] Dictated By:[Last Name (NamePattern4) 8358] MEDQUIST36 D: [2147-3-13] 09:09 T: [2147-3-14] 19:22 JOB#: [Job Number 48947] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6209 }	Medical Text: Admission Date: [2154-9-21] Discharge Date: [2154-9-28] Date of Birth: [2154-9-21] Sex: M Service: NEONATOL male admitted to the NICU secondary to prematurity. Mom is a 16-year-old G1, P0-1, Hispanic female from [Country 7192]. Prenatal screens: B-positive, antibody negative, RPR negative, GC negative, Chlamydia positive, HIV negative, PPD negative, GBS unknown. Dating by last menstrual period and 16-week ultrasound. Treated for Chlamydia with two subsequently negative At 48 hours prior to delivery, she was seen at a regular rate down to the 90s. She was sent to [Hospital6 1597] labor and delivery, where preterm labor and decelerations were noted, along with primary genital herpes. She was started on magnesium sulfate and betamethasone and transferred to the [Hospital Ward Name 26168] [First Name (Titles) ] [Last Name (Titles) ] for care. Ultrasound at the [Hospital Ward Name 26168] [First Name (Titles) ] [Last Name (Titles) ] revealed a breech with low amniotic fluid index, with no history of ruptu re of membranes. Estimated fetal weight 1468 grams. She continue d on magnesium sulfate, a second dose of betamethasone was given around [9-20] at 4:45 p.m., about 20 hours prior to delivery, and she was started on acyclovir. Delivery was by cesarean section with intact membranes secondary to preterm labor. Oligohydramnios, intrauterine growth restriction, and breech with primary herpes infection. The delivery was done under general anesthesia, rupture of membranes was at delivery. Baby required blow-by O2 and CPAP with vigorous stim. Mild grunting was noted. Apgars were 6 at one minute and 8 at five minutes. The baby was transferred to the [Name (NI) ] Intensive Care Unit for further care. SOCIAL HISTORY: Mother is a teen from [Country 7192] and [Name (NI) 45534] only. Father of baby is in [Country 7192] and may not know of this pregnancy. Mother's family reportedly is supportive and she plans to breast-feed. PHYSICAL EXAMINATION ON ADMISSION: Premature male, pink in room air, mild retractions, temperature 97??????, pulse 118, respiratory rate 64, blood pressure 54/24 with a mean of 32-65/29 with a mean of 42. O2 sat greater than 95% in room air. Birth weight 1665, 40th percentile, length 42.5 cm, 40th percentile, head circumference 29 cm, 25th percentile. Discharge weight 1650 grams. Anterior fontanel flat, non-dysmorphic, intact palate. Clear breath sounds. No murmur. Normal pulses. Soft abdomen. No HSM. Three-vessel cord. Normal male genitalia, both testes descended, patent anus. No hip click, no sacral dimple. Mongolian spot on buttocks and bruises on back. No rash or skin lesions consistent with herpes active. Breech position, normal tone. REVIEW OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Baby remained in room air with no respiratory distress. Baseline respiratory rate is 30 - 50s. No issues. CARDIOVASCULAR: Baby was noted to have a low resting heart rate initially of 97 - 100, currently is 140s - 160s, stable blood pressure. Baby did not require pressor support during this admission. Baseline blood pressure is 50-60s/30-40s with means in the 40s to 50s. There is no murmur. FLUID AND ELECTROLYTES: Baby initially was NPO with peripheral IV fluids of D10/W started at 80 cc/kg. He received one bolus of D10/W 2 mg/kg for a dextrose of 33. Subsequent dextroses have all been greater than 60. The baby had enteral feedings introduced on day of life #1. He advanced to full enteral feedings at 150 cc/kg of PE24. He still requires some PG feedings and has an occasional small aspirate of non-digested formula. The baby is voiding and stooling without issue. He has been noted to have a small rectal fissure. Occasionally has a slightly positive stool with no visible blood. Electrolytes have been stable with the last ones on [9-24] 143, 4.0, 107, 25. At that time, total fluids were 120 cc/kg. Baby has been advanced to 150 cc/kg as stated above. GI: Baby demonstrated physiologic jaundice with a peak bilirubin on day of life 4 of 8.4/0.3, was under single phototherapy which was turned off on [2154-9-27] for a bilirubin of 4.7/0.3. Rebound bilirubin on [2154-9-28] was 5.3/0.2. HEMATOLOGY: Baby did not require any blood transfusions during this admission. Hematocrit on admission was 52.5. ID: Baby had an initial blood culture and CBC with a white count of 5.7, 45 polys, 0 bands, platelet count of 325 and a hematocrit of 52.5. He was started on 48 hours of ampicillin and gentamicin. Blood cultures remained negative and baby was clinically stable at 48 hours and antibiotics were discontinued. He had a herpes skin culture sent on [2154-9-22] which has remained negative to date. Plan is to allow mother to breast-feed once her lesions are all crusted over per resource of the red book. NEUROLOGY: The baby has been neurologically appropriate. Head ultrasound was not done based on gestational age. Baby's exam is appropriate for gestational age. Sensory audiology screening has not been done at this time. Recommend prior to discharge. Ophthalmology exam - not examined based on gestational age of greater than 32 weeks. CARE RECOMMENDATIONS: 1. Continue PE24 150 cc/kg/day PO/PG, encourage oral feeding. 2. Car seat screening has not been done at the time of transfer. 3. State [Year (4 digits) 19402] screen was sent on [2154-9-24], repeat will be due on [2154-10-5]. 4. Immunizations received - none to date as the baby is less than 2 kilograms. Synagis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following 3 criteria: a. Born at less than 32 weeks. b. Born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household or with preschool siblings c. With chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach siz months of age. Before this age, the family and other caregivers should be conbsidered for immunization against influenza in order to protect the infant. FOLLOW_UP APPOINTMENTS: Primary care physician per routine. None planned at this time. DISPOSITION: Transfer to [Hospital6 1597] for further care until maturation adequate for discharge home. DISHCARGE DIAGNOSES: 1. Former 33-2/7 week premature male. 2. Status post transitional respiratory distress 3. Status post rule-out sepsis 4. Status post rule out herpes 5. Status post physiologic hyperbilirubinemia DR.[Last Name (STitle) ],[First Name3 (LF) ] 50-622 Dictated By:[Last Name (NamePattern1) 45535] MEDQUIST36 D: [2154-9-28] 13:11 T: [2154-9-28] 13:21 JOB#: [Job Number 45536] ICD9 Codes: 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6210 }	Medical Text: Admission Date: [2118-10-22] Discharge Date: [2118-10-26] Service: [Hospital1 ] CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: This is a [Age over 90 ] year-old woman with a history of breast cancer, coronary artery disease status post myocardial infarction, peptic ulcer disease, who presented on the date of admission with chest pain and shortness of breath. On route to the Emergency Department the patient received Lasix, nitroglycerin, aspirin and arrived in the Emergency Department pain free. In the Emergency Department she was noted to have anterior and lateral ST depression of 1 mm on her electrocardiogram. She had troponin peak of 6.0. She was started on heparin. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [2117-9-4]. 2. Chronic obstructive pulmonary disease. 3. Hypertension. 4. Peptic ulcer disease diagnosed in [2117-12-4]. The esophagogastroduodenoscopy demonstrated localized friable tissue and erythema with mild oozing in the stomach body over an area of 4 by 2 cm. 5. Diverticulosis. 6. History of herpes zoster. 7. Status post cholecystectomy. 8. TAH/BSO. 9. Rectal prolapse status post repair in [2117-12-4]. 10. Breast cancer, infiltrative ductal status post surgery and radiation therapy in [2112]. 11. Congestive heart failure. 12. Question dementia. 13. Chronic renal failure with a baseline creatinine of 1.5 to 2.0. ALLERGIES: Sulfa, Carafate, aspirin. MEDICATIONS: Lipitor 10 mg po q.h.s., Lasix 40 mg po q day, Imdur 30 mg po q day, Prevacid 30 mg po q.a.m., Lisinopril 10 mg po q day, Metoprolol 25 mg po b.i.d., multivitamins one q.d., Spironolactone 50 mg po q day, Mirtazapine 15 mg po q.h.s., Zolpidem 5 mg po q.h.s. FAMILY HISTORY: Unknown. SOCIAL HISTORY: The patient lives at home with 24 hour caretakers. She is widowed. She has occasional alcohol use. She has a twenty pack year tobacco use, but quit in [2111]. No drug use known. PHYSICAL EXAMINATION: Temperature 96. Heart rate 80. Blood pressure 200/74, 30, 94% on room air. Ill appearing female sitting up in bed. HEENT mucous membranes are moist. Pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. JVD could not be assessed. Lungs [Year (4 digits) ] expiratory wheezes with crackles at bilateral bases left greater then right. Cardiovascular regular rate and rhythm, 2 out of 6 systolic ejection murmur at the left lower sternal border. Abdomen soft, nontender, nondistended. Positive bowel sounds. Extremities no pedal edema. Dry skin. Neurological alert and oriented to place and time. LABORATORY: White blood cell 13.2, hematocrit 32.9 decreased to 26, platelets 316. Chem 7 136, potassium 6.2, chloride 103, bicarb 20, BUN 64, creatinine 2.6, glucose 163, INR 1.2. Electrocardiogram normal sinus rhythm with a [Street Address(2) 4793] depression in 1, V4 through V6. HOSPITAL COURSE: 1. Cardiovascular: The patient was admitted for rule out myocardial infarction. While in the Emergency Department she was given a heparin drip. She had a troponin peak of 6.0 with normal CKs. Three hours later she was sitting on the commode and experienced left lower extremity shaking. Blood pressure decreased to 86/55. She returned to bed and then had several episodes of hematemesis. The heparin and aspirin were discontinued. The patient was medically managed for her myocardial infarction with Metoprolol. She was transferred to the Intensive Care Unit at which time her cardiovascular status remained stable. She did not experience any arrhythmias or episodes of congestive heart failure. Her diuretics were also discontinued secondary to her volume depletion. She remained without congestive heart failure and was discharged to home without her diuretics. She had an echocardiogram, which demonstrated an ejection fraction of 50 to 55%. The patient was also switched from Lisinopril to Mavic for its greater tissue affinity and less decrease in blood pressure. 2. Gastrointestinal: The patient experienced hematemesis following administration of aspirin and heparin. The patient was transferred to the Intensive Care Unit, which was followed by gastrointestinal. The decision was made to medically manage her and not do an emergent esophagogastroduodenoscopy. Recent hematocrit drop from 32 down to 26 and she was transfused 1 unit of packed red blood cells on hospital day one. On hospital day two her hematocrit again took a small decrease and she was transfused 1 additional unit of packed red blood cells. Her hematocrit then stayed stable for the next three days on Protonix only. She did not have any further episodes of hematemesis or any episodes of hematochezia. She was discharged to home to have follow up hematocrits performed. 3. Hyperkalemia: In the Emergency Department the patient's potassium was noted to be 6.2. She received calcium, Gluconate, insulin and dextrose. Her potassium improved and remained stable through her admission. This should also be followed up in one week. 4. Renal: The patient's initial creatinine was 2.6 from her baseline of 1.5 to 2.0. This likely represented mild volume depletion secondary to her diuretic use. Her diuretics were discontinued. She was given gentle intravenous fluids. Her creatinine decreased to 1.8 where it remained stable. She was discharged off her diuretics. DISCHARGE STATUS: Discharge to home. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Non Q wave myocardial infarction. 2. Upper GI bleed. 3. Hyperkalemia. DISCHARGE MEDICATIONS: 1. Combivent one to two puffs inhaled q 6 hours prn. 2. Lipitor 10 mg po q.h.s. 3. Multivitamin one cap po q.d. 4. Protonix 40 mg po q.d. 5. Metoprolol 25 mg po b.i.d. 6. Mavik 2 mg po q.d. 7. Lasix and Aldactone were held, but may need to be reinstituted. NOTE: The patient is not to be given aspirin or heparin secondary to her recurrent bleeding on these medications. FOLLOW UP: The patient will follow up with Dr. [First Name (STitle) 679] in one week. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1379] Dictated By:[Name8 (MD) 16509] MEDQUIST36 D: [2118-10-26] 10:06 T: [2118-10-28] 10:14 JOB#: [Job Number 29453] ICD9 Codes: 4280, 4589, 2767, 496, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6211 }	Medical Text: Admission Date: [2192-10-10] Discharge Date: [2192-10-11] Date of Birth: [2152-12-15] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 492] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: 1. Rigid bronchoscopy with yellow Dumon bronchoscope. 2. Balloon dilatation left main stem. 3. Flexible bronchoscopy. 4. A 14 x 40 mm covered metallic stent placement. History of Present Illness: 39 yo with known esophageal cancer (diagnosed [9-21]) who was transferred from [Hospital2 ] [Hospital3 6783] Hospital with respiratory failure. The patient was due to start chemotherapy but presented to the ED with difficulty breathing at [Hospital2 ] [Hospital3 6783]. Bronchoscopy showed airway compression. He was intubated and transferred to [Hospital1 18] for stent placement. Past Medical History: Esophageal CA diagnosed [2192-9-21] hypertension anemia GERD abdominal surgery-unknown Social History: works in cleaning business no cigarette or alcohol history Family History: No cancer history Physical Exam: On discharge: Vitals: 101.5 99.6 106 117/71 17 99% OC/OP no erythema, no clots Lungs clear bilaterally Good breath sounds RRR Abdom soft, non-tender No peripheral edema Pertinent Results: [2192-10-11] 03:10AM BLOOD WBC-15.3* RBC-3.67* Hgb-8.1* Hct-27.1* MCV-74* MCH-22.1* MCHC-30.0* RDW-22.4* Plt Ct-471* [2192-10-11] 03:10AM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-137 K-3.8 Cl-105 HCO3-27 AnGap-9 [2192-10-11] 03:10AM BLOOD Calcium-10.2 Phos-3.0 Mg-2.2 Brief Hospital Course: The patient was admitted directly to the MICU after being medflighted to [Hospital1 ] Hospital after bronchoscopy demonstrated left main stem obstruction. The patient hypoxic on 100% FIO2 with 12 of PEEP and requiring emergent rigid bronchoscopy with tumor debridement. Due to an elevated white blood cell count and temperature at the outside hospital, he was started on clindamycin, and levoquin. He was taken to the OR for the procedure. Several procedures occurred. 1) Rigid bronchoscopy with yellow Dumon bronchoscope 2) Balloon dilatation left main stem 3) Flexible bronchoscopy and 4) A 14 x 40 mm covered metallic stent placement. Operative findings on [10-10] showed no right side endobronchial lesions or significant secretions. There was a mid left main stem lesion completely occluding with a mixed intrinsic and extrinsic mass. The patient remained intubated following the procedure and was brought to the MICU. In the early AM hours, the patient was extubated successfully. The patient is to remain on clindamycin and levoquin for a total of 10 days. Transfer back to St. [Doctor Last Name 6783] was arranged. The patient will be discharged for transport back to [Hospital2 ] [Hospital3 6783] Hospital. Medications on Admission: lisinopril protonix 40 mg [Hospital1 ] Colace vicodin tylenol iron sulfate MVI Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO Q 8H (Every 8 Hours). 4. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. 5. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: One (1) Intravenous QDAY (). 6. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 7. Famotidine(PF) in [Doctor First Name ] (Iso-os) 20 mg/50 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours). Discharge Disposition: Extended Care Discharge Diagnosis: esophageal cancer Discharge Condition: stable Discharge Instructions: You will need a follow-up bronchoscopy in [3-5] weeks with Dr. [Last Name (STitle) ]. Dr. [Last Name (STitle) ] will be contact[Name (NI) ]. [Name2 (NI) ] should make this appointment at St. [Hospital 80150] Hospital. Followup Instructions: Follow-up as needed with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 7769]. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 494] Completed by:[2192-10-11] ICD9 Codes: 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6212 }	Medical Text: Admission Date: [2156-4-1] Discharge Date: [2156-4-28] Date of Birth: [2088-4-12] Sex: M Service: NEUROLOGY Allergies: Codeine / Codeine Anhydrous / Ambien Attending:[First Name3 (LF) 8747] Chief Complaint: Code Stroke/Altered mental status Major Surgical or Invasive Procedure: MRI EEG History of Present Illness: The pt is a 67 year-old gentleman who presented with alteration in mental status. The pt was unable to offer a history at the time of my encounter. Therefore, the following history is per the primary team, EMS and the medical record. Per EMS, the pt was last seen well by his wife at 1am before going to bed last night (i.e. 8 hours prior to presentation). This morning at approximately 8am, his wife found him in bed not responding to her and "thrashing around." She called EMS. On their arrival, they found the pt to be unresponsive with eyes deviated to the right and "pinpoint". Given history of diabetes mellitus, fingersticks were performed and were 84 and 106. He was given 2mg of IV ativan without effect. He was subsequently brought to the [Hospital1 18] ED for further evaluation. At the time of my initial encounter, the pt was in the midst of intubation. Therefore, a detailed NIHSS could not be performed (see brief examination below). He was subsequently sedated and paralyzed, unfortunately further obscuring the examination. The pt was unable to offer a review of systems. Past Medical History: - Hypertension - Diabetes mellitus, on insulin (insulin regimen NPH 40 q am + SS) with HgA1C 5.[2155-7-2] - Chronic renal failure (Baseline creatinine 1.7 - 3.1) - Peripheral neuropathy - Glaucoma - Hepatitis B: SAg neg, SAb+, CAb+ - Hepatitis C: HCV VL 86K [2155-7-21], genotype IB - Anemia - Baseline Hct 26-32 - H/O Chest pain, no CAD on angiography [6-4] - Substance abuse (none since '[42]) - H/O Osteomyelitis - H/O Back pain - Legally blind - H/O PPD conversion - Erectile dysfunction - H/O MVA with extensive injuries requiring skin graft Social History: Social history is significant for the absence of current tobacco use (quit in [2155-3-31], 2 packs/week for ~50 yrs). There is no H/O of alcohol abuse. No IVDU, although crack abuse till [2138]'s. Patient is married with 3 children, lives with wife. Retired [Name2 (NI) ]. Family History: No CAD in family; h/o cancer Physical Exam: Vitals: T: 98.5F P: 80 R: 16 BP: 253/140 SaO2: 98% General: Lying in bed with eyes closed, intubated. HEENT: NC/AT, MMM Neck: No carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs with transmitted sounds bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes noted, multiple healed scars over abdomen and legs. Neurologic (initial examination just prior to intubation and sedation): -mental status: Does not open eyes to verbal or noxious stimuli. No verbal output. Does not follow commands. -cranial nerves: PERRL 1.5 to 1mm and briskly reactive. Eyes were initially deviated to the right, on reexamination approximately 10 minutes later, EOMI to oculocephalic maneuver. Corneal reflex and nasal tickle present bilaterally. No overt facial asymmetry. Gag reflex intact. -motor: Normal bulk throughout. Could not assess tone. Was seen to move all extremities antigravity in a semi-purposeful manner during line placement before he was chemically paralyzed. No overt adventitious movements were noted. -sensory: Could not assess prior to intubation, sedation and administration of paralytics. -DTRs: Could not assess prior to intubation, sedation and administration of paralytics. Plantar response was mute bilaterally. Pertinent Results: [2156-4-1] 09:50AM WBC-7.4 RBC-3.29* HGB-10.3* HCT-32.9* MCV-100* MCH-31.3 MCHC-31.3 RDW-14.8 [2156-4-1] 09:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2156-4-1] 09:50AM cTropnT-<0.01 [2156-4-1] 09:50AM CK-MB-6 [2156-4-1] 09:50AM ALT(SGPT)-44* AST(SGOT)-76* CK(CPK)-134 ALK PHOS-77 AMYLASE-156* TOT BILI-0.3 [2156-4-1] 11:57AM PHENYTOIN-15.6 Brief Hospital Course: Neurologic: Patient was initially admitted to the neuro-intensive care unit for close observation. Considerations for patient's etiology of mental status change were multiple and included seizure, hypertensive encephalopathy, metabolic, infectious, toxic, medication/substance withdrawl, stroke. A head CT scan did not demonstrate evidence of bleed or evolving infarct. MRI was negative for infarct but showed extensive small vessel disease presumably from poorly controlled hypertension. As seizure was high on the differential patient had bedside EEG monitoring which showed moderate enceohpalopathy on [3-31] and [4-6]. On [4-7] a 15 second seizure was witnessed and captured with EEG showing no epileptiform acitivity and relatively normal background. In the emergency room he received 1.5 grams of IV phenytoin (in addition to total of 4mg IV lorazepam) in ED, and was continued on Dilantin 100/100/130, then increased to 100/100/230. LFTs were slightly elevated on [4-1], but normal on [4-2] and again very mildly elevated [4-8]. Ammonia level was withing normal limits [4-2] and then repeated for continued encephalopathy [4-8] but continued to be normal . TSH was normal. CSF studies were sent to r/o CNS infection and patient had normal results with no growth and negative HSV PCR. A second set of MRI/CTs was obtained to make sure that patient had not developed any interval neurological process that could be affecting his mental status, and these studies were normal. The pateint's delerium began to clear some after he was placed in a windowside bed and forced into a more regular day/night sleep schedule with daytime stimulation. Cardiac wise he was followed on telemetry. No arythmia noted. Hypertension was previously poorly controlled at home on lisinopril, catapress, amlodipine and hydralazine. Lisinopril was increased from 20 to 40, amlodipine continued at 10 daily, hydralazine continued at 75 Q6hrs, catapress increased from 1 to 3. Lopressor was started and eventually titrated up to 150mg TID. Cardiac enzymes were negative at admission. Pulmonary: patient self-extubated [4-2] and tolerated well. Endocrine: Patient's home doses of NPH insulin initially held as he was intubated and not receiving nutrition. Was maintained on a regular insulin sliding scale. When tube feeds started, he had home dose of NPH (24 qAM, 20 qPM) restarted. NPH titrated up as patient's blood sugars continued to be elevated. [Last Name (un) ] consult called [4-23] and patient was started on Lantus 15 with Humalogue sliding scale. Renal: Has history of chronic renal insufficiency. Creatinine was 2.3 on admission and corrected to baseline level of 1.8 within 24 hours. The patient was found to be retaining urine during the admission. He was catheterized. At discharge, he was being treated for a UTI and Foley was discharged. He will need a post-void residual checked after transfer to assure that he is not retaining urine. Should he become aggitated or in pain, urinary retention needs to be ruled out. Inectious Disease: CXR was negative for pneumonia. UA was negative but urine cultures grew beta strep. Was started on Bactrim initially and then changed to clindamycin based on sensitivities. Stool studies showed no Cdiff. CSF studies also sent and negative cultures and HSV PCR. He had one UTI treated with Ciprofolxacin and then a second UTI developed before discharge. He was started on Cipro and Vanc to which the organisms were sensitive. GI: LFTs slightly elevated [4-1], then normal [4-2]. Again mildly elevated [4-8] with AST less elevated than prior but Lipase again similarly elevated with no clear reason. Patient's abnominal exam at this time normal with no tenderness and normal bowel sounds. Patient had normal bowel movements and no diarrhea or tube feeding residuals, then passed swallow eval and started diabetic diet. FEN: was Hypernatremic so replenishing free water deficit of 3.4 L (plus insensible losses) with 100cc/hr of D51/2NS for total of 4 L Prophyllactically received SC heparin, pneumoboots, PPI. Medications on Admission: (Per recent discharge summary): 1. Clonidine 0.2 mg/24 hr Weekly 2. Aspirin 81 mg PO DAILY 3. Omeprazole 20 mg PO once a day. 4. Lisinopril 20 mg PO DAILY 5. Amlodipine 10 mg PO DAILY 6. Insulin: NPH insulin 24 units in the morning, 20 units qhs 7. Atorvastatin 10 mg PO DAILY 8. Oxycodone-Acetaminophen 5-325 mg PO Q6H as needed. 9. Pilocarpine HCl 4% Drops One Drop Ophthalmic Q8H 10. Dorzolamide-Timolol 2-0.5 % One Drop Ophthalmic DAILY 11. Latanoprost 0.005 % Drops One Drop Ophthalmic HS 12. Hydralazine 75 mg PO Q6H 13. Isosorbide Dinitrate 20 mg PO TID Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Hypertensive encephalopathy. Discharge Condition: Good. Patient becoming more oriented daily. Discharge Instructions: FOllow up as below. Do not drink or use drugs. Take medications as directed. REHAB: Please note that the patient has history of urinary retention. Please check a post-void residual tonight to assure that the patient is not retaining. If in the future, there is aggitation or pain, please consider that he may be retaining urine. Please also place the patient in a window-adjacent bed. His delerium seems to improve significantly if he is forced into a regular wake/sleep schedule by daytime stimulation. Followup Instructions: AFter discharge from rehabiliation, please call your [Location (un) 3390]: [Name Initial (NameIs) 3390]: [Last Name (LF) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 250] to arrange Neurologist: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 162], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2156-5-25] 11:30. [Hospital1 18] [Hospital Ward Name 516], [Location (un) ] of [Hospital Ward Name 23] Building. Provider: [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878], M.D. Phone:[Telephone/Fax (1) 435] Date/Time:[2156-6-10] 2:30 ICD9 Codes: 5859, 2762, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6213 }	Medical Text: Admission Date: [2190-9-21] Discharge Date: [2190-9-24] Date of Birth: [2115-3-9] Sex: F Service: SURGERY Allergies: Zinc / Vitamin C Attending:[First Name3 (LF) 974] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 75F presents s/p mechanical fall down three cement stairs. No LOC. Injuries include intracranial hemorrhage, left clavicle and left pubic rami fracture. Past Medical History: HTN, Right TKR [3-15], Sarcoidosis, Transverse myelolysis-due to Sarcoidosis, COPD, DJD, Osteoporosis, Irritable bowel, GERD, Anxiety, Depression, Spinal stenosis s/p surgery in the [2161]??????s-currently wears a brace, Bilateral rotator cuff surgery, Left Ruptured bicep tendon, left carpal tunnel surgery, thyroid cyst removal 30 years ago, cholycystectomy Family History: Noncontributory Physical Exam: Upon admission: O: BP: 114/96 HR:64 R:12 O2Sats:100% 2L Gen: WD/WN, comfortable, NAD. HEENT: Normocephalic. Non-active bleeding to L parietal and bilateral occipital areas. multiple Staples intact (4 staples to Occipital and 4 to L parietal) Pupils: [4-5] Bilaterally. EOMs intact. No Hemotympanum or blood in nares. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and month/year. 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 2mm 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. Has pain to L shoulder d/t clavicle fx. but has full strength when muscles are isolated with support. No abnormal movements, tremors. Also with pain to L groin likely d/t pelvic fracture, but strength full power [6-8] throughout. Unable to assess pronator drift d/t shoulder pain. Toes downgoing bilaterally Pertinent Results: [2190-9-21] 08:04PM GLUCOSE-149* UREA N-38* CREAT-1.4* SODIUM-139 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-29 ANION GAP-14 [2190-9-21] 08:04PM CK(CPK)-210* [2190-9-21] 08:04PM CK-MB-7 [2190-9-21] 08:04PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2190-9-21] 08:04PM WBC-16.0* RBC-3.57* HGB-11.2* HCT-33.7* MCV-95 MCH-31.4 MCHC-33.2 RDW-12.8 [2190-9-21] 08:04PM PLT COUNT-201 [2190-9-21] 08:04PM PT-12.0 PTT-22.2 INR(PT)-1.0 CT Head: IMPRESSION: 1. Right temporal intraparenchymal hematoma compatible with a contracoup hemorrhagic contusion, with adjacent subarachnoid hemorrhage and a 4-mm right frontotemporal subdural hemorrhage. 4-mm of right to left midline shift. 2. Left parietotemporal scalp hematoma. 3. Air-fluid level in the left sphenoid sinus suggestive of acute sinusitis. These findings were communicated to Dr. [First Name (STitle) ] on [2190-9-21] at the time of study acquisition. CT Chest/Abdomen/Pelvis: IMPRESSION: 1. No evidence of solid organ injury within the chest, abdomen, or pelvis. 2. Comminuted fracture of the distal left clavicle. AC joint is intact. 3. Questionable left scapular fracture. 4. Acute fractures of ribs 1 and 6 posteriorly on the left with a contour deformity of the right fifth lateral rib fracture, suspicious for acute fracture. 5. Comminuted fracture of the left iliac [Doctor First Name 362] and non-displaced fractures of the superior and inferior left pubic rami with a large left gluteus maximus intramuscular hematoma. 6. Compression fracture involving the T11 vertebral body with 25 to 50% loss of height and 5 mm of retropulsion with indentation of the ventral thecal sac. 7. Anterior wedge compression fracture of the T7 vertebral body with less than 25% loss of height, of indeterminant age. 8. An 8 mm of anterolisthesis of L4 on L5 of indeterminate chronicity. This may be further evaluated with MRI. 9. Fibroid uterus. 10. Diverticulosis without evidence of diverticulitis. 11. Mild intrahepatic biliary dilatation s/p cholecystectomy. Clinical correlation recommended, and an MRCP can be obtained for further evalaution. MR [Name13 (STitle) 1093] IMPRESSION: 1. Probable acute compression fracture of the superior endplate of the T4 vertebral body without retropulsion of fracture fragments. 2. Non-recent compression fractures of the T7 and T11 vertebral bodies with slight retropulsion of fracture fragments at T7 and more severe retropulsion of fracture fragments at T11 completely effacing the thecal sac at this level without significant spinal canal stenosis. The spinal cord remains unremarkable. 3. Advanced multilevel degenerative changes of the lumbar spine as described above, with spinal canal stenosis at L3-4 and L4-5 secondary to multifactorial degenerative changes. Brief Hospital Course: She was admitted to the Trauma service. Neurosurgery, Spine and Orthopedics were consulted. Her injuries were managed non operatively. She was loaded with Dilantin and admitted to Trauma ICU for close monitoring. Serial head CT scans were followed and remained stable. Her ASA is being withheld for at least 1 week; Heparin SQ was started on HD# 4. Dilantin will continue for 10 days and she will follow up in 4 weeks with Dr. [First Name (STitle) ] for repeat head CT scan. Her spine fractures were determined to be chronic and she will follow up in spine clinic several weeks after discharge. Her clavicle and pelvic fractures did not require any surgery. She is to wear a sling for comfort and may partial weight bear on her LLE. She will follow up in [3-10] weeks in [Hospital 5498] clinic. She was evaluated by Physical therapy and is being recommended for rehab after his acute hospital stay. Medications on Admission: Alprazolam 0.25 mg, Atenolol 25mg, Carisoprodol 350mg, Escitalopram 20mg, Fluticasone-Salmeterol, Lasix 20mg, Omeprazole 20mg, Oxycodone-Acetaminophen, Prednisone 5mg, Propoxyphene-Acetaminophen, Simvastatin 80mg, Aspirin 81, Ca + VitD3 Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Carisoprodol 350 mg Tablet Sig: Two (2) Tablet PO qhs (). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY, EXCEPT SUNDAY (). 8. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY, IN AFTERNOON (). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 4 weeks. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: s/p Fall Intracranial hemorrhage Left distal clavicle fracture Left superior/inferior rami fracture Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: DO NOT restart the aspirin for 1 week. Followup Instructions: Follow up in 2 weeks with Dr. [Last Name (STitle) 1005], Orthoepdics for your clavicle and pelvic fractures; call [Telephone/Fax (1) 1228] for an appointment. Follow up in 4 weeks with Dr. [First Name (STitle) ], Neurosurgery. Call [Telephone/Fax (1) 1669] for an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Follow up in 4 weeks with Dr. [Last Name (STitle) 548], Neurosurgery for your spine fractures. It was recommended that you have flexion/extension films to evaluate spine stability. Call [Telephone/Fax (1) 1669] for an appointment. Completed by:[2190-10-4] ICD9 Codes: 4019, 2724, 4280, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6214 }	Medical Text: Admission Date: [2138-1-15] Discharge Date: [2138-1-24] Date of Birth: [2059-9-9] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: Dysphagia, with a 6- to 8-cm length of Barrett's esophagus who on recent biopsies was found to have high-grade dysplasia with at least 1 experienced pathologist [Location (un) 1131] intramural cancer. Major Surgical or Invasive Procedure: transhiatal esophagectomy History of Present Illness: Mr. [Known lastname 70380] is a 78 year old gentleman patient with longstanding reflux with a 6- to 8-cm length of Barrett's esophagus who on recent biopsies was found to have high-grade dysplasia with at least 1 experienced pathologist [Location (un) 1131] intramural cancer. His comorbidities included anticoagulation for intermittent atrial fibrillation as well as arthritis, but his functional status was excellent. Dr. [Last Name (STitle) ] recommended transhiatal esophagectomy and he agreed to proceed. Past Medical History: DVT, bilateral inguinal hernia repairs, TURP, L. elbow surgery Social History: He is an ex-smoker for 20 years, mostly using a pipe. He is a retired human resources worker with [Company 70381] and lives on [Hospital3 ] with his wife. [Name (NI) ] drinks two vodkas per day and has no other toxic exposures. Family History: Notable for history of colon cancer in his father and his brother as well as congestive heart failure. Physical Exam: PHYSICAL EXAMINATION: GENERAL: He weighs 183 pounds, but otherwise looks fit. VITAL SIGNS: He is afebrile. Pulse is 72 and regular, blood pressure 159/86, respirations 16, and room air saturation is 96%. HEENT: He has no scleral icterus or adenopathy in the neck or either supraclavicular fossa. LUNGS: Breath sounds are clear with equivalent air entry and no focal wheezing. HEART: Regular rhythm and rate, without jugular venous distention, carotid bruit, murmur or gallop. ABDOMEN: Soft and nontender, with normal bowel sounds and well-healed inguinal incisions. NEUROLOGICAL: He is nonfocal. EXTREMITIES: He has classic osteoarthritic changes in his hands and his wrists. Pertinent Results: [2138-1-15] 04:05PM BLOOD WBC-5.6 RBC-3.55* Hgb-10.6* Hct-30.6* MCV-86 MCH-29.8 MCHC-34.5 RDW-15.8* Plt Ct-175 [2138-1-23] 10:25AM BLOOD WBC-10.6 RBC-3.20* Hgb-9.4* Hct-27.9* MCV-87 MCH-29.4 MCHC-33.7 RDW-16.2* Plt Ct-277 [2138-1-24] 07:20AM BLOOD PT-13.0 PTT-38.3* INR(PT)-1.1 [2138-1-15] 09:00AM BLOOD PT-12.8 PTT-29.6 INR(PT)-1.1 [2138-1-23] 10:25AM BLOOD Glucose-132* UreaN-11 Creat-0.8 Na-142 K-4.3 Cl-105 HCO3-27 AnGap-14 [2138-1-15] 04:05PM BLOOD Glucose-127* UreaN-12 Creat-0.8 Na-138 K-3.8 Cl-107 HCO3-24 AnGap-11 [2138-1-20] 04:31PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2138-1-15] 04:05PM BLOOD CK-MB-5 cTropnT-0.03* [2138-1-16] 04:17AM BLOOD CK-MB-3 [2138-1-21] 08:10AM BLOOD TSH-4.1 [2138-1-20] 08:05AM BLOOD TSH-3.5 Brief Hospital Course: Patient admitted to thoracic surgery service and underwent transhiatal esophagectomy on [2138-1-15] which proceeded without any complications. He was placed in the cardiac surgery recovery unit in the immediate postoperative period and was extubated without difficulty. He remained nil per os until tube fees were started at 30mL per hour on postoperative day number three which he tolerated well. He then began to pass flatus on postoperative day number six at which point his tube feeds were advanced to goal. He was then given a trial of grape juice to assess for an anastomotic leak and there was no grape juice noted in the neck drain. Thus he was given clears which by the time of discharge were advanced to full liquids as tolerated which he has done well with. His other issue during the postoperative period involved a likely supraventricular tachycardia and cardiology was involved. They ascribed this to likely atrial fibrillation and he was discharged on diltiazem 90mg four times a day, and metoprolol 50mg [Hospital1 ]. He was on a diltiazem drip off and on for three days prior to discharge however this was able to be weaned and he was placed on oral medications only with his heart rate well controlled. He was also restarted on warfarin prior to his discharge and is written for this to continue per his home schedule he took prior to admission. It has been stated in the discharge paperwork the patient is to follow up with his PCP [Name Initial (PRE) 176] 5 days of discharge to review medication changes and to discuss his INR levels. Medications on Admission: Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS: take 2.5 mg Mon. Wed. Fri. Sun. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO HS: take 5mg Tues. Thurs. Protonix 40mg QD Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:400 ML(s) Refills:0 2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) tab PO once a day. Disp:30 Refills:2 3. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS: take 2.5 mg Mon. Wed. Fri. Sun. 8. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO HS: take 5mg Tues. Thurs. Sat. Have INR checked 3 times per week until further notice. Discharge Disposition: Extended Care Facility: Pleasant Bay Nursing & Rehabilitation Center - [Location (un) 23638] Discharge Diagnosis: Hx of DVT on coumadin, B inguinal hernia repair, B knee surgeries, TURP, left elbow surgery. s/p trans hiatial esophagectomy for superficial adenocarcinoma arising in Barrett's esophagus. Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) ] office [Telephone/Fax (1) 170] if you have chest pain, shortness of breath, fever, chills, difficulty swallowing, nausea, vomiting, diarrhea. continue with tube feedings as ordered and soft solid diet. If your feeding tube stitches break, secure tube with tape and call the office [Telephone/Fax (1) 170]. If the feeding tube falls out, call the office [Telephone/Fax (1) 170] and come immediately to the hospital or to your local emergency room to have it replaced. Followup Instructions: An appointment has been set up for the patient with Dr. [Last Name (STitle) ] for 1130AM [2138-2-20] PATIENT SHOULD FOLLOW UP WITH HIS PRIMARY PHYSICIAN [Name Initial (PRE) ] 5 DAYS OF DISCHARGE TO DISCUSS MEDICATION CHANGES AND TO REVIEW WARFARIN DOSING AND INR LEVELS. THE PATIENT HAS BEEN SENT TO REHAB ON DILTIAZEM WHICH IS A NEW MEDICATION FOR HIM TO CONTROL HIS HEART RATE. HE WAS FOLLOWED BY CARDIOLOGY HERE. HE HAS BEEN DISCHARGED ON HIS HOME DOSING OF WARFARIN. ICD9 Codes: 9971
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6215 }	Medical Text: Admission Date: [2116-12-26] Discharge Date: [2117-1-1] Date of Birth: [2047-9-10] Sex: M Service: SURGERY Allergies: XIBROM Attending:[First Name3 (LF) 2836] Chief Complaint: Necrotizing hemorrhagic pancreatitis Failure to thrive Major Surgical or Invasive Procedure: None History of Present Illness: 69M with necrotizing hemorrhagic pancreatitis complicated by abdominal compartment syndrome, now transferred from OSH at family's request for management. Patient was admitted at [Hospital1 18] from [2116-10-1] to [2116-11-24] after transfer from OSH for cardiac arrest in the setting of necrotizing pancreatitis. On arrival, he was found to have abdominal compartment syndrome for which he underwent decompressive laparotomy with significant improvement in hemodynamics. During his stay, he had a prolonged ICU course complicated by MSSA/Ecoli pneumonia, acute renal failure requiring hemodialysis, and pseudomonas bacteremia, requiring re-exploration with placement of [Last Name (un) ] gastrostomy and debridement of subcutaneous tissue, muscle, and fascia in the suprapubic region and placement of a 16 French pigtail catheter into a right complex air and fluid collection. Patient was eventually weaned from the ventilator, extubated, weaned from dialysis and discharged to rehab on [2116-11-24] (please see discharge summary for details). On [2116-12-1], patient was found in "pool of blood" by rehab nurse and transferred to OSH for evaluation. On arrival, patient's Hct was 15, he was febrile to 39, and hemodynamically unstable. He was intubated and taken to OR for ex lap. Intraop, drainage of multiple hemorrhagic abscess was performed with placement of 3 [5-17] inch triple lumen sump drains and a wound vac. He was taken back to the OR twice for washouts and ultimately closed on [12-10]. He was initially broadly covered with vanc/ linezolid/ cipro/ zosyn/ fluc for pseudomonas pneumonia and UTI and VRE in abdominal abscess. VRE became resistant to linezolid, and patient completed 14 day course with tigecycline and all antibiotics were stopped on [2116-12-16]. On [12-21], patient spiked a fever and was restarted on vanc/zosyn, but eventually weaned to zosyn alone with ID recommendations. Due to his pneumonia, he required prolonged intubation, ultimately requiring tracheostomy on [2116-12-24], with exchange of trach on [2116-12-25]. Over the last week, he was having difficulty tolerating tube feeds with episodes of witnessed aspiration, for which tube feeds were stopped and TPN initiated. He has also had persistent liquid stools which were cdiff toxin and pcr negative. Today, patient's Hct dropped from 27 to 22, prompting a CT abomen/pelvis. Due to poor progress over the last week, patient's family requested transfer to [Hospital1 18] for second opinion. Past Medical History: PSH: Cataract removal with lens prosthesis, [2116-10-2]- Bedside exploratory laparotomy for abdominal compartment syndrome, [2116-10-21]- Re-exploration with placement of [Last Name (un) ] gastrostomy and debridement of subcutaneous tissue, muscle, and fascia in the suprapubic region; [2116-11-17] - Uncomplicated placement of a 16 French pigtail catheter into the right complex air and fluid collection, [2116-12-2]: ex lap, drainage of infected hemorrhagic collections with placement of sump drains x3, [12-4] & [12-7]: wash out and partial closure of abdominal wound, [2116-12-10]: closure of abdominal wound, [2116-12-24]: Open tracheostomy, [2116-12-25]: Tracheostomy exchange . PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease 2. Vitamin deficiency 3. Hypertension 4. B12 deficiency anemia 5. Gastritis 6. Benign prostatic hypertrophy 7. Hyperlipidemia 8. Calculus of the kidney 9. Macular degeneration of the retina 10. Cataracts, status post cataract removal with lens prosthesis Social History: The patient lives with his wife. Denies tobacco and alcohol use or other toxic habits Family History: No family history of pancreatitis or pancreatic malignancy Physical Exam: On Discharge: Vital Signs: 98.8, 102, 132/80, 18, 99% on 50% Trach mask General: Interactive, NAD CV: RRR Resp: Tracheostomy with stitches in place, decreased breath sounds on left with rhonchi Abd: Soft, nontender, mildly distended, large triple lumen sump drains in LLQ, and RLQ with thick purulent drainage, midline incision with steri strips and healing well with no erythema or drainage. LUQ with G/J tube, site c/d/i Ext: Warm, no edema Pertinent Results: [2117-1-1] 05:00AM BLOOD WBC-5.0 RBC-3.30# Hgb-9.6# Hct-28.9# MCV-88 MCH-29.0 MCHC-33.2 RDW-16.1 Plt Ct-186 [2117-1-1] 05:00AM BLOOD Glucose-115* UreaN-11 Creat-0.4* Na-143 K-3.5 Cl-113* HCO3-25 AnGap-9 [2117-1-1] 05:00AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.8 [2116-12-28] 08:52AM BLOOD calTIBC-85* Ferritn-4287* TRF-65* MICRO: [2116-12-26] 10:18 pm BLOOD CULTURE Source: Line-L PICC. FINAL REPORT [2117-1-1] Blood Culture, Routine (Final [2117-1-1]): NO GROWTH. [2116-12-26] 10:18 pm URINE Source: Catheter. FINAL REPORT [2116-12-28] URINE CULTURE (Final [2116-12-28]): YEAST. >100,000 ORGANISMS/ML [2116-12-27] 5:45 pm STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [2116-12-28] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2116-12-28]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [2116-12-28] 3:04 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2116-12-31] MRSA SCREEN (Final [2116-12-31]): No MRSA isolated. RADIOLOGY: [2116-12-28] CXR: IMPRESSION: Small-to-moderate left pleural effusion with associated atelectasis. Brief Hospital Course: The patient well know for Dr. [First Name (STitle) ] was transferred to the General Surgical Service from OSH. The patient was transferred in ICU, blood, stool and urine cultures were sent, and IV Zosyn was stared empirically. In ICU patient was started on Tube feed, continued NPO, with Foley catheter and free H2o boluses for hypernatremia. On HD # 3, he underwent replacement of his G-tube to G/J-tube without any complications. Neuro: The patient was stable from neurological standpoint, no interventions were require. Pain was controlled with Morphine IV prn. CV: Sinus tachycardia in setting of SIRS, hemodynamically normal. Patient was continued on IV metoprolol with good respond. Pulmonary: The patient was remained on 50% Trach mask with stable O2 Sats. Pulmonary service and speech/swallow were followed the patient. Chest PT and pulmonary toilet were continued throughout hospitalization. Please see attached Speech and Swallow consult for details. GI: Patient's G-tube was changed to G/J tube on [12-28]. Tube feed was restarted on [12-29] and advanced to goal. Patient was started on tincture of opium and Creon for diarrhea. Diarrhea improved and Creon was discontinued. Patient will require to continue Speech and Swallow evaluations in Rehab. Hypernatremia: The patient was hypernatremic on admission. He was started on free water boluses and slow D5W IV. Serum sodium improved to normal prior discharge. GU: Foley was placed on admission to monitor urine output. After Foley was d/cd, patient has condom catheter in place. ID: Blood, urine and stool cultures were negative, IV Zosyn was discontinued. Patient remained afebrile with WBC within normal limits during hospitalization. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient has an anemia of chronic disease. He was transfused with 2 units of RBC for HCT = 22.8 on HD # 6. Please continue to monitor HCT as outpatient. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a tube feed, voiding, and pain was well controlled. The patient received discharge teaching and follow-up instructions and family members verbalized understanding and agreement with the discharge plan. Medications on Admission: Nexium 40 mg daily, ferrous sulfate 300 mg daily, haldol 5mg IV q4h prn agitation, floranex TID, lopressor 10 mg IV q4h, zosyn 4.5 mg q8h Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. opium tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO DAILY (Daily). 3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. Thiamine 100 mg IV 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. Pantoprazole 40 mg IV Q24H 7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 8. Metoprolol Tartrate 10 mg IV Q4H hold for sbp <110 and hr <60 Discharge Disposition: Extended Care Facility: [Location (un) 32674] - [Location (un) ] Discharge Diagnosis: 1. Necrotizing hemorrhagic pancreatitis 2. Hypernatremia 3. Anemia of chronic disease 4. Intraabdominal fluid collections Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-19] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. . Abdominal drains ([Doctor Last Name 14837] drains) will continue to wall suction in Rehab . Tracheostomy - place the PASSY-MUIR VALVE during the day. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE. . PICC Left Antecubital, Date inserted: [2116-12-26] . J/G tube, flush with 250 cc of tap water Q6H. Change dressing daily and prn. Monitor for signs and symptoms of infection or dislocation. Followup Instructions: Please call Dr.[Name (NI) 5067] office at [Telephone/Fax (1) 91667] to schedule a follow up appointment in 2 weeks. Completed by:[2117-1-1*] ICD9 Codes: 2760, 5990, 5119, 5859, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6216 }	Medical Text: Admission Date: [2127-7-28] Discharge Date: [2127-8-5] Date of Birth: [2044-1-3] Sex: M Service: MEDICINE Allergies: Meropenem / Penicillins Attending:[First Name3 (LF) 905] Chief Complaint: C2 fracture dislocation with progressive collapse Major Surgical or Invasive Procedure: 1. Open reduction internal fixation C2 fracture/dislocation. 2. Posterior instrumentation C1 to C2 and C2 to C5. 3. Posterior arthrodesis C1 to C5. 4. Left iliac crest bone graft. History of Present Illness: Mr. [Known lastname 12731] is a 83 yo man with MMP including ESRD on HD, CAD s/p MI, Afib not on anticoagulation, GIBs, COPD and restrictive lung disease, CVAs, nephrolithiasis with stent and nephrostomy tube, who was admitted in [4-28] for C2 dens fracture after falling off wheechair, failed conservative medical treatment, admitted on [2127-7-28] to ortho service for surgical management. Past Medical History: - ESRD on HD Tuesday/Thursday/Saturday - Atrial fibrillation, not on anticoagulation - h/o GI bleeds, diverticulitis - C. Diff colitis - h/o CVAs (two, with residual right-sided weakness) - h/o nephrolithiasis w/ stent and nephrostomy tube - CAD s/p MI - Sleep apnea (not on CPAP) - Depression - PFT's [2117] with mild restrictive ventilatory defect - Anemia with h/o iron deficiency - Recent fall with C2 dens fracture with anterior displacement ([4-/2127]) - Numerous line infections, most recently MRSA [4-/2127] which was treated with Vancomycin until [2127-5-10] (also with MRSA [8-/2125], ESBL E. Coli [9-/2125], [11/2125], [6-/2126], and [7-/2126]) - Delirium during hospital admissions - COPD and restrictive lung disease - Common bile duct stone s/p stenting [10/2126] - Urinary tract infections, including VRE and Klebsiella, with urosepsis Social History: Patient recently has been at rehabilitation since fall and C2 fracture. Lives with wife [Name (NI) ], daughter lives downstairs, h/o smoking [12-21] PPD for 50 years, quit 20 years ago, occasional beer, none recently, no drugs. Family History: Non-contributory. Physical Exam: Physical exam on discharge: VS: T 97 HR 80 BP 98/62 RR 20 SaO2: 95% RA GA: Alert and oriented, lying in bed, NAD HEENT: MMM. no LAD. no JVD. Neck in brace. Cards: Soft heart sounds. RRR. S1/S2. no m/g/r. Pulm: Moving air appropriately, bibasilar crackles Abd: soft, NT, +BS. no g/rt. Extremities: wwp, no edema. DPs 2+ Skin: Sacral region with staples and dressing, c/d/i, Posterior neck with dressing. Neuro/Psych: A&O x 3. CN II-XII intact. 4/5 strength in U/L extremities. sensation intact to LT. Pertinent Results: [2127-7-29] 08:10AM BLOOD WBC-6.3 RBC-3.94* Hgb-12.0* Hct-37.6* MCV-96 MCH-30.5 MCHC-31.9 RDW-18.1* Plt Ct-120* [2127-8-4] 10:00AM BLOOD WBC-8.9 RBC-3.42* Hgb-9.9* Hct-31.3* MCV-92 MCH-29.1 MCHC-31.7 RDW-17.4* Plt Ct-158 [2127-7-28] 11:30PM BLOOD PT-14.0* PTT-25.8 INR(PT)-1.2* [2127-8-4] 10:00AM BLOOD PT-13.0 PTT-26.3 INR(PT)-1.1 [2127-7-31] 02:30PM BLOOD Fibrino-420* [2127-7-28] 11:30PM BLOOD Glucose-125* UreaN-46* Creat-5.5# Na-138 K-4.0 Cl-94 HCO3-27 AnGap-21* [2127-8-4] 10:00AM BLOOD Glucose-108* UreaN-28* Creat-3.6# Na-138 K-3.8 Cl-99 HCO3-28 AnGap-15 [2127-7-29] 08:10AM BLOOD Calcium-8.5 Phos-9.5# Mg-2.1 [2127-8-4] 10:00AM BLOOD Calcium-8.2* Phos-4.6* Mg-2.0 [2127-8-1] 03:24PM BLOOD Type-ART pO2-187* pCO2-39 pH-7.45 calTCO2-28 Base XS-3 [2127-7-31] 07:59AM BLOOD freeCa-1.16 [2127-8-1] 02:33AM BLOOD freeCa-1.10* Imaging: 1. C-Spine (portable): In comparison with the study of [7-7], the area of the fracture of the dens is very poorly seen. There appears to be some posterior displacement of the body of C2, though it is difficult to determine whether there is any change from the previous study. Some soft tissue prominence is again seen at this level. CT may be necessary to properly evaluate the degree of displacement. 2. CXR: Questionable new rounded hazy opacities, could be artifactual from rib ends, but cannot exclude other processes such as septic emboli or traumatic etiology. Brief Hospital Course: # C2 dens fracture: Patient had originally been hospitalized in [4-28] after the fall from his wheelchair resulting in C2 dens fracture. At the time, the decision was made to manage him conservatively and patient was discharged to rehab. However, fracture did not heal well and patient developed progressive neurologic loss from spinal cord compression. After medical clearance, patient was admitted to the ortho spine service, where he underwent C1-C4 posterior fusion. Postoperatively he was transferred to the TSICU and kept intubated. He was successfully extubated and then underwent HD per normal regimen. He normally is slightly hypotensive during dialysis and required midodrine. He was transfused 2 units of pRBC at dialysis. Patient did well and then was transferred to the medical floor prior to discharge. . # ESRD: Patient is well known to the renal service. He was kept on his Tue/[Last Name (un) ]/Sat dialysis schedule while inpatient. He received midodrine to keep him normotensive during dialysis. Creatinine ranged from 2.1 to 5.5 during this hospitalization. He was kept on his home medications including nephrocaps and calcium acetate. His volume status and electrolytes were closely monitored. . # History of recurrent UTIs: UA on admission was concerning for UTI. Patient has a history of numerous resistent pathogens (VRE, ESNL, klebsiella). While on the ortho service received one dose of Vanco in OR and was started on bactrim, which was discontinued after urine culture came back negative. Foley was removed after transfer to the medicine floor. Patient remained afebrile with no leukocytosis, and thus did not require any antibiotics treatment. . # CAD: On admission did not show signs of ACS. Aspirin was held in the context of surgery. On discharge aspirin was continued per orthopedics service suggestion. . Medications on Admission: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY 2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY 3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY 4. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO Tues-Thurs-Sat: Give one hour prior to dialysis. 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [12-21] Inhalation Q6H (every 6 hours) as needed for shortness of breath. 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: C2 dens fracture 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 12731], you were admitted to the [Hospital1 ] Hospital because the fracture in your neck that you had was not healing on its own and so you decided to have surgery. Your orthopedic surgeon took bones from your hip and used it to make a bone graft for your neck. Your neck was also stabilized with instrumentation inside. After the surgery, you had a breathing tube, which was removed. You were placed in a soft neck collar which you have to continue wearing until you see the orthopedic surgeon for follow-up. Throughout the hospitalization you continued to get your normal dialysis treatments for end-stage renal disease. We gave you blood and medicine during dialysis to keep your blood pressure up. You never had a fever or had elevated white blood cell after the surgery. . We made the following changes to your medications: 1. Calcium Acetate 1334 mg by mouth three times a day WITH meals Followup Instructions: Department: NEUROLOGY When: FRIDAY [2127-8-8] at 2:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD [Telephone/Fax (1) 2574] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SPINE CENTER When: MONDAY [2127-8-18] at 9:40 AM With: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [Telephone/Fax (1) 3736] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: VASCULAR SURGERY When: WEDNESDAY [2127-9-10] at 8:00 AM [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2127-8-5] ICD9 Codes: 5856, 412, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6217 }	Medical Text: Admission Date: [2161-10-8] Discharge Date: [2161-10-14] Date of Birth: [2085-6-8] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 2704] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: This is a 76 year-old female with a history of coronary artery disease s/p CABG in [2152] (LIMA to LAD, SVG to diagonal, SVG to OM-2, SVG to PDA), s/p AAA repair, right femoral bypass, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, presented to [Hospital3 3583] with worsening shortness of breath. At [Hospital3 3583], she had a work up including echocardiogram, labs and chest x-ray. At OSH, patient developed leukocytosis, diarrhea, abdominal pain and treated empirically with po vancomycin for presumed C Diff. Patient transferred to [Hospital1 18] for flutter ablation, but was deemed to be a poor candidate. While inpatient, she has had increased oxygen requirement of likely multifactorial etiology. Patient was started on a lasix gtt and was not tolerating diuresis because of drops in SBPs. Additionally, she had abdominal discomfort of unclear etiology. Patient has had a CT Abdoment that shows chronic [Female First Name (un) 899] blockage, but no evidence of bowel ischemia. On floor, patient triggered for low oxygen saturation and at time of transfer was on 6L 02 with sats in mid 90s. Past Medical History: -- CABG, in [2152] anatomy as follows: LIMA to LAD, SVG to diagonal, SVG to OM-2, SVG to PDA -- Severe PVD -- H/O GI bleeding -- H/O AAA -- Cataracts -- left hemidiaphramgatic paresis -- Chronic renal insuficiency Social History: Social history is significant for the absence of current tobacco use, prior smoker for many years. There is no history of alcohol abuse. Family History: There is a paternal history of coronary artery disease/peripheral artery disease, died at age 77. Physical Exam: 6:45pm [2161-10-14] Pt warm, pulseless, no heart sounds on auscultation, no respirations on auscultation, no corneal reflex and no oculocephalic reflex. Pertinent Results: [2161-10-14] 05:12AM BLOOD WBC-10.3# RBC-3.06* Hgb-10.1* Hct-29.6* MCV-97 MCH-32.9* MCHC-34.1 RDW-16.4* Plt Ct-207 [2161-10-13] 02:32AM BLOOD WBC-6.6 RBC-3.08* Hgb-10.1* Hct-29.3* MCV-95 MCH-32.8* MCHC-34.6 RDW-15.8* Plt Ct-178 [2161-10-14] 05:12AM BLOOD Neuts-95.6* Lymphs-2.8* Monos-1.2* Eos-0.3 Baso-0.2 [2161-10-14] 10:31AM BLOOD PT-31.6* PTT-73.6* INR(PT)-3.3* [2161-10-14] 05:12AM BLOOD Glucose-162* UreaN-20 Creat-1.3* Na-133 K-4.1 Cl-92* HCO3-29 AnGap-16 [2161-10-9] 11:55AM BLOOD FDP-10-40* [2161-10-9] 08:23AM BLOOD Fibrino-506* [2161-10-13] 02:32AM BLOOD ALT-30 AST-32 LD(LDH)-245 AlkPhos-95 TotBili-0.6 [2161-10-8] 10:22PM BLOOD CK-MB-NotDone cTropnT-0.02* [2161-10-9] 11:55AM BLOOD Lipase-13 [2161-10-13] 02:32AM BLOOD Albumin-2.9* Calcium-6.7* Phos-2.4* Mg-1.6 [2161-10-11] 06:12AM BLOOD Triglyc-133 [2161-10-9] 08:23AM BLOOD Osmolal-275 [2161-10-9] 11:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE [2161-10-9] 11:55AM BLOOD AMA-NEGATIVE [2161-10-14] 10:31AM BLOOD Vanco-21.1* [2161-10-9] 11:55AM BLOOD HCV Ab-NEGATIVE [2161-10-14] 10:43AM BLOOD Type-[Last Name (un) ] pO2-34* pCO2-64* pH-7.33* calTCO2-35* Base XS-4 [2161-10-14] 10:43AM BLOOD Lactate-1.5 [2161-10-11] 02:45PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.034 [2161-10-11] 02:45PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2161-10-11] 02:45PM URINE RBC-62* WBC-30* Bacteri-FEW Yeast-FEW Epi-0 [2161-10-9] 12:18AM URINE CastGr-17* [2161-10-9] 12:18AM URINE AmorphX-RARE Uric AX-MANY [2161-10-9] 12:18AM URINE Mucous-RARE BCx [10-8]: neg BCx [10-12]: pending CDiff neg x 3 UCx [10-9]: neg UCx [10-11]: yeast CXR [10-14]: Moderate left pleural effusion unchanged since [10-8], while small right pleural effusion has increased since [10-13]. Opacification at the base of the left lung is attributable to atelectasis, but on the right, there could be pneumonia. Borderline interstitial pulmonary edema is still present. Severe cardiomegaly is longstanding. Right supraclavicular central venous line ends at the superior cavoatrial junction. No pneumothorax. CTA Abd [10-9]: 1. Extensive atherosclerotic calcifications throughout the aorta, iliac arteries and major branches. 2. Coronary calcifications. 3. Evidence of anasarca with subcutaneous edema and ascites. 4. Ground-glass patchy and emphysematous change in lung bases, bilateral pleural effusion and atelectasis, more prominent on the left side. 5. Stranding surrounding the left kidney with a small focal perinephric subcapsular fluid collection. 6. No evidence of bowel ischemia. There is no evidence of pneumatosis or bowel wall thickening. Brief Hospital Course: Patient is a 76 yo female with CAD, s/p AAA, PVD, CRI, who initially presented to OSH with CHF exacerbation, transferred from OSH for a. flutter ablation and course complication by hypoxia and anasarca. #. Dyspnea/Hypoxia: Pt had worsening hypoxia, thought to be volume overload (diuresed) with component of COPD, and pneumonia (treated with Vancomycin and Zosyn). Diaphragmatic hemiparesis also likely contributor. PE unlikely while anticoagulated. Pt was clear in her wished to avoid intubation and trach and she was maintained on CPAP until family agreed to make pt [Name (NI) 3225]. At that time she quickly desaturated, was started on Morphine drip and expired. Time of death was 6:45PM on [2161-10-14]. #. CAD: Patient has a history of severe three vessel disease s/p CABG. Pt was medically managed on ASA. Beta blocker held for hypotension, and statin held for elevated LFTs. #. AFlutter: Pt was medically managed on digoxin and amiodarone. Cardioversion was postponed given other medical issues. Anticoagulated with argatroban given confirmed history of HIT. #. Abdominal Pain/Distension/Diarrhea: Patient has a history of open AAA repair, cholecystectomy and ventral hernia repair recently. C. Diff negative x3 but completing course of PO Vanc. CT abdomen shows occluded [Female First Name (un) 899] but felt to be chronic as Lactate wnl. Vascular surgery followed, and plan was for flex sig once medically stable. At time of death pt's family expressed interest in particular attention being paid to pt's GI symptoms on autopsy. Medications on Admission: Amiodarone Furosemide Calcium Protonix Metoprolol Coumadin Multivitamin Trazodone Lorazepam Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Respiratory arrest Pneumonia COPD CAD Discharge Condition: expired Discharge Instructions: Pt passed away at 6:45 pm on [2161-10-14] Followup Instructions: None Completed by:[2161-10-14] ICD9 Codes: 486, 4280, 2749, 4439, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6218 }	Medical Text: Admission Date: [2185-2-26] Discharge Date: [2185-3-17] Date of Birth: [2123-1-8] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old female with a history of chronic obstructive pulmonary disease, coronary artery disease, mitral valve replacement and was found to have a right upper lobe mass on chest x-ray in [2184-4-27]. The patient had a follow-up chest CT scan which confirmed the presence of a mass in the right upper lobe and collapse of that lobe in [2184-10-27]. Approximately four weeks prior to admission the patient is noted to have increased dyspnea on exertion and two weeks prior to admission the patient presented to the emergency department with dyspnea on exertion and lower extremity edema. However, at that time she left against medical advise because she did not want to have a bronchoscopy or a thoracentesis done. The patient returned two weeks later on [2-26] with the same symptoms of shortness of breath, dyspnea, exertion and lower extremity edema. She also states she had a chronic cough and a 20 pound weight loss in the past year with one episode of hemoptysis. During the initial part of the hospitalization the patient's Coumadin was discontinued. She had lower extremity ultrasounds which were negative for deep vein thrombosis and chest x-ray showed right pleural effusion and cardiomegaly. When the patient's INR decreased she was taken for a bronchoscopy which showed a pulsatile mass in the right middle lobe. A biopsy and washings were performed. After the procedure the patient did well until approximately 90 minutes later when she went into acute respiratory distress and respiratory failure. She was intubated and brought to the MICU for further care. On arrival to the MICU the patient was awake and appeared comfortable not in any distress. PAST MEDICAL HISTORY: 1. Right upper lobe mass; see History of Present Illness. 2. Atrial fibrillation. 3. Chronic obstructive pulmonary disease. 4. Rheumatic heart disease with mitral valve replacement in [2167]. 5. Coronary artery disease status post coronary artery bypass graft. 6. Pulmonary artery hypertension. 7. Biatrial enlargement. 8. Hyperlipidemia. 9. Hypothyroidism. 10. History of hepatitis. SOCIAL HISTORY: The patient is a 35-pack-year tobacco smoker who quit 12 years ago. No alcohol or drug use. PHYSICAL EXAMINATION: On admission the patient was intubated but following commands. Vital signs; temperature 98.9 F, pulse 78 to 81, blood pressure 89 to 97 over 36 to 69. The patient was having an oxygen saturation of 95 to 100% on controlled ventilation. Chest exam significant for decreased breath sounds on the right with coarse breath sounds and scattered rales anteriorly bilaterally. Heart exam significant for mechanical heart sounds. Abdomen is benign. Extremities show 1+ pitting edema bilaterally with no calf tenderness. LABORATORY ON ADMISSION TO MICU: Complete blood count; white blood cell count 9.8, hematocrit 20.6, platelet count 343,000. Coags significant for an INR of 1.4. Chemistry significant for bicarbonate of 38, chloride of 91. Calcium was elevated at 11.6. Chest x-ray showed complete opacification of the right hemothorax and a large right atrium. Electrocardiogram showed atrial fibrillation at 80 to 85 beats per minute with right axis deviation and T-wave inversions in leads 2, 3 and aVF with nonspecific ST changes. HOSPITAL COURSE: 1. Right upper lobe mass. Due to the size and nature of the mass seen by x-ray and CT as well as bronchoscopy it most likely represented a malignancy. However, the biopsy obtained during the bronchoscopy was not definitive. Numerous sputum cytologies were sent which showed highly atypical keratinized squamous cells highly suspicious for non-small cell lung cancer. The patient was offered more definitive diagnostic modality such as a transthoracic CT guided needle biopsy; however, she did decline due to the likelihood that this was malignancy. PTH related peptide was also sent as the patient was hypercalcemic and this showed that there was an elevated level of PTHrP which again made lung cancer the most likely and very likely diagnosis. Both oncology, radiation oncology and CT surgery were consulted for recommendations on treatment options. Radiation oncology felt that the mass was too large to receive radiation for treatment, however the patient could receive radiation for palliative reasons, perhaps to improve compression on large airways which may improve her respiratory function. Therefore, the patient was taken for two doses of radiation, however, this did not resolve the insignificant improvement in any of her symptoms including her respiratory function. Neither the oncology service nor the cardiac thoracic surgery service felt that there was any definitive treatment that could be done to significantly improve the patient's mortality. 2. Respiratory failure. The patient's respiratory failure was thought to be secondary to the large right lung mass as well as the copious amount of secretions that she was producing possibly secondary to the lung mass and combination of her underlying lung disease of chronic obstructive pulmonary disease. She was continued on mechanical ventilation for her entire Intensive Care Unit stay until the last day. She was also given inhalers for bronchodilation for her chronic obstructive pulmonary disease. Numerous attempts were made to wean the patient from the ventilator. Finally, it was decided since the patient had a terminal illness that the patient and the family both wanted to try extubation and spontaneous breathing. The patient was therefore extubated per her wishes. Initially she did well but after approximately two hours the patient went into respiratory arrest and passed away. Prior to her extubation it was decided that were the patient go into respiratory arrest she would not be reintubated or resuscitated. 3. Cardiovascular. The patient had a rate that appeared to be junctional while she was in the Intensive Care Unit. She was initiated on digoxin; however, was taken off of this and her rate was well controlled. She did not require any other nodal agents for rate control. The patient was maintained on anticoagulation for an artifical valve. Shortly after extubation the patient was found to be asystolic on Telemetry monitor. She passed away at 1:44 p.m. on [2185-3-17]. DISCHARGE DIAGNOSIS: 1. Lung cancer. 2. Intermittent atrial fibrillation. 3. Chronic obstructive pulmonary disease. 4. Hypercalcemia malignancy. 5. Coronary artery disease. Postmortem examination was declined by the family. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2691] Dictated By:[Name8 (MD) 5709] MEDQUIST36 D: [2185-4-28] 15:17 T: [2185-4-29] 09:57 JOB#: [Job Number 109769] ICD9 Codes: 496, 5180, 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6219 }	Medical Text: Admission Date: [2104-8-7] Discharge Date: [2104-8-21] Date of Birth: [2046-1-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: Cardiopulmonary arrest Major Surgical or Invasive Procedure: Endotracheal Intubation Percutaneous Gastrostomy Tube Placement Tracheostomy History of Present Illness: 58 year old male with DM, HTN, elevated cholesterol s/p witnessed cardiopulmonary arrest. Per patients wife, he was in his usual state of health, working as an EMT, able to climb multiple flights of stairs until [2104-8-6] when he felt nauseated and diaphoretic with chills. He went to sleep and then began to have agonal breathing at 1AM and rolled onto his right side. He was unresponsive for 5-10 minutes and then his wife called EMS. When they arrived he was pulseless, AED was attached and 2 shocks were given, patient was still pulseless and CPR was started. He received 2 more AED shocks which restored pulse and breathing. Patient was transiently hypotensive to SBP of 60. He was given 4 liters NS, lidocaine, heparin and dopamine drip. He was intubated for airway protection with pancuronium. ECG with RBBB/LAFB, Afib with RVR. Labs notable for WBC of 11.9 with 20% bandemia. CK 573, TN-I 0.29. Patient was then transferred to [Hospital1 18] CCU. Past Medical History: [Last Name (un) ] [Last Name (un) ] HYPERLIPIDEMIA NEC/NOS OBESITY HYPERTENSION SCREEN MAL NEOP-PROSTATE CELLULITIS NOS PURE HYPERCHOLESTEROLEM INTESTINAL OBSTRUCTION Social History: Married, retired fireman/EMT in the town of [Location (un) 28117], MA. No tobacco, no EtOH, no recreational drugs. Family History: Mother with MI at 84 Physical Exam: Vit: T 98.6 HR 132 BP 159/90 ht. 6'4" wt 330 lbs Gen: obese man, intubated HEENT: bleeding from mouth, PERLA 2mm-->1mm Neck: obese, could not assess JVD CV: Irregular rhythm, normal S1, soft S2, no murmurs, no S3 or S4, no carotid bruit Pulm: CTAB, no w/c/r Abd: obese Ext: no peripheral edema, no femoral bruit Neuro: GCS 4T, moving all extremities, downgoing toes, no reflexes B Pertinent Results: ADMISSION LABS: 24.2 > 14.1/43.2 < 209 MCV - 91 . N:84 Band:9 L:2 M:5 E:0 Bas:0 . 142 / 111 / 31 --------------< 189 3.2 / 20 / 1.5 . Ca: 8.6 Mg: 1.4 P: 2.5 . PT: 15.1 PTT: 113.9 INR: 1.5 . ALT: 40 AST: 44 . [2104-8-7] 0500 - CK: [2117] MB: 10 MBI: 0.5 Trop-T: 0.49 [2104-8-7] 1415 - CK: 516 MB: 12 MBI: 2.3 Trop-T: 0.21 . IMAGING: . CXR [2104-8-7]: 1) The ET tube is in good position. 2) Cardiomegaly. 3) Left lower lobe consolidation vs. atelectasis. The differential diagnosis include aspiration in this patient with cardiac arrest. 4) Plate-like atelectasis in the left mid lung zone. 5) Questionable pulmonary edema. This could be better evaluated with an repeat chest radiograph. . CT HEAD WITHOUT IV CONTRAST [2104-8-7]: There is no evidence of acute intracranial hemorrhage. There is no shift of normally midline structures. The ventricles, cisterns, and sulci are unremarkable. There is preservation of the grey-white differentiation. There is mucosal thickening in the maxillary and ethmoid sinuses bilaterally. IMPRESSION: No evidence of intracranial hemorrhage. . ECHO [2104-8-7]: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (ejection fraction 20-30 percent). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function is borderline normal. 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. There is no mitral valve prolapse. There is no pericardial effusion. . ECHO [2104-8-11]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall systolic function is normal. Left Ventricle - Ejection Fraction >= 55%. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Symmetric left ventricular hypertrophy with cavity dilation but preserved global biventricular systolic function. Compared with the prior study (tape reviewed) of [2104-8-7], there has been a marked improvement in left ventricular systolic function (the ventricular rate isalso slower) . EEG [2104-8-11]: BACKGROUND: Is a markedly low voltage 8 Hz alpha frequency rhythm. HYPERVENTILATION: Could not be performed due to the patient's clinical condition. INTERMITTENT PHOTIC STIMULATION: Could not be performed because this was a portable study. SLEEP: Normal transitions of the sleep architecture were not seen. CARDIAC MONITOR: Initially, there was a normal sinus rhythm with a rate of 72 bpm with intermittent ventricular ectopies. In addition, there are two episodes where the ventricular rhythm showed the sudden onset of a left bundle branch block which lasted for 30-60 seconds and then reverted to a normal conduction pattern. IMPRESSION: This EEG is with in normal limits but shows a low voltage background with excessive drowsiness. No lateralizing or epileptiform abnormalities were seen. Two episodes of a change from normal cardiac ventricular conduction to one with a left bundle branch block were noted. . EKG [2104-8-7]: Atrial fibrillation with a rapid ventricular response. Left axis deviation with left anterior fascicular block. Mild inferior ST-T wave changes which are non-specific. Low QRS voltage in the preordial leads. . EKG [2104-8-10]: Probable idioventricular rhythm or accelerated idioventricular rhythm, rate 87,with retrograde P waves. . EKG [2104-8-16]: Sinus rhythm. Since the previous tracing of [2104-8-11] atrial fibrillation is no longer present and the Q-T interval has increased. . LEFT LE DOPPLERS [2104-8-8]: IMPRESSION: Negative left lower extremity DVT study. Brief Hospital Course: # s/p CP arrest: Reports were obtained from EMTs and Town of [Location (un) ] Police Department. Patient was determined to be in polymorphic VT and VF and after receiving AED shocks X4, he was converted to atrial fibrillation and started on lidocaine drip in the field. When he arrived at [Hospital1 18] the lidocaine was discontinued and he was loaded on amiodarone. He continued to have occasional runs of AIVR and afib, but after 10 days in the hospital, he reverted to stable NSR and was continued on amiodarone 400 mg QD. Reports from [Hospital6 20592] show the patient had an ETT-MIBI on [2103-12-24] which showed: "Reversible anterior wall defect, partially reversible defects of the inferior and apical walls consistent with ischemia and scarring, EF is 44%," without revascularization, making ischemic injury likely as the initiating event for the arrest. . # CAD: Patient was started on empiric aspirin, atorvastatin and a heparin drip. He was hypertensive on admission and was put on a Nitro drip, he was then converted to medications per NG/PEG tube. His discharge antihypertensive regimen includes: metoprolol 100 mg TID, hydralazine 100 mg QID, lisinopril 20 mg [Hospital1 ], lasix 40 mg [Hospital1 ], and isosorbide dinitrate 20 mg TID. . # Pump: EF 20-30% on initial admission ECHO, repeat ECHO on [8-11] showed improvement in EF to greater than 55%, mild LVH with moderate dilation, no AR, trivial MR. [Name13 (STitle) 30983] systolic function is normal. Lasix 40 mg [Hospital1 ] maintained the patient at fluid neutral. . # Pneumonia: WBC count was elevated on admission and his initial CXR showed an opacity in the left lower lobe. He was started on Zosyn for possible aspiration pneumonia and completed a 10 day course of Zosyn with resolution of WBC count and fevers. . # Cellulitis: Patient was noted to have a cellulitis on his left anterior leg on Day 2 of admission. DVT was ruled out with U/S. Cellulitis resolved with course of Zosyn started for pneumonia. . # Respiratory Failure: Patient was intubated in the field and after one week on the ventilator a tracheostomy tube was placed. The patient had spontaneous respirations on CPAP with PS, but given lack of a gag reflex and excessive secretions he was unable to be weaned from the ventilator. Albuterol and atrovent nebs were given on a PRN basis. . # Anoxic brain injury: Initial head CT was (-) for bleed. Neurology was consulted for recommendations regarding further work up and for assessment of prognosis. They recommended an EEG, which showed diffuse slowing without epileptiform activity, and an MRI. The MRI could not be obtained since the patient's shoulders are too broad for our MRI. Their assessment after 10 days of hospitalization was: "eventual prognosis for meaningful recovery is unpredictable at this point. He has sustained a significant anoxic brain injury and at this point, has brainstem and thalamic function (?sleep-wake cycles?) but no meaningful evidence for higher cortical functions that would predict a good prognosis. Time may help to determine his eventual recovery, so we have agreed that beginning to move towards nursing home placement would be in order." He was weaned from propofol IV drip to Ativan 2 mg q4hr and 5 mg Zyprexa qhs for agitation. . # FEN: His electrolytes were repleted throughout the admission to maintain potassium greater than 4 and magnesium greater than 2. A PEG was placed for long term feeding, and he was titrated up to 80 cc/hr of Promote with fiber with residuals less than 10 cc. Free water boluses were added as needed for hypernatremia. Reglan was given to improve gastric motility. He was continued on lansoprazole for gastric ulcer prophylaxis. . # DM: The patient was kept on an insulin sliding scale throughout the admission and was given Lantus at night. At the time of discharge his Lantus dose was in the process of being titrated to achieve blood sugars between 100-125. At discharge his evening Lantus dose was 24 units qhs and his blood sugars ranged from 150-200. . # Prophylaxis: Heparin IV was continued until the patient developed hematuria and heme positive stools. The Heparin was discontinued and pneumoboots were used for DVT prophylaxis. . # Dispo: The patient had a trach/PEG placed as he was not able to be weaned from the ventilator and will require placement at a long term acute care facility. He has a PICC line in place. . # Code Status: DNR (discussed with family on [2104-8-17]) . Medications on Admission: Lisinopril 40 mg QD Actos 45 mg QD Tiazac 360 mg QD Atenolol 50 mg QD Nitrostat 0.4 mg PRN Insulin Lipitor 10 mg QD Timolol 0.5% QD in R eye Discharge Medications: 1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 6. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash/itching. 9. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 18. Insulin Zinc Extended Human 100 unit/mL Suspension Sig: One (1) injection Subcutaneous ASDIR: see sliding scale. 19. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed. 20. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 21. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [Location (un) ] SPECIALTY [Hospital1 ] Discharge Diagnosis: Cardiopulmonary Arrest Coronary Artery Disease Anoxic Brain Injury Discharge Condition: stable Discharge Instructions: Check weight every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Fluid Restriction: 1 liter Please notify care takers of bed sores, fevers, difficulty breathing or swelling of the legs Followup Instructions: Please follow-up with your cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11493] within 2 weeks. Please follow-up with your primary doctor, [Female First Name (un) 28622] Attar, [Telephone/Fax (1) 24306]. Completed by:[2104-8-21] ICD9 Codes: 4275, 5070, 4280, 2760, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6220 }	Medical Text: Admission Date: [2183-8-27] Discharge Date: [2183-9-10] Date of Birth: [2102-12-20] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: aortic stenosis and coronary artery disease Major Surgical or Invasive Procedure: [2183-9-2] AVR (25 mm [Company 1543] Mosaic porcine)/CABG x2 (LIMA-LAD,SVG-OM) History of Present Illness: This 80 year old white male with known aortic stenosis was referred for cardiac catheterization as part of a surgical evaluation. He was found to have left main disease and critical aortic stenosis witha valve area of 0.6cm2 and a 112 mm gradient across the valve. He was transferred here for surgery. Past Medical History: hypertension s/p right lacunar stroke without residua noninsulin dependent diabetes mellitus hypercholesterolemia Social History: Last Dental Exam: Lives with: wife Supportive son close by Occupation: retired Tobacco: Quit 30 years ago ETOH: none Family History: father had coronary disease at uncertain age Physical Exam: Admission; Pulse: 70 Resp:16 O2 sat: 98%-RA B/P Right: 110/70 Left: Height: 5'[84]" Weight: 160 lbs General: lying in bed, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [3-3] blowing murmur Abdomen: Soft[x] non-distended[x]non-tender[x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact[x], A&Ox3,MAE, follows commands. non focal Pulses: Femoral Right: cath/2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: - Left: - Radial Right: 2+ Left: 2+ Carotid Bruit Right: radiated murmur Left: radiated murmur Pertinent Results: CT CHEST REASON FOR EXAM: Pre-op evaluation for CABG, AVR and MVR. TECHNIQUE: Multidetector CT through the chest was obtained without IV contrast. 5-, 1.25-mm collimation images sagittal and coronal reformations were provided and reviewed. FINDINGS: The airways are patent to the subsegmental level. Mild peribronchial wall thickening and atelectasis is present in the lower lobes bilaterally. A nodular opacity in the left lower lobe represents an impacted bronchus (4, 169). There is no pleural or pericardial effusion. The thyroid gland appears unremarkable. Mediastinal lymph nodes do not meet CT criteria for pathologic enlargement. The aorta is normal in caliber. The ascending aorta is clear of calcifications. Mild-to-moderate calcifications are in the aortic arch and descending aorta. Dense coronary calcifications are in all the coronary arteries. Dense calcification is present in the aortic and mitral valves. Cardiac size is normal. There is no pleural or pericardial effusion. This examination is not tailored for subdiaphragmatic evaluation. There is a stone within the gallbladder with no evidence of cholecystitis. There are no bone findings of malignancy. Extensive degenerative changes are in the thoracic spine. IMPRESSION: Mild emphysema. Atelectasis and peribronchial wall thickening in the lower lobes could be inflammatory. Cholelithiasis. Dense calcification of the coronary arteries and the aortic and mitral valves. DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] Approved: FRI [2183-8-29] 11:28 AM Imaging Lab There is antegrade right vertebral artery flow. There is antegrade left vertebral artery flow. Impression: Right ICA stenosis <40%. Left ICA stenosis <40%. DR. [First Name (STitle) 251] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Approved: MON [2183-9-1] 9:50 AM Imaging Lab FINDINGS: There is no evidence of acute hemorrhage, large acute territorial infarction, or large masses. There is no shift of midline structures. There are subcortical paraventricular white matter hypodensities, concerning for chronic small vessel ischemic changes. There is small hypodense area in the right corona radiata, 2:19, likely from an old ischemic event. Ventricles and sulci are prominent, likely age related. The visualized portion of the paranasal sinuses and mastoid air cells also within normal limits. No fracture seen. IMPRESSION: No acute intracranial process; specifically, no acute hemorrhage. Please note that for acute ischemia, MRI is more sensitive. The study and the report were reviewed by the staff radiologist. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] DR. [First Name (STitle) ] [Name (STitle) 12563] Approved: FRI [2183-8-29] 11:38 AM [2183-9-8] 05:25AM BLOOD WBC-10.7 RBC-3.14* Hgb-9.6* Hct-28.9* MCV-92 MCH-30.6 MCHC-33.2 RDW-13.5 Plt Ct-147* [2183-9-4] 02:27AM BLOOD PT-14.7* PTT-35.3* INR(PT)-1.3* [2183-9-10] 06:10AM BLOOD K-3.7 [2183-9-9] 05:25AM BLOOD UreaN-20 Creat-1.1 K-4.1 [2183-9-8] 05:25AM BLOOD Glucose-94 UreaN-27* Creat-1.1 Na-140 K-3.7 Cl-106 HCO3-27 AnGap-11 Brief Hospital Course: He was transferred on [8-27] from [Hospital ] Hospital after catheterization. His pre-op workup was completed which including a dental consult. IV heparin wasstarted for his left main disease. He fell on [8-28] and a CT was done of thehead and neck which ruled out any hemorrhage. Ultimately he underwent surgery with Dr. [Last Name (STitle) ] on [9-2]. He weaned from bypass onPropofol and neosynephrine in stable condition. These were weaned off and he was extubated. He was extubated in the early AM of POD #1, and transferred to the step down unit for ongoing postoperative care. His chest tubes and temporary pacing wires were removed per protocol. He was evaluated by Physical Therapy for strength and conditioning and was thought to benefit from a rehab stay prior to returning home. Diuresis towards his preoperative weight was continued and beta blockers were begun. He had a brief episode of atrial fibrillation which was treated with Amiodarone with conversion to and maintenance of sinus rhythm. He developed serosanguinous drainage from the lower third of his sternal incision on POD#4 and vancomycin was started per request of the covering cardaic surgeon, Dr. [Last Name (STitle) 914]. The drainage ceased, there was no erythema and the vancomycin was stopped and oral cephalosporins were given for a week.. he had transient confusion treated with Haldol, which cleared and the Haldol was discontinued. He remained alert and oriented. [Initials (NamePattern4) ] [Last Name (NamePattern4) 3945] for C. diff was sent and was negative. At discharge he is alert and oriented, all wounds are healing well. Diuretics will be continued for a week after discharge. Arrangements for follow up with his primary care doctor [First Name (Titles) ] [Last Name (Titles) 84927] are as outlined, along with medications, in the summary. Medications on Admission: verapamil 240', ASA 81', MVI QD, Folate 1', Simvastatin 40', Lexapro 10', Lisinopril 10', Colace 100", Senna Discharge Medications: 1. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 11. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 6 days. 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 3 weeks. Discharge Disposition: Extended Care Facility: Commons Residence At Orchard - [Location (un) 2624] (a.k.a. [Location (un) 5481]) Discharge Diagnosis: Aortic stenosis coronary artery disease Hypertension s/p right lacunar stroke( no residual deficit) Noninsulin dependent diabetes mellitus hyperlipidemia Discharge Condition: good Discharge Instructions: no lotions, creams, powders or ointments on any incision shower daily and pat incisions dry no lifting greater than 10 pounds for 10 weeks no driving for one month AND off all narcotics call for fever greater than 100, redness, drainage, or weight gain of 2 pounds in 2 days or 5 pounds in one weeks Followup Instructions: please call and schedule the following appointments: Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] Sanan ([Telephone/Fax (1) 8539]) in [11-29] weeks Dr. [Last Name (STitle) 8579] in [12-31] weeks Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Completed by:[2183-9-10] ICD9 Codes: 5119, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6221 }	Medical Text: Admission Date: [2135-11-26] Discharge Date: [2135-12-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6378] Chief Complaint: [Last Name (un) ] pain Major Surgical or Invasive Procedure: cholecystectomy, ileostomy take down History of Present Illness: 85M transferred from surgery. Had colon cancer s/p colectomy [4-11], complicated by ileal perf leading to ileostomy. Originally planned for ileosotomy revision on [11-30], however, presented to ED [11-25] w/ abdominal pain, found to have acute cholecystitis. Past Medical History: 1. PERIPHERAL EDEMA 2. DYSPHAGIA 3. Immune thrombocytopenic purpura 4. GBS like peripheral neuropathy 5. GASTROESOPHAGEAL REFLUX 6. NECK PAIN 7. CHRONIC CONJUNCTIVITIS 8. PERIPHERAL VASCULAR DISEASE 9. Hemorrhoids 10. SEROUS OTITIS 11. BENIGN PROSTATIC HYPERTROPHY 12. HYPERTENSION 13. Right Colon Cancer 14. Rectal ulcers 15. Myelodysplastic syndrome 16. colon cancer s/p colectomy [4-11], complicated by ileal perf leading to ileostomy placement 17. Chronic myelomonocytic leukemia on prednisone 18. adrenal insufficiency 19. abdominal abscess [10-12] Social History: Founder of Juliard String Quartet. No tobacco, no EtOH, generally lives with wife, however, has been resident of [Hospital ]. Family History: No colon cancer history. Physical Exam: VS T97.3 P84 BP120/56 RR16 O2Sat98 2LNC 1[Telephone/Fax (3) 7834] FS104 125 127 135 GENERAL: NAD NECK: Supple, JVP 4cm, L carotid bruit CARDIOVASCULAR: nl S1, S2, II/VI SEM axilla LUNGS: Continued decreased breath sounds on left base. No rales, wheezes or rhonchi. ABDOMEN: Active bowel sounds, mildly firm, nontender, dressing/wound CDI, 2X2 in place. EXTREMITIES: Warm, continued 2+ edema in lower extremities. Pertinent Results: [2135-11-26] 04:00PM WBC-30.7* RBC-3.29* HGB-10.5* HCT-31.7* MCV-96 MCH-32.0 MCHC-33.2 RDW-15.3 [2135-11-26] 04:00PM PLT SMR-LOW PLT COUNT-95* [2135-11-26] 04:00PM PT-14.1* PTT-33.3 INR(PT)-1.2 [2135-11-26] 04:00PM GLUCOSE-84 UREA N-30* CREAT-0.9 SODIUM-136 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11 [2135-11-26] 04:00PM ALT(SGPT)-72* AST(SGOT)-30 CK(CPK)-14* ALK PHOS-89 AMYLASE-69 TOT BILI-0.7 [2135-11-26] 04:00PM ALBUMIN-3.7 CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.6 [2135-11-26] 04:00PM CK-MB-NotDone [2135-11-26] 04:00PM cTropnT-0.05* ECHO:The left atrium is normal in size. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Mild (1+) 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. Compared with the prior study (tape reviewed) of [2135-7-18], estimated pulmonary artery systolic pressure is now lower and mitral regurgitation is now less prominent. CXR: No significant interval change in bibasilar opacities with bilateral (right greater than left) pleural effusions RENAL U/S:. The right and left kidneys measure 9.7 and 11.6 cm, respectively. There is no evidence of hydronephrosis. No renal stones or masses are visualized. SPUTUM Culture: GRAM STAIN (Final [2135-12-4]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2135-12-8]): MODERATE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| KLEBSIELLA PNEUMONIAE \| \| AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R =>8 R MEROPENEM------------- <=0.25 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN/TAZO----- 64 I RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 2 S VANCOMYCIN------------ <=1 S CT ABDOMEN W/CONTRAST [2135-12-13] 3:56 PM 1. Bilateral pleural effusions and bibasilar atelectasis. 2. Small perihepatic fluid without locualted fluid collection or associated free air. 3. Slightly dilated loops of small bowel without identifiable transition point. 4. Anasarca. 5. Multiple compression fractures. Brief Hospital Course: 85M MDS/CMML with colon cancer, status post resection complicated by ileotomy requiring ileostomy placement, here for cholecystectomy (for cholecystitis) and ileostomy takedown. Patient presented with abdominal pain and had radiological findings consistent with cholecystitis. Therefore, as patient was scheduled to undergo ileostomy takedown within the week of presentation, patient underwent both cholecystectomy and ileostomy takedown on hospital day 4. Patient initially tolerated the procedure well, however post-operative course was complicated by hypotension requiring transfer to the surgical ICU. Patient was stabilized on pressors and a Swan Ganz catheter was placed. Patient was found to have bilateral pulmonary consolidations with sputum notable for methicillin resistant staphylococcus aureus and klebisiella, therefore, vancomycin and meropenem were administered for treatment based upon susceptibility profiles. Subsequently, patient went into acute renal failure, felt to be secondary to episode of hypotension - medications were adjusted for renal dosing. Patient was stabilized and transferred from the SICU to internal medicine service on hospital day 15. * Cholecystectomy/Ileostomy takedown: Post-operative course was complicated as above, however, surgical wound responded appropriately to [Hospital1 ] wet-to-dry dressing changes with healing by secondary intention. Of note, at one point during post-op course, wound was thought to be draining purulent material, however, this was self-limited, and at the time of discharge, patient's wound had development of excellent granulation tissue and no evidence of infection. Staples were removed by surgical consultants without complications. * Pneumonia: As noted above, sputum culture returned MRSA and klebsiella, and patiented was started on a course of vancomycin/meropenem, to continue until [2135-12-20]. On hospital day 17, patient was noted to have a white count elevation to 60, which prompted an infectious workup, although patient had no clinical signs or symptoms of infection or fever. CT scan revealed no abdominal pathology, however, patient was noted to have large pleural effusions bilaterally, right greater than left, consistent with patient's subjective complaints of dyspnea. On hospital day 18, patient underwent thoracentesis of the right pleural space, removing 2 liters of serosanguinous fluid (negative for bacterial growth and few neutrophils). Right lung expanded appropriately, although patient continued to remain intermittently dyspneic, thought to be due to continued resolving fluid overload, as patient remained afebrile throughout rest of hospital course. Patient had a PICC placed on hospital day 17 in anticipation of discharge on IV antibiotics. Of note, with the exception of a one time low grade temp (100.7) the day prior to discharge, patient afebrile for the entire week prior to discharge. * Acute Renal Failure: Felt to be from ATN secondary to episode of hypotension. Improved in house and at discharge, creatinine was: 1.2 (though during the week prior to discharge Cr was as low as 1.0). His baseline creatinine is 0.8. Patient was grossly volume overloaded, but began mobilizing as renal function recovered. Of note, patient's creatinine improved with further Lasix-mediated diuresis, and during the week prior to discharge patient was given Lasix 40-80mg IV with a goal of 500cc-1L out daily. As patient was having less response to Lasix diuresis in final days prior to discharge, patient was given a one time dose of acetazolamide to stimulate further diuresis as bicarbonate was noted to be 33 (thought to be due to contraction/lasix diuresis). * Increased WBC: Patient has a history of chronic myelomonocytic leukemia, treated with minimal doses of prednisone. Patient was noted to have a sharp elevation of white count on multiple occasions during hospitalization. In discussion with patient's primary hematologist, as infectious causes were ruled out, it was felt that these elevations (to max 60,000, ~30% monocytes) were due to exaggerated white cell production/mobilization secondary to chronic myelomonocytic leukemia. Indeed, no blasts were noted on differential. Patient was treated empirically with oral vancomycin, to be continued 10 days following discharge. Patient's prednisone was tapered to 10mg QOD at the time of discharge. * Anemia/Hemolysis: Patient was found to have elevated LDH 377, with haptoglobin <20, however, no schistocytes on smear and no elevation in coagulation factors were noted. Indeed, LDH continued to trend downwards at the time of discharge (LDH 297). However, patient did require two units of packed red cells over the course of the week prior to discharge, felt to be required secondary to combination of low grade hemolysis (from infection), CMML, and myelodysplastic syndrome. Of note, stool guaiac was negative. Patient was transfused with parameters of hematocrit>30%, as patient has previously been symptomatic below that level, and patient was transfused the day of discharge. * Aspiration/Nutrition: Although patient initially failed a swallow study while in SICU, patient later did well on a second swallow study. Patient did initially require NG tube feeds as PO intake was not adequate. However, a week prior to discharge, patient's NG tube was removed (as he was complaining of inability to eat with tube in place) and given one liter of total parenteral nutrition as a bridge. At the time of discharge, patient was taking between 1000-1600kcal/day of oral nutrition. At the time of discharge, patient's respiratory status was excellent (requiring minimal oxygen), had no signs or symptoms of infection or abdominal pathology, and was eager to pursue aggressive physical rehabilitation. Patient was discharged with instructions to continue Lasix 80mg PO daily, with 20meq Potassium chloride supplementation daily, and hematocrit/Chem7 to be checked four days following discharge. Medications on Admission: Ferrous sulfate fluoxetine folate prednisone 15mg qod prevacid 30mg [Hospital1 ] Discharge Medications: 1. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours) for 1 days. 2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. Vancomycin HCl 10 g Recon Soln Sig: One [Age over 90 ]y Five (125) mg Intravenous Q6H (every 6 hours) for 10 days. 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD (). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic 3X/WEEK (MO,WE,FR). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-11] Puffs Inhalation Q4H (every 4 hours). 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatments Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatments Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 12. Meropenem 1000 mg IV Q12H 13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 15. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale Injection four times a day. 16. Lantus 100 unit/mL Solution Sig: Five (5) units Subcutaneous at bedtime. 17. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Congestive heart failure Chronic myelomonocytic leukemia Hypotension Acute renal failure MRSA/Klebsiella Pneumonia Cholecystitis, now status post cholecystectomy Colon cancer, now status post resection and ileostomy takedown Discharge Condition: Fair- still edematous and with 2L nasal cannula O2 requirement Discharge Instructions: Follow up with primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 838], within one week of discharge. Please call Dr.[Name (NI) 1863] clinic to make a followup appointment within two weeks of discharge [Telephone/Fax (1) 1864]. Continue to take your medications as directed. You will continue the antibiotics Vancomycin and Meropenem for one more day following discharge. Please call your primary care physician if you have fever, chills, severe abdominal pain, or increasing shortness of breath. Some shortness of breath is expected as your lungs recover from the pneumonia. However, if your oxygen requirement begins to increase, you may need to see a doctor. Followup Instructions: Provider: [Name10 (NameIs) 395],[First Name3 (LF) ] [Location (un) 2788] MED/[Doctor First Name 147] Where: [Location (un) 2788] MED/[Doctor First Name 147] Date/Time:[2136-3-5] 2:15 Please call Dr.[Name (NI) 1863] clinic to make a followup appointment within two weeks of discharge [Telephone/Fax (1) 1864]. Please followup with your primary care physician. Recommend followup with Dr. [Last Name (STitle) 6160], Hematologist, regarding Chronic myelomonocytic leukemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6384] MD, [MD Number(3) 6385] ICD9 Codes: 5119, 5849, 4280, 2762, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6222 }	Medical Text: Admission Date: [2110-7-16] Discharge Date: [2110-7-25] Date of Birth: [2027-9-7] Sex: F Service: MEDICINE Allergies: Codeine / Keflex / Clindamycin Attending:[First Name3 (LF) 4980] Chief Complaint: Dysphagia, Poor PO intake, Weight Loss Major Surgical or Invasive Procedure: PEG tube placement History of Present Illness: This is an 82 y/o F with two and a half years of dysphagia, who had a feeding tube placed in [5-27]. It remained in until [Month (only) ] of 06, after her weight improved. About 6-8 months ago, she began to have trouble swallowing again. She decribes it as feeling asa if her throat is clogged. She does not feel food getting stuck. Dhe does not drink thin liquids. She has trouble with most foods. She denies the feeling that food is going into her trachea. She reports weight loss from 115 lbs to 99lbs over the last eight months. She also has two and a half years of hoarseness/laryngitis which comes and goes. On ROS, she denies headache, fevers, chills, chest pain, back pain, dyspnea at rest or with exertion, abdominal pain, diarrhea. She does have some constipation. She denies joint pain. She does have rosacia for a long time. Past Medical History: Atrial Fibrillation S/P Ablation Dilated Ascending Aorta Osteoporosis Dysphagia for several years with Weight Loss History of PNA requiring VATS pleural effusion drainage and decortication on the right side Diverticulosis/Diverticulitis History of Bowel Obstruction with Temporary Colostomy Prolapsed Uterus S/P repair S/P Hysterectomy Cerebral Palsy Macular degeneration Ventral Hernias Rosacia Status post removal of bowel obstruction due to diverticulitis requiring a temporary colostomy Status post surgical repair of a prolapsed uterus Status post total hysterectomy Status post abdominal surgery secondary to complications of prolapsed uterus surgery - The patient developed multiple hernias. Status post surgery for exposed keratoses Social History: Non smoker. Lives alone in [Location (un) ]. Totally independent, but recently has not been going to the gym because of weakness for the last several months. Family History: Noncontributory Physical Exam: GENERAL: Extrememly Cachectic Female in no acute distress. Very throaty voice, very fatigueable. VITALS: T 98.1 HR 77 BP 110/68 RR 20 SAT 94%RA SKIN: Thin and tenting. HEENT: Sunken eyes, unable to close eyelids completely, erythematous conjunctiva, cornea with some opacification bilaterally. EOMI. Pupils equal. Sclera Anicteric. NECK: No stiffness, No masses, No LAD, Palpable carotid pulses CHEST: No supraclavicular or axillary LAD, Decreased breath sounds at right base. HEART: Regular with palpable 4/6 systolic murmur over entire precordium. BACK: No spinal tenderness ABDOMEN: Massive ventral hernia with audible bowel sounds. Midline scar. NT. No guarding, No rebound. EXT: Some DIP nodules bilaterally. Bilateral pitting edema of legs to the knee. Right heel ulcer. NEURO: MS oriented to person, place, time CN II-XII intact Muscle Strength RUE [5-26] LUE [5-26] LLE [5-26] RLE [5-26] Pertinent Results: [2110-7-25] 07:00AM BLOOD WBC-7.0 RBC-3.33* Hgb-10.8* Hct-33.6* MCV-101* MCH-32.4* MCHC-32.1 RDW-14.4 Plt Ct-186 [2110-7-21] 07:05AM BLOOD WBC-6.9 RBC-3.63* Hgb-11.9* Hct-36.2 MCV-100* MCH-32.8* MCHC-32.8 RDW-14.3 Plt Ct-148* [2110-7-16] 09:20PM BLOOD WBC-7.1 RBC-3.46* Hgb-11.4* Hct-34.2* MCV-99* MCH-33.1* MCHC-33.4 RDW-14.0 Plt Ct-186 [2110-7-20] 07:50AM BLOOD Neuts-84.9* Lymphs-9.0* Monos-4.4 Eos-1.4 Baso-0.3 [2110-7-19] 03:54AM BLOOD Neuts-88.0* Lymphs-7.4* Monos-3.6 Eos-0.8 Baso-0.2 [2110-7-25] 07:00AM BLOOD Plt Ct-186 [2110-7-21] 07:05AM BLOOD Plt Ct-148* [2110-7-21] 07:05AM BLOOD PT-13.6* PTT-31.6 INR(PT)-1.2* [2110-7-19] 03:54AM BLOOD PT-13.0 PTT-34.5 INR(PT)-1.1 [2110-7-16] 09:20PM BLOOD Plt Ct-186 [2110-7-16] 09:20PM BLOOD PT-14.0* INR(PT)-1.2* [2110-7-24] 05:45AM BLOOD Glucose-150* UreaN-10 Creat-0.4 Na-139 K-3.9 Cl-98 HCO3-38* AnGap-7* [2110-7-23] 06:35AM BLOOD Glucose-115* UreaN-9 Creat-0.4 Na-141 K-4.0 Cl-99 HCO3-39* AnGap-7* [2110-7-21] 07:05AM BLOOD Glucose-88 UreaN-9 Creat-0.4 Na-140 K-3.9 Cl-96 HCO3-37* AnGap-11 [2110-7-18] 07:15AM BLOOD Glucose-68* UreaN-13 Creat-0.5 Na-142 K-4.8 Cl-101 HCO3-35* AnGap-11 [2110-7-16] 09:20PM BLOOD Glucose-98 UreaN-14 Creat-0.5 Na-145 K-3.9 Cl-103 HCO3-35* AnGap-11 [2110-7-23] 06:35AM BLOOD ALT-18 AST-32 LD(LDH)-212 AlkPhos-44 TotBili-0.5 [2110-7-16] 09:20PM BLOOD ALT-18 AST-20 AlkPhos-58 Amylase-46 TotBili-0.7 [2110-7-23] 06:35AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.9 [2110-7-21] 07:05AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.9 Iron-52 [2110-7-16] 09:20PM BLOOD Albumin-3.3* Calcium-9.2 Phos-3.0 Mg-1.8 [2110-7-21] 07:05AM BLOOD calTIBC-212* VitB12-1545* Folate-GREATER TH Ferritn-137 TRF-163* [2110-7-20] 01:30PM BLOOD Type-ART pO2-90 pCO2-67* pH-7.39 calTCO2-42* Base XS-11 [2110-7-18] 01:22PM BLOOD Type-ART pO2-117* pCO2-70* pH-7.31* calTCO2-37* Base XS-6 [2110-7-22] 11:04AM URINE Color-Straw Appear-Hazy Sp [Last Name (un) ]-1.010 [2110-7-22] 11:04AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM [2110-7-22] 11:04AM URINE RBC-1 WBC-11* Bacteri-FEW Yeast-NONE Epi-1 TransE-1 [2110-7-22] 11:04AM URINE Hours-RANDOM UreaN-299 Creat-40 Na-94 Cl-66 . CXR - Bibasilar airspace opacities consistent with aspiration. . Arterial study - Right lower extremity mild arterial occlusive disease. Left- sided ankle-brachial indices are normal at rest. There is evidence of some tibial level disease on segmental pressure readings. . CXR - A single AP chest radiograph compared to [2110-7-17] shows increased bibasilar opacities. Rounded lucency within the left lung base likely represents residual aerated lung. Tip of the NG tube is seen within the stomach. . EKG - Sinus rhythm. A-V conduction delay. Left anterior fascicular block. Compared to the previous tracing of [2108-6-30] the limb lead voltage is more prominent. The axis is more leftward. Otherwise, no diagnostic interim change. Brief Hospital Course: 82 y/o F with a two and a half year history of dysphagia and intermittant voice hoarseness presented with dysphagia, cough, and weight loss, had unsuccessful PEG placement attempt by GI due to hypercarbia, with resultant PEG placement by surgery under general anesthesia on [7-22] with tube feeds, transferred to rehab. 1. Dysphagia - video swallowing study x2 suggestes primary Swallowing problem (intrinsic swallowing muscles), other differential possibilities central CN problem vs. internal esophageal obstruction vs. external compression of esophagus. Further work-up not performed during this stay can include chest CT to assess for compression on esophagus. Patient was kept NPO, initially had tube feedings through a dobhoff/NGT. EGD being performed by GI was unsuccessful due to ?oversedation with hypercarbia and unresponsiveness. PEG tube placement was then successfully attempted with general anesthesia by surgery on [2110-7-22]. Nutrition was consulted and patient was transitioned to continues PEG tube feeds on [7-23] until time of discharge. Patient will need follow-up speech and swallow evaluation, either at rehab or at [Hospital1 ]. . 2. Somnolence/Apnea - as above, patient had somnolent, apneic period in setting of medication for EGD, with resultant hypercarbia, transferred to MICU then called out after 2 days. Patient was fully awake and alert during the last 5 days of her hospitalization. ble, satting well on 2L nasal cannula with good mental status. CXR demonstrated possible RML/RLL pneumonitis vs. pneumonia (aspiration, likely after initial episode of somnolence), but now afebrile. . 3. Respiratory/aspiration - pt had hx of aspiration, CXR was suggestive of aspiration. Since patient was afebrile with normal WBC, no antibiotics were administered. Patient was never intubated but required oxygen during the hospitalization, specifically 2 liters of O2 during the last 5 days of her stay. She did continue to have mild secretions with rhonchi on her exam. Patient will continue to need chest PT, OOB, incentive spirometry, Yankauer suctioning, HOB > 30 degrees, aspiration precautions at rehab. . 4. Right Heel Wound - stage II ulcer, arterial studes performed with results as above. Patient was treated with duoderm and waffle boots. She will continue to require barrier cream for elbows and buttocks and lotion to bilateral legs daily to prevent further skin breakdown. . 5. Cardiovascular/atrial Fibrillation - s/p ablation, was well rate controlled during her stay on metoprolol. Her systolic blood pressures ranged from 90-125 with metoprolol being held one day during her last 5 days due to relative hypotension. . 6. Hoarse Voice - could be vocal cord paralysis, but cords moving normally on video swallow. Recurrent laryngeal nerve involvement from dilated aorta possible. Consider further workup as outpatient. . 7. Hypothyroidism - continued on levothyroxine. . 8. Macular Degeneration - continued eye drops. . 9. Osteoporosis - continued Vitamin D and Calcium. Family was requesting boniva IV treatment while inpatient as she would be missing her treatment as outpatient on Monday, [7-28]. Our inpatient pharmacy did not have this medication and it is not on our inpatient formulary. . 10. Cerebral Palsy - had been on diazepam previously, now continuing to hold given oversedation. . 11. fEN - PEG tube feeds were initiated on [2110-7-23] with nutren pulmonary feeds (due to metabolic alkalosis/high bicarb - lowest carbohydrate feedings available). There were no discreet recommendations on when to transition patient to bolus feedings from continuous. Due to surgical placement, would opt to continue continuous tube feedings for 7 days, then transition to bolus feedings. She will need a nutrition consult to aid in appropriate tube feeding regimen, monitoring of lytes - specifically acid-base status given respiratory issues, and will need monitoring of PEG tube placement and stability. She should also have an appointment scheduled with surgery to follow the PEG tube sometime within the next 4-6 weeks. . 12. [Name (NI) 5] - pt was treated with heparin SubQ and a bowel regimen. She was able to urinate on her own, but her output was not robust on a daily basis and bladder scans did show >600cc on one occasion, but patient able to void. . 13. PT - pt spent most of the days in bed and OOB to chair. Will need physical therapy while at rehab. . 14. CODE: FULL Medications on Admission: ASPIRIN 81 MG Daily DIAZEPAM 2 mg Daily ERYTHROMYCIN 5 mg/gram Ointment - 1 application eyes at bedtime GATIFLOXACIN [ZYMAR] 0.3 % Drops - 1 drop eyes Mon-Wed-Fri IBANDRONATE [BONIVA] - 3 mg injection every three months LEVOTHYROXINE [SYNTHROID] 50 mcg Daily METOPROLOL TARTRATE 25 mg [Hospital1 ] MULTIVITAMINS daily CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - 250 mg-200 unit [Unit Number ] Tab [Hospital1 ] Discharge Medications: 1. Erythromycin 5 mg/g Ointment Sig: One (1) application Ophthalmic HS (at bedtime). 2. Boniva 3 mg/3 mL Syringe Kit Sig: One (1) injection Intravenous every 3 months. 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Citracal + D 250-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic MWF (Monday-Wednesday-Friday). 9. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [1-22] Inhalation Q6H (every 6 hours). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Insulin Lispro 100 unit/mL Solution Sig: asdir Subcutaneous ASDIR (AS DIRECTED). 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for sbp<95. 16. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: One (1) Drop Ophthalmic TID (3 times a day) as needed for dry eyes. 17. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Primary: 1. Dysphagia 2. Aspiration - PEG tube placement . Secondary: Atrial Fibrillation S/P Ablation Dilated Ascending Aorta Osteoporosis Dysphagia for several years with Weight Loss History of PNA requiring VATS pleural effusion drainage and decortication on the right side Diverticulosis/Diverticulitis History of Bowel Obstruction with Temporary Colostomy Prolapsed Uterus S/P repair S/P Hysterectomy Cerebral Palsy Macular degeneration Ventral Hernias Rosacia Discharge Condition: Stable, tolerating PEG tube feeds. Discharge Instructions: You were admitted because of trouble swallowing and significant weight loss. You had a Gastric tube placed for feeding. If you acquire chest pain, shortness of breath, nausea, vomiting, or any other issue that is out of the ordinary for you, please call 911 or seek medical care. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2110-10-8] 10:00 Provider: [Name10 (NameIs) 13644],NURSE [First Name (Titles) 13644] [Last Name (Titles) ] Date/Time:[2110-7-31] 3:00 Provider: [Name10 (NameIs) 1248],CHAIR THREE [Name10 (NameIs) 1248] ROOMS Date/Time:[2110-7-28] 11:15 You should call your PCP to set up an appointment within the next 2-3 weeks for an appointment. You will need an appointment with the general surgeons here to have your PEG tube followed within the next 4-6 weeks (or sooner if any issues arise with its placement). ICD9 Codes: 5070, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6223 }	Medical Text: Admission Date: [2185-5-23] Discharge Date: [2185-6-8] Service: MEDICINE Allergies: Flagyl Attending:[First Name3 (LF) 1253] Chief Complaint: pneumonia, tachycardia Major Surgical or Invasive Procedure: PICC placement History of Present Illness: Ms. [Known lastname 7756] is a [Age over 90 ] year-old woman with dementia and benign meningioma, presenting from [Hospital3 2558] with increased productive cough, SOB and tachycardia. Patient has had one week of increasing productive cough. She denies any chest pain, nausea, vomiting. She is unable to provide further history about her symptoms. . Of note, she was admitted from [Date range (1) 108390] for sinus tachycardia and chronic cough. She was again admitted from [Date range (1) 33900] for a rash that was determined to be from metronidazole, which she was taking for Clostridium difficile colitis, upon which she was placed on PO vancomycin, which she was to take until [2185-5-7]. . In the ED, initial vs were: T 100 P 150 BP 140/84 R 20 Sat 98% 2L. Patient was noted to have wheezing on exam with crackles at bases R>L. She was also noted to have diffuse rash on torso, legs, and arms, documented to be from Flagyl at [Hospital3 2558]. CXR was concerning for RLL pneumonia, so she was given a dose of Vancomycin and levofloxacin IV. She was also noted to have UTI. She was given 1g of tylenol for fever. HRs improved briefly to 90s with brief conversion to NSR after IVF bolus, then converted back to Afib with rates in 150s. She received a total of 1.5L of IVFs in the ED. For ventricular rates intermittently in 150s, she was then given 5mg IV lopressor which decreased HR to 110s-130s. Patient has a signed DNR form in her [Hospital3 2558] records. She had also complained of some abdominal discomfort in the ED, but on exam, she was easily distracted with no signs of tenderness. Vitals in ED prior to transfer were as follows: HR 98 BP 115/61 RR 28 O2sat 99% 2L. . On arrival to the MICU, patient appears comfortable and states that her cough is much better. She complains of no chest pain or dyspnea. She has no noted pain. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness. 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: -HTN -CKD III/IV -Dementia baseline A&O X 1 -h/o SVT (usually post op or during stress) -h/o UTI (pansensitive E.Coli) -Dysphagia -Benign cerebellopontine angle meningioma. -History of diverticulitis. -Osteoporosis, s/p L hip fx s/p ORIF [8-22], vertebral compression fractures (L2/L3) -Depression w/ psychosis -Colonic polyps, s/p partial colorectal resection [2167], for sessile polyp. Postoperative course c/b SVT -s/p thyroid surgery - details unknown -EGD [11/2174], with gastritis, (+) H. pylori. -Colonoscopy [11/2174], adenomatous polyp resection. -Status post C3 through C7 laminectomy. -Glaucoma - recent admission for pancreatitis [4-25] - recent episode of Cdiff [4-25] Social History: She lives at [Hospital3 2558]. Has no surviving family. HCP is friend, [Name (NI) ] [Name (NI) 108388] [Telephone/Fax (1) 108389]. At baseline is not that ambulatory (not at all per pt, minimally so with assistance per [Location (un) ]) since hip fracture. Family History: Not relevant to current presentation. Patient also not able to provide. Physical Exam: Vitals: T: 96.6 BP: 114/64 P: 69 R: 27 O2: 97%RA General: Alert, oriented x 3, no acute distress, cooperative HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: rhonchorous sounds present at the right base > left base, presence of upper airway sounds, no accessory muscle use, no wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: exfoliative, erythematous rash on arms, legs and torso Pertinent Results: CT Chest w/o Contrast: [2185-5-31] 1. Bilateral nonhemorrhagic pleural effusions, with associated dependent atelectasis, including left lower lobe collapse, with additional atelectasis seen dependently in the right middle lobe. There is associated opacification of the left lower lobe bronchi, which may reflect mucus plugging or aspiration. In the aerated lung parenchyma, there are no focal opacities to suggest pneumonia. 2. Redemonstration of left apical lung mass, suboptimally evaluated due to respiratory motion, though little change from [2184-5-21]. 3. Aortic valvular calcifications, with mild ectasia of the ascending aorta. 4. Atrophy of the left kidney, with configuration suggesting chronic left UPJ obstruction. 5. Moderately severe biapical pleural scarring. . CT Abdomen/Pelvis: [2185-5-30] 1. Bibasilar and right middle lobe atelectasis with small bilateral pleural effusions, new since prior imaging. 2. Resolution of the previously described pancreatitis of the tail with a stable 16-mm hypodense lesion which may represent either a pseudocyst or other pancreatic cystic lesion, for example IPMN. This could be further evaluated with MRCP. 3. Unchanged multiple fat-containing anterior abdominal wall hernias. One midline hernia now contains a loop of transverse colon but no evidence for proximal obstruction. 4. No intra-abdominal collection to account for elevated white cell count. . [2185-5-30] RUE U/S: No evidence of right upper extremity DVT. . Microbiology: UCx [2185-5-23] with E.coli; all blood cultures negative; repeat urine culture negative; C.difficile negative x 2 . PENDING C-diff PCR remains pending at this time. [Month (only) 116] discontinue oral vancomycin if returns negative. Note that pt has allergy to flagyl. . [2185-5-23] 07:00PM BLOOD WBC-7.8 RBC-3.58* Hgb-11.8* Hct-33.8* MCV-95 MCH-33.1* MCHC-35.0# RDW-15.0 Plt Ct-163 [2185-5-25] 01:00PM BLOOD WBC-20.4# RBC-3.42 Hgb-10.7* Hct-33.5* MCV-98 MCH-31.2 MCHC-31.8 RDW-15.2 Plt Ct-198 [2185-6-6] 08:00AM BLOOD WBC-10.3 RBC-3.33* Hgb-10.4* Hct-32.2* MCV-97 MCH-31.2 MCHC-32.2 RDW-15.7* Plt Ct-115* [2185-5-24] 03:44AM BLOOD Glucose-159* UreaN-26* Creat-1.4* Na-142 K-4.6 Cl-109* HCO3-19* AnGap-19 [2185-5-27] 06:00AM BLOOD Glucose-101* UreaN-46* Creat-2.4* Na-143 K-4.7 Cl-109* HCO3-22 AnGap-17 [2185-6-6] 08:00AM BLOOD Glucose-83 UreaN-19 Creat-1.9* Na-142 K-3.8 Cl-109* HCO3-21* AnGap-16 [2185-5-30] 04:47AM BLOOD ALT-11 AST-13 AlkPhos-96 TotBili-0.4 [2185-6-6] 08:00AM BLOOD Calcium-7.4* Phos-3.6 Mg-1.5* [2185-5-23] 07:00PM BLOOD cTropnT-0.02* [2185-5-24] 03:44AM BLOOD TSH-1.5 Brief Hospital Course: HEALTH CARE ASSOCIATED PNEUMONIA: Treated with vancomycin and cefepime x 8 day total course. ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RATE: Treated with dilatiazem and metoprolol. Discharge regimen was metoprolol 12.5mg po bid and diltiazem 60 mg po QID. Diltiazem may be converted to Diltiazem XR 240 mg po q day as an outpatient. Heart rates well-controlled when patient takes medications as scheduled. ACUTE ON CHRONIC KIDNEY FAILURE: Treated with IVF and improved to 2.1-2.2 at time of discharge. C DIFF COLITIS: Recent c diff 1 month ago. The patient was treated in the last month with flagyl and developed a rash, at which time she was transitioned to PO vancomycin, which she completed prior to this admission. While on broad spectrum antibiotics for HCAP above she developed a leukocytosis of 20 from 5 so she was started empirically on vancomycin oral 125mg po q6hrs and should continue this for after she is finished with her antibiotics for aspiration pneumonia (See below). Aspiration: Patient noted to be frankly aspirating on [2185-5-28]. She was made NPO and was seen in evaluation by speech and swallow. She had evidence of continued aspiration on three subsequent evaluations, attributed to delirium and weakness from prolonged hospitalization and multiple infections. In the setting of her aspiration, elevated WBC, and findings on chest CT she was started on an eight day course of Piperacillin/Tazobactam for presumed aspiration pneumonia. In discussion with her health care proxy it was decided that parenteral nutrition or placement of a G-tube would not be in keeping with her goals of care, and she was allowed to eat to her comfort and desire. She was followed closely by both Speech and Swallow and Nutrition. Hypernatremia: While NPO for aspiration as above patient became hypernatremic. She was treated for two days with D5W and her sodium normalized. Medications on Admission: brimonidine Dosage uncertain [2184-11-12] clobetasol 0.05 % Ointment apply [Hospital1 ] x 5 days then QOD x 1 wk [2185-5-6] latanoprost [Xalatan] Dosage uncertain [2184-11-12] levothyroxine Dosage uncertain [2184-11-12] metoprolol tartrate Dosage uncertain [2184-11-12] mirtazapine Dosage uncertain [2184-11-12] mupirocin 2 % Ointment Apply to wound daily [2185-1-4] omeprazole Dosage uncertain [2184-11-12] timolol maleate Dosage uncertain [2184-11-12] triamcinolone acetonide 0.1% Oint apply [Hospital1 ] on days not using clobetasol [2185-5-6] * OTCs * acetaminophen Dosage uncertain alum-mag hydroxide-simeth [Mylanta] Dosage uncertain aspirin Dosage uncertain bisacodyl [Dulcolax] Dosage uncertain calcium carbonate-vitamin D3 [Calcium with Vitamin D] Dosage uncertain carbamide peroxide [Debrox] Dosage uncertain cranberry ext-C-L. sporogenes [Azo Cranberry] Dosage uncertain docusate sodium [Colace] Dosage uncertain magnesium hydroxide [Milk of Magnesia] Dosage uncertain sennosides [Senokot] Dosage uncertain sodium phosphates [Fleet Enema] Discharge Medications: 1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): take until [2185-6-16]. 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H (every 12 hours). 3. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl Topical once a day for 5 days: to affected areas (rash) - do not use on face, armpit, or groin. . 8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours): [Month (only) 116] wean off or switch to MDI as tolerated. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 14. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 15. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 16. acetaminophen 650 mg/20.3 mL Solution Sig: 1-2 tabs PO Q8H (every 8 hours) as needed for pain. 17. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary Diagnosis: Health care associated bacterial pneumonia Aspiration pneumonia Possible C diff colitis Atrial fibrillation with rapid ventricular rate Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with a fever and found to have pneumonia. You also may have had a recurrance of your C diff (colon infection), although this is uncertain. Please take your medications as prescribed and make your follow up appointments. Followup Instructions: Please follow up with your primary care physician [Name Initial (PRE) 176] 2 weeks of your discharge from the hospital: [Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (1) 608] ICD9 Codes: 2760, 5990, 5849, 2930, 5070, 4280, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6224 }	Medical Text: Admission Date: [2174-12-18] Discharge Date: [2174-12-24] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10842] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 25414] is a [Age over 90 ] year old male with COPD on home O2, asbestosis, recurrent bilateral pleural effusions, severe pulmonary HTN, chronic aspiration, recent strangulated femoral hernia s/p repair, and multiple recent hospitalizations, returns from rehab with hypoxia in setting of HAP treatment. He has had continued with SOB and cough and this AM desatted to 75-80 on 2L. . He was discharged on [2174-12-16] after an admission for noncardiac chest pain, complicated by hospital-acquired pneumonia. He was discharged to complete an 8 day course of Vanc/Zosyn. In general, he has become significantly deconditioned and malnourished due to aspiration. He has repeatedly refused PEG tube despite his family's encouragement. . In the ED initial vital signs were 97.7 103 123/63 24 89% on 15L [Date Range 597]. Labs showed no leukocytosis, stable anemia, and slightly elevated creatinine. CXR showed worsening consolidation of Right middle/lower lobes. ID was consulted given pt's lack of response to Vanc/Zosyn and will give recommendations after transfer to the floor. Pt received nebs x 3 and tamiflu. Swab to be done in ICU, given no isolated bed in ED. EKG showed tachy sinus at 100, NA, NI, no ischemic changes. Prior to transfer VS 97.1 105 129/52 30 95/[Date Range 597] @10 L, occasionally dropping to 70s on 4L. Given requirement for [Name (NI) 597], pt admitted to ICU. . Code status being discussed by family, although previously has been consistently DNR/DNI given severe lung disease. . Review of systems: Pt denied chest pain, shortness of breath, abd pain, nausea, vomiting, and constipation. Past Medical History: COPD on 2L home O2 -Asbestosis s/p L VATS [6-/2172], placement of pleurex catheter for chronic effusions -discharged on [2174-11-23] after pigtail catheter placed for drainage of bilateral pleural effusion (c/b severe pulmonary hypertension required re-intubation and post-op pneumonia-treated with IV antibiotics -Hypertension -Hypercholesterolemia -h/o gastric ulcers -Glaucoma -Psoriasis -presumed lung CA, ? mesothelioma -Epiglottic dysfunction and aspiration PNA -Strangulated femoral hernia, s/p repair [2174-11-5] Social History: He has been married for 60 years. Retired. He was a supervisor in a shipyard and has significant asbestos exposure. Tobacco: Quit smoking > 40 years ago. Previous to that had a 10-pack-year history. EtOH: Social. Illicits: Denies Lived with wife [Name (NI) 25415]. [Name2 (NI) ] recently been at rehab following hernia surgery. Was previously walking with walker, but has been unable to walk following surgery. Working with PT at rehab. Of note during this admission, his wife had knee replacement surgery and was in rehab. Family History: His brother and his mother had diabetes. Physical Exam: Admission physical exam VITAL SIGNS: T= BP= 133/66 HR= 97 RR= 29 O2=89% on . PHYSICAL EXAM GEN: elderly, frail, cachectic. HEENT: PERRL, EOMI, oral mucosa dry NECK: Supple, no LAD PULM: tachypneic, using neck muscles, significantly decreased BS at both bases/ lower [1-8] of lungs CARD: RRR, prominent S2, [4-11] apical systolic murmur ABD: Thin, BS+, soft, NT, ND, packing in right lower groin, 3-4cm opening without surrounding erythema or tenderness. EXT: No c/c/e, cool extremities, DP pulses +1 SKIN: psoriatic rash on RLE, no skin breakdown on back/coccyx NEURO: CN II-XII intact. moving all extremities, answering questions and following directions appropriately. PSYCH: anxious, appears tired Pertinent Results: Admission labs: [2174-12-18] 05:48AM WBC-8.7 RBC-3.01* HGB-8.8* HCT-29.2* MCV-97 MCH-29.4 MCHC-30.3* RDW-17.1* [2174-12-18] 05:48AM NEUTS-83.8* LYMPHS-8.3* MONOS-2.5 EOS-5.2* BASOS-0.1 [2174-12-18] 05:48AM PLT COUNT-222 [2174-12-18] 05:48AM GLUCOSE-135* UREA N-20 CREAT-1.4* SODIUM-145 POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-31 ANION GAP-11 . Last Labs: [2174-12-23] 06:38AM BLOOD WBC-6.4 RBC-2.90* Hgb-9.0* Hct-28.3* MCV-98 MCH-31.0 MCHC-31.7 RDW-17.2* Plt Ct-218 [2174-12-23] 06:38AM BLOOD Glucose-85 UreaN-19 Creat-1.5* Na-148* K-4.2 Cl-101 HCO3-38* AnGap-13 [2174-12-23] 06:38AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.8 . Imaging [2174-12-18] CXR Increase in acute-on-chronic right middle lobe and right basilar atelectasis. Brief Hospital Course: Mr. [Known lastname 25414] was admitted to the MICU for hypoxia and high oxygen requirement. Upon arrival to the MICU Mr. [Known lastname 25414] [Last Name (Titles) 25424]d his desire to be DNR/DNI. The goals of care were discussed with Mr. [Known lastname 25414] and his family. It was decided to continue treatment with antibiotics and provide assistance with breathing (but no intubation or Bipap). He finished an eight day course of vancomycin and piperacillin-tazobactam. He was also diuresed due to some pulmonary edema. He was transitioned to the general medical floor. A family meeting was held to discuss goals of care. The decision was made to pursue comfort measures only. The palliative care team assisted in the family meeting and making suggestions for symptom management. He passed away on the evening of [12-23]. Medications on Admission: 1. Docusate Sodium 100 mg PO BID 2. Senna 8.6 mg PO BID prn 3. Atorvastatin 10 mg PO DAILY 4. Multivitamin PO DAILY 5. Albuterol Sulfate neb Q6H prn 6. Ipratropium Bromide neb Q6H prn 7. Timolol Maleate 0.5 % drops [Hospital1 ] 8. Doxazosin 0.5 mg PO HS 9. Lansoprazole 30 mg Rapid Dissolve, DR [Last Name (STitle) ] DAILY 10. Aspirin 325 mg PO DAILY 11. Metoprolol Tartrate 25 mg PO TID 12. Piperacillin-Tazobactam 2.25 gram Q6H continue until [12-20]. 13. Vancomycin 750 mg Q 24H (Every 24 Hours) continue until [12-20]. 14. Sodium Chloride [1-7] Sprays Nasal TID as needed for dry nares. 15. Bisacodyl 10 mg Suppository HS as needed 18. Heparin, Porcine (PF) 10 unit/mL Syringe [Month/Day (2) ]: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 19. Guaifenesin 100 mg/5 mL Syrup [Month/Day (2) ]: 5-10 MLs PO Q6H prn 20. Heparin 5,000 unit/mL Injection TID Discharge Disposition: Expired Discharge Diagnosis: Primary: Hospital-acquired pneumonia Aspiration pneumonia . Secondary: Chronic obstructive pulmonary disease Asbestosis Pulmonary hypertension Hypertension Hypercholesterolemia Glaucoma Psoriasis Discharge Condition: Patient passed away prior to discharge. ICD9 Codes: 5070, 5849, 5119, 486, 496, 5859, 4168, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6225 }	Medical Text: Unit No: [Numeric Identifier 65621] Admission Date: [2163-12-20] Discharge Date: [2163-12-22] Date of Birth: [2163-12-20] Sex: F Service: NB HISTORY: Baby Girl [First Name4 (NamePattern1) 8463] [Known lastname 65622], twin #2 delivered at 38-3/7 weeks gestation with a birth weight of 2535 grams and was admitted to the Newborn Intensive Care Unit around 4 hours of life for management of abdominal distention. Mother is a 32 year-old gravida I, para 0, now II woman with estimated date of delivery [2163-12-31]. Prenatal screens included blood type A positive, antibody screen negative, hepatitis B surface antigen negative, rubella immune, RPR nonreactive, and group B strep unknown. The prenatal history was reported as uncomplicated except for twin gestation. Maternal history notable for a tracheal esophageal fistula repair as a child. The delivery was by cesarean section due to breech presentation of this twin. This twin was vigorous at delivery, Apgar scores 9 and 9 at one and five minutes respectively. In the newborn nursery this twin was noted to have increased abdominal distention. She had passed meconium, no vomiting and no bilious aspirates. There was no history of maternal medicines that could affect peristalsis including magnesium sulfate and narcotics. PHYSICAL EXAMINATION ON ADMISSION: Weight 2535 grams (10th to 25th percentile), length 46 cm (25th percentile), head circumference 33.5 cm (50th to 75th percentile). In general a pink well perfused infant in no distress with normal responsiveness and obvious distention of the abdomen. Head, eyes, ears, nose and throat were within normal limits. The nasogastric tube was passed without difficulty. Neck and clavicles within normal limits. Breath sounds clear and equal, soft systolic murmur heard at the left sternal border with regular rate and rhythm. Normal S1 and S2. Normal pulses and perfusion. Abdomen was diffusely distended with active bowel sounds. Nontender. No discoloration. No palpable masses. No hepatosplenomegaly. The umbilicus within normal limits. GU: Normal female. Back: Sacral creases. Palpation of sacrum and spine normal. Anus patent and had passed 3 meconiums during admission. Extremities within normal limits. Neurologic: Appropriate for newborn in tone, strength, responsive movements and reflexes. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: No respiratory issues. Has been comfortable in room air with respiratory rate from 30s to 50s. Oxygen saturations greater than 95%. CARDIOVASCULAR: A soft systolic murmur heard on admission, resolved and there was no murmur audible on day of transfer. Heart rates ranged from 130s to 160s. Recent blood pressure 61/46 with a mean of 51. FLUIDS, ELECTROLYTES AND NUTRITION: Was NPO on admission and placed on intravenous fluid of D10W. She was seen by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] from [Hospital3 28900] (pediatric surgeon) with the decision to monitor with nasogastric tube in place as there was no bilious aspirate and the infant was passing stool and looked comfortable. The following day the abdominal x-ray was concerning for an abdominal bowel gas pattern with bubbly appearance in the left lower quadrant and distribution of dilated bowel loops in the mid abdomen. An upper gastrointestinal series was done at [Hospital1 1926] and was normal. Follow up KUBs normalized. The etiology of the abdominal distension and abnormal KUBs remains unknown. The abdominal distention resolved and in light of normal KUBs feeds were started on the evening of [2163-12-21]. She advanced to all oral feeds on [2163-12-22] and the IV fluids were discontinued. She has been maintaining a blood glucose off IV fluid in the 80s. Electrolytes on [2163-12-22] showed sodium 143, potassium 5.4, chloride 106, CO2 19, and magnesium was requested but there was not enough serum to perform the test. Her discharge weight was 2385 grams. GASTROINTESTINAL: See Fluids, electrolytes and nutrition noted. Abdominal distention of unclear etiology, resolved. A bilirubin was drawn on [2163-12-22]. The total was 8, the direct was 0.3. A follow up bilirubin will be drawn on [2163-12-23]. HEMATOLOGY: Hematocrit on admission was 56%. INFECTIOUS DISEASE: A CBC and blood culture were drawn on admission. She did not receive antibiotics. The CBC was normal. Blood culture was negative. NEUROLOGY: On examination age appropriate. SENSORY: Hearing screening has not been performed as yet. CONDITION AT DISCHARGE: Stable 2 day old twin with resolved abdominal distention, feeding well. DISCHARGE DISPOSITION: Transfer to newborn nursery. NAME OF PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Location (un) ] [Hospital1 ]. CARE AND RECOMMENDATIONS: 1. Ad lib feeds. Monitor for abdominal distention. 2. Medications none. 3. State newborn screen will be drawn on [2163-12-23]. 4. Immunizations: Has not received hepatitis B immunization as yet. 5. Hip ultrasound at 4-6 weeks secondary to breech female. DISCHARGE DIAGNOSES: 1. Term AGA twin #2. 2. Abdominal distention of unknown etiology, resolved. 3. Physiologic jaundice. 4. Rule out sepsis, no antibiotics. 5. Breech female. DR [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 36462] 50.442 Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2163-12-22] 17:10:04 T: [2163-12-22] 18:25:26 Job#: [Job Number 65623] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6226 }	Medical Text: Admission Date: [2123-2-2] Discharge Date: [2123-2-6] Date of Birth: [2078-6-20] Sex: F Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: This is a 44-year-old female who has a history of hypertension and large aortic root diagnosed about 18 months prior at 4.8 cm by last echo report. The patient presented with substernal chest pain and had gone to the Emergency Department. The patient states that she had chest tenderness. PAST MEDICAL HISTORY: 1. Hypertension. 2. Enlarged aortic root. 3. Status post cholecystectomy. 4. Status post appendectomy. 5. Status post hysterectomy. 6. History of GERD. ADMISSION MEDICATIONS: 1. Atenolol 25 q.d. 2. Premarin. 3. Vioxx. ALLERGIES: The patient is allergic to codeine, sulfa, erythromycin, prednisone, and inhalers. PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile. The vital signs were stable on admission. The lungs were clear to auscultation bilaterally with a regular rate and rhythm. One week prior to admission, the patient had undergone a catheterization which showed normal coronary arteries, mild aortic insufficiency, and dilated aortic sinus. LABORATORY DATA: The patient had a white count of 8.5, hematocrit 36.2, platelets 281,000. HOSPITAL COURSE: The patient presented on [2123-2-2] for valve-sparing root replacement, [Last Name (un) 39196] procedure. The patient tolerated the procedure without any incident. The patient was transferred to the floor on postoperative day number two. Th[Last Name (STitle) 1050] was able to tolerate a regular diet, ambulate well with PT clearance, and had good p.o. pain control. The patient was with discharge planning to home pending resolution of some antihypertensive medication adjustments. The patient is to be going home with a follow-up with Dr. [Last Name (Prefixes) 2545] in four weeks. She is to follow-up with her primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) 26775], in one to two weeks, and her cardiologist in two to three weeks. DISCHARGE MEDICATIONS: 1. Calcium carbonate 500 mg p.o. t.i.d. 2. Lasix 20 mg p.o. b.i.d. times seven days. 3. Potassium chloride 20 mEq p.o. b.i.d. times seven days. 4. Colace 100 mg p.o. b.i.d. 5. Zantac 150 mg p.o. b.i.d. until follow-up with cardiac surgeon. 6. Aspirin 325 mg q.d. 7. Tylenol 650 mg q. four hours p.r.n. 8. Ibuprofen 400 mg p.o. q. six hours p.r.n. 9. Milk of magnesia 30 milliliters p.o. q.h.s. p.r.n. 10. Dilaudid 2-4 mg p.o. q. 4-6 hours p.r.n. 11. Lasix dose presently at 75 mg p.o. b.i.d. under adjustment. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Status post valve-sparing root replacement, [Last Name (un) 39196] procedure. Please see addendum for final dosing of antihypertensives. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 5915] MEDQUIST36 D: [2123-2-6] 09:10 T: [2123-2-6] 21:31 JOB#: [Job Number 103844] cc:[Last Name (Prefixes) 103845] ICD9 Codes: 4241, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6227 }	Medical Text: Admission Date: [2132-3-25] Discharge Date: [2132-3-28] Service: MEDICINE Allergies: Plavix Attending:[Location (un) 1279] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Endotracheal intubation Diuresis History of Present Illness: [Age over 90 ] y/o F w/3VD CAD, CHF, severe MR, and mild AS who opresented with shortness of breath. This is patient's 3rd admission in 2 weeks for similar problem. The night prior to admission, she became short of breath at [Hospital 100] Rehab, and was given Lasix 60 mg po, NTG paste, and morphine, and was transferred to the [Hospital1 18] ER. In the ED, she was cyanotic, unresponsive, and saturating 80% on a NRB. She was urgently intubated and given lasix, and admitted to the CCU. Past Medical History: 1. CAD: 3VD, cath [2128] with 99% LAD, 90% LCx, 100% RCA stenoses. Refused CABG. NSTEMI [9-11], hospitalization complicated by cardiogenic shock requiring pressors and intubation and NSVT. 2. Ischemic cardiomyopathy: TTE-[9-11] EF 20 %, 3+MR, 1+TR 3. CHF: Baseline 2 pillow orthopnea, chronic intermittent LE edema. Numerous admissions for flash pulmonary edema. 4. DM type II 4. HTN 5. Hyperlipidemia Social History: Lives at [Hospital 100] Rehab. She lost her husband almost 30 years ago, and has 2 sons. She denies any history of smoking or alcohol use. No IVDU. Family History: non-contributory Physical Exam: T: 100.8 BP: 103/52 P: 81 R: 24 O2 sat 97% on 3L Gen: awake, alert, and oriented, in no apparent distress. Lungs: Decreased breath sounds at both bases, R>L, with rales [2-10] way up bilaterally. CV: RRR, I/VI HSM at apex. Abd: soft, nontender, nondistended, with normoactive bowel sounds. Ext: trace LE edema, which is chronic per pt. Pertinent Results: [2132-3-28] 06:25AM BLOOD WBC-5.7 RBC-3.70* Hgb-11.1* Hct-31.7* MCV-86 MCH-30.1 MCHC-35.1* RDW-15.0 Plt Ct-608* [2132-3-27] 04:22AM BLOOD WBC-5.6 RBC-3.57* Hgb-10.5* Hct-30.1* MCV-84 MCH-29.2 MCHC-34.8 RDW-15.3 Plt Ct-566* [2132-3-26] 04:20AM BLOOD WBC-6.6 RBC-3.35* Hgb-9.8* Hct-28.6* MCV-85 MCH-29.3 MCHC-34.3 RDW-15.0 Plt Ct-621* [2132-3-25] 04:35PM BLOOD WBC-8.2 RBC-3.26* Hgb-9.3* Hct-28.3# MCV-87 MCH-28.6 MCHC-33.0 RDW-14.9 Plt Ct-717 [2132-3-25] 06:55AM BLOOD WBC-13.6# RBC-4.07 Hgb-12.0 Hct-37.9# MCV-93# MCH-29.4 MCHC-31.6 RDW-14.9 Plt Ct-1073# [2132-3-27] 04:22AM BLOOD PT-13.9 PTT-27.7 INR(PT)-1.2 [2132-3-28] 06:25AM BLOOD Glucose-115* UreaN-28* Creat-1.1 Na-140 K-4.3 Cl-105 HCO3-26 AnGap-13 [2132-3-25] 06:55AM BLOOD Glucose-418* UreaN-37* Creat-1.8* Na-136 K-4.7 Cl-104 HCO3-18* AnGap-19 [2132-3-26] 04:20AM BLOOD CK(CPK)-35 [2132-3-25] 04:35PM BLOOD CK(CPK)-44 [2132-3-25] 01:26PM BLOOD CK(CPK)-42 [2132-3-26] 04:20AM BLOOD CK-MB-NotDone cTropnT-0.08* [2132-3-25] 04:35PM BLOOD CK-MB-NotDone cTropnT-0.16* [2132-3-25] 01:26PM BLOOD CK-MB-NotDone cTropnT-0.18* [2132-3-25] 06:55AM BLOOD cTropnT-0.04* EKG from admission: Sinus rhythm. Left atrial abnormality. Old inferior wall myocardial infarction. Old anterior wall myocardial infarction. Non-specific ST-T wave changes. Compared to the previous tracing no significant change. Brief Hospital Course: 1. CHF: This admission was felt to be consistent with the patient's prior admissions for pulmonary edema, with a CXR on admission c/w frank congestive heart failure. She was diuresed while still in the ED, and while she was in the CCU. The evening of admission, she was 1-2 liters negative, with acceptable ABG's on pressure support, and so was extubated. She was slightly hypotensive after that (systolics in the 80s) and was placed on dopamine for a day (the hypotension was felt to be secondary to aggressive diuresis.) Once the dopamine was discontinued, her regular medications were slowly restarted. She was placed back on her lisinopril and restarted on her carvedilol. She was continued with Lasix prn for a goal 500 to 1000 cc negative per day (she usually responded to lasix 40 mg IV). The evening of [2132-3-27], she became acutely short of breath, tachypneic to 34 and with O2 sat 92% on room air (earlier in the day had been 98% on room air). She was wheezing on exam, CXR c/w pulm edema, and was given an ipratropium neb and Lasix 40 IV. She responded well to this. Because of her severe mitral regurgitation, she was also begun on a nitrate, Imdur 30 mg po qd, which should be given at night because her ACE should be given in the morning. She tolerated the addition of these medications well. She was also changed to twice daily dosing of her Lasix (as it seemed that her shortness of breath episodes have been occurring at night.) 2. CAD: Her troponin was mildly elevated on admission, but was not as high as it has been in the past, and she had no worrisome EKG changes. She has refused CABG in the past. It was not felt that her episodes of pulmonary edema are related to ischemia. 3. Pneumonia: She was febrile to 101 the evening of [3-27], and was pan-cultured. Her UA was negative. Her CXR showed a retrocardiac opacity, and she was begun on Levaquin for a 7 day course (renally dosed at 250 mg daily). 4. Renal: Her creatinine was elevated to 1.8 on admission, and had come down to 1.1 by discharge (baseline mid 1's.) 5. Heme: Her platelets were very high at over 1,000 on admission, and came down to the 600s by discharge, which is around her baseline. Her hematocrit was 37 on admission and dropped 9 points that day, which is what has happened for her last 3 admissions. It is unclear why, as her hematocrit should go up with diuresis. She received 2 units of PRBCs throughout her stay, and her hematocrit was stable at 31 by discharge. Her baseline is in the high 20s to low 30s per our records. 6. Code status: On her prior admissions here, the patient seems to have indicated that she wanted to be a DNR/DNI, and there was some confusion about this because it was reversed while she was at the nursing home. Her son [Name (NI) 9464] was very clear that she is a full code, and once she was extubated we discussed this with her. She feels that she wants to be intubated if it is for a short period of time (such as this current episode), but would not want to be intubated for an extended period of time. She realizes that with her significant CHF and MR, these episodes will become more frequent, and that she will likely come to a point where she doesn't want to be intubated again, if even for a short time. However, she currently states that she wants to be a full code, as she has a good quality of life at [Hospital 100] Rehab and is not ready to be a DNR/DNI. This was confirmed with her son. Medications on Admission: Lipitor 80 Coreg 3.125 [Hospital1 ] ASA 325 Lisinopril 2.5 Ticlopidine 250 [Hospital1 ] Lansoprazole 30 mg daily Ipratropium Lasix 60 mg daily Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold for SBP<100. PLEASE give in AM. Tablet(s) 2. Ticlopidine HCl 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lansoprazole 30 mg daily 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO at bedtime: Hold for SBP<100. Please give at night. 7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulized treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [6-17] MLs PO Q6H (every 6 hours) as needed for Cough. 11. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP <100, pulse <60. 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: CHF CAD Mitral Regurgitation Pneumonia Discharge Condition: Stable Discharge Instructions: We have changed around some of your medications. You are still on carvedilol, and we have added another medication for your blood pressure called Imdur, which you should take at night. We have increased the dose of your Lasix and changed the dosing so that you take it twice a day instead of once a day. It is very important that you are weighed on a daily basis, and that if your weight goes up 2 pounds you should speak with your doctor about increasing your Lasix. You should adhere to 2 gm sodium diet, and not add any salt to your food. Fluid Restriction: 1500 ml. If you become short of breath again, your doctor should give you Lasix 60 mg IV as this will work faster than po, and you respond very well to this medication and dose. Please resume taking your regular diabetes medication (you were on insulin while you were here.) Followup Instructions: Please follow-up with your doctors [First Name (Titles) ] [Last Name (Titles) 100] Rehab very closely, and have them monitor your renal function while you are on an ACE inhibitor. ICD9 Codes: 5849, 486, 2762, 412, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6228 }	Medical Text: Admission Date: [2106-9-17] Discharge Date: [2106-9-19] Date of Birth: [2042-10-12] Sex: M Service: ORTHOPAEDICS Allergies: Vicodin / Morphine / Percocet / Adhesive Tape Attending:[Doctor Last Name 1350] Chief Complaint: neck and right arm pain Major Surgical or Invasive Procedure: [2106-9-17] anterior cervical decompression and fusion C5-7 History of Present Illness: [Known firstname ] [Known lastname ] is a generally healthy man, 63 years old, who presented with a prolonged and progressive syndrome of neck and right arm pain. He subsequently developed difficulties with balance, as well as dexterity. He was found to have spinal stenosis. He was diagnosed with cervical myelopathy, as well as right-sided C6 radiculopathy. He underwent a multi modal course of conservative care, without relief. His symptoms are progressive. Due to the severity of his symptoms, the non-refractory nature of the syndrome, and failure of conservative care, he has elected to undergo surgical treatment. Past Medical History: HTN Hyperlipidemia DM II CAD, prior MI Cardiomyopathy Sleep Apnea--on CPAP Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension Cardiac History: No history of CABG Percutaneous coronary intervention: None Pacemaker/ICD: None Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. He is married, lives with his wife, and has a business selling [Location (un) ] seed. Family History: There is a family history of coronary artery disease (father and mother with coronary disease in their 70's, brother with CAD in his 50's, sister with CAD in her 60's). No history of sudden death. Physical Exam: NAD Head and Neck: left sided anterior neck incision c/d/i with steri-strips in place B/L UE's: SILT and motor intact C5-T1 2+ radial pulses B/L Le's: SILT and motor intact L2-S1 2+ DP pulses Pertinent Results: [2106-9-18] 04:25AM BLOOD Hct-33.2* [2106-9-18] 04:25AM BLOOD Glucose-290* UreaN-13 Creat-0.8 Na-139 K-4.4 Cl-105 HCO3-24 AnGap-14 [2106-9-18] 05:15PM BLOOD CK(CPK)-250 [2106-9-18] 05:15PM BLOOD CK-MB-4 cTropnT-<0.01 Brief Hospital Course: Patient underwent above procedure. For full details please see the separately dictated operative note. Post-operative pain was controlled with IV followed by PO meds. PT was consulted for assistance with patient's care. Peri-operative antibiotics were utilized for 24 hrs. A hemovac drain was place intraoperatively and was removed once output tapered down. The patient progressed well post-operatively. Diet was advanced without complication. The patient progressed with PT and was cleared for discharge home. The patient was discharged home, tolerating regular diet and with pain well controlled on oral medications. Medications on Admission: amolodipine 10 daily, carvedilol 37.5 [Hospital1 ], fluoxetine 20 [Hospital1 ], fluticasone nasal spray, furosemide 40 qAM, hydralazine 25 [Hospital1 ], lantus 40 units [Hospital1 ], novolog SS TID, lisinopril 40 qAM, metformin 1000 [Hospital1 ], potassium 20meq, simvastatin 40 qhs, xalatan eye gtts, MVI, ASA 81, stool softener, benadryl, tyenol Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. carvedilol 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for spasm: do not drink alcohol, drive, or operate machinery while taking this medication. Disp:30 Tablet(s) Refills:0 7. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day). 8. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 9. fluoxetine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. insulin aspart 100 unit/mL Cartridge Sig: One (1) Subcutaneous twice a day: per home insulin regimen. 14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [4-27] hours as needed for pain. Disp:29 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: cervical myelopathy Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You have undergone the following operation: Anterior Cervical Decompression and Fusion Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Isometric Extension Exercise in the collar: 2x/day x 10 times perform extension exercises as instructed. - Swallowing: Difficulty swallowing is not uncommon after this type of surgery. This should resolve over time. Please take small bites and eat slowly. Removing the collar while eating can be helpful ?????? however, please limit your movement of your neck if you remove your collar while eating. - Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Followup Instructions: -Follow up: oPlease Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. oAt the 2-week visit we will check your incision, take baseline x rays and answer any questions. oWe will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. ICD9 Codes: 4254, 2724, 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6229 }	Medical Text: Admission Date: [2187-4-20] Discharge Date: [2187-6-19] Date of Birth: [2120-7-17] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: Severe pancreatitis Major Surgical or Invasive Procedure: PICC placement Percutaneous Tracheostomy History of Present Illness: This is a 66 year old female who woke up the morning of [2187-4-19] with severe periumbilical abdominal pain, nausea and vomitting. She vomitted 7 times, and reports no blood. Her pain became epigastric in nature but did not radiate, stayed in midline of her abdomen. She reports normal bowel movements, no diarrhea and no RUQ pain. She had been in her USOH before this time and denies any other concerns. She presented to [Hospital3 ] that day, and her vitals there were significant for low-grade temp (100.4), blood pressure was stable in the 120s-140s, and persistently tachycardic in the 120s. Her ALT was 380, AST 514, T bili 1.1, Alk phos 242, amylase 2960, lipase 3990, and she was admitted to [Hospital1 ] ICU with a presumed diagnosis of gallstone pancreatitis. While there, she initial received not enough IVF per their notes, and her creatinine increased from 1.6 on admit to 2.9 this AM. She received 2L NS bolus and her UOP remained low (15-30 cc/hr). Her LFTs decreased, amylase decreased, calcium was very low at 6.0. Her creatinine increased to 2.6 this afternoon. Her imaging studies demonstrated diffusely enlarged pancreas c/w pancreatitis, cholelithiasis, ascites. MRCP showed pancreatitis, normal bile and pancreatic ducts, diffusely swollen and edematous pancreas, peripancreatic soft tissue stranding, no pseudocyst or abscess. Her gallbladder was distended. Past Medical History: 1. HTN 2. Diverticulitis 3. ETOH Abuse Social History: Used to drink alcohol heavily until [2174]. Smoked [1-12] cigs/day, quit years ago. Lives in [Location 2624] with her daughter and son-in-law. Does not work. Came here from [First Name8 (NamePattern2) 466] [Country 467] 5 years ago. Family History: NC Physical Exam: 100.5 141/80 127 31 95% 2L Gen: awake, alert, oriented, interactive, NAD HEENT: anicteric, MM very dry Neck: supple Lungs: decreased breath sounds with scattered bibasilar crackles CV: tachycardic, reg, no m/r/g Abd: distended, tympanic, no bowel sounds, TTP over epigastrium without rebound Ext: no edema, 2+ distal pulses, feet warm Pertinent Results: TTE [2187-4-23]: Conclusions: The left atrium is normal in size. IVC appears collapsed and underfilled. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 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. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. . CT Abd [2187-4-25]: IMPRESSION: 1. Dilated small bowel to 3.1 cm consistent with ileus, although early small bowel obstruction cannot be excluded. 2. Heterogeneous-appearing pancreas with significant amount of stranding consistent with severe pancreatitis. Comment on necrosis cannot be made without IV contrast, but the appearance is highly supicious. 3. Ascites. 4. Subcutaneous soft tissue nodule in the posterior tissues of uncertain clinical significance. . CT Abd with IV contrast [2187-4-27]: IMPRESSION: Severe pancreatitis with marked inflammatory change about the pancreas and into the mesentery. This follow-up CT with contrast confirms the prior impression that most of the pancreas is replaced by a necrotic fluid collection. Other than increased ascites, the appearance is likely little changed. . [2187-5-1] CT ABD: IMPRESSION: Interval stable appearance of severe pancreatitis with replacement of the neck and body of the pancreas with an inflammatory phlegmon. No residual enhancement of normal pancreas tissue is identified in these regions. Pancreatic and head tissue do enhance. Persistent ileus. CHEST (PORTABLE AP) [2187-5-3] 7:07 PM CHEST (PORTABLE AP) Reason: ET tube [Hospital 93] MEDICAL CONDITION: 66 year old woman on vent, oxygern desat, R mainstem intubation s/p pulling tube out ET tube REASON FOR THIS EXAMINATION: ET tube INDICATION: 66-year-old female on ventilator with O2 desaturation and right mainstem intubation, status post pulling ET tube back. COMPARISON: [2187-5-2]. AP SEMI-UPRIGHT CHEST RADIOGRAPH: After withdrawal of the endotracheal tube, the tube tip now appears 2 cm above the carina with the neck in flexed position. Persistent small effusions versus atelectasis bilaterally. CT ABDOMEN W/CONTRAST [2187-5-9] 2:50 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: eval interval change in pancreas, r/o free air in pancreas, Field of view: 48 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 66 year old woman with necrotizing pancreatitis w/ persistant fever. Pt. also w/ recent ileus. REASON FOR THIS EXAMINATION: eval interval change in pancreas, r/o free air in pancreas, eval ileus/obstruction CONTRAINDICATIONS for IV CONTRAST: None. CT TORSO TECHNIQUE: Multidetector CT through the chest, abdomen, and pelvis with oral and IV contrast. HISTORY: 66-year-old woman with necrotizing pancreatitis with persistent fever. Evaluate interval change in pancreas and ileus, rule out SBO. Comparison is made with prior study dated [2187-5-1]. CHEST CT: The aorta, pulmonary artery, and great vessels are unremarkable. There is mild cardiomegaly. There are no mediastinal or axillary lymph nodes. There is an endotracheal tube in place. There are bilateral subclavian IV lines with tips in the proximal IVC and left brachiocephalic vein. Unchanged bibasilar segmental atelectasis and bilateral pleural effusions. ABDOMEN CT: The liver, spleen, adrenal glands, and right kidney are unremarkable. There is an unchanged simple cyst in the left kidney. There is no hydronephrosis. The gallbladder is mildly dilated. There is no biliary duct dilatation. There is a feeding tube with distal tip within the fourth portion of the duodenum. There is an unchanged mild amount of ascites. Unchanged multiple splenules adjacent to the spleen. There is an unchanged lack of-enhancement of the neck and body of the pancreas, which are replaced by a phlegmon/ fluid. Redemonstration of enhancement within the head and tail of the pancreas. There is no evidence of gas or air within the pancreatic phlegmon. The mesenteric vessels are patent without evidence of pseudoaneurisms Stable extensive peripancreatic stranding. The bowel loops are unremarkable. The aorta is normal in caliber. PELVIC CT: The bladder is not distended with Foley catheter in its interior. The uterus is unremarkable. Multiple diverticula are seen in the sigmoid colon. There is free fluid within the pelvis. BONE WINDOWS: There are no concerning bone lesions. IMPRESSION: 1. Interval resolution of the small [Last Name (un) 12376] dilatation. 2. Stable appearance of severe pancreatitis with inflammatory phlegmon/fluid within the neck and body of the pancreas with retained enhancement of head and tail of pancreas and no new gas collections.CHEST (PORTABLE AP) [2187-5-9] 3:28 AM CHEST (PORTABLE AP) Reason: eval pleural effusions/ pneumonia [Hospital 93] MEDICAL CONDITION: 66 year old woman w/ pancreatitis, eval for pleural effusions/ pneumonia REASON FOR THIS EXAMINATION: eval pleural effusions/ pneumonia AP CHEST, 3:49 A.M., [5-9] HISTORY: Pancreatitis, evaluate for effusions and pneumonia. IMPRESSION: AP chest compared to [5-2] through 28. Moderate-sized bilateral pleural effusions layer posteriorly a function of supine positioning but have probably increased as well. Moderate enlargement of the cardiac silhouette is stable. Left lower lobe consolidation present since [5-2] is probably atelectasis. Lungs are free of consolidation elsewhere but mild interstitial edema is probably present. Tip of the endotracheal tube is at the sternal notch, right subclavian line tip projects over the junction with the jugular vein while a left subclavian line ends at the origin of the SVC. No pneumothorax. CHEST (PORTABLE AP) [2187-5-20] 10:28 AM CHEST (PORTABLE AP) Reason: dobhoff placemtn [Hospital 93] MEDICAL CONDITION: 66 year old woman w/ pancreatitis, intubated, w/ fever, s/p R subcl CVL change, and pull-back of line now REASON FOR THIS EXAMINATION: dobhoff placemtn STUDY: AP chest. HISTORY: 66-year-old woman with pancreatitis. The patient is intubated and has fevers. Evaluate for placement of Dobhoff tube. FINDINGS: There is a Dobbhoff tube whose distal tip is not seen. However, there is at least one loop seen within the fundus of the stomach. There is a tracheostomy and a right-sided central venous catheter, which are unchanged in position. There is cardiomegaly. There is persistent left retrocardiac opacity and likely bilateral effusions. The effusion on the left side is improved. [Last Name (un) ]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [2187-5-22] 12:58 PM [Last Name (un) ]-INTESTINAL TUBE PLACEMENT Reason: needs post-pyloric feeding tube [Hospital 93] MEDICAL CONDITION: 66 year old woman with severe pancreatitis, needs post-pyloric feeding tube REASON FOR THIS EXAMINATION: needs post-pyloric feeding tube INDICATION: Patient with pancreatitis and need for post pyloric feeding tube. NASOINTESTINAL TUBE PLACEMENT UNDER FLUOROSCOPY: A feeding tube was advanced via the right nostril under fluoroscopic visualization to the fourth portion of the duodenum with approximately 5 cc of water soluble contrast administered via the tube to confirm placement. No immediate complications were seen. IMPRESSION: Successful placement of 8 French [First Name8 (NamePattern2) 2174] [Last Name (NamePattern1) 1557] feeding tube into fourth portion of the duodenum. CT ABD W&W/O C [2187-5-25] 1:11 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Reason: Please eval for pseudocyst, abscess, intrabdominal process. Field of view: 36 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 66 yo female with necrotizing pancreatitis. REASON FOR THIS EXAMINATION: Please eval for pseudocyst, abscess, intrabdominal process. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Necrotizing pancreatitis. TECHNIQUE: After administration of oral contrast, MDCT was used to obtain contiguous axial images through the abdomen, followed by IV contrast-enhanced images through the abdomen and pelvis. This study is compared to [2187-5-9]. CT ABDOMEN BEFORE AND AFTER IV CONTRAST: There is dependent atelectasis at both lung bases. Small pleural effusions are seen. There is a nasogastric tube coursing below the diaphragm. The liver, gallbladder, spleen, adrenals, and right kidney are within normal limits. The left kidney has a 22 x 25 mm fluid density round lesion in its anterior aspect, representing a cyst. The nasogastric tube can be seen coursing into the fourth portion of the duodenal. The bowel loops appear normal, without evidence of obstruction or perforation. There is no free air. A 13 mm and a 7-mm round soft tissue densities near the anterior-inferior aspect of the spleen are identified, representing splenules. The pancreatic head, body, and tail are mostly replaced by a large hypoattenuating lesion, consisting of fluid density and some soft tissue, 42 mm in greatest AP diameter. There is residual enhancement of the pancreatic head and tail. The fluid collection extends into the mesentery, where there is extensive nodularity indicating likely fat necrosis. Fluid is seen tracking along the anterior pararenal spaces into the right and left pericolic gutters; some surrounds the liver and the spleen and tracks along into the pelvis. Celiac axis and SMA are both well identified. However, the SMV and splenic vein confluence are very attenuated, and the splenic vein is not well identified. Some collateral vessels have appeared in the interim including short gastrics. The portal vein and hepatic veins appear patent. No saccular outpouchings to suggest pseudoaneurysms are seen, although this is not a CTA study targeted to the abdominal vessels. There is no free air in the abdomen. CT PELVIS WITH IV CONTRAST: As described above, a small amount of free fluid is seen tracking along the pericolic gutters and into the pelvis. A Foley is seen in the collapsed bladder and a rectal tube is seen. The uterus is small. Bowel loops are normal, without evidence of an obstruction or perforation. No lymphadenopathy is identified. Bone windows show no suspicious sclerotic or lytic lesions. IMPRESSION: 1. essentailly unchanged appearance of severe pancreatitis with large phlegmonous/fluid collection within the neck and body of the pancreas. No new gas collections to suggest abscess are seen. There is extensive fat necrosis of the mesentery. 2. Splenic vein thrombosis and interval development of left-sided varices. CT ABDOMEN W/CONTRAST [2187-6-6] 5:53 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: Compare to CT abdomen on [5-25] to make sure that there are no Field of view: 36 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 66 yo female with necrotizing pancreatitis. REASON FOR THIS EXAMINATION: Compare to CT abdomen on [5-25] to make sure that there are no new processes and that she is clear to go home. CONTRAINDICATIONS for IV CONTRAST: None. 66-year-old female with necrotizing pancreatitis. COMPARISON: [2187-5-25]. TECHNIQUE: MDCT continuously acquired axial images of the abdomen were obtained without IV contrast followed by images of the abdomen and pelvis after 150 mL Optiray IV contrast. CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The visualized lung bases are clear. The liver, gallbladder, spleen, adrenal glands, and right kidney are unremarkable. Again demonstrated is a 2 cm cyst of the left kidney. The stomach, duodenum, and intra-abdominal loops of large and small bowel are unremarkable without evidence of obstruction or perforation. There is no free intra-abdominal air. Again demonstrated is replacement of most of the pancreatic head, body, and a portion of the tail with a large fluid density lesion, which has decreased in size compared to [2187-5-25] now with greatest AP diameter of 3 cm. There has also been improvement in adjacent mesenteric fat necrosis. There has been interval resolution of ascites previously seen to track along the pericolic gutters and pararenal spaces. No new fluid collection or abscess is identified. The splenic vein appears less compressed on today's study and opacifies with contrast without definite evidence of thrombosis. No saccular outpouchings to suggest pseudoaneurysms of the adjacent arteries are identified. Please note this is not a CT angiogram study targeted for the abdominal vessels. The celiac trunk, SMA, and [Female First Name (un) 899] opacify well. CT OF THE PELVIS WITH IV CONTRAST: The rectum, urinary bladder, uterus, adnexa, and pelvic loops of bowel are unremarkable. There is free passage of oral contrast through to the rectum. There is no free pelvic fluid or lymphadenopathy. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: Interval improvement in pancreatitis with decrease in size of large phlegmonous/fluid collection of the neck and body of the pancreas. No new fluid collections or abscesses are identified. Mesenteric fat necrosis also appears mildly improved. [2187-5-31] 09:12PM COMPLETE BLOOD COUNT White Blood Cells 10.7 K/uL 4.0 - 11.0 PERFORMED AT WEST STAT LAB Red Blood Cells 3.19* m/uL 4.2 - 5.4 PERFORMED AT WEST STAT LAB Hemoglobin 8.2* g/dL 12.0 - 16.0 PERFORMED AT WEST STAT LAB Hematocrit 25.3* % 36 - 48 PERFORMED AT WEST STAT LAB MCV 79* fL 82 - 98 PERFORMED AT WEST STAT LAB MCH 25.8* pg 27 - 32 PERFORMED AT WEST STAT LAB MCHC 32.6 % 31 - 35 PERFORMED AT WEST STAT LAB RDW 18.8* % 10.5 - 15.5 DIFFERENTIAL Neutrophils 55.8 % 50 - 70 PERFORMED AT WEST STAT LAB Lymphocytes 31.6 % 18 - 42 PERFORMED AT WEST STAT LAB Monocytes 6.0 % 2 - 11 PERFORMED AT WEST STAT LAB Eosinophils 4.1* % 0 - 4 PERFORMED AT WEST STAT LAB Basophils 2.6* % 0 - 2 PERFORMED AT WEST STAT LAB RED CELL MORPHOLOGY Hypochromia 1+ Anisocytosis 2+ Microcytes 2+ BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 427 K/uL 150 - 440 PERFORMED AT WEST STAT LAB [2187-6-3] 05:50AM Report Comment: LINE: PICC RENAL & GLUCOSE Glucose 112* mg/dL 70 - 105 PERFORMED AT WEST STAT LAB Urea Nitrogen 29* mg/dL 6 - 20 PERFORMED AT WEST STAT LAB Creatinine 0.8 mg/dL 0.4 - 1.1 PERFORMED AT WEST STAT LAB Sodium 138 mEq/L 133 - 145 PERFORMED AT WEST STAT LAB Potassium 4.2 mEq/L 3.3 - 5.1 PERFORMED AT WEST STAT LAB Chloride 106 mEq/L 96 - 108 PERFORMED AT WEST STAT LAB Bicarbonate 24 mEq/L 22 - 32 PERFORMED AT WEST STAT LAB Anion Gap 12 mEq/L 8 - 20 CHEMISTRY Calcium, Total 9.5 mg/dL 8.4 - 10.2 PERFORMED AT WEST STAT LAB Phosphate 3.7 mg/dL 2.7 - 4.5 PERFORMED AT WEST STAT LAB Magnesium 2.1 mg/dL 1.6 - 2.6 PERFORMED AT WEST STAT LAB [2187-6-11] 07:08AM CHEMISTRY Albumin 3.5 g/dL 3.4 - 4.8 PERFORMED AT WEST STAT LAB Iron 68 ug/dL 30 - 160 HEMATOLOGIC Iron Binding Capacity, Total 218* ug/dL 260 - 470 Ferritin 549* ng/mL 13 - 150 Transferrin 168* mg/dL 200 - 360 Brief Hospital Course: A/P: 66 year old female with HTN, who presents with severe acute pancreatitis and admitted on [2187-4-20]. 1. Pancreatitis: The patient initially presented as a transfer from [Hospital1 ] with severe pancreatitis. The etiology was unclear thought likely secondary to alcohol, although the patient denies, rather than obstructing gallstone. There was no evidence of biliary ductal dilatation from CT scan at [Hospital1 ]. The patient was hydrated aggressively with IVF on her first day after transfer. She was found to have high fevers and was tachycardic, she was started on empiric antibiotics for pancreatitis. A CT abdomen shows pancreatic necrosis. LFT's were elevated with ALT 380, AST 514, Tbili 1.1, AP 242, Amylase 2960, Lipase 3990. An abdominal CT on [2187-5-9] showed stable appearance of severe pancreatitis with inflammatory phlegmon within the neck and body of the pancreas. Per surgery, it is unlikely infected, at present, fevers may be due to cytokine release. A operation was deferred at present and can be readdressed later if persistent fevers occur without a source. A repeat CT on [2187-5-25] showed essentially unchanged appearance of severe pancreatitis with large phlegmonous/fluid collection within the neck and body of the pancreas. On [2187-6-6] a CT showed interval improvement in pancreatitis with decrease in size of large phlegmonous/fluid collection of the neck and body of the pancreas. No new fluid collections or abscesses are identified. 2. Abdominal Distension/Ileus: The patient had good stool output, and her abdominal exam was stable. On [2187-4-24] she was noted to have abundant bilious output from NG tube. There was concern for ileus vs obstruction on CT abdomen. A surgery consult was obtained and it was thought to be an ileus. The NGT was left in place and TPN started. Next, a Dobbhoff was placed and trophic tube feedings were started and she was tolerating them fine. A rectal tube was placed for liquid stool. There was an increased amount of fecal leakage around the tube. A new tube was inserted. She had no skin breakdown. After several days, the stool became more formed. She continued to have incontinence. She was seen by Speech and Swallow after her tracheostomy was downsized and passed a speech and swallow evaluation. [5-30], a PICC was placed and TPN started after her Dobbhoff was self D/C'd. She was started on a soft diet [2187-5-31] and calorie counts revealed that she was not taking in enough calories by mouth. TPN continues at this time. 3. Fever/leukocytosis: Upon admission, she was febrile to 101.3 with an increasing white count. She was on Vanco and Zosyn for PNA. Also must consider possible pancreatic infected pseudocyst. A CXR on [2187-5-9] showed bilateral pleural effusions, left lower lobe consolidation. 4. ARF: Creatinine improving from OSH, likely volume depletion. Her Bun 38 and Cr 2.3 on admission improved with adequate hydration. 5. Tachycardia: Likely related to volume depletion so would discontinue beta-blocker. Other possibility is alcohol withdrawal as she would now be about 48 hours from last possible drink. TTE shows hyperdynamic EF, impaired relaxation, TR grad 48. A ECHO showed an EF>75%. She was on Metoprolol and Enalapril for HR and BP control. 6. Hypoxia/Wheezing: 91% on RA with decreased breath sounds at bases and now audible expiratory wheezes. [Month (only) 116] develop pulmonary edema as a result of her fluid resuscitation and require intubation. The patient had Respiratory Failure on [2187-4-20] and was intubated. Likely multifactorial, PNA and CHF. CHF in setting of aggressive volume repletion, interstitial infiltrates on CXR, BNP 1305. She was sedated for 22 days while intubated. The sedation was stopped. A tracheostomy was placed on [2187-5-10]. She had a prolonged intubation and was weaned off the ventilator on HD 30. She requires frequent suctioning for thick, white secretions. Passy-Muir valve was attempted with this patient, but she was unable to tolerate it. On [2187-5-28], her tracheostomy was downsized from a 8 to 6 for a PMV trial. She was able to tolerate the Passy-Muir. A trigger was called for a drop in O2 saturation secondary to a mucus plug. She was suctioned and her inner cannula was removed. After suctioning, humidification, and nebulizers, her O2 sats came back up to 98%. She continued to do well with the Trach and Passy-Muir and able to vocalize. 7. Occupational Therapy Initially, the patient did not follow simple commands in Creole or English. She was able to squeeze hand once when asked, but otherwise was not answering questions appropriately. She attempted verbalization x 3, but it was unintelligible secondary to Trach. After the Passy-Muir, she was able to communicate with the staff and family members. She was highly motivated to return to her baseline. 8. Physical Therapy After the Passy-Muir was placed and tolerable, she seemed highly motivated to ambulate and increase daily activity. She improved from basic transfers to the chair, to being able to ambulate the halls short distances. She will continue to need physical therapy to improve functional activity, Comm: with patient and son-in-law, [Name (NI) ]. Daughter, [Name (NI) ] [Telephone/Fax (1) 67011], home [Telephone/Fax (1) 67012], son-in-law ce: [Telephone/Fax (1) 67013] Medications on Admission: Medications at home: Vicodin prn Atenolol 50 mg daily Lisinopril 10 mg daily * Medications on transfer: Colace prn Morphine 2 mg IV prn, last dose today at 9:45 pm Metoprolol 5 mg IV q6hTylenol 650 mg pr q6h, last at 5 pm today Hydralazine 20 mg IV q4h prn last dose at 1:30 this am Protonix 40 mg IV daily Unasyn 3 gm q6h (day 1 = [2187-4-20]) NS, 2L since 3 pm today Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Amylase-Lipase-Protease 468 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). ML(s) 10. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 12. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. Disp:90 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Epigastric Pain Pancreatitis with rising LFT's Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to pass gas or stool * Other symptoms concerning to you Please take all your medications as ordered Continue Trach Care - suction PRN, humidification at all times, change trach sponge and ties PRN, change inner cannula daily Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Call ([Telephone/Fax (1) 15807] for an appointment. Completed by:[2187-6-13] ICD9 Codes: 5849, 5119, 4280, 5990, 2762, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6230 }	Medical Text: Admission Date: [2177-9-14] Discharge Date: [2177-9-22] Date of Birth: [2097-6-3] Sex: F Service: CARDIOTHORACIC Allergies: Codeine Attending:[First Name3 (LF) 1505] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: [2177-9-15] 1. Mitral valve replacement with a [Street Address(2) 11599]. [Hospital 923] Medical Biocor Epic Tissue Valve. 2. Coronary artery bypass grafting x2 with a left internal mammary artery graft to the left anterior descending and reverse saphenous vein graft to the posterior descending artery. History of Present Illness: 80 year old female with hospitalizations for atrial fibrillation with recent echocardiogram that revealed severe mitral regurgitation. Underwent cardiac catheterization which revealed coronary artery disease. Past Medical History: MR/CAD RCA stents [2170] NSTEMI [2170] obesity tremor A Fib/flutter asthma TB CHF GERD osteoarthritis HTN hyperlipidemia PVD with RSFA/R profunda stenoses Social History: retired widowed, lives alone ETOH 2 drinks smoked 1 ppd/ quit [2160] Family History: mother died of MI at 56 Physical Exam: Pulse:58 Resp: O2 sat: 97% B/P Right: 137/60 Left: Height: 5'3" Weight: 166 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 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: 2+ Left:2+ DP Right: 2+ Left:2+ PT [Name (NI) 167]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right:- Left:- Pertinent Results: Pre-bypass: No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is moderately depressed (LVEF= 40 %). with normal free wall contractility. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve is abnormal. There is no pericardial effusion. Post-bypass: The patient is receiving 0.02 mcg/kg/min of epinephrine post-bypass and is paced. There is a well-seated mitral valve bioprothesis without valvular regurgitation. The leaflets appear to move normally. There is a posterior annular paravalvular jet. These findings were discussed with the surgeon. The aorta is intact post-decannulation. All other findings are consistent with pre-bypass findings. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD, Interpreting physician [Last Name (NamePattern4) ] [2177-9-16] 10:13 [2177-9-22] 06:00AM BLOOD WBC-9.8 RBC-3.07* Hgb-9.4* Hct-28.6* MCV-93 MCH-30.7 MCHC-32.9 RDW-14.4 Plt Ct-386# [2177-9-14] 09:05PM BLOOD WBC-7.4 RBC-3.48* Hgb-11.0* Hct-32.6* MCV-94# MCH-31.7 MCHC-33.8 RDW-12.5 Plt Ct-231 [2177-9-22] 06:00AM BLOOD Plt Ct-386# [2177-9-22] 06:00AM BLOOD PT-18.6* INR(PT)-1.7* [2177-9-21] 07:40AM BLOOD PT-17.0* INR(PT)-1.5* [2177-9-14] 09:05PM BLOOD PT-13.1 PTT-19.8* INR(PT)-1.1 [2177-9-14] 09:05PM BLOOD Plt Ct-231 [2177-9-22] 06:00AM BLOOD K-4.1 [2177-9-22] 01:10AM BLOOD Glucose-131* UreaN-13 Creat-0.8 Na-139 K-5.3* Cl-102 HCO3-27 AnGap-15 [2177-9-14] 09:05PM BLOOD Glucose-124* UreaN-23* Creat-0.9 Na-140 K-4.2 Cl-104 HCO3-30 AnGap-10 [2177-9-14] 09:05PM BLOOD ALT-17 AST-24 LD(LDH)-202 AlkPhos-62 Amylase-47 TotBili-0.2 [2177-9-22] 01:10AM BLOOD Calcium-8.8 Phos-4.2# Mg-2.1 [2177-9-14] 09:05PM BLOOD %HbA1c-6.2* [2177-9-17] 03:46AM BLOOD TSH-3.6 Brief Hospital Course: Admitted preoperatively for heparin bridge due to atrial fibrillation. Next day she was brought to the operating room for mitral valve replacement and coronary artery bypass graft, see operative report for further details. She received cefazolin for perioperative antibiotics. Postoperatively she was transferred to the intensive care unit for hemodynamic management. In the first twenty four hours she was weaned from sedation and extubated. Neurologically she was oriented but forgettful which improved over the next few days and returned to baseline. She remained in the intensive care unit awaiting a floor bed. Physical therapy worked with her on strength and mobility. She continued to progress, her medications were adjusted for her rhythm as she goes in and out atrial fibrillation which is her baseline. Her coumadin was preogressively increased and she was ready for discharge to rehab on post operative day seven. Medications on Admission: Medications at home:Lisinopril 20 mg daily, Flovent two puffs b.i.d., Xopenex multidose inhaler two puffs b.i.d., Diltiazem CD 360 mg daily, Aspirin 81 mg daily, Crestor 20 mg daily, Prilosec 20 mg daily, Multivitamin daily, Calcium Carbonate 650 mg plus, Vitamin D daily, Coumadin 5 mg daily ( held ) Flaxseed oil daily, Glucosamine daily, and Metoprolol 25 mg twice a day. Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Three (3) Capsule, Sustained Release PO DAILY (Daily). 5. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation TID (3 times a day). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: goal INR 2.0-2.5 for atrial fibrillation home dose 5 mg daily please check INR twice a week . 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:10 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10 days. 11. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day. 12. medication consider resuming ace inhibitor when blood pressure will tolerate 13. Outpatient [Name (NI) ] Work PT/INR twice a week with goal INR 2.0-2.5 Discharge Disposition: Extended Care Facility: [Hospital3 15644] Long Term Health - [Location (un) 47] Discharge Diagnosis: Mitral regurgitation s/p MVR Atrial fibrillation Atrial flutter Coronary artery disease s/p CABG Right Coronary artery stents [2177] elevaton myocardial infarction [2170] obesity tremor asthma GERD osteoarthritis Hypertension hyperlipidemia Peripheral vascular disease with RSFA/R profunda stenoses Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming Monitor wounds for infection and report any redness, warmth, swelling, tenderness or drainage Please take temperature each evening and Report any fever 100.5 or greater 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Dr. [Last Name (STitle) ] at [Hospital1 ] in [2-4] weeks [Telephone/Fax (1) 6256] Dr. [Last Name (STitle) 43672] after discharge from rehab Dr. [Last Name (STitle) 5874] in [2-4] after discharge from rehab Completed by:[2177-9-22] ICD9 Codes: 4019, 2724, 4280, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6231 }	Medical Text: Admission Date: [2167-11-27] Discharge Date: [2167-12-8] Date of Birth: [2115-10-30] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5018] Chief Complaint: intracerebral hemorrhage (transfer from [Hospital6 204]) Major Surgical or Invasive Procedure: none History of Present Illness: This is a 52 year-old right-handed man with a history of HTN and [Hospital ] transferred from [Hospital3 ] with an intracranial hemorrhage. He woke at 3AM with severe vertigo, chest pain, and palpable tachycardia. He states explicitly that the chest pain woke him from sleep. He had a mild headache at that time, but it was much less intense than his other symptoms. He remained in bed until 5AM with little improvement to his symptoms. He attempted to walk to the bathroom but still suffered from severe vertigo and fell. He denies injury generally, and specifically states that he did not strike his head. After this fall he called 911 and was transferred to [Hospital6 204]. CT there demonstrated a R. basal ganglia bleed, leading him to be transported to [Hospital1 18]. Per the ER resident his symptoms have been stable from his initial presentation at LGH until the present. Neurosurgery evaluated him for possible drainage in the ER and felt that no intervention was indicated at this time. He notes that recent glycemic control has been very poor. On multiple days over the last week he has had glucoses > 400, and his high over the last week was >600. ROS: There have been no changes in vision or hearing, neck pain, tinnitus, weakness, difficulty with comprehension, speaking, language, swallowing, eating or gait. General review of systems was negative for fevers, chills, rashes, change in weight, energy level or appetite, shortness of breath, cough, abdominal pain, nausea, vomiting, and change in bowel or bladder habits (i.e incontinence). Past Medical History: - HTN - IDDM - Industrial exposure to cadmium 15y ago in a workplace explosion - Failure of at least one kidney - he does not know which - Intermittent paralysis of L. or R. arm lasting 2-3 minutes x 1 year, occurs multiple times per month but has not escalated in frequency. - Peripheral vascular disease - Gout vs. osteoarthritis, given Indomethacin treatment and complaint of chronic severe knee pain. Pt does not know distinction between these diagnoses. Social History: The patient lives alone, is disabled and not working secondary to diabetes, and has one daughter. Family History: Little is known - all family members of his and prior generations remained in [Country ] and their later-life histories are unknown. Physical Exam: History primarily in English with Mr. [Known lastname ] daughter intermittently translating from Cambodian for fine points Appearance: WDWN, NAD Skin: No rashes or bruising. HEENT: NCAT, MMM, OP clear. Ext: Trace edema of the LE extending [2-26] inches above the calf. MS: Gen: Sleeping but rousable, falls back asleep rapidly. Alert, interactive, normal affect. Orientation: Full. Speech/[Doctor Last Name ]: Fluent w/o paraphasic errors; Follows simple commands, does well with commands on the R. side but tends to perform L. sided commands with both or only R. hand. This is more likely secondary to neglect than secondary to L-R confusion. Repetition, naming intact. CN: I: Not tested. II: Blinks to threat in all visual fields. PERRL 3mm to 2.75mm. No RAPD. III,IV,VI EOMI w/o nystagmus (or diplopia). No ptosis. V: Sensation diminished to temp, light touch in the lower face. VII: R. NLF flattening. VIII: Hears finger rub equally and bilaterally. IX,X: Voice normal. Palate elevates symmetrically. [Doctor First Name 81]: SCM and trapezii full. XII: Tongue protrudes midline. Motor: Pronator drift on the L, overt. Slowed finger tapping on the L. Normal bulk and tone; no tremor, rigidity, or bradykinesia. Must overcome L. sided neglect for strength testing, then intact. [Doctor First Name ] [Hospital1 ] Tri FE IP Quad Hamst [First Name9 (NamePattern2) ] [Last Name (un) 938] Gastro C5 C6 C7 C8/T1 L2 L3 L4-S1 L4 L5 S1 R 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 Coord: Finger-nose-finger intact on the R, dysmetria on the L. Toe to finger intact on the R, dysmetria on the L. Reflex: [Hospital1 ] Tri Bra Pat [Doctor First Name ] Toes C6 C7 C6 L4 S1 R 1+ 2 1+ 1- 1- down L 1+ 2 1+ 1- 1- down [Last Name (un) ]: Decreased temperature, vibration, and fine touch in L. hand/arm, L. lower face, and L body wall. L. leg has decreased vibration and fine touch, but less severe than arm. Extinguishes to simulatneous fine touch in the lower face, arm - does not extinquish in upper face or L. leg. Decreased proprioception in L. hand. Pertinent Results: [2167-11-27] 05:00PM CK(CPK)-257 [2167-11-27] 05:00PM CK-MB-3 cTropnT-0.03* [2167-11-27] 09:01AM GLUCOSE-362* UREA N-24* CREAT-1.8* SODIUM-135 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-27 ANION GAP-11 [2167-11-27] 09:01AM estGFR-Using this [2167-11-27] 09:01AM cTropnT-0.03* [2167-11-27] 09:01AM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-2.1 [2167-11-27] 09:01AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2167-11-27] 09:01AM URINE HOURS-RANDOM [2167-11-27] 09:01AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2167-11-27] 09:01AM WBC-13.1* RBC-4.78 HGB-14.3 HCT-41.3 MCV-87 MCH-30.0 MCHC-34.7 RDW-13.5 [2167-11-27] 09:01AM NEUTS-87.7* LYMPHS-8.4* MONOS-2.5 EOS-0.8 BASOS-0.6 [2167-11-27] 09:01AM PLT COUNT-266 [2167-11-27] 09:01AM PT-11.4 PTT-21.7* INR(PT)-0.9 [2167-11-27] 09:01AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.027 [2167-11-27] 09:01AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2167-11-27] 09:01AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [2167-11-27] 09:01AM URINE AMORPH-FEW [2167-11-27] 09:01AM URINE MUCOUS-FEW [Known lastname ],[Known firstname 20] [Medical Record Number 88116] M 52 [2115-10-30] Radiology Report CT HEAD W/O CONTRAST Study Date of [2167-11-27] 9:31 AM [Last Name (LF) ],[First Name3 (LF) 488] EU [2167-11-27] 9:31 AM CT HEAD W/O CONTRAST Clip # [Clip Number (Radiology) 88117] Reason: bleed? [Hospital 93] MEDICAL CONDITION: 52 year old man with known IPH, evolving exam REASON FOR THIS EXAMINATION: bleed? CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: MXAk FRI [2167-11-27] 10:53 AM Unchanged right parenchymal hemorrhage with extension into the right lateral ventricle, the frontal [Doctor Last Name 534] of left lateral ventricle, and the third ventricle. These findings were discussed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at 9:45 on [2167-11-27]. Final Report INDICATION: Interval evaluation of known parenchymal hemorrhage. COMPARISON: Outside hospital CT from [2167-11-27] at 6:41 a.m. TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast. Multiplanar reformatted images were prepared. FINDINGS: Again visualized is an unchanged 2.7 x 1.7 cm right basal ganglia parenchymal hemorrhage extending into the right lateral ventricle as well as the frontal [Doctor Last Name 534] of the left lateral ventricle and the third ventricle. A thin surrounding rim of edema is again noted. There is no shift of the normally midline structures. There are no new foci of hemorrhage, infarctions, mass effects, or herniation. No fractures are identified. The visualized portions of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Unchanged right basal ganglia hemorrhage extension into the right lateral ventricle, frontal [Doctor Last Name 534] of the left lateral ventricle and the third ventricle. Location and imaging features favor hypertensive hemorrhage, although CT cannot entirely exclude underlying vascular malformation or mass. These findings were discussed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at 9:45 on [2167-11-27]. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 251] [Name (STitle) 8580] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7411] Approved: FRI [2167-11-27] 12:47 PM [Known lastname ],[Known firstname 20] [Medical Record Number 88116] M 52 [2115-10-30] Radiology Report CT HEAD W/O CONTRAST Study Date of [2167-12-5] 6:23 PM [Last Name (LF) 162],[First Name3 (LF) ] NMED FA11 [2167-12-5] 6:23 PM CT HEAD W/O CONTRAST Clip # [Clip Number (Radiology) 88118] Reason: interval change [Hospital 93] MEDICAL CONDITION: 52 year old man with known IV and IP hemorrhage with worsening MS REASON FOR THIS EXAMINATION: interval change CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: DLrc SAT [2167-12-5] 9:49 PM Slight interval decrease in size of right basal ganglia hemorrhage with little change in known intraventricular extension. Stable size of the ventricular system. Final Report INDICATION: Patient is a 52-year-old male with known intraventricular, intraparenchymal hemorrhage with worsening mental status. Evaluate for interval change. EXAMINATION: CT of the head without intravenous contrast. COMPARISONS: [2167-12-2]. TECHNIQUE: Contiguous axial images were obtained through the brain. No intravenous contrast was administered. Multiple sequences were attempted secondary to patient motion. FINDINGS: Since the prior examination, there has been slight interval decrease in size of a focus of intraparenchymal hemorrhage, now measuring 2.2 x 1.2 cm where previously it measured up to 2.6 cm in maximal dimension. This area of hemorrhage is centered in the right basal ganglia and demonstrates extension into the right lateral ventricle. Overall, there has been slight interval decrease in hemorrhage filling the right lateral ventricle extending into the right frontal [Doctor Last Name 534]. The ventricular system is stable in size and configuration, with the third ventricle measuring up to 7 mm and the right lateral ventricle measuring up to 10 mm. There are no new foci of hemorrhage. There is no evidence of shift of midline structures or transtentorial or uncal herniation. The [Doctor Last Name 352]-white matter differentiation is preserved with no evidence of acute territorial infarction. The bony structures are unremarkable. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Slight interval decrease in size of right basal ganglia hemorrhage with little change in known intraventricular extension. Stable size of the ventricular system. As mentioned earlier, while this can relate to HTN, underlying vascular/neoplastic cause cannot be excluded and work up accdgly. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] LI DR. [First Name (STitle) 10627] PERI Approved: SUN [2167-12-6] 12:13 PM Brief Hospital Course: 52yo man with longstanding HTN and [Hospital ] transferred from [Hospital1 ] with intracranial hemorrhage, suspected secondary to hypertensive crisis. The size of his bleed, the need for frequent neuro checks, and his need for antihypertensives via continuous drip necessitate ICU admission. His Left-sided sensory symptoms were well-explained by his Right-thalamic bleed, and there were no symptoms that were unexplained by this lesion. Although we do not have records of his blood pressure at the time of EMS contact, the presumptive etiology of this hemorrhagic infarct is uncontrolled hypertension. Renal consult was called re. the acute-on-chronic renal failure, and recommended discontinuing his NSAIDs (taken for ?gout), which was done, and measuring urine protein-to-creatinine ratio, which revealed gross proteinuria >5,000. Mr. [Known lastname ] was transferred to the floor after several days in the ICU. Continued issues were blood glucose control (managed with insulin sliding-scale) and acute renal failure (initially ~2.0 and steady, but then up to 2.7 in the setting of UTI and Cipro Tx, all above a reported baseline CKD/Cr 1.5), despite IVF and holding the patient's previous indomethacin. On the floor, he became more confused and febrile, and was found to have a gram-negative UTI. Initially, he was treated empirically with ciprofloxacin, but this worsened his renal failure, and the patient became febrile and somnolent/lethargic, so he was switched to IV vancomycin and Zosyn (vancomycin was discontinued [12-7] after UCx from [12-5] showed gram-positive bacteria). This UCx ultimately speciated a pan-sensitive [Last Name (LF) 88119], [First Name3 (LF) ] on [12-8] (day of discharge) after 3.5d of treatment with IV Zosyn, he was switched to PO Bactrim, plan to finish a 7-8d course for complicated (male) UTI. Fever defervesced rapidly and mental status improved markedly 1-2d after starting IV antibiotics, and creatinine began improving after it peaked at 2.7 the day before discharge (down to 2.5 on [12-8]). Blood cultures and a repeat UCx on [12-5] (after first dose of Cipro) have remained no growth to date. On the day of discharge, Mr. [Known lastname ] was alert and oriented to place and date, with stable and normal VS. Breathing comfortably and BP in good control on current medication regimen, HDS. On Neurologic examination, his speech was fluent and he exhibited a stable mild flattening of his Left NLF, but full power in all tested muscle groups. He is working with PT and getting out of bed to chair [Hospital1 ]. His FSBG were in good control (120-150) on increased dosing of SSI. Plan: -follow up in Neurology/[Hospital 4038] clinic with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] (see discharge information) -arrange follow-up with patient's PCP and if PCP agrees, consider starting him with Nephrology outpatient follow-up in the near future (chronic kidney disease and now recovering from acute renal failure and UTI) -finish 3.5 days more of [Hospital1 ] Bactrim DS 1 tab PO for complicated UTI -continue medication regimen (excluding NSAID) as listed below Medications on Admission: -Indomethacin 50mg [Hospital1 ] -Tylenol with Codeine prn -Lipitor 20mg qDay -HCTZ 25mg qDay -Naprocen 500mg [Hospital1 ] (scheduled) -Insulin 55 units qAM, usually 55 units qPM (does not give evening dose if glucose is not elevated). SSI Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. senna 8.6 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. