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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6300 }	Medical Text: Admission Date: [2104-3-29] Discharge Date: [2104-5-2] Date of Birth: [2043-11-1] Sex: F Service: MEDICINE Allergies: Codeine / Vicodin / Percocet / Compazine / Percodan / Tigan / Latex / Betadine Viscous Gauze / Protonix / Surgical Lubricant Attending:[First Name3 (LF) 943] Chief Complaint: "severe all over body pain" Major Surgical or Invasive Procedure: - Esophagogastroduodenoscopy History of Present Illness: 60-year-old female with history of EtOH/NASH cirrhosis complicated by ascites and encephalopathy (no known varices or history of SBP) who presents with "severe all over body pain". . The patient was recently admitted for hypotension and hyponatremia where she was found to have ESBL UTI and treated with tobramycin/tetracycline. She was discharged to a nursing home on [2104-3-25]. At the nursing home, the patient states that she has not been taking her lactulose and has not had bowel movements. She is confused and states she has "all over body pain" although she is unable to describe it and unsure of if it is different or more severe than her baseline chronic pain. She presents to [Hospital1 18] for further evaluation. . Upon presentation to the EW, intial vitals were: T 98.2, HR 86, BP 130/80, RR 18, SaO2 97% RA. Labs show INR 1.6, Hct 27 (near recent baseline), LFTs okay. She is confused and has asterixis on exam. She denies rectal. CXR with question of focal infiltrate. KUB with dilated loops of small bowel likely secondary to ileus (although cannot rule out obstruction). Ultrasound with difficult anatomy and not enough ascites to safely do diagnostic paracentesis at bedside. Recommend ultrasound guided paracentesis. She received lactulose and was admitted for hepatic encephalopathy treatment. . Currently, patient confused. Yelling at nurses and very slow with movement. She notes chills, nausea, right upper quadrant discomfort and diffuse pain. She is unsure if this is different than baseline. She is unsure of her last bowel movement and is unsure if she is taking lactulose. She denies or does not know about other ROS. Past Medical History: 1. Cirrhosis: thought to be secondary to EtOH use and fatty liver disease 2. H/o pancreatitis 3. ETOH abuse 4. Cholelithiasis 5. Obesity 6. Hypothyroidism 7. Venous Insuffuciency 8. Chronic Lower extremity edema 9. Spinal Stenosis 10. Reflex Sympathetic Dystrophy 11. Hypokalemia 12. Mitral regurgitation 13. Neuropathy 14. Bilateral Hand weakness 15. Osteoporosis 16. Macrocytic anemia 17. Thrombocytopenia 18. Uterine fibroids 19. Chronic renal insufficiency 20. "tummy tuck" 21. Chronic pain: on narcotics Social History: Lives with her roomate. Is a former constable and volunteer police officer. Drinks 3-4 beers/day x 12 yrs. No h/o withdrawl szs. No tobacco or illicit drug use. Estranged from family. No HCP, though patient believes that father or [Name2 (NI) 8317] [Name (NI) ] could be HCP. Family History: Aunt with cirrhosis. Mother with alcoholism. Physical Exam: VS: T 98.2, BP 104/66, HR 86, RR 16, SaO2 94% RA GENERAL: yelling at nurses - "no - I want to do it my own way", no apparent distress HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK: supple LUNGS: limited lung volumes, bibasilar crackles, no cough, wheezes. HEART: RR, nl rate, I/VI murmur ABDOMEN: obese, soft, diffuse tenderness no rebound or guarding, decreased bowel sounds EXTREMITIES: Warm, LE edema 2+ SKIN: Stasis dermatitis bilateral lower extremities, multiple ecchymotic lesions, rash right forearm NEURO - awake, A&Ox2 (name and hospital, wrong day, month, unsure of year) unwilling to participate in neuro examination, very upset when asked to participate, emotionally labile. + asterixis. Pertinent Results: Labs on Admission: [2104-3-29] 06:54PM COMMENTS-GREEN TOP [2104-3-29] 06:54PM GLUCOSE-89 LACTATE-1.4 NA+-131* K+-3.5 CL--97* TCO2-26 [2104-3-29] 06:50PM UREA N-10 CREAT-1.0 [2104-3-29] 06:50PM estGFR-Using this [2104-3-29] 06:50PM ALT(SGPT)-15 AST(SGOT)-22 LD(LDH)-227 ALK PHOS-61 TOT BILI-1.9* [2104-3-29] 06:50PM LIPASE-14 [2104-3-29] 06:50PM CALCIUM-9.3 PHOSPHATE-3.9# MAGNESIUM-1.5* [2104-3-29] 06:50PM WBC-5.7 RBC-2.43* HGB-9.1* HCT-27.0* MCV-111* MCH-37.7* MCHC-33.9 RDW-16.1* [2104-3-29] 06:50PM NEUTS-62.6 LYMPHS-23.1 MONOS-8.5 EOS-4.9* BASOS-0.9 [2104-3-29] 06:50PM PLT COUNT-148* [2104-3-29] 06:50PM PT-17.8* PTT-37.0* INR(PT)-1.6* Labs on Discharge: 131 95 5 ------------<98 3.1 31 0.8 Microbiology: [2104-3-30] 10:57 am URINE Source: CVS. FINAL REPORT [2104-3-31] URINE CULTURE (Final [2104-3-31]): YEAST. >100,000 ORGANISMS/ML.. [2104-4-3] 3:23 pm URINE Source: CVS. FINAL REPORT [2104-4-6] URINE CULTURE (Final [2104-4-6]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. YEAST. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 1 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R [2104-4-17] 11:03 am SPUTUM Source: Endotracheal. FINAL REPORT [2104-4-22] GRAM STAIN (Final [2104-4-17]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2104-4-22]): Commensal Respiratory Flora Absent. ESCHERICHIA COLI. RARE GROWTH. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. YEAST. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R [2104-4-29] 9:39 am URINE NO GROWTH. Imaging: - CHEST (PA & LAT) Study Date of [2104-3-29] 7:11 PM IMPRESSION: Markedly limited study. Question increased density at the medial right lung base. This could represent superimposition of normal structures crowded by significant volume loss, however focal infiltrates cannot be entirely excluded. - PORTABLE ABDOMEN Study Date of [2104-3-30] 9:07 AM IMPRESSION: Two frontal views of the supine abdomen show disproportionate dilatation of the stomach and proximal small bowel with respect to relatively mild gaseous dilatation of the colon, probably the transverse. Appearance is similar to [3-29]; small-bowel obstruction must still be considered. No nasogastric tube is seen despite severe gaseous distention of the stomach. Right lung base is elevated, probably a combination of subpulmonic pleural effusion and upward displacement of the diaphragm. - CT ABD & PELVIS WITH CONTRAST Study Date of [2104-3-30] 2:56 PM IMPRESSION: 1. Proximal small bowel dilatation measuring up to 3.6 cm with a point of transition in the right lower quadrant. Imaging findings are consistent with partial versus complete obstruction likely on the basis of adhesions. 2. Findings of hepatic cirrhosis as on prior exams. 3. Anterior abdominal wall hernia containing mesenteric fat and fluid. - LUNG SCAN Study Date of [2104-3-31] IMPRESSION: Underventilated triple match V/Q defect with low probability of PE. - UNILAT UP EXT VEINS US Study Date of [2104-4-3] 9:53 AM IMPRESSION: No evidence of deep vein thrombosis in the right arm. - CT ABD & PELVIS WITH CONTRAST Study Date of [2104-4-5] 2:58 PM IMPRESSION: 1. Stable mild dilatation of the proximal small bowel loops, maximally measuring 3.6 cm. Distal loops appear less distended, with possible transition point in the right lower quadrant, likely representing mild/partial small-bowel obstruction. 2. Cirrhosis with moderate amount of abdominal and pelvic ascites. - CT HEAD W/O CONTRAST Study Date of [2104-4-16] 6:30 PM IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. If there is continued concern for parenchymal abnormalities, consider MR head if not contra-indicated. 2. Mild diffuse volume loss increased from [2096] CT Head study. - PORTABLE ABDOMEN Study Date of [2104-4-20] 9:38 PM IMPRESSION: In comparison to [2104-4-17] exam, there is mild improvement of ileus without complete resolution. - CHEST (PORTABLE AP) Study Date of [2104-4-25] 8:38 AM FINDINGS: In comparison with the study of [4-23], the degree of pulmonary vascular congestion may have slightly improved. Extensive bilateral atelectatic changes are again seen with blunting of the costophrenic angles consistent with pleural fluid. Area of increased opacification in the right mid zone may merely represent atelectasis, though in the appropriate clinical setting the possibility of pneumonia would have to be considered. Brief Hospital Course: Summary Statement: Ms. [Known lastname 28445] is a 60 year old female with a provisional diagnosis of ETOH cirrhosis who presented from rehab after a brief hospitalization for an MDR E.coli UTI, new diagnosis of cirrhosis, and hyponatremia with chronic pain who was found to have an narcotic ileus who required TPN and then was transferred to the MICU for concern for prolonged epistaxis from presumably NGT trauma who has remained encephalopathic with decompensated cirrhosis, persistent ileus from administration from narcotics, volume overload and hypoxia secondary to pulmonary edema and atelectasis Prior to transfer to the MICU: 1) Narcotic Ilues: Prior to admission she presented with diffuse abdominal pain, and dilated small loops of bowl on KUB. Subsequent Abdominal CT scans reveal potential transistion points and partial small bowel obstruction. She also developed non-bloody bilious emesis necessitating NGT placement and small bowel decompression. Surgery was consulted and a small bowel follow through revealed and an ileus that was secondary to prolonged narcotic use for a presumed diagnosis of RSD. Her narcotics were then stopped, but her ileus persisted which necessitated starting TPN, and subsequently her ileus resolved after methalynaloxone was administered. Her pain from RSD was subsequently controlled with non-opioid analgesia including tramadol and lyrica. Radiographs of the abdomin showed passing of contrast from the small bowel to the colon and her nutrition was transitioned from TPN to PO. She was tolerating PO prior to her transfer to the MICU for epistaxis 2) Decompensated Cirrhosis: She presented with peripherial edema ascities without evidence of encephalopathy. However, she became mildly encephalopathic (grade I) with mild asterixis and disorientation (date) as her ileus persisted. She was given lactulose enemas which helped resolve her confusion. There was also concern that she may have SBP, although she was never febrile, and a a diagnostic paracentesis was negative. Subsequently however, she underwent a therapeutic paracentesis to help remove ascites (3L removed) to improve her respiratory mechanics in addition to her ileus. She remained mildly encephalopathic until her transfer to the MICU. 2) Volume Overload: She developed volume overload secondary to decompensated cirrhosis and portal hypertension, ascities, and the administration TPN in addition to IV medications and antibiotics. She was given albumin and PRBC to maintain her MAP to help diuresis with aldactone and lasix. Due to her UTI, and concern for delerium, a foley was note placed to monitor UOP. Her weights were followed to monitor her fluid balance. 3) Nutrition: Due to her inability to tolerate PO and narcotic ileus. She was started on TPN for several days. She also required additional potassium repletion due to diuresis for volume overload. 4) Hyponatremia: She developed hypervolemic hyponatremia due to decompensated cirrhosis. Her hyponatremia resolved after the administration of diurectics and free water restriction. 5) Enterococcus/Yeast UTI. Upon admission she was noted to have inflammation on her UA in addition to persistent yeast in her urine and VRE. She was treated empirically for seven days for a complicated UTI with linezolid and fluconazole. Subsequent urine cultures were negative for persisent yeast or VRE. 6) MDR E.coli UTI: Upon admission she was completing a course of tobramycin for an ESBL UTI, please see previous Discharge Summary for sensitivities. 7) Anemia: The patient remained anemic on presentation and required multiple PRBC transfusions for volume due to hypotension secondary to decreased intravascular volume. Prior to her transfer to the MICU she did not have evidence of active bleeding. MICU Course: Patient transferred to MICU given concern for hematemesis and upper GI bleed. Was electively intubated for EGD on [4-16]. EGD did not reveal presence of varices, but did show Barrett's and gastropathy. Patient continued on famotidine for GI ppx. There was no recurrence of hematemesis, and HCT remained stable. Patient did develop hypotension while intubated, likely multifactorial secondary to her underlying cirrhosis and to sedating medications. Was briefly on pressors, but quickly weaned off once extubated. Was successfully extubated [2104-4-17]. Patient developed recurrent ileus while in ICU; NGT kept to continuous low wall suction and patient kept NPO. Course notable for persistent AMS, and patient was given lactulose enemas while NPO. No evidence of infection, as patient afebrile without leukocytosis. Diagnostic para [4-16] negative for SBP. Post MICU course # Encephalopathy: The patient's encephalopathy continued after she was transferred from the MICU to the floor. She was AAO x 1 with asterixis. She was treated heavily with Lactulose PO/PR, and began to put out an appropriate amount of stool, but without resolution of her encephalopathy. An infectious work-up with blood, urine, and chest x-ray was negative. Opioid medications, which were given to her in the ICU, were avoided on the floor. The patient's encephalopathy cleared on [2104-4-24], when she was AAOx3, and was following commands, but with occasional asterixis. She no longer required restraints, and had not been using the olanzapine which was written for her PRN for agitation. Her encephalopathy was felt likely secondary to lingering opioid medication, and not to hepatic encephalopathy given her appropriate output of stool. # Epistaxis: Upon transfer back from the ICU, the patient did not have any signs of epistaxis, and did not require any transfusion. # Ileus: The patient had an ileus that was noted on abdominal X-ray upon return from the ICU, which was felt likely secondary to opioid medication. The patient was made NPO, and started on metoclopromide. A few days later the patient's GI motility started to return, and her diet was gradually advanced, and