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): for DVT prophylaxis. 7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 11. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Urianary tract infection for 7 doses. 13. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 14. insulin regular human 100 unit/mL (3 mL) Insulin Pen Sig: One (1) Subcutaneous four times a day: Per sliding-scale insulin regimen for insulin-dependent diabetes mellitus. Discharge Disposition: Extended Care Facility: [Hospital 8971] Rehabilitation Center (at [Hospital6 8972]) - [Location (un) 8973] Discharge Diagnosis: Primary Diagnosis: -Intraparenchymal hemorrhage Secondary Diagnoses: -Acute renal failure on chronic kidney disease -Urinary tract infection (Klebsiella, pan-sensitive) -Hypertension, uncontrolled. -Diabetes, poorly controlled. -Peripheral vascular disease -Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory, slowly recovering from stroke Discharge Instructions: You had a hemorrhagic stroke, which means that there was bleeding in your brain. This caused the neurologic symptoms (sensations, mild weakness) that you experienced. This was caused by your high blood pressure along with your diabetes, which need to be kept in better control to prevent future strokes. Your kidneys, which were already chronically damaged, were also injured, at least in part due to the painkiller medicines (indomethacin and naprosyn) that you were taking every day. This was also related to a urinary tract infection you developed here in the hospital, which is being treated by antibiotic medication that will continue for 3 more days. Followup Instructions: (1) With Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in Vascular Neurology (stroke) clinic on <<Tuesday, [1-12] at 2:00pm>> at the [Hospital Ward Name 23] clinical center, [Location (un) ]. (2) With your Primary Care Provider, [Name10 (NameIs) 138] for appointment ASAP [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2167-12-8] ICD9 Codes: 431, 5845, 5990, 2930, 5859, 3051, 4439, 2749, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6232 }	Medical Text: Admission Date: [2108-7-29] Discharge Date: [2108-8-7] Date of Birth: [2075-6-21] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2186] Chief Complaint: acute pancreatitis Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known lastname ] is a 33 yo M with a history of EtOH use to [6-20] drinks/week admitted yesterday to OSH with nausea, vomiting and abdominal pain and transferred to the [Hospital1 18] for acute pancreatitis. He felt well until the day prior to admission, Saturday at noon while he was at work. He began to feel diffuse abdominal cramping with "tightness" in his back. He initially brushed off the pain until it began worsening over the next two hours. He returned home from work by 4pm that day and endorsed vomiting to NBNB vomitus several times, 3x/hr. His abdominal pain was crampy and diffuse radiating to his back. During this time, he felt febrile and had chills, body aches and shortness of breath with abdominal pain. He was transported by his girlfriend to OSH at midnight for his symptoms. . On arrival to OSH, vitals were T 97.7, HR 133, BP 194/124, RR 36 SaO2 98% RA. His labs were significant for 21.2, no bands. Cr 1.3, calcium 12.2. Tbili 2.3, Dbili 0.7, lipase 893, AST 190, ALT 244. A CT scan done showed pancreatitis and "equivocal partial splenic vein thrombosis at the portal confluence and diffuse hepatic fatty infiltration." CXR wnl. U/A w/ 1000 glucose, 30 protein, trace blood. FS was 303 on exam. Got 100mg labetalol and was started on Q8H meropenem and given IVF. . VS on transfer were T 97.4, HR 101, BP 170/120, RR 16, SaO2 97% RA. . On the floor, patient complains of [4-22] epigastric pain radiating to his back. He says the pain was relieved by his last dilaudid dose but is beginning to worsen. He has occasional dry heaves that cause him a lot of pain. He feels short of breath occasionally as limited by pain. He reports that his last drink was one week ago on Monday, and he had [3-16] drinks. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied chest pain or tightness, palpitations. Denied diarrhea or constipation. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias. Past Medical History: Told by PCP before that he had "borderline" blood pressures. Not on any meds. Social History: Pt lives with his girlfriend and works running the waterfront at a Yacht club. As per his mother and sister, patient has had 13 years of heavy alcohol use and has at least 4 drinks nightly. He does not smoke or use illicits. Family History: He has no family history of pancreatitis or biliary disease that he knows of. Both his father and paternal grandfather were alcoholics. Physical Exam: Vitals: T: 97.2 HR: 112 BP: 142/100 RR: 20 O2: 96RA General: In pain, not diaphoretic, dry heaves HEENT: NC/AT, PERRL, sclera anicteric, mucus membranes dry, oropharynx clear Neck: supple, JVP not elevated, thyroid wnl Lungs: CTAB, no wheezes, rales or ronchi CV: Tachycardic, normal S1 + S2, no m/r/g Abdomen: tense, distended, diminished bowel sounds, tender to percussion and light palpation in midepigastrum > RUQ, no guarding or rebound, negative Cullen's and Grey [Doctor Last Name 27210] sign Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A + O x 3. CNII-XII grossly intact. No focal deficits. Pertinent Results: [2108-7-29] 06:50PM WBC-16.3* RBC-4.58* HGB-15.6 HCT-44.9 MCV-98 MCH-34.1* MCHC-34.8 RDW-13.4 [2108-7-29] 06:50PM NEUTS-92* BANDS-3 LYMPHS-2* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2108-7-29] 06:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2108-7-29] 06:50PM PLT SMR-NORMAL PLT COUNT-201 [2108-7-29] 06:50PM PT-13.6* PTT-22.5 INR(PT)-1.2* [2108-7-29] 06:50PM TRIGLYCER-101 [2108-7-29] 06:50PM CALCIUM-7.9* PHOSPHATE-2.8 MAGNESIUM-1.3* [2108-7-29] 06:50PM LIPASE-594* [2108-7-29] 06:50PM ALT(SGPT)-120* AST(SGOT)-109* LD(LDH)-481* ALK PHOS-55 TOT BILI-2.1* [2108-7-29] 06:50PM GLUCOSE-219* UREA N-9 CREAT-1.3* SODIUM-139 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-16 [2108-7-29] 07:13PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [2108-7-29] 07:13PM URINE COLOR-DkAmb APPEAR-Clear SP [Last Name (un) 155]-1.031 [2108-7-29] 07:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-300 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2108-7-29] 07:13PM URINE RBC-2 WBC-3 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 [2108-7-29] 07:13PM URINE MUCOUS-OCC . LIVER OR GALLBLADDER US (SINGLE ORGAN) ([2108-7-29]) IMPRESSION: 1. Extremely limited ultrasound. 2. Echogenic liver consistent with fatty infiltration; more serious forms of liver cirrhosis/fibrosis cannot be ruled out on the basis of this study. 3. Small amount of ascites around the gallbladder and in the right and left lower quadrants consistent with free fluid seen on recent CT scan. . OSH CT Abd/Pel: ([2108-7-29]) moderately severe pancreatic bed inflammtory soft tissue stranding. No pancreatic bed fluid collection. Equivocal partial splenic vein thrombosis at portal confluence. . EKG: [7-29] at 1:24am: sinus tach at 111bpm. NA/NI. No ST changes. . Brief Hospital Course: # Acute pancreatitis: Pt had acute onset abdominal pain, N/V with elevated lipase and OSH CT with pancreatic inflammation, tissue stranding, no fluid collections. It also shows a possible partial splenic vein thrombosis. At OSH, he was also given dilaudid for pain control after he tried morphine to little relief. He was started on IV NS and given meropenem x 1 at OSH. This presentation was consistent with acute pancreatitis. On the floor, meropenem was discontinued after a read of the OSH CT. He was not felt to have necrotizing disease, so meropenem was not indicated. He denied a history of biliary colic and he reported [6-20] drinks weekly. He reported that his last drink was on Monday to [3-16] drinks. His family indicated that he more realistically drinks about 4 drinks daily and that his last drink was likely the day prior to his admission. An abdominal U/S was limited due to pain and body habitus, but no gallstones were visualized on exam. He was continued on dilaudid dilaudid 0.5-2mg Q4H:PRN pain. Urine tox came back negative. He was placed on a foley catheter with strict Is and Os. He got 3L NS 500ml/hr and 2L LR at 250ml/hr in the first 12 hours. After he received these fluids, his abdomen became very distended, which was thought to be most likely secondary to third spacing in the setting of his pancreatitis. His was placed on maintenance fluids 150ml/hr NS. His urine output was 70-75ml/hr. His foley was d/c'd at this time and strict Is and Os were followed. He was NPO on day of admission and advanced to sips of clears by hospital day 1 and tolerated this well. The evening of MICU transfer, the night team had concern for desats to 88% on RA and started him on a course of vanc/cefepime for hospital acquired pneumonia. During rounds the following morning, the patient triggered for nursing concern of coffee-ground emesis to 100ml. That morning, he had increasing tense abdominal distention with diffuse tenderness. Additionally, morning labs were concerning for hypocalcemia to 6.4 down from 7.1 the previous day, hyperbilirubinemia with a bump from 2.1 to 7.1, low phos at 1.0, and a Hct drop of 7 points from 45 to 37.9. These issues are discussed independently below. A stat AP CXR and KUB was followed up. He was then transferred to the ICU for further eval. . In the ICU, he was noted to have abd distension and tension, worsen transaminitis that was concerning for 3rd spacing and ascitis, progression to necrotizing pancreatitis and splenic artery aneurism. He had a repeat CT abd with contrast that showed are of necrotizing pancreatitis, and extend of splenic thrombus now completely obstructing his splenic vein and extending into portal vein. He was also noted to have non-occlusive thrombus of his SMV. Pt also had significant drop on his HCT 45->35->31 that was concerning for retroperitoneal bleed and he was given 1 unit of PRBCs. He responded appropriately with Hct increase to 35. He was HD stable and his Hct has remained stable. Hepatology did an EGD in the AM for evaluation of esophageal bleed. The EGD did not show varices or active bleeding, but did showed diffused ulcerations. Hepatology discussed his case during the liver board and the recommendation was made to not anticoagulate given his risk of bleeding and the fact that pt is a heavy drinker and would not be a good candidate for anti-coagulation. . He was tx with fluids and symptomatically. He was started on clears today and his pain has been controlled with dilaudid, now transitioned to oxycodone. . On the floor, he continued to get supportive care. His pain is now controled with morphine Q3H, although he is not having so much abdominal pain as he is having lower back pain that is likely secondary to his chronic low back pain that he has had since prior to his hospitalization. His IVF were discontinued and his diet was progressed. His captopril was increased from 12.5mg to 37.5mg for better blood pressure control. He was otherwise hemodynamically stable for the rest of his stay. Hct was stable at around 35. His calcium was followed and was repleted on the first day back on the floor. A repeat CT scan was done prior to discharge which revealed fluid around the pancreas that was immature and not organizing; surgery evaluated the patient and did not feel it was necessary to drain. He was discharged with PCP, [Name10 (NameIs) ] hepatology, follow-up. . # GI Bleed: Pt had a Hct drop from 45 to 39->37 with hemocult positive coffee ground vomitus. He likely has a GI bleed. Initiall Ddx includes bleeding esophageal varices from previously undiagnosed liver disease, [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 19916] tears from vomiting. He is tachycardic to 120s and BP is 150/90. He was written for 2U PRBC, but this was not given. Later in the evening this HCT trendeded down to 31 which was concerning for acute bleed including retroperitoneal and he was given 1unit of PRBCs. He responded appropriately with Hct increase to 35. He was HD stable and his Hct has remained stable. Hepatology did an EGD in the AM for evaluation of esophageal bleed. The EGD did not show varices or active bleeding, but did showed diffused ulcerations. 2 small isolated gastric varices in the fundus of the stomach with NO stigmata No evidence of ulcers, AVM's, active bleeding or masses ulcers in the distal bulb. Two small clean base superficial ulcerations were identify in the 2nd portion of the duodenum with no recent bleeding stigmata. His Hct was stable for the rest of his stay on the floor. . #) Hepatitis: This is likely acute ETOH hepatitis with increase in transaminitis and increase in tbili. His AST/ALT ratio is 2 while his LFTs do not exceed 500s which is also consistent with this dx. We have likely caught this pt in the early phase of alcoholic hepatitis. Discriminant function is 12, so no steroids indicated at this time. Pt however complains of increase in abd girth and 45lb wt gain in the last year w/ decrease in appetite and PO intake. This is somewhat concerning for more chronic process. His skin looks tan which could be due to sun exposure and jaundice, however given symptoms we checked iron studies and serum ferritin. The iron was low and ferritin was elevated which in the setting of acute illness, makes difficult to interpreter results. His LFTs are also quickly trending down so there is also a possibility of a change in labs were due to biliary stone that was passed. He is to follow up with hepatology outpatient upon discharge. # Hypoxia: On the floor, there was concern for PNA in the L retrocardiac area and so was started on Vanc/Cefepime. However, this is unclear and it seems more likely that abdominal distention and IVF's/3rd spacing are creating basilar atelectasis and L effusion. Of note, CXR's also [Location (un) 381] lung volumes. Once on floor, his oxygen sats resolved to 96% RA after he no longer required fluid resuscitation. . # SIRS: Patient still meets [4-16] of SIRS criteria, likely due to his acute pancreatitis and a possibility of acute alcoholic hepatitis. He was started on vanc/cefepime for concern for hospital-acquired PNA given his decreasing O2 sats. His hypoxia is more likely secondary to his apparent third spacing/ascites and contributing pulmonary edema, although retrocardic opacity was seen on CXR last night. All cultures pending this AM. His vanc/cefepime was discontinued and he was placed on telemetry. His clinical picutre improved after complete workup in the MICU and he was transferred to the floor hemodynamically stable. . # Hyperglycemia: Patient had hyperglycemia at the OSH to 300. His FS had been stably in the 200s in hospital day 2. This was thought to be secondary to his pancreatitis. He was place on insulin sliding scale for FS > 200 until his hyperglycemia resolved. . # HTN: HTN at admission in the OHS and he was given a dose of labetolol. In the ICU his BP was as high as 190s/110s he was given labetolol and started on atenolol 25mg. His BP remained elevated and the atenolol dose was increased to 50mg. He was also started on captopril 12.5mg TID. It was increased to captopril 37.5mg TID by time of discharge. It is likely that he had HTN. He will need to be continue to monitor as outpatient. Medications on Admission: None. Discharge Medications: 1. morphine 15 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 4 days. Disp:15 Tablet(s) Refills:0 2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. insulin lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous ASDIR (AS DIRECTED). Disp:qs month supply Refills:0 7. Outpatient Lab Work please check basic metabolic panel (on new lisinopril medicine and was on lasix) as well as CBC (to trend WBC count) Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: severe acute pancreatitis . Secondary diagnosis alcoholic hepatitis hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you at the [Hospital1 ]. You were admitted to this hospital because you were found at your outside hospital to have acute pancreatitis with signs of severe disease on CT scan. You came here and immediately received a lot of fluids and pain medication and were watched for the improvement of your symptoms. When you got sicker, you were taken to the intensive care unit for closer management. You were seen by gastroenterologists, hepatologist and surgeons who followed the progression of your disease. You also had a high blood sugar that we thought was because of your pancreatitis. You were also found to have some liver disease. Once you were stable, you came back to the regular inpatient floor and were able to be off the fluids and were able to recover the rest of the way. . You were noted to have high blood pressures during your admission. . Please note the following changes to your medications: -- START lisinopril 20 mg daily (for high blood pressure) -- START pantoprazole 40 mg twice a day (a medicine that protects your stomach from further bleeding) -- START a multivitamin daily . You will have an appointment with the hepatologist to follow up for your liver disease. You also need to see your primary care doctor to follow up lab work because you had a high white count at the time of discharge (16-20) and recently started a new medicine that can lower your potassium. . The health problems that were diagnosed on this admission are because of your alcohol use. In order to improve your health, it would be best if you reduced your alcohol intake. You spoke with the in-house social worker about programs and resources to help you reduce your drinking. Please consider these resources as you go forward. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ], the hepatologist in [2-16] weeks. Please follow up with your primary care physician to follow up on your hypertension and your blood sugar. ICD9 Codes: 5180, 2761, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6233 }	Medical Text: Admission Date: [2100-9-13] Discharge Date: [2100-10-15] Date of Birth: [2028-7-8] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4748] Chief Complaint: right foot cellulitis Major Surgical or Invasive Procedure: right above the knee amputation gastrojejunostomy tube placement percutaneous tracheostomy multiple central line placements swan ganz catheter placement PICC line placement lumbar puncture History of Present Illness: 72M h/o PVD who p/w worsening right foot ulcer & cellulitis to mid calf, as well of necrotic right 3rd-5th toes. He is 3 weeks s/p R hallux amputation for necrosis, from which his foot never completely healed & the necrotic process has progressed. He denies claudication or rest pain, but is wheelchair bound, and reports fevers at home despite treatment with keflex and augmentin. ROS: +angina, no dyspnea, h/o CVA with swallowing difficulties at home, +BPH Past Medical History: PMH: 1.CAD; h/o angina 2.s/p CVA [2096] 3.Type 2 DM, with retinopathy 4.Hepatitis (shellfish) [2064]'s 5.BPH 6.PVD 7.Dementia PSH: 1.Aortobifemoral BPG [2090-3-30] by Dr.[Last Name (STitle) 1391] 2. L great toe amp [8-/2100] Social History: Pt lives with his wife. Uses [Name2 (NI) ] and wheelchair at home. Smoking 1/2pk cigarettes per day x 50 years. He does not drink alcohol. Family History: Noncontributory. Physical Exam: T 98.6 P 70 BP 130/70 RR 20 02 98% RA wt 165 lbs Alert, NAD bilat carotid bruits, no JVD RRR 2/6 SEM CTA bilat soft nontender Necrotic R [2-6] toes, surrounding erythema to midcalf R knee flexion contracture, 1+ pedal edema (R>L) Pulses (R/L): car [1-6], fem [1-6], [Doctor Last Name ]/dp/pt no signals Pertinent Results: ON PRESENTATION [2100-9-13] 08:25PM BLOOD WBC-13.0* RBC-3.92* Hgb-11.9* Hct-33.3* MCV-85 MCH-30.3 MCHC-35.7* RDW-13.5 Plt Ct-314 [2100-9-13] 08:25PM BLOOD Glucose-110* UreaN-11 Creat-1.1 Na-142 K-3.4 Cl-104 HCO3-26 AnGap-15 [2100-9-14] 06:40AM BLOOD Triglyc-132 HDL-38 CHOL/HD-3.5 LDLcalc-68 [9-13] R foot swab: PROBABLE ENTEROCOCCUS. MODERATE GROWTH. YEAST. SPARSE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. INPATIENT CULTURES [9-20] blood culture: coag negative staph (1/4 bottles) [10-4] swabs: VRE+, MRSA- [10-12] sputum cx: pseudomonas SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I IMIPENEM-------------- =>16 R MEROPENEM------------- 8 I PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S [10-12] urine cx: pseudomonas (>100K colonies) SENSITIVITIES: MIC expressed in MCG/ML ______________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 16 I CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I IMIPENEM-------------- =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ <=1 S [2100-9-29] 01:13PM BLOOD Cortsol-16.6 [2100-9-29] 03:20PM BLOOD Cortsol-22.5* RADIOLOGY [9-23] TTE: EF 45%. septal & apical hypokinesis and possible inferior hypokinesis. No AI/AS, 1+ MR, 2+ TR, moderate pulm systolic HTN. No vegetations. [9-23] CT head: no acute stroke. chronic microvascular infarcts. [9-23] CT chest: 1. New moderate to large bilateral pleural effusions and marked progression of bilateral consolidation. Dependent distribution suggests aspiration pneumonia. 2. Additional perihilar ground-glass opacity, in the setting of bilateral pleural effusions, consistent with pulmonary edema or ARDS. 3. Two round, hypodense lesions in the right kidney are too small to accurately characterize but likely represent cysts. 4. Prominence of the left adrenal gland without focal mass identified. 5. Prostate enlargement. [10-8] CT A/P: 1. Interval improvement in bilateral perihilar ground glass opacities suggestive of interval improvement in pulmonary edema. There are persistent bilateral pleural effusions, which have increased in size since the prior study with bibasilar compressive atelectasis/consolidation. 2. Small pericardial effusion. 3. Small amount of ascites which has increased in the interval. 4. Stable appearance of fullness in the left adrenal gland without a focal mass. 5. No focal fluid collections within the torso to suggest an abscess. 6. Anasarca. [10-12] PICC placement, GJ tube placement DISCHARGE LABS [2100-10-14] 11:32PM BLOOD Type-ART Temp-36.4 Rates-/28 PEEP-5 FiO2-40 pO2-159* pCO2-33* pH-7.47* calHCO3-25 Base XS-1 Intubat-INTUBATED [2100-10-15] 03:18AM BLOOD WBC-12.9* RBC-3.03* Hgb-9.4* Hct-27.6* MCV-91 MCH-30.9 MCHC-34.0 RDW-18.2* Plt Ct-245 [2100-10-14] 02:18AM BLOOD PT-14.3* PTT-26.0 INR(PT)-1.4 [2100-10-15] 03:18AM BLOOD Glucose-156* UreaN-13 Creat-0.6 Na-141 K-4.2 Cl-110* HCO3-23 AnGap-12 [2100-10-15] 03:18AM BLOOD Albumin-2.1* Calcium-7.7* Phos-4.0 Mg-1.7 Brief Hospital Course: Admitted on [9-13] with necrotic toes & cellulitis of his right lower leg. Given rising CK levels, an amputation was unavoidable. After appropriate cardiac clearance, he was taken to OR for a right above-the-knee amputation on [9-16] (refer to op note for specifics). Was cleared for PO diet (thickened liquids) by swallow team on [9-17], but developed acute respiratory distress requiring intubation & transfer to ICU setting on [9-18]. An organ system-based synopsis of his prolonged ICU course is summarized below. NEURO: He was sedated with propofol & ativan while intubated, and was unresponsive until about 1 week prior to discharge. Numerous Head CT's were negative. At discharge, he responds to voice and is able to move all extremities, but does not follow commands. CV: Because of his septic shock, he required significant pressor to maintain an adequate blood pressure (MAP>60). These were weaned off as his sepsis improved. He did develop cardiac enzyme leak around the time of his respiratory failure, but an echo did not show any significant loss of ventricular function. RESP: [9-18] respiratory event attributed to aspiration pneumonia, which worsened over next few days to fulminant ARDS & septic shock. Improved over weeks in ICU with broad spectrum antibiotics (empiric for presumed infection), xigris (for refractory septic shock) & ultimately steroids (for adrenal insufficiency). He was intubated on [9-18], and remained intubated throughout the remainder of his hospital stay. He was changed to a tracheostomy on [10-7], and gradually weaned down to pressure support ventilation. +pseudomonal PNA 3 days prior to discharge, being treated with tobramycin & suctioning q1-2h prn. FEN: Currently about 15kg above his baseline weight of 75kg. Being diuresed with lasix IV drip about [12-6] kg/day. Transitioned to PGT lasix prior to discharge & will continue diuresis to his baseline weight. GI: Perc GJ tube placed by Interventional Rediology [10-12] with position confirmed with 11/10 KUB. Respalor tube feeds via GT at goal of 50cc/hr. Last albumin 2.1. Regular BMs with bowel regimen of colace + prn laxatives. HEME: Required multiple transfusions for anemia of chronic disease (baseline hct 33). Due to immobility, need to continue with SC heparin (or lovenox) and L foot P boots to prevent DVTs. ID: Never had positive cultures from suspected aspiration pneumonia or for several weeks following respiratory event, despite almost daily cultures & multiple CVL changes. He was treated for 3 weeks with broad spectrum antiobiotics (linezolid, levaquin, meropenem, flagyl & fluc). After stopping antibiotics, his WBC & temperatures recurred & he developed copious diarrhea. All of these symptoms improved on flagyl, despite no positive stool cultures. His last temperature was on [10-12] days prior to discharge. Sputum & urine cultures from then grew out pseudomonas, and this is being treated with 2 weeks of tobramycin. Given diuresis with lasix & tobramycin therapy, renal toxicity is a concern & his creatinine should be checked at least q48-72 hours. Tobramycin levels should also be checked (with goal trough < 1 and peak [2-6]). Any bump in his creatinine should prompt relaxation of the diuresis as well as complete discontinuation of the tobramycin, per our infectious disease team. ENDO: He was treated with insulin to maintain a blood glucose of 80-120. At the time of discharge, he was receiving standing doses of NPH & regular insulin q6. The sliding scale is attached with the prescriptions. DISP: full code, wife [Name (NI) 450] is HCP (cell [Telephone/Fax (1) 40228]) Medications on Admission: 70/30 15u qam, zocor 40, enalapril 10, Celexa 40, ASA 81, Lopressor 12.5, Imdur 30, Flomax 0.4, diltiazem CD 120, Lasix 160, KCl 10meq' Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). Disp:90 ML Refills:2 2. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 1 weeks. Disp:21 Tablet(s) Refills:0 3. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day: hold for sbp<100, hr<60. Disp:60 Tablet(s) Refills:2 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-6] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:5 6. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:30 Patch 24HR(s) Refills:2 7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) DOSE PO DAILY (Daily). Disp:30 doses Refills:2 8. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) teaspoons PO BID (2 times a day). Disp:120 teaspoons Refills:2 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:250 ML(s) Refills:3 10. Ibuprofen 100 mg/5 mL Suspension Sig: Six Hundred (600) MG PO Q8H (every 8 hours) as needed for fever. Disp:3000 MG Refills:2 11. Acetaminophen 160 mg/5 mL Solution Sig: One (1) teaspoon PO every eight (8) hours as needed. Disp:30 teaspoon Refills:0 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-6] Drops Ophthalmic PRN (as needed). Disp:qs containers Refills:2 13. Lorazepam 2 mg/mL Syringe Sig: 0.5-1 mg Injection every six (6) hours as needed: hold for confusion, sedation. Disp:30 mg Refills:2 14. Insulin Sliding Scale Follow attached NPH regimen & regular insulin sliding scale. Goal fingersticks 80-120. 15. Outpatient Lab Work Twice weekly labs: CBC, Chem-10 [10-17]: tobramycin peak & trough levels 16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: continue until he approaches his baseline weight of 70kg. CHECK REGULAR LABS TO EVAL K & CREATININE. Disp:30 Tablet(s) Refills:2 17. Potassium Chloride 20 mEq Packet Sig: Two (2) packet PO once a day: 40 mEq QD while using lasix. hold for K > 4.6. Disp:30 packets Refills:2 18. Tobramycin Sulfate 10 mg/mL Solution Sig: One [Age over 90 ]y (120) mg Injection every twelve (12) hours for 10 days. Disp:20 doses Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: right foot ullcers & cellulitis right knee contracture aspiration pneumonia respiratory failure ARDS sepsis septic shock coag neg staph bacteremia pseudomonas UTI & pneumonia Discharge Condition: good Discharge Instructions: Tube feeds as tolerated. Finish your courses of antibiotics. Continue diuresis until you reach your baseline weight, unless you develop increasing creatinine or signs of renal failure. Contact your MD if you develop any concerning symptoms. Followup Instructions: You should follow up with your primary care physician [Last Name (NamePattern4) ] 1 month. Schedule an appointment with Dr [Last Name (STitle) 1391] in his office ([Telephone/Fax (1) 1393]) after you are discharged from the rehab hospital. Completed by:[2100-10-15] ICD9 Codes: 0389, 5185, 5990, 4240, 5070, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6234 }	Medical Text: Admission Date: [2178-10-7] Discharge Date: [2178-10-12] Date of Birth: [2125-4-2] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This 53 year old gentleman, who is a known insulin dependent diabetic, was referred in from [State 3914] with increasing symptoms of shortness of breath and fatigue for the past year. He has no warning symptoms of chest pain or pressure. His stress echocardiogram in [Month (only) 205] showed multiple wall motion abnormalities. He then had a positive ETT and referred in to Dr. [Last Name (STitle) ] for cardiac catheterization. Catheterization on [2178-10-7], showed 50% left main lesion, 80% left anterior descending lesion, 80% right coronary artery lesion and ejection fraction of 55%. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus with an insulin pump. 2. Hypertension. 3. Hypercholesterolemia. 4. Gastroparesis. 5. Peripheral neuropathy to all four extremities and left face. 6. Macular degeneration. PAST SURGICAL HISTORY: Bilateral laser surgeries to his eyes. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg p.o. once daily. 2. Toprol XL 100 mg p.o. once daily. 3. Viagra p.r.n. 4. Multivitamin once daily. 5. Cozaar 50 mg p.o. once daily. 6. Reglan 20 mg p.o. three times a day. 7. Zocor 20 mg p.o. once daily. 8. Insulin pump with alternating basal rate. ALLERGIES: Dilantin which produces hives. PHYSICAL EXAMINATION: On examination, he is five foot nine inches, 200 pounds, heart rate 93, blood pressure left arm 148/102, right arm 165/83. He had no jugular venous distention. His heart was regular rate and rhythm, normal S1 and S2 with no murmur. He had no carotid bruits that could be appreciated. His lungs were clear bilaterally. His abdominal examination was benign. His extremities were cool but well perfused. He had no cyanosis, clubbing or edema. He had peripheral pulses present in bilateral radials, femorals, dorsalis pedis and posterior tibials. He had a normal neurologic examination with the exception of slight left face numbness. LABORATORY DATA: White blood cell count 8.2, hematocrit 43.2, platelet count 331,000. Sodium 141, potassium 4.3, chloride 105, CO2 24, blood urea nitrogen 15, creatinine 1.0 with an INR of 1.2. HOSPITAL COURSE: He was referred to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] from cardiothoracic surgery where he underwent a coronary artery bypass graft times three with a left internal mammary artery to the left anterior descending, left radial artery to the right coronary artery and a vein graft to the OM. He was transferred to the Cardiothoracic Intensive Care Unit in stable condition. Date of operation was [2178-10-8]. On postoperative day one, he had been extubated and on a Nitroglycerin drip at 0.5 for radial artery coverage and continued on his perioperative Vancomycin. Postoperative laboratories were a white count of 12.4, hematocrit 28.3, platelet count 203, sodium 138, potassium 3.9, chloride 110, CO2 22, blood urea nitrogen 8, creatinine 0.7. His examination was benign with the exception of decreased breath sounds at the bases. His chest incision was clean, dry and intact. On neurologic examination, he was alert and on Morphine with good respiratory saturations. His diet was advanced and he was transferred out to the floor. He was seen by [Last Name (un) ] Diabetes fellow for tighter management of his insulin pump. On postoperative day two, he had no events overnight. He continued on his perioperative Vancomycin. He had a good blood pressure of 115/58, sinus tachycardia at 103, and his hematocrit was steady at 26.6. Blood urea nitrogen was 11, creatinine 0.7. He had decreased breath sounds at the bases again. All incisions were clean, dry and intact. His sternum was stable. His diet was advanced. He had good urine output. He was switched over from an insulin drip back to his insulin pump [First Name8 (NamePattern2) ] [Last Name (un) ] recommendations. He was seen by physical therapy for evaluation and continued to ambulate on the floor. On postoperative day three, he had temperature maximum of 101.1 and was hemodynamically stable with a blood pressure of 100/50. He was back on his oral medications. His laboratory values remained stable. His Lopressor was increased to 75 mg p.o. twice a day to take his tachycardia back down. He was again visited by the [Last Name (un) ] diabetes fellow. On postoperative day four, [2178-10-12], he was discharged to home in stable condition with instructions to follow-up with Dr. [Last Name (STitle) 1537] in his office in four weeks and Dr. [Last Name (STitle) 43705] in three to four weeks. On the day of discharge, he was alert and oriented, following all commands. His lungs were clear bilaterally. His heart was regular rate and rhythm. He was approximately three kilograms above his preoperative weight. His blood urea nitrogen was 10 with a creatinine of 0.8. The sternum was stable. All incisions were clean, dry and intact. His left forearm incision also had Steri-strips on it and it was clean and intact. MEDICATIONS ON DISCHARGE: 1. Imdur 60 mg p.o. once daily times three months. 2. Aspirin 325 mg p.o. once daily. 3. Ranitidine 150 mg p.o. twice a day. 4. Simvastatin 20 mg p.o. once daily. 5. Lasix 20 mg p.o. once daily for number of days to be determined. 6. Potassium Chloride 20 meq p.o. once daily, also for predetermined number of days, to be evaluated at discharge. 7. Metoprolol 100 mg p.o. twice a day. 8. Insulin via his own insulin pump. 9. Percocet one to two tablets p.o. p.r.n. q4hours. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting times three. 2. Insulin dependent diabetes mellitus. 3. Hypertension. 4. Hypercholesterolemia. 5. Gastroparesis. 6. Peripheral neuropathy. 7. Macular degeneration. DISCHARGE STATUS: The patient was discharged to home in [State 3914] with instructions to follow-up with his surgeon and Dr. [Last Name (STitle) 43705]. CONDITION ON DISCHARGE: The patient was discharged in stable condition on [2178-10-12]. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 76] MEDQUIST36 D: [2178-10-12] 17:00 T: [2178-10-12] 18:33 JOB#: [Job Number 43706] ICD9 Codes: 3572, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6235 }	Medical Text: Admission Date: [2114-12-26] [Month/Day/Year ] Date: [2115-1-7] Date of Birth: [2058-6-13] Sex: F Service: MEDICINE Allergies: Penicillins / Azithromycin / Lipitor Attending:[First Name3 (LF) 5037] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 56 year old female with past medical history significant for ESRD s/p live donor kidney [First Name3 (LF) ] in [2108] currently immunosuppressed with tacrolimus/ prednisone/cellcept who was recently admitted from [2114-11-8] to [2114-11-28] and [2114-12-5] to [2114-12-20] to [Hospital1 69] for hypoxic respiratory failure requiring intubation and acute tubular necrosis requiring CVVH during both admissions. No cause of her hypoxic respiratory distress were found at either admission but thought to be precipated by a pneumonia which was treated with broad spectrum antibiotics. . She is reported to be doing well since [Hospital1 ]. She woke up this morning went to the bathroom and on her way back to the bedroom experienced sudden onset [7-10] tight left sided chest pressure that radiated to her back. She was noted to have SBP in 230s, hypoxic in 80% on room air at outside hospital. She received IV lasix and was started on nitro gtt for chest pain and transferred to [Hospital1 18] for further evaluation and management. . In the ED, she was noted to have SBP in 150s and satting well on 3LNC. Chest x-ray was consistent with pulmonary edema. V/Q scan showed low probability of pulmonary embolism. She was transferred to MICU on nitro gtt for furthere evaluation and management. . In the unit, she reports having [4-9] pleuritic chest pain but improved shortness of breath. She does not report fever, cough, abdominal pain, nausea, vomiting or headache. She does report she had soup from a can yesterday. Past Medical History: 1. Fulminant liver failure [1-5] likely caused by Azithromycin 2. End-stage renal disease s/p living related donor in [2108] 3. Hypertension 4. Depression 5. Dyslipidemia 6. Nephrolithiasis 7. Melasma 8. Hepatitis B - carrier Social History: Married with 5 children. Lives at home with husband, daughter and grandchildren. She moved from [Country 5737] in [2098] and last visited in [Month (only) ]. She denies any cigarette use, and quit alcohol, though she used to abuse alcohol. No IVDU. While in [Country ], she lived on a farm for 3 years-- exposure to many domestic farm animals. She does not recall any skin rashes or febrile illnesses during that period. She does not know if she received the BCG vaccine as a child. Family History: No history of liver or renal disease. Five brothers and father were killed in [Country ]. Mother had stroke. Sister alive and well. Physical Exam: ADMISSION: Gen: Awake. Alert and oriented to person, place and time. Vitals: 98.3 154/73 72 18 95%2LNC HEENT: Normocephalic. Nontraumatic. Anicteric. PERRLA. Supple neck wtihout lymphadenopathy. Chest: Crackles upto mid lung bases Heart: Regular rate and rhythm. No murmurs or gallops appreciated Abdomen: Soft and nondistended. Grimaces to palpation but no guarding appreciated. No rebound tenderness. External: No edema. No rash. Appropriate temperature of the extremities. 2+ radial and dorsalis pedis pulses . [Country 894]: VS: 98.1 185/93 74 16 100%RA 119 Pertinent Results: IMAGING: CXR ([2114-12-28]): Stable cardiomegaly and pulmonary vascular congestion as well as persistent mild volume loss in the right upper lobe. Possible very small pleural effusions. . CXR ([2114-12-26]): 1. Moderate vascular congestion and interstitial edema have developed, right greater than left, most consistent with asymmetric edema, although superimposed infection can not be excluded. 2. Moderate cardiomegaly. . CTA chest ([2114-12-26]): 1. Moderate vascular congestion and interstitial edema have developed, right greater than left, most consistent with asymmetric edema, although superimposed infection can not be excluded. 2. Moderate cardiomegaly. . V/Q scan ([2114-12-26]): Matched, non-segmental decrease in perfusion and ventilation in the posteromedial right lung. Low likelihood ratio of recent pulmonary embolism. . Renal US ([2114-12-27]): Stable mild-to-moderate hydronephrosis of the [Month/Day/Year ] kidney with patent vasculature. . EKG ([2114-12-26]): Sinus rhythm. Borderline prolonged QTc interval. Diffuse non-specific inferolateral ST segment changes. Compared to the previous tracing of [2114-12-9] the ST segment changes are less evident on the current tracing. Rate PR QRS QT/QTc P QRS T 73 144 80 452/474 33 11 24 . LABS ON ADMISSION: [2114-12-26] 02:30PM BLOOD WBC-8.7# RBC-3.09* Hgb-9.2* Hct-27.3* MCV-89 MCH-29.9 MCHC-33.7 RDW-16.8* Plt Ct-123# [2114-12-26] 02:30PM BLOOD Neuts-94.1 Lymphs-3.8* Monos-0.9* Eos-0.5 Baso-0.7 [2114-12-27] 02:24AM BLOOD PT-12.9 PTT-24.4 INR(PT)-1.1 [2114-12-26] 02:30PM BLOOD Glucose-160* UreaN-28* Creat-1.6* Na-134 K-5.0 Cl-109* HCO3-15* AnGap-15 [2114-12-26] 02:30PM BLOOD ALT-9 AST-15 LD(LDH)-433* AlkPhos-53 TotBili-0.9 [2114-12-26] 02:30PM BLOOD cTropnT-<0.01 proBNP-[Numeric Identifier 59032]* [2114-12-27] 02:24AM BLOOD CK-MB-3 cTropnT-<0.01 [2114-12-27] 02:24AM BLOOD Albumin-3.4* Calcium-8.4 Phos-5.3* Mg-1.8 [2114-12-27] 08:05AM BLOOD tacroFK-8.0 . LABS ON [Month/Day/Year 894]: . MICRO: [2114-12-29] URINE CULTURE-PENDING [2114-12-28] URINE CULTURE-PENDING [2114-12-26] MRSA SCREEN-PENDING . URINE: [2114-12-28] 07:14PM URINE Color-Straw Appear-Hazy Sp [Last Name (un) ]-1.006 [2114-12-28] 07:14PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [2114-12-28] 07:14PM URINE RBC-1 WBC-43* Bacteri-MOD Yeast-NONE Epi-0 [2114-12-28] 07:14PM URINE WBC Clm-FEW [2114-12-29] 10:19AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.007 [2114-12-29] 10:19AM URINE Blood-NEG Nitrite-NEG Protein-150 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2114-12-29] 10:19AM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-NONE Epi-0-2 Brief Hospital Course: 56F w/PMH significant for ESRD s/p live donor kidney [Month/Day/Year ] admitted to ICU with chest pain and SOB in setting of hypertensive emergency, transferred to floor in stable medical condition without supplemental O2 or chest pain after diuresis. Remained hypertensive but asymptomatic. . # Hypertensive urgency: Patient had one episode of hypertensive emergency approximately 1 week prior to [Month/Day/Year ] with headache, visual changes, chest pressure and nausea. For the remainder of her admission, patient had ongoing elevated blood pressures but was asymptomatic. Overall, blood pressures trended down. Denied any headache, vision changes or nausea on [Month/Day/Year ]. Her antihypertensive regimen was changed significantly throughout admission in an attempt to achieve optimal blood pressure control. Serum metanephrines, renin & aldosterone were pending at the time of [Month/Day/Year ]. . # Acute on chronic kidney injury: Patient is s/p kidney [Month/Day/Year ] in [2108]. She was continued on tacrolimus and prednisone. Creatinine was 2.3 at the time of transfer to the floor, 1.6 at time of admission; s/p contrast load for CTA on [12-26]. Baseline creatinine ~1.2 previously; as high as 3.5 during recent admissions. Creatinine trended down after patient was transferred to floor. Renal ultrasound showed patent vasculature and stable mild-to-moderate hydronephrosis. . # Urinary tract infection: Urine cultures from [2114-12-28] and [2114-12-29] grew E. coli & cipro-resistant Psuedomonas. Patient denied any urinary symptoms, but was treated in the context of immunosuppression. She will complete a 14 day course of meropenem (day 1 = [12-31]; last dose on [1-13]). # Anemia: Secondary to chronic inflammation and renal disease. Hematocrit stable and at baseline. # Hyperglycemia: Patient stated that she was not on insulin at home. It appears that lantus and HISS were started in the context of increasing her prednisone dose during her previous admission. Glucose was well controlled overall and she was placed on a humalog sliding scale during admission. # Depression: Continued citalopram 20 mg po daily. # Prophylaxis: Patient received heparin products during this admission. Medications on Admission: 1. Citalopram 20 mg po qdaily 2. Aspirin 325 mg po qdaily 3. Tacrolimus 2 mg po BID 4. Sevelamer HCl 800 mg po BID 5. Prednisone 5 mg po qdaily 6. acetaminophen 325 mg po q6 prn pain 7. docusate sodium 100 mg po BID 8. pantoprazole 40 mg po q12 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol [12-2] puff q4-6 hrs prn shortness of breath 10. fluticasone-salmeterol 250-50 mcg/dose inhalation twice a day 11. diazepam 5 mg Tablet po q8 prn anxiety 12. Lantus 5 units SC qhs 13. Humalog sliding scale 14. epoetin alfa 4,000 unit/mL Solution every MWF 15. Labetalol 400 mg po BID [Month/Day (2) ] Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. tacrolimus 1 mg Capsule, twice daily Sig: One (1) Capsule, twice daily PO every twelve (12) hours. Disp:60 Capsule, twice daily(s) Refills:2 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache, pain. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [12-2] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 8. diazepam 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. 9. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Recon Soln Intravenous Q12H (every 12 hours) for 6 days: last dose [1-13]. Disp:qs mg Recon Soln(s) Refills:0 10. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 12. epoetin alfa 10,000 unit/mL Solution Sig: One (1) injection Injection once a week. Disp:qs Refills:2 13. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 14. isosorbide mononitrate 30 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 15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 16. amlodipine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 17. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 [Month/Year (2) ] Disposition: Home With Service Facility: Home Solutions [Month/Year (2) ] Diagnosis: Primary: Hypertensive emergency Pulmonary edema Asymptomatic bacteriuria . Secondary: End-stage renal disease status post [Month/Year (2) ] [Month/Year (2) ] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [Month/Year (2) ] Instructions: # You were admitted to the hospital for high blood pressure and difficulty breathing. Your blood pressure and breathing improved with some changes to your medications. You were also found to have a urinary tract infection that is being treated with antibiotics. . We made the following changes to your medications: -STOP sevelamer -STOP labetalol -STOP lantus -STOP humalog . -START meropenem (last dose on [1-13]) -START Lasix (furosemide) 80mg every morning -START Imdur (isosorbide mononitrate) 30 mg daily -START amlodipine 5 mg every night -START carvedilol 25 mg twice a day -START lisinopril 20 mg twice a day . -CHANGED dose of prednisone to 2 mg daily -CHANGED dose of tacrolimus to 1 mg twice a day -CHANGED dose of epoetin to 10,000 units once weekly . # Please continue all of your other medications as prescribed. . # It is important that you keep your follow up appointments. . # Dr. [Last Name (STitle) ] requested that you get your labs checked next week (per your usual routine). Followup Instructions: Department: PULMONARY FUNCTION LAB When: MONDAY [2115-1-14] at 1:10 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: PFT When: MONDAY [2115-1-14] at 1:30 PM . Name: [Year (4 digits) ],[Year (4 digits) ] Location: [Hospital ] COMMUNITY HEALTH CENTER Address: [Location (un) 59033], [Hospital1 ],[Numeric Identifier 59034] Phone: [Telephone/Fax (1) 59035] When: Wednesday, [1-16], 1PM . Department: [Month (only) ] CENTER With: [Name6 (MD) 2105] [Name8 (MD) 2106], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage We are working on a follow up appointment with Dr. [Last Name (STitle) ] for you on Friday [1-25]. You will be called at home with the appointment. If you have not heard or have questions, please call the above number. [Name6 (MD) 2105] [Name8 (MD) 2106] MD [MD Number(2) 5038] Completed by:[2115-1-13] ICD9 Codes: 5849, 2762, 5990, 2875, 311, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6236 }	Medical Text: Admission Date: [2179-11-30] Discharge Date: [2179-12-13] Date of Birth: [2118-8-2] Sex: F Service: NEUROSURGERY Allergies: All drug allergies previously recorded have been deleted Attending:[First Name3 (LF) 1835] Chief Complaint: brain tumor Major Surgical or Invasive Procedure: [2179-12-3]:Left Pterional craniotomy for pituitary mass resection History of Present Illness: Pt is a 61 yo F with known sellar mass was seen in neurosurgery clinic on [2179-11-30] with persistent nausea, vomiting, and dizziness. Was referred to the ED for "review by medicine for general failure to thrive as well as SOB, nausea, dizziness." Patient herself reports that she requested to be admitted to the hospital as she was tired of being in the nursing facility because everyone forgot about her there. Patient has been in nursing facility for last 2 months as her dizziness incapacitated her and made it impossible for her to care for herself at home. She is not ambulatory, but can transfer to a wheel chair in order to get around at the nursing facility. Vitals upon presentation to the ED: T 97.2, HR 100, BP 116/69, RR 17, O2Sat 98% RA. Patient wsa having nausea and pain in the ED and was given ondansetron 4 mg, meclizine 25 mg, and 2 tabs percocet. Vitals prior to transfer to the floor were: T afebrile, HR 76, BP 133/77, RR 18, O2Sat 100% RA. REVIEW OF SYSTEMS: (+): blurry vision, nausea, vomiting, diarrhea, rhinorrhea, nasal congestion, cough, arthralgias (-): fever, chills, dysphagia, chest pain, paliptations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, constipation, hematemesis, hematochezia, melena, focal numbness, focal weakness, myalgias Past Medical History: 1) Seizure disorder, seizure free for the past 20 years 2) hypertension 3) sellar mass 4) Labyrinthine hemorrhage 5) s/p hysterectomy 6) s/p R ankle surgery 7) schizoaffective d/o Social History: Lives in a nursing home (Sachem skilled nursing), not happy there. Tobacco: 1 PPD EtOH: Denies Illicits: Denies Family History: No family history of pituitary or thyroid disorders. Grandmother had [Name2 (NI) 499] cancer. Physical Exam: On Admission: VS: T 97.6, HR 91, BP 125/96, RR 18, O2Sat 100% RA GEN: NAD HEENT: PERRL, EOMI, no nystagmus, oral mucosa moist, edentulous, oropharynx benign NECK: supple, no [Doctor First Name ] PULM: CTAB, occasional cough CARD: RR, nl S1, nl S2, no M/R/G ABD: BS+, soft, ventral scar, NT, ND EXT: R nonpitting ankle edema, L wihtout edema SKIN: no rashes NEURO: Oriented x 3, can stand and transfer to wheelchair unassisted, CN II-XII intact aside from visual field confrontational testing revealing questionable loss of lateral fields PSYCH: Mood and affect appropriate On Discharge: XXXXXX Pertinent Results: Labs on Admission: [2179-11-30] 05:15PM BLOOD WBC-5.8 RBC-4.45 Hgb-11.7* Hct-36.0 MCV-81* MCH-26.4* MCHC-32.6 RDW-13.7 Plt Ct-394 [2179-11-30] 05:15PM BLOOD Neuts-67.3 Lymphs-25.6 Monos-6.0 Eos-0.8 Baso-0.3 [2179-12-3] 04:40AM BLOOD PT-13.8* PTT-36.7* INR(PT)-1.2* [2179-11-30] 05:15PM BLOOD Glucose-101 UreaN-7 Creat-0.7 Na-137 K-3.4 Cl-99 HCO3-30 AnGap-11 [2179-12-3] 04:40AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.4 [2179-12-3] 04:40AM BLOOD Cortsol-19.5 [2179-11-30] 05:15PM BLOOD Phenyto-12.9 Labs on Discharge: XXXXXXXXX Imaging: Brief Hospital Course: Medicine Course: 61 yo AAF recently was seen in neurosurgery clinic for sellar mass, now here for chronic symptoms of nausea, headaches and dizziness. - Nausea, HAs, dizziness: Likely [2-22] to sellar mass. Pt did not report an acute worsening and did well with symptomatic treatment. Neurosurg plans for surgery this week. - Acute anemia: Hct dropped from 36 to 32 overnight. Repeat Hct is pending. - Microsopic hematuria: UA shows large blood, [6-30] RBC. Pt does not report gross hematuria. UA does not indicate infection, but repeat UA/urine culture would be beneficial. - Seizure disorder: Stable, seizure free for more than 20yrs. Pt was continued on home Dilantin (level in therapeutic range). - Hypertension: Well-controlled. Pt was continued on home Amlodipine. - Pt was on a cardiac diet, and on SC Heparin for DVT ppx. At transfer of care to NEUROSURGERY SERVICE([2179-12-2]): NSURG assumed care on [12-2], in preparation for pituitary mass decompression/resection on [12-3]. Plans were made for general anesthesia to be induced prior to obtaining pre-operative imaging due to claustrophobia history. On [12-3], patient was electively intubated, and MRI and CT imaging was obtained for surgical planning. Due to the neuroanatomy, transphenoidal approach was not attempted, and resection/decompression was pursued via left pterional craniotomy. Post-operatively, the patient was transferred to the ICU for frequent neurochecks and DI surveillance. At post-op check, the patient was observed to have a dense right sided hemiplegia and was emergently sent for her MRI. An anterior choroidal infarct was appreciated, and stroke neurology was consulted. It was recommended to keep her blood pressure 120-160, obtain additional labs, ECHO, and carotid ultrasound. These were obtained. She was subsequently extubated, however failed her speech and swallow evaluation. In the setting of this, a general surgery consult was obtained to place a PEG. This was done on [12-7] without incident. On [12-8] the patient was transferred out of the ICU to the neurosurgical floor. She continued to work with PT/OT and was screened for rehab. Endocrine continued to follow the patient and assisted in managing her glucose, Sodium levls and control her hydrocortisone taper. Medications on Admission: 1) Dilantin 100 mg in AM, 100 mg in afternon, 200 mg at bedtime 2) Senna 2 tabs nightly 3) Prilosec 20 mg DAILY 4) Multivitamin DAILY 5) Simethicone 80 mg QID:PRN flatus 6) Meclizine 25 mg PO TID:PRN dizziness 7) Colace 100 mg [Hospital1 ] 8) Risperidone 0.25 mg PO BID 9) Diazepam 25 mg PO BID 10) Melatonin 2.5 mg QHS 11) Phenergan 25 mg [Hospital1 ] 12) Amlodipine 5 mg PO DAILY 13) Loratadine 10 mg DAILY 14) Percocet 5/325 Q4H:PRN pain Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for dizziness. 3. Risperidone 0.5 mg Tablet Sig: .5 Tablet PO BID (2 times a day). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Phenytoin 125 mg/5 mL Suspension Sig: Two (2) PO Q12H (every 12 hours): 200 mg [Hospital1 ]. 6. HydrALAzine 10 mg IV Q6H:PRN SBP>160 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 11. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-22] Drops Ophthalmic PRN (as needed) as needed for DRY EYE. 20. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO Q am. 21. Hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 22. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 23. Metoclopramide 10 mg IV Q6H high residuals please hold if residuals drop below 50cc or if patient develops diarrhea and alert NS team Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Sellar Mass Hypernatremia adrental insuficiency Hemiplegia Left ptosis Malnutrition dysphagia hyperglycemia Discharge Condition: Neurologically Stable Discharge Instructions: General 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, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? You have been discharged on Prednisone, take it daily as prescribed. ?????? You are required to take Prednisone, an oral steroid, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as this medication can cause stomach irritation. Prednisone should also be taken with a glass of milk or with a meal. CALL YOUR DOCTOR 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. ?????? If you notice your urine output to be increasing, and/or excessive, and you are unable to quench your thirst, please call your endocrinologist. Followup Instructions: Follow-Up Appointment Instructions Please call [Telephone/Fax (1) 2731] to schedule an appointment to be seen for a wound check and suture removal. This appointment should be made for 10-14 days after surgery, and will be made with the nurse practitioner. If you live far away, you may have this done by your PCP [Name Initial (PRE) ]/or at rehab facility. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with your surgeon, Dr. [Last Name (STitle) ], to be seen in 4 weeks. Dr. [Last Name (STitle) ] will speak with you at this time about when you should restart radiation therapy. You will not need a CT scan or MRI of the brain as this was done during your acute hospitalization. ??????You have an appointment with your endocrinologist, Dr. [Last Name (STitle) ] [Name (STitle) ] on Tues. [2180-1-4] at 1:40 pm. The phone number is ([Telephone/Fax (1) 9072]. ??????Please call ([Telephone/Fax (1) 5120] to schedule Formal Visual Field Testing to be done before you are seen in follow-up with your surgeon. The Opthalmology department is located on the [Hospital Ward Name ] in the [Hospital Ward Name 23] building, [Location (un) 442]. ?????? You have an appointment with your neurologist, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Name8 (MD) 83444], MD on [2180-1-10] at 2:30 pm. His office is on the [Hospital Ward Name 5074] on [Hospital Ward Name 23] 8. Please call [Telephone/Fax (1) 2574] with questions. Completed by:[2179-12-13**] ICD9 Codes: 2760, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6237 }	Medical Text: Admission Date: [2162-6-5] Discharge Date: [2162-6-25] Date of Birth: [2123-3-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: fever Major Surgical or Invasive Procedure: PICC line placed: [2162-6-18] History of Present Illness: Mr. [Known lastname 38598] is a 39 year old patient with NHL s/p alloSCT [2155] and DLI [2156], in remission but with GVHD-associated bronchiolitis obliterans and severe restrictive lung disease who was recently admitted with fever, hypoxia and respiratory distress and discharged to [Hospital1 ] on [2162-6-3]. He is readmitted today in the setting of fever and increased cough. . Please see discharge summary from [2162-6-3] and [2162-5-19] for details of his previous hospitalizations. In brief, the patient has pseudomonal infection of his lungs, he has been treated with 21 day course of Colistin and Meropenem to treat this, and was on Colistin IH for suppression. Additionally, he has an upper extremity DVT that, since that admission, is being treated with Fondaparinux 2.5 mg SubQ, lower dose secondary to history of serious GI bleeding. . Per rehabilitation notes, the patient spiked temperature to 101.6, and wbc count increased to 25.5. He resports increased coughing. He had some low bloood pressures, 90/53 and 107/73. Additionally, given the worsening symptoms, on [2162-6-4], he recieved 1 dose of 125mg IV colistin (rehab discussed with outpatient ID attg, Dr. [Last Name (STitle) 724]. . On admission to the ICU the patient is comfortable. He denies, abdominal pain, dysurea. reports increased cough and fevers while at rehab. . In the ER, initial vitals T101.1, BP 122/79, HR 122, RR 18, vented. He recieved Vancomycin 1gm IV, Zosyn 4.5mg IV, tylenol 1gm PO, morphine 2mg IVx1. Past Medical History: Past Oncologic History: - [4-/2154] p/w fevers, night sweats, and weight loss in the setting of a left inguinal lymph node. - CT scan: 15x14x10cm mass in the LUQ. - Bx grade II/III follicular lymphoma. - Treated with six cycles of CHOP/Rituxan with good response, but showed evidence for relapse in [12/2154] and was treated with MINE chemotherapy for two cycles. - [3-/2155]: Underwent stem cell mobilization with Cytoxan followed by autologous stem cell transplant in - [7-/2155]: Noted for disease recurrence. He was initially treated with a course of Rituxan without response followed by Zevalin with - [3-/2156]: Noted progression of his disease. He was treated with one cycle of [Hospital1 ] followed by one cycle of ESHAP. - [2156-7-29]: Nonmyeloablative allogeneic stem cell transplant with a [5-30] HLA-matched unrelated donor with Campath conditioning - Six-month follow-up CT noted for disease progression. - [1-/2157]: Received donor lymphocyte infusion in , complicated by acute liver/GI GVHD grade IV, for which [Known firstname ] required a prolonged hospitalization in the summer of [2156]. - Multiple GI bleeds requiring ICU admissions and multiple transfusions and embolization of his bleeding. - Noted to have CNS lesions felt consistent with PTLD and this was treated with a course of Rituxan. No evidence for recurrence of the PTLD. - Acute liver GVHD, on CellCept, prednisone, and photophoresis. - [2157-12-28] Photophoresis was d/c'd due to episodes of bacteremia and eventual removal of his apheresis catheter. - [2158-6-13] restarted photopheresis on a weekly basis on , but then discontinued this again on [2158-9-7] as this was felt not to be making any impact on his liver function tests. - undergone phlebotomy due to iron overload with corresponding drop in his ferritin. He has continued with transient rises in his transaminases and bilirubin and has remained on varying doses of CellCept and prednisone which has been slowly tapered over the time. - [2160-1-10] CellCept discontinued. - [2159-1-19] admission due to increasing right hip pain. MRI revealed edema and infiltrating process in the psoas muscle bilaterally. After extensive workup, this was felt related to an infection and required several admissions with completion of antibiotics in 03/[2158]. - [7-/2160]: Last scans showed no evidence for lymphom and he has remained in remission. - [2160-10-20]: URI and treatment with course of Levaquin. - [2160-11-13] completed a 4 week course of Rituxan to treat his GVHD. -In [5-/2161], noted to have tiny echogenic nodule on abdominal [Year (4 digits) 950]. MRI of the liver also showed this nodule but was not as concerning on review and he is due to have a repeat MRI imaging in early [Month (only) ]. -- GI varices and attempts at banding have been unsuccessful due to difficulty with passing the necessary instruments. He has been on a low dose beta blocker as well as simvastatin, which was started on [2161-7-7] to help with medical management of his varices. -On [2161-8-3], worsening cough and was noted to have a small new pneumothorax in the left apical area. This has essentially resolved over time - Issues with weight loss (followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]); multiple tests done with no etiology found; question malabsorption related to GVHD - Has on and off respiratory infections and has been treated with antibiotics (now colistin inhaled and IV) for resistant pseudomonas. Question underlying exacerbations of pulmonary GVHD in setting of his URIs. - Currently receives IVIG every month. . Other Past Medical History: 1. Non-Hodgkin's lymphoma s/p allo SCT 2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed, chronic transaminitis, portal HTN with esophageal varices (not able to band) 3. History of intracranial lesions felt consistent with PTLD. 4. Extensinve chronic GVHD of lung, liver, skin, mucous membranes. 5. Grade II esophageal varices, intollerant to beta blockade. 6. HSV in nasal washing [11/2159](completed course of Valtrex) 7. Hypothyroidism 8. hx of Psoas muscle infection Social History: Smoke: never EtOH: none currently; occassional use prior to NHL dx Drugs: never Born in [Country ] and moved to the U.S. for college ([Hospital1 ]). Married in [2160-8-25] and lives in [Location ]. No children. Stays at home and writes (currently writing a book on being diagnosed with cancer at young age). Family History: No lymphoma or other cancers in the family. Father had CAD s/p PCI. Physical Exam: On Admission: Vitals: T 99, HR 93, BP 91/61, sat 100% on AC 500/18/8/50% Gen: Cachectic male HEENT: sclera anicteric NEC: trach in place CV: Tachycardic, no m/r/g Pulm: coarse breath sounds bilaterally, no wheezes, crackles Abd: soft, NT, ND, bowel sounds present Ext: no peripheral edema Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2162-6-20] 06:25 11.1* 2.54* 7.4* 23.6* 93 29.0 31.2 16.3* 344 [2162-6-15] 05:29 58* 70* 640* 0.7 Source: Line-picc OTHER ENZYMES & BILIRUBINS Lipase [2162-6-5] 05:30 80* IMAGING: [6-5] CT chest FINDINGS: The endotracheal tube terminates 1.9 cm above the carina. A right-sided PICC line terminates at the cavoatrial junction. An NG tube is identified inferiorly to level of the stomach. There has been interval worsening of multifocal bilateral nodular airspace opacities which are most prominent in the right upper lobe, some of which have air bronchograms. Also noted are numerous tiny centrilobular nodules at the lung bases, right greater than left. Moderate bilateral pleural effusions and adjacent compressive atelectasis is again identified. Secretions are noted within the superior aspect of the trachea. he heart is normal in size. There is no pericardial effusion. No pathologically enlarged mediastinal lymph nodes are identified. The visualized upper abdominal organs are unchanged in appearance with no gross abnormalities identified. No suspicious lytic or sclerotic lesions are identified within the osseous structures. IMPRESSION: 1. Interval worsening of multifocal nodular opacities, most prominent in the right upper lobe compared to prior CT of [2162-4-27], which may represent recurrent or residual worsening infection. However, given the possible chronicity of these findings, organizing pneumonia cannot entirely be excluded. 2. Stable moderate bilateral pleural effusions and adjacent airspace disease, which is at least in part secondary to atelectasis. 3. Redemonstration of secretions within the superior trachea, slightly increased when compared to the prior study. [6-15] Chest X ray: FINDINGS: The tracheostomy tube is in place, with its tip 3 to 3.5 cm above the carina. An endogastric tube projects over the antrum of the stomach. Additionally, coils projecting over the epigastrium are consistent with embolization coil. The heart and mediastinal contours appear unremarkable. The previously described right upper lobe and retrocardiac opacities persist with increase of the retrocardiac opacity. This likely represents components of atelectasis and consolidation. Additionally, in the right lower lobe, at the right cardiophrenic angle, there is developing opacity concerning for additional foci of pneumonia. Bilateral effusions persist. There is no pneumothorax. The osseous structures appear intact. IMPRESSION: Multifocal opacities, worse in the retrocardiac and right cardiophrenic regions; unchanged small bilateral pleural effusions. [2162-6-6] 10:07 am SPUTUM Source: Endotracheal. FINAL REPORT [2162-6-18] GRAM STAIN (Final [2162-6-6]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2162-6-17]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. COLISTIN SUSCEPTIBILITY REQUESTED BY DR. [Last Name (STitle) ] (#[Numeric Identifier 38652]) [2162-6-8]. COLISTIN SENSITIVE AT <=2 MCG/ML. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. COLISTIN SUSCEPTIBILITY REQUESTED BY DR. [Last Name (STitle) ] (#9/0841) [2162-6-9]. COLISTIN SENSITIVE AT <=2 MCG/ML, Sensitivities performed by [Hospital1 ] laboratories. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| AMIKACIN-------------- 8 S 16 S CEFEPIME-------------- 8 S 16 I CEFTAZIDIME----------- 4 S 8 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM------------- 4 S 8 I PIPERACILLIN/TAZO----- =>128 R =>128 R TOBRAMYCIN------------ =>16 R =>16 R Brief Hospital Course: Fevers: The patient was admitted from rehab after less than 48 hrs since his discharge for multidrug resistant pseudomonas. He presented with fevers and hypotension. He complained of increased yellow/white sputum, so it was thought that the source of his fevers was recurrent lung infection. A CT chest revealed multifocal nodular opacities, most prominent in the right upper lobe consistent with recurrent pneumonia. He was started on meropenem in addition to IV and inhaled Colistin. C diff was initially in the differential and he was started on PO vancomycin. However he had two stools that were negative for C diff so this antibiotic was stopped. Urine and blood cultures were obtained and were negative. Sputum showed two strains of psuedomonas that were sensitive to Amikacin and intermediately sensitive to meropenem. ID was closely involved and felt that slow infusion meropenem was appropriate treatment in addition to IV Colistin. He did well with only occasional low grade fevers and decreased sputum. He completed 17/28 days of meropenem and colistin by day of discharge. Last day of antibiotics will be on [7-1]. He was discharged on a regimen of meropenem and colistin for 6 more days (to be completed [7-1]) and daily [Month (only) 3242] prophylaxis of bactrim, acyclovir, voriconazole. He will follow up with ID outpatient. Leukocytosis: Mr. [Known lastname 38598] presented with an elevated white count of 28 with left shift. WBC trended down with initiation of meropenem and colistin and was 11 on day of discharge. Pt was briefly given flagyl for empiric treatment of presumptive C. Diff but stopped treatment when toxins repeatedly returned negative. Ventilator dependence: Pt has history of Bronchiolitis Obliterans from allo-SCT with tracheostomy. He has history of pseudonomas infections and hospitizations for pneumonias. The patient initially presented on a ventilator with the following settings: Assist Control 400/18/8/50%. He had been unable to wean off the vent at rehab and during his previous hospitalization due to increased secretions. While in ICU, was put on pressure support trials and some days was able to undergo trach collar for a few hours at a time. At night he would request to be put back on assist control and tolerated PS during the day. He was given chest PT. It will be important to continue to encourage trach collar trials and aggressive chest PT for the goal of becoming ventilator independent. There was some discussion of lung transplant and coordinating outpatient meeting with the Pulm transplant team at [Hospital1 112]. Before meeting with physicians there, he must meet criteria of walking 500 ft in 6 minutes which he has not yet achieved. Upper extremity DVT: The patient was found at his previous hospitalizations to have a LUE DVT. Given his history of massive GI bleed (secondary to GVH of GI)it was decided not to anticoagulate him with theraputiuc doses of heparin. He was eventually switched to fundaparinoux. During the present hospitalization he was continued on low dose fundaparinox, 2.5mg. On [6-6] there was questionable right upper extremity swelling in the arm with his PICC. LENI negative. Day before discharge he had repeat U/S of Left Upper Extremity and showed no progression of clot in brachial v. Decision was made to stop fundaparinox. Graft versus Host Disease: The patient was continued on his regimen of prednisone 15mg, mycophenolate 250mg dialy, and prophylactic Bactrim, acyclovir, and voriconazole. Nutrition/Electrolytes: He lost about 4kg since admission despite appropriate tube feeds and TPN. Nutrition was closely involved. Pt likely has malabsorption in setting of GVHD of GI. By day of admission, he was getting TPN 42 mL/hr, Tube feeds 60mL/hr in addition to 200cc free water boluses every 4 hours through NGT. NHL: Mr. [Known lastname 38598] is status post allo [Known lastname 3242] complicated with GVHD of GI and Bronchiolitis obliterans. [Known lastname 3242] was closely involved in patient's care. He was given prednisone, mycophenolate, acyclovir, bactrim, and voriconazole. Pt also received IVIG [2162-6-23] for low levels of IgG. Pt has been recieving infusions of IVIG every 2-3 weeks. Psych: Seen by psych who felt that he had adjustment disorder related to medical illness but he declined treatment with SSRI at this moment. Medications on Admission: Acyclovir 400mg every 12 hours Ascorbic Acid 500mg daily Colistin 75mg INH [Hospital1 ] qMWF Ergocalciferol 50,000 units every saturday Ferrous sulfate 300mg liquid daily Fluticasone intranasally 1 spray daily Fondiparinux 2.5mg SC dailt Lansoprazole 20mg daily Levothyroxine 125mcg daily Mycophenolate Mofetil 250mg daily Prednisone 15mg daily BActrim DS qMWF Voriconazole 200mg every 12 hours Zinc sulfate 22mg daily PRNS: Tylenol 650mg ever 4 hours as needed Acetylcysteine 10% neb every 4 hours as needed Albuterol 6 puffs every 2 hours as needed Guaifenesin 200mg every 6 hours as needed Lorazepam 1mg every 4 hours as needed Morphine 2mg every 2 hours as needed Zogran 8mg as needed Senna 10mg as needed Simethicone 80mg as needed Trazdone 25mg as needed nightly insomnia . Discharge Medications: 1. Colistimethate Sodium 150 mg Recon Soln [Hospital1 ]: 75mg Recon Solns Injection DAYS (MO,WE,FR) as needed for [Hospital1 ]: Continue indefinitely . 2. Meropenem 1 gram Recon Soln [Hospital1 ]: 1000 mg Recon Solns Intravenous Q8H (every 8 hours): 6 more days through [7-1]. 3. Colistimethate Sodium 150 mg Recon Soln [Month (only) ]: 125 mg Recon Solns Injection Q12H (every 12 hours): Take 6 more days through [7-1]. 4. Acetaminophen 325 mg Tablet [Month (only) ]: 650 mg Tablets PO Q6H (every 6 hours) as needed for pain/fever: indefinitely . 5. Acyclovir 400 mg Tablet [Month (only) ]: 400 mg Tablets PO Q12H (every 12 hours): Take indefinitely. 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Month (only) ]: Six (6) Puff Inhalation Q2H (every 2 hours) as needed for SOB: take as needed. 7. Ascorbic Acid 500 mg/5 mL Syrup [Month (only) ]: 500 mg PO DAILY (Daily): take indefinitely. 8. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [Month (only) ]: 5mL MLs PO Q6H (every 6 hours) as needed for cough: Take as needed. 9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [Month (only) ]: 50,000 U Capsules PO 1X/WEEK (SA): take once a week. 10. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [Month (only) ]: 300 mg PO DAILY (Daily). 11. Fluticasone 50 mcg/Actuation Spray, Suspension [Month (only) ]: One (1) Spray Nasal DAILY (Daily). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: 30 mg Tablet,Rapid Dissolve, DRs [Last Name (STitle) ] [Name5 (PTitle) ] (Daily). 13. Levothyroxine 125 mcg Tablet [Name5 (PTitle) ]: 125 mcg Tablets PO DAYS (MO,TU,WE,TH,FR,SA). 14. Ondansetron 8 mg Tablet, Rapid Dissolve [Name5 (PTitle) ]: 8mg Tablet, Rapid Dissolves PO Q8H (every 8 hours) as needed for nausea. 15. Prednisone 5 mg Tablet [Name5 (PTitle) ]: 15 mg Tablets PO DAILY (Daily): take indefinitely. 16. Senna 8.6 mg Tablet [Name5 (PTitle) ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Simethicone 80 mg Tablet, Chewable [Name5 (PTitle) ]: 40-80mg Tablet, Chewables PO QID (4 times a day) as needed for indigestion. 18. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [Name5 (PTitle) ]: 1 tab Tablet PO DAYS (MO,WE,FR): take indefinitely. 19. Trazodone 50 mg Tablet [Name5 (PTitle) ]: 25 mg Tablets PO HS (at bedtime) as needed for insomnia. 20. Voriconazole 200 mg Tablet [Name5 (PTitle) ]: 200 mg Tablets PO Q12H (every 12 hours): Take indefinitely. 21. Zinc Sulfate 220 mg Capsule [Name5 (PTitle) ]: 220 mg Capsules PO DAILY (Daily). 22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Name5 (PTitle) ]: One (1) Inhalation Q2H (every 2 hours) as needed for SOB/wheezing. 23. Acetylcysteine 20 % (200 mg/mL) Solution [Name5 (PTitle) ]: 20% 6-10 mL neb MLs Miscellaneous Q2H (every 2 hours) as needed for secretion. 24. Cyanocobalamin 250 mcg Tablet [Name5 (PTitle) ]: 250mcg Tablets PO DAILY (Daily). 25. Insulin Regular Human 100 unit/mL Solution [Name5 (PTitle) ]: One (1) Injection ASDIR (AS DIRECTED): Please follow attached sliding scale. 26. Heparin, Porcine (PF) 10 unit/mL Syringe [Name5 (PTitle) ]: 10 U MLs Intravenous PRN (as needed) as needed for line flush: prn to flush PICC line. Flush 10 mL NS followed by heparin (10U/ml) 2 mL IV daily and prn per lumen. 27. Lorazepam 2 mg/mL Syringe [Name5 (PTitle) ]: 0.5-2.0mg Injection Q4H (every 4 hours) as needed for anxiety. 28. Morphine 2 mg/mL Syringe [Name5 (PTitle) ]: 2mg Injection Q2H (every 2 hours) as needed for pain. 29. Mycophenolate Mofetil HCl 500 mg Recon Soln [Name5 (PTitle) ]: 250 mg Recon Solns Intravenous [Hospital1 ] (2 times a day): take indefinitely. 30. Ondansetron HCl (PF) 4 mg/2 mL Solution [Hospital1 ]: 4mg Injection Q8H (every 8 hours) as needed for nausea. 31. Diphenhydramine HCl 50 mg/mL Solution [Hospital1 ]: 25 mg Injection Q6H (every 6 hours) as needed for pre-medication for IVIG: take before IVIG. 32. Heparin, Porcine (PF) 10 unit/mL Syringe [Hospital1 ]: 2mL (10U/mL) MLs Intravenous PRN (as needed) as needed for line flush: Flush PICC with NS followed by heparin. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Ventilator associated pneumonia Deep vein thrombosis Acute on chronic hypoxemic respiratory failure malnutrition Non hodgkins lymphoma status post bone marrow transplant Acute renal failure Graft versus host disease Bronchiolitis obliterans hypothyroidism Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with fever and high white blood cells possibly indicating infection. Your infection was partially treated with antibiotics. Please continue taking Meropenem and Colistin antibiotics for total course of 28 days through [7-1]. You have 6 more days left at the day of discharge. Please continue your TPN (42mL/hr) and Tube feeds (60ml>hr) to ensure appropriate nutritional status. Continue to take your prophylactic bone marrow transplant medications each day: Bactrim, Acyclovir, Voriconazole to prevent infections in an immunocompromised state. You made great progress with walking toward the end of your hospitization. Please continue to walk each day with a goal of 500 ft in 6 minutes. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 3241] Date/Time:[2162-6-29] 2:00 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [2162-7-22] at 11:30 am. [Hospital Ward Name 23] [Location (un) 436] on [Hospital Ward Name ]. phone: [Telephone/Fax (1) 3237] Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 13645], M.D. Phone:[Telephone/Fax (1) 1803] Date/Time:[2162-9-23] 2:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD and pulmonary transplant group at [Hospital6 1708]. Clinic number [Telephone/Fax (1) 23428]. Pt's family to call to set up appt. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3919], [Name12 (NameIs) 280] Phone:[Telephone/Fax (1) 3241] Date/Time:[2162-7-22] 11:30 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] ICD9 Codes: 5849, 2761, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6238 }	Medical Text: Admission Date: [2149-5-5] Discharge Date: [2149-5-9] Service: . HISTORY OF PRESENT ILLNESS: This is a [Age over 90 ] year old woman who presented to [Company 191] on [5-5], after two episodes of bright red blood per rectum. She denied nausea, vomiting, lightheadedness, abdominal pain, fevers and chills. She was also orthostatic in the Emergency Department. She had a negative NG lavage and an initial hematocrit of 33. She had an anoscopy without clear evidence of obvious bleeding source. She was admitted to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Asthma. 2. Diverticulitis with lower gastrointestinal bleed. 3. Coronary artery disease status post coronary artery bypass graft times two in [2140]. 4. Leiomyoma sarcoma with total abdominal hysterectomy, bilateral salpingo-oophorectomy. 5. Hypertension. 6. Glaucoma. ALLERGIES: She has no allergies to drugs. MEDICATIONS ON ADMISSION: 1. Verapamil SR. 2. Lasix. 3. Albuterol. 4. Xalatan drops. 5. Beclomethasone. 6. Aspirin. 7. Zantac. 8. Colace. 9. [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002]. SOCIAL HISTORY: She denied tobacco and alcohol use. PHYSICAL EXAMINATION: Temperature 97.2 F.; pulse 66 to 92; blood pressure was 106 to 170 over 40 to 76; respirations 13 to 26; and O2 saturation is 95% on room air. In general, she is alert and oriented times three in no acute distress, comfortably resting. HEENT: Pupils equally round and reactive to light. Extraocular movements are intact. Mucous membranes were moist. Oropharynx was clear. Heart is regular rate and rhythm; no murmurs, rubs or gallops. Lungs bibasilar crackles two-thirds of the way up. No rhonchi. Abdomen soft, nontender, nondistended, active bowel sounds. Extremities with no cyanosis, clubbing or edema. Neurologic examination is grossly nonfocal. LABORATORY: On admission are notable for a creatinine of 1.6, hematocrit of 33.3, and white blood cell count of 5.1. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit and started on intravenous Pantoprazole. The aspirin and verapamil were held. Bleeding scan was positive in the distal descending colon. The patient's clinical bleeding resolved, but the hematocrit continued to decrease, therefore, was transfused two units of packed red blood cells on [5-6] and another two units of packed red blood cells on [5-7]. GI was consulted and performed a colonoscopy on [5-7], showing non-bleeding Grade II internal hemorrhoids, multiple diverticula in the colon without active bleeding; otherwise normal colonoscopy. Further hospital course was complicated by supraventricular tachycardia which responded well to Lopressor. She was also ruled out for myocardial infarction now. Currently hemodynamically. She presented to the floor hemodynamically stable and did not require any further transfusions as of the 9th when her blood count was 36. DISPOSITION: The patient transferred to Rehabilitation on the following medications. DISCHARGE MEDICATIONS: 1. Verapamil SR 240 p.o. q. day. 2. Minoxidil 7.5 p.o. q. day. 3. Pantoprazole 40 p.o. q. day. 4. Furosemide 40 p.o. q. day. 5. Docusate 100 p.o. twice a day. 6. [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002] 20 p.o. q. day. FINAL DIAGNOSES: 1. Gastrointestinal bleeding secondary to diverticulosis. 2. Hypertension. 3. Acute mental status change consistent with sundowning. 4. Hypokalemia. 5. Hypomagnesemia. DR.[Last Name (STitle) ],[First Name3 (LF) ] 16-403 Dictated By:[Name8 (MD) 6069] MEDQUIST36 D: [2149-9-11] 16:42 T: [2149-9-18] 12:46 JOB#: [Job Number 101607] ICD9 Codes: 2765, 2930, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6239 }	Medical Text: Admission Date: [2169-9-22] Discharge Date: [2169-9-27] Date of Birth: [2169-9-22] Sex: M Service: NB HISTORY: Baby boy [Known lastname 10166], twin #2, is the 2.8 kg product of a 37-1/7 week twin gestation born to a mother who is 38 years old, G2, P now 3 mother. PRENATAL SCREENS: A+, antibody negative, RPR nonreactive, rubella immune, hepatitis surface antigen negative. GBS unknown. Spontaneous rupture of membranes of other twin 7 hours prior to repeat cesarean section. This is an IVF conception, twin gestation with an estimated date of confinement of [2169-10-12]. This twin with abdominal rupture of membranes at delivery. No maternal fever, no intrapartum antibiotic prophylaxis. Required only routine care in O.R. Apgars of 8 and 9. Twin with persistent grunting, flaring, retracting admitted to the Newborn Intensive care unit. PHYSICAL EXAMINATION: On admission weight 2.825 kg, intermittent tachypnea, anterior fontanel soft, open and flat. Palate intact. Mild intermittent subcostal retractions. Breath sounds clear and equal but diminished. Regular red reflex present bilaterally. Regular rate and rhythm without murmur. Abdomen benign without hepatosplenomegaly. Normal male with testes descended bilaterally. Normal back and extremities with hips stable, skin slightly pale, pink and well perfused, appropriate tone and strength normal neonatal reflexes. HOSPITAL COURSE: Respiratory: The infant was admitted to the newborn intensive care unit with grunting, flaring and retracting, tachypnea, was placed on CPAP for a total of 24 hours at which time he was weaned to room air. He has been stable on room air since that time. He has had occasional desaturations to the mid-80's with p.o. feeding otherwise has been stable. Cardiovascular: Has been stable without issue. Fluid and Electrolyte: Birth weight was 2.825 kg. Discharge weight is 2630 gm. He was initially started on 80 cc per kilo per day of D10 W. Enteral feedings were initiated on day of life #2. Infant is ad lib feeding taking in approximately 100 cc per kilo per day. He is discoordinated with feeding requiring some nasal cannula O2 to support oxygen saturations. Initially had some glucose issues which have since resolved. GI: Peak bilirubin was on day of life #4 of 11.2/0.3, the repeat bilirubin on [2169-9-27] was 11.6. He has not received any therapy. Hematology: Hematocrit on admission was 56.2, has not required any blood transfusions. Infectious Disease: The CBC and blood culture obtained on admission, CBC was benign. Blood culture remained negative at 48 hours at which time ampicillin and gentamicin were discontinued. Neurological: Appropriate for gestational age. Sensory: He passed on both ears. CONDITION ON DISCHARGE: Stable. DISPOSITION: [Hospital ] Hospital. PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 62815], [Telephone/Fax (1) 41579] RECOMMENDATIONS: Continue ad lib feeding Enfamil 20 calorie or breast milk. MEDICATIONS: Not applicable. Car seat testing is recommended. IMMUNIZATIONS: Hepatis B Vaccine is not given eyt at the time of this written note. State newborn screens have been sent for protocol and have been within normal limits. DISCHARGE DIAGNOSIS: 1. 37 week twin. 2. Mild respiratory distress syndrome. 3. Discoordination with feeds. 4. Rule out sepsis with antibiotics. [Doctor First Name ] [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 62348] Dictated By:[Name8 (MD) 62816] MEDQUIST36 D: [2169-9-26] 20:30:59 T: [2169-9-26] 22:01:02 Job#: [Job Number 62817] ICD9 Codes: 769, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6240 }	Medical Text: Admission Date: [2131-6-23] Discharge Date: [2131-6-28] Date of Birth: [2045-2-7] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 4691] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: [6-23] Exploratory laparotomy and adhesiolysis for small-bowel obstruction. History of Present Illness: Mrs.[Doctor Last Name 7517] is a 86 year-old female who presents to the [Hospital1 18] ER after awaking that morning with lower abdominal pain. Patient was otherwise in her usual state of health until day of admission when she noted bilateral lower abdominal pain. The pain was initially dull and gradually worsened over the course of the day. This was associated with several episodes of nausea and vomiting. She had not been passing flatus, however has passed loose stool. Past Medical History: Hypertension. Social History: Lives alone in [Hospital1 ]. Widowed 11 years ago, no children. No tobacco/ETOH. Niece lives in [Location 2199]. Family History: father died of throat cancer, mother of uterine cancer, no h/o stroke Physical Exam: On admission: Physical Exam: Vitals: T 97.8 P 67 BP 146/63 RR 18 O2 97%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, mild lower abdominal distention, tender to palpation in the lower abdomen, no rebound or guarding, no palpable masses or hernias Ext: No LE edema, LE warm and well perfused On discharge: Vitals T 98.5 po, HR 59, SBP 138/54, RR 16, sat 95% RA. Gen: AAO x 3, extremely hard of hearing. Card: S1, S2. Regular with occasional premature beats. Pulses 2+ in UE, LE. Lungs: Posteriorly clear bilaterally, diminished in right lower lobe. Abd: Active BS. Soft, non-tender, non-distended. Vertical mid-line incision closed with staples. CDI. No exudate or drainage noted. GI: Voiding. Extrem: Cool, well perfused. Pertinent Results: [2131-6-22] 06:10PM BLOOD WBC-12.9* RBC-4.02* Hgb-11.6* Hct-33.8* MCV-84 MCH-28.8 MCHC-34.2 RDW-13.9 Plt Ct-311 [2131-6-22] 06:10PM BLOOD Neuts-88.0* Lymphs-8.7* Monos-2.6 Eos-0.3 Baso-0.3 [2131-6-22] 06:10PM BLOOD Plt Ct-311 [2131-6-22] 09:18PM BLOOD PT-10.3 PTT-29.6 INR(PT)-0.9 [2131-6-22] 06:10PM BLOOD Glucose-124* UreaN-24* Creat-1.1 Na-135 K-5.0 Cl-98 HCO3-30 AnGap-12 [2131-6-22] 06:10PM BLOOD ALT-13 AST-19 AlkPhos-57 TotBili-0.6 [2131-6-25] 06:05AM BLOOD CK(CPK)-387* [2131-6-25] 02:30PM BLOOD CK(CPK)-413* [2131-6-25] 06:05AM BLOOD CK-MB-7 cTropnT-0.04* [2131-6-25] 02:30PM BLOOD cTropnT-0.04* [2131-6-22] 06:10PM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.9 Mg-2.0 [2131-6-22] 06:08PM BLOOD Lactate-1.2 [2131-6-26] 03:11AM BLOOD WBC-10.7 RBC-3.31* Hgb-9.7* Hct-27.9* MCV-84 MCH-29.2 MCHC-34.6 RDW-13.8 Plt Ct-268 [2131-6-27] 05:55AM BLOOD Glucose-127* UreaN-36* Creat-0.8 Na-136 K-3.7 Cl-102 HCO3-28 AnGap-10 [2131-6-27] 05:55AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.3 [2131-6-22] CT A/P with contrast 1. Findings concerning for closed loop obstruction with evidence of mesenteric edema and ascites. Early bowel ischemia cannot be excluded. 2. Fat-containing abdominal wall hernia. [2131-6-25] ECG Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave abnormalities, likely secondary to rate. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 156 0 70 286/454 0 -1 157 [2131-6-25] CXR (AP) No previous images. Cardiac silhouette is mildly enlarged. There is engorgement of ill-defined pulmonary vessels, consistent with the clinical impression of congestive failure. Poor definition of the hemidiaphragms is consistent with bilateral effusions and compressive atelectasis at the bases. [2131-6-26] CXR (AP) In comparison with the study of [6-25], there is increased haziness of the right hemithorax, suggesting worsening layering pleural effusion. Again there is evidence of congestive failure with bilateral effusions and basilar atelectatic changes. Mild enlargement of the cardiac silhouette persists. Brief Hospital Course: Mrs.[Doctor Last Name 7517] was admitted to [Hospital1 18] on [6-23] with complaints of abdominal pain. Imaging revealed a closed-loop bowel obstruction. She was kept NPO and IV fluids were initiated. An NG tube was inserted for decompression of her stomach. While NPO, the patient's hypertension was treated with IV lopressor and hydralazine as needed. She was taken to the OR on [6-23] where she underwent a exploratory laparotomy with lysis of adhesions. Please see the operative report for further details. Ms. [Name13 (STitle) ] was transferred from the surgical floor to the ICU on [6-25] for atrial fibrillation w/ RVR. She was placed on a diltiazem infusion to control her heart rate. The patient was loaded with digoxin and given a dose of IV furosemide during the time of rapid atrial fibrillation. Serial troponin levels where checked, all of which were within normal limits, and an ECG was obtained. It was also discovered that she had a urinary tract infection (positive UA) with an elevated serum WBC, so she was started on a short course of ciproflaxacin. She returned to the floor on [2131-6-26] and placed on telemetry monitoring. Her rhythm was noted to be in sinus rhythm. She was hypertensive to the 180s systolic with IV Lopressor. Additional IV anti-hypertensives were initiated. When she was able to tolerate POs, she was placed on her home anti-hypertensive medications Amlodipine 10mg PO QD and Labetalol 200mg [Hospital1 ] PO which provided adequate blood pressure control. She was placed on a regular diet which she tolerated well. On [2131-6-27], Mrs.[Doctor Last Name 87796] diet was advanced to regular. She tolerated the oral intake well, had positive flatus and began moving her bowels. IV fluids and foley catheter were discontinued as well. Physical therapy was ordered for evaluation of her function status prior to discharge. At the time of discharge, Mrs.[Doctor Last Name 7517] is hemodynamically stable and afebrile. Telemetry shows normal sinus rhythm with occasional PACs and PVCs. Her leukocytosis has resolved. She has minimal abdominal pain and has required little analgesia. Her entire home medication regime has been resumed. Follow-up appointments have been made with her PCP and the ACS service. Medications on Admission: Miralax, MVI, Colace 100'', Labetalol 200'', Ranitidine 150'', Amlodipine 10', Norvasc 5', Xalatan 0.005% eye drops daily, ASA 81', losartan potassium 50''. Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Labetalol 200 mg PO BID 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 6. Ranitidine 150 mg PO BID 7. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN itching Place thin layer sparingly to back as needed for itching. 8. Losartan Potassium 50 mg PO BID 9. Polyethylene Glycol 17 g PO DAILY 10. Acetaminophen 325-650 mg PO Q6H:PRN pain Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA of [Location (un) 5087] Discharge Diagnosis: Closed loop obstruction Intermittent rapid atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [Hospital1 69] with abdominal pain. Imaging showed that you suffered from a small bowel obstruction. You were taken to the operating room on [6-23] where you underwent a lysis of adhesions. Since that time, our bowel function has returned and you have resumed a regular diet. Please follow with your PCP as well as in the [Hospital 2536] clinic at the appointment scheduled for you below. Your staples will be removed at this appointment. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. o You may go outside, but avoid traveling long distances until you see your [Hospital 5059] at your next visit. o Don't lift more than 20-25 lbs for 4-6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. o Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. HOW YOU [Month (only) ] FEEL: o You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your [Month (only) 5059]. YOUR INCISION: o Your incision may be slightly red around the staples. This is normal. o You may gently wash away dried material around your incision. It is normal to feel a firm ridge along the incision. This will go away. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [Month (only) 5059]. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. o Over the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [Month (only) 5059]. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [Name2 (NI) 5059]. You will receive a prescription from your [Name2 (NI) 5059] for pain medicine to take by mouth. It is important to take this medicine as directied. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your [Name2 (NI) 5059] about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your [Name2 (NI) 5059] has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the folloiwng, please contact your [Name2 (NI) 5059]: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your [Name2 (NI) 5059]. DANGER SIGNS: Please call your [Name2 (NI) 5059] if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: Department: Primary Care Name: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10543] When: Wednesday [2131-7-11] at 1:15 PM. Location: [Hospital3 ] INTERNAL MEDICINE ASSOCIATES Address: [Street Address(2) 4472], [Apartment Address(1) 4473], [Hospital1 ],[Numeric Identifier 9331] Phone: [Telephone/Fax (1) 4475] Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2131-7-19] at 2:15 PM With: Dr. [Last Name (STitle) ] [Name (STitle) ] in the ACUTE CARE CLINIC Phone: [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2131-6-28] ICD9 Codes: 5119, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6241 }	Medical Text: Admission Date: [2128-3-2] Discharge Date: [2128-3-15] Date of Birth: [2071-6-27] Sex: M Service: MEDICINE Allergies: Tapazole Attending:[First Name3 (LF) 2009] Chief Complaint: Clotted AV graft, DKA. Major Surgical or Invasive Procedure: Thrombectomy of AV graft times two. History of Present Illness: 56 year-old man with DM1 with insulin autoantibody receptor syndrome, ESRD, PVD, chronic diastolic CHF, poor historian with numerous admissions for hypoglycemia who presents from HD with hyperglycemia. Pt presented for HD today which was unable to be performed due to a clotted AVG. He was found to have a FSBS >450. He also reported nausea and small amounts of vomiting beginning this afternoon. Per his sister, he had been more lethargic starting on Saturday. He denies any fevers, chills, cough, chest pain, diarrhea, or dysuria. . In the ED, initial VS were: T 98, P 106, BP 185/111, RR 24, O2sat 100. Labs showed WBC 12.7 (no bands but neut predominant), K 5.4, bicarb 24, gluc 580, anion gap 23. EKG was without peaked t waves but was notable for new TWI in V4-V6. Added on CE with nl CK & CK-MB but trop 0.33 in setting of Cr 6.8. CXR showed a RLL opacity. PIV 20g x 2 placed. Pt was given insulin 10 units, then started on a gtt at 7 units/hour. He was also given IVF at 150 cc/h (conservative as not dialyzed today and limited UOP ~ once weekly) and started on vanc/zosyn for PNA. Lactate initially 2.8 -> 1.8. He was evaluated by Surgery re: HD access. Renal was made aware with plan for HD tmrw pending access. On transfer, vitals: 98. 108, 28, 143/97, 100% 1L. ABG: 7.43/24/144/16 with lytes on that Na 144, K 1.9, Cl 121, Glc 259, question if drawn near running IVF. . On the floor, pt is lethargic. He is responsive to voice and does sit up to pull on more blankets and complains of feeling cold but variably answering questions although responses appropriate when he does. Does admit to noncompliance with his insulin. No vomiting since earlier this afternoon. Past Medical History: 1. Type 1 diabetes with insulin autoantibody receptor syndrome -since age 16 on insulin, followed by Dr. [Last Name (STitle) 10088] [Name (STitle) 21002] hypoglycemic episodes, has required intubation for altered MS in the past -high level of anti-insulin Ab -complicated by nephropathy -complicated by retinopathy (s/p right eye laser surgery, repeated [8-2]) -on immunosuppression ?? no records at [Hospital1 18] 2. End-stage renal disease on dialysis 3. Diastolic heart failure 4. Hypertension 5. Hyperlipidemia 6. Peripheral vascular disease 7. Hypothyroidism 8. Anemia 9. Recent burn on his left upper extremity, now s/p skin graft 10. S/p left first toe distal phalangectomy in [2127-9-28] 11. Pancreatic lesions seen on an abdominal CT done in [2127-5-28] Social History: He states that he currently lives with his parents. Several other relatives also live there at different times. He worked in construction but was laid off. He denied alcohol tobacco, or illicit drug use. Family History: Per OMR, history of DM (Type 1 and 2), RA and HTN. Mother - Type 2 Diabetes [Year (4 digits) ], Rheumatoid Arthritis Maternal Aunt - Type 2 Diabetes [Name (NI) ] Nephew - Type 1 Diabetes [Name (NI) ] Physical Exam: Vitals: T 96.4, P 108, BP 130/79, P 24, RR 99 2L. General: Alert, oriented, no acute distress. Arousable to voice, responds appropriately but selectively to questions. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, unable to assess JVD, no LAD Lungs: Coarse BS b/l CV: Regular rate, tachyardic, 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 Pertinent Results: Complete Blood Count: [2128-3-2] 01:30PM BLOOD WBC-12.7# RBC-4.28* Hgb-11.9* Hct-36.8* MCV-86 MCH-27.8 MCHC-32.3 RDW-14.8 Plt Ct-333# [2128-3-3] 06:00AM BLOOD WBC-11.8* RBC-4.07* Hgb-11.6* Hct-34.7* MCV-85 MCH-28.6 MCHC-33.5 RDW-15.0 Plt Ct-372 [2128-3-4] 03:35PM BLOOD WBC-9.5 RBC-3.62* Hgb-10.6* Hct-31.1* MCV-86 MCH-29.3 MCHC-34.0 RDW-14.8 Plt Ct-317 [2128-3-5] 12:00PM BLOOD WBC-9.7 RBC-3.54* Hgb-9.9* Hct-30.1* MCV-85 MCH-28.0 MCHC-33.0 RDW-15.2 Plt Ct-207 [2128-3-6] 05:14AM BLOOD WBC-7.5 RBC-3.34* Hgb-9.6* Hct-29.1* MCV-87 MCH-28.6 MCHC-32.9 RDW-14.9 Plt Ct-178 [2128-3-8] 07:10AM BLOOD WBC-5.4 RBC-3.61* Hgb-10.5* Hct-31.6* MCV-88 MCH-29.0 MCHC-33.1 RDW-15.1 Plt Ct-171 [2128-3-9] 07:00AM BLOOD WBC-6.1 RBC-3.67* Hgb-10.5* Hct-32.1* MCV-88 MCH-28.7 MCHC-32.8 RDW-15.6* Plt Ct-204 [2128-3-10] 06:45AM BLOOD WBC-5.0 RBC-3.57* Hgb-10.2* Hct-31.5* MCV-88 MCH-28.7 MCHC-32.5 RDW-15.7* Plt Ct-197 [2128-3-11] 07:10AM BLOOD WBC-3.5* RBC-3.41* Hgb-9.9* Hct-30.0* MCV-88 MCH-29.0 MCHC-32.9 RDW-15.9* Plt Ct-171 [2128-3-12] 07:45AM BLOOD WBC-3.9* RBC-3.32* Hgb-9.8* Hct-29.4* MCV-89 MCH-29.6 MCHC-33.4 RDW-15.6* Plt Ct-176 [2128-3-13] 07:00AM BLOOD WBC-4.3 RBC-3.67* Hgb-10.7* Hct-32.3* MCV-88 MCH-29.1 MCHC-33.0 RDW-16.1* Plt Ct-173 [2128-3-14] 10:05AM BLOOD WBC-4.4 RBC-3.78* Hgb-11.0* Hct-34.0* MCV-90 MCH-29.0 MCHC-32.3 RDW-15.8* Plt Ct-170 [2128-3-15] 07:30AM BLOOD WBC-4.4 RBC-3.76* Hgb-10.9* Hct-33.9* MCV-90 MCH-29.0 MCHC-32.2 RDW-15.9* Plt Ct-156 [2128-3-2] 01:30PM BLOOD Neuts-84.6* Lymphs-12.1* Monos-2.4 Eos-0.7 Baso-0.1 . Basic Metabolic Profile: [2128-3-2] 01:30PM BLOOD Glucose-580* UreaN-33* Creat-6.8# Na-143 K-5.4 Cl-96 HCO3-24 AnGap-28* [2128-3-2] 07:32PM BLOOD Glucose-273* UreaN-35* Creat-7.4* Na-146* K-3.5 Cl-106 HCO3-20* AnGap-24* [2128-3-2] 07:32PM BLOOD Glucose-636* UreaN-31* Creat-6.6* Na-134 K-2.8* Cl-95* HCO3-25 AnGap-17 [2128-3-3] 12:00AM BLOOD Glucose-53* UreaN-34* Creat-7.2* Na-149* K-3.6 Cl-109* HCO3-29 AnGap-15 [2128-3-3] 06:00AM BLOOD Glucose-113* UreaN-33* Creat-7.3* Na-146* K-3.8 Cl-104 HCO3-30 AnGap-16 [2128-3-4] 03:35PM BLOOD Glucose-298* UreaN-34* Creat-7.7* Na-138 K-3.3 Cl-102 HCO3-26 AnGap-13 [2128-3-5] 12:00PM BLOOD Glucose-279* UreaN-36* Creat-8.3* Na-140 K-4.2 Cl-101 HCO3-21* AnGap-22* [2128-3-6] 05:14AM BLOOD Glucose-64* UreaN-16 Creat-4.7# Na-142 K-4.0 Cl-102 HCO3-29 AnGap-15 [2128-3-8] 07:10AM BLOOD Glucose-50 UreaN-10 Creat-4.4* Na-142 K-3.9 Cl-102 HCO3-32 AnGap-12 [2128-3-9] 07:00AM BLOOD Glucose-94 UreaN-9 Creat-3.8* Na-142 K-3.9 Cl-102 HCO3-30 AnGap-14 [2128-3-10] 06:45AM BLOOD Glucose-85 UreaN-8 Creat-3.2* Na-144 K-4.2 Cl-104 HCO3-32 AnGap-12 [2128-3-11] 07:10AM BLOOD Glucose-190* UreaN-11 Creat-4.1* Na-140 K-4.2 Cl-102 HCO3-29 AnGap-13 [2128-3-12] 07:45AM BLOOD Glucose-175* UreaN-12 Creat-3.3* Na-140 K-4.4 Cl-102 HCO3-31 AnGap-11 [2128-3-13] 07:00AM BLOOD Glucose-277* UreaN-19 Creat-4.0* Na-137 K-4.7 Cl-98 HCO3-31 AnGap-13 [2128-3-14] 10:05AM BLOOD Glucose-158* UreaN-17 Creat-3.4* Na-142 K-4.9 Cl-99 HCO3-34* AnGap-14 [2128-3-15] 07:30AM BLOOD Glucose-293* UreaN-25* Creat-4.0* Na-136 K-5.1 Cl-98 HCO3-30 AnGap-13 . [2128-3-2] 07:32PM BLOOD Calcium-8.9 Phos-2.7# Mg-1.9 [2128-3-2] 07:32PM BLOOD Calcium-7.8* Phos-2.5* Mg-1.7 [2128-3-3] 12:00AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8 [2128-3-3] 06:00AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.4 [2128-3-5] 12:00PM BLOOD Calcium-8.1* Phos-4.9# Mg-2.1 [2128-3-6] 05:14AM BLOOD Calcium-8.2 Phos-3.7 Mg-1.8 [2128-3-8] 07:10AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.6 [2128-3-9] 07:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7 [2128-3-10] 06:45AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.7 [2128-3-11] 07:10AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.7 [2128-3-12] 07:45AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.7 [2128-3-13] 07:00AM BLOOD Calcium-8.7 Phos-2.3* Mg-1.8 [2128-3-14] 10:05AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.1 [2128-3-15] 07:30AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.1 . Cardiac Enzymes: [2128-3-2] 01:30PM BLOOD CK(CPK)-126 [2128-3-2] 07:32PM BLOOD CK(CPK)-84 [2128-3-2] 07:32PM BLOOD CK(CPK)-71 [2128-3-3] 06:00AM BLOOD CK(CPK)-70 [2128-3-3] 03:25PM BLOOD CK(CPK)-68 [2128-3-2] 01:30PM BLOOD cTropnT-0.33* [2128-3-2] 07:32PM BLOOD CK-MB-NotDone cTropnT-0.31* [2128-3-2] 07:32PM BLOOD CK-MB-NotDone cTropnT-0.30* [2128-3-3] 06:00AM BLOOD CK-MB-5 cTropnT-0.31* [2128-3-3] 03:25PM BLOOD CK-MB-NotDone cTropnT-0.31* . [2128-3-2] 07:32PM BLOOD TSH-4.9* [2128-3-3] 06:00AM BLOOD Free T4-1.3 [2128-3-2] 07:32PM BLOOD Cortsol-20.8* . [2128-3-2] 04:55PM BLOOD Type-MIX pO2-144* pCO2-24* pH-7.43 calTCO2-16* Base XS--5 Comment-[Known lastname ] TOP [2128-3-2] 07:47PM BLOOD Type-ART pO2-142* pCO2-19* pH-7.73* calTCO2-26 Base XS-7 [2128-3-3] 12:16AM BLOOD Type-[Last Name (un) ] pO2-60* pCO2-38 pH-7.52* calTCO2-32* Base XS-7 [2128-3-2] 01:33PM BLOOD Glucose-GREATER TH Lactate-2.8* K-5.4* [2128-3-2] 04:55PM BLOOD Glucose-259* Lactate-1.4 Na-144 K-1.9* Cl-121* . ECG ([2128-3-2]): Sinus tachycardia. Left anterior fascicular block. Anterolateral T wave abnormalities are non-specific but cannot exclude myocardial ischemia. Clinical correlation is suggested. Since the previous tracing of [2128-1-30] further precordial T wave changes are now present. . Chest Radiograph ([2128-3-2]): IMPRESSION: Given the volume loss, the hazy basilar opacity in the right lung is felt most likely to represent atelectasis. It is difficult to entirely exclude an early developing pneumonia and clinical correlation is recommended. There is likely a small pleural effusion on the right as well. No signs of fluid overload. . Chest Radiograph ([2128-3-4]): Lung volumes are much improved and there is no consolidation any longer at the right lung base. Mild peribronchial opacification in the left lower lobe is comparable in appearance to [3-2] and could be either atelectasis or a very small focus of pneumonia. The upper lungs are clear. Fullness in the upper mediastinum could be due to venous engorgement in the supine position. Would recommend upright views when feasible for clarification. Heart size is normal. No pneumothorax or pleural effusion is evident on the supine view. . Chest Radiograph ([2128-3-6]): FINDINGS: Upright portable chest x-ray compared with [2128-3-5]. There is resolution of the right lower lobe consolidation. There is new small left pleural effusion with minimal atelectasis. No focal consolidation is seen. There is no pneumothorax. Cardiomediastinal silhouette is normal. IMPRESSION: 1. No evidence of pneumonia in the right lower lobe. 2. New small left pleural effusion with linear atelectasis. Brief Hospital Course: 56 yo man with a h/o DM I with insulin autoantibody receptor syndrome, ESRD, PVD, chronic diastolic CHF (last echo [7-5]) who presented originally with DKA and clotted AV graft. . # DKA: Patient found to be in DKA secondary to insulin noncompliance, which has been a pattern illustrated by numerous prior hospitalizations. Also with history of extremely labile blood sugars. He was started on an insulin drip and intravenous fluids. His gap (initially 23) closed with normalization of his glucose and patient was transitioned to subcutaneous insulin with improvement in blood sugar control. [Last Name (un) ] Diabetes service was consulted and followed sugars daily with uptitration in insulin as needed. At the time of discharge, was changed to levemir insulin 8 units in the AM supplemented with insulin sliding scale with meals. No clear infectious precipitant. Patient was continued on his PO steroids 10mg daily, though it remains unclear whether this has improved glycemic control. Patient will be discharged home with VNA to ensure proper medication administration and compliance. Will follow up with PCP and [Name9 (PRE) 1944] clinic closely. . # AV graft thrombus: With stabilization of DKA, patient was taken to OR for RUE AV graft thrombectomy. The venous anastamosis was successfully revised, which required repeat thrombectomy due to rethrombosis. He was able to continue HD successfully after this procedure. . # ESRD: Patient continued HD as an inpatient and will follow up as an outpatient with no changes to his HD schedule. . # Diarrhea: Patient reported several episodes during his hospitalization that resolved spontaneously. Was without chills, leukocytosis, or abdominal pain. . # Cognitive dysfunction and inability to care for self: Several team meeting held throughout hospital course with family, legal, case management, social work, and primary care physician. [Name10 (NameIs) 15421] [Name11 (NameIs) 21030] evaluation on [2128-3-4], reported that given patient's cognitive dysfunction, it would be best to have a guardian appointment for medical decision making (not just admitted to a nursing facility) given his processing difficulties and repeated problems with poor self care. Ethics team was consulted and it was deemed safe for patient to be discharged home, as was the wish of the patient and his son, the temporary legal guardian in regards to placement. The patient's father is currently contemplating full guardianship for medical decision making. . # HTN: Patient was continued on home dose of metoprolol 50mg PO TID. Diltiazem was decreased to 180mg PO daily with plan to uptitrate as an outpatient as needed. . # Pneumonia: With radiographic suggestion of PNA on admission. Patient was initially treated with vanco/zosyn for three days before antibiotics were stopped due to low suspicion given that patient remained afebrile, with no leukocytosis, or cough. . # Chronic diastolic CHF: Patient was euvolemic on exam. . # Hypothyroidism: Stable, continued outpatient levothyroxine. . # Anemia: Stable. He continued epo at HD. Medications on Admission: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for n/v. 11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 15. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 17. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Ten (10) Subcutaneous QAM. 18. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6) Subcutaneous QPM. 19. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 20. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 21. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 22. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for toe pain. 23. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) capsule, Delayed Release(E.C.) PO DAILY (Daily). 24. Insulin Lispro 100 unit/mL Cartridge Sig: as directed units Subcutaneous four times a day: Please check fingersticks QID and administer insulin based on the attached sliding scale. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO twice a day. 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 15. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO twice a day. 16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. 17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for pain. 20. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 21. Humalog 100 unit/mL Cartridge Sig: as directed Subcutaneous four times a day: Please check fingersticks four times a day and administer insulin based on the attached sliding scale. 22. Levemir 100 unit/mL Solution Sig: 8 units Subcutaneous qAM. Disp:1 month supply Refills:2 23. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) Subcutaneous AS DIR: Please take as directed with insulin sliding scale. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Diabetic Ketoacidosis DM1 with insulin autoantibody receptor syndrome . Secondary: ESRD Diastolic congestive heart failure Hypertension Hyperlipidemia Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [Hospital1 827]. You were admitted to the hospital due to very high sugars and a condition called diabetic ketoacidosis. You initially were treated in the Intensive Care Unit with insulin. As your sugars stabilized, you were transferred to the medicine floor for further monitoring. Your AV graft for dialysis was also surgically repaired. Your sugars remain stable and you are medically cleared to return home. You will have a visiting nurse who will be able to help make sure that you are taking your medications properly. . We have made the following changes to your medications: --> decreased diltiazem to 180mg by mouth daily --> decreased prednisone to 10mg by mouth daily --> changed levemir to 8 units in the morning --> changed your insulin sliding scale. Please see attached chart. Followup Instructions: Department: [Hospital3 249] When: FRIDAY [2128-3-19] at 3:10 PM With: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: MONDAY [2128-3-29] at 3:25 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: TRANSPLANT CENTER When: MONDAY [2128-4-5] at 10:00 AM With: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage ICD9 Codes: 5856, 486, 4280, 2449, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6242 }	Medical Text: Admission Date: [2137-5-9] Discharge Date: [2137-5-16] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: colon CA Major Surgical or Invasive Procedure: s/p right colectomy History of Present Illness: : Mr. [Known lastname 10239] is an 83 year-old gentleman who presented with some anemia and underwent a colonoscopy which demonstrated a fungating lesion in the right ascending colon. Biopsy of the colon was consistent with carcinoma. The patient was then booked for elective right colectomy. Past Medical History: CAD s/p STEMI [2126], RCA stent, LAD stent failed->CABGx3 [3-/2128], L CEA for infarct, basal cell ca with resection, seborrheic dermatitis, actinic keratosis, CHF (class I-II [4-21]) with LV dysfunction, hyperlipidemia, CCY in [2077] Family History: mother died in [2110] of "old age", father died when pt was 6 yo (unclear cause) Physical Exam: NAD, AAOx3 Card: RRR, no m/r/g Pulm: CTAB Abd: soft, mildy tender, ND, incision c/d/i with staples Ext: no LE edema Pertinent Results: [2137-5-13] 10:45AM BLOOD CK(CPK)-135 [2137-5-13] 02:15AM BLOOD CK(CPK)-130 [2137-5-12] 03:12PM BLOOD CK(CPK)-173 [2137-5-10] 07:43PM BLOOD CK(CPK)-211* [2137-5-10] 04:04PM BLOOD CK(CPK)-188* [2137-5-10] 08:31AM BLOOD CK(CPK)-146 [2137-5-10] 02:30AM BLOOD CK(CPK)-113 [2137-5-13] 10:45AM BLOOD CK-MB-4 [2137-5-13] 02:15AM BLOOD CK-MB-4 [2137-5-12] 03:12PM BLOOD CK-MB-4 cTropnT-<0.01 [2137-5-10] 07:43PM BLOOD CK-MB-3 [2137-5-10] 04:04PM BLOOD CK-MB-3 [2137-5-10] 08:31AM BLOOD CK-MB-2 cTropnT-<0.01 [2137-5-10] 02:30AM BLOOD CK-MB-2 cTropnT-<0.01 [2137-5-15] 11:02AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.9 Brief Hospital Course: Pt was admitted to the floor on telemetry s/p his colectomy where he went a normal postoperative course until POD #2 in which it was noted that he had a few beats of ventricular tachycardia during the night. The patient was asymptomatic and was cleard by both an EKG and negative CK-MB and troponin enzymes. On POD #3, also during the night the patient went into atrial fibrillation. He was rate controlled with lopressor and converted back to a normal sinus rhthym. Cardiac enzymes were again negative The patient remained in NSR until POD#4 where he again had 5 beats of vtach. The patient remained asymptomatic and cardiology consult was called. They reccomended to continue his current medication regimen and to add coumadin for the new onset intermittent afib. This was discussed with his PCP who asked for him to be started on 2mg/day. The patient also had elevated blood sugars for the last 2 days of his hospital stay which were discussed with his PCP who [Name9 (PRE) 10240] no home treatment and that he would follow and decide whether the patient need outpatient treatment. The patient continued to do well and was sent home on POD#6 in good condition with VNA assistance, home PT, and close f/u with his PCP and [Name Initial (PRE) ] new cardiologist, Dr. [Last Name (STitle) 10241], due to the fact that his cuurent cardiologist is leaving town. Medications on Admission: lovastatin 20, toprol xl Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 7. Outpatient [Name (NI) ] Work Pt/INR daily. Call Dr. [Last Name (STitle) 1266], [Telephone/Fax (1) 608] with results. 8. Outpatient [Telephone/Fax (1) ] Work Basic Metabolic panel on 1st blood draw for INR. Once. 9. Diovan 160 mg Tablet Sig: One (1) [11-19] Tablet PO once a day. Disp:30 Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: s/p right colectomy for CA, new onset intermittent afib Discharge Condition: good Discharge Instructions: [Name8 (MD) ] M.D. if fever > 100.4, abdominal pain, nausea, vomiting, chest pain, shortness of breath, blood in stool or urine, or other concerns. Pt. started on coumadin 2mg daily will need INR's drawn daily until followup with Dr. [Last Name (STitle) 1266]. Please draw first INR INR>3. Followup Instructions: call Dr.[Name (NI) 10242] office for f/u in 2 weeks. f/u with PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 10243] in 1 week. Please call for appt. # [Telephone/Fax (1) 608]. Cardiology appointment on [2137-6-18] for echo @ 8:00 AM and appt. with Dr. [Last Name (STitle) 7965] at 9:00 AM. Please call the office at [Telephone/Fax (1) 902] prior to confirm. Completed by:[2137-5-16] ICD9 Codes: 4280, 4271, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6243 }	Medical Text: Admission Date: [2199-6-24] Discharge Date: [2199-7-4] Date of Birth: [2125-4-7] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1666] Chief Complaint: respiratory failure, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 74 yo female brought to [Hospital1 18] ED from St. [Hospital 6783] hospital for ICU admission. The patient initially presented to [Hospital2 ] [Hospital3 6783] from her nursing home in [Hospital1 1559], MA with increasing lethargy and SOB. History is extremely limited as the patient is not responsive, obtained entirely through documentation in chart. Per notes from [Hospital2 ] [Hospital3 6783], the patient was in extremis upon arrival, unable to give history. The patient was quickly intubated for respiratory failure, lactate found to be 2.9. Purulent urine was noted from foley. Blood and urine cultures were sent, and the patient was given Ampicillin and 4 liters IVF, with 1.4 liters of urine output documented at OSH. A left femoral line was placed. The patient was started on Levophed, up to 8mcg at one point, titrated down to 0.15 mcg on arrival to ICU. . On arrival to [Hospital1 18] ED, the patient was febrile to 103. Blood and urine cultures were sent again, pt was given dose of Vanc and Zosyn, and 2 more liters of IVF. About 30 minutes after arrival, the patient was noted to have arm twitching and tonic/clonic seizure activity per nursing, resolved with 2 mg IV ativan. The patient was sent for a head CT and CXR. UA was repeated which again showed mod leuks, >50 WBCs, many bacteria, 0-2 epis. The patient was admitted to the ICU for further management. Past Medical History: hypertension schizophrenia depression dementia diabetes- insulin dependent Parkinsons Social History: lives at [Location ], not able to obtain further info Family History: not able to obtain Physical Exam: GEN: intubated, not responsive to voice, responsive to painful stimuli HEENT: atraumatic, dry mucosa, NG tube in place with dark brown return NECK: no LAD, no JVD CV: RRR, no murmurs, no rubs LUNGS: decreased BS at left base, no crackles or wheeze ABD: distended, soft, no focal tenderness elicited on exam, no rebound, G-tube in place, hypoactive BS EXT: cool, dry. Right LE and UE contracted, + muscle rigidity SKIN: no rash NEURO: non responsive to voice, pupils constricted and minimally reactive, withdraws to painful stimuli, no spontaneous movement of extremities at rest Pertinent Results: notable for hypernatremia, elevated lactate, elevated creatinine, leukocytosis, anemia [2199-6-23] 11:45PM GLUCOSE-170* UREA N-71* CREAT-2.3* SODIUM-159* POTASSIUM-3.7 CHLORIDE-130* TOTAL CO2-17* ANION GAP-16 [2199-6-23] 11:45PM URINE RBC-0 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 RENAL EPI-0-2 [2199-6-23] 11:45PM WBC-22.0* RBC-3.27* HGB-9.6* HCT-29.4* MCV-90 MCH-29.4 MCHC-32.6 RDW-15.6* [2199-6-23] 11:45PM CK-MB-5 [2199-6-23] 11:45PM cTropnT-0.05* [2199-6-24] 02:47AM LACTATE-2.5* . [6-24] CXR: No pneumonia or CHF. . [6-24] CT HEAD: 1. No intracranial hemorrhage or mass effect. 2. Marked cerebral atrophy. 3. Mucosal thickening in the paranasal sinuses with aerosolized secretions in the nasopharynx. The patient may benefit from suctioning . EKG: sinus rhythm, normal rate, LAD, normal intervals, low voltage, poor r wave progression, no acute ST changes . [2199-6-25] EEG: IMPRESSION: mild diffuse encephalopathy. no focal, lateralized, or epileptiform features although encephalopathies can, at times, obscure focal findings. Of note, there was no clear electrographic correlate to observed episodes of leg shaking or body jerking on video and reported by the EEG technician. There were no electrographic seizures. . [6-26] MRI head w/o contrast: CONCLUSION: No definite evidence for acute brain ischemia. Brief Hospital Course: The patient is a 74 yo female brought to ICU for respiratory failure and hypotension. # Respiratory failure- Unclear history of onset of SOB and tachypnea. On presentation patient had a metabolic acidosis (AG and non-anion gap), with elevated lactate in the setting of hypotension and decreased perfusion. Increased ventilation was likely partially [12-21] compensatory respiratory alkalosis. Also with likely underlying COPD as pt on inhaler at nursing home. Metabolic acidosis resolved with volume and free water repletion, however the patient continued to hyperventilate and became slightly alkalotic. CXR findings intially suggested RLL pneumonia, likely aspiration, as well as possible LLL pneumonia. Also likely an element of fluid overload after aggressive volume resuscitation for sepsis. Patient continued to show a pattern of hyperventilation followed by apnea while on mechanical ventilation, thought most likely ataxic breathing secondary to parkinson's disease. Antibiotics were dc'd [6-30]. Extubated on [7-1], sat'ing high 90s-100% on 50% face mask and ultimatley oxygen was weaned to room air prior to transfer to the regular medical floor. # Altered mental status- Patient showed improvement ([6-29]) and has been stable since then. Pt is opening eyes spontaneously, tracking with her eyes, lip smacking c/w parkinson's dementia. Had previously been unresponsive, off sedation, in the abscence of receiving narcotics. EEG [6-25] showed no epileptiform activity, consistent with encephalopathy, thus her change in mental status is likely not explained by subclinical seizures as previously hypothesized. Head CT ruled out cerebral edema [12-21] rapid correction of hypernatremia. Neurology was consulted, and felt taht toxic/metabolic etiology was most likely. LFTs were normal. TSH elevated with normal T3 and free T4, possibly related to illness. MRI brain without evidence for anoxic brain injury. There was also Likely an element of polypharmacy as patient has improved s/p d/c'ing sedating meds-- ativan and keppra. Per the patient's guardian, in the past when she has been very sick she has had similar change in mental status with prolonged period of recovery back to baseline. # UTI/Urosepsis/hypotension- Thought secondary to sepsis given UA suggestive of infection, purulent urine, fever, and leukocytosis. All cx data negative so far. ECHO was negative for effusion or systolic dysfunction. Adrenal insufficiency was ruled out. Blood culture have remained negative to date. Patient was weaned off levophed on day 1 of admission, CVP was responsive to 500cc LR boluses, and she completed a course of vanc/zosyn. # Erythema at R SC insertion site- first noticed [6-27] with significant erythema at the insertion site. Likely [12-21] chloraprep reaction, significantly improved after d/c'ing use of chlorhexadine. There is an area of skin breakdown next to the tape but it does not look infected. She has been afebrile without a leucocytosis or any other evidence to suggest a line-related infection. # Hypernatremia- likely hypovolemic hypernatremia, sodium 151 at OSH, up to 159 in ED. Na normalized quickly with free water repletion. . # ARF- baseline creatinine unknown, creatinine at OSH 3.3, improved here with volume repletion, suggesting prerenal etiology. Cr stable now at 1.2, . # Anemia- baseline hct unknown, hct at OSH 43, likely reflecting hemoconcentration. However residual in NG tube was also concerning for UGIB. Labs ruled out hemolysis. Iron studies suggest iron deficiency anemia and AOCD. No clear etiology for acute hct drop. There was no evidence of bleed on head CT, no other obvious source of bleed other than GI. Guiac negative. Received transfusion [6-26] 2 u RBC for hct 20.8 Had appropriate bump to 29.9 and HCT has been stable since then. # Diabetes- insulin dependent, last hgb A1c not known, FS 95-161 over past 24 hours. She should continue her insulin sliding scale as prior to admission. # [Name (NI) 73501] pt with tonic-clonic activity in the ED, which resolved with ativan. On Depakote at NH, but seizure history unclear. [Name2 (NI) 116] be secondary to fever/ infection/ hypernatremia. CT head negative for acute bleed. Pt had seizure-like activity again twice on [6-26] (rhythmic UE shaking) that resolved with 2mg and 2.5mg IV ativan respectively. EEG c/w encephalopathy, no epileptiform activity. Per neuro recomendations, keppra was d/c'd. The patient was continued on depakote and aspiration precautions # Access- R SC central line placed ([6-24]). removed prior to transfer back to her long term care facility # Communication- guardian [Name (NI) ] [Name (NI) 73444] [Telephone/Fax (1) 73502] (cell). . # Code Status - was full code during this hospitalization per discussion with legal guardian. Medications on Admission: buproprion 50 mg [Hospital1 ] depakote 250 mg [Hospital1 ] famotidine 20 mg metoprolol 12.5 mg [Hospital1 ] mirtazapine 7.5mg qhs calcium carbonate w/ vitamin D combivent tylenol novolog sliding scale Discharge Disposition: Extended Care Facility: Odd Fellows Home Discharge Diagnosis: urosepsis respiratory failure diabetes type II with complications Dementia Parkinson disease schizophrenia Discharge Condition: improved Discharge Instructions: no new specific discharge instructions. No new discharge medications. Resume previous medications. Other care plans per extended care facility. Followup Instructions: per long term care facility [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673] Completed by:[2199-7-15] ICD9 Codes: 0389, 5070, 5990, 2760, 2762, 5849, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6244 }	Medical Text: Admission Date: [2113-9-14] Discharge Date: [2113-9-17] Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[First Name3 (LF) 443] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Heart Catheterization History of Present Illness: [Age over 90 ] year old man with CAD s/p CABG [2086] h/o PCI to SVG and PDA ([2108]) and to ostial, proximal Lcx and distal Lcx ([2110]), systolic CHF (LVEF 50%), HTN and HLD, who presented initially to OSH with chest pain beginning around 8PM on night of admission. He was in his usual state of health until 2 days ago when he was wading in the pool at his senior center and had brief transient chest pain that spontaneously resolved. On the afternoon of admission, he felt fatigued and "off" in general. He walked to a function at the senior center and then sat down where he developed gradual onset dull chest pressure in the lower chest radiating in a band and downward to his abdomen. He had associated SOB, diaphoresis, and nausea. Denied lightheadedness, back/jaw/arm pain. He became more and more uncomfortable and thus EMS was called. At the OSH, ECG showed inferior ST elevations and anterior ST depressions. There he received atorvastatin, aspirin full dose, metoprolol 5mg IV, and nitro SL x2 with resolution of chest pain. He was not started on anticoagulation due to a reported history of hemoptysis (described by patient as specks of blood with cough). In the [Hospital1 18] ED, initial vitals were 98.2 76 161/83 18 97% 2L NC. Labs and imaging significant for trop <0.01, creatinine 1.2, WBC 10, HCT 45, INR 1.0. ECG showed ST elevation [Hospital1 1105] and ST depression anteriorly. Received SL nitro 0.4mg once and then was started on a nitro drip for hypertension (no further chest pain). He was also started on a heparin drip but not [Hospital1 4532] loaded (guaiac was negative). Vitals on transfer were afebrile, 94 157/83 17 100% RA. On arrival to the floor, he is chest pain free. Denies SOB, lighteadedness or abdominal pain. REVIEW OF SYSTEMS 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. He denies recent fevers, chills or rigors. Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: CAD s/p CABG [2086], s/p PCI [2108] with Taxus stent x 2 to SVG to PDA and PCI [2110] of the ostial, proximal LCx and distal LCx. 3. OTHER PAST MEDICAL HISTORY: GERD Glaucoma OSA on CPAP Cataracts Glaucoma Prostate CA s/p radiation Social History: Lives w/ son in [Name2 (NI) 13089] housing in [Name (NI) ] ([Hospital1 ] Village), not [Hospital3 ]. Occupation: None. Drugs: None. Tobacco: None. Quit 60 years ago. Alcohol: 1 drink daily Family History: Son w/ 2 previous MIs, otherwise no arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission: GENERAL: NAD. Oriented x3. Hard of hearing. HEENT: PERRL, EOMI. No OP lesions. No xanthalesma. NECK: Supple, unable to localize JVP. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Discharge: GENERAL: NAD. Oriented x3. Hard of hearing at baseline. No complaints overnight. HEENT: EOMI. No OP lesions. No xanthalesma. Hearing aids in place. NECK: Supple, unable to localize JVP given large neck. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. 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: EKG [2113-9-14]: sinus rhythm at 97 bpm with prolonged AV conduction (1st degree heart block), normal axis, ST elevation [Last Name (LF) 1105], [First Name3 (LF) ] depression I, avL, V4-V6, q wave [First Name3 (LF) 1105] . 2D-ECHOCARDIOGRAM: [2110]: IMPRESSION: Suboptimal image quality. Moderate concentric LVH with mild regional systolic dysfunction LVEF 50%. Mild pulmonary hypertension. Mild aortic and mitral regurgitation. . ECHOCARDIOGRAM [2113-9-15]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with hypo-to akinesis of the basal and mid-inferior segments, and near-akinesis of the mid- and distal septum, distal anterior wall and the apex (multivessel CAD). The remaining segments contract normally (LVEF = 35-40%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild to moderate regional left ventricular systolic dysfunction, c/w multivessel CAD. Mild mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [2110-9-2], distal LAD-territory regional LV dysfunction is new. The other findings are similar. . CARDIAC CATH: [2110]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent SVG -> PDA and LIMA -> LAD. 3. Systemic arterial hypertension. 4. Successful PTCA and stenting of the ostial and proximal LCx. 5. Successful direct stenting of the distal LCx. . [2113-9-14] 10:00PM PT-10.5 PTT-30.6 INR(PT)-1.0 [2113-9-14] 10:00PM PLT COUNT-169 [2113-9-14] 10:00PM NEUTS-86.2* LYMPHS-7.9* MONOS-4.2 EOS-1.4 BASOS-0.2 [2113-9-14] 10:00PM WBC-10.0# RBC-4.81 HGB-15.7 HCT-45.1 MCV-94 MCH-32.6* MCHC-34.8 RDW-13.5 [2113-9-14] 10:00PM CALCIUM-8.7 PHOSPHATE-1.7* MAGNESIUM-2.1 [2113-9-14] 10:00PM cTropnT-<0.01 [2113-9-14] 10:00PM estGFR-Using this [2113-9-14] 10:00PM GLUCOSE-122* UREA N-18 CREAT-1.2 SODIUM-140 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 . DISCHARGE: [2113-9-17] 07:30AM BLOOD WBC-7.9 RBC-4.52* Hgb-14.8 Hct-42.2 MCV-94 MCH-32.8* MCHC-35.0 RDW-13.5 Plt Ct-173 [2113-9-17] 07:30AM BLOOD Plt Ct-173 [2113-9-17] 07:30AM BLOOD Glucose-93 UreaN-31* Creat-1.5* Na-134 K-3.6 Cl-98 HCO3-27 AnGap-13 [2113-9-16] 05:56AM BLOOD CK-MB-9 cTropnT-0.60* [2113-9-17] 07:30AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1 Brief Hospital Course: [Age over 90 ] year old man with CAD s/p CABG (LIMA-->LAD and SVG-->PDA), systolic CHF (LVEF 50%), HTN and HLD, who presented initially to OSH with chest pain found to have ST elevations inferiorly and ST depressions antero-laterally that improved with sublingual nitroglycerin. . # STEMI: The patient presented with chest pain that was suspected to be secondary to acute coronary syndrome given ST depressions anteriorly and initial ST elevations in the inferior leads. His chest pain resolved with sublingual nitroglycerin and ECG findings improved. Likely vessels affected are LAD territory potentially involving the LIMA. The patient received heparin drip and nitroglycerin drip. He also received aspirin 325mg daily, and his rosuvastatin was increased from 20 to 40mg daily. His clopidogrel was continued, as was his home lisinopril. He had previously been taken off of a beta blocker for episodes of bradycardia, but we started him on a low dose of metoprolol. He did become bradycradic to the 30s while sleeping, so his evening dose of metoprolol was held. The decision was made not to go to the cardiac cath lab for PCI initially. CK-MB peaked at 25 and troponin at 0.96 on [9-15] and then trended down. He was taken for exercise stress test on [9-17], (submaximal) exercise stress test, where he exercised for 3 METs (about as much as he does at home), had no further EKG changes beyond baseline and no angina. He was d/c with [Month/Day (4) ] 75mg QD, Imdur 60mg qd, Metoprolol XL 12.5mg PO QD, Lisinopril 40mg daily and amlodipine 10mg. His home lasix was held because Cr uptrended with diuresis and he was euvolemic on discharge. He was discharged home and will follow-up with Dr. [Last Name (STitle) 4469] as an outpatient to f/u on his Cr and reassess for restarting lasix. . # Chronic Systolic CHF: Most recent LVEF prior to admission was 50% in [2110]. Repeat echo during this admission showed an EF of 35-40%, likely due to the STEMI. In addition to the medications listed above, Lasix was used for diuresis. . # HTN: Poorly controlled on admission. The patient was initially started on a nitro drip. He was transitioned to Imdur. His home amlodipine and lisinopril were continued. Metoprolol was started as above. . # GERD: Home ranitidine was continued. . # OSA: The patient is on CPAP at home and used CPAP during this hospitalization. When he fell asleep during the day without CPAP, he woke up disoriented, likely due to obstruction and CO2 retention. In addition, he was more confused at night which also occurs in his [Last Name (un) ] setting per his family. . Transitional Issues: # Elevated Cr - pt Cr 1.5 on discharge, we held his Lasix and will need CMP two days after discharge. Please follow results # CODE: Confirmed FULL # EMERGENCY CONTACT: [Name (NI) ] (daughter?) [Telephone/Fax (1) 95855], [Telephone/Fax (1) 95856], [Telephone/Fax (1) 95854] # HCP: [Name (NI) 2411] [Name (NI) ] (daughter) [Telephone/Fax (1) 95857] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Isosorbide Dinitrate 60 mg PO BID 2. Amlodipine 10 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Ranitidine 150 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Acetaminophen 500 mg PO BID:PRN pain 8. Psyllium 1 PKT PO DAILY:PRN constipation 9. Lisinopril 40 mg PO DAILY 10. Rosuvastatin Calcium 20 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. travoprost NF 0.004 % OU daily 13. Nitroglycerin SL 0.4 mg SL PRN chest pain 14. Sertraline 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO BID:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Clopidogrel 75 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. Ranitidine 150 mg PO DAILY 7. Rosuvastatin Calcium 40 mg PO DAILY RX rosuvastatin [Crestor] 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY hold for SBP<90 RX isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 10. Metoprolol Succinate XL 12.5 mg PO DAILY hold for HR <50 RX metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #30 Tablet Refills:0 11. Multivitamins 1 TAB PO DAILY 12. Nitroglycerin SL 0.4 mg SL PRN chest pain RX nitroglycerin 0.4 mg 1 tab sublingually as needed for chest pain, can repeat after five minutes if chest pain persists, please call Dr. [Last Name (STitle) 4469] immediately or go to the emergency room if you develop chest pain Disp #30 Tablet Refills:0 13. Psyllium 1 PKT PO DAILY:PRN constipation 14. Sertraline 25 mg PO DAILY 15. travoprost NF* 0.004 % OU daily 16. Outpatient Lab Work Please have creatinine, BUN, Na, K, HCO3 drawn on [2113-9-19] or [2113-9-20] and have results faxed to Dr. [Last Name (STitle) 4469] (see below for contact information). Dr. [Last Name (STitle) 4469]: Phone: [Telephone/Fax (1) 4475] Fax: [Telephone/Fax (1) 29683] Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary Diagnoses: ST elevation myocardial infarction Secondary Diagnoses: Coronary artery disease Hypertension Chronic systolic congestive heart failure Hyperlipidemia Heart block: Type 2, Mobitz I Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ], You came into the hospital because of chest pain. You were found to have had a heart attack. You were treated with medications and improved. You had a stress test that showed that you did not have chest pain with your normal activity. Please continue to take your medications as perscribed in order to prevent a further heart attack. In particular, please take aspirin and clopidogrel ([Known lastname ]) everyday and do not stop these medications unless instructed to do so by your cardiologist, Dr. [Last Name (STitle) 4469]. Stopping aspirin or clopidogrel could cause another heart attack. It was a pleasure caring for you. We wish you a speedy recovery. Followup Instructions: Tomorrow morning, please make an appointment to see Dr. [Last Name (STitle) 4469]. You will need to have blood work drawn in 2 days to check your kidney function and the results should be faxed to Dr. [Last Name (STitle) 4469]. You should see Dr. [Last Name (STitle) 4469] for a follow up visit this week. ICD9 Codes: 4280, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6245 }	Medical Text: Admission Date: [2136-12-30] Discharge Date: [2137-1-8] Date of Birth: [2077-9-6] Sex: M Service: VASCULAR CHIEF COMPLAINT: Left third toe cellulitis and gangrene. HISTORY OF PRESENT ILLNESS: This is a 59 year-old male who was transferred from [State 20192] Center. His past medical history is significant for diabetes, coronary artery disease status post myocardial infarction [4-7] and [6-7] associated with congestive heart failure, status post coronary artery bypass graft in [2129] with a redo in [2134-6-8] requiring an AICD implantation for ventricular tachycardia. The patient presented to an outside hospital on [2136-12-26] after having "stubbed" his left foot approximately three weeks prior to admission. He presented with cellulitis and gangrene of the left third toe. He had duplex done, which was negative for deep venous thrombosis. He was treated with Unasyn and underwent arterial noninvasives, which revealed inferior popliteal disease on the left. Given the fact that Dr. [Last Name (STitle) ] had performed the surgery on the other leg he was transferred here for further evaluation and treatment. PAST MEDICAL HISTORY: 1. Diabetes with retinopathy and neuropathy. 2. Coronary artery disease status post myocardial infarction times two [4-7] and [6-7] associated with congestive heart failure. 3. History of ventricular tachycardia. 4. Status post implantable defibrillator. 5. Status post pacemaker. 6. Orthostatic hypertension secondary to his neuropathy. 7. Chronic obstructive pulmonary disease. 8. Sleep apnea. 9. Hypercholesterolemia. 10. Chronic anemia. 11. Tubulovillous adenoma of the colon. 12. Vitreous hemorrhage of the right eye. 13. Bilateral carotid disease. 14. Right foot osteomyelitis. 15. MRSA. 16. History of depression. PAST SURGICAL HISTORY: 1. Coronary artery bypass graft initial in [2129] with redo coronary artery bypass graft times four in [2134-6-8]. 2. Status post cholecystectomy, remote. 3. Status post appendectomy remote. 4. Status post right femoral AT bypass graft in [2132] with a right ray amputation. 5. Status post right foot flap in [2132]. ALLERGIES: Avandia manifestations unknown. MEDICATIONS ON ADMISSION: 1. Lipitor 40 mg q.d. 2. Zoloft 150 mg q.d. 3. Altace 2.5 mg q.d. 4. Hydrochlorothiazide 25 q.d. 5. Glucotrol XL 10 mg b.i.d. 6. Lasix 40 mg q.a.m. and 20 mg q.p.m. 7. Coreg 1.875 mg b.i.d. 8. Humalog sliding scale as follows glucoses greater then 100 3 units, 101 to 180 6 units, greater then 181 9 units. 9. Ferrous sulfate 65 mg b.i.d. 10. Multivitamin tablet q.d. 11. Folic acid 1 mg q.d. 12. Aspirin 325 mg q.d. 13. Elphagen eye drops left eye two q.d. PHYSICAL EXAMINATION: Vital signs 98.1, 62, 137/76, 20, O2 sat 96% on room air. General appearance, this is an alert, cooperative male in no acute distress. HEENT examination without carotid bruits or JVD. Lungs are clear to auscultation bilaterally. Cardiac examination regular rate and rhythm with a normal S1 and S2. Abdominal examination was unremarkable. There were no palpable masses. Vascular examination pulse femorals are 2+ bilaterally. Popliteals were triphasic dopplerable signals bilaterally. The right dorsalis pedis pulse was palpable. The right posterior tibial pulse was dopplerable signal only. The left dorsalis pedis pulse and posterior tibial pulse were dopplerable signals only. There is left lower extremity edema bilaterally with the left great toe with dry gangrene with surrounding erythema. The right lower extremity is warm. The graft is palpable. HOSPITAL COURSE: The patient was admitted to the Vascular Service. He was placed on bed rest. The patient was continued on preadmission medications. He was placed on bed rest. The left toe was dressed with dry gauze b.i.d. with 2 by 2 between the toes and Ace wrap from foot to knee at all times. The patient was placed on Vancomycin 1 gram q 12 hours, Levofloxacin 500 q 24 and Flagyl 500 intravenously q 8 hours. Subq heparin was begun for deep venous thrombosis prophylaxis. The patient was allowed to use his own CPAP from home at bedtime. Admission laboratories, white blood cell count 10.4, hematocrit 34.8, platelets 245. Urinalysis was negative. Electrolyte sodium 136, potassium 5.0, chloride 98, bicarb 30, BUN 32, creatinine 1.4, glucose 141. Admitting chest x-ray showed ill defined opacities within the right upper lobe and within the right lower lobe consistent with an infectious process and/or atelectasis. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2137-1-8] 11:17 T: [2137-1-8] 11:21 JOB#: [Job Number 26282] ICD9 Codes: 9971, 4280, 496, 2930, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6246 }	Medical Text: Admission Date: [2107-8-28] Discharge Date: [2107-9-10] Service: MEDICINE Allergies: Lipitor / Lovastatin / Vancomycin Attending:[First Name3 (LF) 106] Chief Complaint: Suprapubic pain on Initial Presentation. Admitted to the ICU because of Dyspnea. Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] y/o female with history of CAD s/p CABG, HTN, Hypercholesterolemia, and atrial fibrillation who was in her USOH until 1 wk before presentation when she developed intermittent epigastric tenderness she believes began after an episode of vomiting (perhaps associated with taking a medication). Since then, she has experienced mild epigastric pressure. No N/V/hematemesis. No diarrhea, melena. She denies any chest pressure, CP, SOB, dyspnea, cough, fever/chills. She was brought into the ED today. In the ED, VSS AF. Received 1L NS and admitted to medical floor. On arrival to the floor, she states that her epigastric pressure has spontaneously resolved. No other c/o. ROS otherwise normal. Past Medical History: Hypertension Hypercholesterolemia CAD s/p CABG at [Hospital1 112] [2092] CHF (EF 30%) Carotid stenosis AFib Cholecystitis Left cataract surgery Vaginal cyst removal Seasonal allergies hx of MRSA Social History: She works as a volunteer at the [Hospital1 18]. Denies tobacco, alcohol, IVDU. She lives by her self [Last Name (NamePattern1) 18764] at baseline but has been at [Hospital3 2558] in [Location (un) ] since recent d/c. Has a daughter who lives in [Name (NI) 4628]. Family History: Non Contributory. Physical Exam: GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM RESP: CTA b/l with good air movement throughout. No rales throughout both lung fields CV: Regular rate, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 1+ edema to mid-shins bilaterally; appears chronic SKIN: no rashes NEURO: AAOx3. Pertinent Results: ADMISSION LABS: [2107-8-28] 02:30PM BLOOD WBC-12.4# RBC-3.52 Hgb-10.5* Hct-31.5* MCV-89 MCH-29.9 MCHC-33.5 RDW-16.6* Plt Ct-313 [2107-8-28] 02:30PM BLOOD PT-24.2* PTT-26.3 INR(PT)-2.4* [2107-8-28] 02:30PM BLOOD Glucose-118* UreaN-25* Creat-1.1 Na-142 K-4.0 Cl-102 HCO3-26 AnGap-18 [2107-8-28] 02:30PM BLOOD CK-MB-7 cTropnT-0.05* proBNP-[Numeric Identifier ]* . U/A - negative leuk est, nitrite. 0-2 WBC, occ bact . CXR [8-28]: Relative to the prior examination, there is mild engorgement of the vascular structures with mild cephalization. No overt failure is evident. There has, however, been interval increase in the bilateral pleural effusions previously noted. There is a tortuous atherosclerotic aorta. The cardiac silhouette again is enlarged but stable. The bones are diffusely osteopenic with a severely exaggerated kyphosis of the thoracic spine again seen. . Cardiology Report ECG Study Date of [2107-8-28] 2:41:48 PM Baseline artifact Sinus rhythm Atrial premature complexes Left ventricular hypertrophy with ST-T abnormalities Delayed R wave progression - could be due in part to left ventricular hypertrophy or prior septal myocardial infarction Since previous tracing of [2107-7-20], probably no significant change . Cardiology Report ECHO Study Date of [2107-8-31] The left atrium is elongated. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. LV systolic function appears moderately-to-severely depressed (ejection fraction 30 percent) secondary to hypokinesis of the anterior septum, anterior free wall, and apex. There is no ventricular septal defect. The right ventricular cavity is mildly dilated. There is focal hypokinesis of the apical free wall of the right ventricle. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild to moderate ([1-11]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [2089-12-16], the mitral regurgitation is increased; mild aortic stenosis is now present. . RENAL US [2107-9-6] No appropriate demonstration of diastolic arterial flow in either kidney, suggestive of increased resistive indices which can be seen in the setting of renal artery stenosis. . DISCHARGE LABS: [2107-9-9] 06:30AM BLOOD WBC-6.5 RBC-3.74* Hgb-10.5* Hct-34.5* MCV-92 MCH-28.2 MCHC-30.6* RDW-15.4 Plt Ct-432 [2107-9-7] 07:15AM BLOOD PT-14.3* PTT-25.3 INR(PT)-1.3* [2107-9-9] 06:30AM BLOOD Glucose-103 UreaN-28* Creat-PND Na-139 K-3.9 Cl-99 HCO3-32 AnGap-12 [2107-9-8] 06:20AM BLOOD Glucose-90 UreaN-30* Creat-1.1 Na-141 K-3.9 Cl-101 HCO3-34* AnGap-10 [2107-9-7] 07:15AM BLOOD ALT-19 AST-20 LD(LDH)-227 AlkPhos-72 TotBili-0.3 [2107-9-9] 06:30AM BLOOD Mg-2.6 [2107-8-31] 05:26AM BLOOD Triglyc-54 HDL-78 CHOL/HD-2.1 LDLcalc-74 Brief Hospital Course: [Age over 90 ] y/o Female with PMHx of CAD s/p CABG, CHF (EF 35%), HTN, Hypercholesterolemia, and atrial fibrillation who presented with suprapubic pain, with a negative urine culture spontaneous resolution. She then developed respiratory distress requiring tranfer to ICU without intubation (she is DNR/DNI). She was transfered from the MICU to the CCU for treatment of heart failure and possible need for catheterization, which was untimately not required. 1. Abdominal Pain NOS: Unclear etiology, may potentially be related to episode of vomiting vs mild gastritis. Spontaneously resolved. U/A negative for cystitis. No further traetment needed. 2. Respiratory Distress: Likely systolic heart failure and may have had some component of flash pulmonary edema. Off oxygen with good O2 saturations. 3. Pneumonia: Completed a seven day course for community acquired PNA with antibiotics (Ceftriaxone). 3. Systolic Heart Failure: Baseline EF 35%, elevated BNP to 35K (prior baseline 5-7K), and evidence of CHF. Repeat Echo showed EF 30% with hypokinesis of the anterior septum, anterior free wall, and apex. Continued on low dose beta blocker. Ace inhibitor was held due to renal insufficiency and possible renal artery stenosis on renal ultrasound. Please consider restarting once creatinine comes down for afterload reduction. Patient has shown labile blood pressure, and per Dr. [Last Name (STitle) ] will revisit staring ACE as an outpatient. 4. CAD s/p CABG: Concern for prior ischemic espisode given anterior wall motion abnormality. Continue ASA, low dose metoprolol. ACE held for likely RAS, which can be restarted if Cr is returning to normal. 5. HTN - Stopped ACE because of concermn for renal artery stenosis. Beta blocker continued at 2 mg [Hospital1 ]. 6. Afib - Currently in NSR with occassional ATach. Decision was made to stop anticoagulation because of fall risk based on PT evaluation. 7. Transaminitis: Resolved despite being on amiodarone. Will need to be followed while on amiodarone. Code - DNR/DNI Medications on Admission: 1. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Propafenone 150 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Metoprolol Tartrate 25 mg Tablet Sig: 2mg elixir PO BID (2 times a day). Disp:qs mg/ml Refills:2 8. Citalopram 20 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily). Discharge Medications: 1. Metoprolol Tartrate (Bulk) 100 % Powder Sig: Two (2) mg Miscellaneous [Hospital1 ] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Systolic Congestive Heart Failure Pneumonia Atrial Taachycardia Discharge Condition: Improved breathing, comfortable on room air with oxygen saturations in the upper 90's. Fall risk with need for physical therapy. Discharge Instructions: You were treated for heart failure and pneumonia. Sone changes in your medications were made. Your proprafenone, lisinopril, and your coumadin were stopped, and you were started on amiodarone. Please weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) 1730] [Name12 (NameIs) ] appointment should be in 2 weeks Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 904] Appointment should be in [7-19] days Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 722], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2107-10-6] 11:20 ICD9 Codes: 486, 5849, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6247 }	Medical Text: Admission Date: [2145-8-2] Discharge Date: [2145-8-25] Date of Birth: [2145-8-2] Sex: M Service: NEONATOLOGY HISTORY OF THE PRESENT ILLNESS: The patient was born to a 39-year-old G2, P1 to P2 Chinese mother. Prenatal screens were normal and include the following: Blood type of the mother B positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, GBS negative. AFP syndrome. Ultrasound was performed at that time and discovered in utero fetal demise of the co-twin approximately six weeks in size. The fetal survey was, otherwise, unremarkable, although the obstetrician later noted a two-vessel cord. Parents were counseled that the triple screen results were not interpretable so they decided to not have an amniocentesis performed. The pregnancy, otherwise, progressed Labor was unremarkable, vaginal delivery. Apgars 9 and 9. The neonatology service was called to the delivery room because the patient was noted to have marked jitteriness. For this reason, the baby was transferred to the NICU for further evaluation. PHYSICAL EXAMINATION: Examination on admission revealed the following: Weight 2880 grams, length 48 cm, head circumference 33 cm. Temperature 98.9, pulse 162, respiratory rate 60, blood pressure 61/47 with a mean of 53. Initial D stick was 37. Saturation on room air was 98%. Normally developed, well grown, pink baby. Did have diffuse exaggerated jittery movements of the arms and legs that settled and resumed almost continuously. Of note was the hand posture, which showed that the fingers were pinched with long fingernails. The head was round and normal in shape. The anterior fontanelle was normal in size and contour. The face was smooth, almost featureless appearing. The eyes, mouth, and ears, however, were normally formed and set. Has effective suck, normal palate and gums. The neck was normal, opened lids, red reflex bilaterally. The skin was smooth and shiny. Lungs were clear with good air entry bilaterally and no respiratory distress. Cardiac examination revealed normal heart sounds, no murmur. Abdomen was benign, normal male genitalia with bilaterally descended testes. The hips were flexible with some limited abduction, no contractures, however. Of note, the other extremities were normal in appearance. The tone appeared normal. Again, of note, was extreme jitteriness. HOSPITAL COURSE: (by systems) RESPIRATORY: For the first few days of life, baby [Name (NI) 20540] would occasionally have drifts in his oxygen saturation to the mid 80s. Only a few times did he actually need supplemental oxygen saturation to bring the oxygen saturations back up. These were monitored closely and resolved within several days. Since then, he has remained stable on room air with no respiratory distress. CARDIOVASCULAR: At the beginning of his hospital admission during some of the above-mentioned desaturations, the patient would occasionally have bradycardia down into the 80s. However, these also spontaneously resolved after several days of life. Around that time, baby [Name (NI) 20540] was noted to have a soft murmur. This was initially followed, but around day of life #15 he was also noted to have some premature atrial contractions on his cardiovascular monitor. At that time, a cardiology consultation was obtained. They felt that both the PACs and the murmur were benign. The PACs spontaneously resolved, however, the murmur remained intermittent. It is a soft, 2/6 systolic murmur that radiates to the back and it is most likely consistent with peripheral pulmonic stenosis and should resolve spontaneously. Further cardiac evaluation is suggested should the mrumur persist. FLUIDS, ELECTROLYTES, AND NUTRITION: Baby [Known lastname 20540] was initially maintained NPO UNTIL day of life #2 when enteral feeds by the PO route were started. He was initially uncoordinated with his feeds, but this improved gradually and currently he tolerates PO feeds without difficulty. Baby [Known lastname 20540] takes E20 ad lib, with intake of 150 to 200 per kilogram per day. He has shown adequate weight gain and the discharge weight is 3430 grams. GASTROINTESTINAL: As mentioned above, he initially remained NPO. He had some discoordinated feeding, initially, which resolved promptly. HEMATOLOGY: On day of life #6, a bruise was noted at the site of a blood draw. A CBC and PT and PTT were obtained, which showed a markedly prolonged PTT. Further investigation revealed that baby [Name (NI) 20540] had severe factor [Name (NI) 7060] deficiency, with activity less than 1%. Factor IX was 40% activity. Hematology was consulted at that point. Over the next few days, he developed hemarthrosis of the right wrist and right ankle and also a large bruise on the left arm. He received Factor [Name (NI) 7060] replacement for approximately five days. The bruising had subsequently resolved and he has not required additional Factor [Name (NI) 7060]. Most recent hematocrit on day of life #11 was 29.6 with a reticulocyte count of 1.1. He has been on supplemental iron. GENETICS: The Department of Genetics was consulted. Given the extreme jitteriness, a metabolic workup including ammonia level, urine organic acids, serum amino acids, was performed. All results were within normal limits. In addition CT of the brain, MRI of the brain, and EEG were all obtained and were all within normal limits. NEUROLOGICAL: The Department of Neurology also was consulted given the jitteriness. CT and MRI of the brain, as well as electroencephalogram, were obtained and were within normal limits. Thus far, we do not have a specific diagnosis with the jitteriness. However, serious acute disorders have been ruled out and the neurology service will continue to follow baby [Name (NI) 20540] as an outpatient. ORTHOPEDICS: The orthopedics service was consulted given the hemarthrosis. They will continue to follow baby [Name (NI) 20540] in conjunction with the hematology follow up as an outpatient. INFECTIOUS DISEASE: Baby [Known lastname 20540] had no infectious disease issues while in house. AUDIOLOGY: Baby [Known lastname 20540] passed the hearing screen. OPHTHALMOLOGY: He has occasionally had obstruction of the tear ducts bilaterally. IMMUNIZATIONS: He received the hepatitis B immunization on the [8-15]. The hematology service will consult with Dr. [First Name (STitle) ], the primary pediatrician, regarding to further administration of immunizations, both IM and subcutaneously. SOCIAL: The [Hospital1 69] social worker was extensively involved with the family through the help of a Cantonese interpreter. They have worked very closely with the family and supported them given the gravity of patient [Known lastname 44216] diagnosis. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: The patient is discharged to home. PRIMARY PEDIATRICIAN: Dr. [First Name (STitle) ]. Telephone #: [Telephone/Fax (1) 44217]. FEEDS ON DISCHARGE: Enfamil 20 PO ad lib. MEDICATIONS: Baby [Known lastname 20540] will continue on iron supplementation and will receive via the Medicaid Pharmacy two [Last Name (un) ] of Factor [Last Name (un) 7060] on the day after discharge to be kept at home and to be brought by his parents along with the baby if there is any type of bruising. They were specifically also instructed that whenever there is bleeding or bruising, they should immediately call either Dr. [First Name (STitle) ], or the Hematology Fellow at [Hospital3 1810]. Baby [Known lastname 20540] passed his car-seat testing. State newborn screen was positive for an elevated TSH. T4 was sent here and it was normal, however, the TSH was slightly elevated to 5.2. The Endocrine Service was consulted and recommended a follow up of the T4 and TSH in approximately two weeks. IMMUNIZATIONS RECEIVED: As mentioned earlier hepatitis B. FOLLOW-UP 1. Dr. [First Name (STitle) ] (primary pediatrician), [8-27] at 2 pm. 2. Dr. [Last Name (STitle) 44218] (CH neurology), [9-29] 3. Dr. [Last Name (STitle) 44219] (CH hematology), [9-1] 4. Orthopedics service, [9-1] during hemophilia clinical appointment, DISCHARGE DIAGNOSES: 1. Factor [Month (only) 7060] deficiency. 2. Jitteriness, not yet diagnosed. 3. Lacrimal duct obstruction. [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36095] Dictated By:[Last Name (NamePattern1) 43659] MEDQUIST36 D: [2145-8-25] 15:05 T: [2145-8-25] 15:12 JOB#: [Job Number 44220] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6248 }	Medical Text: Admission Date: [2137-3-9] Discharge Date: [2137-3-17] Date of Birth: [2082-3-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 17865] Chief Complaint: Hepatic encephalopathy Major Surgical or Invasive Procedure: mechanical intubation, central line placement, arterial line placement History of Present Illness: Ms. [Known lastname ] is a 54 year-old woman wtih a history of ESLD secondary to [Known lastname ] was initially admitted on [3-9] to the MICU for hepatic encephalopathy requiring intubation for airway protection who is being called out to the Hepatorenal service today for futher treatment. . Ms. [Known lastname 48600] liver history began in [2130] when she was first diagnosed with [Year (4 digits) ] by Dr. [Last Name (STitle) 10924] at [Hospital1 18]. She followed up there approximately yearly and was well compensated and essentially asymptomatic. Since [2134] he has only been following up with a general gastroenterologist near his home, [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) ] of [Hospital6 48601]. In [11/2136], Ms. [Known lastname ] was admitted to [Hospital6 302] for pneumonia. Since then, she has been re-admitted multiple times for hepatic encephalopathy. Each time, she was given lactulose with improvement in mental status. She has also been on a home dose of lactulose which her son is confident she takes twice every day, with two consistent bowel movement. Over the past 3 months, however, her baseline mental and functional status has deteriorated. Whereas she used to be completely independent in her ADLs/IADLs, she has recently been able to walk only with assistance. She generally is able to toilet herself but is frequently incontinent of urine. She does communicate meaningfully with her family but has frequent episodes of increased confusion. Most recently, she was hospitalized for 1 week approximately 2 weeks ago for hepatic encephalopathy and weakness. She was discharged from this hospitalization on a prednisone taper for unclear reasons, although her son thinks it was related to chest pain. This was tapered over ~ 1 week from 40 mg to 5 mg on [3-7]. Beginning on [3-4], Ms. [Known lastname 48600] son noted that she seemed increasingly confused. She was requiring more assistance for ambulation. On [3-9], she did not recognize her family members and was speaking to people who have been in her home country for some time. Because of this he brought her to [Hospital3 ] ED. . Ms. [Known lastname 48600] son denied that she has complained of any abdominal pain, nausea, vomitting, fevers, or chills recently. Review of systems was otherwise negative. He reports that she has continued to take the lactulose faithfully even through the recent few days. At the OSH, head CT was negative for acute intracranial pathology. Labs were notable for K 6.2. Patient received insulin, D50, and bicarb. CXR was notable only for low lung volumes. Patient's family wished to transfer to [Hospital1 18]. . In [Hospital1 18] ED, labs notable for K 5.9, Na 132. Kayexalate 30 mg and lactulose 30 g were given. She was intubated for airway protection with etomidate and rocuronium (given elevated K). Paracentesis was attempted to r/o SBP, but no fluid pocket could be found. Instead, she was covered empirically for SBP with ceftriaxone. She was also found to be guaiac positive and given protonix 40 mg IV. Her BP was initially 100-110 systolic but fell to 80s with midazolam gtt. She received a total 3 L of fluid with good BP response to the ~100 systolic. She was admitted to the MICU for further management. Of note, she had no bowel movements while in the ED. Past Medical History: [Hospital1 ] cirrhosis Hyperlipidemia HTN Anxiety/Depression Herniated discs Social History: She lives with her son (who works in a pharmacy) and husband. She and her husband are [Name (NI) ] speaking only. She has never smoked or drank alcohol Family History: son and brother with [Name2 (NI) ] Physical Exam: GEN: intubated, sedated, opens eyes to loud voice, appears comfortable SKIN:No rashes or skin changes noted HEENT:No JVD, neck supple, No lymphadenopathy i CHEST:Lungs are clear anteriorly without wheeze, rales, or rhonchi. CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. ABDOMEN: No apparent scars. Slightly distended. Soft to deep palpation without any evidence of pain. EXTREMITIES: warm, no peripheral edema NEUROLOGIC: intubated, sedated, opens eyes to loud voice. Pertinent Results: [2137-3-9] 11:11AM WBC-14.0# RBC-3.75# HGB-12.6# HCT-38.2 MCV-102# MCH-33.6 MCHC-33.0 RDW-18.5* [2137-3-9] 11:11AM NEUTS-79.6* LYMPHS-11.9* MONOS-6.7 EOS-1.5 BASOS-0.2 [2137-3-9] 11:11AM PLT COUNT-106# [2137-3-9] 11:11AM PT-22.1 PTT-35.6* INR(PT)-2.1* [2137-3-9] 11:11AM AMMONIA-125* [2137-3-9] 11:11AM GLUCOSE-91 UREA N-37* CREAT-1.0 SODIUM-132* POTASSIUM-5.9* CHLORIDE-102 TOTAL CO2-24 ANION GAP-12 [2137-3-9] 11:11AM ALT(SGPT)-115* AST(SGOT)-93* CK(CPK)-65 ALK PHOS-254* TOT BILI-9.6* [2137-3-9] 11:11AM cTropnT-<0.01 [2137-3-9] 11:11AM CK-MB-NotDone [2137-3-9] 11:11AM CALCIUM-8.2* PHOSPHATE-3.5 MAGNESIUM-2.4 RUQ u/s [3-9]: 1. Reversal of flow within the left portal vein. No color flow identified in the right portal vein or main portal vein, although Doppler signal was able to be identified. This may represent an extremely slow flow versus thrombus within these vessels. 2. Ascites and pericholecystic fluid. A spot in the left lower quadrant was marked for paracentesis. 3. There is no evidence of cholelithiasis. Chest/abd CT [3-10]: 1. Moderate left pleural effusion with left lower lobe consolidation likely representing compressive atelectasis, less likely pneumonia. 2. Elevated diaphragm, much greater on the left. 3. ET tube and NG tube in place. 4. No discrete pulmonary embolus or aortic dissection is demonstrated. 5. Moderate simple ascites. 6. Findings consistent with cirrhosis. No sequelae of portal hypertension or enhancing hepatic mass lesion. 7. Colonic distention with air fluid levels, incompletely assessed on teh current exam. 8. Body wall edema suggestive of fluid overload. 9. L4 body focal hypodensity of unclear etiology. This may represent focal osteopenia, and attention to this area is suggested on follow-up imaging. Echo [3-15]: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). with normal free wall contractility. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Suboptimal study. Grossly preserved biventricular systolic function. Brief Hospital Course: During her first stay in the MICU, the patient was maintained on the ventilator for airway protection. She was then extubated without difficulty. Of note, she has a left sided pleural effusion, with no evidence of pneumonia. The patient was initially treated for suspected SBP with ceftriaxone. However, a paracentesis was performed which did not show evidence of infection. Her mental status remained altered when she was transferred to the floor. Her clinical status quickly deteriorated, however, and patient was re-admitted to the MICU. She was intubated. Because of severe hypotension, she required two pressors. She was treated empirically with broad-spectrum antibiotics. Her acidosis rapidly worsened. Despite aggressive therapy, patient continued to decline clinically. Family decided on comfort measures only, and pressors were removed. Patient died on [2137-3-17] with family by her side. Medications on Admission: colesevelam HCTZ 625 3 tabs [Hospital1 ] metoprolol 12.5 mg [Hospital1 ] ezetimibe 10 mg daily fluoxetine 40 mg daily lacutlose 30 mg tid furosemide 40 mg qod spironolactone 100 mg daily KCl 20 meq daily clonazepam 2 mg qid b12 1000 mcg qmonth alprazolam .5 mg prn prednisone taper (last dose 2/18) Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired ICD9 Codes: 5849, 0389, 5119, 5990, 2762, 5715
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6249 }	Medical Text: Admission Date: [2107-10-20] Discharge Date: [2107-10-22] Service: CCU CHIEF COMPLAINT: Complete heart block. HISTORY OF PRESENT ILLNESS: This is an 86 year old Caucasian male with past medical history significant for hypertension and possible v-tach. He presented to an outside hospital with a syncopal episode. Previously he had been in his usual state of health until one day prior to admission when he had a brief episode of lightheadedness. Today while walking to the bedroom he syncopized for an unknown period of time. He denies preceding chest pain, lightheadedness, shortness of breath, nausea, vomiting, palpitations or diaphoresis. He felt well without confusion or loss of continence after the event. Apparently he called his neighbor and came to the hospital and had one more episode of lightheadedness prior to arrival to the hospital. At [First Name (Titles) 4527] [Last Name (Titles) ] showed complete heart block with ventricular wide complex, right bundle branch block, escape rhythm at 30 to 40 with some bigeminy. He was hemodynamically stable with blood pressure of 120/58 and was transferred to [Hospital1 190] for further management. In the E.D. systolic blood pressure was between 130 to 140 with a heart rate of 30 to 40 with [Hospital1 ] verifying the same. He was admitted to the CCU for further management. At the time of transfer he was without any symptoms. PAST MEDICAL HISTORY: Left total hip replacement 14 years ago. Status post appendectomy. Hypertension. Glaucoma. Gout. Chronic lower extremity edema. GERD. MEDICATIONS ON ADMISSION: Xalatan gtt., Lopressor 50 mg p.o. b.i.d., Prilosec 20 mg p.o. q.d., colchicine 0.6 mg q.o.d., Lasix, timolol gtt., prazosin 5 mg b.i.d. ALLERGIES: Penicillin, unknown reaction. SOCIAL HISTORY: He is widowed three times. He lives alone. He denies tobacco use. He has occasional alcohol use. FAMILY HISTORY: Noncontributory. LABORATORY DATA: On admission white blood cells were 8.6, hematocrit 37.2, platelets 133. Chem-7 showed sodium of 139, potassium 4.6, chloride 103, bicarb 22, BUN 38, creatinine 2.3, sugar 249. First CPK was 120 with troponin less than 0.3. INR was 0.8, PTT 31.5. [Hospital1 ] at the outside hospital showed complete heart block with ventricular rate of 32, atrial rate of 75 with a wide escape complex which was at times bigeminal with right bundle branch morphology. There were no obvious ischemic changes. [Hospital1 ] here showed atrial rate of 70, ventricular rate of 40 with right bundle branch morphology. PHYSICAL EXAMINATION: Vitals were pulse of 36, respiratory rate 21, sating 99% in room air, blood pressure 180/59. In general, he was a pleasant, conversant, elderly male in no acute distress. HEENT: pupils equal, round and reactive to light. Extraocular movements intact. Oropharynx clear. Mucous membranes dry. There was a right cheek fungulating growth. Neck: JVD to earlobe, positive [Doctor Last Name ] A waves, carotids 2+ without bruit. Trachea midline. Chest clear to auscultation bilaterally. Cardiovascular bradycardic, S1, S2 normal, no murmurs, rubs or gallops. Abdomen soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly or masses. Extremities had 3+ pitting edema unchanged from baseline, warm. Neuro: alert and oriented times three, grossly nonfocal. HOSPITAL COURSE: The patient was admitted to the CCU for further evaluation and observation. Immediately on transfer to the CCU transvenous pacemaker was placed by right IJ approach. He began to be ventricularly paced at a rate of 70. There were no complications from the procedure. The next morning he underwent electrophysiology study and a permanent pacemaker was placed. Again there were no complications from the procedure. Prior to pacemaker placement, Lopressor was held. However, after pacemaker placement, Lopressor was reinstated. Pump. Echo will be checked on the patient prior to discharge especially with the patient's history of chronic lower extremity edema. Various differential diagnosis for new complete heart block includes infection such as Lyme or syphilis, serology pending; ischemic cardiomyopathy; valvular disease; endocarditis. DISPOSITION: The patient will be discharged home. He received P.T. and O.T. prior to discharge. DISCHARGE MEDICATIONS: Unchanged. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Name8 (MD) 8073] MEDQUIST36 D: [2107-10-21] 15:47 T: [2107-10-21] 15:55 JOB#: [Job Number 35918] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6250 }	Medical Text: Admission Date: [2194-1-25] Discharge Date: [2194-1-28] Date of Birth: [2138-8-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4654] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: This is a 55 y/o gentleman with Asthma and Hepatitis C cirrhosis presented to the ED with asthma exacerbation [1-22], who represented to ED on [1-25] w/ same symptoms after not having Prednisone available over the weekend. On [1-24] pt. had develped worsening cough, SOB, wheezing that were unresponsive to albuterol prn nebs. . He also had chest/abdominal tightness and dizziness very similar to his usual asthma exacerbation. Patient also had chills and sweats however states that these have been present over past 2 years on and off. After no improvement w/ Albuterol nebs and peak flow of 150, he called EMS, who found the patient tachypneic to 40s. They gave him combivent and brought him to [Hospital1 18] ED. On presentation to [Hospital1 18] ED the patient was wheezy throughout. Vitals signs on initial triage assessment was BP 230/120 HR 120 RR 44 100% on RA. He received 1 L NS, combivent nebs x 2, Solumedrol 125 mg IV once and started on heliox. His vitals improved to HR 98 BP 158/98 RR 20 with oxygen saturation improvement to 98%. CXR was clear and without infiltrate. . The patient had just completed a steroid taper on [1-14] for an asthma exacerbation (80->10mg over 5 days [dosing per patient]), and presented to [Hospital1 18] ED on [1-22] once again with an asthma exacerbation, and received another 60 mg of prednsione x1. He discharged home with pulmonary followup. States that felt better after the ED visit, however visited family/friends/work where was exposed to tobacco smoke, spices and car exhaust while providing an estimate for cleaning job. He has a history of intubation unrelated to asthma (previous knife wound). At baseline pt states that PF are 650-800. His triggers include: seasonal allergies, exhaust fumes, cigarrette smoke, dust and spices. . ROS: Patient denies any nausea, vomiting, cough, weakness, diarrhea, contipation, dysuria, hematuria, blood in stool. There is no CP. Denies wt. loss, changes in skin, no polyuria, polydypsia, does report hx of "brittle bones," denies abdominal pain but reports hx of fatigue over past several years. Denies constipation at baseline but reports being currenlty constipated. Has had RLE paresthesias x 2yrs. He has no other complaints. Past Medical History: - Asthma, baseline peakflow > 600, recently completed an 18 day taper on 2/17th - Hepatitis C cirrhosis, refractory to interferon treatment,followed by Dr.[Last Name (STitle) ] - GERD - Hypercholesterolemia - Hypertension - Tinea versicolor, tinea cruris, tinea pedis. - Stabbed in [2161] during robbery- required mult surgeries. Social History: Lives alone, has daughter who visits, works as a window washer prn, does not have a full time job. History of occasional smoking but quit 10 years ago and denies use in past 2mo. No acute alcohol intake. Denies street drugs Family History: Both parents healthly- ? of mother with asthma. Aunt with DM Physical Exam: On admission to MICU: GENERAL: Pleasant gentleman, following commands, very talkative HEENT: Normocephalic, atraumatic. MMM CARDIAC: S1S2 tachycardic LUNGS: Diffuse wheezes ABDOMEN: abdominal scar, soft, ND, mild tenderness in bilateral upper quadrant, no rebound or guarding. EXTREMITIES: WWP, no edema NEURO: A&Ox3. spontaneously moves all 4 ext. . On transfer to floor: . VS 93-95% on RA. HR 100s BP 118/60, RR 22-26 GENERAL: Pleasant gentleman, following commands, very talkative HEENT: Normocephalic, atraumatic. MMM. No thyromegaly or nodularity. Nasal mucosa erythematous and purple. Cobblestoning. CARDIAC: S1, S2 tachycardic LUNGS: Diffuse wheezes posteriorly and anteriorly, no crackles. PF 550. ABDOMEN: abdominal scar, soft, ND, mild tenderness in bilateral upper quadrant, no rebound or guarding. EXTREMITIES: WWP, no edema NEURO: A&Ox3. Carries on goal directed conversation. Normal gate. 5/5 strength throughout extremities. Sensation grossly intact to LT and temperature. DTRs are 2+ biceps/triceps, 3+patellar b/l. Pertinent Results: [2194-1-25] 10:35PM BLOOD WBC-19.6# RBC-5.21 Hgb-16.5 Hct-47.9 MCV-92 MCH-31.6 MCHC-34.4 RDW-13.7 Plt Ct-337 [2194-1-25] 10:35PM BLOOD Neuts-38.0 Lymphs-49.7* Monos-4.9 Eos-6.9* Baso-0.5 [2194-1-25] 10:35PM BLOOD Glucose-115* UreaN-11 Creat-0.9 Na-142 K-4.7 Cl-106 HCO3-27 AnGap-14 . Labs on discharge: . [2194-1-28] 07:00AM BLOOD WBC-20.8* RBC-5.02 Hgb-15.5 Hct-45.1 MCV-90 MCH-30.9 MCHC-34.4 RDW-14.1 Plt Ct-330 [2194-1-28] 07:00AM BLOOD Glucose-106* UreaN-26* Creat-0.8 Na-140 K-4.9 Cl-104 HCO3-26 AnGap-15 [2194-1-28] 07:00AM BLOOD Calcium-12.0* Phos-3.3 Mg-2.4 [2194-1-27] 05:01AM BLOOD PTH-135* [2194-1-26] 05:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2194-1-27] 05:17PM BLOOD freeCa-1.50* [2194-1-26] 05:54PM BLOOD Lactate-1.4 . Imaging: . CXR [2194-1-25] . AP AND LATERAL CHEST: Heart size is normal. Mediastinal and hilar contours are unchanged. The pulmonary vascularity is normal. The lungs are clear, and there is no pleural effusion or pneumothorax. Surgical clips are noted in left upper quadrant. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: Patient was admitted to the MICU, where he was tachypneic and wheezing on presentation. He was initially treated with continuous albuterol nebs and IV steroids, with gradual improvement. ABG on [1-26] showed 197/42/7.35/42 while on continuous nebulizer treatments. He remained afebrile but in light of productive cough was started empirically on therapy for a community-acquired pneumonia with Ceftriaxone and azithromycin. He was noted to AG of undetermined etiology upon presentation, which had resolved by HD3. IV steroids were changed to PO prednisone. On the morning of [1-27], he had a peak flow of 500 and was transferred out of the ICU to the Medical [Hospital1 ] team. Steroid course was planned for a two-week taper. Ceftriaxone was switched to oral Cefpodoxime with plan to complete a 7-day course of cephalosporin and a 5-day course of azithromycin. . Medical floor course: . 55 y/o gentleman with Asthma and Hepatitis C cirrhosis presented to the ED with asthma exacerbation, initially admitted to MICU now transferred with improved respiratory status. . # Asthma Exacerbation. Patient was much improved by [2194-1-27] with PF in 550s and no subjective senation of dyspnea. Based on further interview, it appears that exacerbation was triggered by known culprit exposures (auto exhaust, cigarrette smoke, spices) and possible URI. It was felt that exacerbation was unlikely due to CAP, given no fever, clear sputum and no opacities on CXR. No sputum data was available. Patient was discontinued from cefpodoxime and completed course of Azithromycin. Pt. also had PE findings consistent with allergic rhinitis. He was continued on albuterol nebs Q2H prn, ipratropium nebs q6h, prednisone 60mg. With this treatment he continued to improve with PF of 650 on [2194-1-28]. Based on this response, he was discharged home with a 2wk prednisone taper, continued on Advair and singulair. Given findings consistent with allergic rhinitis, patient was started on loratadine at discharged and instructed to resume flonase after completion of PO prednisone. He was also provided with clotrimazole troches tid prn for hx of oral candidiasis with previous prednisone treatments. He was also treated with HISS for high dose steroids with FS ranging 106 - 175. Patient was also referred to [Hospital 9039] clinic to further assess for asthma triggers. . # Hep C cirrhosis: nonresponder to prior treatment as per last Dr[Doctor Last Name ] note. No stigmata of chronic liver disease on exam, but last RUQ u/s consistent with cirrhosis. Not an active issue during this admission. Patient is to followup with Dr. [Last Name (STitle) ] as outpatient. . # Hypercalcemia. Appears chronic at least from [2180] from OMR Total Ca > 11. Alb was 4.0, Phosphate 2.4, low. PTH elevated at 153, and Mr. [Known lastname 79115] had normal renal function. Hypercalcemia was confirmed with iCa value of 1.50. Patient did report having vague abdominal pain over the past two years, as well as fatigue and paresthesias on/off in LE of the same duration. No other complaints consistent w/ symptomatic hypercalcemia. This was felt to most likely represent primary Hyperpara, given elevated PTH and nl renal function. Can also be related to chronic vitamin D defficiency, and a 1,25 Vitamin D level was sent prior to discharge. This work up was communicated with PCP via email. Patient may require 24hr calcium and bone density measurements as OP as well as parathyroid imaging. [Month (only) 116] need to consider Raloxefine/bisphosphonate based on above results. . # HTN. SBPs 130 - 140s. Monitored during admission. . # PPX: sc heparin, can d/c once patient ambulated tid. continue protonix given high dose steroids. . # CODE STATUS: Full Code, confirmed with patient . # Contact: Daughter [Name (NI) 1894] [Telephone/Fax (1) 103597], Father [Name (NI) 9102] [Telephone/Fax (1) 103598] . Patient was discharged with improved breathing, peak flows and with mild cough with appropriate follow up. Medications on Admission: Albuterol 90 inh 2 puffs qid prn Albuterol nebs q4-6h prn Ciclopirox cream [Hospital1 ] Clotrimazole 10 mg troche tid Epipen prn Flonase 50 mcg 2 sprays daily Advair diskus 500/50 mcg 1 puff [Hospital1 ] Montelukast 10 mg qhs Prednisone taper completed on 2/17th Omeprazole EC 20 mg daily Discharge Medications: 1. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day for 11 days: take only while taking prednisone by mouth. resume 20mg dosing thereafter. Disp:22 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation twice a day as needed for shortness of breath or wheezing for 5 days. Disp:10 vials Refills:0 5. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. Disp:2 inhaler Refills:2 6. Albuterol Sulfate 1.25 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 8. Ciclopirox 0.77 % Cream Topical 9. Clotrimazole 10 mg Troche Sig: One (1) Mucous membrane three times a day for 10 days. Disp:30 troches Refills:0 10. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays each nostril Nasal once a day: two sprays each nostril daily after completion of oral prednisone. Disp:2 bottles Refills:2 11. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:1 Tablet(s) Refills:0 12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 13. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 14. Prednisone 10 mg Tablet Sig: see dosing below Tablet PO once a day for 11 days: 60mg QD: 1 day ([2194-1-30]); 50mg QD: 2 days ([1-31]- [2194-2-1]); 40mg QD: 2 days ([Date range (1) 35348]/09); 30mg QD: 2 days ([Date range (1) 103599]); 20mg QD: 2 days ([Date range (1) 103600]); 10mg QD: 2 days ([Date range (1) 103601]). Disp:36 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation Pneumonia Discharge Condition: Improved breathing, peak flow back to baseline and normal oxygen saturations. Discharge Instructions: You were admitted to [Hospital1 18] with a severe asthma exacerbation (shortness of breath, cough). It was felt that this was due to exposure to triggers known to you (e.g. car exhaust, cigarette smoke, spices) as well as a possible infection. For this you required high dose steroids, nebulizers and treated with antibiotics. You did not require intubation but did require intensive care unit stay. You will require to continue the steroids for a total of two weeks (see below). You will also requrie to take one more day of antibiotics (Azithromycin). In addition, you should also continue to take your flovent on daily basis and albuterol as needed. Finally because evidence of allergic rhinitis (allergies) were noted on your exam, you should continue to take singulair and you were started on loratadine (claritin). After you complete the prednisone tablet course, you should resume the use of your flonase on a regular, daily basis. In addition, you were found to have a high calcium blood level. Evaluation showed that this may be due to a gland in your neck. A test was obtained (Vitamin D level) that will need to be followed up with your PCP. [Name10 (NameIs) ] will also need to discuss with your PCP further evaluation of this high calcium level. Changes to your medications: Started on: - Prednisone taper (see below for details) 60 mg daily for 1 day [2194-1-30] 50 mg daily for 2 days [2194-1-31] - [2194-2-1] 40 mg daily for 2 days [2194-2-2] - [2194-2-3] 30 mg daily for 2 days [2194-2-4] - [2194-2-5] 20 mg daily for 2 days [2194-2-6] - [2194-2-7] 10 mg daily for 2 days [2194-2-8] - [2194-2-9] - Loratadine 10mg daily - Azithromycin 250 mg once Changes: - Omeprazole EC 20mg tablet, take two tablets daily while on oral Prednisone, then resume to 20mg daily. You were arranged for follow up with PCP's office, your pulmonologist and an allergy specialist (see below). Should you experience a worsening shortness of breath, severely worsening cough, fevers, chills, Peak flow < 250, or any other symptom concerning to you, please call your primary care doctors office [Name5 (PTitle) ] [Name5 (PTitle) ] to the nearest emergency room. Followup Instructions: Please follow up with your appointments: MD: Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] Specialty: Pulmonary Date and time: Wednesday [2194-2-12] at 1 PM Location: [Hospital1 69] [Hospital Ward Name 23] Center [Location (un) ] Medical Specialities Phone number: ([Telephone/Fax (1) 513] Special instructions if applicable: Your appointment on [2-26] with Dr. [Last Name (STitle) ] has been cancelled in lieu of this one. Appointment #2 MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], ANP Specialty: Internal Medicine Date and time: Tuesday [2194-2-4] at 4:20 PM Location: [Hospital1 69] [Hospital Ward Name 23] [Location (un) 895] North Suite Phone number: ([Telephone/Fax (1) 1300] Appointment #3: NP[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Allergy and Asthma [2194-1-29] 3:30pm [Location (un) ] [Hospital Ward Name 23] Building [Location (un) ] Medical Specialities [Telephone/Fax (1) 9051] [First Name8 (NamePattern2) ] [Name8 (MD) 474] MD [MD Number(2) 4658] Completed by:[2194-1-28] ICD9 Codes: 486, 2720, 4019, 5715