her medications were returned to PO. Opioid medication was again thought to play the largest role in the patient's ileus. Metoclopromide was discontinued on patient's discharge. # Tachypnea: The patient was noted on the floor for tachypnea during her stay, with a normal ABG and normal O2 sats. Her tachypnea was felt to be secondary to abdominal ascities with ateletasis and an element of volume overload. She was treated on the floor with IV lasix, and ultimately her O2 requirements were removed. The patient was started on a dose of 40 mg Lasix PO BID and her home dose of Spironolactone (50 mg Daily). She was discharged on her home dose of 40 mg Lasix Daily and a new dose of 100 mg Spironolactone daily without tachypnea. # Decompensated Cirrhosis: Underlying EtOH cirrhosis. No history of varices or SBP; EGD from [4-16] confirmed patient does not have varices, and diagnostic para [4-16] not suggestive of SBP. The patient was continued on Lactulose and rifaximin. # Hypernatremia/Hyponatremia: The patient transiently became hypernatemic with Na of 154 after diuresis, which resolved with free water administration. On discharge she was hyponatremic without end organ signs likely secondary to diuresis. # Nutrition: Given resolving ileus and multiple BM, the patient was discharged on regular diet low salt/heart healthy diet # Pain: The patient's chronic leg and back pain had previously been treated with opiod medication, but her hospital course was complicated by several adverse events secondary to opioid medication (ileus, encephalopathy). Her morphine doses were discontinued, and the patient was started in house on standing Tylenol for pain control. # History of restless legs: The patient previously had been on mirapex 1mg qhs for restless legs. This was stopped while in the hospital, but may be restarted as needed. Medications on Admission: 1. alendronate 70 mg PO qweekly 2. morphine 30 mg PO q12H 3. morphine 15 mg PO Q6H prn 4. omeprazole 20 mg PO DAILY 5. potassium chloride 20 mEq PO BID 6. Mirapex 1 mg PO qHS 7. trazodone 300 mg PO qHS 8. hydroxyzine HCl 25 mg PO q6H prn 9. lactulose 30ml PO TID 10. phenazopyridine 100 mg PO TID prn 11. triamcinolone acetonide 0.1 % Cream Topical [Hospital1 ] 12. lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY 13. Zofran 8 mg PO QID prn 14. Calcium Citrate + D 630-400 mg-unit PO BID 15. Vitamin D-3 1,000 unit PO DAILY 16. cyanocobalamin (vitamin B-12) 1,000 mcg PO DAILY 17. docusate sodium 100 mg PO BID 18. Centrum Silver PO DAILY 19. furosemide 40 mg PO DAILY 20. spironolactone 50 mg PO DAILY 21. rifaximin 550 mg PO BID 22. tetracycline 500 mg PO QID last day [2104-3-31] 23. azithromycin 250mg daily (started at rehab) 24. albuterol nebulizer (started at rehab) Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. potassium chloride 10 mEq Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO twice a day. 4. trazodone 300 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 5. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for itching. 6. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO three times a day. 7. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 8. triamcinolone acetonide 0.1 % Cream Sig: One (1) application to affected areas Topical twice a day. 9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day. 10. Zofran 8 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 11. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO twice a day. 12. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 13. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 16. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 17. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day. 18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 19. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:3 20. acetaminophen 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours. Disp:120 Capsule(s) Refills:0 21. Artificial Tears(glycerin-peg) 1-0.3 % Drops Sig: One (1) drop to both eyes Ophthalmic PRN as needed for dry eye. Disp:1 tube Refills:0 22. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary Diagnosis: - [Female First Name (un) 564] and VRE Cystitis - Opioid-induced ileus - Hepatic encephalopathy Secondary Diagnosis: - EtOH Cirrhosis 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: Ms. [Known lastname 28445], it was a pleasure taking care of you in the hospital. You were admitted to the hospital with diffuse body pain. You were found to have an infection in your bladder, and we treated you with the appropriate antibiotics. However, your hospital course was complicated by a slow moving GI tract that likely happened because of the high dose of narcotics which you normally take. We confirmed that you did not have an obstruction in your abdomen, and gave you some medications to help your gut move along. During that time when you were not eating, we were giving your nutrition through your veins. Also during your hospital stay, you had started vomiting some blood; we took you to the ICU were we put a breathing tube down your throat and also looked at your stomach lining, where we did not see any bleeding. We believe that your vomiting of blood may have been blood which dripped into your stomach from your nose. Unfortunately, when you were intubated, we needed to give you more doses of narcotics, which caused your GI tract to slow down again. Your gut motility improved, but you still remained a little bit confused, which improved once the narcotics had worked their way out of your system. When you leave the hospital: - STOP Morphine 30 mg every 12 hours - STOP Morphine 15 mg every 6 hours as needed for pain - STOP Tetracycline 500 mg four times a day - STOP Azithromycin 250 mg every day - STOP Mirapex 1mg before bedtime - START Ipratropium bromide inhaler 1 puff inhalation every four (4) hours as needed for shortness of breath or wheezing - START Acetaminophen 500 mg every 6 hours - START Artificial Tears(glycerin-peg) 1-0.3 % Drops: Use One (1) drop to both eyes as needed for dry eyes - INCREASE your dose of Spironolactone to 100 mg Daily (previously you had been taking 50 mg Daily) We did not make any other changes to your medications, so please continue to take them as you normally have been. Followup Instructions: When you leave the hospital, please have your rehab facility make the following appointments for you: - Make an appointment to see your primary care doctor, Dr. [First Name (STitle) 1022], one week after your discharge from rehab by calling [Telephone/Fax (1) 250] Department: LIVER CENTER When: WEDNESDAY [2104-5-7] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7128], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage ICD9 Codes: 2761, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6301 }	Medical Text: Admission Date: [2197-3-15] Discharge Date: [2197-3-16] Date of Birth: [2137-12-27] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2763] Chief Complaint: Dark stools Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 59 year old male with history of cirrhosis and hepatitis C on treatment with interferon and ribavirin with chief complaint 2-3 days of black stools. He had labs drawn in Dr.[Name (NI) 948] office on [2197-3-13] which revealed a HCT drop from 40.0 to 25.0. He reports a few episodes of "purple" from saturday night into sunday morning. He thinks this is from drinking a purple powerade mixed with his lactulose. . Of note his pegylated inteferon and ribavirin was stopped [3-14]. . In the ED, initial vs were: T 98.2 P 78 BP 131/68 R17 100% O2 sat. Patient refuesed NG lavage and was started on protonix gtt, octreotide gtt. He was also give ceftriaxone 1gm for SBP prophylaxis. . He also c/o feeling lightheaded with standing and feeling slightly SOB, pale, dry. Brown guaiac stool was found on rectal exam. He was typed and crossed for 4 units, which he will receive when it is available. IV access is bilateral 18g IVs. . Past Medical History: HCV cirrhosis history of elevated AFP history of varices Social History: lives in [Hospital1 392] with his fiance. He does not have any children. He has smoked a pack of cigarettes a day for 30 years, quit last month. He denies any alcohol in 20 years, but did drink heavily in the past. IVDU with no drugs in four years. Family History: the patient denies any known family history of liver disease or liver cancer. His mom had heart issues, but he does not know the details of this. His father had congestive heart failure. He has one brother who was diagnosed with colon cancer at age 56. There is no other significant family history Physical Exam: Vitals: T:99.6 BP:95/63 P:67 R:18 O2:100 % RA General: Alert, oriented, no acute distress HEENT: Pale conjunctiva and skin overal, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: [2197-3-15] 11:20AM PT-15.4* INR(PT)-1.3* [2197-3-15] 11:20AM PLT COUNT-117* [2197-3-15] 11:20AM NEUTS-76.7* LYMPHS-17.7* MONOS-4.7 EOS-0.7 BASOS-0.2 [2197-3-15] 11:20AM WBC-5.8 RBC-2.22* HGB-8.0* HCT-24.6* MCV-111* MCH-36.2* MCHC-32.6 RDW-19.0* [2197-3-15] 11:20AM LIPASE-32 [2197-3-15] 11:20AM ALT(SGPT)-64* AST(SGOT)-124* [2197-3-15] 11:20AM GLUCOSE-93 UREA N-17 CREAT-0.8 SODIUM-138 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12 [2197-3-15] 09:23PM HCT-26.4* Brief Hospital Course: Pt admitted [3-15] with dark stools. He recieved IV PPI and octreotide gtt and transfused 1 unit of PRBC. Endoscopy performed was unremarkable and pt's hematocrit was stable. He was dishcarged in stable condiation and will follow with Dr. [Last Name (STitle) 497]. [Hospital ] hospital course and will follow up for repeat HCT to evaluate for continued bleeding as cause of anemia. Medications on Admission: furosemide 40 mg once a day, lactulose 30 mL TID, methadone 60 mg QD, nadolol 20 mg once a day, PegIntron 150 mcg injecting 0.4 mL once per week ribavirin 1000 mg daily ?stopped [2197-3-14], rifaximin 550 mg 1 by mouth twice a day, Zoloft 100 mg once a day, Aldactone 50 mg once a day, Boost twice a day, multivitamins simethicone. Discharge Medications: 1. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. lactulose 10 gram/15 mL Solution Sig: Thirty (30) milliliters PO three times a day. 3. methadone 10 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily). 4. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. Boost Liquid Oral 10. simethicone Oral Discharge Disposition: Home Discharge Diagnosis: 1. Anemia 2. Cirrhosis 3. Hepatitis C 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 anemia, or low blood counts, and dark stools. We were concerned that you might be bleeding from your gastrointestinal tract. You received blood transfusions and your blood counts improved. You underwent upper endoscopy which did not show any explanation for your low blood counts and no evidence of bleeding. It is very important you follow up tomorrow for a repeat check of your blood counts. . None of your medications were changed during this admission. You should continue to take all of your other medications as prescribed. Followup Instructions: Department: LIVER CENTER When: FRIDAY [2197-3-17] at 10:00 AM With: [First Name11 (Name Pattern1) 674] [Initial (NamePattern1) ] [Last Name (NamePattern4) 13146] [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] Completed by:[2197-3-16] ICD9 Codes: 5715, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6302 }	Medical Text: Admission Date: [2131-4-13] Discharge Date: [2131-4-26] Date of Birth: [2071-8-13] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2131-4-16] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending and saphenous vein grafts to diagonal and posterior descending artery History of Present Illness: Mr. [Known lastname ] is a 59 year-old male who presented to [Hospital1 25157] with 3 week history of chest pain radiating to his left arm with exertion. A subsequent EKG revealed NSR with ST elevation in V1-5 with Q waves and a troponin was found to be 1.16. He was cathed and found to have severe two vessel coronary artery disease. An echo revealed moderate to severe mitral regurgitation with an LVEF of 15-20%. He was subsequently transferred to [Hospital1 18] for surgical revascularization. Past Medical History: Remote Bronchitis/Pneumonia History of Kidney Stones Denies previous surgeries Social History: Denies tobacco. Occasional alcohol use. Married, employed as a truck driver. Family History: Father with coronary arery disease, requiring stent at age 65, then bypass surgery. Passed away 1 yr after surgery. Physical Exam: Pulse:83 Resp: 16 O2 sat: 95 RA B/P Right: 95/67 Height: 5'5" Weight: 147 lbs General: No acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [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:none Varicosities: None [x] Neuro: Grossly intactX Pulses: Femoral Right: 1+ Left:1+ DP Right: 1+ Left:1+ PT [Name (NI) 167]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit Right: - Left:+ Pertinent Results: [2131-4-13] BLOOD WBC-6.0 RBC-3.79* Hgb-12.3* Hct-37.4* MCV-99* MCH-32.3* MCHC-32.8 RDW-13.2 Plt Ct-617* [2131-4-13] BLOOD PT-15.5* PTT-34.4 INR(PT)-1.4* [2131-4-13] BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-139 K-4.5 Cl-107 HCO3-25 [2131-4-13] BLOOD ALT-27 AST-23 LD(LDH)-307* CK(CPK)-85 AlkPhos-55 Amylase-46 TotBili-0.4 [2131-4-13] BLOOD CK-MB-4 cTropnT-0.88* [2131-4-14] BLOOD CK-MB-NotDone cTropnT-0.98* [2131-4-13] BLOOD Albumin-3.2* [2131-4-13] BLOOD %HbA1c-5.5 [2131-4-26] 05:10AM BLOOD WBC-7.1 RBC-3.41* Hgb-10.7* Hct-32.5* MCV-95 MCH-31.3 MCHC-32.8 RDW-14.7 Plt Ct-718* [2131-4-23] 03:50AM BLOOD PT-15.3* PTT-32.8 INR(PT)-1.3* [2131-4-26] 05:10AM BLOOD Glucose-86 UreaN-22* Creat-1.0 Na-136 K-5.3* Cl-102 HCO3-24 AnGap-15 [2131-4-19] 04:48AM BLOOD LD(LDH)-343* TotBili-1.3 [2131-4-23] 03:50AM BLOOD Calcium-8.2* Mg-2.5 [2131-4-16] Carotid Ultrasound: On the LEFT systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 388/167, 135/65, 32/17 cm/sec. CCA peak systolic velocity is 52/13 cm/sec. ECA peak systolic velocity is 82 cm/sec. The ICA/CCA ratio is 7.5. These findings are consistent with 80-99% stenosis. On the RIGHT systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 99/39, 100/34, 68/25 cm/sec. CCA peak systolic velocity is 75/21 cm/sec. ECA peak systolic velocity is 98 cm/sec. The ICA/CCA ratio is 1.3. These findings are consistent with < 40%stenosis. [2131-4-16] Intraop TEE: PREBYPASS - 1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium. No atrial septal defect of PFO is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %) with akinesia of the apex and anterior wall. The anterior septum and inferior septum are moderately hypokinetic. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. POST BYPASS - 1. Patient is in sinus rhythm receiving an infusion of milrinone and norepinephrine. 2. LVEF slightly improved post revascularization. LVEF 25- 30%. 3. Aorta is intact post decannulation. 4. Mitral regurgitation is mild to moderate. Brief Hospital Course: Mr. [Known lastname ] was admitted to the cardiac surgical service. He was maintained on intravenous Heparin and Nitro and remained pain free. Preoperative echocardiogram showed LVEF 20-25% with 2-3+ mitral regurgitation - see result section for additional detail. Preoperative carotid ultrasound revealed severe left internal carotid artery stenosis - see result section for further detail. Vascular surgery was consulted and recommended left carotid endarterectomy six to eight weeks after cardiac surgery. Preoperative course was otherwise uneventful. Just prior to surgical revascularization, an IABP was placed given his severely depressed left ventricular function. On [4-16], Dr. [First Name (STitle) ] performed coronary artery bypass grafting surgery. Given inpatient stay was greater than 24 hours prior to surgery, Vancomycin was given for perioperative antibiotic coverage. For surgical details, see dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. The IABP was weaned and removed on postoperative day one without complication. Due to persistent hypotension, he was slow to wean from pressor support. Midodrine was initiated. Hemodynamics gradually improved and he was eventually transferred to the telemetry floor on postoperative day seven. Over next couple of days he received further medical management and remained stable without any complications. He worked with physical therapy for strength and mobility and on post-operative day ten he was discharged home with VNA services and the appropriate follow-up appointments. Patient was unable to be started on ACE-inhibitor due to hypotension post-operatively. He will follow-up with his cardiologist for possible addition of an ACE. Medications on Admission: None Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:1 6. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:1 7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Coronary Artery Disease status post Coronary Artery Bypass Graft Ischemic Cardiomyopathy, Ejection Fraction 15-20% Preoperative Myocardial Infarction Mitral Regurgitation Carotid Disease Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr. [First Name (STitle) ] in [4-8] weeks, call for appt Dr. [First Name (STitle) ] in [2-6] weeks, call for appt Dr. [Known firstname ] [Last Name (NamePattern1) ] in [2-6] weeks, call for appt [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2131-4-26] ICD9 Codes: 4280, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6303 }	Medical Text: Admission Date: [2104-2-19] Discharge Date: [2104-2-26] Date of Birth: [2037-4-15] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2104-2-22] Coronary artery bypass graft x 3 (left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to obtuse marginal) [2104-2-19] Cardiac Catheterization History of Present Illness: 66 year old male presents with chest pains. [2-14] year history of exertional chest pain. Described as substernal chest tightness radiating to the left arm causing left arm ache. He also has an associated urge to burp. No palpitations nausea diaphoresis or presyncope. He feels that the symptoms may be coming on with decreasing exertion but this is likely for a subtle over the last several years. He feels these symptoms are different from his usual heartburn symptoms. His chest discomfort also comes on with constipation. In the past he has had food allergies to peppers which caused similar chest tightness. He has not had peppers recently. He had positive stress test and was admitted for cardiac catheterization for further evaluation. Cath showed severe three vessel coronary artery disease and he was referred for surgery. Past Medical History: Hypertension, Cardiac syndrome X Hypothyroid Gastroesophageal reflux disease Prostate Cancer Environmental allergies Macular degeneration s/p left cataract Right knee meniscal tear Social History: [Hospital1 ] educator. Wife is [Name (NI) 16883]. Has 2 grown children. Downhill skiing and yard work for exercise. Denies tobacco, recreational drugs, or alcohol excess. Family History: Father died of tongue cancer. Brother with prostate cancer. Mother died of HTN, hyperinsulinemia, and macular degeneration, CHF Brother with macular degeneration Physical Exam: Pulse:65 Resp:22 O2 sat:100/2L B/P Right:149/88 Left: 135/87 Height:5'8" Weight:167 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 + Extremities: Warm [x], well-perfused [x] no Edema Varicosities: None 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: no Left: no Pertinent Results: Stress [2104-2-19]: LV dysfunction with anginal symptoms and MARKED ischemic ECG changes at a very low level of exercise. Nuclear report sent separately. Patient transferred to cath lab for further evaluation. Cardiac catheterization [2104-2-19]: 1. Selective coronary angiography in this right dominant system revealed two veseel coronary artery disease. The LMCA has minimal disease. The LAD has a 90% ostial stenosis and a 40% distal stenosis. There is a 80% stenosis in the mid diagonal branch. The LCx has a total occlusion of the OM branch. The RCA has minimal disease. 2. Limited resting hemodynamics demonstrated normal systemic arterial pressures with central aortic pressure 122/68 with a mean of 88 mmHg. Echo [2104-2-22]: Pre Bypass: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Post Bypass: Patient is A paced on Phenylepherine infusion. Preserved biventricular funciton. LVEF >55%. MR remains mild. Aortic contours intact. Incidental note made of a possible web versus artifact at the pa branch point which was not flow limiting. Most likely this represents an artifact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [2104-2-25] 05:55AM BLOOD WBC-8.7 RBC-3.72* Hgb-10.8* Hct-32.6* MCV-88 MCH-28.9 MCHC-33.0 RDW-12.7 Plt Ct-218 [2104-2-19] 11:30AM BLOOD WBC-6.7 RBC-4.32* Hgb-12.9* Hct-37.3* MCV-87 MCH-30.0 MCHC-34.7 RDW-12.7 Plt Ct-195 [2104-2-22] 01:08PM BLOOD Neuts-82.0* Lymphs-14.2* Monos-2.3 Eos-1.2 Baso-0.4 [2104-2-25] 05:55AM BLOOD Plt Ct-218 [2104-2-24] 05:10AM BLOOD PT-13.4 PTT-29.9 INR(PT)-1.1 [2104-2-19] 11:30AM BLOOD Plt Ct-195 [2104-2-19] 11:30AM BLOOD PT-13.3 INR(PT)-1.1 [2104-2-22] 01:08PM BLOOD