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6251 }	Medical Text: Admission Date: [2188-6-24] Discharge Date: [2188-7-3] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 10493] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Right IJ central line placement. History of Present Illness: [Age over 90 ]yo man with PMH significant for CAD s/p NSTEMI, recent PNA, GIB, presented initially with hypotension and tachycardia, and found to have c diff. For the last several months, he has been in and out of the hospital. Recent admissions include d/c on [4-19] after medical management of NSTEMI & LLL PNA, admission [Date range (1) 24468] with c diff colitis, admission [5-23]- w/ LLL PNA, leukocytosis, tachycardia, SVT requiring esmolol gtt, and persistent c diff. He was treated with vanco and flagyl for 2 wks. He was readmitted to the [Hospital1 18] on [2188-6-24] with hypotension to 60s despite 1.5L IVF and ?increased diarrhea. In the ED, his BP was in the 90s, T 100, 15% bands on CBC, ARF. He was started on the sepsis protocol with RIJ CVL placed (PICC removed), approx 3L IVF given, vancomycin and levofloxacin started, and was admitted to the ICU. Past Medical History: NSTEMI [2187-4-18], managed medically paroxysmal atrial fibrillation and RBBB CHF with EF 65% at [Hospital1 ] [4-14] h/o syncope, s/p [Month/Year (2) 4448] placement for SSS BPH, s/p prostate surgery lower back surgery years ago cataracts, s/p surgery hard of hearing C dif colitis [4-14] GI bleeding [4-14], pt refused endoscopy meneire's disease Social History: He is married, lived previously in [Location (un) 1468] but recently at [Hospital ] rehab. History of smoking until recently (one pck every 36 hours) x many years. History of wine every night. Family History: noncontributory Physical Exam: Physical exam on admission VS: 98.8 90/50 130 tele: ?aflutter 19 100%2L 2850/380 Levaphed gtt at 0.17, mvo2 in 50's Gen: elderly male, cachexic, shivering in bed, oriented to [Hospital1 ], date HEENT: arcus senilus, dry mm, rij cath in place, clean CV: s1, s2 tachy but regular w/ no mrg appreciated Lung: ctab Abd: intermittent hyperactive bs, soft, mild tender llq, no rebound, cvat Extr: skin turgor nl, cool extremties, ?LUE PICC Neuro: moving all extremities Pertinent Results: Laboratory studies on admission [2188-6-24] 02:00AM WBC-9.6 RBC-3.08* HGB-8.6* HCT-26.7* MCV-87 MCH-28.0 MCHC-32.3 RDW-16.8* [2188-6-24] 02:00AM NEUTS-61 BANDS-15* LYMPHS-21 MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2188-6-24] 02:00AM PLT SMR-NORMAL PLT COUNT-178 [2188-6-24] 02:00AM PT-12.5 PTT-25.4 INR(PT)-1.1 [2188-6-24] 02:00AM GLUCOSE-103 UREA N-46* CREAT-2.1# SODIUM-138 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-21 ANION GAP-15 [2188-6-24] 02:00AM CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-1.6 [2188-6-24] 02:15AM LACTATE-2.2* [2188-6-24] 03:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Micro: c diff + 5/16 [6-24] EKG: atrial fibrillation, right bundle branch block, Diffuse ST-T wave changes could be in part primary are nonspecific [6-24] KUB: nonspecific bowel gas pattern, no obstruction [6-24] CXR: extensive bilateral pleural plaques, ?left sided pleural effusion unchanged from prior CXR, no consolidation Brief Hospital Course: [Age over 90 ]yo man with recent hospitalizations for C diff, NSTEMI, and pneumonia presented with hypotension and ARF thought secondary to persistent c diff colitis with resulting dehydration and aflutter with rapid ventricular rate. . In the ICU, he was started on levophed (which was changed to neosynephrine and titrated off [6-24] at approximately 4pm). He was started on ceftazidime for possible PNA, vancomycin IV, and flagyl. He was noted to be in SVT and converted to sinus rhythm after amiodarone loading. Stool cx was positive for c diff, and he was changed to flagyl/vanco po, other antibiotics were discontinued. He was noted to have a Hct of 24 on admission and received 1 unit PRBC with minimal change in hematocrit, but was guaiac negative. He was transferred to the general medical floor on [2188-6-25]. . Summary of hospital course: 1) Atrial flutter: While in the MICU, the patient had hypotension in the setting of atrial flutter in the 150s, after which he converted to normal sinus rhythm following amiodarone drip. Following transfer to the floor, he had several episodes of atrial flutter in the 140s, converting following IV metoprolol/dilitazem. The electrophysiology service was consulted, who recommended titrating up beta blocker as tolerated by blood pressure. His metoprolol was titrated up gradually to 50 mg PO BID, amiodarone was continued, and, at time of discharge, the patient had been in paced rhythm (60s) without atrial flutter for >72 hours. He will follow-up in pacer clinic as scheduled. Thyroid function tests revealed an elevated TSH at 6.3, however but free T4 was within normal limits at 1.2; recheck as an outpatient in 6 wks. 2. C. diff colitis: The patient was initially on metronidazole/vancomycin, with improvement in diarrhea. Metronidazole was discontinued on [6-29], and the patient will continue on PO vancomycin 250 mg PO q6hrs to complete a 3 week course, after which the dose will be gradually tapered and pulsed (see discharge medications). Rifaxamin was added to his regimen on [7-2]. In the future, if he should be started on antibiotics for an other infection, vancomycin 125 mg PO q6h should be given at the same time. The patient's abdominal exam was closely monitored throughout his hospital course, and he had several KUBs (last [6-26]) without evidence of megacolon. At time of discharge, he is having ~ 5 BM/day. His stool output should be monitored to ensure gradual clearance of infection. The gastroenterology service followed him throughout his hospital course 3. Hypotension: The hypotension noted on admission was likely multifactorial due to C. diff-associated sepsis and cardiogenic shock from atrial flutter. Cortisol stimulation test in the ICU was within normal limits, indicating the patient was not adrenally insufficient. At time of discharge, the patients blood pressure is stable (sbp 110s-130s). 4. Anemia: At time of discharge, the patients hematocrit is stable at 30.5 (baseline low-mid 30s). He has a history of GI bleed, but, while he had several trace guaiac positive stools during his admission, there was no evidence of significance GI bleeding. He received 2 units of PRBC during his hospital stay ([6-24] and [6-29]). Iron studies were consistent with anemia of chronic disease. 5. Acute renal failure: The patient's creatinine was 2.1 on admission, improving to ~ 1 on discharge. His renal failure was likely due to hypovolemia with pre-renal azotemia, with possible contributor of ATN in the setting of diarrhea and hypotension. 6. Thrombocytopenia: The patient's platelets dropped to 119 on [2188-6-25], likely due to a combination of dilutional effect (in the setting of fluid resuscitation) and sepsis. HIT Ab was negative. At discharge, the patient's platelets are stable at 275. 7. Code status: DNR/DNI. The palliative care followed the patient during his hospital stay. Medications on Admission: 1. Heparin 5000 tid 2. Metronidazole 500 mg tid completed on [2188-6-5] 3. Methylphenidate 5 mg [Hospital1 ] 4. Amiodarone 200 mg qd 5. Lansoprazole 30 mg qd 6. Vancomycin 1,000 mg qd x 7 d, completed on [2188-6-5] 7. Metoprolol 12.5 [Hospital1 ] Discharge Medications: 1. Amiodarone 200 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Megestrol 40 mg/mL Suspension [Hospital1 ]: Four Hundred (400) mg PO BID (2 times a day). 5. Vancomycin 250 mg Capsule [Hospital1 ]: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks: last dose 5/24, then change to 125 mg dosing schedule. 6. Vancomycin 125 mg Capsule [Hospital1 ]: One (1) Capsule PO asdir: Begin [7-2] - 1tab q6h until [7-9], then 1tab [Hospital1 ] until [7-16], then 1tab daily until [7-23], then 1tab every other day until [7-30], then 1tab every 3 days until [8-13], then stop. 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: 5000 (5000) units Injection TID (3 times a day). 9. Rifaximin 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day) until completion of vancomycin course. Discharge Disposition: Extended Care Facility: [Street Address(1) 19427] Nursing & Rehabilitation Center Discharge Diagnosis: Primary: Clostridium difficile colitis Secondary: Sepsis, Atrial flutter with rapid ventricular rate, Acute renal failure, Anemia of chronic disease, Thrombocytopenia Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. Please follow up with your PCP [Last Name (NamePattern4) ] [2-11] weeks. Call your doctor or go to the emergency room if you have any chest pain, difficulty breathing, persistent rapid heart rate or palpitations, worsening diarrhea, abdominal pain, worsening abdominal distention, lack of any bowel movements, or any other concerning symptoms. Followup Instructions: Call Dr. [Last Name (STitle) 1007] ([Telephone/Fax (1) 10492]) for a follow up appointment. Please see him in [2-11] weeks. You have the following previously scheduled appointments: Provider: [Name10 (NameIs) ] CALL Phone:[Telephone/Fax (1) 59] Date/Time:[2188-9-11] 10:00 Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2188-12-8] 11:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10491] MD, [MD Number(3) 10495] Completed by:[2188-7-3] ICD9 Codes: 0389, 5849, 2875, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6252 }	Medical Text: Admission Date: [2156-12-1] Discharge Date: [2156-12-7] Service: MEDICINE Allergies: Depakote Er Attending:[First Name3 (LF) 898] Chief Complaint: cough/fever Major Surgical or Invasive Procedure: 1. Central Line Placement History of Present Illness: [Age over 90 ] y.o. man with h/o seizure, orthostatic hypotension on hydrocort, prostate ca, and chronic cough, p/w worsening cough productive of sputum x 3 days. He has difficult getting the sputum out of his lungs. He also c/o right pleuritic chest pain only with coughing or movement, as well as fever at home. Also c/o increased weakness and difficulty using his walker. Denies sub-sternal CP, abd pain. . Upon arrival to ED, he had a rectal temp of 103.4, was tachycardic to 100 and tachypneic so code sepsis was called. His initial BP was 146/57 but dropped to 88/30. A right IJ was placed and he was given 3L NS. CXR revealed left retrocardiac and LUL pneumonia. He was given CTX and Azithromycin. His is requiring 4L NC. Per his PCP (Dr. [First Name8 (NamePattern2) 1312] [Last Name (NamePattern1) 1313]) his baseline SBP is in the 90s, last office visit, 98/60. . MICU Course: Patient was initially hypotensive and placed on neosynephrine for 12 hours for blood pressure support. After adequate hydration this was weaned successfully. He was started on stres dose steroids given he is on hydrocort 10mg [Hospital1 ] at baseline for orthostatic hypotension. This was reduced back to his home dose within 24 hours. His O2 was weaned from 4L at the time of admission to RA by the time he was transferred to the medicine floor. Creatinine trended down from 1.4 to his baseline of 1.0. Past Medical History: 1. Complex partial seizures 2. Prostate cancer, diagnosed 5 years ago. Being followed expectantly and treated with Proscar. 3. Sleep apnea with daytime sleepiness and sleep disordered breathing noted in past. Trialed on Modafanil but this caused oral buccal dyskinesias. Did not tolerate BiPap. Daytime sleepiness improved after discontinuation of Depakote. 4. History of orthostatic hypotension in remote past, on Cortef 5. Left eye cataract status post surgery 6. Ptosis on right as a result of surgery for detached retina 7. Peripheral neuropathy 8. ? Esophageal diverticulum 9. Pacemaker Social History: The pt is widowed since [2151]. Retired at age 70. Was on the Board of Directors at [Hospital1 18]. Former smoker of 10 pack years but quit 50+ years ago. Drinks one shot or cocktail nightly. Has 24 hour housekeeping and homecare assistance, driver. Walks with cane for past one year. Family History: Noncontributory. Physical Exam: VS T 102 (rectal) BP 105/38, HR 97, RR 23, 92% 4L NC Gen: ill appearing, conversant HEENT: moist discharge from b/l eyes. PERRL, OP dry. No JVD Lungs: poor air mvmt. scattered crackle on left Heart: RRR nl S1S2, no M/R/G Abd: +BS, soft, ND/NT Ext: 2+ pitting edema of ankles b/l Neuro: AAO x 3 Pertinent Results: [2156-12-1] 09:00PM GLUCOSE-125* UREA N-31* CREAT-1.4* SODIUM-136 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15 [2156-12-1] 09:00PM ALT(SGPT)-21 AST(SGOT)-26 LD(LDH)-249 CK(CPK)-118 ALK PHOS-72 TOT BILI-0.9 [2156-12-1] 09:00PM WBC-10.7# RBC-3.72* HGB-12.6* HCT-35.9* MCV-97 MCH-33.8* MCHC-35.0 RDW-13.8 [2156-12-1] 09:00PM NEUTS-68 BANDS-15* LYMPHS-7* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-7* MYELOS-0 [2156-12-1] CXR - 1. New extensive consolidation of the left upper lobe and lingula, likely pneumonic, with small left pleural effusion. 2. No CHF. [2156-12-2] ECG Sinus rhythm with first degree atrio-ventricular conduction delay. Compared to previous tracing of [2156-9-11] no definite change. Brief Hospital Course: Mr. [Known lastname 452] is a [Age over 90 ] y.o. man with seizure d/o and chronic cough p/w worsening productive cough, pleuritic chest pain, and fever up to 103.4 rectally. He was originally admitted to the MICU for a transiet pressor requirement. He was started on ceftriaxone and azithromycin antibiotic therapy for a likely left-sided pneumonia. His oxygenation status was stable throughout his hospital course. He was changed to cefpodoxime and azithromycin PO for a total 2-week course. Cardiac etiology for his pleuritic chest pain was continued but the EKG remaied unchanged and his cardiac enzymes were negative. I slightly elevated troponin was attributed to acute renal failure. . During the hospitalization he had frequent evening episodes of delirium thought to be secondary to his hospitalization and recent infection. Repeat blood and urine cultures remained negative. He was redirectable. Concern for seizure was raised but per his family and health care aid, his seizures present with tonic clonic movements or episodes of staring. He remained on his home dose of Keppra. His family requested to not use any antipsychotics. He had a 1:1 sitter and was alert and oriented at discharge. . The patient presented with an elevated creatinine to 1.4 with a baseline Cr of 1.0 to 1.2. This was believed to be . Acute renal failure: baseline cr 0.8-1.0. Admission creatinine peaked at 1.4 thought to be likely pre-renal in setting of sepsis. Creatinine trended down with hydration and was 0.7 on discharge. . He was discharged home with VNA services and physical therapy and has 24-hour caregivers at home. . # Contact: HCP, son Dr. [First Name8 (NamePattern2) 449] [Known lastname 452] ([Telephone/Fax (1) 97313], home. pager in system. Also [First Name8 (NamePattern2) 11705] [Last Name (NamePattern1) 97314] ([Telephone/Fax (1) 97315] # FULL CODE Medications on Admission: MULTIVITAMIN TAB one po qd COLACE CAP 100MG one po tid RESTASIS 0.05% Oph OU [Hospital1 ] AZOPT 0.1% Oph OU [Hospital1 ] ASPIRIN TAB 81MG EC daily PROSCAR TAB 5MG one po qhs KEPPRA 750 MG TAB 1 [Hospital1 ] CORTEF 10 MG TAB (HYDROCORTISONE) One po bid- NO SUBSTITUTION [Doctor First Name ] CAP 60MG one po bid MUCINEX 600 po bid Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO three times a day. 2. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 8 days: Your last dose will be on [2156-12-14]. Disp:8 Capsule(s) Refills:0 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic [Hospital1 ] (). 7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic [Hospital1 ] (). 8. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days. Disp:32 Tablet(s) Refills:0 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. [Doctor First Name ] 60 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & Children Services Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Pneumonia 2. Hypotension 3. Delirium SECONDARY DIAGNOSIS: - Complex partial seizures - Prostate cancer, diagnosed [2144] - chronic LE edema - Sleep apnea with daytime sleepiness - h/o chronic PEs, not on anticoagulation - Chronic bronchitis - History of orthostatic hypotension in remote past, on Hydrocort - Left eye cataract status post surgery - Right eye retinal detachment - Ptosis on right as a result of surgery for detached retina - Peripheral neuropathy - ? Esophageal diverticulum - Pacemaker [3-/2156] for sinus pauses w/syncope - h/o pericarditis Discharge Condition: Stable. Patient was tolerating room air and working with physical therapy for help with ambulation. Discharge Instructions: You were admitted to the hospital for treatment of pneumonia. We started you on antibiotics for your pneumonia, and you will complete a total 14 day course of the antibiotic cefpodoxime and azithromycin at home. These should be completed on [2156-12-14]. You also developed low blood pressures with this infection, and this improved rapidly with medications and with intravenous fluids. You were also slightly confused for a short time in the hospital, and this also improved as we treated your infection. . Please continue to take your medications as prescribed. . If you have fevers, shaking chills, night sweats, shortness of breath, increased cough, lower extremity swelling, chest pain, diarrhea, light-headedness, or dizziness, please seek immediate medical attention. . It will be important for you to continue to take all your medications as prescribed. The only medications that we have added are the following: - cefpodoxime and azithromycin to treat your infection Followup Instructions: - Please schedule an appointment with your Primary Care Physician [Telephone/Fax (1) ] Dr. [First Name (STitle) 1313] within 1 week after your discharge - Please follow-up with your urologist [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 276], M.D. at your previously scheduled appointment on [2156-12-29] 11:00. If you need to reschedule, please call his office at [Telephone/Fax (1) 277]. - Please also follow-up with your neurologist [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 16747], M.D. at your previously scheduled appointment on [2156-12-31] 2:00. If you need to reschedule, please call his office at [Telephone/Fax (1) 16748]. - Please also follow-up in DEVICE CLINIC at your previously scheduled appointment on [2157-2-21] 11:30. If you need to reschedule, please call his office at [Telephone/Fax (1) 59]. ICD9 Codes: 0389, 486, 5849, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6253 }	Medical Text: Admission Date: [2129-12-17] Discharge Date: [2129-12-19] Date of Birth: [2083-2-23] Sex: F Service: CARDIOTHORACIC Allergies: Morphine / Iodine Containing Agents Classifier Attending:[First Name3 (LF) 1505] Chief Complaint: 46F with ^DOE and intermittent CP for 2 days. Major Surgical or Invasive Procedure: CABGx3(SVG->LAD, Diag, OM) [2129-12-18] History of Present Illness: 46F with a h/o IDDM, HTN, ^chol., CHF, who had progressive DOE and intermittent CP for 2 days. She presented to [Hospital1 2519] and had Q waves in V1-V2 and [Street Address(2) 5366]^ in V1-V2 with a CK of 607 and an MB of 59(10%), troponin was 11.9 and she was transferred to [Hospital1 18] for further treatment. Past Medical History: IDDM since age 9 HTN ^chol. Neuropathy Retinopathy s/p C section Social History: Lives with husband and 3 children, works in childcare Cigs: minimal, quit 22 yrs ago ETOH: none Family History: + DM Physical Exam: Gen: WDWN WF in NAD Temp: 100.3 HR:95 RR: 20 96% on 2 liters NC BP: 93/61 HEENT: NC/AT, PERRLA, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+=bilat. without bruits. Lungs: Bibasilar rales CV: RRR without R/G/M, nl S1, S2 Abd: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, pulses 2+=bilat. throughout Neuro: nonfocal Pertinent Results: [2129-12-19] 08:20AM BLOOD WBC-11.6* RBC-3.66* Hgb-12.0 Hct-32.6* MCV-89 MCH-32.8* MCHC-36.8* RDW-15.4 Plt Ct-141* [2129-12-19] 08:20AM BLOOD PT-13.9* PTT-33.7 INR(PT)-1.3 [2129-12-19] 03:14AM BLOOD Glucose-193* UreaN-28* Creat-1.4* Na-139 K-4.7 Cl-105 HCO3-24 AnGap-15 [2129-12-19] 08:20AM BLOOD ALT-92* AST-413* LD(LDH)-PND AlkPhos-54 Amylase-23 TotBili-3.6* [2129-12-19] 08:20AM BLOOD Lipase-10 [2129-12-18] 02:25AM BLOOD CK-MB-34* MB Indx-7.6* cTropnT-1.64* [2129-12-19] 08:20AM BLOOD Albumin-3.1* [2129-12-17] 09:14PM BLOOD Triglyc-54 HDL-58 CHOL/HD-2.3 LDLcalc-65 [2129-12-19] 08:27AM BLOOD Type-ART pO2-82* pCO2-39 pH-7.45 calHCO3-28 Base XS-2 [2129-12-19] 08:27AM BLOOD Glucose-117* Lactate-3.5* Na-138 K-4.4 Cl-104CHEST (PORTABLE AP) [2129-12-19] 5:03 AM CHEST (PORTABLE AP) Reason: please eval lungs, patient s/p emergent CABG POD 1, previous [Hospital 93] MEDICAL CONDITION: 46 year old woman s/p emergency cabg x3 with IABP REASON FOR THIS EXAMINATION: please eval lungs, patient s/p emergent CABG POD 1, previously manifested ARDS pulmonary picture high PIPs and plateau pressure with PaO2/FiO2<200 AP CHEST COMPARED TO [12-18]: Severe pulmonary edema has changed in distribution but not in severity. Right lung is now more consolidated than the left. This raises the possibility of pulmonary hemorrhage or pneumonia, but could be explained entirely by shift in edema. Heart is normal size and mediastinal vasculature is not particularly engorged. Tip of the intra-aortic balloon pump is approximately a centimeter below the level of the left main bronchus, approximately 6 cm from the apex of the aortic knob. Small left pleural effusion is stable. No right pleural effusion is demonstrated and there is no pneumothorax. Tip of the Swan-Ganz catheter projects over the right pulmonary artery, ET tube is in standard placement, midline and right pleural drains are in place. Nasogastric tube passes to the distal stomach. Mediastinum midline. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Brief Hospital Course: The patient was admitted and evaluated by cardiology and had CP with hypotension during the night of admission. She underwent emergency cardiac catheterization which revealed: 90%LMCA stenosis, diffusely diseased tight ostial LAD 60% lesion, 80% ostial, diffusely diseased, 80% diseased RCA, elevated filling pressures and 20%EF. An IAPB was placed and she went for emergency CABGx3(SVG->LAD, Diag, OM)on [2129-12-18]. She was transferred to the CSRU on Levophed, Milrinone, Epi, Vasopressin, Insulin, and Propofol. She had persistent hypotension and the propofol was d/c'd and she was placed on Cisatricurium, Fentanyl, and Midaz. She desaturated and required bronchoscopy and had copius mucous plugging. She improved following this, but had persistent tachycardia in the 130-150 range and had a good cardiac output and urine output throughout. Dr. [Last Name (STitle) 40858] at [Hospital1 2025] was consulted and she was transferred for the possibility of a Heartmate insertion. Medications on Admission: Humalog SS Lantus 9U SC BID Lisinopril 2.5 mg PO daily Allergies: MSO4 Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. 3. Ranitidine HCl 15 mg/mL Syrup Sig: One [Age over 90 1230]y (150) mg PO BID (2 times a day). 4. Epinephrine 1 mg/mL Solution Sig: .03 mg/kg/min Injection INFUSION (continuous infusion). 5. Vasopressin 20 unit/mL Solution Sig: 1.5 mg/kg/min Injection TITRATE TO (titrate to desired clinical effect (please specify)). 6. Norepinephrine Bitartrate 1 mg/mL Solution Sig: 0.2 mg/kg/min Intravenous INFUSION (continuous infusion). 7. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: One Hundred Fifty (150) mg/kg/min Injection INFUSION (continuous infusion). 8. Midazolam 5 mg/mL Solution Sig: 1.5 mg/kg/min Injection INFUSION (continuous infusion). 9. Furosemide 10 mg/mL Solution Sig: Ten (10) mg/kg/min Injection INFUSION (continuous infusion). 10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) [Hospital1 ] Intravenous Q12H (every 12 hours) for 6 doses. 11. Milrinone 1 mg/mL Solution Sig: 0.5 mcg/kg/min Intravenous infusion. 12. Cisatracurium 10 mg/mL Solution Sig: 0.15 mg/kg/min Intravenous INFUSION (continuous infusion). Discharge Disposition: Extended Care Discharge Diagnosis: CAD IDDM HTN MI ^chol. CHF Neuropathy Retinopathy Discharge Condition: Critical Discharge Instructions: Continue intensive care. Being transferred to [Hospital1 2025] Followup Instructions: Tx->Dr. [Last Name (STitle) ] Completed by:[2129-12-19] ICD9 Codes: 5185, 4280, 4019, 4240, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6254 }	Medical Text: Admission Date: [2143-11-22] Discharge Date: [2143-11-25] Date of Birth: [2075-10-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Reason for ICU admission: ROMI, coffee ground emesis Major Surgical or Invasive Procedure: endoscopy History of Present Illness: HPI: 68 y.o. man with HTN presented to PCP for routine visit on day of admission, c/o 2 months of worsening DOE and chest pressure with exertion. He reports having a stress test 1 year ago which was stopped after 3 minutes for hypertension (SBP in the 230s). He had no symptoms and no ST wave changes. In addition, he complains of severe heartburn (different than his chest pressure) intermittently every few days x 3 months, along with violent coughing fits which cause him to vomit dark brown liquid. He denies frank blood in his emesis. The heartburn is worse at night with lying flat. He denies NSAID use, but does admit to drinking at least [2-9] drinks of burbon daily. . He was referred to the ED for concern of ACS. In the ED, he was afebrile, HR 70s, BP 116/73m RR 16, and 97% RA. Hct was 41. His trop was negative but ECG showed TWI in V1-V3 which were new. He was given ASA 325, Lopressor, and started on nitroglycerin and heparin gtt. Became hypotensive with nitro to SBP 80s, BP responded to 2L NS. He then started to vomit brown colored, guiac positive emesis. The heparin and nitro drips were stopped. He was given IV protonix and Reglan. He was admitted to MICU for further monitoring/ROMI. . ROS: Denies fever, chills. No h/o blood clot or recent travel. . Past Medical History: PMH: HTN ETOH abuse h/o perianal abscess CKD, baseline Cr 1.3-1.4 Glaucoma . Social History: Social hx: Lives with his partner (male). Retired budjet analyst for park service. Has history of alchoholism, quit for 20 yrs, then starting drinking again when he retired, but much less. Drinks 2-3 glasses burbon daily, more when with friends. Starts drinking around 5pm. Former smoker, >50 pack years, quit 1.5 years ago. No illicits . Family History: . Family hx: Father died age 51 of melanoma, but had "silent MI" in late 40s. Mother had MI in her 70s. Physical Exam: PE: VS: T 97.8, BP 160/61, RR 16, HR 79, 96% 2L Gen: shaky, no apparent distress HEENT: eomi, moist mucous membranes Neck: supple, no appreciable JVD Lungs: CTA b/l Heart: RRR nl S1S2, no M/R/G Abd: +BS, soft, ND/NT Ext: no edema, +PP b/l Neuro: intention tremor. No asterixis. No pronator drift. +dysmetria with FNF. Strength 5/5 b/l upper and lower. CN II-XII intact . Pertinent Results: ECG: NSR @ 81. TWI V1-V3, new since [8-/2140] . CXR [2143-11-22]: AP upright chest radiograph is obtained. A small amount of left basilar atelectasis is noted. There is no evidence of pneumonia, CHF. There is no pneumothorax. Cardiomediastinal silhouette is unremarkable. Mildly unfolded thoracic aorta noted. Visualized osseous structures are intact. IMPRESSION: No evidence of pneumonia or CHF . [2143-11-22]. The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([1-8]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2142-12-6], the findings are similar. . [2143-11-25]. EGD. Severe esophagitis in the middle third of the esophagus and lower third of the esophagus compatible with severe reflux esophagitis (biopsy) Erythema in the antrum compatible with gastritis (biopsy, biopsy) Erythema and congestion in the second part of the duodenum compatible with duodenitis (biopsy) Otherwise normal EGD to second part of the duodenum Brief Hospital Course: In summary, Mr. [Name14 (STitle) 2469] is a 68 y.o. man with PMH significant for HTN and alcohol abuse, admitted for DOE and chest pressure. Patient was ruled out for MI, but developed coffee ground emesis while on heparin drip. EGD showed severe esophagitis and gastritis. . Upper GI bleed. Patient developed coffee-ground emesis in ED in setting of chronic heartburn and alcohol abuse while on heparin drip. EGD showed severe esophagitis and gastritis, likely due to chronic alcohol use. Hct fell to 32 from 42 on admission, but patient did not require transfusions. He was sent home on PPI [Hospital1 ]. Gastric biopsies for H. pylori were pending at time of discharge. . Chest pressure/ SOB. Patient presented with CP and SOB on exertion. He has no history of CAD. He had a stress test one year ago which was terminated early due to hypertension. Cardiac enzymes were negative. He was initally started on a heparin drip in the ED due to concern for unstable angina, but this was stopped when patient developed coffee ground emesis. His antihypertensives were intially held, but resumed on hospital day 2. A lipid panel was checked and his LDL was in the 40s. He was advised to get outpatient stress test and PFTs. Patient has a significant smoking history and CSR showed hyperinflation, suggesting that his DOE may be pulmonary in origin. . Alcohol abuse. Patient has history of alcoholism and quit drinking for 20 years and now drinks daily. He denies history of DTs or seizure. He was tremulous and required a CIWA scale. He was given thiamine, folate, and multivitamin during his hospitalization. . Transaminitis. Patient had mildly elevated LFTs that were thought to be due to alcohol hepatitis. Hepatitis serologies were sent, but were pending at time of discharge. . Contact: patient and his partner [Name (NI) ] [Name (NI) 2470] [Telephone/Fax (1) 2471] Medications on Admission: Home Meds: Toprol XL 25mg daily Lisinopril 40mg daily Amlodipine 10mg daily Xalatan oph drops, 1 drop each eye QHS Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. 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 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Upper GI bleed GERD . Secondary diagnosis: Hypertension Alcohol abuse Chronic kidney disease Glaucoma Discharge Condition: good Discharge Instructions: You were admitted for chest pain. You were coughing up blood in the emergency department, so you went to the intensive care unit for monitoring. You had an endoscopy on [11-25] which showed severe inflammation in the esophagus and stomach due to acid reflux. . Please resume all medications as you were taking prior to admission. In addition, please take pantoprazole twice daily for acid reflux. You should avoid alcohol use and avoid using over the counter anti-inflammatory medications like Aleive or Advil. . You should follow up with Dr. [Last Name (STitle) 2472] in [1-8] weeks and schedule pulmonary function tests and a stress test. . Please call your physician or come to the emergency department for shortness of breath, chest pain, chest pressure, fevers, chills, leg swelling, coughing up blood, blood in stool, or any other concerning symptoms. Followup Instructions: Please schedule a follow up appointment with Dr. [Last Name (STitle) 2472] in [1-8] weeks. You will likely need a stress test and pulmonary function tests, but you should discuss this with your Dr. [Last Name (STitle) 2472] first. Ph. [Telephone/Fax (1) 133]. The results of the gastric biopsy were pending at the time of discharge, so Dr. [Last Name (STitle) 2472] will check the results for you. . You will need a repeat endoscopy in [6-14] weeks. Please call [Telephone/Fax (1) 463] to schedule it. . You will need a follow up appointment in [Hospital ] clinic with Dr. [Last Name (STitle) 2473] in 4 weeks. Please call [Telephone/Fax (1) 463] to schedule appointment. ICD9 Codes: 4241, 4168, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6255 }	Medical Text: Admission Date: [2119-12-10] Discharge Date: [2119-12-15] Date of Birth: [2046-12-27] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 2080] Chief Complaint: Urosepsis Major Surgical or Invasive Procedure: [2119-12-10] right percutaneous nephrostomy tube placement [2119-12-10] left internal jugular central venous catheter placement History of Present Illness: This is a 72-year-old gentleman with a pmhx. significant for hypertension, diabetes, BPH, epididymitis, orchitis, and urinary retention who is admitted from the ED for sepsis from urinary source. Patient states that he developed back pain 2 days prior to admission; this pain was different than his typical renal colic in that it was bilateral. Denied fever or chills at home but did endorse dysuria. In the ED, initial vitals were: 99.2 102 146/82 20 99%. Patient was found to have an elevated WBC, creatinine of 1.8 from a baseline of 0.8, lactate of 3.6, and grossly positive u/a. A CT scan without contrast showed an obstructing 5mm stone in the right proximal ureter. SBPs dropped into the 90s and a LIJ was placed; patient was given 5L of fluid and started on Levophed. Urology and IR were consulted, and decision was made to place right percutaneous nephrostomy tube. Patient also received 500mg of cipro and 1gram of Ceftriaxone. On arrival to the MICU, vitals were: Temp 102, BP: 101/71, HR: 106, Cvp of 16, RR26, 97% 3l. Levophed was at 0.1mcg. Past Medical History: --Diabetes --epididymitis --Orchitis --Hypertension --BPH --Urinary retention Social History: Denies tobacco or illicit drug use. Ocassional ETOH. Married with 6 children. Family History: No CAD Physical Exam: Admission exam VS: 102, 97, 105/43 (on .03mcg of Levophed), SP02 95% on 3L GENERAL: Lethargic, diaphoretic, no acute distress HEENT: Mucous membranes dry NECK: JVP not elevated CHEST: CTA bilaterally with slight crackles at bases CARDIAC: Tachycardic, regular rhythm ABDOMEN: +BS, soft, non-tender BACK: Right nephrostomy tube in place, draining pink urine GU: Foley in place EXTREMITIES: Warm and well-perfused, no edema bilaterally . DISHCARGE PHYSICAL EXAM afebrile, vital signs stable. BP 100s-120s/80s changes include: alert and interactive, oriented x 3 no murmurs right nephrostomy tube well placed, no erythema or tenderness at insertion site foley in place, draining good urine Pertinent Results: Admission labs [2119-12-10] 10:25AM BLOOD WBC-15.7# RBC-4.59 Hgb-13.6* Hct-38.7* MCV-84 MCH-29.7 MCHC-35.2* RDW-12.7 Plt Ct-206 [2119-12-10] 10:25AM BLOOD Neuts-89.7* Lymphs-6.4* Monos-3.0 Eos-0.6 Baso-0.4 [2119-12-10] 10:50PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2119-12-10] 07:04PM BLOOD PT-11.1 PTT-29.6 INR(PT)-1.0 [2119-12-10] 10:25AM BLOOD Glucose-235* UreaN-29* Creat-1.8* Na-137 K-4.0 Cl-97 HCO3-28 AnGap-16 [2119-12-10] 10:25AM BLOOD ALT-22 AST-22 AlkPhos-79 TotBili-1.5 [2119-12-10] 10:25AM BLOOD Lipase-27 [2119-12-10] 10:50PM BLOOD Calcium-7.5* Phos-2.7 Mg-1.9 [2119-12-10] 03:32PM BLOOD Lactate-3.6* . Discharge labs [2119-12-14] 07:30AM BLOOD WBC-10.1 RBC-4.28* Hgb-12.9* Hct-36.7* MCV-86 MCH-30.1 MCHC-35.2* RDW-12.4 Plt Ct-237 [2119-12-14] 07:30AM BLOOD Glucose-115* UreaN-15 Creat-0.8 Na-141 K-4.2 Cl-105 HCO3-26 AnGap-14 [2119-12-14] 07:30AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9 [2119-12-10] 01:20PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.013 [2119-12-10] 01:20PM URINE Blood-MOD Nitrite-POS Protein-TR Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG [2119-12-10] 01:20PM URINE RBC-25* WBC-61* Bacteri-FEW Yeast-FEW Epi-0 TransE-<1 [2119-12-10] 01:20PM URINE Mucous-RARE . MICRO: Blood Culture, Routine (Final [2119-12-14]): STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES. STAPHYLOCOCCUS EPIDERMIDIS. SECOND MORPHOLOGY. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS EPIDERMIDIS \| STAPHYLOCOCCUS EPIDERMIDIS \| \| CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- =>8 R 4 R OXACILLIN-------------<=0.25 S <=0.25 S TETRACYCLINE---------- 8 I 4 S VANCOMYCIN------------ <=0.5 S <=0.5 S . [12-13] BLOOD CULTURES NO GROWTH TO DATE . IMAGING: [12-10] CT ABD/PELVIS COMPARISON: CT examinations dated [2118-5-25] and [2113-12-19]. FINDINGS: The included portions of the lung bases demonstrate minimal atelectasis but no focal consolidation or pleural effusion. Within the abdomen, there is mild right-sided hydronephrosis and proximal right hydroureter. A 5-mm obstructing stone is seen within the proximal right ureter (2:44). A cyst within the interpolar region of the right kidney is unchanged (2:33). On the left, large non-occlusive calculi measuring up to 12 mm in the upper pole appear grossly similar to the prior examination. Smaller 1- to 2-mm non-obstructing calculi are seen within the lower pole and interpolar region. A focal area of cortical thinning/scarring in the left kidney appears unchanged (2:35). No left-sided hydronephrosis or hydroureter is seen. Again noted are several stones within the urinary bladder which lie dependently (2:70). The non-contrast appearance of the gallbladder, spleen, pancreas and adrenal Glands is grossly unremarkable. There is some fatty deposition within the liver without evidence of focal liver lesion. Loops of small and large bowel are normal in size and caliber. The patient is status post anterior abdominal hernia wall repair. There are bilateral fat-containing inguinal hernias. The prostate gland is enlarged measuring up to 6.5 cm in diameter. The seminal vesicles are prominent, however, unchanged. Distal loops of large bowel and rectum are normal in size and caliber. No evidence of diverticulosis or diverticulitis. The appendix appears normal. No intra-abdominal free air, free fluid or lymphadenopathy is seen. No concerning osseous lesion is seen. IMPRESSION: 1. 5 mm obstructing stone within the right proximal ureter with mild proximal right hydroureter and hydronephrosis. 2. Multiple non-obstructing stones in the left kidney. 3. Multiple bladder stones layering dependently. 4. Enlarged prostate. 5. Fatty liver. Brief Hospital Course: This is a 72-year-old gentleman with a history of kidney stones, hypertension(HTN), hyperlipidemia, epididymitis, orchitis, and urinary retention who was admitted to the MICU with sepsis from a urinary source. . ACTIVE ISSUES BY PROBLEM: # Septic shock/Sepsis due to UTI: His sepsis was in the setting of grossly positive urinalysis and obstructing stone in right ureter. IR placed uncomplicated right nephrostomy tube prior to MICU admission on [2119-12-20]. Mr. [Known lastname 21006] was given fluid in ED and started on vasopressors for hypotension. Blood cultures came back with staph epidermidis, sensitive to vancomycin. He was treated with vancomycin and ceftriaxone intially however after the sensitivities returned he was narrowed to just vancomycin for a 14 day total course from [2119-12-10]. His nephrostomy tube is to remain in place until he can have an outpatient lithotripsy in [2-4] weeks (appointment [12-25]). He was also discharged with a foley (see BPH below). . # Urinary tract infection: Although his urine did not grow any specific organism, he did have a grossly positive urinalysis and became bacteremic after nephrostomy tube placement. His surveillance blod cultures were no growth to date at the time of discharge. . # Benign prostatic hypertrophy (BPH)/Obstructive uropathy: Initially held tamsulosin due to hypotension, but restarted once his pressures were normal. Even after restarting the tamsulosin, however, he was having great difficulty urinating. He had to have a catheter placed again. Another voiding trial was done, however, he again had urinary retenetion. He reports that this has happened to him before and he had to have a catheter for about 1 week. Urology was notified and they recommended that he leave the foley in place and follow-up with them on [12-25]. . CHRONIC ISSUES: # ANEMIA: Patient with Hct drop of 38.7 down to 33.1. Unclear cause but stable, likely dilutional. . # HTN: Initially was holding all his home medications due to hypotension from sepsis. When he was normotensive, he was restarted on lisinopril 10 mg daily. His thiazide was still held due to blood pressures being well controlled. This can be restarted by his primary care doctor if his blood pressures are elevated. . TRANSITIONAL ISSUES: - Please make sure that he completes his course of vancomycin until [2119-12-24] - Please make sure that his blood pressure remains well controlled, if not, restart hydrochlorothiazide - Please make sure that his kidney stone is treated, the plan is for outpatient lithotripsy and then removal of the right nephrostomy tube - Please make sure that he has better management of his BPH and removal of the foley catheter Medications on Admission: hctz 25mg QD, ASA 81mg QD, tamsulosin 0.4mg QD, metformin 100mg 1 tab in AM, [12-4] tabx2 per day, lisinopril 10mg QD, glyburide 2.5mg QD. Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. 3. metformin 1,000 mg Tablet Sig: as directed Tablet PO once a day: 1 tab in the morning and then [12-4] tab at lunch and [12-4] tab at dinner. 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. Disp:60 Tablet(s) Refills:0 7. vancomycin 1,000 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 12H (Every 12 Hours) for 11 days: end date [12-24]. Disp:qs mg Refills:0 8. 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. 9. Outpatient Lab Work Please obtain CBC, chemistry panel (sodium, potassium, Chloride, bicarb, BUN, creatinine, glucose), liver function tests (ALT, AST, Alk Phosp, Total Bili), vanc trough. please obtain labs on Monday [12-18]. please call in results: [First Name9 (NamePattern2) ] [Last Name (LF) ],[First Name3 (LF) ] F. [Telephone/Fax (1) 608] Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Septic shock Urinary tract infection Right nephrolithiasis Benign prostatic hypertrophy . SECONDARY DIAGNOSES Hypertension Diabetes mellitus, type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 21006], . You were admitted to the hospital because you were having back pain. You were found to have a stone in your ureter which is the tube draining urine from your kidney into the bladder. Because the stone is still blocking the drainage of urine, you need a tube in your right side to drain the urine that your right kidney makes. You will follow-up with the urologists (kidney specialists) so they can break the stone and take out this tube. . This kidney stone was also infected and caused you to have bacteria in your blood stream. For this, you received antibiotics through the IV and lots of IV fluids. For a brief time, you were in the ICU because your blood pressure was low from the infection. . The following changes were made to your medications: START vancomycin 1250mg IV twice daily until [2119-12-24] STOP hydrochlorothiazide until you visit your primary care doctor . It is also very important that you keep all of the follow-up appointments listed below. . It was a pleasure taking care of you in the hospital! Followup Instructions: Department: BIDHC [Location (un) ] When: THURSDAY [2119-12-21] at 10:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 607], MD [Telephone/Fax (1) 608] Building: 545A Centre St. ([Location (un) 538], MA) None Campus: OFF CAMPUS Best Parking: Department: SURGICAL SPECIALTIES When: MONDAY [2119-12-25] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4653], MD [Telephone/Fax (1) 164] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 5849, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6256 }	Medical Text: Admission Date: [2128-8-9] Discharge Date: [2128-8-23] Date of Birth: [2055-9-16] Sex: M Service: SURGERY Allergies: Imuran Attending:[First Name3 (LF) 1] Chief Complaint: medically recalcitrant ulcerative colitis Major Surgical or Invasive Procedure: total abdominal colectomy hartmann pouch umbilical hernia repair drainage of intraabdominal abscess CVL placement PICC line placement hyperalimentation hypokalemia History of Present Illness: 72M with ulcerative colitis (diagnosed 9 yrs ago), who presented for elective total abdominal colectomy on [2128-8-9]. On presentation, he was noted to dyspneic and a CXR did not reveal any infiltrate. No fevers/chills, but he reports a decreased appetite over last few days. Past Medical History: UC, COPD (on home O2), gout, anxiety, HTN Social History: +etOH, +cigs (but quit) Family History: noncontributory Physical Exam: Afeb, VSS but requiring O2 Tachypneic RRR Coarse BS Soft obese nontender [1-18]+ pedal edema Pertinent Results: [2128-8-23] 03:55AM BLOOD WBC-15.1* RBC-3.17* Hgb-10.2* Hct-32.5* MCV-103* MCH-32.2* MCHC-31.3 RDW-18.3* Plt Ct-304 [2128-8-23] 03:55AM BLOOD Glucose-131* UreaN-23* Creat-0.6 Na-148* K-3.9 Cl-106 HCO3-37* AnGap-9, Calcium-8.0* Phos-4.0 Mg-1.7 [8-10] sputum culture: Pseudomonas ([Last Name (un) 36] zosyn) [8-21] CXR: improved lower lobe opacities & CHF [8-18] CT abdomen/pelvis: no abscess, PO contrast progresses into ostomy bag Brief Hospital Course: After preoperative chest XRay on [8-9], he was taken to OR for ex lap w/ total abdom colectomy. Please refer to previously dictated op note for details of this procedure. Briefly, an intraabdominal abscess was found adjacent to a particularly inflamed region of the sigmoid colon. This was promptly drained, and a total colectomy with hartmann pouch & end ileostomy was performed. His 15 day postop course was relatively complicated and can be summarized via organ systems as follows. NEURO: He continued his preop ativan for anxiety, but as his pain improved, he required less anxiolysis & less narcotics. CV: Right bundle branch block. 1 intermittent episode of postop atrial fibrillation. He was rate controlled with lopressor, which was continued for periop cardiac protection. RESP: Preoperative pneumonia, which blossomed after surgery. He improved with double antibiotic coverage for pseudomonas. He currently has O2 sats in the mid 90s on supplemental oxygen & he receives neb treatments & advair. FEN: Still markedly over his baseline weight (70 kg), he is being maintained on a standing lasix dose. This can be tapered once he is more euvolemic. His electrolytes should be checked regularly while on the lasix. Nutritionally, he required TPN for 10 postop days while awaiting stoma function. GI: The ostomy has been functional for several days now. He has tolerated PO nutrition over the last few days without complication. He should receive boost supplements TID to maintain his caloric intake. He is written for PPI for gastric prophylaxis while on his steroids. HEME: stable hct. He is on DVT prophylaxis with SQ heparin. His WBC of 15 on discharge is trending downward from the low 20s last week. No other issues. ID: He finished a 2 week course of antibiotics for pseudomonal pneumonia. There had been a concern for a persistent abdominal process, given his high WBC & slow ostomy progression, but an [8-19] CT scan was unremarkable. ENDO: He was pulsed with high dose hydrocortisone perioperatively, and was weaned to current dose of 20mg prednisone without adrenal insufficiency. He will be further tapered following his outpatient f/u with Dr [Last Name (STitle) ]. He briefly required IV insulin while on TPN & high dose steroids. DISPO: going to [Hospital 26478] Rehab Facility. Full code. HCP: [Name (NI) ] [Name (NI) ] ([Telephone/Fax (1) 26479]) Medications on Admission: lasix 40', norvasc 2.5', ativan 0.5', folate, asacol 1200qid, prednisone 40', loperamide, hydrocort enemas, albuterol, advair, MVI, vitamin E, fibercon, fish oil, caltrate, rolaids prn, Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). Disp:30 ML Refills:2 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. Disp:1 neb Refills:5 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. Disp:1 neb Refills:5 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): hold for SBP<100, HR<60. Disp:270 Tablet(s) Refills:2 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:250 ML(s) Refills:1 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:30 Tablet(s) Refills:2 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. Disp:1 inhaler Refills:2 10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed): to affected skin. Disp:qs container Refills:2 13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 14. Outpatient Lab Work CBC, Chem 10 q WK to follow WBC & electrolyte trends Discharge Disposition: Extended Care Facility: [Location (un) 26478] - [Location (un) 1157] Discharge Diagnosis: ulcerative colitis, s/p total colectomy COPD (on home O2) abdominal abscess s/p operative drainage gout anxiety disorder HTN pseudomonal pneumonia Discharge Condition: good Discharge Instructions: Diet as tolerated. Continue your medications as prescribed. You will be taking a smaller dose of prednisone. Contact your MD if you develop fevers > 101, increasing abdominal pain or inability to tolerate oral diet, inadequate ostomy output, or if you have any questions or concerns at all. Followup Instructions: Contact Dr.[Name2 (NI) 10946] office at [Telephone/Fax (1) 9] to arrange a follow up appointment in about 10 days. You should try to arrange a follow up appointment with the ostomy nurses in the next 2-3 weeks as well. Call ([Telephone/Fax (1) 26480] to schedule an appointment. Completed by:[2128-8-23] ICD9 Codes: 4280, 2768, 2749, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6257 }	Medical Text: Admission Date: [2179-1-26] Discharge Date: [2179-1-31] Date of Birth: [2102-5-31] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: elective transbronchial biopsy. Major Surgical or Invasive Procedure: bronchoscopy with transbronchial biopsy intubation History of Present Illness: HPI: 76 yo M with Afib, pacer, CAD s/p CABG, Ischemic CHF EF <40% w/2+MR [First Name (Titles) ] [Last Name (Titles) 34514] dx RUL mass admitted to MICU after failing extubation from an outpatient bronchoscopy. On [2179-1-26], the patient had an elective bronchoscopy and biopsy of the lung mass by interventional pulmonolgy. He tolerated the procedure well. 1-2 minutes post procedure the patient became hypertensive (SBP 170's to 200's), tachycardic (130's), and hypoxic to the 70's on NRB. He was intubated and transferred to the CCU. [Date Range ] failure attributed to flash pulmonary edema. He was treated with nitroglycerin gtt, lasix and saturations improved. He ruled out for MI, ecg was unchanged and PE was ruled out with CTA. TTE was repeated [2179-1-26] w/ EF<25% which is significantly decreased from [2179-1-7]. Possible etiologies of flash edema vs COPD exacerbation were considered and he has been on a 2 month slow taper of Prednisone 5mg daily. He was extubated on [2178-1-27] successfully and has remained on 2L NC thoughout today. . Of note, he also recently hospitalized [Date range (1) 34515]/05 for symptomatic bradycardia. Pacer placed. He presented again with SOB and found to have a mass consistent with lung cancer on CT. He is PPD negative ([2179-1-14]). . He currently reports no sob and is sitting on the edge of his bed without oxygen. C/o discomfort in his right chest wall since the biopsy that has been alleviated with acetominophen. NO cp/palp/n/v/anorexia. Ambulating well with assist and taking pos with normal BM and urination. Past Medical History: 1) COPD/chronic bronchitis, on chronic prednisone, [2161] fev 1.0/fvc 52% no recent PFTs on file 2) Afib - started coumadin [2172] currently off anti coagulation for bronch 3) s/p [Company 1543] V/V/I [Company 4448] placement [2178-12-23] for symptomatic bradycardia with prolonged QT leading to torsades and VT 4) CAD - s/p CABG in [2168] in non-Q wave MI. LIMA to LAD, SVG to RCA and PVA, recent normal stress nuclear study [12-28] 5) h/o small cerebellar bleed w/supratherapeutic INR [12-28] 6) Ischemic cardiomyopathy systolic dysfunction 7) hypercholesterolemia 8) RUL mass 9) Negative PPD [2179-1-14] (while on steroids) 10) recent 30lb unintentional wt loss [12-28] 11) syncope 12) hearing loss 13) h/o ETOH abuse/dependence 14) iron deficiency anemia since [9-28], pt previously refused c-scope or iron replacement Social History: h/o ETOH dependence, no illicits, former smoker quit in his 50s retired, ambulates with walker at home Family History: Non-contributory Physical Exam: After call out from ICU: VS: 97.4 115/70 80 18 97% on 2L tele: AF Gen: pleasant, cachectic man, well-appearing, conversant HEENT: anicteric, mmm Neck: supple, jvp at 10 cm CV: irreg, nl s1, loud s2, no split, 2/6 systolic m, no r/g Resp: poor air movement, decreased bs and dullness on right, exp wheezes on left Abd: s/nt/nd/nabs Back: no cva or spinal tenderness Ext: warm, trace edema, cap refill <2sec Neuro: A&Ox3, appropriate, CN grossly intact, MAE, gait not assessed Pertinent Results: [2179-1-26] CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST IMPRESSION: 1. No evidence of pulmonary embolism. 2. Perihilar mass and prominent perihilar lymph nodes, as seen previously. 3. Nodular opacities in the right upper lobe as seen previously. 4. New vaguely defined bibasilar nodular densities as well. 5. Status post sternotomy and coronary artery calcifications. 6. Severe emphysema. . [2179-1-26] Trans-Thoraci Echocardiogram Ejection Fraction <25% 1. The left atrium is mildly dilated. 2. The left ventricular cavity is dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The aortic root is mildly dilated. 5. The aortic valve leaflets are mildly thickened. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. Compared to the findings of the prior study of [2179-1-7], left ventricular systolic function has deteriorated. . Head CT: There is stable widening of the extra-axial spaces, prominence in the sulci and ventricles, consistent with age-related involutional changes. The previously noted focus of hyperdensity in the lateral right cerebellum is not appreciated on this study. There are cerebellar calcifications, which are unchanged, as well as basal ganglia calcifications. Some relative hypodensity in the left temporal lobe is unchanged. There are vascular calcifications. There is a small calcified extra-axial mass in right frontal region suggestive of calcified meningioma, unchanged. With the administration of contrast, there are no metastases evident. There is an opacity in the right maxillary sinus, probably a retention cyst. There is sclerosis in the right mastoid air cells, which is unchanged, and to a lesser degree on the left. IMPRESSION: No evidence of metastatic disease. Brief Hospital Course: Impression/Plan: Pt is a 76 yo M with CHF/systolic dysfunction 2+MR [First Name (Titles) 151] [Last Name (Titles) ] failure in setting of hypertensive/tachycardic stress leading to flash pulmonary edema. . # Hypoxia: It was felt that this was likely [2-25] to CHF and chronic COPD. After the flash pulmonary edema he improved greatly with lasix diuresis and when called out the floor was sat'ing in the mid 90's on room air. He was continued on an ACE inhibitor and slow steroid taper was completed. He was evaluated by PT and it was determined that he did not require home O2. He was continued on his [Month/Day (2) ] inhalers and on discharge was recommended to consider using Spiriva. . # CHF: as above, his symptoms improved with diuresis. Echo showed new global HK and depression in EF <20%, and this was felt potentially from stunning and demand ischemia. ACEi was started for afterload reduction and remodeling benefits and he was started on low dose beta blocker trial and spironolactone. 2g Na diet, fluid restrict, CHF teaching, daily wts were done. At the time of discharge the pt was euvolemic and did not require any po lasix daily. He will follow up with his PCP in the next week to determine if this might be needed in the future. . # Lung Mass: Bronchoscopic biopsy showed squamous cell lung cancer. Pt was informed of this result and his PCP recommended that he see Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in oncology, so the pt was given the phone number to call and make an appointment. He was instructed to discuss with his PCP if he should see a CT surgeon for evaluation if this might be a possibility. . # AF s/p pacer: HR was initially high, but then was controlled with diltiazem. This was then changed to Toprol and HR and BP was in good range. He underwent a head CT to rule out metastases, and when no mets were seen, he was restarted on coumadin at his previous dose. . # Metabolic alkalosis: it was felt that the pt had a mild volume contraction given aggressive diuresis in setting of CO2 retention and baseline HCO3 of 30s when outpt. O2 sats were in the mid 90's on room air and the pt was not given supplemental oxygen to increase this so that further CO2 retention would occur. . # h/o CAD: presumed stable, ruled out for MI in setting of stress, recent nuclear study within normal limits. He was started on asa, statin, bb and continue ace-I for secondary prevention. . # Microcytic anemia: stable. New since [2178-5-24]. Outpatient c-scope needed . # Wt loss 30lb: stable. Likely due to malignancy. . F/E/N: Cardiac, 2g Na diet, no IVF Access: PIVs Contact: Wife Prophylaxis: SC Heparin, PPI while on steroids Code Status: FULL CODE Medications on Admission: Complete list unclear per pt and wife, adherence unclear [Name (NI) 19188] MDI [Name (NI) 4010] 250/50 1 puff [Hospital1 ] coumadin 2.5mg (stopped taking 1 week ago) protonix 40mg qday prednisone taper since 2 months ago (on 5mg qday to finish thursday) lisinopril (per cards but wife did not have this med listed) Not clear why pt not on BB, ASA or statin with CAD hx Discharge Medications: 1. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain/fvr. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 11. [Hospital1 19188] 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 12. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:1 Cap(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Hypoxic [Hospital ] failure CHF exacerbation Discharge Condition: stable Discharge Instructions: If you develop fevers, chills, shortness of breath, chest pain, or trouble breathing, please call your PCP or come to the ED. Followup Instructions: Please follow up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] in the next week. Call [Telephone/Fax (1) 1579] to make an appointment. Please discuss with him if he has a recommendation for a thoracic surgeon. You will also likely need to get pulmonary function tests, which can be arranged by Dr. [Last Name (STitle) ]. Please also call to make an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in oncology ([Telephone/Fax (1) 5562]. Provider: [Name10 (NameIs) ] CALL Phone:[Telephone/Fax (1) 59] Date/Time:[2179-3-2] 11:30 Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2179-4-2] 1:00 ICD9 Codes: 4280, 496, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6258 }	Medical Text: Admission Date: [2122-1-7] Discharge Date: [2122-1-16] Date of Birth: [2067-6-22] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old female without significant past medical history who presented to [Hospital1 69] Emergency Department on [1-6] with complaints of fever and increasing shortness of breath. Chest x-ray at her primary care pneumonia. She took one dose of Levofloxacin at home, but her family noted persistent temperature at 103.0 F and mental status change so they brought the patient to the Emergency Department. At the Emergency Department, the patient received Ceftriaxone and evaluation by MICU Team given her vital signs with a 80/42. Oxygen saturations were 90 to 03% on four liters nasal cannula. She was transferred to the MICU on [1-7] where she was intubated secondary to worsening respiratory distress and hypoxemic respiratory failure. Due to persistent hypotension, she was transiently maintained on a Neo-Synephrine drip on [1-7] and [1-8]. Her systolic blood pressure has been stable since then and her blood pressures were supportive of IV fluids. Her respiratory status slowly improved and she was able to be weaned from the ventilator and was extubated on [1-14]. Studies performed in the MICU as part of her evaluation and treatment included CT Scan of the chest on [1-7] which showed consolidation of the right lower lobe and part of right middle lobe with multiple patchy opacities and ground-glass opacities bilaterally as well as small bilateral pleural effusions, left more than right. Of note, the CT Scan was also significant for diffuse fatty liver infiltration. Bronchoscopy was done [1-8] which showed no intrabronchial lesions. TT was done on [1-9] and was significant for an ejection fraction of 60%, no valvular disease, normal LV and RV function, no pulmonary artery systolic hypertension. PA catheter was placed on [1-9] through [1-12] to monitor the volume status. This showed increased CVP and decreased urine output. This showed pulmonary capillary wedge pressure of 18 to 20. The patient also had decreased urine output, however she had no rising creatinine. Given her clinical improvement, she was transferred to the floor on [2122-1-15]. PAST MEDICAL HISTORY: 1. Viral meningitis. 2. History of ectopic pregnancy. 3. History of ovarian cyst. MEDICATIONS AS OUTPATIENT: Motrin p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Married and lives with her husband. Smokes two to three packs per week for 40 years. Denies alcohol use. PHYSICAL EXAMINATION: Temperature 98.6 F, heart rate 63, blood pressure 140/80, respirations 18. Saturations 96% on three liters. In general awake, alert, breathing comfortably on three liters of nasal cannula. Able to answer questions appropriately in no acute distress. Slow, but appropriate. Extraocular movements intact. Anicteric sclerae. Oral mucosa dry. Neck supple. Thyroid is palpable, mildly enlarged without any palpable nodules. No lymphadenopathy noted. Lung exam: Crackles at the bases bilaterally and right mid field, no wheezes. Cardiac exam: Regular rhythm and rate, normal S1, S2, no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended with positive bowel sounds. Extremities: No edema with 2+ pulses in all four extremities. Neuro exam: Cranial nerves II through XII intact. Sensation is intact in all four extremities. Extremities: Strength is 3 to [5-16] in all four extremities. PERTINENT LABORATORIES: White cell count 9.5, hematocrit 31.1, platelets 579, INR 1.1. Sodium 144, potassium 4.1, chloride 106, bicarbonate 27, BUN 10, creatinine 0.5, glucose 104, calcium 8.8, phosphorus 3.8, magnesium 2.2. Microbiology data: Clostridium difficile was negative on [1-12]. Viral cultures sent on [1-9] and negative for date, negative for influenza and B antigen. BL culture sent on [1-8]. Gram stain showed PMNs, but no organisms, no AFB, no fungus was isolated. Cultures negative to date. Legionella cultures negative to date. PCP IF test was negative. Blood cultures times four drawn on [1-7] negative to date. Legionella urine antigen negative. HOSPITAL COURSE: She was transferred from the MICU to the floor on [2122-1-15] for pneumonia. The patient was continued on Azithromycin and Ceftriaxone, both started on [1-7]. Her oxygen saturations improved over the next two days with oxygen saturations at 96% on room air at the time of this dictation. 2. GASTROINTESTINAL: The patient had diffuse fatty liver infiltration on CT Scan on [1-6] and mild transaminase. At the time of admission, the liver function tests were repeated and came back with ALT, AST normal at 25, alkaline phosphatase normal at 79 and total bilirubin normal at 0.2. 3. HEMATOLOGY: The patient was admitted with anemia at baseline with a hematocrit of 33. Her hematocrit remained stable with no symptoms or signs of bleeding. 4. NEUROLOGIC: The patient had profound weakness upon transfer. This with mild mental status changes was contributed to a prolonged MICU stay and resolved on [2122-1-16] with improved muscle strength. She was evaluated by Physical Therapy who recommended acute rehab. DISCHARGE DIAGNOSES: Pneumonia. CONDITION ON DISCHARGE: Stable. DIET: Regular. DISCHARGE MEDICATIONS: 1. Miconazole powder 2% to apply as needed. 2. Ceftriaxone 1 gram IV q. 12 hours, last day [1-22]. 3. Azithromycin 250 mg p.o. q. 24 hours, last day [1-22]. 4. Colace 200 mg p.o. b.i.d. 5. Dulcolax 10 mg p.r. at night as needed. 6. Atrovent two puffs inhaler q. four to six hours p.r.n. 7. Albuterol one to two puffs q. four to six hours p.r.n. FOLLOW UP: The patient will follow up with her primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 838] upon discharge from acute rehab. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6384], M.D. [MD Number(1) ] Dictated By:[Last Name (NamePattern4) 26613] MEDQUIST36 D: [2122-1-16] 10:50 T: [2122-1-16] 11:36 JOB#: [Job Number 26614] ICD9 Codes: 2765, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6259 }	Medical Text: Admission Date: [2109-1-2] Discharge Date: [2109-1-8] Date of Birth: [2076-10-12] Sex: M Service: [Hospital1 139] Medicine HISTORY OF PRESENT ILLNESS: Patient is a 32-year-old man with a [2-5] year history of intermittent episodes of bright red blood per rectum with former EtOH/IV drug abuse as well as questionable history of hepatitis and history of Crohn's disease versus diverticulosis. Patient presented to the Emergency Department on [2109-1-2] with severe bright red blood per rectum. Patient had an episode of passing bright red blood without stool in the morning of admission at work. Patient then decided to proceed to his physician's office, however, while walking, he experienced another significant bleed with blood running down his leg. Subsequent to that episode, he had a syncopal episode after sitting down on a sidewalk subsequent to the bleed. Furthermore, the patient had two more episodes of bright red blood per rectum in the Emergency Department on arrival. He does describe feeling fatigued for the past 2-3 weeks. In the Emergency Department, the patient arrived at 10:30 am tachycardic to the 100's and hypotensive to 88/palp with large amounts of frankly bloody stool. His initial hematocrit was 35 and dropped to 30 status post hydration. Patient was aggressively hydrated with 6 liters of normal saline and transfused with 3 units of packed red blood cells with improvement to a heart rate of 96 with a blood pressure of 144/56. His nasogastric lavage was negative. Two large bore IVs were placed. The prior workup of the patient's episodes of rectal bleeding include two esophagogastroduodenoscopies and two colonoscopies by Dr. [Last Name (STitle) ] in [Location (un) ], which revealed mainly a colonic polyp. Two more "suboptimal" colonoscopies at [Hospital6 27253] with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] which revealed a small amount of diverticulae. At that point, the patient had been started on Asacol for presumed Crohn's disease. He had remained asymptomatic until this episode on the date of admission. Regularly, the patient has one bowel movement per day. He has no history of coagulopathy or blood dyscrasia. PAST MEDICAL HISTORY: 1. Bright red blood per rectum x3-4 years intermittently with approximately 3-4 episodes requiring hospitalization. 2. Hepatitis. 3. Diagnosis of Crohn's disease versus diverticulae in approximately the year [2105]. PAST SURGICAL HISTORY: None. MEDICATIONS: Asacol 200 mg tid (the patient ran out of this medication three days prior to admission). FAMILY HISTORY: 1. Significant for both parents dying of drug overdoses. 2. Sister with a history of UC versus diverticulitis. 3. No other history of gastrointestinal disease in his family. SOCIAL HISTORY: The patient works as a systems analysis and lives in [Location 46391] with his wife and children. He denies any EtOH or drugs now, however, does report a 10 year history of alcohol abuse as well as IV drug abuse. He quit both of those approximately 10 years ago. The patient does smoke about a half a pack per day and has done so for 20 years. He is sexually active with his wife. LABORATORIES ON ADMISSION: White blood cell count of 8.9, hematocrit of 35.7, platelets of 209. PT was 13.0, PTT was 25.9, INR was 1.1. Urinalysis was negative. Electrolytes: Sodium of 145, potassium 4.0, chloride 113, bicarb 24, BUN 18, creatinine 0.8, glucose 119. AST 23, ALT 29, LD 156, alkaline phosphatase 64, amylase slightly elevated at 114. Total bilirubin of 0.3, lipase is elevated at 205. Albumin is 3.6, calcium 8.2, phosphorus 3.6, magnesium at 1.4. Hepatitis serologies were sent and the patient was found to be hepatitis B surface antigen negative. Hepatitis B surface antibody positive. Hepatitis B core antibody positive and HAV positive antibody, HCV antibody positive. PHYSICAL EXAMINATION ON ADMISSION TO THE MICU: Temperature was 96.7, heart rate 86, blood pressure 113/68, O2 saturation was 96% on room air. In general, the patient was in no apparent distress. HEENT: Pale conjunctivae, moist mucous membranes, no scleral icterus. Neck showed no jugular venous distention, no bruits, no lymphadenopathy. Chest was clear to auscultation bilaterally. Cardiovascularly regular, rate, and rhythm, normal S1, S2, no murmurs, rubs, or gallops appreciated. Abdomen with positive bowel sounds, slightly tense and mildly distended, however, nontender. Large amount of blood and clot around rectum, and no exterior hemorrhoids are visualized. Extremities: No cyanosis, clubbing, or edema. Skin with no spider angiomata or caput medusae. Neurologic: No asterixis and alert and oriented times three. IMPRESSION: A 33-year-old man with a [2-5] year history of intermittent gastrointestinal bleed with bright red blood per rectum admitted with copious bloody bowel movements and anemia. Initially, the patient was hypotensive and tachycardic and on transfer to the MICU, was stable subsequent to volume resuscitation and multiple blood transfusions. Patient has a questionable history of left sided diverticulosis versus Crohn's disease. HOSPITAL COURSE: The patient was initially admitted to the Medical Intensive Care Unit for close monitoring and management of his GI bleed. 1. Heme. The patient was anemic secondary to brisk gastrointestinal bleeding. There was no suggestion of coagulopathy secondary to his laboratories. He was transfused for a hematocrit greater than 28 throughout his stay. The patient underwent a tagged red blood cell scan on hospital day two, which was negative for any evidence of continued brisk bleeding. His hematocrit was checked serially throughout his stay. The patient's hematocrit eventually stabilized to a level of 28.9. However, on hospital day four, the patient was found to be orthostatic and therefore was further transfused another unit of packed red blood cells with resolvement of his symptoms. Patient's hematocrit then stabilized out at a level greater than 30 to approximately 32 for the remainder of his stay. The patient received a total of 5 units of packed red blood cells with hematocrit stabilized to 35 on discharge. 2. Cardiovascular. During the patient's MICU stay, he was monitored on Telemetry without incident. Electrocardiogram was performed and was normal with a heart rate of 90 beats per minute and normal sinus rhythm. There were no ST elevations or depressions and there were no T-wave inversions. No other evidence of cardiac injury secondary to his anemia. 3. Gastrointestinal. As stated before, the patient underwent TAG red blood cell scan on [2109-1-3] which was negative for any acute gastrointestinal bleed. The patient was begun on Protonix for GI prophylaxis. On [2109-1-4], patient was scheduled to undergo enteroscopy, however, the patient was unable to tolerate the procedure secondary to inability to appropriately be sedated. Therefore, the examination was halted as it was not deemed safe to continue. Subsequently, the patient was deemed hemodynamically stable and was transferred to the regular Medicine floor on [2109-1-4]. As per stated above in the laboratories on admission, the patient was found to be hepatitis B and hepatitis C positive. Also he had evidence of having hepatitis A in the past. He does have normal LFTs. Hepatitis C viral load was sent and per the result was not detected via HCV RNA PCR. On [2109-1-8], the patient underwent a Meckel scan to rule out possible gastrointestinal bleed for Meckel's diverticulum. The scan was negative for Meckel's diverticulum. The patient had no further episodes of bright red blood per rectum subsequent to being transferred out of the Medical Intensive Care Unit on [2109-1-4]. The patient's diet was initially NPO and was advanced slowly to clears and then regular diet. He tolerated that well, and again continued to have normal bowel movements throughout his stay. The patient will have further followup as an outpatient with his gastroenterologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Please note that the patient was followed by the Gastroenterology Service throughout his entire stay at [Hospital1 1444]. The patient did undergo a colonoscopy during his admission. This showed diverticulae, however, did not show any source of active bleeding. This examination was performed prior to the attempt at the enteroscopy. 4. FEN. Patient was aggressively hydrated on initial admission to the Emergency Department. Throughout his stay his diet was gradually advanced. On discharge, he was tolerating a full diet and was hemodynamically stable. DISCHARGE DIAGNOSES: 1. Severe episode of bright red blood per rectum - question of diverticular bleed despite no evident site of bleeding diverticulae per colonoscopy. 2. Diverticulosis. 3. Hepatitis B. 4. Hepatitis C. 5. History of hepatitis A. CONDITION ON DISCHARGE: Stable and improved. DISCHARGE STATUS: Home without services. DISCHARGE MEDICATIONS: Protonix 40 mg po bid. FOLLOWUP: 1. The patient is to followup with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 44650] to schedule an enteroscopy for Friday, [2109-1-11]. 2. The patient will return immediately to the Emergency Department if patient has another episode of bright red blood per rectum. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Last Name (NamePattern1) 38927] MEDQUIST36 D: [2109-1-29] 17:43 T: [2109-1-30] 06:48 JOB#: [Job Number ] ICD9 Codes: 5789, 2851, 4589, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6260 }	Medical Text: Admission Date: [2154-11-9] Discharge Date: [2154-11-13] Date of Birth: [2069-5-3] Sex: F Service: MEDICINE Allergies: Amlodipine Attending:[First Name3 (LF) 832] Chief Complaint: hypotension, altered mental status, fever Major Surgical or Invasive Procedure: Right femoral CVC. Failed RIJ CVC placement. History of Present Illness: 85-year-old female with history of diastolic congestive heart failure, hypertension, hyperlipidemia, CAD s/p CABG x 3 in [8-31], and s/p multiple orthopedic procedures most recently a L total shoulder replacement [9-19] who has been in rehab and recently discharged to home. She was last hospitalized in [2155-9-23] for a segmental and subsegmental pulmonary embolism involving the right lower lobe and right upper lobe with subpleural consolidation in the right lower lobe suggestive of pulmonary infarct. She presented to the ED today via ambulance (field records unavailable) with fevers (not quantified), chills, ?rigors, nausea, vomiting, and new oxygen requirement. The patient was in her otherwise normal state of health except for joint-associated pains at baseline. Over the past 24 hours, she felt she decompensated with the aforementioned symptoms. She denies sick contacts and aspiration although some difficulty swallowing pills at time. She endorses decreased PO intake over the past few days. Her last dose of anti-hypertensives was before she presented. In the ED, she was triggerred for BP 95/44. She also spiked a fever of 103.3 in the ED. CXR suggested ?bilateral pneumonia, and she was started on vancomycin/zosyn. Labs were suggestive of acute renal failure. Around 8 AM on the day of admission, her blood pressures dropped to 59/24 with resultant peripheral levophed started. She was given a total of 7 L NS for resuscitation. Access was attempted with CVC in the RIJ but failed. She subsequently had a right femoral line placed. Pressures were subsequently 105/41, and she came to the flow on Levophed 0.08. She also required oxygen. In the ED, she was 91-92 % on 6 L NC. Initial VS on the floor were HR 95 BP 122/46 RR 21 O2 95 % on 4 L T 99.6. Patient denied any overt complaints and felt much better. She was oriented to person, time but not place. She could not say the days of the week backwards. For her functional status, she has been in rehab recurrently for orthopedic issues. She does some ADLs, limited [Year (4 digits) 12210]. She can ambulate well. Past Medical History: History of pulmonary embolism in setting of immobility Chronic Diastolic Congestive Heart Failure Hypercholesterolemia Hypertension Osteoporosis Glaucoma Osteoarthritis left sided carpal tunnel syndrome with hand numbness s/p Left knee replacement s/p Partial hysterectomy s/p Tonsillectomy s/p Bladder suspension s/p Appy s/p Breast reduction Social History: Lives in an apartment near daughter, who checks on her frequently. Her daughter does many ADLs and [Name (NI) 12210] for her. No alcohol, tobacco, or drugs. . Family History: Both mother and father died of heart attack/stroke. Physical Exam: Tmax: 37.2 ??????C (99 ??????F) Tcurrent: 37.2 ??????C (98.9 ??????F) HR: 82 (74 - 82) bpm BP: 111/56(69) {83/38(51) - 161/127(136)} mmHg RR: 16 (13 - 22) insp/min SpO2: 88% Heart rhythm: SR (Sinus Rhythm) General Appearance: No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace Skin: Warm, laceration healing on LLE Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): person, place not time, Movement: Not assessed, Tone: Not assessed Pertinent Results: I. Labs A. Admission [2154-11-9] 06:00AM BLOOD WBC-5.4 RBC-3.76* Hgb-10.8* Hct-31.9* MCV-85 MCH-28.7 MCHC-33.8 RDW-17.2* Plt Ct-399 [2154-11-9] 06:00AM BLOOD Neuts-86.6* Bands-0 Lymphs-10.6* Monos-2.1 Eos-0.5 Baso-0.2 [2154-11-9] 06:00AM BLOOD Plt Ct-399 [2154-11-9] 09:17AM BLOOD PT-48.1* PTT-39.4* INR(PT)-5.2* [2154-11-10] 02:14AM BLOOD Fibrino-518# [2154-11-10] 10:00AM BLOOD Ret Aut-2.3 [2154-11-9] 06:00AM BLOOD Glucose-106 UreaN-65* Creat-2.4# Na-132 K-5.2* Cl-95* HCO3-24 AnGap-18 [2154-11-9] 06:00AM BLOOD ALT-15 AST-22 CK(CPK)-60 AlkPhos-58 TotBili-0.4 [2154-11-9] 08:43PM BLOOD Albumin-2.8* Calcium-7.4* Phos-4.2 Mg-1.8 [2154-11-10] 02:14AM BLOOD Hapto-257* [2154-11-10] 02:14AM BLOOD Cortsol-5.8 [2154-11-9] 06:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2154-11-9] 06:14AM BLOOD Lactate-2.0 B. Cardiac biomarkers [2154-11-10] 02:14AM BLOOD CK-MB-4 cTropnT-0.02* [2154-11-9] 08:43PM BLOOD proBNP-5933* [2154-11-9] 03:34PM BLOOD CK-MB-5 cTropnT-0.02* [2154-11-9] 06:00AM BLOOD CK-MB-4 cTropnT-0.01 C. Urine [2154-11-9] 06:00AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2154-11-9] 06:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2154-11-9] 03:34PM URINE Eos-NEGATIVE [2154-11-9] 03:34PM URINE Hours-RANDOM UreaN-498 Creat-68 Na-22 K-27 Cl-18 [2154-11-9] 03:34PM URINE Osmolal-330 [2154-11-9] 06:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG II. Imaging A. CXR INDICATION: Fevers TECHNIQUE: Single frontal radiograph of the chest was compared to prior examinations, most recent radiograph dated [2154-9-22]. FINDINGS AND IMPRESSION: New opacification extending from the left hilum to both the upper and lower lobes is concerning for developing pneumonia. A small left pleural effusion may be present. A question of luceny over the left mid thorax is seen and PA and lateral views may be useful to exclude cavitation. No pneumothorax is seen. The cardiomediastinal silhouette is unchanged. The patient is status post median sternotomy. A left humeral prosthesis is partially imaged. B. CT Abd/pelvis IMPRESSION: 1. Small bilateral pleural effusions with adjacent compressive atelectasis. This is increased since the [2154-9-23] study. 2. There is no free fluid within the abdomen or pelvis to suggest an RP bleed. A right-sided femoral line is appropriately positioned with no iatrogenic complication seen. III. Cardiology A. EKG Sinus tachycardia with poor baseline. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [2154-9-22] no diagnostic interval change. Intervals Axes Rate PR QRS QT/QTc P QRS T 105 144 102 350/428 153 110 38 B. ECHO IMPRESSION: Suboptimal image quality. Right ventricular cavity enlargement with preserved free wall motion. Mild pulmonary artery systolic hypertension. Normal regional and global left ventricular systolic function. Possible small secundum atrial septal defect. Compared with the prior study (images reviewed) of [2153-10-9], the right ventricular cavity size is larger, the severity of tricuspid regurgitation is increased, and the estimated pulmonary artery systolic pressure is higher. Is there a history to suggest a primary pulmonary process - e.g., pulmonary embolism, pneumonia, etc. CLINICAL IMPLICATIONS: Based on [2150] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. IV. Microbiology [2154-11-9] 10:19PM URINE Streptococcus pneumoniae Antigen Detection-PND [2154-11-12] 2:27PM C. Diff Toxin A & B Negative [2154-11-10] Urine Legionella Negative x 2 [2154-11-9] : Bld Cultures x 2 negative, pending final results DIRECT [2154-11-10]: Influenza DFA A&B negative ### Pending studies: URINE Streptococcus pneumoniae antigen Brief Hospital Course: 85-year-old female with chronic diastolic congestive heart failure along with hypertension, hyperlipidemia, CAD s/p CABGx3, history of PE in setting of immobility, and multiple recent orthopedic procedures that presents with fever, hypotension requiring massive fluid resuscitation and pressor support thought to be secondary to septic process and decreased PO intake, resolved altered mental status, and infiltrate suggestive of pneumonia that is improving clinically. . . #. Pneumonia: Pt was admitted to ICU in septic shock as well as hypoxia requiring 6L of Oxygen. Chest xray showed multifocal pneumonia which was thought to be cause of her sepsis. She was admitted to the ICU and was briefly on pressors for a day, she did not require intubation. She was treated empirically on Zosyn, Vancomycin and Azithromycin. Urine Legionella was sent and ultimately negative. A sputum culture was order however Ms. [Known lastname ] was never able to expectorate a sample. After 2 days in the ICU she was transferred to the medical floor where she had no oxygen requirement. On the floor her antibiotic regimen was further tapered down to Zosyn, Vancomycin given her recent hospitalization and stay in rehab. (She was diagnosed with a Pulmonary Embolism last month and was in rehab following discharge, she was home several days before presenting for this hospitalization). She has been written for a total treatment course of 8 days. Her last day of antibiotics will be on [2154-11-15]. Other causes of her hypoxia were also evaluated, she had an Echo performed which showed a larger RV cavity size and tricuspid regurgitation however her clinical exam was notable for hypovolemia. . # Hypotension: In the ED Ms. [Name13 (STitle) ] was noted to be in septic shock and required 7L of normal saline for fluid resuscitation as well as Levophed for approximately 24 hours in the ICU. Her hypotension was likely a combniation of her sepsis, hypovolemia and taking her anti-hypertensives. Her cortisol level was 5.81 in the ICU but did not require steroids for adrenal insufficiency. Prior to her discharge she was actually hypertensive in the 160s-180s, asymptomatic. . # Diarrhea: Following her ICU transition to the floor Ms. [Name13 (STitle) 12101] was noted to have diarrhea, several times a day. Given her recent hospital course and antibiotic coverage a C. Diff toxin was sent and was ultimately negative, she also had no evidence of fevers or leukocytosis. She was started on Maalox for her diarrhea. Her diarrhea may be related to her antibiotic regimen, specifically Zosyn given its 8-11% association with diarrhea. Recommend continuing Maalox for now, if the diarrhea persists would recommend recheck a C. Diff toxin as well as a complete blood count to check for leukocytosis. - recommend continuing Maalox for diarrhea - recommend rechecking C. Diff toxin assay, complete blood count for leukocytosis if diarrhea is persistent . #. Acute renal failure: Patient had creatinine of 2 on admission with baseline around 1 consistent with pre-renal acute renal given responsive to fluids and FeUREA of 25 %. Her Creatinine was trended and decreased to 1.2 prior to discharge. She will need to have a Creatinine check on [2154-11-15] to ensure she remains close to her baseline especially as her furosemide regimen will be restarted. - recommend check a repeat BUN, Creatinine on [2154-11-15] to ensure Ms. [Name13 (STitle) ] renal function remains stable and close to her baseline - would restart her home dose of Furosemide 20mg on [2154-11-14] . # Supratherapeutic INR: Ms. [Name13 (STitle) 12101] was diagnosed with a segmental and subsegmental pulmonary embolism involving the right lower lobe and right upper lobe, as well as a possible pulmonary infarct of the right lower lobe on [2154-9-23] in the setting of immbolity from recent shoulder surgery. When she presented for this admission she had on presented with a supratherapeutic INR. Her INR was 5.2 and increased to 6.7 with concomitant PTT increase. The etiology is uncertain, initially the concern was the patient was not taking the appropriate amount, however, her daughter appears to be monitoring her dosing. Her INR was reversed with PO vitamin K and 3 units of FFP with a subsequent nadir to 1.2 in the ICU given the Hgb drop and concern for a possible bleed. With her hgb remaining stable she was restarted on Coumadin and bridged on a heparin gtt. - Recommend checking daily INR until it reaches a goal of [12-26]. Would redose Coumadin based on INR goal. - Recommend continuing Heparin bridge until Coumadin is therapeutic . # Hypertension Prior to discharge Ms. [Name13 (STitle) 12101] was noted to be hypertensive with systolic pressure ruanging from 160 to 180. She has remained asymptomatic, her Metoprolol was increased to 25mg [Hospital1 ]. If her blood pressure remains elevated would recommend increasing her Lisinopril if her Creatinine remains stable. . # Anemia: On admission Ms. [Name13 (STitle) 12101] had an admission Hgb of 10.8 with subsequent drop to 7.6, which was initially concerning for a bleed in setting of supratherapeutic INR. In the IC hemolysis labs were checked and were negative. The patient also had a CT abdomen/pelvis which did not show any retroperitoneal bleed, this was checked as she had a femoral line placed for her septic shock. She has not had any melena during hospitalization, she received 2units of PRBCs in the unit with her Hgb increasing from 7.6 to 10.2. Her hgb has remained stable for the past 2 days, her Hgb decrease may have been dilutional secondary to her fluid resuscitation. . # Altered Mental Status: Patient had altered mental status initially in ED likely from hypoperfusion and acute illness. She was fully orientated following stabilization of her pressures. . # Hypercholesterolemia Patient was continued on statin. . # CODE STATUS: Full code (confirmed with patient and HCP) . # EMERGENCY CONTACT: HCP [Name (NI) 1743] [Name (NI) 12211] [Telephone/Fax (1) 12212] [Known firstname ] [Last Name (NamePattern1) 805] (daughter who lives nearby patient)[Telephone/Fax (5) 12213] . Medications on Admission: senna 8.6 mg 1 tab PO prn constipation xalatan 0.005 % 1 drop in each eye once a day bedtime calcium 500 D 500 mg (1,250)- 400 unit [Unit Number ] tablet PO BID APAP 325 2 tabs PO q 4 prn pain Tylenol arthritis 650 mg 1 tab PO TID prn arthritis Lisinopril 20 mg PO qD simvastatin 80 mg 1 tab PO qHS omeprazole 20 mg PO qD prochlorperazine PO q 4 hr prn nausea Percocet 5/325 [11-24] tab PO q4-6 prn pain Tramadol 50 mg [11-24] tab PO q6 hr prn arthritis pain gabapentin 600 mg 1 tab PO BID metoprolol 25 mg PO daily warfarin 2.5 mg 11 tablets once daily (?? error, ask family to bring in bottle) Lasix 20 mg PO daily Discharge Medications: 1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for shoulder pain. 4. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q48H (every 48 hours). 10. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 gram Intravenous Q8H (every 8 hours). 11. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: 15-30 ml PO four times a day as needed for diarrhea. 12. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: per insulin sliding scale. 13. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: per Heparin scale units Intravenous continuous: Please dose per weight based guidelines. Discharge Disposition: Extended Care Facility: [Hospital1 685] Discharge Diagnosis: Primary: Septic Shock Multifocal Pneumonia Secondary: Anaemia requiring blood transfusion Acute Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital in septic shock which we think is from your Pneumonia. In the Emergency Room you were confused, you needed oxygen and your blood pressure was dangerously low; you required care in the Intensive Care Unit. There you were treated with intravenous antibiotics. You blood level was also noted to drop so you were given blood transfusions, you were checked to see if there was a source of bleeding, none was found. Your blood level has remained stable throughout your hospitalization. As you got better you were transitioned to the medical floor. As you had become weak after being so sick you were recommended to [Hospital 5511] rehab. You were also noted to have diarrhea which we think may be related to your antibiotics. The rehab will monitor your diarrhea. Your last dose of antibiotics will be [2154-11-15]. Followup Instructions: Department: ORTHOPEDICS When: WEDNESDAY [2154-11-27] at 12:00 PM With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 5500], M.D. [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Last Name (un) 12214] [Doctor Last Name ] MED GRP When: TUESDAY [2154-12-3] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], MD [Telephone/Fax (1) 5068] Building: [Location (un) ] ([Location (un) 86], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: [Hospital1 ] When: WEDNESDAY [2155-3-5] at 11:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7476], MD [Telephone/Fax (1) 7477] Building: [State 7478] ([Location (un) 86], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: None ICD9 Codes: 0389, 486, 5849, 4280, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6261 }	Medical Text: Admission Date: [2120-9-20] Discharge Date: [2120-10-21] Date of Birth: [2060-7-1] Sex: F Service: NMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5378] Chief Complaint: s/p fall mechanical AVR s/p rheumatic fever and on coumadin Major Surgical or Invasive Procedure: SDH drainage of blood by neurosurgery with drain in place for one day. History of Present Illness: 60 year-old woman with a history of rheumatic fever s/p mechanical AVR on coumadin presents s/p falling in shower [9-19]. Pt reports that while taking a shower on Thursday, she slipped and fell out of the tub, landing with her low back on the edge of the tub and banging the side of her head into the wall. She was unable to get up by herself, and called her daughter for assistance, who was asleep and took ~10 minutes to hear pt's calls. Denies any LOC, dizziness, lightheadedness, weakness before the fall; pt insists she simply slipped. Per pt, she had only a tiny amount of bleeding from her head, and thus she took some advil and went to bed with a heating pad. Reports being able to walk at that time with no difficulty and no unsteadiness. By the morning of [9-20], pain had significantly increased, and pt was unable to move as a result. Pain was mostly in her low back/coccyx and in her pelvis, especially around the pubis. Reports only mild headache, mild chronic neck stiffness. She took 600 mg advil without relief and went to her PCP's office, where she arrived in a wheelchair due to inability to walk from the pain. She was seen and was sent to ED for further evaluation. In ED, labs with INR 4.8. Given this, head CT and abdominal/pelvic CT were performed to rule out head and retroperitoneal bleed; both were negative. Additionally, plain films of LS spine and pelvis were negative for fracture. Pt was then admitted to the Observation unit for further pain control. At ~midnight, she reported to the RN that she was unable to urinate. On further questioning, she reports that she had been having difficulty urinating since her fall Thursday, but not previously. This was manifested mostly as a difficulty in initiating stream of urine, though perhaps also associated with a decreased flow rate. Denies incontinence, and denies any change from her baseline constipation. Additionally, pt had single temperature to 100.3 while in ED, and ED started empiric zosyn, for concern for epidural abscess. Foley placed with total ~430 cc out when seeing pt, unclear what exact output was after initial placement. ROS: Denies malaise, feeling ill. One episode of vomiting in ED, possibly secondary to pain meds. Denies any other constitutional, pulmonary, cardiac, gastrointestinal, urologic, dermatologic, or neurologic symptoms. Past Medical History: 1. Rheumatic fever as child, now s/p AVR with mechanical valve in [4-/2102], on coumadin 2. Hypertension 3. Depression 4. h/o chronic abdominal pain, now resolved 5. s/p TAH Social History: Widowed. Lives alternately with daughter, mother. [Name (NI) ] EtOH, drugs. Family History: HTN Physical Exam: Tm 100.3, Tc 99.8 BP 121/47 HR 93 O2 sat 96% RA General: Appears stated age, in mild distress from pain, though appears relatively comfortable when not moving [Name (NI) 4459]: NC/AT Sclera anicteric. OP clear Neck: FROM, but with some (chronic) mild neck "tightness". Lungs: Clear to auscultation bilaterally Back: Spinal tenderness ~ L4/5 to coccyx CV: RRR, nl S1, S2, no murmur. 2+ carotids without bruit Abd: Soft, normoactive bowel sounds. +tenderness over symphysis pubis and somewhat laterally as well Extr: No edema Neurologic Examination: Mental Status: Alert and oriented to person, place and date, cooperative with exam, normal affect Attention: Able to tell full story with good details Language: Fluent, no dysarthria, no paraphasic errors No neglect Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally, brisk. Extraocular movements intact, no nystagmus. Facial sensation and facial movement normal bilaterally. Hearing intact to finger rub bilaterally. Normal oropharyngeal movement. Tongue midline, no fasciculations. Motor: Normal bulk and tone bilaterally, fasiculations absent in upper and lower extremities. No tremor. Strength: D T B WF WE FiF [Last Name (un) ] FiA IP Q H DF PF TE Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 No pronator drift Decreased rectal tone Sensation was intact to light touch, pin prick, temperature (cold), vibration, and proprioception, except decreased to absent pinprick on right perianal area. Reflexes: B T Br Pa An Right 2 2 2 2 2 Left 2 2 2 2 2 Grasp reflex absent. Toes were downgoing bilaterally Coordination is normal on finger-nose-finger, rapid alternating movements, heel to shin. Gait was narrow based and normal, negative Romberg. Pertinent Results: [2120-9-20] 08:40PM WBC-9.2 RBC-3.40* HGB-10.9* HCT-31.2* MCV-92 MCH-32.0 MCHC-34.8 RDW-12.4 [2120-9-20] 08:40PM NEUTS-77.8* BANDS-0 LYMPHS-16.3* MONOS-3.8 EOS-1.5 BASOS-0.6 [2120-9-20] 08:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2120-9-20] 08:40PM PLT COUNT-170 [2120-9-20] 05:24PM URINE HOURS-RANDOM [2120-9-20] 05:24PM URINE GR HOLD-HOLD [2120-9-20] 05:24PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-<=1.005 [2120-9-20] 05:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2120-9-20] 04:55PM GLUCOSE-83 UREA N-9 CREAT-0.7 SODIUM-142 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 [2120-9-20] 04:55PM WBC-6.2 RBC-3.23* HGB-10.4* HCT-29.7* MCV-92 MCH-32.1* MCHC-34.9 RDW-12.6 [2120-9-20] 04:55PM NEUTS-48.4* LYMPHS-41.4 MONOS-6.6 EOS-3.0 BASOS-0.7 [2120-9-20] 04:55PM PLT COUNT-160 [2120-9-20] 04:55PM PT-27.6* PTT-40.2* INR(PT)-4.8 Brief Hospital Course: Pt was admitted to neurology and was found to have a bleed into a pre-existing Tarlov's cyst (in the lumbrosacral roots as they exit the cord). She was initially monitored for difficulties producing urine and feces, with question of conus medullaris syndrome but this has since resolved. On admission, her INR was 4.4 and this is likely the reason for her bleed. Her high INR was reversed with Vitamin K and FFP. She was then found to have a headache for which she recieved a CT scan of her brain showing a large SDH on the left. The pt was seen by neurosurgery and they placed a drain into the SDH and removed 300 cc of blood. After the sx, pt remained in the ICU for several days and then was stable enough for transfer to the floor. After a few days, pt was found to have a thrombus on her AVR, measuring 1.5 cm as well as an aortic aneurysm of 5 cm that has been stable in past months per cardiology. This aneurysm is an effect of the AVR and cardiology has advised watching it. We have also begun her on a heparin drip and coumadin again in light of her AVR thombus and her goal PTT is 50-70 and her INR goal is 2.0 minimum. We repeated the cardiac echo and found a resolution of the thrombus after several days of anticoagulation. The patient finally attained an INR of 2.3 on [2120-10-21] at which time she was discharged in stable condition. Medications on Admission: CLONAZEPAM 1MG--One three times a day COUMADIN -As directed HYDROCHLOROTHIAZIDE 25 MG--One tablet by mouth every day IBUPROFEN 200MG--2 three times a day as needed for abdominal pain MECLIZINE HCL 25MG--One as needed for dizziness METOPROLOL SUCCINATE 50 MG--One tablet by mouth every day -- hold for sbp<100, hr<50 Lexapro Calcium Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO QD (once a day). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal Q6H PRN () as needed for anal pain. 8. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:30 Tablet(s) Refills:0 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for PRN. 10. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Fall leading to subdural hemmorhage s/p drainage 2. Supratherapeutic INR 3. Aortic valve thrombus (not seen on most recent ECHO) 4. Hypertension 5. Anxiety Discharge Condition: Stable, tolerating an oral diet, afebrile, ambulatory. Discharge Instructions: Return to care if severe headache, nausea, vomitting, or fever occur Please take all your medications as prescribed. Please call your doctor or return to the emergency department if you notice fevers, chills, worsening headaches, prolonged bleeding, changes in your vision, difficulty moving your arms or legs, increasing confusion or somnolence, bowel or bladder incontinence, chest pain, difficulty breathing or any other symptoms concerning to you. Followup Instructions: Please follow up with your doctor in [2-21] weeks. Please follow up with the coumadin clinic within one week of discharge, and weekly thereafter. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5379] MD, [MD Number(3) 5380] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6262 }	Medical Text: Admission Date: [2168-6-22] Discharge Date: [2168-7-1] Date of Birth: [2106-7-7] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Amnesia, and mental status changes. Major Surgical or Invasive Procedure: [6-24]: Right Craniotomy for IPH History of Present Illness: Pt is a 61 yo male w/ PMHx sig for HTN and diverticulosis who presents as a transfer from [Location (un) 8117], NH for ICH. The patient has been complaining of a R sided headache over the last 4 days. In particular he has been quite photophobic to the point that he has needed to wear a hat. He went to work today as part of his normal routine, however; he left early due to a severe R sided headache. He describe the pain as behind the R eye and traveling up to the scalp. He drove home and apparently hit another car (unclear if other car was parked or moving) damaging the left side of his car. The patient continued driving and after arriving home, got into bed. His wife came home and found the left side of the car damaged. She spoke with the patient and he did not know that the care was damaged. As a result, he was brought to the ER and found to have a large R temporal hemorrhage. Past Medical History: 1. HTN 2. Diverticulosis Social History: Married, resides at home with wife in [Name (NI) ]. Family History: non-contributory Physical Exam: On Admission: Vitals: T 97.8; BP 180/100; P 74; RR 10; 100% 2L General: lying in bed, mildly lethargic HEENT: NCAT, moist mucous membranes Neck: supple Pulmonary: CTA b/l Cardiac: regular rate and rhythm, with no m/r/g Carotids: no blood flow murmur Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. Neurological Exam: Mental status: A & O x3, Able to say MOYF, breaks down with MOYB. Fluent speech with no paraphasic or phonemic errors. Adequate comprehension. Follows simple commands. Registers [2-1], recalls [2-1] at 5 min. Repetition intact (no ifs, ands or buts). Able to name low and high frequency objects. Prominent L sided neglect. + Anosagnosia. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. optic discs sharp. Left hemifield cut. III, IV, VI: EOMI. no nystagmus. V, VII: facial sensation intact, L facial droop. VIII: hearing intact b/l to finger rubbing. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: SCM [4-4] XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. L pronator drift with L hemiparesis and L leg externally rotated. Sensation: intact to light touch but diminished to absent for pinprick and proprioception on L hemibody. Extinguishes to double simultaneous stimulation Reflexes: relatively increased in the L. Toe upgoing on L and downgoing on R. Coordination: FNF intact. Gait: did not walk patient. Pertinent Results: Admission Head CT([6-22]): FINDINGS: There is a large intraparenchymal hemorrhage with mixed-attenuation hemorrhagic foci in the right frontal, parietal, and superior temporal lobes measuring approximately 5.7 x 7.5 cm at the widest cross-sectional dimension. Overall extent unchanged. There is some mass effect causing leftward 7.8-mm leftward subfalcine herniation and mild uncal herniation. Basilar cisterns remain patent. Small amount of erihemorrhagic edema is also noted. There is cortical breakthrough of the hemorrhage into the right frontoparietal subdural space with approximately 3.5-mm subdural hematoma. Small foci of subarachnoid hemorrhage are also noted in the right posterior temporal region (2:15). Overall appearance unchanged since prior study. There is also compression of the frontal and occipital horns of the right lateral ventricle. Overall appearance unchanged since the outside hospital study. The osseous structures are unremarkable without fractures. There is lipoma in the right frontal scalp measuring 6.5 mm. Post-op Head CT([6-25]): FINDINGS: There is evidence of a new right frontal/parietal/temporal craniotomy, with postoperative pneumocephalus. There has been considerable reduction in the amount of hyperdense hemorrhage within the right cerebral hemisphere, particularly in the temporal region. Blood products remain present in the frontal and parietal lobes. Mild effacement of the right-sided sulci is unchanged. There is a persistent right uncal herniation and a persistent right subfalcine herniation. The right lateral ventricle remains effaced, but its frontal [Doctor Last Name 534] is slightly less compressed. New on today's examination is hyperacute blood layering dependently within the left occipital [Doctor Last Name 534]. Subcutaneous emphysema adjacent to the right craniotomy site is expected in the immediate post-operative setting. Mastoid air cells and paranasal sinuses are well aerated. Pre-op EKG([6-22]): Sinus rhythm. Normal tracing. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 118 96 374/395 41 29 35 Labs(Admission) [6-22]: [2168-6-22] 09:10PM BLOOD WBC-10.1 RBC-5.04 Hgb-15.4 Hct-42.7 MCV-85 MCH-30.6 MCHC-36.1* RDW-14.0 Plt Ct-194 [2168-6-22] 09:10PM BLOOD Glucose-137* UreaN-12 Creat-1.1 Na-133 K-3.6 Cl-101 HCO3-21* AnGap-15 [2168-6-23] 04:08AM BLOOD ALT-16 AST-16 CK(CPK)-78 AlkPhos-81 TotBili-0.7 [2168-6-22] 09:10PM BLOOD Calcium-9.4 Phos-1.8* Mg-1.8 [2168-6-23] 04:08AM BLOOD Triglyc-54 HDL-65 CHOL/HD-3.2 LDLcalc-130* Labs(Discharge): [2168-6-30] 06:00AM BLOOD WBC-7.8 RBC-3.84* Hgb-11.5* Hct-34.6* MCV-90 MCH-29.8 MCHC-33.2 RDW-13.3 Plt Ct-224 [2168-6-30] 06:00AM BLOOD Glucose-84 UreaN-27* Creat-1.0 Na-143 K-4.0 Cl-109* HCO3-28 AnGap-10 [2168-6-30] 06:00AM BLOOD Albumin-3.4 Calcium-8.4 Phos-3.3 Mg-2.4 Brief Hospital Course: Mr. [Known lastname 79220] was admitted to [Hospital1 18] from OSH on [2168-6-22] with 7x6x5cm IPH(atraumatic) in the right temporal and frontal lobes. He was admitted to the ICU for q1H neurochecks and mannitol therapy. On [6-24] he was taken to the OR by Dr. [Last Name (STitle) ] for evacuation of the IPH via right crani. Post operative CT was largely improved, but was intermittant with following commands. He continued to be intubated until better command following and respiratory efforts could be established. On [6-27], he was extubated and mannitol was stopped. He tolerated this without incident. On [6-28] he was transferred out of the ICU to the step-down until for observation. Physical therapy worked with him on this day and determined that it would be appropriate to discharge to a rehab facility. On [6-30], he was transferred to "floor" status and discharge planning to continue. On __________ he was discharged to _____________ with a appropriate rehabilitation plan, and instructions to follow up with Dr. [Last Name (STitle) ] in [7-12] weeks. Medications on Admission: 1.Carvedilol 12.5 mg [Hospital1 ] 2. Chlordiazepoxide 25 mg q day 3. Niacin 500 mg q day 4. Colace 600 mg q day. Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO TID (3 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Northeast Acute Rehab Discharge Diagnosis: Right Temporal, frontal atraumatic intraparenchymal hemorrhage Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days for removal of your staples or sutures (This may be done in rehab). ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ], to be seen in [7-12] weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[2168-7-1] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6263 }	Medical Text: Admission Date: [2166-7-30] Discharge Date: [2166-8-19] Date of Birth: [2166-7-30] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: This is an interim summary serving [7-30] to [2166-8-19]. This is a 27 [4-25] week twin male admitted to the Newborn Intensive Care Unit after delivery to a 23 year old gravida 5, para 4 mother with unclear dates. Mother's laboratory studies were A positive, antibody negative, hepatitis B negative, RPR nonreactive, Rubella immune and unknown Group B Streptococcus. Mother is positive for sickle cell trait. Prenatal course was significant for diamniotic/dichorionic twins with late prenatal care at 24 weeks, when she presented in preterm labor. At that time she received magnesium and Betamethasone and preterm labor resolved. It recurred three days prior to delivery and we were unable to stop her. She had received Betamethasone with her first episode of preterm labor. The infants were delivered by cesarean section for breech and due to prior cesarean section. The infants came out and had some moderate respiratory distress requiring CPAP in the Delivery Room. Heart rate was always greater than 100 and Apgars were 7 and 8. She was brought to the Newborn Intensive Care Unit on CPAP and was intubated on arrival. PHYSICAL EXAMINATION: Weight was 1080, 50th percentile to 75th percentile, length 38 cm, 50th percentile to 75th percentile, head circumference was 60 which is in the 75th percentile. He was in moderate respiratory distress with coarse breath sounds. The abdomen was soft. He had a regular rate and rhythm without any murmur. His abdomen was nondistended. He had good pulses. Testes were not palpable. HOSPITAL COURSE: Respiratory - The infant was intubated on admission and given Surfactant two times. He required a fair moderate settings and oxygens into the 30 percent. On day of life No. 2 he had a significant pulmonary hemorrhage with copious amounts of blood coming from his endotracheal tube. At that time, he was switched to the high frequency oscillatory ventilator and requiring very high pressures to oxygenate well. At this time, an echocardiogram showed a large ductus arteriosus and he was treated for this. He continued to have pulmonary hemorrhage intermittently for one week despite the duct closing and required very high settings on the oscillator for many days. He was, however, able to be weaned after the first week of life and the bleeding slowly decreased. He was switched over a conventional ventilator on day of life No. 14 and weaned from that Foley catheter. He did go to CPAP on day of life No. 16 and came off of CPAP today on day of life No. 20. He is still requiring 24 to 30 percent oxygen and has had no apneic or bradycardiac spells. He is on caffeine to prevent apnea or bradycardia and we will be watching him closely as he has had no further episodes of pulmonary hemorrhage. Cardiovascular - With his pulmonary hemorrhage on day of life No. 2 he had an echocardiogram which showed a large ductus arteriosus. He was treated with one course of Indocin and follow up electrocardiogram showed that the duct had been closed. He has had no further issues from that standpoint. His blood pressures have been stable. He did require Dopamine for a short period of time surrounding his pulmonary hemorrhage, but since then has had no pressor support. Fluids, electrolytes and nutrition - The patient was initially made NPO and remained NPO on parenteral nutrition. For many days he did not start enteral feeds until day of life No. 13 when his umbilical venous catheter had been removed for several days. He was advanced slowly on feeds and is currently nearly to full feeds. He will be fortified over the next several days. He has had a significant metabolic alkalosis at his start of life and required multiple doses of bicarbonate. However, this has improved with time and he has had no further problems with that. Gastrointestinal - The infant has had some hyperbilirubinemia on and off and has been on phototherapy for the majority of his life, most recently, his bilirubin was 7.8. He is off of phototherapy and this will be followed up in two days. Infectious diseases - Initially the infant was started on Ampicillin and Gentamicin. When his cultures were negative for two days the antibiotics were stopped. Subsequently he has had an episode of fevers to 100 on day of life No. 15. He had a septic workup at this time of blood cultures and antibiotics of Vancomycin and Gentamicin were started. He was continued on these for three days and once the cultures were negative for three days, subsequently they were stopped. He also had swabs sent at this time for herpes simplex virus which remain negative at this time. He had no elevation of his liver function tests and low clinical suspicion for herpes infection. He was not started on Acyclovir. Neurology - The infant had an initial head ultrasound on day of life No. 2 which showed a left Grade 3 hemorrhage. Follow up head ultrasound on day of life No. 7 showed continuation of the left Grade 3 and a small right Grade 1. We have had one further follow up ultrasound on day of life No. 9 which showed evolution of these hemorrhages to bilateral, Grade 2 bleeds and he will have a follow up head ultrasound on day of life No. 30. The infant from a neurologic standpoint has required significant sedation with his pulmonary hemorrhage and other issues. He was started on a Fentanyl drip and maintained on this at 2 mcg/kg/hr until day of life No. 14. At this time, we started weaning the Fentanyl drip and went to bolus Fentanyl on day of life No. 16. We had been weaning slowly, and today switched to oral morphine every four hours in order to wean from an oral standpoint. State screening - Of note, his state screening showed a high methionine level of 1.7, this was repeated on day of life No. 16 and should be followed. DISCHARGE DIAGNOSIS: Prematurity. Pulmonary hemorrhage. Patent ductus arteriosus. Feeding intolerance. Hyperbilirubinemia. Rule out sepsis. Narcotic dependency. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2166-8-19] 16:45:08 T: [2166-8-19] 19:41:55 Job#: [Job Number 58334] ICD9 Codes: 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6264 }	Medical Text: Admission Date: [2173-2-9] Discharge Date: [2173-2-13] Date of Birth: [2115-4-23] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: DOE/ angina with activity Major Surgical or Invasive Procedure: AVR/ aortic root enlargement with 19 mm pericardial valve/pericardial patch History of Present Illness: 57 yo female with dyspnea/angina that developed in Spring [2171]. ETT was stopped for dyspnea and angina. Echo showed critical AS, [Location (un) 109] 0.7 cm2, peak gradient 64 mm, mean 41 mm, Ef 60%. She was referred to Dr. [Last Name (STitle) 1290] for AVR. Cath in [12-11] showed minimal CAD, severe AS, LAD 30%, AM 40%. Past Medical History: HTN GERD NIDDM AS obesity elev. chol bursitis left shoulder glaucoma Social History: lives with husband and 2 children runs a market research company smoked 1 ppd for 25 years, quit 17 years ago rare ETOH used MJ [9-9] Family History: positive for premature CAD/MI Physical Exam: HR 68 reg RR 14 right 130/52 left 152/59 155# 4'[76]" NAD skin warm ,dry NCAt, PERRL, anicteric sclera, OP benign neck supple full ROM, no JVD Bilat. transmitted murmur versus carotid bruits RRR S1 S2 3/6 SEM, radiating to carotids abd soft, NT, ND, + BS extrems with trace LE edema no appreciable varicosities alert and oriented, [4-9] strengths, gait steady, nonfocal exam fems/ DP/ PT 2+ bilat Pertinent Results: [2173-2-11] 01:15PM BLOOD WBC-9.8 RBC-3.19* Hgb-8.8* Hct-26.2* MCV-82 MCH-27.5 MCHC-33.4 RDW-16.9* Plt Ct-182 [2173-2-12] 10:40AM BLOOD Hct-26.2* Plt Ct-223 [2173-2-12] 10:40AM BLOOD PT-11.6 PTT-21.3* INR(PT)-1.0 [2173-2-12] 10:40AM BLOOD Plt Ct-223 [2173-2-12] 10:40AM BLOOD UreaN-27* Creat-0.7 Na-138 K-4.0 [2173-2-12] 10:40AM BLOOD Mg-1.9 Brief Hospital Course: Admitted [2-9] and underwent AVR and root enlargement with Dr. [Last Name (STitle) 1290]. transferred to the CSRU in stable condition on titrated phenylephrine and propofol drips. Remained in inusilin and propofol drips the following morning, and was weaned and extubated. She was transferred to the floor later in the day to begin increasing her activity level. She had some complaints of back pain and shoulder pain which she has had preoperatively as a chronic problem. Beta blockade and gentle diuresis continued on the floor. Chest tubes were removed on POD2 without complication. On POD 3 her epicardial wires were removed without incident. The physical therapy service was consulted to assist with her postoperative strength and mobility. Her oxygen saturations improved to 100% on room air. On POD4 Mrs [Known lastname 64670] had good exercise tolerance, no SOB, or Chest pain. Her systolic blood pressure was stable in the 90's without lightheadedness, diaphoreis, or DOE. Her sternotomy incision was clean, dry, and intact without evidence of infection. She was discharged home on POD4 with services in good condition, cardiac diet, sternal precautions, and instructed to follow up with her PCP and cardiologist in [12-7] weeks. She will follow up with Dr. [Last Name (STitle) 1290] in four weeks. Medications on Admission: avandia 8 mg daily ECASA 325 mg daily glyburide 5/metformin 500 mg daily toprol XL 50 mg daily zetia 10 mg daily avapro 150 mg daily lipitor 80 mg daily naproxen 500 mg [Hospital1 ] protonix 40 mg daily lasix 20 mg daily KCL 20 mEq daily xalatan 0.005% one drop OU Q pm timolol 0.5% one drop OS q AM MVI/Vit C/Vit E/calcium daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). Disp:qs qs Refills:2 5. Glyburide-Metformin 5-500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:30 Refills:2 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:50 Tablet(s) Refills:0 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 11. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 13. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:14 Packet(s) Refills:0 14. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for incisional pain. Disp:21 Tablet(s) Refills:1 15. Ferronate 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: s/p AVR/ root enlargement 19 mm CE pericardial valve elev. chol. obesity HTN NIDDM bursitis left shoulder glaucoma GERD Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) You may wash your incision and pat dry. No swimming or bathing until it has healed. 5) No lotions, creams or powders to wound. 6) No lifting greater then 10 pounds for 10 weeks. 7) No driving for 1 month. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 1290] in 4 weeks [Telephone/Fax (1) 170] follow- up with Dr. [Last Name (STitle) 64671] in [12-7] weeks follow up with Dr. [Last Name (STitle) 7047] in [1-8] weeks Completed by:[2173-2-13] ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6265 }	Medical Text: Admission Date: [2138-3-20] Discharge Date: [2138-3-20] Service: SURGERY Allergies: No Drug Allergy Information on File Attending:[Doctor First Name 5188] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: exploratory laparotomy History of Present Illness: This patient is an 83-year-old female who was transferred to us from the [Hospital6 8283] with approximately 28 hours of progressive worsening abdominal pain, nausea and vomiting. She was seen at [Hospital6 8278] where she was noted to have significant tenderness on exam of the abdomen and subsequent workup showed based on a CT scan that there was evidence of portal venous air, pneumatosis of the small bowel, the exact length of which was not clear based on the imaging studies that was done there as well as a lactic acidosis, leukocytosis size 26,000 and progressively worsening abdominal pain since the initial presentation to the emergency room. The patient had in the prior 24 hours had had her scheduled hemodialysis as she has multiple comorbidities including end-stage renal disease and significant atherosclerotic disease. She had undergone her scheduled hemodialysis and thereafter had progressive abdominal pain, nausea, and emesis, which subsequently required her to be taken to the hospital. Past Medical History: ESRD, CAD, PVD Social History: unknown Family History: n/c Physical Exam: mentating, alert, following commands but in obvious distress CTAB sinus tachy, no m/r/g abd: extremely tender abdominal exam consistent with rigidity and peritonitis. ext: warm, well perfused Pertinent Results: [2138-3-20] 12:00PM WBC-24.3* RBC-4.16* HGB-13.9 HCT-44.0 MCV-106* MCH-33.5* MCHC-31.7 RDW-14.2 [2138-3-20] 12:00PM ALT(SGPT)-36 AST(SGOT)-71* CK(CPK)-63 ALK PHOS-102 AMYLASE-443* TOT BILI-1.2 [2138-3-20] 12:00PM GLUCOSE-127* UREA N-40* CREAT-4.2* SODIUM-143 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-16* ANION GAP-27* Brief Hospital Course: Patient was seen and a decision was made to proceed to the OR for an exploratory laparotomy to try to salvage any remaining non-necrosed small bowel. During the operation it became aparent that the entire length of the small bowel from the ligament of Treitz to its termination at the ileocecal valve appeared to be completely non-viable and necrotic. At this time, we replaced the intestinal contents within the abdomen and felt that this was a non-survivable insult. We then subsequently closed the fascia and the skin and dressed it appropriately. The patient was then subsequently taken intubated in stable condition up to the intensive care unit. After a lengthy discussion with her husband, it was decided to make the patient CMO and she was started on a morphine drip, extubated and expired shortly thereafter. She was pronounced dead at 2350, and the chief, attending and patient's family were all notified. Medications on Admission: unknown Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: small bowel necrosis Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190] Completed by:[2138-3-25] ICD9 Codes: 4280, 496, 5856