Fibrino-255 [2104-2-25] 05:55AM BLOOD Glucose-97 UreaN-18 Creat-1.0 Na-135 K-4.3 Cl-99 HCO3-30 AnGap-10 [2104-2-19] 01:05PM BLOOD ALT-22 AST-33 CK(CPK)-172 AlkPhos-61 Amylase-36 TotBili-1.1 [2104-2-25] 05:55AM BLOOD Mg-2.0 [2104-2-20] 03:15AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2 [2104-2-19] 01:05PM BLOOD Albumin-3.7 [2104-2-19] 01:05PM BLOOD VitB12-427 [2104-2-19] 01:05PM BLOOD %HbA1c-6.2* eAG-131* [2-26] CXR HISTORY: CABG. FINDINGS: In comparison with the study of [2-24], there may be a tiny residual left apical pneumothorax. Some increased opacification at the left base with poor definition of the hemidiaphragm and costophrenic angle is consistent with atelectasis and pleural effusion. There may also be a small effusion with minimal atelectasis on the right. Brief Hospital Course: 66 year old male admitted to [Hospital1 1516] service after an ETT showed marked ST segment depressions in the inferolateral leads. He was taken immediately for cardiac catheterization which revealed multivessel disease. He was treated medically at the onset with heparin gtt, Plavix and ASA. He was then evaluated by the Cardiac Surgery and underwent usual pre-operative work-up. His medications were adjusted for afterload and cardiac remodeling reduction with metoprolol, and his statin was increased to a maximum dose. On [2-22] he was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Beta-blockers and diuretics were started and he was gently diuresed towards his pre-op weight. Chest tubes and epicardial pacing wires were removed per protocol. On post-op day two he was transferred to the step-down unit for further care. He continued to progress and was ready for discharge with services on post operative day four. Medications on Admission: Verapamil SR 180 mg q. day Levoxyl 100 mcg q. day Prilosec 20 mg 2 tablets q. day terazosin 2 mg q. day Viagra p.r.n. Ocuvite Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): 75 mg twice a day . Disp:90 Tablet(s) Refills:1 2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every [6-18] hours. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 6. terazosin 2 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:1 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 10 days. Disp:10 Tablet, ER Particles/Crystals(s) Refills:0 9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:20 Tablet(s) Refills:0 11. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:1 Discharge Disposition: Home With Service Facility: [Hospital ] homecare Discharge Diagnosis: Coronary artery disease s/p CABG Hypertension Cardiac syndrome X Hypothyroid Gastroesophageal reflex disease Prostate Cancer Macular degeneration Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol ATC Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace lower extremities bilateral Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [3-20] 1:00pm Cardiologist: Dr [Last Name (STitle) ] on [3-27] at 11:00am (recommended by PCP) Urology Dr [Last Name (STitle) 261] [Telephone/Fax (1) 277] Date/Time:[2104-3-12] 2:15 Wound check [Hospital Ward Name 121] 6 on tuesday [2104-3-5] at 10:30 am with Cardiac Surgery [Telephone/Fax (1) 3071] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 2472] in [4-15] weeks [Telephone/Fax (1) 133] 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:[2104-2-26] ICD9 Codes: 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6304 }	Medical Text: Admission Date: [2179-9-17] Discharge Date: [2179-10-16] Date of Birth: [2102-1-20] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1561] Chief Complaint: Tracheobronchomalacia Major Surgical or Invasive Procedure: 1. Right thoracotomy with posterior membranous wall tracheoplasty with mesh. 2. Bilateral bronchoplasties with mesh. 3. Flexible bronchoscopy-multiple 4. Open tracheostomy tube placement 5. Left thoracotomy with open lung biopsy 6. Percutaneous endoscopic gastrostomy tube placement 7. Foley catheter placement 8. Central line placement 9. Chest tube placement History of Present Illness: Patient was a 77 year-old gentleman who developed dyspnea in high 40s and was diagnosed with asthma years ago becaming progressively worse over the years and much worse in the last several months. He had multiple admissions for COPD exacerbations, bronchitis and pneumonia requiring steroids and antibiotic therapy. He had never been intubated for any of these episodes. He had a terrible intractable cough and inability to clear secretions having to sleep with his head elevated. He has required 2.5 to 3 liters of oxygen continuously over the past 5 months at home. He has required prednisone over the last 8 months and he is dyspneic to the point where he could not walk more than 50 to 100 feet nor could he walk up a flight of stairs. He was eventually diagnosed with tracheobronchomalacia and underwent stringent preoperative evaluation including respiratory questionnaires, 6-minute walk test, functional bronchoscopies, dynamic airway CT scan and a stenting trial. He did well with all these such that it was felt that he would benefit from definitive surgical management; namely, a tracheo- and bilateral bronchoplasties with mesh. Past Medical History: COPD Tracheobronchmalacia Osteoarthritis Diverticulosis Nephrolithiasis MRSA Asbestosis GERD Social History: Former insulation (asbestos) worker minimal smoking history Family History: none Brief Hospital Course: Mr. [Known lastname 4580] was admitted to Dr.[Name (NI) 1816] service on [2179-9-17] at [Hospital1 18]. On that day, he underwent a tracheobronchoplasty. The operation went smoothly, and his initial postoperative course was uneventful. Unfortunately, he developed an ARDS pattern requiring reintubation with progressive ventilatory support. The patient was then taken back to the operating room on [2179-10-7], where a left lung biopsy was performed. The initial pathological examination demonstrated end-stage lung disease with honeycomb change and moderate chronic interstitial inflammation with focal fibroplastic foci favoring end-stage UIP. It was known that the patient had some degree of UIP in his preoperative CT scan, but it was felt that his main respiratory issue limiting his functional status was his tracheobronchomalacia. Unfortunately, it appears that he developed an acute exacerbation of his UIP in the perioperative period. On [2179-10-16], he went into a peculiar arrhythmia of supraventricular tachycardia superimposed on atrial fibrillation with periods of hemodynamic instability. The patient's daughters were immediately contact[Name (NI) ] and informed. The immediate family was then present at the bedside within the hour as was the Attending Surgeon. After discussion with the Nursing staff, House Staff and Attending Surgeon, the family decided to withdraw hemodynamic and ventilatory support and make the patient as comfortable as possible. He succumbed to his underlying condition in the presence of his family on the evening of [2179-10-16]. An autopsy was declined by the family. Medications on Admission: Fexofen Fluticasone Albuterol Ipratropium Guaifenesin Protonix Lopressor 25mg PO BID Diltiazem 60mg PO TID Psyllium Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary Collapse Usual interstitial pneumonia Discharge Condition: Expired ICD9 Codes: 5180, 486, 496, 4280, 5185