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6266 }	Medical Text: Admission Date: [2169-1-11] Discharge Date: [2169-1-15] Date of Birth: [2084-9-8] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1253] Chief Complaint: septic shock secondary to UTI Major Surgical or Invasive Procedure: 84 y.o male with h.o ischemic CMP EF 25%, CAD, DVT/afib on coumadin as outpt, bladder cancer s/p transurethral resection requiring straight cath for stricture patency who presented with hematuria s/p attempt to straight cath and hypotension and found to be in shock. . Pt was home today and wife was doing routine q 3 day straight cath to maintain patency of urethral strciture when the pt began to pass large blood and clots. He then became dizzy and laid down. He reports shaking chills. Then tried to obtain BP by telemonitoring but no BP registered. His daughter drove the pt to the [Name (NI) ] where vitals were 99.8 BP 58/33 HR 89 RR 20 91% RA. A three was foley was placed and he was having hematuria it cleared after 3L CBI. He initially responded to 250cc bolus with SBP improved to the 90s. He then dropped his BP again was started on levophed which was titrated up to 0.21 and MAPS were 55-60. He received a total of 5L NS in the ED with increased o2 requirement to NRB was 90% on 6L prior to NRB. Given previous pansensitive UTI he was given a dose of ceftriaxone when he was found to have a significant UTI. Lactate was 6.1 and trended down to 4.7 while in ED. WBC was suppressed to 0.2. A right IJ was placed while in ED. He complained of right and left thigh cramping [9-4] that started at home which he received morphine 2mg for. His INR was noted to be 3.9. AST 87 and ALT 41. HCT concentrated at 40 baseline somewhere between 30 and 39. EKG showed V pacing. Vitals at tranfer were 96.2 96/41 24 and 97% on NRB. He was transfered to ICU with urosepsis. . On arrival to ICU vitals were. He complained of bilateral upper thigh pain. He denied SOB, chest pain. he had no hematuria. He is otherwise feeling well at home. Of note he had a similar ICU admission in [Month (only) 404] notable for UTI with septic shock, hematuria and rewuired pressors in the ICU. He did not require a NRB at that time but required diuresis with lasix due to his volume recussitation. He was d/c to rehab on ciprofloxacin for his pan sensitive UTI. He finished the course went home for 1 day and was admitted to an OSH with c diff. He received 10 days of tx that ended approx [2169-1-4]. He has not had diarrhea at home since prior to discharge. Social History: Father died of emphysema. Mother died at age [Age over 90 ]. There is no known history of kidney or GU tract disorders; there likewise is no known history of platelet disorders. Family History: Father died of emphysema. Mother died at age [Age over 90 ]. There is no known history of kidney or GU tract disorders; there likewise is no known history of platelet disorders. Physical Exam: GEN: tired appearing, ill appearing, mentating well HEENT: dry mucosa, EOMI, PERRL, sclera anicteric CV: RRR, distant heart sounds. no M/G/R. Neck: no carotid bruit PULM: wheeze at right lung base ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: no c/c/e, warm NEURO: alert, oriented to person, place, and time. Symmetric. EOMI. DTRs. SKIN: [Name2 (NI) ] jaundice, cyanosis, or gross dermatitis/cellulitis. No ecchymoses. R central line in place Pertinent Results: [2169-1-10] 12:55PM BLOOD WBC-8.1 RBC-4.00# Hgb-12.1# Hct-38.8# MCV-97 MCH-30.4 MCHC-31.3 RDW-15.8 Plt Ct-94* [2169-1-13] 03:23AM BLOOD WBC-38.0* RBC-4.07* Hgb-12.3* Hct-38.8* MCV-95 MCH-30.2 MCHC-31.7 RDW-16.8* Plt Ct-76* [2169-1-10] 12:55PM BLOOD Neuts-65.5 Lymphs-23.3 Monos-6.6 Eos-4.0 Baso-0.6 [2169-1-13] 03:23AM BLOOD Neuts-52 Bands-38* Lymphs-0 Monos-8 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [2169-1-10] 12:55PM BLOOD PT-34.0* INR(PT)-3.5* [2169-1-13] 03:23AM BLOOD Plt Smr-VERY LOW Plt Ct-76* [2169-1-10] 12:55PM BLOOD UreaN-47* Creat-2.3* Na-145 K-4.9 Cl-108 HCO3-25 AnGap-17 [2169-1-13] 05:30PM BLOOD Glucose-82 Na-134 K-5.5* Cl-109* HCO3-11* AnGap-20 [2169-1-10] 12:55PM BLOOD ALT-31 AST-36 AlkPhos-164* [2169-1-12] 04:56AM BLOOD ALT-35 AST-77* AlkPhos-95 TotBili-1.9* [2169-1-13] 03:23AM BLOOD DirBili-1.0* [2169-1-11] 11:48PM BLOOD Calcium-6.8* Phos-2.6* Mg-1.7 [2169-1-13] 05:30PM BLOOD Calcium-7.5* Phos-6.5* Mg-2.1 [2169-1-10] 12:55PM BLOOD TSH-3.3 [2169-1-10] 12:55PM BLOOD Free T4-1.8* [2169-1-12] 04:56AM BLOOD Cortsol-61.2* [2169-1-12] 01:26PM BLOOD Type-ART Temp-36.9 O2 Flow-6 pO2-78* pCO2-20* pH-7.34* calTCO2-11* Base XS--12 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2169-1-11] 05:04PM BLOOD Lactate-6.1* K-4.6 [2169-1-12] 01:26PM BLOOD Lactate-4.2* . UA: [2169-1-11] 05:10PM URINE Color-Red Appear-Cloudy Sp [Last Name (un) ]-1.006 [2169-1-11] 05:10PM URINE Blood-NEG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2169-1-11] 05:10PM URINE RBC->1000 WBC->50 Bacteri-MANY Yeast-NONE Epi-0 [2169-1-11] 05:10PM URINE [2169-1-13] 04:59PM URINE Hours-RANDOM UreaN-261 Creat-81 Na-20 K-57 Cl-30 [2169-1-13] 04:59PM URINE Osmolal-272 . [2169-1-12] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2169-1-12] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2169-1-11] URINE URINE CULTURE-FINAL {KLEBSIELLA PNEUMONIAE} EMERGENCY [Hospital1 ] [2169-1-11] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2169-1-11] BLOOD CULTURE Blood Culture, Routine-FINAL {KLEBSIELLA PNEUMONIAE}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL Brief Hospital Course: 84 y.o male with h.o ischemic CMP EF 25%, CAD, DVT/afib on coumadin as outpt, bladder cancer s/p transurethral resection requiring straight cath who presented with hematuria s/p attempt to straight cath and then with severe hypotension, lactic acidosis, increased INR, and rapidly increasing white count consistent septic shock. His GU bleeding resolved prior to transfer to the ICU. His septic shock was secondary to to a klebsiella UTI. He received aggressive fluid resuscitation in the ED but had an increased 02 requirement which limited our ability to give him aggressive fluids due to his poor underlying cardiac function (severe ischemic cardiomyopathy) and code status of DNR/DNI. He was given packed RBCs and IVF while in the ICU. During his ICU stay he required both levophed and vasopressin to maintain his BP. He was initially given broad spectrum antibiotics of vancomycin, zosyn, cipro, flagyl, and po vanco (to cover c diff as he had recent inefection). His regimen later was changed to meropenem based on ID recs. He was ultimately switched back to cipro once sensitivites for his UTI returned. A renal ultrasound showed no hydronephrosis. He was made CMO on [2169-1-13] as he expressed his wishes to not not experience respiratory distress. He was transferred to the medicine floor on a morphine gtt and scopolamine patch. Medications on Admission: ATORVASTATIN - 10 mg Tablet - one Tablet(s) by mouth every day CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth each every tuesday and friday. CARVEDILOL [COREG] - 3.125 mg Tablet - 1 Tablet(s) by mouth twice a day ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - one Capsule(s) by mouth weekly for 8 weeks FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth daily LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth once per day LIDOCAINE HCL - 2 % Gel - inject into urethra every third day before catheterization. - No Substitution LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day every evening NITROGLYCERIN - 400 MCG (1/150 GR) TABLET - PLACE ONE TABLET UNDER TONGUE Q5 MIN X 3 AS NEEDED FOR JAW OR CHEST PAIN WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - 0.5 (One half) Tablet(s) by mouth daily as directed by coumadin clinic. WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth as directed. Patient normally takes3.5mg Tues/Thurs/Saturday, 2.5mg all other days ASPIRIN [ADULT LOW DOSE ASPIRIN] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth qd. Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: Septic shock secondary to UTI Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6267 }	Medical Text: Admission Date: [2184-10-27] Discharge Date: [2184-11-19] Date of Birth: [2119-12-26] Sex: M Service: MEDICINE Allergies: Keflex Attending:[First Name3 (LF) 5037] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Lumbar puncture PICC line placement PEG tube placement History of Present Illness: Patient is a 64 yo male with recent renal transplant on [2184-9-22], diabetes mellitus, HTN, admitted [2184-10-27] with 24-48 hours of confusion and aphasia. The patient was doing well post-transplant and was off of dialysis, with improving kidney transplant. . On [2184-10-25], the patient's VNA thought he was a little more confused than usual. The patient was seen in nephrology on [2184-10-26], and had a fall on the way to the car, without head trauma. He then presented to [Hospital6 3105], where he was felt to have a toxic metabolic encephalopathy. Urine showed 119 RBC and 14 WBC. Urine tox was negative. Non-contrast head CT showed small vessel ischemic change and atrophy with no acute process. He was given a dose of levofloxacin for question of UTI. Given his recent renal transplant, he was transferred to [Hospital1 18] for further management. . According to the patient's wife, the patient became more confused [10-26], and his speach became incomprehensible, with impaired naming. No other symptoms. The only recent medication change was a decrease in tacrolimus dose several days ago. The patient took oxycodone 2.5 mg x 2 for knee pain during the weekend, with some sleepiness but no change in mental status. . He was admitted to the renal service for further work-up. LP was unremarkable, viral studies pending, on empiric acyclovir. MRI showed no infarct or hemorrhage. He was started on acyclovir per ID recs. Creatinine is stable at 1.5. On [2184-10-31], he was found to be in non-convulsive status epilepticus and was started on keppra. He was monitored with EEG. . On [2184-11-1] at 12:30 am, he was triggered for worsened AMS. His VS were AF, P: 96, BP: 166/56, RR: 45, 98% on RA. He has been able to open his eyes to name. At midnight, she was non-responsive to sternal tub with RR in the 40s. He was also having shaking movements. EEG showed slow waves with occasional spikes not correlated with seizure activity. He was given ativan 1 mg iv x 2 without improvement. He was transferred to the MICU for further management. Past Medical History: ESRD from diabetic nephropathy, s/p deceased donor kidney transplant [2184-9-21] Diabetes mellitus HTN SDH after fall, resolved actinic keratosis RUE AV fistula creation CAD Social History: Married. Lives with wife. -Tobacco: none -EtOH: None -Drugs: None Family History: HTN Physical Exam: General: tachypneic, non-responsive, occasionally opens eyes to sternal rub HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: tachypneic, Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: sl. tachy, reg and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: AV fistula in place in RUE, +thrill; LUE- Neuro: pupils 6 mm->3 mm sluggish but responsive bilaterally, unable to fully assess CNII-XII as patient was not following commands Pertinent Results: [2184-10-26] 01:35PM BLOOD WBC-9.4 RBC-3.25* Hgb-10.6* Hct-33.8* MCV-104* MCH-32.5* MCHC-31.3 RDW-14.6 Plt Ct-216 [2184-10-27] 07:30PM BLOOD WBC-7.3 RBC-2.75* Hgb-9.1* Hct-27.9* MCV-101* MCH-33.0* MCHC-32.6 RDW-14.6 Plt Ct-198 [2184-10-28] 05:40AM BLOOD WBC-7.7 RBC-2.86* Hgb-9.1* Hct-28.9* MCV-101* MCH-31.9 MCHC-31.5 RDW-14.7 Plt Ct-184 [2184-10-29] 05:50AM BLOOD WBC-6.5 RBC-2.66* Hgb-8.6* Hct-27.5* MCV-103* MCH-32.3* MCHC-31.3 RDW-14.0 Plt Ct-192 [2184-10-30] 07:25AM BLOOD WBC-UNABLE TO RBC-UNABLE TO Hgb-UNABLE TO Hct-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO Plt Ct-UNABLE TO [2184-10-30] 10:40AM BLOOD WBC-9.5 RBC-2.85* Hgb-8.9* Hct-29.2* MCV-103* MCH-31.4 MCHC-30.6* RDW-13.8 Plt Ct-192 [2184-10-31] 06:20AM BLOOD WBC-10.8 RBC-3.13* Hgb-9.9* Hct-31.4* MCV-100* MCH-31.7 MCHC-31.6 RDW-14.2 Plt Ct-178 [2184-11-1] 02:14AM BLOOD WBC-12.3* RBC-3.07* Hgb-9.7* Hct-30.0* MCV-98 MCH-31.7 MCHC-32.5 RDW-14.2 Plt Ct-211 [2184-11-2] 03:51AM BLOOD WBC-9.8 RBC-2.75* Hgb-8.8* Hct-27.1* MCV-99* MCH-32.0 MCHC-32.4 RDW-14.0 Plt Ct-205 [2184-10-27] 07:30PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-1+ [2184-11-1] 02:14AM BLOOD PT-13.5* PTT-30.6 INR(PT)-1.3* [2184-10-26] 01:35PM BLOOD UreaN-31* Creat-1.9* Na-137 K-5.7* Cl-102 HCO3-18* AnGap-23* [2184-11-2] 03:51AM BLOOD Glucose-201* UreaN-16 Creat-1.3* Na-138 K-4.2 Cl-104 HCO3-28 AnGap-10 [2184-10-26] 01:35PM BLOOD ALT-9 AST-15 TotBili-0.5 [2184-11-1] 02:14AM BLOOD ALT-7 AST-14 LD(LDH)-268* AlkPhos-81 TotBili-0.6 [2184-11-2] 03:51AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0 [2184-10-29] 05:50AM BLOOD VitB12-1675* [2184-10-28] 05:40AM BLOOD TSH-0.94 [2184-11-2] 03:51AM BLOOD CRP-87.4* antiTPO-PND [2184-11-1] 02:36AM BLOOD Type-[Last Name (un) ] Temp-39.1 pO2-61* pCO2-49 pH-7.39 calTCO2-31* Base XS-3 Comment-AXILLARY T [2184-11-1] 01:24AM BLOOD Glucose-221* Lactate-1.4 Na-135 K-3.8 Cl-101 [2184-11-1] 01:24AM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-96 COHgb-1 MetHgb-0 Brief Hospital Course: Patient is a 64 yo male with recent renal transplant on [2184-9-22], diabetes mellitus, HTN admitted with confusion and aphasia now with worsened AMS after being found to have non-convulsive status epilepticus this am. # Altered Mental Status: Likely toxic metabolic given extensive work-up including negative LP and MRI. He was found to be in non-convulsive status epilepticus on the floor and was transferred to the ICU. He was treated with keppra and his seizures have resolved. He was placed on continuous EEG which showed persistent encephalopathy. EEG is not suggestive of further seizure activity at this time and no dose adjustment of his anti-epileptic medications were made. Tacrolimus is thought to be contributing to his new onset encephalopathy. Tacrolimus was stopped and he was started on sirolimus and prednisone. Tacrolimus levels in his blood have been undetectable now for several days and very little mental status improvement has been seen. Neurology has been involved and feel that the pt's recovery will be a slow process and he will require in patient rehabilitation. Infectious Disease has also been consulted and his infectious workup has all been negative to date including a lumbar puncture with cultured CSF. . #Fever / Leukocytosis- During this hospital admission the pt developed fever, tachypnea and leukocytosis. A CXR was obtained which showed right and left opacities that were consistent with either a new pneumonia or aspiration pneumonitis. Vancomycin and Zosyn were started. He again spiked a fever through the anitbiotics the next day and Ciprofloxacin was added for double coverage of pseudomonas. Blood and urine cultures were obtained. Two of fourteen bottles were positive for Coagulase Negative Staph. The PICC line was removed and he completed a 7 day course of Zosyn, cipro was discontinued after three days of treatment. He has remained afebrile with negative blood cultures now for over 48 hours. A new PICC line was placed and we will continue Vancomycin for 14 days with a start of [2184-11-14]. Vancomycin should be stopped on [2184-11-27]. . # Renal Transplant: On admission to the hospital the patient's creatinine was elevated to 1.9. He was administered IV fluids and a tacrolimus level was checked and found to be elevated. Tacrolimus was held due to the elevated level and because it was though to be contributing to his altered mental status. she instead was started on prednisone and sirolimus. we also continued CellCept Bactrim and valganciclovir for prophylaxis as well. His creatinine improved with increased oral intake and IV fluids and at the time of discharge was within normal limits. . #Right knee effusion: on admission the patient had a right knee effusion. It was tender to palpation On exam. The joint aspiration was performed for which was positive for inflammatory cells only without evidence of infection. It was felt that this was due to a gout flare. . # Hypertension: The patient was noted to be hypertensive during this hospital stay. We increased his dose of metoprolol and added amlodipine and lisinopril for better blood pressure control. . #DMII: He was placed on an insulin sliding scale. . #Gout: We continued allopurinol. . #Transitional: the patient was discharged to a [Hospital 4820] rehab facility. He has follow-up appointments with the kidney transplant center and neurology. You will also need a urology appointment for your stent removal. He should have labwork drawn on [2184-11-24] and faxed to Dr. [Last Name (STitle) 6729] office at [Telephone/Fax (1) 697]. Medications on Admission: Mycophenolate Mofetil 1000 mg PO BID Acyclovir 700 mg IV Q8H HSV encephalitis Metoprolol Tartrate 37.5 mg PO/NG [Hospital1 ] Allopurinol 100 mg PO/NG DAILY Miconazole Powder 2% 1 Appl TP [Hospital1 ] Amlodipine 5 mg PO/NG DAILY Nystatin Oral Suspension 5 mL PO QID:PRN thrush Quetiapine Fumarate 12.5 mg PO/NG QHS Docusate Sodium (Liquid) 100 mg PO/NG [Hospital1 ] Famotidine 20 mg PO/NG DAILY Senna 1 TAB PO/NG [Hospital1 ] Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Sulfameth/Trimethoprim SS 10 mL PO/NG DAILY Insulin SC (per Insulin Flowsheet) ValGANCIclovir 900 mg PO Q24H LeVETiracetam 1000 mg IV Q12H Discharge Medications: 1. mycophenolate mofetil 200 mg/mL Suspension for Reconstitution Sig: Five (5) ml PO BID (2 times a day). 2. senna 8.8 mg/5 mL Syrup Sig: [11-30] ml PO BID (2 times a day). 3. valganciclovir 50 mg/mL Recon Soln Sig: Eighteen (18) ml PO Q24H (every 24 hours). 4. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY (Daily). 5. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). 8. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 12. levetiracetam 100 mg/mL Solution Sig: Five (5) ml PO BID (2 times a day). 13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 15. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. sirolimus 1 mg/mL Solution Sig: Five (5) ml PO DAILY (Daily). 17. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. insulin glargine 100 unit/mL Cartridge Sig: Twenty Five (25) units Subcutaneous in am and at bedtime. 19. insulin lispro 100 unit/mL Cartridge Sig: One (1) as directed Subcutaneous as directed : please see attached sliding scale. 20. Outpatient Lab Work Please obtain a CBC, Chem 7, Sirolimus trough on [11-30] and fax results to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 697] 21. vancomycin 500 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 9 days. 22. Outpatient Lab Work Please draw a sirolimus trough (prior to am dose) and vancomycin trough on [2184-11-20] and fax results to Dr. [Last Name (STitle) ] @ [Telephone/Fax (1) 697] 23. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: PRIMARY: Metabolic encephalopathy Status Post Kidney Transplant hypertension diabetes mellitus gout Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname ], It was a pleasure taking care of you at [Hospital1 ]. You admitted to the hospital with confusion. We believe your confusion was caused by one of the immunosuppressive medications that you were previously taking called tacrolimus. We have stopped tacrolimus and started you on a new medication called sirolimus along with prednisone instead. We have determined that your altered mental status is not due to a stroke or infection. We would like you to continue to follow-up with neurology as an outpatient. The following changes have been made your medications: STOP: Tacrolimus Nortriptyline Gabapentin Zantac CHANGE: Valganciclovir 900mg daily Metoprolol Tartrate 150mg every 8hrs Vitamin D 1000IUs daily START: Nystatin 5ml swish in mouth up to four times per day as needed for thrush Miconazole Powder 2% apply twice per day to groin Heparin 5000Units inject subcutaneously three times per day Levetiracetam 500mg twice per day Amlodipine 10mg daily Polyethylene Glycol 17grams daily Famotidine 20mg daily Sirolimus 6mg daily Prednisone 5mg daily Lisinopril 40mg daily Vancomycin 500mg IV twice per day last day [2184-11-27] Glargine Insulin inject 25units in the am and at bed time Humalog Insulin sliding scale please see attached sheet See below for follow-up appointments have been made on your behalf. Followup Instructions: Name: [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location: [Hospital ] MEDICAL & WALK IN CENTER, LLC Address: [Last Name (un) 39144], [Hospital1 ],[Numeric Identifier 66038] Phone: [Telephone/Fax (1) 72680] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Department: TRANSPLANT When: TUESDAY [2184-11-16] at 8:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2088], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: NEUROLOGY When: WEDNESDAY [2184-11-17] at 2:00 PM With: [Name6 (MD) 2341] [Last Name (NamePattern4) 2342], M.D. [Telephone/Fax (1) 2343] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) 2105] [Name8 (MD) 2106] MD [MD Number(2) 5038] ICD9 Codes: 2930, 7907, 4019, 2749, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6268 }	Medical Text: Admission Date: [2160-3-5] Discharge Date: [2160-3-12] Date of Birth: [2119-9-25] Sex: M Service: MEDICINE Allergies: Haldol / Trazodone Attending:[First Name3 (LF) 465] Chief Complaint: Seizure in setting of 3 days N/V/D Major Surgical or Invasive Procedure: None History of Present Illness: 40 yo male with a history of depression and seizures presented [2160-3-4] to [Hospital 5871] Hospital ED with c/o nausea, vomiting, diarrhea, and headache x 3 days. In [Name (NI) ], Pt experienced chest pain x 2 hours, felt shaky and chilled. He became agitated, then dazed, then had a witnessed grand-mal seizure approximately 2 minutes in duration. . History obtained from patient's wife. Patient's history is not reliable [12-21] mental status changes. Reports that sxs began on Sunday [2160-3-2] when he had profuse, watery, foul-smelling diarrhea, accompanied by nausea and vomiting. For the next two days, he was unable to take any POs, was having diarrhea 4x/day, and hydrating with only water and ice chips. Sick contacts include his 5-yr-old son who had similar symptoms that resolved spontaneously in [1-20] days. ROS significant for low-grade fever, shaking, chills, severe migraine. Denies unusual foods, undercooked foods, recent travel, abdominal pain. . Wife reports that Pt was very pale, shaky, and acting unusual since Monday [2160-3-3]; she stated that he was "out of it". She brought him to the [Hospital 5871] Hospital ED on Tuesday, [2160-3-4] for further evaluation. While in the [Name (NI) ], Pt had a 2 min grandmal seizure. Pt has had one similar episode in the past, approximately 3 yrs ago. He reports that it was similarly preceded by a flu-like illness with nausea, diarrhea, migraine. Prior to the seizure, he experienced shaking/tremor/agitation, followed by loss of consciousness and convulsions. At the time, he was evaluated at [Hospital1 498] with CT, MRI, MRA, and EEG, all of which were normal. He was started on Dilantin, experienced myoclonus, and stopped the Dilantin after 9 mos of treatment. Since then, has had no seizure activity prior to this episode. Pt reports no alcohol or drug use. . ROS is significant for h/o multiple head traumas [12-21] work in construction business - none of which have required further evaluation. Wife also reports that Pt filled his Ambien prescription on [2160-3-1] (sixty - 10 mg tabs). On [2160-3-4] there were 20 tabs missing from the bottle. Pt reports that he does not remember taking the pills. He has no h/o drug overdose, and ususally takes 1-2 tabs (10-20 mg) at night. Other ROS include impaired memory (unable to recall events between Saturday, [2160-3-1] and awakening in the ED) and difficulty starting urine stream. . At [Hospital 5871] [Hospital 12018] Medical Center: Pt given Ativan 1 mg, Morphine 4 mg, Tylenol 975 mg, Ativan 1 mg prior to transfer to [Hospital1 18]. Head CT: negative, no bleed, no masses, no acute changes CXR: negative, no infiltrates, no PTX, no hemothorax, no masses, no effusion, no free air, no CHF, no cardiomegaly. LP: CSF protein 30, Glu 66, 1 WBC, 2 RBC - negative CK MB 2.5, CPK 201, [Doctor First Name ] 44, lip 14 Alb 4.5, Tprot 7.2, alk phos 73, AST 18, ALT 15, Tbili 0.8, Dbili 0.1 Chem 7: 135/4.2/98/27/6/0.8/93 Ca 9.4 CBC: 7.6/14.5/40.3/357 Past Medical History: 1. Seizure - 1 prior episode in [2156]. Similar flu-like illness preceding. Similar pre-ictal shaking, chills, agitation. Grand-mal with loss of consciousness, post-ictal confusion. 2. Depression - dx 9 yrs ago. 1 prior suicide attempt in [2152] (slit wrists). Followed by psychiatrist, Dr. [Last Name (STitle) ], at [Hospital ] Health Center in [Hospital1 1559], MA. Sees Dr. [Last Name (STitle) ] q 3-6 mos for 15 mins. 3. Migraines - controlled with Excedrin pm. 4. Hypercholesterolemia - untreated. Pt does not like to go to the doctor. 5. h/o kidney stones. . ALLERGIES: NKDA Social History: Pt lives with his wife and 2 children, 7 yr old Max, and 16 yr old [Last Name (un) 61509], in [Location (un) 5871], MA. He owns a construction business, but has been working less in past couple years, and spending more time home with the kids. He denies any history of tobacco, alcohol, or illicit drug use. Family History: FH: NC. No history of seizure disorder. Physical Exam: Physical Exam on admission [2160-3-5]: T 100.1 BP 116/60 HR 69 RR 20 02sat 99RA Gen: Thin male, tired-appearing, slightly confused, lying comfortably in bed, in NAD HEENT: NC/AT. EOMI. PERRLA. MM dry, OP clear Neck: supple, no LAD, no tenderness to palpation, no JVD Chest: CTAB, no wheezes, rales, rhonchi CV: RRR, nl S1 S2, no murmurs, rubs gallops Abd: soft, NT, ND, NABS. No peritoneal signs. No organomegaly. Ext: cold hands and feet, o/w well-perfused with 2+ DP, PT, radial and ulnar pulses. No cyanosis or clubbing. Neuro: Motor - generalized weakness, with strength 4/5 bilaterally upper and lower extremities Sensation - intact Reflexes - 2+ and symmetric, downgoing Babinski Finger-nose testing, Romberg, and gait WNL Mental status - Poor attention (Pt could only recite 2 of 12 mos of yr backwards, then started coutning). Difficulty maintaining task. Perseveration even with redirection. Poor recall (0 of 3 objects). Poor long-term memory (did not know street name or age of child). Visual/sensory misperceptions (calling ceiling lights [Last Name (un) 3625] DVDs, getting concerned about ceiling mildew and water leaking into room). Pertinent Results: At [Hospital 5871] [Hospital 12018] Medical Center: Pt given Ativan 1 mg, Morphine 4 mg, Tylenol 975 mg, Ativan 1 mg prior to transfer to [Hospital1 18]. Head CT: negative, no bleed, no masses, no acute changes CXR: negative, no infiltrates, no PTX, no hemothorax, no masses, no effusion, no free air, no CHF, no cardiomegaly. LP: CSF protein 30, Glu 66, 1 WBC, 2 RBC - negative CK MB 2.5, CPK 201, [Doctor First Name ] 44, lip 14 Alb 4.5, Tprot 7.2, alk phos 73, AST 18, ALT 15, Tbili 0.8, Dbili 0.1 Chem 7: 135/4.2/98/27/6/0.8/93 Ca 9.4 CBC: 7.6/14.5/40.3/357. . EEG ABNORMALITY #1: Occasional bursts of generalized 3 Hz rhythmic spike and slow wave discharges, occurring in runs up to 3 seconds were noted in the waking state. During one episode, the patient appeared to stare off. ABNORMALITY #2: With photic stimulation, asymmetric arhythmic muscle jerks were noted, producing large amplitude movement artifact. It was difficult to determine whether any underlying discharges were seen within the movement artifact, although at 4 Hz photic stimulation, generalized spike and polyspike and slow waves were noted. BACKGROUND: A 9 Hz posterior predominant rhythm was noted in the waking state, which attenuated with eye opening. The normal anterior to posterior voltage gradient was seen. HYPERVENTILATION: Contraindicated due to patient's mental status. INTERMITTENT PHOTIC STIMULATION: As above. SLEEP: The patient progressed from the waking to drowsy state, but did not attain stage II sleep. CARDIAC MONITOR: A generally regular rhythm was noted with an average rate of 54 beats per minute. IMPRESSION: This is an abnormal EEG in the waking and drowsy states due to the bursts of 3 Hz generalized rhythmic spike and wave discharges and the arhythmic jerks with photic stimulation, with likely underlying spike and polyspike and wave discharges. The first abnormality suggests a primary generalized epilepsy. The muscle jerks with photic stimulation represent a photoconvulsive response, although the movement artifact obscured the background rhythm. A photoconvulsive response may be seen with primary generalized epilepsies. . [2160-3-10] 04:50AM BLOOD WBC-6.5 RBC-4.30* Hgb-13.6* Hct-38.0* MCV-89 MCH-31.7 MCHC-35.8* RDW-13.1 Plt Ct-348 [2160-3-7] 10:19PM BLOOD WBC-5.7 RBC-4.22* Hgb-13.7* Hct-37.6* MCV-89 MCH-32.4* MCHC-36.4* RDW-13.1 Plt Ct-270 [2160-3-5] 01:05AM BLOOD WBC-9.3 RBC-4.25* Hgb-13.7* Hct-39.0* MCV-92 MCH-32.2* MCHC-35.1* RDW-13.2 Plt Ct-336 [2160-3-7] 10:19PM BLOOD Neuts-73.6* Lymphs-19.4 Monos-6.1 Eos-0.5 Baso-0.4 [2160-3-5] 01:05AM BLOOD Neuts-84.9* Lymphs-9.5* Monos-5.0 Eos-0.2 Baso-0.4 [2160-3-10] 04:50AM BLOOD Plt Ct-348 [2160-3-5] 01:05AM BLOOD Plt Ct-336 [2160-3-5] 01:05AM BLOOD PT-12.5 PTT-28.9 INR(PT)-1.1 [2160-3-10] 04:50AM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-140 K-3.9 Cl-101 HCO3-31 AnGap-12 [2160-3-5] 01:05AM BLOOD Glucose-88 UreaN-6 Creat-0.7 Na-140 K-3.9 Cl-105 HCO3-23 AnGap-16 [2160-3-10] 04:50AM BLOOD ALT-23 AST-12 CK(CPK)-102 [2160-3-9] 05:00AM BLOOD CK(CPK)-175* [2160-3-7] 10:19PM BLOOD ALT-16 AST-16 CK(CPK)-426* AlkPhos-60 TotBili-0.5 [2160-3-6] 04:40AM BLOOD ALT-15 AST-13 LD(LDH)-133 AlkPhos-63 TotBili-0.3 [2160-3-5] 01:05AM BLOOD CK(CPK)-390* [2160-3-5] 01:05AM BLOOD cTropnT-<0.01 [2160-3-5] 01:05AM BLOOD CK-MB-4 [2160-3-10] 04:50AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.1 [2160-3-6] 04:40AM BLOOD Albumin-4.0 Calcium-9.0 Phos-2.2* Mg-2.1 [2160-3-6] 04:40AM BLOOD VitB12-257 Folate-8.5 [2160-3-6] 04:40AM BLOOD TSH-0.44 [2160-3-5] 01:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2160-3-6] 02:53PM URINE bnzodzp-NEG barbitr-POS opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG. . RPR (-) Blood cultres (-)/NGTD at time of discharge Brief Hospital Course: This 40 year old white male preseted from outside hospital for work-up of grand-mal seizure in the setting of four days of mausea, vomiting, and diarrhea, who while hospitalized had significant worsening delerium and suspected drug overdose withdrawal. . 1. Seizure - Initial inquiry was to etiology of seizures: withdrawal vs organic disease, likely thought due to withdrawal presentation given negative LP and CT at outside hospital and with return to baseline after acute delirium state. Neurology followed the patient while in house. Patient's EEG showed abnormalities, as noted above, and patient was initiated on Keppra. As per neurology recommendations, patient will need an outpatient MRI for follow-up. . 2. Change in MS - Initially upon transfer, showed minimal signs of hallucinations and/or abnormal behavior, but on hospital day two, became acutely combative, hyperactive requiring restraint codes, haldol, and ativan, and eventually, transfer to the unit for hemodynamic monitoring and possible further work up. Patient had a dystonic-type reaction to the haldol and was treated with cogentin, ativan, and benadryl. By report, there was concern patient had overdosed on either ambien, fiorcet, or ativan, or all of the above. Patient's TSH, B12, RPR, and serum toxicologies were negative, while the urine toxicologies were positive for barbs. By hospital day number four, patient returned to what appeared to be his baseline with coherent thought processes and without agitation. . 3. Depression - Patient had a nine year history of depression with two suicidal attempts - one by "cutting" his wrists. By report, patient had previously been apathetic, had decreased interest in daily activities, and was eating much less. When lucent, patient admitted to a rough work year and to stressors with his wife, but denied suicidal ideations or homicidal ideations. He denied that this event was an attempt to commit suidice. He is followed by phsyciatrist, Dr. [Last Name (STitle) ] - [Hospital ] Health Center, [Hospital1 1559]. Patient reports he has tried multiple anti-depressants, but does not like to take medications or see doctors, and is currently not taking any medication for his depression. Psychiatry followed the patient throughout his stay.- Followed by Dr. [Last Name (STitle) ] in [Hospital1 1559], MA [Telephone/Fax (1) 71915]. Due to patient's multiple suicidal attempts/ideations and psychiatry evaluation, patient was discharged to inpatient psychiatric unit here at [Hospital1 ]. . 4. Contact: [Name (NI) 402] [Name (NI) 71916] (wife) - [Telephone/Fax (1) 71917] or [Telephone/Fax (1) 71918] (cell). Request by wife and approved by Pt that [Name (NI) 1094] mother does not get information about Pt care if she calls. . 5. Code. Presumed full . 6. Left elbow wound - tetanus shot was administered. Medications on Admission: Meds on Admission: 1. Ambien 10-20 mg qhs - sleep 2. Clonazepam 2 mg [Hospital1 ] - anxiety 3. Excedrin pm prn - migraine Discharge Medications: 1. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 doses. 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 doses. 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Primary: 1. seizure . Secondary: 1. Seizure - 1 prior episode in [2156]. Similar flu-like illness preceding. Similar pre-ictal shaking, chills, agitation. Grand-mal with loss of consciousness, post-ictal confusion. 2. Depression - dx 9 yrs ago. 1 prior suicide attempt in [2152] (slit wrists). Followed by psychiatrist, Dr. [Last Name (STitle) ], at [Hospital ] Health Center in [Hospital1 1559], MA. Sees Dr. [Last Name (STitle) ] q 3-6 mos for 15 mins. 3. Migraines - controlled with Excedrin pm. 4. Hypercholesterolemia - untreated. Pt does not like to go to the doctor. 5. h/o kidney stones. Discharge Condition: Good condition. Vital signs stable. Tolerating POs with no nausea, vomiting, or diarrhea. Able to ambulate independently. Discharge Instructions: You were evaluated for a grandmal seizure in the setting of 3 days of nausea, vomiting, diarrhea. The etiology of your grandmal seizure is unknown. Seizure etiologies include alcohol withdrawal, drug or medication withdrawal, brain tumor, head trauma, cerebrovascular disease, infectious, and electrolyte abnormalities. Highest on the differential was medication withdrawal. Patient should: 1. Take all medications as prescribed. 2. Keep all follow-up appointments. 3. Seek medical attention if you acquire chest pain, shortness of breath, nausea, vomiting, fevers greater than 101, or any other issue that is out of the ordinary for him. Followup Instructions: 1. Primary care physician. [Name10 (NameIs) ] have an appointment scheduled with Dr. [First Name (STitle) ] ([Company 191] at [Hospital1 18]) on Friday, [2160-3-28] at 1:30pm. [Location (un) ] [Hospital Ward Name 23], South Suite. Phone [Telephone/Fax (1) 250] 2. Psychiatry - our psychiatrists here spoke with your outpatient psychiatrist. This appointment has already been arranged - please call to verify. 3. [Hospital 875] clinic - You are scheduled for an appointment with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ] on Thursday [2160-3-27] at 9:00 am. This is in the [Hospital Unit Name ] on the [Hospital Ward Name ] of [Hospital1 18] [Location (un) 6332]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] ICD9 Codes: 311, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6269 }	Medical Text: Admission Date: [2164-1-15] Discharge Date: [2164-1-17] Date of Birth: [2083-11-8] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Benadryl / Aspirin Attending:[First Name3 (LF) 99] Chief Complaint: s/p fall, seizure Major Surgical or Invasive Procedure: Intubation ([2164-1-15]) Extubation ([2164-1-16]) History of Present Illness: 80 year old female presents s/p fall last night at her nursing home. Patient fell out of bed at 11PM last night, was placed back in bed by the nursing home staff. Some reports that she could have perhaps had a headache or slightly confused at that time, but this is unclear. This morning was noted to have garbled speech, non-fluid speech, and so was sent to [Hospital1 18] for evaluation. Per NH, patient has baseline dementia but is usually alert and oriented. Here she was initially A&Ox2 (person, hospital) and moving all extermities. Per discussion with the husband, patient is alert and oriented x2 only and per previous [Hospital6 1597] Records, the patient is confused at baseline possibly in the setting of persistent uremia. Did not receive any antibiotics at the rehab such as Cipro. . In the ED, initial vs were: 98.8, 71, 171/96, 18, 97% 2L NC. Patient triggered for generalized tonic clonic seizure which lasted for 1-2 minutes. Was given 2mg IV ativan and intubated for airway protection. Noted to be a very difficult intubation. Given concern for head bleed, she received CT head which showed no acute intracranial bleed preliminarily. She was also loaded with phenytoin 1000 mg. CXR showed a widened mediastinum, because there was no prior CXR to compare to, the ED performed CTA neck/chest which showed no arterial dissection or major occlusions. It was noted to have some diffuse subcutaneous emphysema, which may have been a result of the difficult intubation. An LP was performed given acute mental status change to rule out meningitis which did not show any evidence of meningitis. Patient was given emperic vancomycin 1g, ceftriaxone 1g, levofloxacin 750mg, and metronidazole 500mg. Was noted to have creatinine of 5.6, unfortunately got IV contrast with CTA, was given 1 L of IV fluids. Vital signs on transfer were: HR 70 (A-paced), 170/105, 16, 100% (ventilated PEEP 5, Fio2 60) . In the MICU, patient is intubated and sedated and not responding to commands. Sedation is being weaned. . Review of systems: Unable to obtain due to intubation/sedation Past Medical History: Mild dementia with agitation Atrial fibrillation not on coumadin, likely secondary to history of GI bleed and frequent falls Subdural hematoma, History of acute tubular necrosis with increased calcium in the past, chronic renal insufficiency (Stage V CKD) with baseline creatinine of 4.5-5.3 Hypertension Seizure disorder Osteoporosis Pacemaker for tachybrady syndrome (pacer is Guidant Insignia [2157-3-30] Mode DDD, programed rate 70 bpm, underlying rhythm SB, not pacer dependent). History of GI bleed Bilateral total knee replacement Remote history of CVA, B12 and folate deficiency, s/p appendectomy, Cholecystectomy, Stress test in [5-/2163] with Myoview negative, Echocardiogram and [2163-11-12], EF of 55%, mild LVH, mild MR, mild TR. Social History: lives at a Nursing Home ([Hospital1 ] Village). - Tobacco: denies (per report) - Alcohol: denies (per report) - Illicits: denies (per report) Family History: unknown Physical Exam: Admission Exam General: intubated, sedated, not following commands HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD; pacemaker in place. 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, 2+ pitting edema . Discharge Exam General: Alert and oriented to person but not time and place HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD; pacemaker in place. 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, 2+ pitting edema Pertinent Results: Admission Labs [2164-1-15] 07:00AM BLOOD WBC-6.7 RBC-3.71* Hgb-11.5* Hct-39.5 MCV-107* MCH-31.0 MCHC-29.1* RDW-17.9* Plt Ct-216 [2164-1-15] 07:00AM BLOOD PT-12.7 PTT-22.4 INR(PT)-1.1 [2164-1-15] 07:00AM BLOOD Glucose-117* UreaN-75* Creat-5.6* Na-146* K-4.2 Cl-103 HCO3-26 AnGap-21* [2164-1-15] 07:00AM BLOOD Albumin-4.1 Calcium-8.1* Phos-4.2 Mg-2.6 [2164-1-15] 07:14AM BLOOD Lactate-6.4* [2164-1-15] 09:35AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-0 [2164-1-15] 09:35AM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2164-1-15] 11:53AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG . Pertinent Labs [2164-1-15] 07:00AM BLOOD CK-MB-4 [2164-1-15] 07:00AM BLOOD cTropnT-0.04* [2164-1-16] 03:34AM BLOOD CK-MB-4 cTropnT-0.04* [2164-1-15] 03:25PM BLOOD Phenyto-9.4* [2164-1-17] 03:41AM BLOOD Phenyto-9.1* [2164-1-15] 03:35PM BLOOD Lactate-1.1 . Discharge Labs [2164-1-17] 03:41AM BLOOD WBC-5.7 RBC-3.76* Hgb-11.8* Hct-39.6 MCV-105* MCH-31.3 MCHC-29.7* RDW-18.0* Plt Ct-200 [2164-1-17] 03:41AM BLOOD Glucose-84 UreaN-64* Creat-4.9* Na-143 K-4.8 Cl-106 HCO3-25 AnGap-17 . Pertinent Reports EKG ([2164-1-15]): Atrial paced rhythm at 70 beats per minute. Q waves in leads V1-V3 suggesting possible prior anterior wall myocardial infarction. No previous tracing available for comparison. . CTA Head/Neck/Chest ([2164-11-14]): There is no evidence of acute intracranial hemorrhage. Evidence of small vessel ischemic disease as described above. Subcutaneous emphysema in the cervical soft tissues, extending into the mediastinum and tracking along the facial planes and carotid space. Bilateral atelectasis and pleural effusions. Multiple thyroid nodules are visualized, correlation with thyroid ultrasound is recommended . . CXR ([2164-11-14]): 1. Wide mediastinum. No prior examinations available for comparison. Given history, CT examination should be considered. 2. Linear lucencies in the soft tissues over the neck could indicate subcutaneous emphysema. CT examination may be considered to evaluate this and for the presence of pneumomediastinum. 3. Satisfactory position of endotracheal and nasogastric tubes. Brief Hospital Course: 80 year old female with multiple medical problems including atrial fibrillation not on coumadin, frequent falls, seizure disorder, chronic kidney disease who presents from rehab s/p fall and with altered mental status. . 1. Altered mental status post fall: Likely due to seizures that led to her fall and perhaps was post-ictal morning of the fall. Patient also had frequent falls noted and has been transitioned to a nursing home since her last admission to [Hospital3 ] in [Month (only) ] [2162]. No fever or leukocytosis to indicate an infection. No evidence of ventricular arrythmias on her pacer per EP, only a few episodes of atrial fibrillation. No evidence of meningitis on LP. Head and neck CT negative for acute intracranial bleed or aortic dissection. Toxicology screen is negative so less likely ingestion leading to AMS. . She was intubated in the setting of her altered mental status. No MRI done as she had a pacemaker. She was loaded with phenytoin IV 1000 mg and received phenytoin 100 mg IV TID. She was extubated on [2164-11-15] and she has done well clinically since then. She was transitioned to 100 mg po TID. Neurology wants to have her follow-up with them in one month as outpatient. . # Respiratory Failure: Patient intubated in the ED for airway protection during the seizure. Oxygenating well with no evidence of pneumonia or aspiration in the ED. Patient was a very difficult intubation and has signs of subcutaneous emphysema on CXR. Home lasix was held on admission. She was extubated on [2164-11-15] and was weaned down to room air. She has been oxygenating well on room air. Home lasix was restarted on [2164-11-16]. . # Seizure: Patient with witnessed tonic clonic seizure in the ED. Has a history of seizure disorder. She was loaded with phenytoin 1000 mg IV x 1 and started on phenytoin 100 mg IV TID which was transitioned to 100 mg po TID when she was tolerating oral diet. . # Acute on chronic renal failure: Admitted with creatinine of 5.4 which is higher than her baseline creatinine of 4.8. She received IV bicarbonate and mucomyst as she was given dye load for her CT angiogram. Home lasix was held on admission. Creatinine improved with intravenous fluid repletion to 4.9 prior to discharge. Home lasix was restarted. She was continued on home sodium bicarbonate, nephrocaps and vitamin D. . # Hypernatremia: Sodium slightly elevated at 146 which resolved with fluid repletion. . # HTN: Restarted on home metoprolol and increased amlodipine to 10 mg po qdaily. . # AF: A-paced. EP interrogated pacer and noted some episodes of AF but no VT or VF noted. No anticoagulation given hx of falls. . # Communication: Patient/ Husband [Name (NI) ] [Name (NI) 90106] [Telephone/Fax (1) 90107] (HCP) . # Code: Full (discussed with HCP) Medications on Admission: Sodium Bicarbonate Tablets 1300 mg PO TID Vitamin D 400 mg PO BID Metoprolol 25 mg PO BID Risperdone 0.25 mg PO BID Bisacodyl Milk of Magnesia Tylenol 325 mg PO q6H:PRN pain, fever Procrit 60,0000 U/mL 1 ml SQ on Fridays Vicodin 1 table PO q6H:PRN pain Ativan 0.5 mg PO q6H:PRN anxiety Folic Acid 1 tablet PO daily Nephrocaps PO TID with meals Protonix 40 mg PO daily Lasix 40 mg PO daily Celexa 10 mg PO daily Was also discharged on amlodipine 5 mg PO daily for hypertension but not on rehab meds. Discharge Medications: 1. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO once a day as needed for constipation. 7. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for fever or pain. 8. Procrit 20,000 unit/2 mL Solution Sig: 60,000 units Injection once a week: On Sundays. 9. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 16. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital1 ] Village Discharge Diagnosis: Primary Diagnosis 1. Seizure disoder 2. Atrial fibrillation 3. History of falls Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted because you were noted to have a fall in setting of likely seizure. You had seizure in the emergency department which led to intubation. You were given a medication called PHENYTOIN to treat your seizures. You were extubated next day and have had not difficulty breathing since then. . Following medication changes were made to your medication regimen: START PHENYTOIN 100 mg by mouth three times a day INCREASE AMLODIPINE to 10 mg by mouth once a day Followup Instructions: Please follow up with Neurology in one month Completed by:[2164-1-17] ICD9 Codes: 5845
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6270 }	Medical Text: Admission Date: [2137-9-18] Discharge Date: Date of Birth: [2082-1-4] Sex: M Service: ACOVE CHIEF COMPLAINT: Chest discomfort. HISTORY OF PRESENT ILLNESS: The patient is a 55 year old male with a history of pulmonary embolism diagnosed in [2137-7-4], who presented to the Emergency Department complaining of right sided pleuritic chest pain. The patient noted increased pain on right side similar in nature to past symptoms when he had a pulmonary embolus. Also with increased bowel movements consistent with an ulcerative colitis flare three days prior to admission which have gradually been improving over the past several days prior to admission. PAST MEDICAL HISTORY: Significant for: 1. Pulmonary embolism in [2137-7-4], currently on Coumadin. 2. Ulcerative colitis diagnosed in [2136], by colonoscopy. 3. Lower back pain, status post laminectomy. 4. Status post appendectomy. 5. Cervical spondylosis. 6. Sleep apnea, status post uvuloplasty. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Asacol. 2. Coumadin 10 mg p.o. once daily. 3. Paxil 30 mg p.o. once daily. 4. Diazepam 10 mg p.o. q.h.s. 5. Lomotil p.r.n. FAMILY HISTORY: Mother died of cerebrovascular accident and diabetes mellitus. Father has history of deep vein thrombosis. SOCIAL HISTORY: No alcohol or tobacco use. Son and daughter are living with the patient. PHYSICAL EXAMINATION: On admission, temperature is 100.4, pulse 101, blood pressure 145/76, oxygen saturation 90% in room air and 95% on three liters. The patient is awake and alert, breathing comfortably, no accessory muscle use. Anicteric. Mucous membranes are moist. Neck is supple, jugular venous distention not well visualized. Lungs are clear to auscultation bilaterally with decreased breath sounds at right base with increased dullness to percussion at right base. Cardiovascular examination is regular rate and rhythm, slightly tachycardic, normal S1 and S2, no murmurs. The abdomen is soft, mild bilateral lower quadrant tenderness, nondistended, positive bowel sounds, no rebound or guarding. Extremities revealed 1+ pretibial edema bilaterally, warm, no cords, no Homans' sign, nontender. LABORATORY DATA: On admission, white blood cell count was 7.6, hematocrit 38.4, platelet count 294,000. Sodium 134, potassium 4.1, chloride 101, bicarbonate 23, blood urea nitrogen 14, creatinine 1.0, glucose 109. INR 2.8. Chest x-ray revealed right pleural effusion. CT angiogram right pleural loculated effusion. Bilateral upper zone small old pulmonary embolus, no infiltrates. IMPRESSION: The patient is a 55 year old male with a history of pulmonary embolism, ulcerative colitis, presenting with increased shortness of breath, cough, fever, chills, in the setting of increased inflammatory bowel disease symptoms and found to have new right pleural effusion without evidence of new pulmonary embolus. HOSPITAL COURSE: 1. Pulmonary - The patient was evaluated by Cardiothoracic surgery who recommended VATS for diagnosis as well as treatment of the pleural effusion which was done on [2137-9-19], with open wedge resection, removal of infarcted lung. Postoperative with poor gas, pH 7.18, pO2 78, which improved significantly with nasal airway. Respiratory acidosis thought secondary to narcotics as well as splinting. The patient was admitted to the Intensive Care Unit for observation. While in the Intensive Care Unit, the patient did well, did not require intubation and was saturating well with five liters of oxygen and was transferred to the floor for further management. At the time of this dictation, the chest tube is still in place and will be removed according to Cardiothoracic surgery recommendations. The patient is to be continue on Levofloxacin as well as Flagyl for treatment of pulmonary infection and will be slowly weaned from oxygen requirement and was put on Lovenox which was changed over to Coumadin for treatment of the pulmonary embolism from [Month (only) 216]. 2. Infectious disease - The etiology of current presentation is unclear; as due to necrotic lung mass or to superinfection for other reasons, the patient will be continued on Levofloxacin and Flagyl for now. Further workup was done with PPD and HIV testing, the results of which are pending at this time. 3. Hematology - The patient with a hypercoagulable state which was addressed with hypercoagulable workup including lupus anticoagulant, Factor [Initials (NamePattern4) ] [Last Name (NamePattern4) 5244], prothrombin G mutation, however, the patient's current presentation may be secondary to the ulcerative colitis which is actually an increased risk factor for hypercoagulable state. The patient will be continued on Coumadin to complete course of treatment for pulmonary embolism. 4. Gastrointestinal - The patient was initially started on Asacol for continued treatment of ulcerative colitis, however it was recommended by gastroenterology that this could actually increase symptoms of ulcerative colitis and the Asacol was discontinued. If he is to reflare, the patient will be started on steroids instead. 5. Depression - The patient was on Paxil as an outpatient for which he is doing well with his depression and will be continued on this while an inpatient and postdischarge. This discharge summary is to be addended by Dr. [First Name8 (NamePattern2) 4036] [Last Name (NamePattern1) ] for discharge diagnosis, condition on discharge and discharge medications. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Name8 (MD) 4630] MEDQUIST36 D: [2137-9-21] 13:29 T: [2137-9-21] 14:10 JOB#: [Job Number 11158] ICD9 Codes: 5119, 2762, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6271 }	Medical Text: Admission Date: [2128-12-16] Discharge Date: [2129-3-17] Date of Birth: [2073-2-10] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole / Motrin / Depakote / Reglan Attending:[First Name3 (LF) 6780] Chief Complaint: Fever, hypotension, altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 55 y/o F with neurosarcoidosis, panhypopituitarism, DM, HTN, presents to ED from home this am with fever, altered mental status and hypotension. Patient was recently hospitalized for similar symptoms secondary ot pseudomonas uti, discharged [12-8]. Patient fluid recusitation and given stress dose steroids with improvement in BP and mental status. Lactate 3.8 -> 1.8 with hydration. Patient denies recent illness, did skip prednisone on day of admission, no n/v/d/c, does c/o sore throat, no congestion, mild abdominal pain, no urinary symptoms. Past Medical History: 1. Neurosarcoidosis 2. Panhypopituitarism. 3. Status post right temporal craniotomy for brain biopsy. 4. Diabetes insipidus. 5. Diabetes mellitus type 2. 6. Questionable gastroparesis in the past. 7. Hypertension. 8. Hypercholesterolemia. 9. Migraines. 10. Gastroesophageal reflux disease. 11. History of upper gastrointestinal bleed. 12. Anemia. 13. Obesity. 14. History of subarachnoid hemorrhage 20 years ago. 15. Shingles. 16. L4 through L5 disc disease. 17. Stroke with left hemiparesis in [2106] Social History: The patient denies any tobacco, alcohol or intravenous drug use. She lives with a friend in [Name (NI) 669]. She is originally from [Country ]. Family History: noncontributory Physical Exam: Unavailable Pertinent Results: [2128-12-15] 10:20PM GLUCOSE-164* UREA N-13 CREAT-1.6* SODIUM-143 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-30* ANION GAP-17 [2128-12-15] 10:20PM WBC-15.2* RBC-4.34 HGB-13.6 HCT-40.2# MCV-93 MCH-31.3 MCHC-33.8 RDW-16.1* [2128-12-15] 10:20PM NEUTS-79.9* LYMPHS-13.2* MONOS-3.8 EOS-2.8 BASOS-0.3 [2128-12-15] 10:20PM ANISOCYT-1+ MACROCYT-1+ [2128-12-15] 10:20PM PLT COUNT-280 [2128-12-15] 10:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1 [2128-12-15] 10:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2128-12-15] 10:40PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.006 [2128-12-15] 10:45PM LACTATE-3.4* [2128-12-16] 03:38AM LACTATE-1.8 [2128-12-16] 05:00AM PT-14.8* PTT-30.2 INR(PT)-1.4 [2128-12-16] 05:00AM PHENYTOIN-1.2* [2128-12-16] 05:00AM TSH-0.045* [2128-12-16] 05:00AM CALCIUM-7.9* PHOSPHATE-1.9* MAGNESIUM-1.3* [2128-12-16] 05:00AM LIPASE-40 [2128-12-16] 02:00PM CK(CPK)-243* [2128-12-16] 02:00PM CK-MB-3 cTropnT-<0.01 [2128-12-16] 09:25AM TYPE-ART TEMP-36.2 O2 FLOW-4 PO2-70* PCO2-44 PH-7.31* TOTAL CO2-23 BASE XS--4 INTUBATED-NOT INTUBA [2128-12-29] 07:00AM BLOOD WBC-12.8* RBC-3.24* Hgb-10.5* Hct-29.9* MCV-92 MCH-32.4* MCHC-35.2* RDW-16.4* Plt Ct-274 [2128-12-27] 06:32AM BLOOD Glucose-103 UreaN-14 Creat-1.1 Na-132* K-3.9 Cl-93* HCO3-30* AnGap-13 [2128-12-29] 07:00AM BLOOD Glucose-86 UreaN-20 Creat-1.4* Na-133 K-4.1 Cl-92* HCO3-28 AnGap-17 --- See records for results of numerous studies while an inpatient. Brief Hospital Course: 1. ID: With concerns of a septic etiology of her fever and hypotension, the patient was empirically treated with vanc/zosyn on admission but was stopped after two days of treatment secondary to negative blood and urine cultures and afebrile stability. Blood and urine cultures were repeated on [12-19] off of the antibiotics- urine grew yeast (likely colonization, <10,000), and the blood remained negative. THe patient did have an inframammary fold rash which appeared fungal and improved on miconazole powder. She also had a skin lesion on her back, however the breakdown was not consistent with zoster or any other infectious cause; it improved with duoderm. On the third week, she began to have first low grade fevers, then spiking to 102 over 4 days. Serial cultures were primarily negative but then third set grew MRSA. Patient had already been started on empiric vancomycin for presumptive PICC line infection as source of fevers, which was then continued for eventual 14day course. Pt remained afebrile after second day of vancomycin, survellience cultures negative. She was noted to have a slight leukocytosis w/inc WBC [Date range (1) 6782]. U/A was dirty and ahe was started on cipro 500mg [Hospital1 ]. UCx were again positive only for yeast. CXR neg. BCx were also negative. Pt was also noted to have ulcerative lesions on her tongue. These were initially thought to be [Female First Name (un) ] (pt on chronic immunosuppressive steriods and has hx of candidal esophagitis) but ddx included herpes simplex (pt with hx of cold sores), CMV, and aphthous ulcers. Derm was consulted for DFA and cultures were sent, including: HSV (neg), bact (neg), viral, and candidal (neg for yeast and [Doctor Last Name 6783] organisms). CMV viral load was negative. Clotrimazole troches/magic mouthwash were prescribed. Viral cx's positive for herpes and pt received full course of acylovir with complete resolution of lesions. Pt had witnessed aspiration on [1-21] with acute desaturation and hypotension. Pt was treated with 7 days of Vanco, Levo and Flagyl. After this episode, she did well for several weeks but then began to develop daily fevers. Multiple sets of blood cultures were drawn and she grew GNRs in several sets. SHe was treated with vancomycin until these returned as coag neg staph. ~1 week later, she again began to have fevers and elevations in her chronically elevated WBC ct. FOund to have yeast in her urine and treated with fluconazole for 1 week with resolution. Continued to have fevers, and occ episodes of mild hypotension, so started on vancomycin and levaquin. Fevers resolved, but no source found. Again grew coag neg staph, but determined to be contaminant. Also, grew VRE in urine, but recheck was negative and per conversation with ID, believed to be contaminant. After ~5 days of abx, they were discontinued as she was stable and no source was found. She remained stable off the abx. * 2. AMS: the patient has a severely limited baseline, although the admission mental status was indeed a change. The differential diagnosis for cause of her AMS was originally infection, hypotension, hypercarbia, or somnolence due to OSA. The patient remained without s/s of an infection, and pt rebounded back to her baseline after stress dose steriods with taper and BIPAP at night. Pt MS changed with any infection or stress. On [1-28] pt complained of chest pain and found to have ECG changes with + troponins. After this stress, pt's MS continued to decline for unknown reasons. After Na normalized and pt receiving steroids she did not improve. Psychiatry consulted for ? depression. Felt that she had a form of akinetic mutism and suggested adding Bromocryptine. Neuro also consulted for possible CVA. MRI repeared on [2-5] with no changes from [12-31]. Neuro recommended decreasing dose of Dilantin and giving Ritalin. Due to her recent MI, decided not to use Ritalin. Neuro revisited situation and believe that ot is suffering from akinetic mutism. For this she was started on bromocriptine, with gradually escalating doses. Unclear whether it was due to medication or not, but pt appeared to wake up significantly over the month that I knew her. She still had moments of relative unresponsiveness, but the majority of the time she would talk to me, and by the end of the month, she was making jokes and coming up with spontaneous comments. Contineud her dilantin and saw no evidence of seizures. Of note, her limited baseline status from her neurosarcoid does not allow her to take care of herself at home, and there is no family or other support who can care for her appropriately. 3. HYPOTENSION: On admission, patient was hypotensive and febrile and was resuscitated in the ED and MICU for presumed sepsis although without ever a cultured source. Intermittently the patient still has occasional episodes of hypotension, that is responsive to NS boluses. Likely these episodes are [2-16] her disability of her thirst mechanism and her adrenal insufficiency. She was given maintenance fluids nearly every day as patient was unable to be properly encouraged to drink enough on her own. Attending spoke with family and decided that pt would not want MICU stay and no pressors. She had 1-2 episodes of asymptomatic hypotension over the month I took care of her, relieved by IVFs. Otherwise she was stable from this standpoint. 4. PANHYPOPITUITARISM/ SECONDARY ADRENAL INSUFFICIENCY: This patient needs exogenouspituitary replacmenet to survive- she has no thirst mechanism and cannot respond appropriately to stress. -Secondary Adrenal Insuffic: On admission, she recieved stress dose steriods and then was tapered over two weeks slowly back to prednisone 10mgQD (baseline dose). With continued hypotension episodes associated with nausea and vomiting, the suspicion of adrenal insufficiency arose and was verified by a cortisol level of 0.8. Likely secondary adrenal insufficiency from hypopituitarism, and therefore she was started on prednisone [Hospital1 ] (10am and 5pm) for maintanence. However on MRSA bacteremia infection and high fevers, she was restarted on Hydrocortisone/ fludricortisone stress steriods on [1-5] and then retapered. - Fludrocort stopped as pt has central deficit. SHe was on solumedrol IV for the month I had her. SHe did well on this and was given stress doses for fevers, suspected infection. Typically ,would give extra 20 mg IV solumedrol for every degree her temp rose over 100.(ie. 100-101=20 mg extra, 101-102=40 mg extra, etc.). She did well with this regimen. The plan is to switch her to oral prednsione through the PEG tube to take her completely off IV medications. -Central Diabetes Insipidus: from her neurosarcoid- Endocrine consulted for regulation of Na. With pts poor MS she could not properly take nasal DDAVP and was therefore started on IV. Pt placed on standing dose of 0.4mcg with good results. Pt requring 2 liters of fluid per day. Alternating fluids between D5W and D51/2NS. She tolerated this well. After PEG tube placed, she was converted to oral ddavp and after some trial and error with her IVFs and free water boluses through her PEG, we found a steady state inher sodium levels. This was very sensitive, and her I/Os had to be watched closely daily along with her sodium in order to keep her in balance. She would start to drift up or down at times with no changes made for unclear reasons, but was stable by the time I left the wards. -Hypothyroidism: appropriately replaced as demonstrated by free T4 level. This was followed every 10 days when she was switched to oral levothyroxine, and she is currently stable at 175 mcg qday through her PEG. 5. NEUROSARCOID: Her neurosarcoid is followed by Dr [First Name8 (NamePattern2) 1151] [Last Name (NamePattern1) ] Neuro-oncology [Hospital1 18] and has been treated with cytoxan every few months via portacath. However with progressive decline of her mental status over several months and no significant improvement on interval MRI, the cytoxan therapy was aborted per Dr [Last Name (STitle) 724]. progression of disease has left Ms [Known lastname ] unable to care for herself / take meds/ feed herself / etc... according to NeuroOnc Cytoxan is only a prolonging measure, not a curative solution. She will die from this disease (likely from endocrine effects) but no time table can be reasonably named. She was continued on her seizure prophylaxis with dilantin/neurontin. 6: ACCESS: The patient's Left sided port-a-cath was removed during admission. Her first PICC line was eventually nidus for bacteremia episode and was removed; another was placed for IV antibiotics and hydration purposes after survellience cultures negative x 3days. This PICC clotted and a third was placed on [2-1]. The pt pulled this PICC line out, and a 4th was placed by IR that functioned well for >1 month. 7. DIABETES MELLITUS: the patient is on metformin at home, which she tolerated well here until she was on stress dose steriods. She then was maintained on glargine and ISS. Her blood glucose levels were initially high, and get higher when she gets higher doses of steroids for temps. She is currently stable with good levels on glargine 7 units and a customized sliding scale. 8. HYPERLIPIDEMIA: The patient was continued on lipitor. 9.DVT: Pt found to have RLE DVT despite pneumoboots. Staretd Lovenox as pt has extreme heparin sensitivity. Checked factor Xa levels and she is in the therapeutic range on Lovenox 60 mg/kg. Started coumadin after several days at dose of 2.5 initially due to history of sensitivity to anticoagulation. Wasn't effective, so increased dose to 5 mg qday and INR climbed to only 1.6. 10.Cardiology: Pt with chest pain on [1-28]. Found to have slightly elevated trop with deeper diffuse T wave inversions. + MB fraction on [1-30] so pt was started on heparin gtt for 48 hours. Extremely sensitive, and low doses only needed to get her therapeutic(ie SQ haprin doses) - Medically managed on Lopressor, Lisinopril and ASA 11.Shoulder pain:Pt started to c/o shoulder pain. Xray clear so MRI performed. Found to have 3 rotator cuff muscles with complete tears through the tendons. Also had bllod in joint capsule, which explained concurrent 6 point Hct drop. Unclear how this occured, but staff was using lift to get pt from bed to chair and suspect that she was injured in this process, alternatively, may have fallen and gotten up without anyone seeing her. Seen by ortho and felt no intervention unless joint became septic. Began to improve on its own and pt was able to use joint without pain eventually. No intervention performed. 12. Nutrition: Had long discussion with attending and team on [2-1] regarding nutrition. Pt not eating with altered MS. - PEG placed [2-12]. Tube feeds recommended by nutrtion and she tolerated them well. Currently getting 150 cc q8h water boluses to maintain stable sodium levels. This volume and frequency was manipulated often to get to this eventual steady state, and she responds well to changes in this if her levels begin to change. 13.On the day before death, pt was found by her intern in the morning to have right sided weakness and facial droop. She was sent for MRI which showed pontine hemorrhage. Unclear why she had this hemorrhage, but she has multiple reasons for such an insult. However she developed [Last Name (un) 6055]-[Doctor Last Name ] respirations in the MRI scanner and was taken back to the floor. Pt was found to have BP of 240/120 and bradycardia. O2 sat then dropped down into 60s. Pt was a DNR/DNI, but upon speaking with family, her son asked that this be reversed and that she be intubated/resuscitated. She was intubated and had central line placed. Transferred to the unit. Once there, team spoke with family about poor prognosis and decision was made to withdraw care. Pt was then sent for organ donation. Medications on Admission: Lipitor Prednsione (tapered to 10mg) Lisinopril Desmospressin Cipro (completed [12-15]) Metformin Humulin Protonix Sucralfate Levothyroxine Flovent Discharge Medications: None Discharge Disposition: Extended Care Facility: unknown Discharge Diagnosis: neurosarcoid, adrenal insufficiency Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None ICD9 Codes: 0389, 2760, 2761, 5070, 4275, 4589, 4019, 2724, 2859, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6272 }	Medical Text: Admission Date: [2189-8-10] Discharge Date: [2189-8-13] Date of Birth: [2154-6-9] Sex: F Service: Medicine, Intensive Care Unit CC:[CC Contact Info 111173] HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old female with a h/o depression, seizure disorder (unspecified), and alcoholism who was brought to the [Hospital1 1444] Emergency Department by Emergency Medical Service after being found unresponsive at a T-station. Of note, all of the patient's medications were with her at the time she was found. In the field, her blood pressure was noted to be 86/60, pulse was 92, and oxygen saturations were 96% on room air. Fingerstick was 94. In the Emergency Department, the patient was found to be minimally responsive but with stable vital signs. As a result, she was quickly intubated for airway protection. Further information at the time of admission could not be obtained due to the patient's decreased mental status and the absence of any family or friends. PAST MEDICAL HISTORY: 1. Depression; last hospitalization for suicidal ideation in [2189-4-7]. 2. Seizure disorder diagnosis three months ago. 3. Mitral valve prolapse. 4. Bipolar disorder. 5. History of trazodone overdose 10 years ago. 6. History of bulimia. 7. History of alcohol abuse with multiple detoxification treatments. MEDICATIONS ON ADMISSION: 1. Remeron 7.5 mg by mouth q.h.s. 2. Celebrex 100 mg by mouth twice per day. 3. BuSpar 20 mg by mouth twice per day. 4. Trazodone 150 mg by mouth q.h.s. 5. Prozac 80 mg by mouth once per day. 6. Dilantin 300 mg by mouth q.h.s. 7. Neurontin 300 mg by mouth q.a.m. and 600 mg by mouth q.h.s. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient has a heavy alcohol history, but apparently has been fairly sober for the past three years. A one pack per day tobacco history for several years. No history of any intravenous or recreational drug use. The patient is engaged but estranged from her immediate family. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed temperature was 98.9 degrees Fahrenheit, blood pressure was 114/55, heart rate was 78, respiratory rate was 17, and oxygen saturation was 95% on room air. On initial examination, the patient was obtunded and virtually unresponsive. Pupils were equal, round, and reactive to light. The oropharynx was clear. The mucous membranes were moist. The head was atraumatic. The neck had a cervical collar in place, but there was no focal point tenderness to palpation noted. No adenopathy. The lungs were clear bilaterally without any chest wall tenderness or visible ecchymosis. Cardiovascular examination revealed a regular rate and rhythm. A [2-12] holosystolic murmur at the apex. The abdomen was soft and benign with good bowel sounds. Extremities were without any edema. Good pulses bilaterally. Neurologic examination displayed 2+ patellar reflexes bilaterally with downgoing toes. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission were notable for a white blood cell count of 8.3, hematocrit was 31.9, and platelets were 285. Blood urea nitrogen was 25 and creatinine was 0.7. Urinalysis showed a specific gravity of 1.023, with large blood, trace protein, and trace ketones. ALT was 67, AST was 59, alkaline phosphatase was 36, and total bilirubin was 0.1. Dilantin level was low at 0.6. Toxicology screen was only positive for alcohol with a level of 266. Arterial blood gas was noted to be 7.46, PCO2 was 36, and PAO2 was 528, with a lactate level of 2. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm at a rate of 66 with a normal axis. A slightly prolonged Q-T interval at 462. A head computed tomography was negative. A chest x-ray was normal. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. ACUTE INTOXICATION ISSUES: The patient's decreased mental status/unresponsiveness was thought to be solely due to alcoholic intoxication; although polysubstance abuse could not be ruled out. Once the patient's mental status improved, a further history was obtained. It turned out that the patient had been exercising increased emotional stressors recently and admitted to drinking one pint of rum and Coke on the day of admission and then subsequently losing consciousness. She also stated that by mistake she took an extra dose (actual dose unspecified) of Neurontin to help her relax. She vehemently denied ingestion of any other substance. Because of her virtual unresponsive, the patient was immediately intubated in the Emergency Department for airway protection but soon self-extubated within a few hours upon arrival to the MICU. She also received 50 grams of activated charcoal, via a nasogastric tube in the Emergency Department. After her self-extubation, the patient slept for about 12 hours with all vital signs stable. She subsequently returned back to her baseline on hospital day two; in terms of her mental status. Initially, she was kept nothing by mouth with aspiration precautions. All sedative medications were avoided. Given her history of alcoholism, she was placed on a multivitamin, thiamine, and folate. She was also placed on a CIWA scale. However, she did not exhibit any signs or symptoms of alcohol withdrawal. Therefore, as a result, she did not receive as needed Valium during her hospital stay. The Addiction Service team was consulted and provided information about various support groups that the patient could follow up with upon discharge. Because the patient was found in an area where multiple assaults have taken place recently against women, the Acute Intoxication Center for Rape and Violence against Women was consulted, and the patient was counseled in terms of their services. However, she refused any evidence collection. 2. DEPRESSION ISSUES: The inpatient Psychiatry Service was consulted, and it was determined that the patient's acute intoxication was not a suicidal gesture. She was continued on all of her outpatient psychiatric medications and determined to be safe for discharge by the Psychiatry Service. 3. SEIZURE DISORDER ISSUES: The patient's Dilantin level was noted to be subtherapeutic on admission. Thus, she was loaded with Dilantin and placed on her regular outpatient regimen of 300 mg by mouth q.h.s. An electroencephalogram was also obtained prior to discharge; the results of which were pending at the time of this dictation. She was placed on seizure precautions while in house, but at no timed displayed any signs or symptoms of a true seizure. 4. ABNORMAL LIVER FUNCTION TEST(S) ISSUES: The patient's liver function enzymes were all noted to be slightly elevated. The etiology included Dilantin toxicity or viral hepatitis. The patient will need a full outpatient workup. 5. MILD ABDOMINAL PAIN ISSUES: The patient complained of mild epigastric abdominal pain for the first 24 hours of her hospital stay. This was attributed to either alcoholic gastritis or residual effects of the activated charcoal. As a result, she was placed on daily Protonix for adequate prophylaxis. Her abdominal pain resolved by the time of discharge, and she was tolerating oral intake. 6. ELECTROLYTE(S) ISSUES: The patient's electrolytes were checked on a daily basis, and her potassium and magnesium were repleted as needed. DISCHARGE DIAGNOSES: 1. Acute EtOH intoxication, respiratory depression 2. Alcoholism. 3. Seizure disorder; unspecified. 4. Depression. 5. Mildly elevated liver function tests. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg by mouth once per day. 2. Neurontin 300 mg by mouth q.a.m. and 600 mg by mouth q.6h. 3. BuSpar 20 mg by mouth twice per day. 4. Dilantin 300 mg by mouth q.h.s. 5. Prozac 80 mg by mouth once per day. 6. Remeron 7.5 mg by mouth q.h.s. 7. Celebrex by mouth as needed. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: The patient was discharged back to the [Hospital1 ] Shelter. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to take all of her prescribed medications; especially her Dilantin dose on a regular basis. 2. The patient was also instructed to avoid alcohol at all times. She was given the names and telephone numbers of various support groups in the area to help her avoid alcohol. She agrees to continue AA meetings, beginning the day of discharge. 3. The patient was to follow up with her primary care physician (Dr. [Last Name (STitle) 111174] on [Last Name (LF) 766], [8-17], at 9 a.m. (a) I have called and updated Dr. [Last Name (STitle) 111174] on the patient's status and all of her followup needs. (b) Her electroencephalogram results will be faxed over to Dr.[Name (NI) 111175] office. (c) At that time, her Dilantin level will also be checked, and her dose adjusted as needed. (d) Dr. [Last Name (STitle) 111174] was also to perform a full workup of the patient's elevated liver function tests and make sure that an appropriate Neurology followup was arranged. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437], M.D. [MD Number(1) 2438] Dictated By:[Name8 (MD) 111176] MEDQUIST36 D: [2189-8-17] 20:25 T: [2189-8-17] 10:13 JOB#: [Job Number 111177] ICD9 Codes: 4240, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6273 }	Medical Text: Admission Date: [2155-8-21] Discharge Date: [2155-9-2] Date of Birth: [2085-11-11] Sex: M Service: SURGERY Allergies: Metoprolol Attending:[First Name3 (LF) 2597] Chief Complaint: 5.5 cm abdominal aortic aneurysm Major Surgical or Invasive Procedure: [8-21] s/p retroperitoneal AAA repair [8-23] re-exploration, evacuation of hematoma, 1 stitch to anterior suture line History of Present Illness: This 70-year-old gentleman was found to have a pulsatile abdominal mass and a 5.5 cm abdominal aortic aneurysm starting just below the renal arteries. The neck was too short for placement of an endovascular graft, and he was advised to have an open repair. Past Medical History: PMH: CAD s/p PTCA/stent LAD, PTA marginal circumflex branch [3-15], HTN, hypercholesterolemia PSH: none Social History: He is married. He and his wife have no children. He has moved to United States about five years ago from [Location (un) 6847]. While there he was a technician working in streetcar repair, I think on the electrical aspects. He does not smoke. He has occasional alcohol. Family History: His mother was diagnosed with premature heart disease at 55. She passed away at 73. He has two older sisters, the oldest has heart disease, CAD status post PCI. The younger sister evidently has valvular heart disease. Physical Exam: VSS: afebrile, 118/60, 59, 97%RA GEN: NAD Neuro: A&OX3 CV: RRR Resp: CTA ABD: soft, NT Ext: B/L fem palp, B/L DP/PT palp Pertinent Results: [2155-9-1] 07:06AM BLOOD WBC-7.8 RBC-3.86* Hgb-11.8* Hct-34.5* MCV-90 MCH-30.5 MCHC-34.1 RDW-14.7 Plt Ct-357 [2155-9-1] 07:06AM BLOOD Plt Ct-357 [2155-9-1] 07:06AM BLOOD Glucose-103 UreaN-21* Creat-0.9 Na-134 K-4.1 Cl-99 HCO3-30 AnGap-9 [2155-9-1] 07:06AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.3 [2155-8-23] CTA IMPRESSION: 1. Findings concerning for a focus of active extravasation at the proximal anastomosis of the aortic graft, as detailed above. There is a large associated retroperitoneal hematoma. Findings were discussed with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. 2. Large left hydropneumothorax. Brief Hospital Course: Underwent AAA repair on [8-21]. Uneventful, Extubated transferred to PACU- VICU. Post op, febrile- IS/chest PT encouraged. SBP 90's- bolus X3. Epidural discontinued. Hespan start started. Transfused 2uPRBCs. [8-22]: Tmax 102.6, Pulmonary toilet encouraged. [8-23]: Slowly declining hematocrit which initially responded to transfusion and then declined again with some mild hemodynamic instability. This prompted a CT scan which demonstrated a likely leak at the proximal anastomosis with a fairly large hematoma in the retroperitoneum. He was therefore taken urgently for exploration. . Retroperitoneal exploration and suture repair of an anastomotic bleed. Chest x-ray showing small left effusion. [8-24]: In ICU, extubated. Vanco X2 doses. Blood pressure controlled. [Date range (1) 57511]: IN ICU. VSS, no events, electrolytes repleted. IVF continued, NPO. On Nitro gtt for BP control. Epidural controlling pain. Transfused 1u PRBS. [8-27]: Transferred to VICU, Continue diuresis, monitoring I/O. Electrolytes repleted. Epidural discontinued. Tolerating po diet. PICC inserted for access. [8-28]- [8-29] Doing well, VSS. OOB with nursing and physical therapy. Tolerating diet, foley discontinued. Cardiology/Dow consulted-no change in management, will see patient for follow up in [5-16] weeks. Transferred to floor. Incisions without evidence of infection. [Date range (1) 32271] VSS Doing well. Evaluated by PT and OT. Transferred to [Hospital ] Health Center. Medications on Admission: lovastatin 40', atenolol 50',triamteren/HCTZ 1tab', aspirin 81', MVI, prilosec 200' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for HR<65, sbp<100 . 3. Senna 8.6 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. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Triamterene 50 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 ] center Discharge Diagnosis: 69 M w/ 5.5 cm asymptomatic infrarenal AAA not amenable to EVAR, now s/p repair PMH: CAD s/p PTCA/stent [3-15], HTN, hypercholesterolemia Discharge Condition: VSS Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [5-16] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [1-11] 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 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Call Dr.[Name (NI) 5695] office at [Telephone/Fax (1) 3121] to schedule post operative appointment Provider: [Name10 (NameIs) 900] [Name8 (MD) 901], M.D. Phone:[Telephone/Fax (1) 902] Date/Time:[2155-9-19] 9:40 Completed by:[2155-9-2] ICD9 Codes: 2851, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6274 }	Medical Text: Admission Date: [2111-5-15] Discharge Date: [2111-6-6] Date of Birth: [2111-5-15] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby girl [Known lastname 72019] is a 33 and [7-16] week twin A born at 1900 grams on [2111-5-15], and admitted to the NICU for issues of prematurity at 33 and 6/7 weeks gestation in respiratory distress secondary to surfactant deficiency resulting in right pneumothorax, re sepsis evaluation. She delivered to a 35-year-old primigravida with an EDC of [2111-6-27]. Maternal antenatal labs included maternal blood type of O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis C surface antigen negative and GBS status is unknown. Pregnancy was notable for spontaneous di-di twin gestation complicated by development of PIH, developing signs of preeclampsia. The infants were delivered via cesarean section. There was no labor and membranes were intact at delivery. Mother did not receive antenatal steroids or antibiotics. This infant was delivered from breech position and emerged with moderate tone requiring stimulation and oxygen in the DR. [Last Name (STitle) ] [Name (STitle) ] were 7, 8 and the infant was brought to the NICU. In the NICU moderate respiratory distress was noted and the infant was begun on CPAP. Birth weight was 1900 grams, 25th to 50th percentile; head circumference 31.5 cm, 50th percentile; length 44.5 cm, 40th percentile. Discharge weight on [6-6] is .. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Initially she was started on CPAP for 24 hours. She was noted to have a right sided pneumothorax which was needle decompressed. She was intubated and given Surfactant. She was placed thereafter on high frequency ventilation and remained on high frequency ventilation for 5 days. She extubated to nasal cannula and remained on nasal cannula for 5 days. She never had any history of apnea and without history of spells and was never started on caffeine. CARDIOVASCULAR: An echo was performed on [5-19] which documented no evidence of PDA. Access: She has a history of UAC, UVC, and PICC placement. FLUIDS, ELECTROLYTES AND NUTRITION: She remained on TPN for 11 days. She attained full enteral feeds by day of life 12. She will be discharged home with mother on [6-2], supplemented with Similac powder. Discharge weight is 2195 grams INFECTIOUS DISEASE: She was placed on ampicillin and gentamycin for 2 days and then switched to ampicillin and Zosyn for empiric treatment for total course of 10 days. An LP was performed on [5-24] and was negative. Blood cultures with no growth to date. HEMATOLOGY: Maximum bilirubin was 10.7 on day of life 9. Her last bilirubin 8.2 on day of life 11. She received phototherapy on day of life 6 and day of life 9. She has no history of blood transfusions. Her initial hematocrit was 44.3, and subsequent CBCs have been drawn. NEUROLOGY: A head ultrasound was performed on day of life 7 on [5-22] which was normal. SENSORY: Audiology: Hearing screening was performed with automated auditory brain stem responses on [6-6] ... Ophthalmology: Eyes were examined most recently on [6-1] revealing immaturity of the retinal vessels in zone 3 but no ROP as of yet. A follow up examination should be scheduled for the week of [6-22]. CONDITION ON DISCHARGE: Fair. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 34570]. Telephone No.: [Telephone/Fax (1) 47109]. A copy of this discharge summary will be faxed to her office. CARE RECOMMENDATIONS: A. Feeds at discharge: Breast milk 24, Similac 24. B. Medications: Iron and vitamin D supplementation. 1. Iron supplementation is recommended for preterm and low- birth weight infants until 12 months of corrected age. 2. All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 international units which may be provided as a multivitamin preparation daily until 12 month corrected age. 3. Car seat position screening will be performed prior to discharge on [6-6]. 4. State newborn screening status was sent on [5-18] and repeated on [5-29]. 5. Immunizations received: She received hepatitis B vaccination on [2111-6-4]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria: a) Born at less than 32 weeks. b) Born between 32 and 35 weeks with two of the following: 1. daycare during the RSV season. 2. a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. 3. with chronic lung disease. 4. hemodynamically significant congenital heart disease. 1. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. 1. This infant has not yet received Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infant at or following discharge from hospital when they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. Follow up appointments should be scheduled with Dr. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 34570] within few days of discharge and also with ophthalmology during the month of [Month (only) 116]. DISCHARGE DIAGNOSES: 1. Prematurity at 33 weeks. 2. Hyaline membrane disease. 3. History of right pneumothorax, resolved. 4. Sepsis evaluation. 5. Hyperbilirubinemia. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) 71811] MEDQUIST36 D: [2111-6-5] 16:05:30 T: [2111-6-5] 23:55:58 Job#: [Job Number 72020] cc:[Name8 (MD) 72021] ICD9 Codes: 7742, 769, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6275 }	Medical Text: Admission Date: [2172-10-6] Discharge Date: [2172-10-9] Date of Birth: [2107-1-7] Sex: M Service: NEUROSURGERY ADMISSION DIAGNOSIS: Transient ischemic attacks and vertebrobasilar insufficiency. HISTORY OF PRESENT ILLNESS: This is the first [Hospital1 346] admission for this 65 year-old white the [Hospital 1474] Hospital after a transient ischemic attack. The patient apparently was well until approximately [Month (only) 956] of this year at which time he experienced a transient ischemic attack and has had two subsequent transient ischemic attacks within the past two weeks prior to his admission to the [Hospital 1474] Hospital on the [2172-9-23]. These transient ischemic attacks were manifested as some blurring of the consciousness. He has no prior cardiac history and there is no history of rheumatic fever, heart murmur, cardiac enlargement or prior history of coronary artery disease. There is also no history of prior myocardial infarction or symptoms of angina pectoris. At the time of admission to the [Hospital1 69] the patient was taken to the Angiography Suite for a diagnostic and potentially therapeutic angiogram. MEDICATIONS ON ADMISSION: Zocor 60 mg q.d., Plavix 75 mg q.d., DynaCirc 10 mg q.d., Humalog 20 units at noon and 20 units at 5:00 p.m., Flutamide 250 mg po t.i.d. and he is also on Lupron injections. PAST MEDICAL HISTORY: He is a patient with known prostate cancer stage four on Lupron as well as history of insulin dependent diabetes and labile hypertension. At the time of his admission to the [Hospital 1474] Hospital earlier in the month of [Month (only) ] he had an elevated troponin. REVIEW OF SYSTEMS: He denies any history of recent, fevers or chills, sweats, nausea, vomiting, diarrhea, constipation, no recent headaches. No recent easy bruising, but he did complaint of mild claudication in the bilateral lower extremities after approximately [Age over 90 ] yards of walking. PAST SURGICAL HISTORY: History of laser eye surgery in the past. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: He was afebrile. Blood pressure 218/95. Heart rate 91. He was approximately 5'[80]" and 183 pounds. He is a well developed, well nourished white male elderly in appearance and appearing pale and chronically ill, but pleasant and cooperative with fluent speech and conversation. The skull was normocephalic, atraumatic. Eyes were anicteric. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. ENT examination was unremarkable. Tongue was midline. Chest was clear to auscultation and percussion, but decreased at the bases. Cardiac examination showed an S1 and S2 normal, a 1 to 2/6 systolic ejection murmur was heard at the right upper sternal border and radiated to the left lower sternal border. The abdominal examination showed the abdomen to be soft, nontender with scattered ecchymosis secondary to his insulin injection, but otherwise unremarkable. Extremities are without edema and ulceration, but he had decreased bilateral lower extremity pulses. HOSPITAL COURSE: Due to the clinical findings the patient was admitted on the morning of the [2172-10-6] to the Neurosurgical Service and to the care of Dr. [Last Name (STitle) 1132] who took the patient to the angiography suite where under monitored anesthesia care the patient underwent a diagnostic cerebral angiogram followed by a placement of a right vertebral artery stent for treatment of a severely narrowed right vertebral artery origin. The patient was also noted to have multiple sites of intracranial stenosis which will be followed for now. The patient tolerated the procedure well. Postoperatively, the patient was admitted to the Post Anesthesia Recovery Room overnight for monitoring and subsequently transferred on the first postoperative day to the Neurosurgical Intensive Care Unit where he remained for approximately 24 to 48 hours, but was stable throughout that time. He was subsequently transferred to the Medical [Hospital 2947] Hospital Floor where the remainder of his postoperative hospitalization was unremarkable and he was discharged home on the morning of the [2172-10-9] with follow up to see Dr. [Last Name (STitle) 1132] in the clinic in approximately four weeks time. He was also instructed to resume his aspirin 325 mg po q day and Plavix 75 mg po q.d. and return to use of all of his preoperative medications. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Name8 (MD) 22907] MEDQUIST36 D: [2172-10-9] 10:34 T: [2172-10-14] 09:11 JOB#: [Job Number 45625] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6276 }	Medical Text: Admission Date: [2138-8-11] Discharge Date: [2138-8-19] Date of Birth: [2058-8-10] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9824] Chief Complaint: Dyspnea, Gastrointestinal bleed Major Surgical or Invasive Procedure: NONE History of Present Illness: 80 yo F s/p inferior MI, HTN, HLP, DM II, smoking hx, diastolic CHF (last EF 55%), COPD (2L home O2, last FEV1= 0.61) presenting with 2-3 weeks of worsening of baseline exertional dyspnea x [5-6] months. Of note, has been on successive prednisone tapers x2 since [6-5] for COPD exacerbation. Two weeks ago was tapered off steroids, and promptly had worsening SOB at rest, was placed back on steroids, which have been tapered to 10 mg qday currently. Over past 5 months, progressive exertional dyspnea progressed to SOB after [3-6] steps in her home, relieved by rest x several minutes. Yesterday, woke up in middle of night with sudden-onset SOB, assx with diaphoresis and warmth. Better with position upright and hand-held O2, enabling her to return to sleep. In AM, when walking to car outside her home for MD appointment, felt recurrence of similar feeling of SOB, not clearly relieved with nebulizers x2, advair, oxygen, poorly relieved by rest. Driven by daughter to clinic, where found to have 81% on 3L NC, HD stable (no tachycardia). Referred to [Hospital1 18] for further eval and mgmt. Of note, during her episodes of exertional dyspnea does she NOT experience CP/pressure, palpitations, lightheadedness, dizziness, syncope, LE pain or increased edema. No fever, chill, night sweat, change in weight. No wheeze, hemoptysis, history of DVT/PE; chronic cough x1 year productive of green phlegm. Does have stable 3-pillow orthopnea and some PND (not as severe as yesterday). No recent med changes other than prednisone taper, increase in Advair to 500/50, and lisinopril from 10 to 20 mg qd ([7-2]). Compliant with meds, no dietary indiscretion. ROS otherwise negative. ED COURSE: Was hypotensive to SBP 80s in ED, tachycardic to 120s, w/desat to 80??????s-90??????s. CXR negative for acute process; +CHF. Labs showed HCT drop to 26 (baseline 35), acute on chronic RF with K at 5.9, no EKG changes. Received kayexalate x 30 gm PO and 1 U PRBC + lasix w/ improvement in BP. Found to be guiac positive w/history of leiomyoma per EGD. NGT dropped w/+aspirate that cleared w/lavage => ?traumatic. GI consulted, pt to EGD in AM. Admitted to [Hospital Unit Name 153] for hemodynamic monitoring overnight. [Company 191] COURSE: Was given a trial of lasix and her breathing improved. Was continued on lasix 80 mg QD. Her creatinine started rising (1.4 to 1.9) while on lasix and so her lasix dose was changed to 40 mg QD. Her lisinopril was held [3-5] rising creatinine. She was put on a taper of Prednisone 5mg and will be continued until [8-21]. She had few days of gross hematuira [3-5] to foley coming out with balloon inflated. Her hematuria eventually got better. Her HCT was stable during the course of admission to the [Hospital1 ]. She has an appointment with GI on [8-28] for a Esophageal USG for evaluation of GI bleed. Past Medical History: MGUS COPD (last FEV1 = 0.61, FEV1/FVC 70% pred, no home O2) CRI (baseline Cre 1.1) HTN HLP DM II HIP FRACTURE DUODENAL LEIOMYOMA per EGD [3-6] COMPRESSION FRACTURES ANEMIA DEPRESSION OSTEOPOROSIS Social History: +Smoking x 20 pack-years. No ETOH, IVDU, sick contacts, pets/ticks, travel. +flu shot this year. Up to date with mammogram (1 year PTA), colonscopy in last 5 years, EGD. Currently retired, taking care of sick husband at home with son-in-law and daughter (who live upstairs). Patient is still +ADLs. Family History: +brother with CAD/MI/CHF; +sister with pancreatic cancer Physical Exam: VS: T97.1 P80s BP 100s/60s RR15-20 O2 Sat 93-2L NC Gen: Elderly woman, mild respiratory distress, dyspneic to sentences, using accessory muscles, audible upper airway sounds HEENT: OP clear, dry. No sinus tenderness. Pupils [5-4] bilaterally. Neck: JVP to level of earlobe +HJR (on admission). JVP not raised, Neck veins flat - on discharge. No thyromegaly or LAD, carotids 2+ without bruits. Chest: Fine rales in bases. Mild wheezing. Trachea midline Cor: Distant HS. +S1, S2, but no S3 or S4. No heaves, rubs, murmur Abd: Distended, no fluid wave or RUQ tenderness. +BS, tympanitic (passing gas, BM) Extr: 2+ DP pulses, warm. No edema. Neuro: AAOx3, appropriately interactive Pertinent Results: * [2138-8-11] 11:20AM BLOOD WBC-17.1# RBC-3.42# Hgb-7.9# Hct-26.2# MCV-77* MCH-23.1* MCHC-30.2* RDW-17.1* Plt Ct-260 [2138-8-11] 09:16PM BLOOD Hct-27.8* [2138-8-12] 04:05AM BLOOD WBC-12.2* RBC-4.10* Hgb-10.0# Hct-31.7 MCV-78* MCH-24.4* MCHC-31.5 RDW-17.2* Plt Ct-207 [2138-8-12] 12:28PM BLOOD Hct-30.7* [2138-8-12] 06:56PM BLOOD WBC-12.9* RBC-3.99* Hgb-10.0* Hct-30.4* MCV-76* MCH-25.1* MCHC-32.9 RDW-16.9* Plt Ct-205 [2138-8-13] 04:20AM BLOOD WBC-12.9* RBC-4.13* Hgb-10.1* Hct-31.1* MCV-75* MCH-24.4* MCHC-32.4 RDW-17.0* Plt Ct-204 [2138-8-11] 11:20AM BLOOD Neuts-94.8* Bands-0 Lymphs-3.0* Monos-1.6* Eos-0.6 Baso-0.1 [2138-8-12] 04:05AM BLOOD Neuts-96.5* Bands-0 Lymphs-2.6* Monos-0.9* Eos-0.1 Baso-0 [2138-8-11] 11:20AM BLOOD PT-12.2 PTT-24.4 INR(PT)-1.0 [2138-8-12] 04:05AM BLOOD PT-12.3 PTT-25.4 INR(PT)-1.0 [2138-8-13] 04:20AM BLOOD Plt Ct-204 [2138-8-11] 11:20AM BLOOD Glucose-284* UreaN-79* Creat-2.1* Na-140 K-5.9* Cl-107 HCO3-23 AnGap-16 [2138-8-11] 09:16PM BLOOD K-5.3* [2138-8-12] 04:05AM BLOOD Glucose-237* UreaN-82* Creat-2.1* Na-146* K-4.4 Cl-109* HCO3-25 AnGap-16 [2138-8-12] 06:56PM BLOOD Glucose-269* UreaN-83* Creat-2.0* Na-146* K-4.1 Cl-106 HCO3-28 AnGap-16 [2138-8-13] 04:20AM BLOOD Glucose-97 UreaN-74* Creat-1.6* Na-151* K-3.4 Cl-109* HCO3-30 AnGap-15 [2138-8-11] 09:16PM BLOOD ALT-19 AST-20 LD(LDH)-200 CK(CPK)-18* AlkPhos-45 TotBili-0.3 [2138-8-12] 04:05AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-3908* [2138-8-11] 11:20AM BLOOD CK-MB-2 cTropnT-0.01 [2138-8-11] 09:16PM BLOOD CK-MB-2 cTropnT-<0.01 [2138-8-12] 04:05AM BLOOD %HbA1c-7.6* [Hgb]-DONE [A1c]-DONE [2138-8-11] 09:16PM BLOOD TSH-0.28. . [8-12] Echo The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to hypokinesis of the posterior wall. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([2-2]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior report (tape unavailable for review) of [2137-7-29], the posterior wall may now be hypokinetic, but the technically suboptimal nature of the present study precludes definitive assessment of regional left ventricular contractile function. . [8-13] Blood SPEP - TRACE ABNORMAL BAND IN GAMMA REGION UNCHANGED IN MIGRATION FROM [2137-4-23] EXAM PREVIOUSLY IDENTIFIED AS MONOCLONAL IGG KAPPA NOW REPRESENTS ROUGHLY 2% (100 MG/DL) OF TOTAL PROTEIN INTERPRETED BY [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 19695], MD . [8-13] UPEP - no monoclonal bands Brief Hospital Course: ED COURSE: Was hypotensive to SBP 80s in ED, tachycardic to 120s, w/desat to 80??????s-90??????s. CXR negative for acute process; +CHF. Labs showed HCT drop to 26 (baseline 35), acute on chronic RF with K at 5.9, no EKG changes. Received kayexalate x 30 gm PO and 1 U PRBC + lasix w/ improvement in BP. Found to be guiac positive w/history of leiomyoma per EGD. NGT dropped w/+aspirate that cleared w/lavage => ?traumatic. GI consulted, pt to EGD in AM. Admitted to [Hospital Unit Name 153] for hemodynamic monitoring overnight. Respiratory: Etiology of dyspnea was felt to be multifactorial, primarily CHF exacerbation in the face of COPD, chronic steroid use, renal insufficiency, and anemia likely [3-5] GIB (given guiac positivity and preciptious drop in hematocrit since [7-5]) versus exacerbation of baseline COPD. Patient responded well to qAM boluses of intravenous lasix, with a net TBB -2.5 L at end of ICU stay. BNP was 3908 and echo demonstrated EF 50% with inferior HK, evidence of [2-2]+ MR (new since [7-5]) and pulmonary hypertension, felt likely [3-5] new MR. Afterload reduction with coreg and captopril were added once BP tolerated in face of MR. [Name13 (STitle) ] also placed on standing albuterol and atrovent nebulizers and was taking MDI at time of transfer, with good relief of WOB. Her dyspnea aggravated after transfer to floor and was given a trial of IV lasiv 60mg to which she improved. Was continued on lasix 80 mg QD PO. Her creatinine started rising (1.4 to 1.8) while on lasix and so her lasix dose was changed to 40 mg QD. The Cr then cont to increase to 2.4 the day prior to discharge. The lasix was stopped and her Cr remained stable. ACE inhibitor held [3-5] rising creatinine. She was put on a taper of 5 mg of Prednisone and will be continued until [8-21]. Patient has been sent out off of diuretic secondary to increased creatinine. Her creatinine on day of dicharge was 2.4 (stable from prior day since lasix stopped). She will need to have her creatinine checked every 1-2 days. If it continues to rise or stays stable [Name6 (MD) 138] her MD ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1968] [Telephone/Fax (1) 250]). If it decreases patient should be restarted on lasix. Once Cr is < 2.0 she should be started on lasix 40mg po qday. Cardiovascular: Patient was R/O MI, and echo and BNP as above. Patient's BP s/p 2 U PRBC transfusion increased from 80 to 120s-150s, at which time afterload reduction with coreg and captopril were added for HTN control/afterload reduction. Although HTN may have been chronic (only one note in system about SBP to 180s), likely secondary to recent steroid use. Statin was continued; ASA was held given concern for recent GI bleed. Rhythm was NSR throughout. Her lisinopril on was held secondary to rising creatinine. GI: GI service consulted and felt that inpatient EGD and colonoscopy warranted, but held off until acute cardiorespiratory issues resolved. HCT increased appropriately from 26 to 30 s/p 2 U PRBC on admission, and has been stable throughout. Pantoprazole IV added for GIB. Heparin prophylaxis and ASA held. GI singed off and she is scheduled for an outpatient appointment for Endoscopic USG on [8-26]. The patient is scheduled for an endoscopy on [2138-8-26]. Her materials are probvided in the discharge paper work. The preparation listed in these documents should be followed prior to the procedure. Renal/FEN: Patient with acute on chronic renal failure w/ K to 5.9 (no EKG changes) on admission with Cre to 2.1 (baseline 1.1). Fractional excretion of urea was 28% (pre-renal) on admission, consistent with CHF w/decreased forward flow versus intravascular hypovolemia from GIB + dehydration. Urine eosinophils were negative and urinalysis was negative. Cre improved with blood pressure, diuresis, afterload reduction. SPEP and UPEP were sent for concern of myeloma given history of MGUS and are pending. Creatinine increased from 1.4 to 2.4 secondary to lasix treatment and so her lasix and lisinopril were stopped. See respiratory section for further discussion. Heme: Anemia attributed to recent GIB on chronic B-thalassemia. Followed by Druce ([Hospital1 18]), on aranesp q-2week per patient. Aranesp injection held on [2138-8-13], as patient was stable s/p transfusion. Will be evaluated for GIB by GI on [8-26]. Medications on Admission: ADVAIR DISKUS 500-50 mcg/Dose--1 puff [Hospital1 ] ASPIRIN 325MG qd CELEXA 10MG x3 qd COMBIVENT 103-18MCG??????1 [Hospital1 ] COREG 6.25MG [Hospital1 ] DIAZEPAM 2MG [Hospital1 ] DUONEB 2.5-0.5/3 qid FOLIC ACID 1MG qd FOSAMAX 70MG qd GLYBURIDE 5 mg [Hospital1 ] LASIX TABLETS 20MG qd LIPITOR 40MG qd LISINOPRIL 30MG qd MIRTAZAPINE 15MG qd-[Hospital1 ] PREDNISONE 10MG on taper, currently 10 mg TYLENOL/CODEINE NO.3 30-300MG tid prn LBP ARANESP q2week Discharge Medications: 1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. 6. Celexa 10 mg Tablet Sig: Three (3) Tablet PO once a day. 7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [2-2] Puffs Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q3H (every 3 hours) as needed. 12. Insulin Regular Human 100 unit/mL Solution Sig: AS Dir units Injection ASDIR (AS DIRECTED): please follow QID sliding scale on attached sheet. 13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week. 17. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 582] of [Location (un) 583] Discharge Diagnosis: Primary: CHF exacerbation (diastolic) COPD exacerbation GI bleed Blood Loss anemia Acute Renal Failure Secondary: CRI Depression Osteoporosis Duodenal Leiomyoma Discharge Condition: Stable hemodynamics Breathing well on 2 liters NC of oxygen Eating Well Discharge Instructions: Please take all medications and make all appointments as listed in the discharge paperwork. If you have any chest pain, shortness of breath, fevers, chills, bleeding from your rectum, or dizziness please call Dr. [Last Name (STitle) 1968] or come to the hospital. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Patient has been sent out off of diuretic secondary to increased creatinine. Her creatinine on day of dicharge was 2.4 (stable from prior day since lasix stopped). She will need to have her creatinine checked every 1-2 days. If it continues to rise or stays stable [Name6 (MD) 138] her MD ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1968] [Telephone/Fax (1) 250]). If it decreases patient should be restarted on lasix. Once Cr is < 2.0 she should be started on lasix 40mg po qday. The patient is scheduled for an endoscopy on [2138-8-26]. Her materials are probvided in the discharge paper work. The preparation listed in these documents should be followed prior to the procedure. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2138-8-21] 11:50 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1982], MD Where: [First Name8 (NamePattern2) ] [Hospital Ward Name ] BUILDING ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX) ENDOSCOPY SUITE Phone:[Telephone/Fax (1) 463] Date/Time:[2138-8-26] 8:00 Provider: [Name Initial (NameIs) ] SUITE GI ROOMS Where: GI ROOMS Date/Time:[2138-8-26] 8:00 [2138-9-18] 8:40 am Dr. [Last Name (STitle) ] - Pulmonary [Telephone/Fax (1) 612] [2138-10-14] 1:00 pm Dr. [Last Name (STitle) ] - Hematology [Telephone/Fax (1) 9645] ICD9 Codes: 5849, 2767, 4280, 5789, 4240, 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6277 }	Medical Text: Admission Date: [2190-11-12] Discharge Date: [2190-11-17] Date of Birth: [2130-8-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 943] Chief Complaint: Altered mental status after MVA Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: Please see MICU GREEN admission note for complete HPI. Briefly, Pt is a 60 yo M with PMHx significant for Hep C cirrhosis c/b esophageal varices, portal vein thrombus on coumadin, s/p TIPS, who presented with progressive confusion after MVC. He was brought by EMS to OSH, where he remained confused and was noted to have coffee ground emesis. Ethanol level was negative. He reportedly had a negative head CT and he was intubated for airway protection and transferred to [Hospital1 18], where he was admitted to the MICU. Hepatology consulted and pt was started on octreotide, PPI, lactulose and cipro. Hct remained stable and EGD was deferred. U/S showed stable TIPS, stable velocities, and unchanged left portal vein thrombus. He had no further evidence of upper GI bleed and was extubated earlier today. He is now being transferred to the liver/kidney service for further management Past Medical History: Hepatitis C cirrhosis: history of decompensation with a variceal bleed in [2188] followed by TIPS placement. He is currently listed as of [10-29]. No repeat EGD since TIPS. Diabetes Mellitus Hypertension OSA, being evaluated for CPAP Chronic back pain, off methadone, on codeine Social History: lives with wife and 2 kids 19 and 15 in lunenberg. smokes 1 PPD, total of ~40pack year history smoking. Denies ETOH, IVDU. Per pt., likely hepC exposure was through sexual contact Family History: h/o DM, no CAD Physical Exam: Vitals - T:98.5 BP:143/74 HR:67 RR: 21 02 sat: 97%RA GENERAL: NAD, lying comfortably in bed SKIN: warm, pink, numerous scabs over upper extrem b/l HEENT: NCAT, MMM, no scleral icterus, OP clear, poor dentition CARDIAC: RRR, nl S1, S2, II/VI soft systolic murmur radiating to axilla LUNG: diffusely rhonchorus b/l, partially clears with cough ABDOMEN: soft, ND, ttp in epigastrium and RUQ (especially over rt ribs), voluntary guarding, no rebound EXT: no c/c/e, 2+ peripheral pulse b/l NEURO: A&Ox2 (not oriented to time), + asterixis Pertinent Results: CBC: [2190-11-12] 01:42PM BLOOD WBC-6.3 RBC-2.86* Hgb-9.2* Hct-25.5* MCV-89 MCH-32.3* MCHC-36.3* RDW-16.4* Plt Ct-56* [2190-11-12] 01:42PM BLOOD Neuts-91.6* Bands-0 Lymphs-4.7* Monos-2.8 Eos-0.7 Baso-0.1 [2190-11-12] 07:46PM BLOOD WBC-6.1 RBC-2.91* Hgb-9.6* Hct-26.2* MCV-90 MCH-32.9* MCHC-36.6* RDW-16.4* Plt Ct-54* [2190-11-13] 05:24AM BLOOD WBC-5.0 RBC-3.10* Hgb-9.9* Hct-28.2* MCV-91 MCH-31.9 MCHC-35.1* RDW-16.6* Plt Ct-60* [2190-11-13] 01:53PM BLOOD Hct-26.7* [2190-11-14] 05:32AM BLOOD WBC-4.6 RBC-3.19* Hgb-10.5* Hct-28.9* MCV-90 MCH-33.0* MCHC-36.5* RDW-16.5* Plt Ct-49* [2190-11-15] 06:00AM BLOOD WBC-4.5 RBC-3.11* Hgb-9.9* Hct-27.9* MCV-90 MCH-32.0 MCHC-35.6* RDW-16.9* Plt Ct-59* [2190-11-16] 05:40AM BLOOD WBC-4.8 RBC-3.14* Hgb-10.2* Hct-28.1* MCV-90 MCH-32.4* MCHC-36.2* RDW-16.0* Plt Ct-63* [2190-11-17] 06:10AM BLOOD WBC-5.1 RBC-3.26* Hgb-10.5* Hct-29.2* MCV-90 MCH-32.0 MCHC-35.8* RDW-16.1* Plt Ct-74* Coags: [2190-11-12] 01:42PM BLOOD PT-15.8* PTT-33.2 INR(PT)-1.4* [2190-11-13] 05:24AM BLOOD PT-15.0* PTT-32.6 INR(PT)-1.3* [2190-11-14] 05:32AM BLOOD PT-14.4* PTT-32.8 INR(PT)-1.2* [2190-11-15] 06:00AM BLOOD PT-14.0* PTT-33.1 INR(PT)-1.2* [2190-11-16] 05:40AM BLOOD PT-14.8* PTT-33.9 INR(PT)-1.3* [2190-11-17] 06:10AM BLOOD PT-15.1* PTT-34.7 INR(PT)-1.3* Chemistry/Glucose/Renal: [2190-11-12] 01:42PM BLOOD Glucose-208* UreaN-23* Creat-1.7* Na-141 K-4.0 Cl-112* HCO3-20* AnGap-13 [2190-11-13] 05:24AM BLOOD Glucose-107* UreaN-24* Creat-1.8* Na-143 K-3.7 Cl-112* HCO3-21* AnGap-14 [2190-11-13] 05:24AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 [2190-11-14] 05:32AM BLOOD Glucose-123* UreaN-22* Creat-1.7* Na-143 K-3.4 Cl-112* HCO3-21* AnGap-13 [2190-11-14] 05:32AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.7 [2190-11-15] 06:00AM BLOOD Glucose-165* UreaN-20 Creat-1.5* Na-144 K-3.5 Cl-110* HCO3-24 AnGap-14 [2190-11-15] 06:00AM BLOOD Albumin-3.5 Calcium-8.6 Phos-2.6* Mg-1.8 [2190-11-16] 05:40AM BLOOD Glucose-116* UreaN-18 Creat-1.4* Na-143 K-3.7 Cl-112* HCO3-23 AnGap-12 [2190-11-16] 05:40AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.6 [2190-11-17] 06:10AM BLOOD Glucose-117* UreaN-19 Creat-1.5* Na-143 K-3.7 Cl-109* HCO3-25 AnGap-13 [2190-11-17] 06:10AM BLOOD Albumin-3.4 Calcium-8.4 Phos-3.2 Mg-1.5* LFTs: [2190-11-12] 01:42PM BLOOD ALT-15 AST-28 AlkPhos-74 TotBili-0.9 [2190-11-13] 05:24AM BLOOD ALT-18 AST-36 LD(LDH)-282* AlkPhos-85 TotBili-1.1 [2190-11-14] 05:32AM BLOOD ALT-16 AST-33 LD(LDH)-270* AlkPhos-86 TotBili-0.9 [2190-11-15] 06:00AM BLOOD ALT-15 AST-35 LD(LDH)-281* AlkPhos-85 TotBili-0.9 [2190-11-16] 05:40AM BLOOD ALT-20 AST-32 LD(LDH)-275* AlkPhos-85 TotBili-0.9 [2190-11-17] 06:10AM BLOOD ALT-17 AST-28 LD(LDH)-272* AlkPhos-82 TotBili-1.0 Lactate: [2190-11-12] 01:53PM BLOOD Lactate-2.3* Urinalysis: [2190-11-12] 08:44PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.019 [2190-11-12] 08:44PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [2190-11-12] 08:44PM URINE RBC-9* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 [2190-11-12] 08:44PM URINE Mucous-RARE [2190-11-12] 01:42PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 [2190-11-12] 01:42PM URINE Blood-LG Nitrite-NEG Protein- Glucose-100 Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [2190-11-12] 01:42PM URINE RBC-[6-30]* WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 Blood/Urine/CSF culture: No growth to date Brief Hospital Course: # AMS: The patient was believed to have hepatic encephalopathy--potentially secondaryy to medication non-compliance--as workup for other causes of altered mental status was unrevealing. Upon arrival on the floor, the patient was continued on lactulose and rifaximin. His home codeine was held, so as to not exacerbate his altered state. He was initially oriented to only person and place, but not date. Within 2-3 days, however, the patient was fully oriented and his mental status was much clearer. He was discharged with clear instructions to take his medications as directed. He was also clearly instructed to not drive. # Upper GI bleed: Reported at outside hospital. At [Hospital1 18], he was hemodynamically stable, and did not have hematemesis or hemoptysis. He was continued on a PPI and his home propanolol. His hematocrit was generally stable, and slowly improved during the admission. He remained stable on the floor for several days, then underwent upper endoscopy, which revealed portal hypertensive gastropathy and duodenitis. No interventions were performed. # Pain control: The patient complained of right side and RUQ pain when palpated directly, but did not appear excessively uncomfortable at any time. Chest x-rays revealed a healing rib fracture. His home codeine, taken for low back pain, was held for mental status. He was given lidocaine transdermal patches at the site of his pain, with moderate analgesic effect. # Hypertension: The patient did not come to the floor on an anti-hypertensive regimen, and was started on amlodipine 5 mg daily. This was increased to 10 mg daily on the day of discharge. # Diabetes Mellitus: Patient's blood glucose well controlled on his home dose of lantus and sliding scale # CRI: Creatinine was at baseline on the day of discharge # History of portal vein thrombosis: Stable by ultrasound on admission. The patient's warfarin was held given concern for upper GI bleed at the outside hospital Medications on Admission: codeine 60 mg q4 hrs glipizide ER 20mg PO daily Metformin 500 mg TID Lantus 22 units qhs lactulose 30 mg TID Prilosec 40mg PO daily paroxetine 20mg PO daily warfarin 5 mg daily Propranolol 80mg PO daily Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). [Hospital1 ]:60 Tablet(s) Refills:0 2. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day. 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 hours on, then twelve hours off as needed for pain. [Hospital1 ]:10 Adhesive Patch, Medicated(s) Refills:0 6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). [Hospital1 ]:180 Tablet(s) Refills:0 7. Lantus 100 unit/mL Solution Sig: Twenty Two (22) Units Subcutaneous at bedtime. 8. Propranolol 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: Two (2) Tablet Extended Rel 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Hepatic encephalopathy . Hepatitis C cirrhosis Diabetes Mellitus Hypertension Obstructive sleep apnea Discharge Condition: Awake, alert, oriented. Medically stable for discharge home. Discharge Instructions: Mr [Known lastname ], . You were transferred to the intensive care unit at [Hospital1 18] for mental status changes, following your motor vehicle accident. There was concern that you may have been confused while driving. You were also noted to have some blood in your vomit at the other hospital, so there was also some concern that you may have had an internal bleed. . You were transferred to the liver/kidney floor where you underwent an upper endoscopy, which did not reveal any significant bleeding in your esophagus, stomach, or intestine. You recovered from the procedure without any difficulty, and were medically stable to be discharged home. . We made the following changes to your medications: -Please take AMLODIPINE 10 mg by mouth DAILY for blood pressure -Please take RIFAXIMIN 200 mg by mouth THREE TIMES DAILY -Please use LIDOCAINE transdermal patches over your ribs for pain relief . Please keep your appointment in the [Hospital1 ] clinic [12-8] @ 2:40 PM. Please call [Telephone/Fax (1) 673] if you need to reschedule the appointment. . Please call your doctor or return to the Emergency Department if you experience any severe abdominal pain, nausea, or vomiting, or if you have any blood in your vomit. Please keep your scheduled follow up appointments. Followup Instructions: Provider: [Name10 (NameIs) ] [Hospital 1389] CLINIC Phone:[Telephone/Fax (1) 673] Date/Time:[2190-12-8] 2:40 Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 62] Date/Time:[2191-1-5] 11:00 Provider: [Name10 (NameIs) ] [Hospital 1389] CLINIC Phone:[Telephone/Fax (1) 673] Date/Time:[2191-1-5] 1:40 ICD9 Codes: 5789, 5715, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6278 }	Medical Text: Admission Date: [2143-5-14] Discharge Date: [2143-5-23] Date of Birth: [2143-5-14] Sex: F Service: NB HISTORY: Baby Girl [Known lastname ] delivered at 36-2/7 weeks gestation with a birth weight of [2106] grams and was admitted to the newborn Intensive Care Unit around 1 hour of life for evaluation and management of respiratory distress. The mother is a 37 year-old gravida II, para I, now II mother with estimated date of delivery [2143-6-10]. Prenatal screens included blood type B positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative and group B strep negative. The pregnancy was uncomplicated until recently when ultrasound showed estimated fetal weight was in the 7th percentile with an amniotic fluid index of 3. The decision was made to deliver by repeat cesarean section under spinal anesthesia. There was no labor. Ruptured membranes with clear fluid at delivery. No intrapartum maternal fever. The infant received bulb suctioning, tactile stimulation and free flow oxygen. At birth scores were 9 at one minute and 9 at five minutes. The infant developed grunting around an hour of age and was transferred to newborn Intensive Care Unit. PHYSICAL EXAMINATION ON ADMISSION: Weight [2106] (10 to 25th percentile), length 40.5 cm (less than 10th percentile), head circumference 30 cm (10th percentile). A nondysmorphic infant with palate intact. Neck and mouth normal. Nasal prongs CPAP in place. Chest with mild intercostal retractions. Good breath sounds bilaterally. Cardiovascular: Is well perfused with regular rate and rhythm. Femoral pulses normal. No murmur. Abdomen soft, nondistended, no organomegaly, no masses. Active bowel sounds. Patent anus. GU: Normal female external genitalia. Skin: Normal without rashes or lesions. Normal spine, hips and clavicles. Neurologic: Active, alert, tone is slightly decreased with symmetric distribution. Moves all extremities equally. Suck and gag intact. Symmetric grasp. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: She was placed on nasal CPAP 6 cm of water on admission for grunting. She did not have an oxygen requirement. She remained on CPAP for about 26 hours and then was weaned off to room air. She has remained in room air since with comfortable work of breathing. Respiratory rate ranged from 30s or 50s. No apnea or bradycardia. CARDIOVASCULAR: She has been hemodynamically stable throughout hospital admission. No murmur. Heart rate ranges in the 110 to 140s. Recent blood pressure 75/42 with a mean blood pressure of 53. FLUIDS, ELECTROLYTES AND NUTRITION: She was initially NPO and received D10W. Electrolytes at 24 hours were within normal limits. She was started on feedings when CPAP was discontinued. She is ad lib breast and bottle feeding. Due to mother's large nipples it is difficult for her to get a good latch. Mother is seeking lactation consultation. The baby has been maintaining her glucose levels off her IV fluids in 60s to 80s, and is voiding and stooling appropriately. Discharge weight is 1880 grams. GASTROINTESTINAL: Peak bilirubin was 10.8/0.4 on day of life 5. She was started on phototherapy. Phototherapy was discontinued after 24 hours, and a rebound bilirubin level was 6.1/0.3 on day seven. HEME: Hematocrit on admission 47.3%. INFECTIOUS DISEASE: Due to respiratory distress, a CBC and blood culture were drawn on admission and baby received 48 hours of ampicillin and gentamicin. The blood culture was negative at 48 hours and CBC was benign. NEUROLOGIC: Examination is age appropriate at time of transfer. SENSORY: Hearing screening was passed. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to home. NAME OF PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17470] in [Location (un) 932], [State 350]. CARE AND RECOMMENDATIONS: 1. Feedings: Ad lib breastfeeding with supplementation 3xday with expressed BM or NeoSure 24. 2. Medications: None. 3. State newborn screen was drawn on [2143-5-17] and [5-27], [2142]; results are pending. 4. Immunizations received: Hepatitis B vaccine [2143-5-18]. 5. Follow up appointments: Pediatrician on [Last Name (LF) 2974], [5-24]. 6. Car Seat Screening - passed. DISCHARGE DIAGNOSES: 1. Appropriate for gestational age preterm female infant delivered at 36-2/7 weeks gestation. 2. Transient tachypnea of the newborn, resolved. 3. Hyperbilirubinemia, resolved. 4. Sepsis evaluation, ruled-out. [Last Name (LF) ],[First Name3 (LF) 36400] 50-595 Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2143-5-17] 17:37:17 T: [2143-5-17] 18:22:23 Job#: [Job Number 67700] ICD9 Codes: 769, 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6279 }	Medical Text: Admission Date: [2200-8-25] Discharge Date: [2200-8-28] Service: NEUROSURGERY Allergies: Codeine / Sulfa (Sulfonamides) / Penicillins Attending:[First Name3 (LF) 1271] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] F who lives in an independent living facility has been taking OTC meds for a chest cold of which the robitussin makes her lightheaded. She stood up to get out of bed this morning and fell down. Does not rememebr hitting her head or LOC but admits it took quite a while to get back up. She was taken to an OSH where a head CT showed a 0.9cm R SDH with a 0.45cm midline shift. A CXR was c/w pneumonia. Pt has a h/o CAD with 2 stents, currently anticoagulated with Plavix and ASA. Past Medical History: type 2 diabetes, previous myocardial infarctions, deafness, thyroid surgery, hysterectomy, cholecystectomy, hip surgery, shingles. Social History: Independent living facility Family History: non-contributory Physical Exam: Exam upon admission: T: 101.8 BP: 144/54 HR: 81 R 20 O2Sats 91/2l NC Gen: Well appearing, comfortable, NAD. HEENT: PERRL 3mm to 1mm b/l EOMI Neck: Supple. Lungs: rhonchi throughout b/l. Cardiac: RRR. S1/S2. Abd: Soft, NT Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 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 [5-3] throughout. No pronator drift Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: CT head [2200-8-25]: FINDINGS: There is a mixed attenuation subdural collection layering along the right cerebral hemisphere, compatible with acute on chronic subdural hematoma, which measures up to 1 cm. There is mild right- to- left midline shift measuring approximately 4 mm. There is sulcal effacement along the right cerebral hemisphere. No intra- axial hemorrhage or edema is seen. There is focal calcification in the left basal ganglia. Subcutaneous tissues and orbits are grossly unremarkable. The mastoids are clear. There is nasal septal deviation to the right. Mucosal thickening is noted in the ethmoid and sphenoid sinuses as well as air- fluid level in the bilateral maxillary sinuses. The lamina papyracea appear intact. There is calcification of the carotid siphons. IMPRESSION: 1. Acute on chronic subdural hematoma along the right cerebral hemishpere causing sulcal effacement and mild shift of midline. 2. Small air-fluid levels in the maxillary sinuses and paranasal sinus mucosal thickening. CT facial bones may be obtained if there is concern for facial bone fracture. CT head [2200-8-26]: Comparison is made with [2200-8-25]. Right hemispheric acute subdural hematoma is unchanged in size. There is minimal midline shift, which is also unchanged. A small amount of hemorrhage along the left tentorial reflection is also seen. There has been no extension of the hematoma or new hemorrhage seen. There is mild small vessel ischemic sequela in the subcortical and periventricular white matter. Ventricles are stable. IMPRESSION: Essentially no change. CT head [2200-8-27]: Comparison with [2200-8-26], 12:03 p.m. The subdural hematoma outlining the right cerebral convexity is unchanged, as is the amount of blood along the tentorial reflections. No significant midline shift, hydrocephalus, or acute major vascular territorial infarct is identified. No fractures are seen. Imaged sinuses are notable for scattered opacification of scattered ethmoid air cells and sphenoid sinuses. Mastoid air cells and frontal sinuses are clear. IMPRESSION: Similar appearance of subdural hematoma. CHEST (PORTABLE AP) [2200-8-25]: FINDINGS: AP portable chest radiograph was obtained in a semi-upright position. The lungs appear clear bilaterally. There is no evidence of pneumonia or CHF. No pleural effusion or pneumothorax is present. The heart size is top normal. Mediastinal contour is unremarkable. Aortic arch calcification is noted. Degenerative changes are seen at the AC joints bilaterally. Surgical clips in the right upper quadrant likely from prior cholecystectomy. There may be slight compression of a lower thoracic vertebra, though this is suboptimally assessed. Degenerative changes are noted in the spine. IMPRESSION: 1. No evidence of acute intrathoracic process. 2. Borderline cardiomegaly. 3. Possible compression deformity in the mid thoracic spine. Correlation with lateral view may be helpful to further evaluate. CHEST (PA & LAT) [2200-8-27] 5:23 PM Reason: pneumonia [Hospital 93] MEDICAL CONDITION: [Age over 90 ] year old woman with pneumonia REASON FOR THIS EXAMINATION: pneumonia CHEST, PA AND LATERAL VIEWS IN COMPARISON WITH [2200-8-25]. PA and lateral views of the chest reveals the heart to be enlarged. There is calcium in the aorta with uncoiling. There is slight blunting of the left costophrenic angle and haziness at the left base. The vascular markings are prominent. There is pleural fluid in both fissures as well as both costophrenic angles posteriorly. The pattern is that of congestive failure. Small patch of pneumonitis cannot be excluded, however. A focal area cannot be identified. CONCLUSION: Changes consistent with cardiac failure, however, a small area of pneumonitis cannot be excluded. Brief Hospital Course: Pt was admitted to neurosurgery service on [8-25] after a fall with a CT showing a 0.9cm R Subdural hematoma. A chest-x-ray from her referring hospital was consistent with pneumonia and the pt was c/o cough with productive sputum. A 5 day course of levofloxacin was initiated. Plavix and ASA were held, the pt recieved a unit of platelets, was loaded on dilantin for seizure prophylaxis and Pt was admitted to the ICU for strict neurological monitoring. On the night of HD#1 the pt's blood pressure dropped to a systolic in the 80s with a corresponding HR in the 30s and required dopamine to maintain her SBP>100. Her antihypertensive medications were held. A reduced dose of metoprolol was restarted the next day when she was tranfered out of the ICU to the neurosurgical floor. Follow-up CTs on [8-26] and [8-27] showed no progression of her subdural hematoma. Her hospital course was uncomplicated. Neurological exam showed no defecits on admission and remained normal throughout her hospital course. Her pneumonia continued to resolve during her hospital stay, treated with levofloxacin and robitussin for cough. Follow-up CXR was consistent with resolving pneumonia. Her aspirin was restarted during her hospital course and her plavix is to be restarted on [9-1]. Medications on Admission: Plavix 75 mg daily Nexium 40 mg daily Lipitor 20 mg nightly Diovan 150 mg nightly Levothyroxine 0.075 mg nightly Amiodarone 200 mg nightly Metoprolol 100 mg [12-31] in the morning and [12-31] at dinnertime. Aspirin 325 mg nightly. Trazodone 2.5 mg nightly. Aerobid inhaler two puffs twice a day. Metformin 500 mg daily Lisinopril 5 mg daily. Calcium carbonate 600 mg twice a day Centrum one daily. Discharge Medications: 1. Plavix Please restart Plavix 75mg Daily on [9-1]. 2. Outpatient Lab Work Dilantin level: Please send results to your primary care physician. 3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 4 weeks: Continue until follow-up appointment with neurosurgery. Disp:84 Capsule(s) Refills:0 4. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Trazodone 50 mg Tablet Sig: [12-31] Tablet PO HS (at bedtime) as needed for sleep. 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 2 days: Dose 4 of 5 on [8-28], final dose on [8-29]. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. Diovan 160 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 17. Calcium Antacid 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 18. Multivitamin Centrum One Daily Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) ] Discharge Diagnosis: Stable Right Subdural hematoma, Pneumonia Discharge Condition: Good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. Followup Instructions: Please call the office of Dr.[Last Name (STitle) 739] at ([Telephone/Fax (1) 88] to schedule a follow-up appointment for 4 weeks from discharge. You will need to have a Head CT scan at this time. Please follow up with your primary care physician [Last Name (NamePattern4) ].[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 66752] regarding your recent pneumonia as well as your blood pressure medication. Your metoprolol dose was reduced during your hospital stay because of a decrease in your heart rate and blood pressure. You should also have your primary care physician check your dilantin level. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] ICD9 Codes: 486, 4280, 4589, 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6280 }	Medical Text: Admission Date: [2142-5-2] Discharge Date: [2142-5-6] Date of Birth: [2075-12-7] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: echocardiogram showed [Location (un) 109]=0.6 Major Surgical or Invasive Procedure: [2142-5-2] 1. Redo sternotomy. 2. Redo coronary artery bypass grafting x1 with a reverse saphenous vein graft from the aorta to the previously placed double sequential vein graft to the posterior descending coronary artery and second obtuse marginal coronary artery 3. Aortic valve replacement with a 25-mm [Doctor Last Name ] Magna Ease aortic valve bioprosthesis model number 3300TFX, serial number [Serial Number 69062]. 4. Endoscopic vein harvesting. History of Present Illness: 66yo male s/p CABG in [2137-9-15]. He had known aortic stenosis at time of surgical revascularization but it was not significant enough to require aortic valve replacement. However since that time, serial echocardiograms have confirmed progression of aortic valve stenosis. Currently he denies chest pain, dyspnea, syncope, presyncope, palpitations, orthopnea, PND and pedal edema. He has been referred for surgical evaluation. Past Medical History: - Aortic Stenosis - Myocardial infarction - Coronary Disease - Dyslipidemia - Hypertension - History of postop PAF - Hypothyroid related to amiodarone Past Surgical History - Emergent coronary bypass grafting x5, on intra-aortic balloon pump with endoscopic left greater saphenous vein harvesting and endoscopic right greater saphenous vein harvesting on [2137-9-19] - Re-Exploration for bleeding following CABG Social History: Lives with: Wife in [Name2 (NI) ] Occupation: Lithographer for [Location (un) 86] Globe Tobacco: Smoked infrequently between ages 16-21. ETOH:1 beer and 1 whiskey nip/day Family History: Non contributory Physical Exam: Pulse:59 Resp:16 O2 sat: 98/RA B/P Right:137/82 Left: 157/79 Height:5'9" Weight:200 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Sternotomy incision, sternum stable Heart: RRR [x] Irregular [] Murmur III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Bilateral vein harvest sites Neuro: Grossly intact Pulses: Femoral Right: cath site Left: +2 DP Right:+2 Left:+2 PT [Name (NI) 167]:+2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit Right/Left:transmitted murmur Discharge Exam VS:T: 98.6 HR: 93 SR BP: 124/70 RR 18 Sats: 95% RA WT: 97 kg General: 66 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: bibasilar crackles otherwise clear GI: benign Extr: warm tr edema bilateral Incision: sternal clean dry intact no erythema. Neuro: awake, alert oriented Pertinent Results: [2142-5-2], Intraop TEE Conclusions Pre CPB (before first bypass run): No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is low normal (LVEF 50-55%). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to moderate ([12-17]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Wire was seen in descending aorta during femoral artery cannulation. Femoral venous cannula seen entering SVC during placement by surgeon. Post CPB: The patient is being A-paced on phenylephrine and epinephrine infusions. The is a well seated bioprosthetic valve in the aortic position which has mean/peak gradients of 7/16mmHg with a cardiac output of 6/1L/minute. There is trivial mitral regurgitation. The visible contours of the thoracic aorta are intact. [2142-5-6] WBC-10.9 RBC-2.81* Hgb-9.3* Hct-27.1* MCV-96 MCH-33.3* MCHC-34.5 RDW-12.6 Plt Ct-179 [2142-5-2] WBC-20.5# RBC-3.08 Hgb-10.2* Hct-29.4* MCV-96 MCH-33.1* MCHC-34.7 RDW-12.6 Plt Ct-132* [2142-5-6] Glucose-109* UreaN-17 Creat-0.9 Na-137 K-4.2 Cl-98 HCO3-29 [2142-5-2] UreaN-17 Creat-0.7 Na-139 K-3.9 Cl-112* HCO3-21* AnGap-10 [2142-5-6] Mg-2.3 Brief Hospital Course: The patient was brought to the operating room on [2142-5-2] where the patient underwent redo, AVR (tissue), revision of PDA/OM graft . Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. He developed urinary retention. Foley was re-inserted and Flomax started, he voided following 2nd foley removal. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with Partners [Name (NI) 269] in good condition with appropriate follow up instructions. Medications on Admission: AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1 Tablet(s) by mouth daily CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth daily LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth twice a day METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth twice a day SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ASPIRIN [ENTERIC COATED ASPIRIN] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CHLORHEXIDINE GLUCONATE - 4 % Liquid - apply topically daily Shower daily using chlorhexidine for 5 days prior to surgery and the day of surgery MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - Tablet - Tablet(s) by mouth daily THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day --------------- --------------- --------------- --------------- Discharge Medications: 1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Ext Release 24 hr(s) Refills:2 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:60 Tablet(s) Refills:0 14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 15. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day: take with furosemide. Disp:5 Capsule, Extended Release(s) Refills:0 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: - Aortic Stenosis - Myocardial infarction - Coronary Disease - Dyslipidemia - Hypertension - History of postop PAF - Hypothyroid related to amiodarone Past Surgical History - Emergent coronary bypass grafting x5, on intra-aortic balloon pump with endoscopic left greater saphenous vein harvesting and endoscopic right greater saphenous vein harvesting on [2137-9-19] - Re-Exploration for bleeding following CABG 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] WOUND CARE NURSE Phone:[Telephone/Fax (1) 170] Date/Time:[2142-5-15] 10:15 [Last Name (un) 2577] Building [Last Name (NamePattern1) ] [Location (un) 551] [Hospital Unit Name ] Surgeon Dr. [First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2142-5-29] 1:00 [Last Name (un) 2577] Building [Last Name (NamePattern1) ] [Location (un) 551] [Hospital Unit Name ] Cardiologist Dr. [Last Name (STitle) 4469] [5-30] at 1:45pm Please call to schedule the following: Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] J. [Telephone/Fax (1) 14328] in [3-20] 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 Completed by:[2142-5-8] ICD9 Codes: 4241, 412, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6281 }	Medical Text: Admission Date: [2157-1-5] Discharge Date: [2157-1-12] Date of Birth: [2091-10-2] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1167] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: This is a 65 yo M who is 5 weeks s/p tricuspid valve replacement for severe nonischemic cardiomyopathy with h/o [Hospital1 ]-V IVCD (lead causing wide open TR) and chronic afib on coumadin, who p/w one day history of worsening DOE and orthopnea. Pt has noted DOE with walking since his operation on [2156-11-28]. Three days ago his DOE increased. Two nights ago, he noted increased orthopnea and had 2 episodes of PND. He saw his cardiologist, Dr. [First Name (STitle) 437], for f/u yesterday, at which point he had no complaints. After the appointment he noted increased DOE, occurring after a few steps. All of these were acute changes from the past few weeks. No appreciable increase in edema. Denies prior PND. Denies CP. Has had nonproductive cough since leaving hospital on [12-29] for constipation. No f/c. No n/v/d. Came in today because of acute change in symptoms. . On [Hospital1 1516] this AM, pt received 100mg IV lasix. Went for RHC after which swan was placed. Now being admitted to CCU for milrinone +/- lasix gtt for fluid management. . On arrival to CCU, pt was comfortable without complaints. Past Medical History: s/p Tricuspid valve replacement for TR s/p biventricular pacer/ICD placement [2155-8-10] s/p removal of pacer/ICD s/p Left achilles tendon repair s/p Sinus Surgery chronic atrial fibrillation nonischemic dilated cardiomyopathy chronic dysphagia Social History: Retired pipe fitter. Lives with wife [Name (NI) ] in [Name (NI) 392]. Never smoked. Denies illicits. Drank EtOH only rarely after diagnosed with CHF; quit in [2156-4-9]. Family History: Mother with renal failure. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION VS - HR 70 BP 89/59 97%RA GENERAL - thin elderly M in NAD, comfortable, appropriate, AAOx3 HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, JVD 1/2 up neck @30 degrees LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted. Heart sounds distant. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 2+ bilateral pitting edema. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, grossly non-focal . DISCHARGE GENERAL - thin elderly M in NAD, comfortable, appropriate, AAOx3 HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD appreciated LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no edema. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, grossly non-focal Pertinent Results: ADMISSION LABS [2157-1-5] 03:25PM BLOOD WBC-6.1 RBC-3.48* Hgb-11.2* Hct-33.6* MCV-96 MCH-32.3* MCHC-33.5 RDW-16.5* Plt Ct-145# [2157-1-5] 03:25PM BLOOD Neuts-77.9 Lymphs-15.0* Monos-4.8 Eos-1.8 Baso-0.5 [2157-1-5] 03:25PM BLOOD PT-24.8* PTT-40.0* INR(PT)-2.4* [2157-1-5] 03:25PM BLOOD Glucose-90 UreaN-47* Creat-1.7* Na-138 K-4.7 Cl-94* HCO3-34* AnGap-15 [2157-1-7] 05:39AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.2. . CARDIAC ENZYMES [2157-1-5] 03:25PM BLOOD cTropnT-0.03* [2157-1-6] 07:25AM BLOOD CK-MB-3 cTropnT-0.03* [2157-1-6] 07:25AM BLOOD CK(CPK)-33* . DISCHARGE LABS . PERTINENT LABS . PERTINENT STUDIES CXR [2157-1-5] FINDINGS: Frontal and lateral views of the chest were obtained. The patient is status post median sternotomy. There are small bilateral pleural effusions with overlying atelectasis. No overt pulmonary edema is seen. The cardiac silhouette remains top normal to mildly enlarged. IMPRESSION: Small bilateral pleural effusions with overlying atelectasis. . CARDIAC CATH [2157-1-6] COMMENTS: 1. Resting hemodynamics revealed right and left filling pressures with RVEDP of 20 mmHg and PCW 27 mmHg. There was moderate pulmonary artery systoic hypertension with PASP of 53 mmHg. The cardiac index was low at 1.9 L/min/m2. . FINAL DIAGNOSIS: 1. Biventricular elevated filling pressures. 2. Moderate pulmonary arterial hypertension. . ECHO [2157-1-6] Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. The left ventricular cavity is dilated. Systolic function of apical segments is relatively preserved. Overall left ventricular systolic function is severely depressed (LVEF= 15%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Moderate to severe (3+) mitral regurgitation is seen. A bioprosthetic tricuspid valve is present. The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Biatrial enlargement. Dilated, severely hypokinetic left ventricle with relative preservation of the apical segments. Dilated, hypokinetic right ventricle. Mild aortic regurgitation. Moderate to severe mitral regurgitation. Well-seated, normally functioning tricuspid annuloplasty ring. Mild pulmonary artery systolic pressure. . Compared with the prior study (images reviewed) of [2156-12-20], there is worsening left ventricular global and regional systolic function with a decrease in ejection fraction from 25% to 15%. The severity of mitral regurgitation has increased minimally. Mild pulmonary artery systolic hypertension is now appreciated; its presence could not be determined previously. [2157-1-11] TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (LVEF = 25 %). The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. A bioprosthetic tricuspid valve is present. The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. Compared with the findings of the prior study (images reviewed) of [2157-1-6], systolic function of both ventricles is improved. Brief Hospital Course: Mr. [Known lastname 85439] is a 65-year-old-man who is five weeks status post tricuspid valve replacement for severe tricuspid regurgitation, severe right ventricular enlargement, and severe right heart failure, with recent removal of defibrillator coil that revealed a massively dilated right atrium and right ventricle who is presenting with worsening dyspnea on exertion. . #. ACUTE ON CHRONIC HEART FAILURE (RIGHT-SIDED, SYSTOLIC): patient is 5 weeks s/p tricuspid valve replacement, now with worsening right heart failure symptoms. TTE with worsening systolic function as well with depressed EF. Attempts were made with IV diuresis, but ultimately he required CCU admission for milrinone. Initially he was started on milrinone alone and his UOP was measured, and ultimately he required a lasix drip as well to maintain good UOP. His cardiac output doubled with milrinone therapy. Length of stay he was out approximately 9-10L net negative, his edema cleared, his lungs remained clear and his JVP was no longer elevated. Symptomatically, he felt much better, having improved exercise tolerance and a greatly increased appetite. Milrinone was on for approximately 3.5 days, after which it and the lasix were stopped. He had a repeat ECHO ~14 hours after cessation of his milrinone, showing improved global function. He was started back on his home torsemide without metolazone and maintained euvolemia. . #. AFIB/ectopy: patient therapeutic on warfarin with INR of 2.4. Also rate-controlled with home digoxin and metoprolol. These medications were continued throughout the admission. His afib was rate controlled well, never having a rapid ventricular rate. He did have a few episodes of ventricular ectopy with small runs of NSVT although these were likely related to hypokalemia and electrolyte shifts rather than the milrinone or other intrinsic cardiac etiology. . #. ACUTE KIDNEY INJURY: Creatinine at 1.7 from a baseline in late [Month (only) ] of 1.0. Etiology is likely secondary to poor forward flow rather than overdiuresis as his diuretics had actually been decreased recently 1.5 weeks ago. His renal function quickly improved with milrinone and at the time of discharge was at his baseline. Medications on Admission: Omeprazole 20 mg EC PO BID Aspirin 81 mg PO daily Warfarin 5mg PO daily at 4pm Trazodone 50mg PO qHS PRN insomnia Polyethylene glycol 3350 17 gram/dose Powder one packet daily Senna 8.6 mg Tablet PO BID Docusate sodium 100 mg PO BID Digoxin 125 mcg PO daily Potassium chloride 10 mEq Tablet ER PO TID Metoprolol succinate 12.5 mg PO daily Torsemide 40mg PO daily Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. warfarin 5 mg Tablet Sig: 1-1.5 Tablets PO once a day. 4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO three times a day. 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 10. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. 11. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Acute on chronic systolic heart failure Nonischemic cardiomyoapthy s/p ICD [8-19] later removed Chronic AF Chronic dysphagia 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 with shortness of breath and found to be in acute heart failure. You were given medication to take off the extra fluid and no longer appear to be fluid overloaded. In the future- please call Dr. [First Name (STitle) 437] or the heartline right away if you have symptoms of too much fluid: shortness of breath, swelling in your feet or ankles, weight gain. You should increase your Torsemide to 60mg daily. You will need to have your electrolytes repeated in 1 week (you can have it all done on Monday when you see Dr. [Last Name (STitle) 4469]. Your INR has been low. You should increase your Coumadin to 5mg alternating with 7.5mg daily. You should take 7.5mg tonight. You will need to have your INR checked on Monday [2157-1-17]. You should resume your Digoxin (seems like you may have been on and off this medication in the past). Medication changes: -INCREASE Coumadin to 7.5mg alternating with 5mg daily (take 7.5mg tonight) -INCREASE Torsemide to 60mg daily -ADD Losartan 12.5mg daily -RESUME Digoxin 125mcg daily For your heart failure diagnosis: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in 2 days. Follow a low salt diet and a fluid restriction of 1500 ml/ day. Patient offered VNA services at home, declines the need for them at this time. Please let us know if you reconsider. Followup Instructions: Dr. [Last Name (STitle) 4469] ([Telephone/Fax (1) 4475]) Monday [1-17] 1:45pm have your blood work repeated at this visit Department: CARDIAC SERVICES When: TUESDAY [2157-1-18] at 1 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2157-3-11] at 2:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 4280, 5849, 4254, 4168, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6282 }	Medical Text: Admission Date: [2153-12-3] Discharge Date: [2153-12-3] Date of Birth: [2083-4-5] Sex: F Service: NEUROLOGY Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 618] Chief Complaint: "Found down" Major Surgical or Invasive Procedure: -Status post intubation -Mechanical ventilation -Status post extubation History of Present Illness: This is a 70 year old woman with a past medical history significant for hypertension who was found down in parking lot with altered mental status on the evening of admission. Apparently, she was on a trip to [Location (un) 6185] to visit her sister and flew back to the [Name (NI) 86] area earlier in the evening. She apparently was driving home from the airport, but between the airport and home, stopped at her place of work (she is a Home Health Aide). She was then found there in the parking lot unresponsive by a bystander. EMS was called and she was brought to [Hospital1 18] ED. Time schedule as it is known: 8:20pm, arrived at [Location (un) 6692]. 9:52pm, Neurology was paged regarding her soon arrival. 9:55pm, she arrived. On initial exam, she reportedly had right sided facial droop and right-sided weakness. She was noted to have unequal pupils, with left pupil 5mm and right 3mm but both reactive. While she being stabilized in the ED, she vomited, had urinary incontinence and was intubated for airway protection. By 10:10pm her pupils were both dilated and fixed. Past Medical History: 1. Hypertension 2. Amputation of left toes Social History: Divorced. Worked as a home health aide. Has one child, [Doctor First Name ], in the area. Family History: Not known. Physical Exam: Vitals BP 251/150 ; HR 84 ; RR 16; O2 sat 100% on vent General Appearance-Intubated. HEENT: Mucosa moist. Oropharynx clear. No scleral icterus or injection. Neck: Supple. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm. Normal s1/s2 heart sounds. Abdomen: Soft, non-tender, non-distended. Extremities: Warm. No edema. Neurologic: Mental Status: Intubated, not responding to commands. Cranial Nerves: Pupils 6mm bilaterally and fixed. No Doll's eyes. +Corneal reflexes bilaterally. No gag. Motor: Bilateral decerebrate posturing. No withdrawal to pain. Reflexes: Toes mute, (L great toe absent). Sensation: No withdrawal to pain. Coordination: Not able to assess. Gait: Not able to assess. Pertinent Results: [2153-12-2] 10:05PM WBC-7.2 RBC-3.61* HGB-11.1* HCT-32.6* MCV-90 MCH-30.8 MCHC-34.1 RDW-11.9 [2153-12-2] 10:05PM PLT COUNT-301 [2153-12-2] 10:05PM PT-12.3 PTT-19.9* INR(PT)-1.0 [2153-12-2] 10:05PM GLUCOSE-121* UREA N-16 CREAT-0.6 SODIUM-144 POTASSIUM-2.7* CHLORIDE-105 TOTAL CO2-30* ANION GAP-12 ----- CT head without contrast [2153-12-2]: There is a large area of intraparenchymal hemorrhage centered in the left thalamus. This measures 5.2 x 3.8 cm in greatest dimension. There are surrounding low attenuation changes consisting of edema. High attenuation material is seen within the ventricles consistent with intraventricular extension of hemorrhage. The lateral ventricles are moderately dilated. Hemorrhage extends into the superior midbrain. There is mass effect with displacement of the third ventricle to the right by approximately 1 cm., and anterolateral displacement of the left caudate and putamen. Periventricular white matter foci of low attenuation are present, likely consistent with chronic microvascular infarctions. The osseous structures, mastoid air cells, and visualized paranasal sinuses are unremarkable. IMPRESSION: Large left thalamic hemorrhage with intraventricular extension and hydrocephalus. Brief Hospital Course: This is a 70 year old woman with known history of hypertension who presented with elevated blood pressure right-sided weakness and vomiting. Her status rapidly deteriorated in the ED, requiring emergent intubation for airway protection. On later exam, she had fixed and dilated pupils, absence of oculocephalic and gag reflexes and bilateral decerebrate posturing, all consistent with brainstem compression. Head CT revealed a large left basal ganglia bleed with right-sided shift, intraventricular hemorrhage with blood in fourth ventricle and obstructive hydrocephalus. Neurosurgery was contact[Name (NI) ] regarding role of ventriculostomy; given the patient's grave prognosis, they did not feel a drain was warranted. The severity of the patient's condition was discussed with her daughter. [Name (NI) ] remained full code overnight from [Date range (1) 57406] per her daughter's wishes. She was transported to the intensive care unit where she received maximal medical management with blood pressure control, mannitol, and dilantin therapies. The following morning, the patient's exam was remarkable for continued brainstem compression. By noon on [2153-12-3], she had absence of brainstem function and she was no longer overbreathing her ventilator. A meeting was held between the neurology team, ICU team, nursing staff, and patient's daugther and sister. The gravity of the patient's condition was outlined for her family. Later that evening, the patient's daughter opted to withdraw care and focus on comfort measures only. The patient was extubated and expired shortly thereafter. Medications on Admission: 1. Verapamil 180 mg po bid 2. Lisinopril 40 mg po bid 3. Labetalol 300 mg po qAM, 600 mg po qPM 4. HCTZ 12.5 mg po qd 5. Protonix 20 mg po qd 6. Aspirin 81 mg po qd Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Intracerebral hemorrhage Discharge Condition: Expired. Discharge Instructions: Not applicable. Followup Instructions: Not applicable. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6283 }	Medical Text: Admission Date: [2130-8-13] Discharge Date: [2130-8-18] Date of Birth: [2098-8-12] Sex: M Service: SURGERY Allergies: Oxaliplatin / Minocycline Attending:[First Name3 (LF) 5880] Chief Complaint: fever Major Surgical or Invasive Procedure: ERCP removal of portacath x 2 PTC placement PICC line placement History of Present Illness: 32M s/p takedown of enterocutaneous fistula [2130-7-13] following pelvic exenteration 3/[2128]. His EC fistula takedown surgery was complicated by a prolonged SICU admission & he was discharged home 2 days prior to ED presentation for fevers & abdominal pain. Past Medical History: Metastatic colon cancer, s/p palliative partial pelvic exoneration (Dr. [Last Name (STitle) 1888] Social History: +ETOH, +tobacco Married and lives with his wife Family History: Noncontributory Physical Exam: On discharge: AVSS AOx3, NAD, jaundiced RRR CTA bilat Soft, midline VAC in place, nontender [Name (NI) 5283] PTC (bilious) [Name (NI) 5283] perc nephrostomy (bloody urine) LUQ nephrostomy (urine) RLQ ileostomy LLQ colostomy no CCE Pertinent Results: please refer to carevue for specifics [2130-8-13] 09:35PM BLOOD WBC-30.6* RBC-3.30* Hgb-9.6* Hct-28.5* MCV-87 MCH-29.1 MCHC-33.7 RDW-20.2* Plt Ct-331 [2130-8-13] 09:35PM BLOOD Neuts-88* Bands-2 Lymphs-1* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* [2130-8-13] 09:35PM BLOOD ALT-342* AST-268* AlkPhos-542* Amylase-113* TotBili-26.1* DirBili-18.0* IndBili-8.1 [2130-8-13] 09:51PM BLOOD Lactate-2.7* [2130-8-13] 10:20 pm BLOOD CULTURE X3-LFTAC. (confirmed in [6-13] bottles) FINAL REPORT [2130-8-17] AEROBIC BOTTLE (Final [2130-8-17]): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of streptomycin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. . AMPICILLIN Sensitivity testing confirmed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ 4 S PENICILLIN------------ 16 R VANCOMYCIN------------ <=1 S ANAEROBIC BOTTLE (Final [2130-8-16]): REPORTED BY PHONE TO [Last Name (un) ] [Doctor First Name ] [2130-8-11] 14:55. ENTEROCOCCUS FAECIUM. FURTHER IDENTIFICATION TO FOLLOW. SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. [8-15] nephrostomy: IMPRESSION: 1. Closed previous nephrostomy tract. 2. Mildly dilated RIGHT renal collecting system with successful placement of new 8- French nephrostomy drainage catheter. [8-16] ERCP ([Doctor Last Name ]): Impression: 1. The post bulbar/2nd portion of the duodenum appeared fixed with wall edema, erythema and superficial erosions. The lumen appeared narrowed. This raises the question of neoplastic infiltration of the duodenum. The duodenoscope was able to traverse with gentle pressure. 2. Deep cannulation of the biliary duct was unsuccessful despite multiple attempts with a Rx sphincterotome using a free-hand technique. Contrast medium was injected resulting in partial opacification. The procedure was highly difficult. 3. The guidewire could not be passed beyond the distal CBD due to severe stricturing. This may be due to neoplastic infiltration and/or extrinsic compression/fibrosis.Due to distal CBD stricturing, limited cholangiogram showed dilation of up to 20mm in the proximal and mid portions of the CBD. [8-17] PTC ([Doctor Last Name ]): IMPRESSION: 1. Moderately dilated intrahepatic biliary system with 3-4 cm distal common bile duct stricture. 2. Successful introduction of 8-French biliary internal-external drain, with external bag placed. [8-18] PICC IMPRESSION: Successful placement of 41 cm double lumen PICC in the right basilic vein with tip in the distal SVC, ready for use. Brief Hospital Course: [8-13] Admitted to SICU in frank sepsis, with temperature 103, WBC 30K. Pancultured & started on broad spectrum antibiotics. Right nephrostomy tube dislodged in ED. [8-14] Blood cultures revealed VSE in all bottles. Ultrasound revealed mild right hydronephrosis & dilated biliary tree. Urology & ERCP consulted. [8-15] Right nephrostomy successfully replaced in IR. [8-16] ERCP unsuccessful at cannulating CBD. Portacaths removed by Dr. [Last Name (STitle) ] because of high grade bacteremia. [8-17] PTC placed in IR. [8-18] Transfused x1 RBC for blood loss anemia. Medications on Admission: paxil, zofran, ativan, lopressor 25", dilaudid prn Discharge Medications: 1. Ampicillin-Sulbactam [2-8] g Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 1 doses: take 1 dose 1 hour prior to follow up cholangiogram. Disp:1 Recon Soln(s) Refills:0 2. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:10 Patch 72HR(s) Refills:2 3. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO TID (3 times a day). Disp:30 ML Refills:2 4. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. Disp:14 gram Refills:0 5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:5 6. Anzemet 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:30 Tablet(s) Refills:3 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. intravenous fluids D5 1/2 NS @ 100cc/hr x 10 hours (8pm-8am) 9. Heparin Lock Flush 10 unit/mL Solution Sig: One (1) ML Intravenous twice a day: heparin flushes for PICC line. Disp:30 CC Refills:2 10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:60 Tablet(s) Refills:0 11. IV fluid request D5 1/2NS @ 100cc/hr x10 hrs daily (at night) please dispense 30 bags Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: colon cancer s/p pelvic exenteration enterocutaneous fistula s/p enterocutaneous fistula takedown sepsis enterococcal bacteremia portacath line infection biliary obstruction Discharge Condition: improved Discharge Instructions: Diet as tolerated. Continue intraveous fluid overnight as ordered. Contact your MD or report to ED if you develop fevers>101, increasing abdominal pain, markedly decreased output from your drains, or if you have any other concerns. Followup Instructions: Contact Dr.[Name (NI) 6433] office at [Telephone/Fax (1) 6439] to arrange a follow up appointment in about 2 weeks. Contact the interventional radiology department ([Telephone/Fax (1) 327]) to confirm your appointment for a follow up cholangiogram on the morning of [2130-8-30]. Completed by:[2130-8-18] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6284 }	Medical Text: Admission Date: [2132-8-7] Discharge Date: [2132-8-27] Date of Birth: [2132-6-25] Sex: M Service: Neonatology HISTORY: This is a discharge summary for [Known lastname 122] [Known lastname ], triplet #2, who was admitted from home on [2132-8-7], day of life #42 for apnea. [Known lastname 122] was a former 30-6/7 weeks gestation infant, who has been home since being discharged from the [Hospital1 69] NICU on [2132-7-29]. At home, he was initially well, then mother noted over the 24 hours prior to readmission, a decrease in interest in feeding and decreased number of wet diapers. On the day of admission, mother noted the infant to have apnea and a color change and a limp period lasting approximately one minute. Mother reports she had an upper respiratory infection for the three days prior to delivery. On admission, the infant was noted to have nasal congestion, a cough, frequent apnea with desaturation requiring initially blow-by oxygen and then nasopharyngeal continuous positive airway pressure. The infant's previous medical history was that he was the second of triplets delivered at 30-6/7 weeks gestation to a 37-year-old gravida 3, para 2 now 5 woman with negative prenatal screens. The pregnancy was complicated by mild pregnancy-induced hypertension and antepartum hemorrhage leading to cesarean section. The infant's Apgars were 8 at 1 minute and 8 in 5 minutes. His birth weight was 1,575 grams. His neonatal course was notable for surfactant deficiency requiring only continuous positive airway pressure, apnea of prematurity, cardiac murmur followed clinically, initial sepsis rule out, mild hyperbilirubinemia with peak bilirubin of 8.6, choroid plexus cyst on cranial ultrasound (otherwise normal), normal ophthalmological exam. His discharge weight was 2,730 grams. ADMISSION PHYSICAL EXAMINATION: Anterior fontanel is soft and flat, nondysmorphic, intact palate, moderate nasal flaring, mild subcostal retractions, fair breath sounds bilaterally with scattered coarse crackles, well perfused. Heart with a grade 2/6 systolic ejection murmur. Soft and nondistended abdomen. Liver 3 cm below the right costal margin. No splenomegaly. Bowel sounds active. Normal male genitalia. Testes descended bilaterally with the left hydrocele. Initially, hypotonic, but improving tone. Musculoskeletal system normal. NICU COURSE BY SYSTEM: Respiratory status: He was placed on nasopharyngeal continuous positive airway pressure at the time of admission. That was discontinued at 24 hours after admission and he was weaned to nasal cannula oxygen, where he remains at the time of transfer of care requiring 13-25 cc flow. Arterial gas at the time of admission was pH 7.24, CO2 56, pO2 189, bicarbonate 25, and base deficit -4. He has some scattered coarseness and nasal congestion. He had a nasopharyngeal swab sent for viral cultures, which were negative , and he had nasal washings sent for respiratory syncytial virus that also was negative. Chest film reread by Dr. [Last Name (STitle) 52153] was essentially normal. Infant remained in nasal cannula from day of admission untl [8-12] and then occasionally required oxygen for feedings, but remained in RA even for feedings for 1 week prior to discharge. Cardiovascular status:. Cardiovascular: He initially required an 8occ bolus of normal saline for a mean blood pressure of 36 a the time of admission and has remained normotensive since that time. He has had an intermittent grade 1-2/6 systolic ejection murmur heard over precordium and may be consistant with PPS or flow, and this has been followed clinically and softer following packed RBC transfusion. There are plans for followup of that murmur after discharge home if murmur persists for 1 month post discharge . Fluids, electrolytes, and nutrition status: At the time of admission, his weight was 3,015 grams. At the time of discharge his weight is 4150 grams. At the time of admission, he was started on IV fluid. His laboratory values at that time were sodium 142, potassium 4.3, chloride 104, bicarbonate 24, BUN 18, and creatinine 0.4. He has since weaned to formal feeding of Enfamil AR on an adlib schedule taking approximately 200 cc/kg/day. He was having frequent desaturations with and after feeds, consistent with GI reflux. He was having marked improvement on the Enfamil AR. Gastrointestinal status: Laboratory values drawn at the time of admission were ALT of 13, AST of 25, alkaline phosphatase of 230, and there are no active issued. A KUB study at the time of admission showed some mildly distended abdominal loops with well dispersed gas pattern. Hematology status: His hematocrit at the time of admission was 24.8. He had a transfusion of packed red blood cells. A follow-up hematocrit was 38.5 on [8-8]. His platelets on admission were 146,000. Followup 24 hours later was 374,000. Infectious disease status: At the time of readmission, [Known lastname 122] was started on ampicillin, gentamicin, and Vancomycin. His complete blood count results were within normal limits. He had a spinal tap prior to the initiation of antibiotics, which had one white blood cell and one red blood cell, and the cultures remained negative. His antibiotics were discontinued after 72 hours when the infant was clinically improved and his blood cultures remained negative. Medications: He is discharged on no medications. He had a car seat position screening test prior to his initial discharge. A hepatitis B vaccine will be done in the pediatrician's office, so that all three infants can be immunized simultaneously. DISCHARGE DIAGNOSES: 1. Intermittent Heart murmur 2. Resolved viral upper respiratory syndrome. 3. Sepsis ruled out. 4. GI reflux improved on Enfamil AR 5. Left hydrocele. 6. Small umbilical hernia Discharge Plans: VNA day post discharge, mom has pedi appt at VMA/CAM, Dr.[Last Name (STitle) ] a on [8-28], Home health aid for 3 hours/day. If cardiac m persists, f/u at [Location (un) 2274]/Dr [Last Name (STitle) 1537], cardiologist in 1 month. Dictated By: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], N.P. Attending:[Last Name (NamePattern1) 52154] D: [2132-8-14] 14:10 T: [2132-8-14] 07:03 JOB#: [Job Number ] ICD9 Codes: 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6285 }	Medical Text: Admission Date: [2114-1-16] Discharge Date: [2114-2-5] Date of Birth: [2114-1-16] Sex: F HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 49892] is a 32 5/7 weeks 1710 gm female who was admitted to the Neonatal Intensive Care Unit for management of prematurity. She was born to a 35 year old gravida 3, para 1, now 2 mother with hepatitis B surface antigen negative, RPR nonreactive, Rubella immune, Group B Streptotoccus unknown. Pregnancy was complicated by gestational diabetes, controlled by diet as well as increased AFP with fetal ultrasound findings of hemivertebra, echogenic focus in the left ventricle of the heart, two vessel cord and subsequent amniocentesis reportedly 46XX. Fetal ultrasound on [1-12] revealed an mother presented to [Hospital6 256] [1-15], after a visit to her obstetrician revealing increased blood pressure. During fetal monitoring there was deceleration noted. Decision to deliver on [1-16] was made, given continued fetal heartrate decelerations. Baby Girl [Known lastname 49892] emerged with good tone, pink, spontaneous respiratory effort. She was given some blow-by oxygen and responded well. Her Apgars were 8 at one minute and 8 at five minutes. Growth parameters revealed weight 1710, 50th percentile, length 42 cm, 25th to 50th percentile, head circumference 29 cm, 25th percentile. Initial examination revealed a nondysmorphic baby in mild respiratory distress. Anterior fontanelle was open and flat. Heartrate regular rate and rhythm, no murmurs, normal S1 and S2. Respirations with moderate retraction and grunting. Abdomen soft with good bowel sounds, no hepatosplenomegaly. Normal female genitalia with patent anus. No sacral dimple. Extremities were warm and well perfused. Hips were stable. The baby had good tone throughout. IMPRESSION: Baby Girl [Known lastname 49892] presented as a preterm newborn with mild to moderate respiratory distress, a rule out sepsis evaluation is initiated given her prematurity and her Group B Streptotoccus status. A genetic workup was also initiated given fetal anomalies, fetal ultrasound report as well as a two vessel cord. HOSPITAL COURSE: 1. Respiratory - Baby Girl [Known lastname 49892]'s initial presentation was with chest x-ray findings of bilateral haziness, consistent with the diagnosis of surfactant deficiency. She was intubated on day of life #1 with the administration of two doses of Surfactant. She was extubated to CPAP after significant improvement with the Surfactant administration. On day of life #3 she was weaned from CPAP to nasal cannula and then to room air and has been on room air ever since with minimal number of apneic or brady episodes. Her apneic and brady episodes occurred on day of life #7. 2. Cardiovascular - The patient had a II/VI mild systolic ejection murmur on day of life #4 at which time Cardiology was consulted and echocardiogram revealed large patent ductus arteriosus with atrial septal defect versus patent foramen ovale. Baby Girl [Known lastname 49892] received a course of Indomethacin with resolution of hemodynamic instability and the loud murmur. She continued to have intermittent soft, I/VI systolic ejection murmur best heard at the apex. These will all be followed up by Cardiology on [2-13] at 10:00 at [Hospital3 1810]. 3. Fluids, electrolytes and nutrition - The patient was initially started on parenteral nutrition for nutritional support while on Indomethacin. She was restarted on enteral feeds on day of life #4 and has been tolerating enteral feeds since then. Prior to discharge, she was on breast milk 26 with good weight gain. Her weight on discharge was [2030] gm, up from a birthweight of 1710 gm. She was discharged home on Poly-Vi-[Male First Name (un) ]. 4. Gastrointestinal - Baby Girl [Known lastname 49892]'s bilirubin peaked on day of life #3 at 10.1 at which time she was placed on double phototherapy. Phototherapy was discontinued on day of life #6 with a rebound bilirubin level of 6.1 on day of life #7. 5. Hematology - Baby Girl [Known lastname 49892]'s initial hematocrit was 48.9. She did not require any transfusion during her admission. She is currently on iron supplement. 6. Infectious disease - Given the initial respiratory distress, Baby Girl [Known lastname 49892] was started on Ampicillin and Gentamicin for 48 hours. Blood culture has been negative and she has since had no infectious disease issues. 7. Neurology - As part of her genetic workup, she had a head ultrasound on day of life #6 which revealed impression of septa versus old Grade 1 bleed in the ventricle. She has not had any neurologic findings during this admission. 8. Genetics - During this admission, Genetics was consulted given the finding of hemivertebra and two vessel cord. Renal ultrasound was negative and chromosome studies along with FISH 22 were all within normal limits. 9. Audiology - Hearing screen was performed with automated brain stem responses and the patient passed both ears. CONDITION ON DISCHARGE: The patient has been stable on room air, no hemodynamic issues, tolerating full feeds of breast milk 26. DISCHARGE DISPOSITION: The patient will be discharged home with parents. Primary pediatrician - Dr. [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) 37946], phone [Telephone/Fax (1) 37949]. CARE/RECOMMENDATIONS: 1. Feeds - Breast milk 26, p.o. ad lib 2. Medications - Poly-Vi-[Male First Name (un) ] 1 cc p.o. q. day; Fer-In-[Male First Name (un) ] 25 mg/cc .2 cc p.o. q. day 3. Carseat position screening - Passed. 4. State newborn screening - Sent. 5. Immunizations received - The baby received [Name (NI) 38801] on [2-4], hepatitis B vaccination was deferred at this time. 6. Immunizations recommended - I. [Month (only) 38801] 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: A. Born at less than 32 weeks; B. 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 C. With chronic lung disease. II. 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: Appointments scheduled or recommended - Baby Girl [Known lastname 49892] has a follow up appointment with primary physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 37946] toward the end of this week. She has a scheduled cardiology follow up appointment on [2114-2-13] at 10 o'clock at [Hospital3 1810] with Dr. [Last Name (STitle) 48354]. Baby Girl [Known lastname 49892] should also have an orthopedic follow up for her hemivertebra. DISCHARGE DIAGNOSIS: 1. Prematurity 2. Hyaline membrane disease 3. Patent ductus arteriosus status post Indomethacin 4. Hemivertebra Reviewed By: [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36250] Dictated By:[Name8 (MD) 47634] MEDQUIST36 D: [2114-2-5] 15:40 T: [2114-2-5] 15:57 JOB#: [Job Number 49893] ICD9 Codes: 769, 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6286 }	Medical Text: Admission Date: [2101-2-6] Discharge Date: [2101-2-11] Date of Birth: [2101-2-4] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: [Known lastname 55190] [Known lastname 55191] is the former 38-4/7 week gestation male infant, birth weight 3405 grams born to a 33-year-old G1 P0 woman. The mother is a native from [Name (NI) 48229] and has been in the United States for four years. PRENATAL SCREENS: Blood type O-positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, group B Strep positive. Pregnancy was notable for polyhydramnios from 31 weeks gestation and history of shorten cervix. She presented on [2101-2-3] with spontaneous rupture of membranes. Her labor was augmented with pitocin. She was treated intrapartum with antibiotics for GBS prophylaxis. There was no maternal fever or other sepsis risk factors. Infant was born on [2101-2-4] by vaginal delivery. Apgars were eight at one minute and nine at five minutes. His newborn nursery course was notable for poor establishment of breast-feeding, 7% weight loss, and rare urine output. He had persistent tachypnea in the 60s-80s, but was otherwise stable. He was admitted to the Neonatal Intensive Care Unit at two days of life for treatment of hyperbilirubinemia. PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 3180 grams down 7%. General: Active alert baby. Normal [Name2 (NI) ] and reflexes. Head, eyes, ears, nose, and throat: Anterior fontanel is soft and flat. Palate intact. Chest was clear to auscultation, tachypnea, but no significant retractions or grunting. Cardiovascular: Regular rate and rhythm, no murmur, 2+ femoral pulses. Abdomen is soft, positive bowel sounds, no hepatosplenomegaly. GU: Slight chordee with centrally located urethral meatus. Testes down bilaterally. Concentrated urine in diaper with uric acid crystals. Patent anus. Spine: No sacral anomalies, Mongolian spots noted. Extremities: Well perfused. Skin: Jaundice without rashes. Neurologic: Normal [Name2 (NI) ], activity, and reflexes. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Shortly after admission to the Neonatal Intensive Care Unit, oxygen saturations were noted to be in the 80% range. The baby was treated with nasal cannula O2 briefly for approximately eight hours. He then remained in room air for the rest of his Neonatal Intensive Care Unit admission. Respiratory rates remained in the 40-70 range without any distress. 2. Cardiovascular: No murmurs had been noted. He has maintained normal heart rates and blood pressures. 3. Fluids, electrolytes, and nutrition: An intravenous line was started shortly after admission to the Neonatal Intensive Care Unit and IV fluids were administered at 100 cc/kg/day. He continued to breast-feed with improving intake and was also fed formula as well. Urine output gradually increased to over 2 cc/kg/hour. Serum sodium upon admission to the Neonatal Intensive Care Unit was 148 with a repeat on day of life three of 141 mEq/L. At the time of transfer from the Neonatal Intensive Care Unit, his weight was 3.265 kg. 4. Infectious disease: There were no septic risk factors from delivery, but with the onset of hyperbilirubinemia, [Known lastname 55190] was evaluated for sepsis. A white blood cell count was 11,600 with a differential of 39% polys, 4% bands. A blood culture was obtained and intravenous ampicillin and gentamicin were administered. Blood culture had no growth at 48 hours and the antibiotics were discontinued. 5. Hematological: Initial hematocrit was 44.7% with a reticulocyte count of 9.2%. Repeat hematocrit on day of life three was 39.9% with a reticulocyte count of 8.3%. With the significant hyperbilirubinemia, hematology workup was undertaken. A G-6-P-D screen was sent with results of 25.8 units/gram of hemoglobin, the normal range being stated 6-12.4/grams/hemoglobin. Urine for reducing substances was sent. Hematology consult from [Hospital3 1810] was obtained, and recommended a [Doctor Last Name 17012] body screen and hemoglobin electrophoresis, which are to be drawn prior to discharge. It is also recommended that an osmotic fragility test be performed 1-2 weeks after discharge by the primary pediatrician. [Known lastname 55190] is blood type O-positive, direct Coombs negative. Most recent hematocrit was on [2101-2-10] at 40.2% with reticulocyte count of 2.9%. 6. Gastrointestinal: Bilirubin at 40 hours of age was a total of 19. Phototherapy was started and a repeat bilirubin obtained three hours later was 23. [Known lastname 55190] was admitted to the Neonatal Intensive Care Unit for treatment with maximum phototherapy and intravenous fluids. His bilirubin at 50 hours of life was 20 and a repeat four hours later was 17.4. He continued on phototherapy for the next five days. Phototherapy was discontinued for bilirubin of a total of 9.7/0.4 direct, 9.3 indirect. Rebound bilirubin will be pending for the morning of [2101-2-11]. 7. Sensory: Hearing screening was performed automated auditory brain stem responses. [Known lastname 55190] initially passed on day of life #1. A repeat screen was performed after the resolution of his serum bilirubin, which surpassed 20 mg/dl. [Known lastname 55190] passed the second screening in both ears as well. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to the Newborn Nursery for continuing care. The primary pediatrician after discharge will be Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Hospital 1426] Pediatrics, [Hospital1 55192], [Location (un) 86], [Numeric Identifier ]. Phone number is [Telephone/Fax (1) 37802]. Fax number is [Telephone/Fax (1) 38332]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Breast-feeding adlib. 2. No medications. 3. State newborn screen was sent on [2101-2-7] with no notification of abnormal results to date. 4. Immunizations received: Hepatitis B vaccine to be administered prior to discharge. 5. 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 and for the first 24 hours months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW-UP APPOINTMENTS: 1. Appointment with Dr. [Last Name (STitle) ] within five days of discharge. 2. Follow up with Urology, Dr. [Last Name (STitle) ] at [Hospital3 1810] for the chordee. Phone number is [Telephone/Fax (1) 55193]. 3. Recommendation for an osmolatic fragility test 1-2 weeks after discharge by the primary pediatrician. A number for followup with Pediatric Hematology at [Hospital3 1810] at the discretion of the primary pediatrician. DISCHARGE DIAGNOSES: 1. Respiratory distress due to retained fetal lung fluid. 2. Unconjugated hyperbilirubinemia. 3. Hemolytic process as of yet unspecified. 4. Suspicion for sepsis ruled out. 5. Chordee with incomplete foreskin. [Name6 (MD) ] [Name8 (MD) 38353], M.D. [MD Number(1) 38354] Dictated By:[Last Name (Titles) 37548] MEDQUIST36 D: [2101-2-10] 23:57 T: [2101-2-11] 05:25 JOB#: [Job Number 55194] (cclist) ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6287 }	Medical Text: Admission Date: [2129-1-21] Discharge Date: [2129-1-26] Date of Birth: [2051-2-2] Sex: M Service: NEUROLOGY Allergies: No Allergies/ADRs on File Attending:[Last Name (NamePattern1) 1838] Chief Complaint: IPH Major Surgical or Invasive Procedure: none History of Present Illness: 77 yo M with hx fall in [2127-8-28] with left frontal hemorrhage and baseline speech difficulties and subsequent seizure disorder, HTN, HLD, MI with DES in [2123], transferred from OSH after found to have two small areas of hemorrhage in left frontal region as well as small layering of IVH. Per wife he was agitated this morning and did not want to get dressed. He walked to the kitchen and appeared to lose his footing, falling on his left side and hitting his head on the ground. After the fall he was breathing heavily and was unresponsive with eyes open and had fine shaking of all extremities lasting for one minute, believed by wife to be consistent with seizure. He went to OSH where he was found to have two areas of left frontal IPH, CT c-spine per report showed degnerative changes but no fracture or dislocation, received 1g dilantin and transferred here for further care. Upon arrival he was agitated and intubated in order to expedite further imaging studies. Prior to intubation he was reported to be awake and alert, not following commands and nonverbal, moving all extremities with good strength. His wife reports at baseline he is agitated at times and he speaks "when he wants to" and is nonfluent. He exercises independently and requires daily supervision by her. He developed seizures shortly after his hemorrhage in [2126] and initially was started on dilantin which caused drowsiness. Since he has been on keppra 250 mg [Hospital1 ] with one seizure approximately four months ago. Past Medical History: -TBI in [2126] with left frontal hemorrhage -Post Traumatic seizures -HTN -HLD -MI with DES in [2123] -BPH - Vascular dementia Social History: -lives with wife, had worked as a salesman prior to injury. No tobacco, etoh, or drugs Family History: -no history of stroke or seizures Physical Exam: HEENT; ecchymosis over left eye with laceration above eye covered with a dressing. Neck; c-collar in place CV; RRR, no murmurs Pulm; CTA anteriorly Abd; soft, nt, nd Extr; no edema Neuro: Alert. Minimal verbal output. States name, hi, staes when he is hungry. [Last Name (un) 90230] in [12-30] word phrases. Does not follow commands. Able to feed himself. Moving all four extremities but prefers his right side, likely has some weakness of his left side. Positive jaw jerk. EOMI with jerk saccades. Face appears symmetric. Increased tone in legs b/l. upgoing toes b/l. Pertinent Results: CT head: IMPRESSION: 1. Unchanged left frontal lobe intraparenchymal hemorrhage. 2. Decreased degree of hemorrhage in the occipital [Doctor Last Name 534] of the left lateral ventricle. 3. Decreased size of the subdural hematoma overlying the right frontal convexity. MR [Name13 (STitle) 1093] (C): 1. Changes of cervical spondylosis as described above without high-grade spinal stenosis but with foraminal narrowing as discussed above. No evidence of ligamentous disruption or acute vertebral edema seen. An endotracheal intubation with a small amount of retained fluid in the oropharynx. Brief Hospital Course: Upon arrival to the [Hospital1 ], Mr. [Known lastname ] was agitated and intubated in order to expedite further imaging studies. Prior to intubation he was reported to be awake and alert, not following commands and nonverbal, moving all extremities with good strength. CT revealed a L intraparenchymal hemorrhage with interventricular blood and a R subdural hematoma. He was evaluated by neurosurgery and no intervention was completed; He was transferred to the neuroICU. He was extubated after 24 hours. MRI revealed no c-spine injury. Able to move all extremities, PERRL. After extubation, his vocalization was at his baseline, which per his wife includes saying simple words like "yes" "no" and appropriate nodding and head shaking. He is able to ambulate, eat and drink with supervision. He is incontinent of urine overnight. Cardiac enzymes were negative for MI. Repeat head CT on [1-22] was stable. His Keppra was initially increased to 500mg twice daily and changed to 250 qam and 500mg qpm because of concerns for lethargy by wife. [Name (NI) ] was transferred to the Neurology floor service on [2129-1-23]. He was not observed to have seizures while in the hospital. He was assessed by PT/OT and Speech and Swallow, and was cleared to go home with PT and 24h care(per family's request), and self-feed regular solids and thin liquids. Repeat CT on [1-24] showed stable L frontal IPH,with decreased hemorrhage in L lateral ventricle and decreased size of subdural hematoma overlying the R frontal convexity. He was discharged at baseline mental status; he did not consistently follow commands and had very minimal verbal output. Medications on Admission: -keppra 250 mg [Hospital1 ] -plavix 75 mg daily -proscar 5 mg daily -lopressor 25 mg [Hospital1 ] -lipitor 20 mg daily -iron 325 mg daily Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:30 Tablet(s) Refills:2 3. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:30 Tablet(s) Refills:2 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: New - Traumatic Left frontal IPH with IVH. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you during your stay here. You were admitted from an outside hospital after experiencing one of your seizures and suffering a traumatic brain bleed after falling. You had multiple CT scans of your brain which have demonstrated a stable bleed. Because of your seizure we have increased your medication Keppra to 250mg in the morning and 500mg in the evening. We also increased your medication called metoprolol to 37.5mg twice daily. Followup Instructions: You have a follow up appointment with Dr. [Last Name (STitle) ] in Neurology ([Telephone/Fax (1) 2574]) on [3-16] at 2:30 in the [Hospital Ward Name 23] Building, [Location (un) 6749]. You will need to have your primary care doctor fax a referral to his office (fax [Telephone/Fax (1) 44948]). ICD9 Codes: 4019, 2724, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6288 }	Medical Text: Admission Date: [2129-12-20] Discharge Date: [2129-12-30] Date of Birth: [2055-8-25] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [2129-12-26] - Coronary artery bypass x3 with the following grafts: Left internal thoracic artery to left anterior descending with reverse saphenous vein graft to obtuse marginal branch and reverse saphenous vein graft to a right posterior descending branch. [2129-12-20] - Cardiac Catheterization History of Present Illness: 74 yo male with history of CAD (3 BMS in [2119]) who presented to PCP office today complaining of exertional/rest/post-prandial epigastric chest pain/tightness for the past 3 weeks. The pain has been progressive and now occurs at rest and reminds him of his chest pain 10 yrs ago. Pt was initialy on aspirin but stopped it 1 mo when had hematuria. He restarted it 1.5 weeks ago when recurrent chest pain, orinally intermittent and associated with exertion describes as exertional. At 5am today chest pain awoke from sleep. . This morning, pt reports chest pain which awoke him from sleep. It was [10-1] and lasted an hour relieved with 325 mg of ASA. He then reported to PCP office who referred him directly cardiac cath. . In cath lab, pt was found to have mid 80% LAD, 60%OM1, distal 90%RCA, mid RCA stent with some in-stent restenosis, no interventions occured. Cardiac surgery team will see pt for likely CABG. Did not receive any plavix. Will place on heparin gtt, continue aspirin 325, dilt and lipitor. . On arrival to the floor, patient had no complaints and reported tolerating the procedure well. Past Medical History: 1. CARDIAC RISK FACTORS: -HTN +CHOL -PRIOR CIGS -DM +FH 2. CARDIAC HISTORY: CAD s/p 3 BMS in [2119] (LCX/OM and RCA) -CABG:None -PERCUTANEOUS CORONARY INTERVENTIONS: [2119] (see above) 3. OTHER PAST MEDICAL HISTORY: -BPH, -asthma -Asbestos exposure (with possible scar tissue) -hematuria past 3 weeks with newly diagnosed bladder tumor that is tentatively scheduled for resection on [2130-1-13] Social History: From NH. Retired Millwright, lives with wife on farm in [Name (NI) ], no tobacco, 2 drinks per night. 