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6305 }	Medical Text: Admission Date: [2109-9-24] Discharge Date: [2109-9-27] Date of Birth: [2032-10-9] Sex: M Service: CCU CHIEF COMPLAINT: Fall off ladder. HISTORY OF PRESENT ILLNESS: This is a 76 year old male with a history of atrial fibrillation, benign prostatic hypertrophy, history of left carotid bruit, history of seizure disorder, who was on a ladder the evening of admission and fell. He was noted to be pulseless and to be cyanotic afterwards. He was given Epinephrine/Atropine with heart rate in the 30s to 40s. He had been down for about fifty minutes. He had a history of such episodes as well in the past. The patient then had been intubated and then transferred for further treatment to [Hospital1 190]. Per family, he had a history of falls about twelve years ago and nine years ago, but not recently. PAST MEDICAL HISTORY: 1. History of basal cell carcinoma. 2. Squamous cell carcinoma. 3. History of left carotid bruit. 4. Seizure disorder, [2051], started with episode of spinal meningitis. 5. History of sleep apnea, has been on CPAP. 6. Atrial fibrillation. 7. Cataracts. 8. Contractures. 9. Benign prostatic hypertrophy. 10. History of osteoarthritis. 11. History of aortic and mitral regurgitation. 12. Echocardiogram in [2-23], showed left atrium moderately dilated, right atrium markedly dilated, left ventricular systolic function 60%, 3+ aortic regurgitation, 1 to 2+ mitral regurgitation, 3+ tricuspid regurgitation, mild to moderate pulmonary artery systolic hypertension (37). 13. Stress test in [1-26], nine minute modified [Doctor First Name ] Protocol showed good exercise tolerance, no 2D echocardiogram evidence of inducible ischemia to the achieved workload. ALLERGIES: Levaquin. FAMILY HISTORY: Father with trigeminal neuralgia. Siblings with Parkinson's. No history of coronary artery disease, diabetes mellitus or hypertension otherwise. SOCIAL HISTORY: Active, gardener, walks, one glass per night of wine, no tobacco. PHYSICAL EXAMINATION: Vital signs on admission showed a temperature of 100.1, pulse range of 101 to 115, blood pressure 128/59, respiratory rate 22, oxygen saturation 100% quantitative saturation. Generally, the patient was in no acute distress, intubated. Head, eyes, ears, nose and throat - diffuse contusions on face. Cardiovascular is irregularly irregular. Respiratory clear to auscultation bilaterally. The abdomen is soft, nontender, nondistended. Extremities no edema. Neurologically, intubated, sedated, moved extremities but not to command. LABORATORY DATA: On admission, white blood cell count was 8.5, hematocrit 37.3, platelet count 191,000. Sodium 131, potassium 4.1, chloride 97, bicarbonate 20, blood urea nitrogen 35, creatinine 1.5. The patient had an anion gap of 17, glucose 240, lactate 7.2. INR 2.9, partial thromboplastin time 25.2. Fibrinogen 194, amylase 59, CK 121, CK MB 4.0. Urinalysis was negative. X-ray of the pelvis - The hips are normally aligned without fractures or dislocations. Head CT showed no intracranial bleeding evidence or mass effect. Low density lesions consistent with subacute or chronic infarct. Mild brain atrophy. CT also showed no evidence of fractures or dislocations of cervical spine. Mild wedge compression deformity and possible T2 evaluation of prevertebral soft tissue linked with secondary ETT vacuum phenomenon present of disc C4-C5, C5-C6 and C6-C7. Abdominal pelvic CT showed a small right pleural effusion, bilateral atelectasis, no intra-abdominal problems. Electrocardiogram showed findings consistent with atrial fibrillation. Urine toxicology screen was negative for all except positive for barbiturates. Arterial blood gases while intubated on admission showed pH 7.52, CO2 29, O2 295 and bicarbonate of 24. This was on a tidal volume of 700 and rate of 12. HOSPITAL COURSE: The patient is now status post trauma. Trauma surgery had evaluated the patient and there was no plan on treatment. The patient was transferred to CCU for observation. In terms of his neurological symptoms, etiology of his symptoms that may have led to the fall were unclear, but thought to be possibly secondary to transient ischemic attack/stroke. Neurology was consulted. Head CT as noted above, and he was continued on his Tegretol. For his cardiac issues, given history of atrial fibrillation, he was rate controlled with Vasotec, Metoprolol, and his Coumadin was held given the possibility of the patient going for cardiac catheterization. On [2109-9-25], the patient was continued on his cervical collar and log roll precautions per trauma surgery advice until he was cleared by trauma surgery who is following peripherally. Head CT again showed no bleed, has a T1, T2 fracture, new versus old, unsure but needs examination without sedation to be able to evaluate or a magnetic resonance scan. At this point, we are waiting for trauma team to clear his neck or a magnetic resonance scan which is planned for the day after. Neurology had noted given the patient's past history of transient ischemic attack and falls, this could have been secondary to transient ischemic attack and cerebrovascular accident events. Neurology was consulted and they recommended a magnetic resonance scan and a neural check q1hour. He also has a history of seizures and they recommended to continue his home medications Mebaral and Tegretol and levels pending and a.m. results. Also, they ordered an electroencephalogram once the patient is off the cervical collar and stable. Cardiac was continued as discussed before. His electrocardiogram had shown ST depressions in V4 to V6. He was kept on Aspirin and beta blockers for his cardiac care and we are cycling enzymes while the patient was on our service. There is a question of maybe the patient might go to cardiac catheterization laboratory once INR has decreased. At the time of admission, INR was 2.9. He was being rate controlled with Vasotec and Metoprolol as discussed previously. The morning before the patient had passed away the patient was continued still on the cervical collar and log rolling precautions. Orthopedics had come on board to clear spine and there was a thought that the patient might have had a cerebellar infarct. Per neurology recommendation, the patient was also started on steroids to decrease possible inflammatory processes that could contribute to the patient's symptoms. Cardiac as before with no change. It was thought the patient was going through generalized seizures based on electroencephalogram results. On [2109-9-27], there was no improvement in mental status when evaluated the patient. The patient was started on Dilantin the day before the time of death, but no improvement was noticed in the patient's condition. On [2109-9-27], Dr. [Last Name (STitle) ] had discussed with daughters and wife regarding the patient's prognosis and recovery chances. At that time, the patient's family felt that he would not want to be resuscitated. Also, the family had agreed that no more medical support should be necessary since that could prolong the patient's suffering while in the hospital. At 4:30 p.m. on [2109-9-27], resident physician was called to bedside for the patient being unresponsive. The pupils were fixed, nonreactive, no audible heart sounds were felt, followed one minute, no sounds still, no spontaneous respirations, no response to sternal rub. The family was notified immediately and the attending physician was also notified immediately. Time of death at that point was called at 7:25 p.m. on [2109-9-27]. DR.