2 kids, 8 grandkids Family History: Father Died of MI at 58. Mother alive in nursing home at age [Age over 90 ] with dementia. Paternal uncle died of MI at 60. Physical Exam: ADMISSION EXAM VS: 134/68, 95% on RA GENERAL: in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Right radial artery with occlusive band in place, no hematoma. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: See below EKG: [12-20] at 3pm: NSR HR 65, PR 150, QRS<120, NA, NI, No ST or TW changes. No q waves. . 2D-ECHOCARDIOGRAM: [2129-12-21]: The left atrium is mildly dilated. There is probable mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal inferior wall. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The remaining left ventricular segments contract normally. 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 but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Possible basal inferior wall motion abnormality with preserved left ventricular ejection fraction. Normal right ventricular systolic function. No pathologic valvular disease. . ETT: [2123-12-13] INTERPRETATION: This 68 year old man with a history of CAD was referred to the lab for evaluation. The patient exercised for 6.5 minutes of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] protocol and stopped for fatigue. This represents a fair physical working capacity for his age. No arm, neck, back or chest discomfort was reported by the patient throughout the study. At peak exercise, there was 0.5-1 mm upsloping ST segment depression in V4-6. These resolved within 1 minute of stopping the test. The rhythm was sinus with occasional isolated apbs, vpbs and 1 ventricular couplet. Appropriate hemodynamic response to exercise. IMPRESSION: Borderline ischemic EKG changes in the absence of anginal type symptoms. Nuclear report sent separately. MIBI IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and function. LVEF of 53%. . CARDIAC CATH: [2119]: 1. Coronary arteriography in this right dominant system revealed two-vessel coronary artery disease. The LMCA was long and had mild plaquing. The LAD was a long vessel that wrapped around the apex with a proximal 30% stenosis after the first septal perforator and before the first diagonal branch. The left circumflex artery had a proximal calcified plaque with 70% stenosis extending into the major OM2 which contained a 90% stenosis at the origin of the small superior pole. The RCA had a mid-vessel 80% stenosis just beyond the acute marginal and a 60% stenosis just before the r-PDA. Overall, there was diffuse disease along the entire length of the RCA. 2. Resting hemodynamics showed normal filling pressures, with PCW 8 and LVEDP 11 mm Hg. 3. Left ventriculography showed normal wall motion and a calculated LVEF of 60%. No mitral regurgitation was seen. 4. Successful PTCA and stenting of LCx/OM was performed with <10% residual stenosis, TIMI 3 flow and no angiographically-apparent dissection (see PTCA comments). 5. Successful PTCA and stenting of RCA was performed without residual stenosis, TIMI 2 fast flow into 2 jailed acute marginal branches, and no angiographically-apparent dissection (see PTCA comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Normal left ventricular systolic and diastolic function. 3. Normal right ventricular diastolic function. 4. Successful stenting of LCX/OM and RCA. . [2129-12-20]: LMCA- No CAD LAD- Diffuse prox 50-60%, mid 80% OM1- 60% Mid RCA 70-80% Eccentric instent restenosis, Distal RCA has 90% [2129-12-30] 06:40AM BLOOD WBC-12.3* RBC-2.89* Hgb-8.8* Hct-26.0* MCV-90 MCH-30.5 MCHC-33.9 RDW-13.4 Plt Ct-220 [2129-12-26] 04:19PM BLOOD PT-12.9* PTT-31.6 INR(PT)-1.2* [2129-12-30] 06:40AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-139 K-4.0 Cl-104 HCO3-28 AnGap-11 Radiology Report CHEST (PA & LAT) Study Date of [2129-12-29] 8:38 AM [Hospital 93] MEDICAL CONDITION: 74 year old man cabg REASON FOR THIS EXAMINATION: eval for effusion CHEST RADIOGRAPH INDICATION: CABG, evaluation for pleural effusion. COMPARISON: [2129-12-27]. FINDINGS: As compared to the previous radiograph, the venous introduction sheath on the right has been removed. The lung volumes are unchanged. Small bilateral pleural effusions are present. Subsequent bilateral areas of basal atelectasis. Moderate cardiomegaly without evidence of pulmonary edema. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Brief Hospital Course: Mr. [Known lastname 884] was admitted to the [Hospital1 18] on [2129-12-20] for further evaluation of his chest pain. He underwent a cardiac catheterization which revealed severe three vessel coronary artery disease. Given the severity of his disease, the cardiac surgical service was consulted for surgical evaluation. He was worked up in the usual preoperative manner. A urology consult was obtained given his known bladder tumor. Although there was some risk of bleeding associated with the tumor, it was recommended that he proceed with revascularization. Heparin was continued for anticoagulation. On [2129-12-26], Mr. [Known lastname 884] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. He later awoke neurologically intact and was extubated. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He was noted to have leukocytosis however no fever or signs of infection were noted. His white blood cell count trended slowly back towards normal. Mr. [Known lastname 884] continued to make steady progress and was discharged home on postoperative day 4. He had a CTU of the abdomen and pelvis on the day of discharge and will need a BUN/creatinine drawn on Mon. [2130-1-2]. He will follow-up with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 172] as an outpatient. He will also need a referral to a cardiologist from Dr. [Last Name (STitle) 172]. Medications on Admission: ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth once a day DILTIAZEM HCL [CARTIA XT] - 240 mg Capsule, Ext Release 24 hr - one Capsule(s) by mouth once daily FINASTERIDE - 5 mg Tablet - one Tablet(s) by mouth daily FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other Provider) - 100 mcg-50 mcg/Dose Disk with Device - one puff(s) inhale daily at bedtime MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth in the evening RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth one time a day ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily Discharge Medications: 1. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. Disp:28 Tablet Extended Release(s) Refills:0 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 vial Refills:2 8. 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:2 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 12. montelukast 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 90634]health and home services Discharge Diagnosis: CAD with PCI X 4 stents in [2119] dyslipidemia BPH asthma hematuria past 3 weeks with newly diagnosed bladder tumor that is tentatively scheduled for Transurethral resection of bladder tumor on [2130-1-13] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Left - healing well, no erythema or drainage. Edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] 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 Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 172] [Telephone/Fax (1) 133] in [4-26] weeks, please call your PCP for referral to a cardiologist. Provider: [Name10 (NameIs) ] CARE NURSE Phone:[Telephone/Fax (1) 170] Date/Time:[2130-1-5] 11:15 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8941], MD Phone:[Telephone/Fax (1) 4537] Date/Time:[2130-1-31] 2:00 Provider: [Name10 (NameIs) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2130-2-1] 1:00 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:[2129-12-30] ICD9 Codes: 4111, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6289 }	Medical Text: Admission Date: [2189-5-26] Discharge Date: [2189-5-28] Date of Birth: [2134-8-24] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3127] Chief Complaint: post liver biopsy bleed Major Surgical or Invasive Procedure: sp liver biopsy [2189-5-26] History of Present Illness: 54 yo w/ h/o HC cirrhosis s/p OLT [2-4]. s/p scheduled biopsy 4/26 per hepatitis LT protocol. Incidentally had mild tranaminitis. After biosy complained of nausea. HCT from 31 to 28 to 24. Admitted for transfusion and monitoring. Past Medical History: HEP C (tatoos); Grade III esophageal varices; CCY; HTN; RFA of hepatocellular CA; Repair of ruptured cervical disc Social History: multiple tatoos Physical Exam: Afebrile HR 80's, bp 127/82 NAD A&OX3 RRR CTAB Soft, NT/ND biopsy site-C/D/I, no hematoma warm, well perfused, +2 DP/PT Pertinent Results: [2189-5-26] 10:30AM BLOOD WBC-2.4* RBC-3.55* Hgb-10.8* Hct-31.4* MCV-88 MCH-30.5 MCHC-34.5 RDW-14.0 Plt Ct-86* [2189-5-26] 01:15PM BLOOD WBC-2.9* RBC-3.19* Hgb-9.6* Hct-28.2* MCV-88 MCH-30.0 MCHC-34.0 RDW-13.9 Plt Ct-104* [2189-5-26] 03:13PM BLOOD WBC-3.7* RBC-2.71* Hgb-8.3* Hct-24.3* MCV-90 MCH-30.6 MCHC-34.1 RDW-14.0 Plt Ct-103* [2189-5-26] 04:27PM BLOOD WBC-3.6* RBC-2.77* Hgb-8.2* Hct-24.4* MCV-88 MCH-29.8 MCHC-33.8 RDW-14.6 Plt Ct-82* [2189-5-26] 05:42PM BLOOD Hct-31.5# [2189-5-27] 12:34PM BLOOD Hct-33.3 [2189-5-27] 03:38PM BLOOD Hct-33.4* [2189-5-28] 12:29AM BLOOD Hct-32.8* [2189-5-28] 08:34AM BLOOD Hct-32.8* [2189-5-26] 10:30AM BLOOD Glucose-93 UreaN-14 Creat-0.9 Na-140 K-3.9 Cl-105 HCO3-26 AnGap-13 [2189-5-28] 04:05AM BLOOD Glucose-107* UreaN-7 Creat-0.7 Na-140 K-3.4 Cl-110* HCO3-25 AnGap-8 [2189-5-26] 10:30AM BLOOD ALT-82* AST-78* AlkPhos-120* TotBili-0.4 [2189-5-28] 04:05AM BLOOD ALT-46* AST-37 AlkPhos-87 TotBili-0.4 [2189-5-26] 10:30AM BLOOD rapamycin-TEST [2189-5-27] 07:50AM BLOOD rapamycin-TEST Brief Hospital Course: Pt was admitted to the ICU for serial monitoring, exams and Hct. The pt was transfused prn and Hct had remained stble for > 24 hrs prior to DC. A CT abdomen was obtained upon admission [5-26] and revealed the following: Medium-attenuation fluid in the abdomen and pelvis consistent with hemorrhage mixed with peritoneal fluid. Higher attenuation blood at the 9th, 10th rib interspace on the right consistent with the site of hemorrhage. It is uncertain if the hemorrhage originates from the hepatic parenchyma or an intercostal vessel. No active extravasation from the liver is observed. The pt was without complaints throughout the hospital course. The pt spiked a fever to 101.9 on HD2. A fever work-up was obtained and was negative upon DC. It was presumed that the fever was secondary to the bleed. Upon DC, the pt was afebrile for almost 24 hours. Preliminary biopsy results were obtained and were as follows: recurrent HCV, no evidence of rejection. The pt was DC's to home on HD3 and was to follow up at the transplant clinic per the coordinator's instructions. Medications on Admission: Cellcept, Bactrim, Protonix, Calium, Lopressor, Lasix, [Last Name (un) 1380], Pravachol Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin Regular Human 100 unit/mL Solution Sig: Five (5) mg Injection ASDIR (AS DIRECTED). 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: post liver biopsy bleed [2189-5-26] Discharge Condition: stable Discharge Instructions: Please call physician if experiencing fever/chills, nausea/vomiting, dizziness/visual changes, or questions/concerns. Resume pre-procedure medications. [Last Name (un) 1380] level/biopsy results pending. Please call physician if experiencing fever/chills, nausea/vomiting, dizziness/visual changes, or questions/concerns. Resume pre-procedure medications. [Last Name (un) 1380] level/biopsy results pending. Followup Instructions: Follow up as per instructed by transplant coordinator. [Last Name (un) 1380] level/biopsy results pending. Completed by:[2189-5-28] ICD9 Codes: 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6290 }	Medical Text: Admission Date: [2200-3-31] Discharge Date: [2200-4-17] Date of Birth: [2129-1-2] Sex: F Service: CARDIOTHORACIC Allergies: doxycycline Attending:[First Name3 (LF) 1406] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [2200-4-11] Aortic valve replacement with a 19-mm [Doctor Last Name ] Magna Ease pericardial tissue valve History of Present Illness: THis 71F w/HTN, COPD, AS and chronic diastolic heart failure was admitted to [Hospital3 ] w/CHF exacerbation and RLE cellulitis on [2200-3-28] and was transferred to [Hospital1 18] cardiology after referral from Dr. [Last Name (STitle) ] for further AS evaluation and management. At [Hospital3 ] she was diagnosed w/CHF exacerbation - presenting complaints included 10-lb weight gain, leg swelling, and dyspnea on exertion. Currently the patient feels better. Her dyspnea has improved and she has no presenting complaints. She has lost 17 Ibs since friday and diuresis. Her dry weight is between 205 -210 Ibs. She did stop smoking this past [Month (only) ] and has had a dry cough since then. This cough has been slowly improving. She denies any fevers/chills, chest pain, current dyspnea, leg pain, abdominal pain, diarrhea, syncope. Past Medical History: Hypertension Aortic Stenosis OTHER PAST MEDICAL HISTORY: OSTEOPOROSIS OSTEOARTHRITIS MILD PARKINSON'S DISEASE CHRONIC VENOUS STASIS OBESITY COPD ANXIETY DEPRESSION STRESS URINARY INCONTINENCE Social History: Lives with: widowed. Has supportive daughter [Name (NI) ] Occupation: retired Cigarettes: Smoked no [] yes [x] last cigarette [2199-11-12] Hx:50 pk year Other Tobacco use:none ETOH: < 1 drink/week [x] [2-18] drinks/week [] >8 drinks/week [] Illicit drug use; none Family History: non-contributory Physical Exam: ON ADMISSION: VS: 98.5, 155/74, 82, 20 95% 2L GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate, speaking in full sentences. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP up to the mandible CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [5-18] pan systolic murmurin the second intercostal space radiating to the carotids. Second systolic murmur in the 4th intercostal space [4-18] radiating to the left axilla. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, insp crackles bibasilar, no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 1+Pitting edema to the knees b/l. No erythema or rubor b/l. No femoral bruits. SKIN: Chronic stasis dermatitis changes b/l lower extremities, no ulcers, scars, or xanthomas. PULSES: 1 + DP pulses B/l Foley in place with yellow urine Pertinent Results: Cardiac cath [2200-4-4] FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Markedly elevated left-sided filling pressures 3. Mildly elevated right-sided filling pressures. 4. Moderate pulmonary arterial hypertension 5. Borderline cardiac index. . XR ankle Three views of the right ankle were reviewed. There is no evidence of fracture, dislocation, lytic or sclerotic lesions demonstrated. Minimal soft tissue swelling around lateral malleolus is noted with otherwise no appreciable abnormality seen. If clinically warranted, correlation with cross-sectional imaging might be considered. . CAROTID U/S SHOWED Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. Impression: Right ICA <40% stenosis. Left ICA <40% stenosis . [2200-4-11] Intra-op TEE Conclusions PRE-CPB: 1. The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. 3. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 4. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The annulus measures 19 mm. 5. The mitral valve appears structurally normal with trivial mitral regurgitation. 6. Moderate [2+] tricuspid regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results. POST-CPB: On infusion of nitroprusside. AV pacing transiently. Well-seated bioprosthetic valve in the aortic position with no AI seen. Gradient measures peak of 26 at a cardiac output of 5.1 L/min. MR [Name13 (STitle) ] trace, TR is 2+. The aortic contour is normal post decannulation. . [Known lastname ],[Known firstname 3679] [Medical Record Number 110263] F 71 [2129-1-2] Radiology Report CHEST (PORTABLE AP) Study Date of [2200-4-14] 1:38 PM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] FA6A [2200-4-14] 1:38 PM CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 110264] Reason: eval for effusion Final Report INDICATION: Recent aortic valve replacement. Evaluation for effusion. TECHNIQUE: Portable AP chest radiograph. COMPARISON: [4-11] through [2200-4-13]. FINDINGS: Low lung volumes are noted along with obscuration of the left costophrenic angle, likely representing a pleural effusion. There is mild pulmonary vascular congestion. The right IJ catheter terminates in the right atrium. There is no focal consolidation or pneumothorax. Median sternotomy wires and aortic valve replacement are noted. There is no change in the cardiomediastinal silhouette. IMPRESSION: Left pleural effusion and mild pulmonary vascular congestion. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 251] [Name (STitle) 20492] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] [2200-4-16] 06:35AM BLOOD WBC-7.3 RBC-2.55* Hgb-7.0* Hct-22.8* MCV-89 MCH-27.6 MCHC-30.9* RDW-14.4 Plt Ct-188 [2200-4-12] 01:03AM BLOOD PT-12.9* PTT-25.6 INR(PT)-1.2* [2200-4-16] 06:35AM BLOOD Glucose-132* UreaN-36* Creat-0.9 Na-138 K-4.7 Cl-100 HCO3-27 AnGap-16 Brief Hospital Course: This 71F w/HTN, COPD, AS and chronic diastolic heart failure admitted to [Hospital3 ] w/CHF exacerbation and RLE cellulitis on [2200-3-28], transferred to [Hospital1 18] for AS eval/mgmt. She continued to be gently diuresed and had a cardiac cath which revealed no coronary artery disease. Her cellulitis in the RLE was treated initially with Keflex with an inadequate response. She was changed to Vancomycin and the cellulitis improved. Cardiac surgery was consulted and on [2200-4-11] she underwent aortic valve replacement. She 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. Blood pressure was initially labile, requiring high volume resuscitation. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Parkinson's meds were resumed. 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. Neurology was consulted for the patient's history of Parkinson's with generalized weakness/lethargy post-op. She was started on Sinemet and became more alert and less rigid. Speech and Swallow evaluated the patient for aspiration risk and diet modifications were made. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged on POD#6 to [Hospital1 ] [Location (un) 86] in good condition with appropriate follow up instructions. Medications on Admission: Home Medications Lasix 40mg daily Amodipine Setraline 100mg daily Potassium supplements . Transfer MEDICATIONS: ZOLOFT 100 qd ASA 81 MG QD AZILECT 1 MG QAM MIRAPEX 1.5 MG QAM DILTIAZEM CR 180 QD (NEW MED) LASIX 40 IV QD CALCIUM +D 1 TAB QD NORVASC (DISCONTINUED AT OSH) Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 7. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. AZILECT 1 mg Tablet Sig: One (1) Tablet PO Q AM (). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 11. petrolatum Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 12. Mirapex 1.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. carbidopa-levodopa 10-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 17. furosemide 10 mg/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 18. potassium chloride 10 mEq Tablet Extended Release Sig: Four (4) Tablet Extended Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Hypertension Aortic Stenosis OTHER PAST MEDICAL HISTORY: OSTEOPOROSIS OSTEOARTHRITIS MILD PARKINSON'S DISEASE CHRONIC VENOUS STASIS OBESITY COPD ANXIETY DEPRESSION STRESS URINARY INCONTINENCE 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 Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2200-5-14] 8:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8583], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2200-5-15] 1:15 Please call to schedule the following: Primary Care Dr. [First Name (STitle) ],[First Name3 (LF) ] [First Name3 (LF) 251] [Telephone/Fax (1) 39393] in [4-17] weeks Completed by:[2200-4-17] ICD9 Codes: 4241, 4280, 496, 2859, 2875, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6291 }	Medical Text: Admission Date: [2148-4-16] Discharge Date: [2122-2-2] Service: CARD [Doctor First Name 147] DATE OF DISCHARGE: Pending, awaiting rehabilitation bed. CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is an 83 year old male transferred to the [Hospital1 69] from [Hospital6 33] after cardiac catheterization on [2148-4-15], which showed three vessel disease. The patient was initially admitted to [Hospital6 33] on [4-12], for chest pain and ruled in for a myocardial infarction. The patient also has a history of chronic renal insufficiency and GI bleed. He was evaluated at [Hospital3 ] by GI for decreased hematocrit and guaiac positive stool. His CT scan done at the outside hospital was negative. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Type 2 diabetes mellitus. 4. Benign prostatic hypertrophy. 5. Arthritis. 6. Gout. 7. Bleeding duodenal ulcer in [2146-4-4]. 8. Chronic renal insufficiency. 9. Gastrointestinal bleed. ALLERGIES: None known. MEDICATIONS ON TRANSFER: 1. Captopril 50 mg twice a day. 2. Levoxyl 50 micrograms q. day. 3. Aspirin 81 mg q. day. 4. Protonix 40 mg twice a day. 5. Lipitor 10 mg q. day. 6. Glyburide 5 mg q. day. 7. Iron sulfate 325 mg twice a day. 8. Lopressor 12.5 mg q. six hours. 9. Hydrochlorothiazide 12.5 mg q. day. 10. Nitroglycerin infusion. 11. Heparin infusion. SOCIAL HISTORY: The patient lives with his wife. [Name (NI) ] is an ex-smoker. Six ounces of wine per day. HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery Service and he was continued on the Nitroglycerin and heparin infusions. He was stable during the preoperative period. He was taken to the Operating Room on [2148-4-18], and underwent an elective coronary artery bypass graft times three, with left internal mammary artery to diagonal, saphenous vein graft to left anterior descending, saphenous vein graft to obtuse marginal. He had an uneventful operative room course and he was transferred to the CSRU in stable condition. He was extubated on the day of surgery. He was considered stable enough to discharge to the regular floor on postoperative day one. His subsequently postoperative course was relatively smooth. His chest tubes were discontinued on postoperative day two. He has been ambulating with limited mobility due to gout. His pacing wires were discontinued on postoperative day four. He is now considered ready for discharge to a rehabilitation facility on postoperative day five. MEDICATIONS ON DISCHARGE: 1. Lopressor 25 mg p.o. twice a day. 2. Lasix 20 mg q. day for one week. 3. Kayciel 20 mEq q. day for one week. 4. Colace 100 mg twice a day. 5. Enteric coated aspirin 325 mg q. day. 6. Lipitor 10 mg q. day. 7. Glyburide 5 mg q. day. 8. Levoxyl 150 micrograms q. day. 9. Protonix 40 mg q. day. 10. Percocet one to two tablets q. four to six hours p.r.n. 11. Regular insulin sliding scale. CONDITION AT DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: 1. Follow-up with primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1968], in two weeks. 2. Follow-up with Dr. [Last Name (STitle) ] in four weeks. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2148-4-23] 11:03 T: [2148-4-23] 11:23 JOB#: [Job Number 41593] ICD9 Codes: 2749, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6292 }	Medical Text: Admission Date: [2116-10-11] Discharge Date: [2116-10-20] Date of Birth: [2068-11-17] Sex: F Service: SURGERY Allergies: Penicillins / Cephalosporins / Sulfa (Sulfonamides) / Aztreonam / Clindamycin Attending:[First Name3 (LF) 473] Chief Complaint: Abdominal Pain Duodenal Perforation Major Surgical or Invasive Procedure: s/p Duodenal perforation repair w/ [Location (un) ] patch History of Present Illness: 47 yo F transferred to [Hospital1 18] CCU on [10-11] from [Hospital3 417] with hypotension requiring pressors, ST elevation on EKG, and elevated troponins. Initially the patient was admitted to the OSH with a severe rash, nausea, vomiting, and hypotension on [10-8]. Prior to this she was being treated for a L toe infection, which ultimately was treated with a toe amputation by Podiatry at the OSH. The rash and other symptoms were thought to be due to antibiotics, presumably Cephalosporins or Penicillin. The patient was also noted to be in ARF with a Cr of 3. ST changes were noted on EKG and her troponin was elevated following a run of AF with RVR. She was then transferred to [Hospital1 18]. On arrival here, she had pressures as low as 60/40. A PAC was placed and showed a distributive shock-like picture with a low SVR. She was treated with pressors, including Neosynephrine and Levophed. She was weaned off of these in the last 24 hours. She is now in sinus without recent AF on BB's. An ECHO was performed on [10-12], which was positive for WMA's and a LVEF of 35%, however this appeared to be from an old infarct per the CCU team. Her troponins peaked at .88 and have since been trending down, currently 0.4 on AM labs. Her ARF is also resolving, with a Cr of 1.3 this AM. This morning the patient awoke around 8AM with sharp, constant epigastric pain. She rated the pain as [6-16] and has not increased throughout the day. The pain eventually migrated to her lower abdomen. She denies any nausea or vomiting. She has not eaten today. She denies any fevers or chills. She has never had pain like this before. The patient had a RUQ US done earlier today, which was essentially unremarkable. A CT scan was obtained later in the day, at 6PM, which shows mild to moderate free air with a significant amount of inflammation around the duodenum. Of note, she has been taking NSAID's recently for her toe pain. She also does not appear to have been on any GI prophylaxis while here in the CCU. Her lactate has been normal throughout her hospitalization. She was being treated with Vanc, Cipro, and Flagyl for her toe infection. All cultures were negative and these were stopped this morning. Past Medical History: PMH: Newly diagnosed DM type II, HTN, ? Hypercholesterolemia, Rheumatic fever age 13 PSH: Podiatry surgeries (including recent toe amp), T&A, Lithotripsy Social History: Lives with husband, 4 children and 1 grand-child. Works as kindergraden teacher. Tobacco history: Quit 3 weeks ago. 1 ppd for > 25 years. ETOH: Denies. Illicit drugs: Denies. . Family History: Mother passed away [Name (NI) 65091] lymphoma at 60s. Father lung cancer at 60. Father had a heart attack in age 60s. Denies family history of early MI, DM or HTN. Physical Exam: PE: 99.8 98.4 117/58 96 27 97%2L NAD. A&Ox3. Somewhat labored breathing. Obese. Anicteric. Tacky mucosal membranes. Supple. Mildly tachycardic and regular. Diminished bases. Limited inspiration secondary to abdominal pain. Obese. ND. No BS. + Guarding and mild rebound, both consistent with mild to moderate peritonitis. Normal tone. No masses. No gross or occult blood. L foot bandaged. Amp site c/d/i. No peripheral edema. Pertinent Results: [2116-10-11] 07:39PM BLOOD WBC-5.2 RBC-3.34* Hgb-9.4* Hct-27.9* MCV-83 MCH-28.2 MCHC-33.8 RDW-15.7* Plt Ct-157 [2116-10-17] 04:58AM BLOOD WBC-7.8 RBC-3.23* Hgb-9.1* Hct-27.0* MCV-84 MCH-28.2 MCHC-33.7 RDW-15.0 Plt Ct-151 [2116-10-17] 04:58AM BLOOD Glucose-125* UreaN-11 Creat-1.2* Na-136 K-3.9 Cl-105 HCO3-25 AnGap-10 [2116-10-14] 09:43AM BLOOD ALT-20 AST-19 CK(CPK)-47 AlkPhos-35* Amylase-26 TotBili-0.2 [2116-10-11] 07:39PM BLOOD CK-MB-NotDone cTropnT-0.78* [2116-10-12] 05:05AM BLOOD CK-MB-NotDone cTropnT-0.69* [2116-10-14] 09:43AM BLOOD CK-MB-NotDone cTropnT-0.44* [2116-10-17] 04:58AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.8 [2116-10-11] 07:56PM BLOOD %HbA1c-6.8* [2116-10-12] 04:13PM BLOOD Triglyc-235* HDL-25 CHOL/HD-5.0 LDLcalc-52 [2116-10-13] 05:45AM BLOOD Cortsol-21.4* [2116-10-13] 06:31AM BLOOD Cortsol-33.5* [2116-10-13] 06:49AM BLOOD Cortsol-37.4* [2116-10-12] 04:13PM BLOOD [Doctor First Name ]-POSITIVE Titer-1:40 . [Known lastname ],[Known firstname ] [Medical Record Number 80346] F 47 [2068-11-17] Normal sinus rhythm. Q waves in leads V2-V5 aer consistent with anterior myocardial infaction. No previous tracing available for comparison. TRACING #1 Read by: [Last Name (LF) ],[First Name8 (NamePattern2) 2206] [Doctor Last Name ] Intervals Axes Rate PR QRS QT/QTc P QRS T 89 178 90 350/400 60 -22 57 . [Hospital1 18] ECHOCARDIOGRAPHY REPORT Conclusions The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the anterior septum and anterior wall, distal inferior wall and apex. The remaining segments contract normally (LVEF = 35 %). No masses or thrombi are seen in the left ventricle. There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with mild resting LVOT gradient and moderate regional systolic dysfunction c/w CAD (mid-LAD distribution). CLINICAL IMPLICATIONS: Based on [2115] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended . Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of [2116-10-14] 10:17 AM Provisional Findings Impression: RSRc WED [2116-10-14] 1:11 PM PFI: Study limited due to patient body habitus and increased hepatic echogenicity. Pericholecystic, hyperechoic foci are most consistent with fat. However, if patient's symptoms continue or there is concern for emphysematous cholecystitis, CT scan would be more useful. RIGHT UPPER QUADRANT ULTRASOUND: The liver is diffusely increased in echogenicity, a finding that is most often consistent with fatty infiltration of the liver due to obesity or other causes. However, fibrosis and/or cirrhosis cannot be excluded given this appearance. In this setting, sensitivity for focal liver lesion is markedly decreased. Additionally, evaluation of the gallbladder is difficult due to poor beam penetration. The gallbladder measures 3.6 cm in maximal transverse dimension, which is at the upper limits of normal. A few foci of hyperechogenicity at the periphery of the gallbladder most likely represent pericholecystic fat. However, pericholecystic gas cannot be excluded. IMPRESSION: Markedly limited study. Likely foci of fat at gallbladder periphery; however, air cannot be excluded. If the patient's symptoms continue and there is concern for emphysematous cholecystitis, CT examination would be more useful. . Radiology Report CT PELVIS W&W/O C Study Date of [2116-10-14] 5:46 PM IMPRESSION: 1. Mild-to-moderate amount of pneumoperitoneum with wall edema and some surrounding inflammatory changes surrounding the region of the duodenal bulb most suggestive of a perforated duodenal ulcer. Urgent surgical consultation is recommended. Mild-to-moderate amount of simple free fluid within the abdominal and pelvic cavities. 2. Probable fibroid uterus. This can be better defined with a dedicated pelvic ultrasound on a non-emergent basis. 3. Nonobstructive right renal calculi as described above. 4. Trace right pleural effusion. . Brief Hospital Course: This is a 47 year old female who woke early this morning around 8AM with sharp, constant epigastric pain. She rated the pain as [6-16] and has not increased throughout the day. Imaging: [10-14] CT A/P: Mild-to-moderate pneumoperitoneum with CT findings suggestive of probable perforated duodenal ulcer. She had mild to moderate peritonitis and free air on imaging, likely anterior perforation of duodenum secondary to stress ulceration vs NSAID use. She is currently hemodynamically stable and non-toxic appearing at this time. Heparin gtt was stopped at 7PM, therefore we will take her to the operating room at approximately 10PM. She of moderate risk from a cardiac standpoint, although the CCU team does not feel her recent issues can be explained by an acute cardiac event, despite her troponin elevation and ST changes. In the mean time, please add Fluconazole to the current antibiotics regimen of Vanc, Cipro, Flagyl. Also, please start PPI gtt ASAP. She had a DIAGNOSES: 1. Perforated duodenal ulcer. 2. Peritonitis. She went to the OR on [2116-10-14] for: 1. Exploratory laparotomy with suture duodenal ulcer closure of a single perforation. 2. Modified [Location (un) ] patch overlay omental closure. She did well post-operatively and recovered without complications. Pain: She had a PCA for pain control. Once her diet was advanced and she was tolerating, she was switched to PO pain meds. GI/ABD: She was NPO with IVF and NGT. The NGT was D/C'd on POD 3. Her diet was slowly advanced and at time of discharge was tolerating a regular diet. She was discharged home with Protonix [Hospital1 ]. Cards: titrate home BP meds-->lopressor...if BP is a problem, lisinopril first, then HCTZ . Cards: ([2116-10-11]) heart rate was 140-160 with new-onset A Fib and hypotension 60/40. The patient did not complain of chest pain or shortness of breath. She received IV fluid boluses and IV Cardizem 5 mg X 3. EKG demonstrated ST elevation V2, V3, I, II. Troponins 8.08, 8.19, 7.51. CPK 92, 104, 94. Creatinine was 3.06 and on admission 1.7. C. Diff negative for stool. Patient was transferred to ICU and started on Neo-Synephrine to maintain pressure support. ECHO reported as akinesis of mid-to-distal septum, apex, anterior wall and distal lateral wall with EF 35-40%. No valvular lesion. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Patient describes dizziness and light-headedness during hospital stay at [Hospital3 ] which has since improved. SHOCK: Differential includes septic shock vs. cardiogenic shock. Could be cardiogenic in setting of new ST elevation, elevated troponins, localized akinesis on ECHO. However, CK was flat. In addition, CO increased with decreased SVR making septic shock more likely based on hemodynamics. Septic shock supported by recent metatrasal infection as possible source. - Patient transferred on Neo for pressure support, switch to Levophed to optimize septic shock therapy - Source of infection DM cellulitis. Patient with multiple allergies. Started Vancomycin, Cipro and Flagyl. Discussed with ID. - CVP goal > 12 . # ACS: EKG demonstrates borderline ST elevation, possible infarct to LAD. Troponins at outside hospital elevated (trop peak 8.19). ECHO demonstrated focal hypokinesis. However, CO increased not decreased making cardiogenic shock less likely. Patient asymptomatic throughout course. Was plavix loaded and started on Heparin drip. - cardiac enzymes c. Trop elevated to 0.79 - Continue conservative therapy of Heparin drip, Plavix and ASA - Cath currently not indicated in setting of infection and possible septic shock - ACE and B-blocker on hold in setting of shock - Start Lipitor 80 mg qd - Smoking cessation counselling (patient recently quit) . # A Fib: Patient with new onset A Fib at [Hospital3 ]. Currently in sinus. B-blocker on hold in setting of shock. - Monitor on tele . # Acute Renal Failure: Creatinine 3.0 which per OSH records above baseline (on admission creatinine 1.7). Differential includes prerenal vs. obstruction. Obstruction unlikely as patient has foley. Most likely pre-renal related to poor perfusion secondary to shock. - Optimize CVP > 12, pressor support to increase renal perfusion. - Send urine eosinophils to rule out allergic nephritis - Send lytes, Ua, urine culture . # Hypersensitivity Rash: Blanching puritic rash with centralized clearing. Most likely Multiforme Erythema secondary to antibiotics. - Benadryl 50 mg q6 hr prn - Hold Steroids in setting of possible acute MI . # Diabetes: recently diagnosed in [Month (only) 205]. Was on Metformin as outpatient. Hold as risk for lactic acidosis, and most likely will require contrast during admission. - Insulin sliding scale - She was ordered to restart Metformin at time of discharge. . # HTN: Hold outpatient HTN meds in setting of shock. She was restarted on Lopressor at time of discharge and Lisinopril and HCTZ were held. . # left foot ulceration: full thickness ulceration extending from prior amp site dorsally and laterally to approximately the mid-shaft of 4th/5th metatarsal. The wound appears very clean with a beefy, granular base. There is no tracking or probing noted about the wound. There is no periwound erythema or any sign to suggest infection. There is no noted drainage from the wound. The wound is very sensitive for the patient. Although it cannot be excluded, it seems unlikely at this point that the wound is the source for any sepsis, if indeed the patient is septic. Cultures were taken of the wound but, unsure of the utility at this point given the patient's extensive antibiotic regimen for the last several weeks. She will follow-up with Podiatry as an outpatient. Medications on Admission: Metoprolol, HCTZ, Lisinopril, Metformin, Aztreonam, Clindamycin Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:25 Tablet(s) Refills:0 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Metformin Oral 9. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. Disp:4 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: Duodenal perforation SHOCK: Differential includes septic shock vs. cardiogenic shock ACS A Fib Acute Renal Failure Toe Infection Diabetes HTN Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please take all new meds as ordered. Stop taking HCTZ and Lisinopril. Please see your PCP about continuing Metformin as your blood sugars have been well controlled in the hospital. * Continue with foot/toe dressing changes * Monitor your incision for signs of infection (redness, drainage). * No heavy lifting (>10lbs) for 6 weeks. * No tub baths or swimming. It is OK to shower and wash. Pat incision dry. . Congratulations on quitting smoking. Information was given to you on admission regarding smoking cessation and preventing relapses. Followup Instructions: Please follow-up with your PCP [Last Name (NamePattern4) ] [1-8] weeks to review medications. . Please follow-up with Dr. [Last Name (STitle) 468] in 3 weeks. Call [Telephone/Fax (1) 2835] to schedule an appointment. . Follow-up with GI for an EGD on [2116-11-23] at 10:30. [Hospital Ward Name 1950] [Location (un) ]. Call [Telephone/Fax (1) 463] for questions or concerns. . Podiatry recommends follow-up Dr. [Last Name (STitle) ] [Telephone/Fax (1) 543]. Completed by:[2116-10-20] ICD9 Codes: 0389, 5849, 4111, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6293 }	Medical Text: Admission Date: [2166-10-3] Discharge Date: [2166-10-22] Date of Birth: [2120-12-21] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5883] Chief Complaint: Right sided open type IIIb tib-fib fracture with substantial soft-tissue defect s/p motorcycle accident. Acute Osteomyelitis. Major Surgical or Invasive Procedure: [2166-10-6]: right distal tibia incision and drainage, ORIF fibula, ex-fix of tibia, VAC dressing [2166-10-8]: right tibia nail, antibiotic cement spacer, VAC dressing [2166-10-13]: incision and drainage, VAC dressing change [2166-10-15]: right rectus free flap to right lower extremity soft tissue defect and split thickness skin graft to right medial ankle History of Present Illness: 45 yo male s/p MCC vs. SUV T-bone ([10-3]) slid 40 feet on pavement suffering right sided type IIIB tib/fib fracture with substantial tissue loss over posterior and lateral calf. Past Medical History: chronic pancreatitis, GERD Social History: smokes 1.5 ppd, [6-18] drinks per week, construction worker Family History: non-contributory Physical Exam: Vitals: 99.7 98.5 130/98 18 96 RA - general: NAD, A + O x 3 - pulm: CTAB, no WRR - cardiac: RRR, no MRG - abd: mild TTP, no R or G, incision CDI - ext: right thigh donor site open to air, no drainage or signs of infection, abdominal free flap WWP with CR < 1 S, doppler +, mildly edematous, STSG over medial portion of right ankle good take without erythema or discharge Pertinent Results: [2166-10-3] 09:20PM BLOOD WBC-12.2* RBC-3.77* Hgb-12.6* Hct-36.5* MCV-97 MCH-33.4* MCHC-34.6 RDW-12.6 Plt Ct-163 [2166-10-16] 01:33AM BLOOD WBC-9.2 RBC-3.32* Hgb-10.4* Hct-30.9* MCV-93 MCH-31.2 MCHC-33.6 RDW-13.6 Plt Ct-479* [2166-10-3] 09:20PM BLOOD PT-11.1 PTT-19.6* INR(PT)-0.9 [2166-10-3] 09:20PM BLOOD Plt Ct-163 [2166-10-14] 01:45PM BLOOD PT-12.0 PTT-23.7 INR(PT)-1.0 [2166-10-16] 01:33AM BLOOD Plt Ct-479* [2166-10-3] 09:20PM BLOOD Glucose-117* UreaN-13 Creat-0.9 Na-143 K-4.1 Cl-110* HCO3-21* AnGap-16 [2166-10-16] 01:40AM BLOOD Glucose-126* UreaN-10 Creat-0.7 Na-138 K-4.8 Cl-101 HCO3-26 AnGap-16 [2166-10-4] 03:38AM BLOOD Calcium-7.4* Phos-4.2 Mg-1.6 [2166-10-16] 01:40AM BLOOD Calcium-8.7 Mg-2.0 Brief Hospital Course: Patient was admitted to the orthopedics-trauma service on [2166-10-3] s/p motorcycle accident in which he suffered a type IIIb tib-fib fracture of his right lower extremity with substantial free tissue loss to his posterior-medial calf and multiple non-operative right foot fractures. On [10-3] the patient was taken by Dr. [Last Name (STitle) 7376] for [MD Number(4) 84407] of the right tibia fracture, irrigation and debridement and application of a VAC dressing. On [2166-10-6] the plastics service was consulted concerning coverage of a substantial soft tissue defect on his right lower extremity. On [2166-10-6] the plastics team began following the patient, obtaining imaging as necessary for surgical planning of the RLE wound. The patient remained with a vac covering the leg wound and underwent several washouts of the site to ensure a clean and non-infected surface ontowhich to place a free tissue falp. On [2166-10-15] the pt was taken to the OR with plastics for a rectus free flap to cover LE wound - the procedure went without complication and a split thickness skin graft, taken from the right lateral thigh, was used to cover the rectus muscle flap. A large bolster was placed and the flap was followed post-operatively with regular doppler ultrasounding of the flap's pedicle. The patient had an uneventful post-operative course transitioning to oral pain medications early and tolerating a regular diet without problems. Following the reconstruction, on post operative day 5 the patient began dangling the leg from the side of the bed to slowly allow the flap to fill with blood as it will in the anatomic position - he tolerated this without event and has increased this dangling to 15 minutes/day. He was seen by physical therapy who helped him to transition to using crutches and he proved agile in their use. At the time of discharge the patient was taking PO dilaudid and had adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: After each operation the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#4. He has been voiding without problem. Intake and output were closely monitored. ID: Post-operatively, the patient was started on IV cefazolin, because the patient had been afebrile and had no signs of infection, on POD 5 his antibiotics were discontinued. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. He is being discharged on Subq heparin as his mobility is somewhat limited and should remain on this until he is active. At the time of discharge, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. He will go to [Hospital3 ] facility. Medications on Admission: Amylase-lipase-protease Ca carbonate Vit D3 Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:28 Capsule(s) Refills:0 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. Disp:28 Tablet(s) Refills:0 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily) for 30 days. 6. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO q 3 hours as needed for pain. Disp:30 Tablet(s) Refills:0 8. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS): Please resume your usual home dose. 9. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous QPM (once a day (in the evening)): Please continue this medication until you leave rehab. Disp:30 syringes Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) ] Discharge Diagnosis: Open tib-fib fracture of right lower extremity with open reduction internal fixation. Free rectus flap and split thickness skin graft to fill in soft tissue defect to right lower extremity. Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the emergency department for any of the following: - vomiting and cannot keep in fluids or your medications. - shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. - any serious change in your symptoms, or any new symptoms that concern you. - please resume all regular home medications and take any new meds as ordered. - do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. You will be non-weightbaring on your right lower extremity for the next 2-3 weeks to ensure that your skin graft takes and that your flap remains healthy. Continue to increase the dangling of the leg by 5 minutes a day TID (starting at 15 min) - if the flap looks overly dark and congested then re-elevate it. Please also doppler the leg q8hrs for the next 4 days, please contact MD if unable to find pulse. You will need to follow up weekly at plastics clinic on Fridays. Each visit your flap and graft will be evaluated and you will gradually progress to more weight-baring on the extremity. Please keep your right lower extremity dry until you follow up at plastics clinic. Followup Instructions: You will need to follow up weekly at plastics clinic on Fridays. Each visit your flap and graft will be evaluated and you will gradually progress to more weight-baring on the extremity. Please call the number below to schedule your appointment for NEXT friday [10-31]. [Telephone/Fax (1) 5343] Please also call Dr. [Last Name (STitle) 1005] to schedule an appointment with his office for Orthopedic follow up: he can be reached at: ([Telephone/Fax (1) 15940] ICD9 Codes: 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6294 }	Medical Text: Admission Date: [2169-2-20] Discharge Date: [2169-3-5] Date of Birth: [2094-4-2] Sex: M Service: SICU ID: A 74 year old male with metastatic renal cell carcinoma to the lungs with obstruction and transferred to [Hospital6 1760] for evaluation for a palliative stent, after persistent respiratory failure at an outside hospital with failure to wean. HISTORY OF PRESENT ILLNESS: A 74 year old male with renal cell carcinoma metastatic to the lungs, embolic cerebrovascular accident history with residual left-sided paresis, atrial fibrillation, status post failed cardioversion times three, left ventricular hypertrophy, insulin dependent diabetes mellitus admitted to [Hospital ] Hospital on [2169-1-22] with nausea, vomiting, diarrhea and decompensated on the floor and was in severe respiratory distress and was intubated on [2169-1-26]. He had failure to wean since [1-26]. Workup at the outside hospital included a spiral computerized tomographic angiography which was negative for pulmonary embolism but showed bilateral mid bronchus mass that was narrowing the airways. An echocardiogram at the outside hospital showed an ejection fraction of 65%, biatrial enlargement, 2+ mitral regurgitation, and a small effusion. The patient there received radiation to the chest for two weeks and suffered radiation burns to his back. The patient was also treated for Methicillin-resistant Staphylococcus aureus, pneumonia and Clostridium difficile there. He was transferred here for evaluation of placement of a stent palliatively. The patient's primary oncologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1729] works here. On arrival to this hospital the patient was complaining of being hungry, no other complaints, no shortness of breath, no chest pain, no abdominal pain and no nausea. PAST MEDICAL HISTORY: Metastatic renal cell carcinoma to the lungs diagnosed in [2161], status post two cycles of IL2 and status post nephrectomy, embolic cerebrovascular accident with residual left hemiparesis, atrial fibrillation status post unsuccessful cardioversion times three on Lovenox for anticoagulation, left ventricular hypertrophy, insulin dependent diabetes mellitus, nasal polyps, thyroid disease not otherwise specified, adrenal nodules. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: Flovent 100 mcg inhaled b.i.d., Cardizem 120, 60, 60 q.d., Lipitor 10 mg p.o. q.d., [Doctor First Name ] 50 mg p.o. q.d., Lovenox 80 mg subcutaneously b.i.d., the patient only on Coumadin at home, Reglan 10 p.o. q. 6, Vancomycin 750 mg intravenously q. 12 hours, started course on [2169-1-31] and completed it at the outside hospital. Flagyl 500 mg intravenously t.i.d., Respalor tube feeds start [2-8], at the outside hospital, Colace, Senna, Lasix 40 mg intravenously b.i.d., Silvadene ointment to back, Albuterol and Albuterol nebulizers, Morphine prn, Milk of magnesia and Ativan prn. SOCIAL HISTORY: Married with four children. PHYSICAL EXAMINATION: Examination on admission revealed temperature 98.0, blood pressure 117/32, respiratory rate 23, pulse of 123, pulse oximetry 94% on EC ventilation 400 cc by 14 breaths per minute, positive end-expiratory pressure 5, 50% oxygen. In general, awake, alert and follows commands. Intubated. Head, eyes, ears, nose and throat: Extraocular movements intact. Pupils equal, round and reactive to light and accommodation. Dry mucosal membranes. Neck: No lymphadenopathy, no thyroid mass, no jugulovenous distension. Chest: Vented breath sounds on respirator, very decreased breath sounds on the left. Heart: Regularly irregular, S1 and S2, no murmurs, rubs or gallops. Abdomen, nontender, nondistended, normoactive bowel sounds, no organomegaly. Extremities: Right PICC line, dorsalis pedis 2+ bilaterally equal, no cyanosis, clubbing or edema. Neurological, left hemiocclusion. Normal left foot clonus, brisk left brachial radialis reflex. Right side [5-24] arm and leg strength. LABORATORY DATA: White count 13.4, hematocrit 37.7, platelets 408, PT 13, INR 1.1, sodium 148, potassium 3.9, chloride 107, bicarbonate 32, BUN 51, creatinine 0.9. glucose 108, calcium 8.8, phosphorus 4.1, magnesium 2. Arterial blood gases was 7.46 pH, pCO2 46, and pO2 was 97 on AC 400 by 14 by 5 by 50%. INITIAL ASSESSMENT: A 74 year old male with metastatic renal cell carcinoma to the lungs with right brachial and pulmonary artery compromised by tumor, transferred for evaluation for palliative set by the Interventional Pulmonary Team here and to be primary oncologist. The patient has been intubated for three weeks with respiratory failure and failure to wean prior to transfer here. HOSPITAL COURSE: 1. Respiratory failure - We thought that the most likely cause of the respiratory failure was mucous plugging plus airway compression. Dr. [Last Name (STitle) ] did an initial bronchoscopy the day after admission which showed extrinsic compression of the left main stem bronchus. The plan was to go on to stenting, however, the patient quickly decompensated once he got here, was febrile and hypotensive. He was started on a sepsis protocol with an initial lactate of 4.9, white count increased from 13.4 to 16.5 and the patient was in atrial fibrillation, atrial flutter. The patient was restarted on Vancomycin, kept on Flagyl and placed on Ceftazidime to cover ventilator-associated pneumonia. The patient recovered from his septic episode relatively quickly. Gram stain and sputum culture were sent off and came back positive for Methicillin-resistant Staphylococcus aureus. He is continued on his Ceftazidime and Vancomycin. As he began to do better in terms of his sepsis profile, his atrial fibrillation became the next issue preventing him from going to the Operating Room for his rigid bronchoscopy with stenting. The patient was in atrial fibrillation with rapid ventricular response felt to be secondary to lung disease plus sepsis plus hypoxemia. He was initially given fluid and was started on Diltiazem and Digoxin and anticoagulated with Lovenox. On [2-20], he progressed into supraventricular tachycardia with aberrancy versus monomorphic ventricular tachycardia, slipping into and out of atrial fibrillation and atrial flutter. Electrophysiology Service was asked to see him and they recommended adding a beta blocker and checking an echocardiogram and discontinuing the Digoxin. Echocardiogram was done on [2-23], which showed an left ventricular ejection fraction of 70 to 80%, 1+ mitral regurgitation and 1+ aortic regurgitation and a small pericardial effusion. The beta blocker was added, Lopressor 5 mg intravenously q. 6 hours, after which his atrial fibrillation remained under reasonable control with less rapid ventricular response and no more episodes of supraventricular tachycardia versus ventricular tachycardia and Electrophysiology felt that he was stable to go to the Operating Room. The operative procedure was delayed until [3-1], secondary to anesthesia and timing issues. On [3-1], he received two stents, one to the left main stem bronchus and one to the right bronchus intermedius. He was also given a percutaneous tracheostomy at that time. He tolerated the procedure extremely well and returned back to us on the ventilator. He then proceeded to put out copious amounts of secretions and with initial attempts to wean the ventilator after the procedure were futile and he was kept on pressure support ventilation 15 and 5 with good ventilation at that time. However, as he was unable to tolerate being on his left side, He was kept on either his back or his right side with fair to good ventilation at that point. 2. Clostridium difficile colitis - On Flagyl, started [2-8]. 3. Fluids, electrolytes and nutrition - The patient was kept on tube feeds, Respalor. 4. Renal - Creatinine was initially up to 1.4 from baseline of .9, likely due to sepsis. The patient was given fluids and the creatinine improved to .8. 5. Tubes, lines and drains - Right PICC was placed on [2-10]. The patient is on an orogastric tube on tube feeds, rectal tube, Foley catheter and a left arterial line was placed on [2-20]. 6. Lingering issues - It is thought that the patient should have a percutaneous endoscopic gastrostomy placed prior to discharge to rehabilitation. Percutaneous endoscopic gastrostomy may be placed next week. That will be dictated as a discharge summary addendum. DISCHARGE DIAGNOSIS: 1. Renal cell carcinoma, metastatic to lungs with extrinsic airway compression. 2. Status post interventional pulmonary procedure with placement of two bronchial stents, one in the left main stem bronchus and one in the right bronchus intermedius. 3. Methicillin-resistant Staphylococcus aureus pneumonia. 4. Clostridium difficile colitis. 5. Insulin dependent diabetes mellitus. 6. Atrial fibrillation with rapid ventricular response. 7. Status post cerebrovascular accident with left hemiparesis. DISCHARGE MEDICATIONS: 1. Metoclopramide 10 mg intravenously q. 8 hours prn 2. Simethicone 40 to 80 mg p.o. q.i.d. prn 3. Metoprolol 20 mg p.o. t.i.d. 4. Aquaphor ointment one application to back t.i.d. prn. 5. Morphine sulfate 1 to 2 mg intravenously q. 2 hours prn. 6. Combivent 2 puffs inhaled q. 4 hours. 7. Lovenox 70 mg subcutaneous q. 12 hours. 8. Vancomycin 1 gm intravenously q. 12 hours, started [2-21], last day should be [3-14]. 9. Ceftazidime 2 gm intravenously q. 8 hours, starting [2-21], last day should be [3-14]. 10. Nystatin ointment one application to affected areas q.i.d. prn. 11. Nystatin swish and swallow 5 ml p.o. q.i.d. prn 12. Regular insulin sliding scale. 13. [Doctor First Name ] 50 mg p.o. b.i.d. 14. Metronidazole 500 mg p.o. t.i.d., last day of this should be [3-14]. 15. Lansoprazole 30 mg in nasogastric q.d. 16. Ipratropium bromide MDI 6 puffs inhaled q. 4 hours 17. Lorazepam 1 to 4 mg intravenously q. 4 hours prn anxiety DISCHARGE STATUS: To rehabilitation. DISCHARGE CONDITION: Good. The rest of this discharge summary will be dictated as an addendum on the day of discharge. [Name6 (MD) ] [Last Name (NamePattern4) 5837], M.D. [MD Number(1) 5838] Dictated By:[Name8 (MD) 6867] MEDQUIST36 D: [2169-3-5] 15:0 T: [2169-3-5] 11:14 JOB#: [Job Number 17658] ICD9 Codes: 5180, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6295 }	Medical Text: Admission Date: [2137-12-1] Discharge Date: [2137-12-19] Date of Birth: [2074-3-4] Sex: F Service: GOLD-GENSU HISTORY OF PRESENT ILLNESS: The patient is a 63 year old white female with a history of bipolar disorder, sexual abuse, borderline hypertension, atypical chest pain and hypercholesterolemia, who was admitted to the hospital on [12-1], with complaints by sister of mental status changes and confusion. The patient had recently undergone medications changes; Topamax was increased to 200 and Trazodone was started. Her symptoms were initially attributed to her medicines. Three days prior to admission, she was noticed to have increased somnolence, fatigue, incoherent speech, disorientation, unsteady gait, as well as decreased appetite. Due to her symptoms, she had fallen three days ago but without apparent ill-effect. The patient denied nausea, vomiting, diarrhea, cough, dysuria. Upon surgical consultation, the patient revealed a three day history of nausea, vomiting, and cramping abdominal pain. PHYSICAL EXAMINATION: Temperature was 102.0 F., blood pressure 145/90; heart rate was 120; respiratory rate 20, O2 saturation was 94% on room air. The patient was ill appearing, lethargic but arousable. Regular rate and rhythm; no murmurs, rubs or gallops. Lungs showed decreased breath sounds at bilateral bases. Abdomen was soft, nontender, nondistended, no edema. No focal deficits on neurological examination. LABORATORY: White blood cell count 22,900, bands 5, neucleocytes 79, lymphocytes 8, hematocrit 38.8. Sodium 134, potassium 3.7, BUN 19, creatinine 0.9. Urinalysis is 6 to 10 white blood cells, few bacteria, zero to 2 epithelial cells. Serum toxicology was negative. Chest x-ray was normal. EKG sinus rhythm [Company 22213] wave inversion in V1 through V6. HOSPITAL COURSE: The patient was put on Levaquin prophylactically for possible urinary tract infection. The same day, the patient was re-evaluated and was found to have mild to moderate diffuse abdominal tenderness which later localized to her right lower quadrant. Her antibiotic coverage changed to Ceftriaxone and Flagyl. A lumbar puncture was performed at that time which was negative. The patient underwent a CT scan of the abdomen and pelvis on day one which demonstrated circumferential thickening with surrounding inflammatory changes of the terminal ileum suggesting acute ileitis and partial small bowel obstruction. The appendix was unremarkable at the time. GI was consulted and felt that terminal ileitis was more likely due to infection than IBD or ischemia. The patient was put on Levofloxacin and Flagyl. NG tube was placed and surgical consult was made. The patient refused the NG tube. Her white blood cell count fluctuated between 13 and 20. Abdominal pain, nausea and vomiting resolved, however the diarrhea was persistent. All stool cultures were negative. On hospital day five, the patient complained of increasing shortness of breath, wheezing, with crackles on examination. Wheezes were unresponsive to nebulizer treatment. Chest x-ray revealed no evidence of congestive heart failure. It revealed a distended thoracic esophagus, marked gastric distention with pleural effusions, right greater than left which are new. A CT angiogram was performed to rule out pulmonary embolism. A KUB was obtained which again showed an unresolved small bowel obstruction. An NG tube was later passed that day which resolved her wheezing, probably due to esophagus distention and compression of her trachea. She became hypotensive in the 80s. She responded to fluids, but her respiratory status was tenuous. She was transferred to the Medical Intensive Care Unit for concern of respiratory fatigue and more intensive management. A GTE demonstrated hyperdynamic ejection fraction of 75%. A thoracentesis removed 500 cc of fluid in the right lung, which was not infected. Cytology later demonstrated no malignancy. A repeat CT scan on [12-11], showed multiple small loculated collections in the pelvis, not amenable to CT guided drainage. There was a small air fluid collection in the right hemipelvis. There were multiple distended small bowel loops, bilateral basilar atelectasis and pleural effusions. On hospital day seven, she was sent back to the Floor. On hospital day 12, a repeat CT scan was done which showed ruptured appendicitis. The patient was hypotensive overnight requiring two liters of intravenous fluids. Surgery was consulted on hospital day 12. On [12-12], the patient was taken to the Operating Room by the surgical team, Dr. [Last Name (STitle) 519] and Dr. [Last Name (STitle) 22214]. Please see Operative Note for further details. An appendectomy and fecaliths were sent to Pathology. They found right lower quadrant phlegmon, abscessed cavities, and the perforated appendix. The procedure went without complications. Postoperatively, the [Hospital 228] hospital stay was unremarkable. The patient was put on Zosyn, however, due to a rash the patient was switched to Levofloxacin and Flagyl. On [12-16], the NG tube was removed. She was started on sips and tolerated well on [12-17]. She experienced flatus and was kept on sips and on [12-18], she was started on clears, a pureed regular diet. TPN was no longer needed. She had used TPN throughout most of her hospital stay. Physical Therapy was consulted due to limited mobility and patient's family requesting rehabilitation. The patient was discharged to Rehabilitation on: DISCHARGE MEDICATIONS: 1. Depakote for mood stabilizer, 250 mg p.o. q. h.s. 2. Zantac 150 mg p.o. twice a day. 3. Miconazole Powder to perineum p.r.n. 4. Levofloxacin 500 mg p.o. q. day. 5. Flagyl 500 mg p.o. q. eight. 6. Atenolol 25 mg p.o. q. day. 7. Benadryl 25 to 50 mg p.o. q. h.s. p.r.n. 8. Percocet one to two tablets p.o. q. four to six p.r.n. for pain. DISCHARGE DIAGNOSES: The patient is status post appendectomy for perforated appendicitis, initially hospitalized for a terminal ileitis. She has a history of bipolar disorder. ALLERGIES: Her allergies include Lithium, Seroquel, MAO inhibitors, sulfa drugs. CONDITION ON DISCHARGE: She is in stable condition. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Name8 (MD) 6908] MEDQUIST36 D: [2137-12-18] 13:49 T: [2137-12-18] 13:54 JOB#: [Job Number 22215] ICD9 Codes: 5119, 2762, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6296 }	Medical Text: Admission Date: [2117-9-15] Discharge Date: [2117-9-30] Date of Birth: [2042-8-13] Sex: F Service: SURGERY Allergies: Cephalosporins / Theophylline / Prevacid Attending:[First Name3 (LF) 1481] Chief Complaint: Abdominal pain with BRBPR Major Surgical or Invasive Procedure: Total abdominal colectomy and ileostomy ([2117-9-15]) Tracheostomy ([2117-9-22]) History of Present Illness: Pt is a 75F with oxygen depended COPD and T2DM on insulin, who was treated at OSH with levaquin from [Date range (1) 25729] for [Date range (1) 25730] pneumonia. She was discharged home and was doing well until yesterday afternoon when she began experiencing sudden left sided abdominal pain with nausea/vomiting and bloody diarrhea. She was evaluated at OSH ED, where on presentation she was afebrile, with SBPs 170s and HR 71. WBC was elevated at 24.4, with 78% PMNs, 8% Bands. LFTs were normal, lactate 2.8. KUB showed no evidence of free air, CT ab/pelvis showed fluid loops in the small bowel and colon with wall thickening transverse and descending colon, and atherosclerotic calcifications throughout the abdominal aorta with apparent decreased flow throughout the celiac axis. The surgery and ID services were consulted, and were concerned for ischemic vs. infectious colitis (given her recent levaquin use for pna). Prior to transfer to [Hospital1 18], she received 100 mg stress dose steroids, IV levaquin and flagyl x 1 this morning, and zosyn IV x1 this afternoon. Past Medical History: -Oxygen and steroid dependent COPD (3L) -T2DM on insulin -Htn -LGIB in past of unclear etiology -[Name (NI) 25730] pna [7-/2117], tx'ed with levaquin [Date range (1) 25729] -GERD Past Surgical History: -s/p CCY -s/p hysterectomy Social History: -Lives with husband, former [Name2 (NI) 1818] but none since [2097]; no EtOH Family History: Noncontributory Physical Exam: On admission: Vitals: T 99.1, HR 107, BP 103/48, RR 30, 94% 3L GEN: Generally uncomfortable, though AOx3 HEENT: No scleral icterus, mucus membranes dry CV: No M/G/R PULM: inspiratory crackles left lower lung fields ABD: Moderately distended, diffuse tenderness, +guarding, evidence of peritoneal irritation Ext: No LE edema, LE warm and well perfused Pertinent Results: [2117-9-30] 02:09AM BLOOD WBC-14.1* RBC-3.26* Hgb-10.6* Hct-30.5* MCV-94 MCH-32.6* MCHC-34.7 RDW-14.2 Plt Ct-434 [2117-9-30] 02:09AM BLOOD Glucose-199* UreaN-19 Creat-0.6 Na-137 K-3.8 Cl-96 HCO3-32 AnGap-13 [2117-9-30] 02:09AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1 [2117-9-28] 06:49PM BLOOD Lactate-1.3 . CHEST (PORTABLE AP) Study Date of [2117-9-22] 3:10 AM FINDINGS: Single AP view of the chest shows an ET tube to be 4.8 cm above the carina. An OG tube courses over the esophagus and off the screen past the GE junction. A right IJ catheter tip terminates in the low SVC. Unchanged small bilateral pleural effusions and left basilar atelectasis. Increasing opacity at the right lung base likely represents gravitational edema recurrence of aspiration in the right clinical setting should be considered. Cardiac silhouette remains large. No pneumothorax. Aortic calcifications noted. CHEST (PORTABLE AP) Study Date of [2117-9-29] 4:32 AM FINDINGS: In comparison with the study of [9-28], the monitoring and support devices remain in good position. Continued opacification at the left base is consistent with atelectasis and effusion. Little overall change in the degree of pulmonary vascular congestion. The patient has taken a somewhat better inspiration. . Portable TTE (Complete) Done [2117-9-16] at 12:40:22 PM Small, hyperdynamic left ventricle with mid-cavitary pressure gradient. Dilated right ventricle. No clinically significant valvular regurgitation or stenosis. Mild pulmonary artery systolic hypertension. Very small pericardial effusion. Compared with the prior study (images reviewed) of [2114-1-5], the left ventricle is now small and hyperdynamic with a mid-cavity pressure gradient identified. Right ventricular dilitation is now seen. Mild pulmonary artery systolic hypertension is present on the current study and was not previously assessed. . Pathology Examination ([2117-9-15]) I. Right and transverse colon, open colectomy, A-M: 1. Patchy mucosal and focal transmural necrosis. 2. Ileal and colonic resection margins free of necrosis. 3. Status post appendectomy. 4. See note. II. Splenic flexure, ascending and descending colon, open colectomy, N-Y and AB: 1. Patchy mucosal and focal submucosal necrosis with focal transmural acute inflammation. 2. Mucosal necrosis present at one resection margin. 3. The other resection margin free of necrosis. III. Terminal ileum, open colectomy, Z-AA: Patchy mucosal necrosis at stapled end; see note. . Microbiology: [2117-9-18] 7:45 am SPUTUM Site: ENDOTRACHEAL SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMIKACIN-------------- 32 I AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R [2117-9-20] 4:26 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. RESPIRATORY CULTURE (Final [2117-9-22]): Commensal Respiratory Flora Absent. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 329-4820F ON [2117-9-18]. Brief Hospital Course: Mrs [Known lastname 25731] was transferred to [Hospital1 18] on [2117-9-15] with severe abdominal pain and bright red blood per rectum concerning for ischemic vs infectious colitis and was taken emergently to the operating room for an exploratory laparotomy, total abdominal colectomy and end-ileostomy. The patient was trensferred to the surgical ICU post-op for close monitoring, where she remained throughout her hospital stay. Neuro: the patient was sedated on propofol and intermittent fentanyl and midazolam while intubated. After tracheostomy was placed, the patient's sedation was weaned to intermittent fentanyl and ativan only. CVS: the patient required pressors post-op and was successfully weaned off within 24 hrs from her operation, and given albumin and pRBCs for fluid status and blood pressure support. Resp: the patient remained intubated until POD2, when she was extubated but subsequently became tachypneic with desaturation, and required re-intubation. A second attempt at extubation was made on POD5, but she again experienced desaturations with RLL mucous plugging suggestive of possible aspiration event. She was again re-intubated at this time. Sputum cultures grew ESBL E.Coli organisms, and she was started on meropenem for a 14 day course. A decision was made to proceed with tracheostomy, and she received a bedside trach on [2117-9-22]. She tolerated this well, and was weaned to pressure support and eventually to intermittent trach collar, with rest periods on the ventilator. GI/FEN: the patient was NPO on IVF with an NGT in place post-op. She was started on tube feeds on POD4 with a concentrated formula, which was eventually switched to Replete (currently at goal rate of 55 cc/hr). GU: urine output was closely monitored post-op. Her creatinine initially increased to 1.3 from a baseline of 1 and went back to baseline on POD1. Her Cr remained stable throughout her stay, and her BUN rose in the postoperative period but then returned to baseline. She was started on Lasix 20 [Hospital1 ] on POD2 due to fluid third-spacing, and was eventually transitioned to her home dose of 80mg daily via her NGT. This dose was decreased to lasix 40 daily on [2117-9-29] and she was started on diamox due to a rising CO2 level. Heme: the patient received 1U of PRBC on POD0. Her Hct was closely monitored, and was stable. She did receive albumin on POD 2,3,and 5, but did not require any additional RBCs. Endo: the patient was on an insulin drip for 24 hrs post-op for tight glycemic control. The [Last Name (un) ] service was consulted and followed this patient throughout her stay. She was transitioned off the insulin drip and eventually to a combination of [Hospital1 ] NPH insulin plus a regular insulin sliding scale. ID: Zosyn and Flagyl was started on POD0, and she was switched to meropenem on POD5 after sputum cultures grew ESBL E.Coli with sensitivity to meropenem. She had a persistently elevated WBC count beginning on POD6 which slowly trended down through the remainder of her hospital course. A CT abdomen/pelvis on [2117-9-25] failed to reveal any abdominal fluid collections to explain her leukocytosis. C.difficile was negative x2, and her central line was replaced with no growth from the catheter tip. Her CVL was eventually D/C'ed after a PICC line was placed on [2117-9-29]. Vancomycin was added on [2117-9-28] after an area of erythema was noticed at the inferior portion of her abdominal incision. There did not appear to be a drainable collection, and the erythema is stable on the vanco, of which she is to complete a 10-day course. Proph: the patient received famotidine and SQH throughout her stay. She also had venodyne boots in place while in bed. Medications on Admission: Singulair 10', Advair 500/50'', Insulin SS, Insulin Humulin 28Units QAM, 10 units QPM, Pravastatin 10' Ativan 0.5mg'', Diltiazem 240'', ventolin inhaler, Lisinopril 40', Fosamax 35, Prednisone 5', Vitamin D, Trazodone 100', Wellbutrin 100'', Lasix 80', Toprol 25' Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 2. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. prednisone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for anxiety. 8. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 11. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 4 days: continue through [2117-10-4] to complete 14 day course. 12. acetazolamide sodium 500 mg Recon Soln Sig: Two Hundred Fifty (250) mg Injection once a day. 13. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 8 days: continue through [2117-10-8] to complete 10 day course. 14. Insulin sliding scale Fingerstick Q6HInsulin SC Fixed Dose Orders Breakfast Bedtime NPH 14 Units NPH 24 Units Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-100 mg/dL 0 Units 101-150 mg/dL 10 Units 151-200 mg/dL 12 Units 201-250 mg/dL 14 Units 251-300 mg/dL 16 Units 301-350 mg/dL 18 Units 351-400 mg/dL 20 Units > 400 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: ischemic colon s/p total abdominal colectomy and ileostomy respiratory failure cellulitis diabetes mellitus pneumonia hypernatremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure to take care of you at [Hospital1 18]. Please continue to take all medications you are receiving in the hospital. Continue to sit in a chair as tolerated and continue to work on taking slow, deep breaths and use your incentive spirometer. Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Your staples will be removed at your follow-up appointment. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in 1 week. Call ([Telephone/Fax (1) 8818] to schedule an appointment. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2117-10-25] 10:40 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2117-12-3] 9:40 Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2117-12-3*] 10:00 ICD9 Codes: 5070, 5185, 2760, 2930, 4280, 4019, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6297 }	Medical Text: Admission Date: [2119-3-30] Discharge Date: [2119-4-7] Date of Birth: [2040-11-20] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1505] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: aortic valve replacement(21mm St. [Male First Name (un) 923] Epic porcine)& coronary artery bypass grafts x 3(LIMA-LAD, SVG-OM, SVG-PDA) [4-3] Left and right heart catheterizations, coronary angiogram,left ventriculogram [3-30] History of Present Illness: This is a 78 year old Russian speaking female patient of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3357] with known aortic stenosis now referred for a cardiac catheterization. The patient complains of exertional chest tightness and shortness of breath that has been occurring for the past three years. These symptoms occasionally occur when she gets nervous. The symptoms subside once she sits and rests. She denies claudication, edema, orthopnea and lightheadedness. Past Medical History: aortic stenosis Macular degeneration Hypertension noninsulin dependent diabetes mellitus Hypothyroidism Hyperlipidemia rheumatoid Arthritis Tonsillectomy S/p polyp removal s/p appendectomy Social History: Lives alone, and has a home health aide. Patient has Macular degeneration and is legally blind, she has not adult to stay with her overnight. ETOH: denies Contact upon discharge: Home Health Aide [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 25937] Home Care Services: Has service does not know name of company. Family History: Mother died of CAD. Physical Exam: Admission: Pulse:81 Resp:18 O2 sat:95%RA B/P Right:146/65 Left:154/70 Height:5'1" Weight:160 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur IV/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right/Left: transmitted murmur Pertinent Results: [2119-4-5] 06:00AM BLOOD WBC-13.8* RBC-3.01* Hgb-8.6* Hct-24.7* MCV-82 MCH-28.4 MCHC-34.6 RDW-14.5 Plt Ct-107* [2119-4-1] 06:30AM BLOOD WBC-7.4 RBC-3.92* Hgb-11.7* Hct-33.7* MCV-86 MCH-29.9 MCHC-34.7 RDW-12.9 Plt Ct-242 [2119-4-5] 06:00AM BLOOD Glucose-120* UreaN-18 Creat-0.7 Na-135 K-4.5 Cl-103 HCO3-26 AnGap-11 [2119-3-30] 09:45AM BLOOD Glucose-135* UreaN-22* Creat-0.7 Na-139 K-4.1 Cl-103 HCO3-26 AnGap-14 [2119-4-6] 05:35AM BLOOD Hct-25.5* Brief Hospital Course: Catheterization revealed severe aortic stenosis and triple vessel disease. Surgical referral was made. The routine preoperative workup was completed. Dental extraction was necessary and performed on [4-2]. On [4-3] she was taken to the Operating Room where aortic valve replacement and revascularization was performed. She weaned from bypass on Neo Synephrine and Propofol infusions in stable condition. She awoke intact, was weaned from the ventilator and extubated the same day. Pressors were weaned easily. She was transferred to the floor. Beta blockade was begun and she was diuresed towards her preoperative weight. Physical Therapy was consulted for strength and mobility. CTs and temporary pacemaker wires were discontinued according to protocol. A short stay at rehab was recommended to allow further optimization prior to return home. She was ready for transfer to rehab on POD 4. Medications, precautions and follow up instructions were discussed with the family prior to her leaving the institution. Diuretics will be continued at rehab for a week. Medications on Admission: AMLODIPINE-BENAZEPRIL - 5 mg-20 mg Capsule - Capsule(s) by mouth twice a day ATORVASTATIN - 10 mg Tablet - one Tablet(s) by mouth daily FENOFIBRATE 96 mg daily METOPROLOL SUCCINATE 100 mg Tablet daily OMEGA-3 FATTY ACIDS [FISH OIL]- Dosage uncertain VIT C-VIT E-COPPER-ZNOX-LUTEIN - 226 mg-200 unit-[Unit Number ] mg-0.8 mg-34.8 mg Capsule - Capsule(s) by mouth twice a day 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fenofibrate Micronized 48 mg Tablet Sig: Two (2) Tablet PO daily (). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. Tab Sust.Rel. Particle/Crystal(s) Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: s/p aortic valve replacement Aortic stenosis s/p coronary artery bypass grafts coronary artery disease macular degeneration hyperlipidemia hypertension noninsulin dependent diabetes mellitus rheumatoid arthritis fatty liver s/p tonsillectomy s/p colonic polypectomy hypothyroidism Discharge Condition: ambulatory, steady gait Pain controlled with Percocet prn Alert and oriented x 3 Discharge Instructions: Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Recommended Follow-up:Please call to schedule appointments Surgeon: Dr.[Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [5-4] at 2:15pm Primary Care: Dr. [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 11488] ([Telephone/Fax (1) 4606]) in [1-28] weeks Cardiologist: Dr. [Last Name (STitle) ] in [1-28] weeks Completed by:[2119-4-7] ICD9 Codes: 4241, 4111, 4019, 2449, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6298 }	Medical Text: Admission Date: [2137-1-7] Discharge Date: [2137-1-13] Date of Birth: [2089-5-8] Sex: M Service: ADMISSION DIAGNOSIS: Coronary artery disease. DISCHARGE DIAGNOSIS: Coronary artery disease. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old male with multiple cardiac risk factors who had exertional angina. His cardiac workup including positive exercise stress test eventually led to cardiac catheterization on the day of admission showing left anterior descending artery disease, right coronary artery disease with right side collateralizing the left. The patient was comfortable and denied chest pain on admission. Severe two vessel disease prompted decision to go forth with bypass grafting at this time. PAST MEDICAL HISTORY: 1. Hypertension. 2. Type 2 diabetes. 3. Strong family history of cardiac disease. 4. Elevated cholesterol. MEDICATIONS: 1. Aspirin 325 mg q day. 2. Lipitor 20 mg q day. 3. Mavik 4 mg q day. 4. Tricor 160 mg q day. 5. Glucophage 500 mg [Hospital1 ]. 6. Plavix 75 mg q day. 7. Toprol 25 mg q day. PHYSICAL EXAMINATION: The patient is a middle-age man in no acute distress. He appears comfortable. Vital signs are stable, afebrile. HEENT is atraumatic, normocephalic. Extraocular movements are intact. Pupils are equal, round, and reactive to light. Anicteric. Throat is clear. Neck: Midline, supple. No masses or lymphadenopathy. Chest was clear to auscultation bilaterally. Cardiovascular is regular, rate, and rhythm with no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended without masses or organomegaly. Extremities are warm and well perfused x4. Neurologic is alert and oriented times three. No focal deficits motor or sensory are noted. LABORATORIES: Complete blood count: 5.7/13.2/37.7/249. Chemistries: 139/4.3/104/28/20/1.0/125. INR is 0.89. Patient had a cardiac catheterization on [2137-1-7] which revealed significant two vessel coronary artery disease. There was preserved left ventricular function. RECOMMENDATION: After catheterization was urgent, revascularization procedure. After evaluation by the Cardiothoracic Surgery Service, the patient was added on for a cardiac coronary artery bypass grafting on [2137-1-8]. The patient tolerated the procedure well and without complication. There was a LIMA/RIMA procedure performed of two bypasses anastomosis. Postoperatively, the patient was admitted to the Intensive Care Unit for closer monitoring. He was initially maintained on a propofol drip, and on the ventilator. Patient also had an insulin drip begun for elevated blood glucose. On postoperative day #1, the patient was seen to do very well with a heart rate in the 90s-100s in normal sinus, systolic blood pressures ranging from 100-160 with nitroglycerin drip at 0.5-1.0. Patient did require some fluid boluses and a 500 cc of bolus Hespan. Patient was extubated at approximately 1 am on postoperative day #1, and did well from this. Imdur was begun on postoperative day #1. This is done because the right internal mammary artery was used during the procedure. On postoperative day two, the patient was seen to have done fairly well overnight, however, he did have a temperature of 101.4, and had a heart rate of 102 in sinus rhythm. Fever workup was obtained which was ultimately uneventful. The patient continued to improve with aggressive pulmonary toilet. Chest tubes were discontinued on postoperative day #3 as well as pacing wires. The patient had excellent blood pressure and heart rate control on his cardiac regimen which was stable until discharge. Patient continued to work with physical therapy throughout his floor stay, and was subsequently cleared for discharge to home. The patient was discharged on postoperative day #5 tolerating a regular diet and in adequate pain control on po pain medications, and having no acute anginal symptoms. PHYSICAL EXAMINATION ON DISCHARGE: Vital signs were stable, afebrile for greater than 24 hours. Chest remained clear to auscultation bilaterally. Sternal incision was clean and dry without drainage. Cardiovascular is regular, rate, and rhythm without murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended. Extremities are warm and well perfused x4. Neurologically intact. LABORATORY ON DISCHARGE: Complete blood count: 6.5/28.0/281. Chem-7: 140/4.2/104/30/17/1.0/200. DISCHARGE CONDITION: Good. DISPOSITION: Home. DIET: Cardiac and diabetic. MEDICATIONS: 1. Lasix 20 mg [Hospital1 ] x7 days. 2. Potassium chloride 20 mEq [Hospital1 ] x7 days. 3. Colace 100 mg [Hospital1 ]. 4. Aspirin 325 mg q day. 5. Percocet 5/325 [12-13] q4h prn. 6. Lipitor 20 mg q day. 7. Metformin 1,000 mg [Hospital1 ]. 8. Lopressor 25 mg [Hospital1 ]. 9. Isordil 60 mg q day x6 weeks. DI[Last Name (STitle) 408]E INSTRUCTIONS: The patient is to followup with his cardiologist in [12-13] weeks and assess for continuation of diuretics as well as adjustment of cardiac medications at that time. The patient should follow up with Dr. [Last Name (Prefixes) ] in four weeks' time. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2137-1-13] 15:55 T: [2137-1-15] 05:40 JOB#: [Job Number 44558] ICD9 Codes: 4111, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6299 }	Medical Text: Admission Date: [2160-9-26] Discharge Date: [2160-10-1] Date of Birth: [2110-11-7] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Prednisone / Latex Attending:[First Name3 (LF) 31014] Chief Complaint: concern for STEMI Major Surgical or Invasive Procedure: [2160-9-26] Cardiac catheterization History of Present Illness: Ms [Known lastname ] is a 49yoF with h/o CVA [2157], MI in [2156], COPD, OSA, current smoker, recent hospitalization concerning for possible aortic vasculitis, who is presenting to CCU from the cath lab with concern for STEMI. She initially presented to [Hospital1 ] on [9-25] with worsening chest pain, SOB, diaphoresis, and nausea. Pain was [3-23], worse with position changes. ECG showed STE's in II, III, and AVF. She was hemodynamically stable. She was then transferred to [Hospital1 18] for cardiac catheterization, which showed... . Of note, she was discharged from [Hospital1 18] on [9-24]. She initially presented on [9-16] with fever, headaches, transient vision loss, chest pain, and bump in troponin to 1.13. MRA showed evidence of aortic arteritis, and there was substantial concern for giant cell arteritis (GCA) vs Takayasu vasculitis. However, temporal artery biopsy was negative for any evidence of GCA. She was initially treated with pulsed prednisone, but developed a substantial rash and then was switched to dexamethasone. In the setting of concern for vasculitis, she did not have a catheterization, as coronary cath from [2157] was clean, thus lowering suspicion for ACS. She was discharged with plan for stress test . On review of systems, she denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension, CAD 2. CARDIAC HISTORY: MI [2156] - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: cath at [Hospital1 ], but report not available on OMR - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: CVA [2157] - no residual deficits, went to [Hospital3 ] Fibromyalgia Asthma Emphysema OSA on CPAP . Laparoscopic Cholecystectomy Back Surgery Hysterectomy Social History: She lives with her daughter, son, and sister. She is working for the recreation department for her town, working with children. - Tobacco history: current smoker, 1 PPD - ETOH: none - Illicit drugs: none Family History: Father has diabetes, brother has diabetes, mother had CHF. No history of vasculitis. No history of Lupus, rheumatoid arthritis, dermatomyositis or polymyositis No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission physical exam: Vital signs: 98.6 144/80 74 16 98%2L 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, no JVD appreciated. Chest: Tenderness to palpation anteriorly over the right side CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Shallow breaths, speaking in short sentences. No chest wall deformities, scoliosis or kyphosis. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Radial 2+ DP 2+ PT 2+ Left: Carotid 2+ Radial 2+ DP 2+ PT 2+ . Discharge physical exam: Vitals - Tm/Tc: 99.3/98.7 HR: 56-60 BP: 105-122/55-78 RR: 18 02 sat: 99% RA (99-100% RA) In/Out: Last 24H: 1380/1150 Last 8H: 60/500 Weight: 78.6 (78.2) Tele: SR, no events GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no JVD appreciated. Chest: No tenderness this am. CARDIAC: RRR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. Normoactive BS. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Radial 2+ PT 2+ Left: Carotid 2+ Radial 2+ PT 1+ Pertinent Results: Admission labs: [2160-9-26] 09:28AM BLOOD WBC-17.4# RBC-4.35 Hgb-12.6 Hct-35.3 MCV-81* MCH-28.9 MCHC-35.5* RDW-14.1 Plt Ct-473* [2160-9-26] 09:28AM BLOOD Neuts-78.7* Lymphs-16.9* Monos-3.8 Eos-0.2 Baso-0.3 [2160-9-26] 09:28AM BLOOD PT-13.2 PTT-52.8* INR(PT)-1.1 [2160-9-26] 09:28AM BLOOD ESR-34* [2160-9-26] 09:28AM BLOOD Glucose-140* UreaN-24* Creat-0.8 Na-135 K-4.3 Cl-99 HCO3-27 AnGap-13 [2160-9-26] 09:28AM BLOOD CK(CPK)-328* [2160-9-26] 09:28AM BLOOD CK-MB-42* MB Indx-12.8* cTropnT-0.44* [2160-9-26] 09:28AM BLOOD Calcium-10.1 Phos-3.8 Mg-2.3 Cholest-210* [2160-9-26] 09:28AM BLOOD %HbA1c-6.2* eAG-131* [2160-9-26] 09:28AM BLOOD Triglyc-234* HDL-61 CHOL/HD-3.4 LDLcalc-102 [2160-9-26] 09:28AM BLOOD CRP-1.2 . Relevant labs: [2160-9-26] 09:00PM BLOOD CK(CPK)-326* [2160-9-26] 09:00PM BLOOD CK-MB-37* MB Indx-11.3* cTropnT-0.87* [2160-9-26] 09:28AM BLOOD CRP 1.2 [2160-9-27] 03:18AM BLOOD CK(CPK)-216* [2160-9-27] 03:18AM BLOOD CK-MB-24* MB Indx-11.1* cTropnT-0.61* [2160-9-26] 03:40PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.030 [2160-9-26] 03:40PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2160-9-26] 03:40PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-1 [2160-9-26] 03:40PM URINE cocaine-NEG [2160-9-28] 20:08 BLOOD dsDNA negative [2160-9-29] 05:37 BLOOD dsDNA . Discharge labs: [2160-10-1] 06:35AM BLOOD WBC-14.6 RBC-3.77 Hgb-11.3 Hct-32.6 MCV-86 MCH-29.9 MCHC-34.6 RDW-13.8 Plt Ct-356 [2160-10-1] 06:35AM BLOOD PT-11.2 PTT-25.8 INR(PT)-0.9 [2160-10-1] 06:35AM BLOOD Glucose-180* UreaN-31* Creat-0.7 Na-135 K-3.6 Cl-99 HCO3-26 AnGap-14 . MICROBIOLOGY: [2160-9-26] Urine culture negative [2160-9-26] Blood cultures x2 NGTD . IMAGING: Cardiac cath [2160-9-26]: 1. Selective coronary angiography in this right dominant system demonstrated no obstructive disease. The LMCA was angiographically normal. The LAD had an ostial 20% plaque (unchanged from the [2157] catheterization). Otherwise, the LAD had no angiographically apparent disease. The flow was somewhat sluggish distally (similar to prior catheterization). The LCx had a 40-50% focal lesion just proximal to the OM take off. This appears worse than prior catherization but was not flow-limiting. The RCA had mild serial smooth 30% proximal and mid lesions. 2. Limited resting hemodynamics demonstrated markedly elevated left-sided filling pressure with an LVEDP of 26 mmHg. Stage II arterial systemic hypertension was present with a central aortic pressure of 170/100 mmHg. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Diastolic Dysfunction. 3. Stage II Systemic Hypertension. . TTE [2160-9-26]: The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate symmetric left ventricular hypertrophy with hyperdynamic systolic function. In absence of longstanding hypertension, consider other causes of significant LVH (hypertrophic cardiomyopathy, [Location (un) 4223]-Fabry disease, etc). . CTA Chest [2160-9-26]: 1. No aortic dissection. No pulmonary embolism. 2. Stable appearance to an aortic wall thickening at the aortic arch, and descending thoracic aorta. Findings remain compatible with aortitis. 3. Severe centrilobular emphysema. . MRI of Brain [2160-9-27]: Except for a few small subcortical signal abnormalities on FLAIR and T2-weighted images, no other abnormalities are seen. Although these abnormalities are nonspecific in nature they could be visualized in early small vessel disease or vasculitis. . MRA of Head and Neck [2160-9-27]: No significant abnormalities on MRA of the head. The neck MRA demonstrates normal flow in the carotid and vertebral arteries without stenosis, occlusion or dissection. . Cardiac MRI [2160-9-29]: 1. Very small pericardial effusion, late gadolinium enhancement and T2 images suggestive of focal myopericarditis. 2. Normal left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was normal at 71%. The effective forward LVEF was normal at 61%. Normal right ventricular cavity size and systolic function. The RVEF was normal at 68%. No CMR evidence of right ventricular fatty infiltration/dysplasia. 3. Trivial aortic regurgitation. Mild mitral regurgitation. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 5. A note is made of mildly thickened thoracic aortic wall as previously noted in prior CTA and MRA. Brief Hospital Course: Ms [Known lastname ] is a 49yoF with h/o CVA [2157], MI in [2156], recent hospitalization concerning for possible aortic vasculitis, who is presenting to CCU with chest pain, ST elevations, cardiac cath with non-occlusive lesion in RCA, with admission complicated by aspirin allergy, question of vasculitis. . ACTIVE ISSUES: # Chest pain: Pt presented with chest pain, was noted to have ST elevations on EKG and was taken to the cath lab, which showed a non-occlusive lesion in the RCA. She was recently admitted and found to have aortitis and it is still unclear if her chest pain was due to vasculitis vs. myocarditis vs. pericarditis vs. Takotsubo. She was admitted to the CCU for ASA desensitization, which she completed successfully. Her chest pain was managed initially with a nitroglycerin drip and high dose amlodipine (10mg [Hospital1 ]). CTA of the chest was negative for dissection and ECHO showed moderate symmetric left ventricular hypertrophy with hyperdynamic systolic function (EF > 75%). Subsequently, a cardiac MRI was performed, which showed a suggestion of focal myopericarditis, which may have been the cause of her chest pain. At the time of discharge, the patient was continued on her amlodipine. . # Aspirin allergy: Pt has history of hives as a child in response to aspirin, but she would benefit from aspirin therapy, given her previous MI. During admission in the CCU, she underwent aspirin desensitization successfully. . # Possible vasculitis: MRA in last admission was suggestive of aortitis. While markers of inflammation were elevated with ESR 72 and CRP 86, and rheumatoid factor mildly elevated at 17, other immunologic tests were unrevealing. Also, temporal artery biopsy on preior admission was negative. The patient had an MRI/MRA, which showed no narrowing of her vessels. Cardiac MRI showed a mildly thickened thoracic aortic wall, which may support a diagnosis of vasculitis. Per Rheumatology recommendations, the patient was started on dexamethasone to reduce any inflammation. It is recommended that she follow with Rheumatology for further work-up as an outpatient. . # Pre-diabetes: HbA1c was 6.2%, and fasting sugars were also elevated. Although pt is on dexamethasone at the moment, she has not been on it long and it should not have affected her hgbA1c much. She should f/u with her PCP regarding exercise, weight loss, dietery changes, and possibly starting metformin given she already has significant vascular disease and diabetes will be very detrimental to her health. . CHRONIC ISSUES: # HTN : Documented history of this problem, for which she had been treated with hydrochlorothiazide, losartan, and amlodipine prior to admission. Initially, her home antihypertensives were held while she was on a nitroglycerin drip. At the time of discharge, the patient was restarted on amlodipine, losartan and HCTZ. . # Anemia: Pt has baseline HCT 36-40. This normocytic anemia was stable and could be consistent with vasculitis. Her anemia was monitored during this admission. . # Fibromyalgia: Documented history of this problem. [Name (NI) ] was continued on her home dose pregabalin. . # Asthma/Emphysema: Documented history of this problem. The patient was continued on her albuterol and fluticasone. . # OSA: Documented history of this problem. [Name (NI) ] was continued on CPAP. . TRANSITIONAL ISSUES: 1.) Follow-up with Rheumatology for further vasculitis work-up. 2.) A follow up CMR is recommended in [5-25] weeks to reassess the late gadolinium enhancement. Medications on Admission: 1. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take with dexamethasone every day. Disp:30 Tablet(s) Refills:0 3. diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily): Please take with dexamethasone daily. Disp:60 Capsule(s) Refills:0 4. dexamethasone 1.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:0 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:0 6. pregabalin 100 mg Capsule Sig: One (1) Capsule PO once a day. 7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 11. amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY Discharge Medications: 1. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day): take with dexamethasone. 4. dexamethasone 1.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:10 Tablet(s) Refills:0 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:120 Capsule, Delayed Release(E.C.)(s) Refills:2 6. hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO once a day. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for sob or wheezing. 8. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain. 10. amlodipine 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 11. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. pregabalin 100 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Vasculitis/Aortits Coronary spasm Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure to participate in your care here at [Hospital1 1535]. You were admitted for chest pain, which we think was due to inflammation in the heart. Initially we thought that you were having a heart attack but a cardiac catheterization did not show any significant blockages in your heart arteries. There was a possiblity that spasm of these arteries was causing your pain and the norvasc was increased to prevent spasm. A brain and heart MRI was suggestive of inflammation in the heart, aorta and possibly the brain. You were started on dexamethasone, a steroid medication to treat this inflammation and your symptoms improved. You will need to taper this medicine off slowly. We sent many labs to look for rheumatologic disorders and these labs are either negative or pending today. Your rheumatologist can follow up these labs at your outpatient appt. Your blood sugars are high and you are at risk for developing diabetes. You need to lose weight and avoid eating foods that raise your blood sugars such as sweets and low fiber foods. Please talk to Dr. [Last Name (STitle) 29117] about this at your next visit. . We made the following changes to your medicines: 1. Increase the losartan to 100 mg daily to lower your blood pressure 2. Increase the omeprazole to 40 mg twice daily to protect your stomach from the dexamethasone 3. Decrease hydrochlorothiazide to 12.5 mg daily to control your blood pressure 4. Increase the norvasc to 10 mg twice daily to prevent spasm in the heart artery. 5. Start lipitor (atorvastatin) to lower your cholesterol 6. Start aspirin every day to prevent another heart attack. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) 640] H. Location: [Location (un) 2274]-[Location (un) ] Address: 111 [Doctor Last Name ] DR, [Location (un) ],[Numeric Identifier 17464] Phone: [Telephone/Fax (1) 70698] Appointment: Wednesday [2160-10-8] 10:20am Name: [Last Name (LF) ], [Name8 (MD) ] MD Location: [Hospital1 641] Address: 111 [Doctor Last Name ] DR, [Location (un) ],[Numeric Identifier 17464] Phone: [Telephone/Fax (1) 56771] Appointment: Wednesday [2160-10-22] 10:00am Name: [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 641] Address: 111 [Doctor Last Name ] DR, [Location (un) ],[Numeric Identifier 70699] Phone: [Telephone/Fax (1) 56771] Appointment: Tuesday [2160-11-11] 2:50pm ICD9 Codes: 412, 3051, 4019, 2859

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.