[Last Name (STitle) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 12-703 Dictated By:[Name8 (MD) 6112] MEDQUIST36 D: [2109-12-6] 11:45 T: [2109-12-9] 18:11 JOB#: [Job Number 95147] ICD9 Codes: 4275, 5185, 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6306 }	Medical Text: Admission Date: [2172-7-19] Discharge Date: [2172-7-30] Date of Birth: [2099-7-1] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: Lethargy and Left sided weakness. Major Surgical or Invasive Procedure: Intubation Left Fem line in ED [7-19] History of Present Illness: 73 yo [Location 7972], Portuguese-speaking male with PMH dilated cardiomyopathy EF 20%, AFIB, s/p epicardial pacer [2172-7-1] for bradycardia/NSVT, chronic renal failure, s/p suprapubic catheter, known fixed inferior defect on [6-21] p-mibi who p/t [Hospital1 18] ED via EMS for 2 days lethargy/MS changes, "hallucinations" per son decreased energy and left sided weakness. This am patient couldn't get out of bed or move his left side so son called EMS. Patient was intubated in ambulance for airway protection and respiratory distress (RR 32). Patient was recently discharged from [Hospital1 18] twice-- last d/ced [7-15] (admitted [2096-7-12]) and on [7-10] ([2091-6-17]). On previous admit, had epicardial pacer placed b/ bradycardic (h/o NSVT) on BB. Did not get pacemaker b/o suprapubic catheter. Also, had acute on chronic RF during admit which improved with IVF (Cr was 4.1 on admit up from baseline in 3s). ACEI d/ced and home on BB. Renal was following. Then, was readmitted [2096-7-12] again for RF (Cr 4.7) thought [1-20] to hypoperfusion and hydralazine started. Was also ruled out for MI. In ED, Cr 5.3, K 6.3 (got kaxeylate), EKG in AFIB rate controlled, and baseline CXR. ECHO in ED revealed HK. Got levoflox 500 iv x 1 for bacteriuria. INR 7- got 10 mg vitamin K SQ. Intubated on vent and sedated on propofol. Seen by cardiology in ED. Admitted to MICU for further evaluation. Past Medical History: 1) Dilated CM, EF 20%, unknown etiology but FE, SPEP wnl 2) NSVT/bradycardia s/p epidural pacer [6-21] 3) Afib/flutter 4) Acute on chronic renal failure- baseline Cr 3s 5) Diarrhea secondary to parasites [6-21] 6) suprapubic catheter x 2 years placed in [Country 3587], elevated PSA- ? prostate CA vs. BPH 7) ? hypothyroidism 8) mild dementia 9) s/p CVAs- evidence old strokes/ischemia on Head CT 10) Positive PPD with neg CXR [2165] Social History: Married lives in [Location 686] with wife, sons. Recently here from [Country 3587]. Portuguese-speaking. Denies etoh, drugs, tobacco. Sniffed tobacco 25 years ago. Family History: F died age 79 from ? CHF M died in 50 s- ? Physical Exam: PE: T 99.4 HR 100 BP 120/80 O2 sat 100% on AC 600 x 12 peep 5 60% fio2 Gtt- propofol Gen- intubated & sedated HEENT- PEERL about 2 mm, anicteric, porr dentition, ETT & OGT in place NECK- supple, no LAD, no JVD, no bruits b/l CV- irreg irreg, distant, steristrips/sutures on chest- left upper and lower chest CHEST- coarse BS diffusely anteriorly ABD- NABS, soft, NT/ND, no HSM, suprapubic catheter in place EXT- [12-20]+ LE edema (L slightly > R), cannot palpate distal pulses b/l Pertinent Results: [2172-7-19] 10:00AM GLUCOSE-127* UREA N-117* CREAT-5.3* SODIUM-139 POTASSIUM-6.3* CHLORIDE-103 TOTAL CO2-22 ANION GAP-20 [2172-7-19] 10:00AM CALCIUM-8.1* PHOSPHATE-6.3* MAGNESIUM-2.7* [2172-7-19] 10:00AM WBC-8.1# RBC-3.08* HGB-10.1* HCT-31.6* MCV-102* MCH-32.7* MCHC-31.9 RDW-18.2* [2172-7-19] 10:00AM NEUTS-79.5* LYMPHS-14.4* MONOS-5.6 EOS-0.2 BASOS-0.2 [2172-7-19] 10:00AM PLT COUNT-267 [2172-7-19] 10:00AM PT-32.1* PTT-40.2* INR(PT)-6.8 [2172-7-19] 10:00AM D-DIMER-4178* [2172-7-19] 09:22AM TYPE-ART PO2-343* PCO2-44 PH-7.26* TOTAL CO2-21 BASE XS--6 [2172-7-19] 09:09AM CK(CPK)-823* [2172-7-19] 09:09AM CK-MB-8 cTropnT-0.03* [2172-7-19] 10:00AM CK(CPK)-178* [2172-7-19] 10:00AM CK-MB-6 cTropnT-0.04* [2172-7-19] 11:17AM LACTATE-2.5* [2172-7-19] 09:09AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-MOD [2172-7-19] 09:09AM URINE RBC-0-2 WBC-[11-7]* BACTERIA-MANY YEAST-NONE EPI-0 [2172-7-19] 09:09AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.019 [2172-7-28] 06:35AM BLOOD WBC-5.0 RBC-3.41* Hgb-10.7* Hct-36.4* MCV-107* MCH-31.6 MCHC-29.5* RDW-17.8* Plt Ct-163 [2172-7-28] 06:35AM BLOOD PT-17.5* PTT-34.0 INR(PT)-1.9 [2172-7-28] 06:35AM BLOOD Glucose-88 UreaN-46* Creat-2.6* Na-144 K-4.9 Cl-112* HCO3-21* AnGap-16 [2172-7-28] 06:35AM BLOOD ALT-69* AST-88* TotBili-1.8* URINE CULTURE (Final [2172-7-26]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. 2ND ISOLATE. <10,000 organisms/ml. Brief Hospital Course: Patient was stabilized in the unit, his mental status change and Left sided weakness resolved. His creatinine came back to baseline while still in the unit. Patient was extubated and [Month/Day/Year ] transferred to the medical floor on hospital day 5. 1. Cardiac. BP was 130-150/80-90 and HR of 70-90 during his most of his hospital stay. Patient was on hydralazine, ISMN, Metoprolol, Dig, Spironolactone and Furosemide for management of his systolic dysfunction and mitral regurgitation. Patient was not placed on ACEinh and was d/c'd from Spironolactone at the end of his hospital stay given multiple recent presentations, including this admission, with hyperkalemia and ARF. At end of the hospital stay, blood pressure decreased to the 110-130/70-80 (goal 110-120/60-70). Also started on a statin. At time of discharge, pt was breathing comfortably, no JVD, no LE edema, and lungs CTA. 2. Acute on chronic RF. ARF is prerenal secondary to decrease PO. Patient was gently rehydrated and by d/c day, his Cr was 2.8 (baseline [2-20]). 3. Hyperkalemia- got kaxeylate x 1 and his K dropped. While asynmptomatic, his potassium rose to 5.3 on spironolactone. It was therefore discontinued. 4. Mental status change and left side weakness- Possible new right water-shed infarct. Back to baseline. Able to ambulate with walker & PT assistance. 5. transaminitis up to 200-300s thought to be from hepatic congestion from CHF. Resolved with optimizing his hemodynamics. Medications on Admission: 1. asa 325 qd 2. lipitor 40 qd 3. metoprolol 150 [Hospital1 ] 4. coumadin 2.5 qhs 5. hydralazine 25 tid Discharge Medications: 1. Trazodone HCl 25 mg PO HS PRN. 2. Digoxin 125 mcg Tablet PO QD. 3. Warfarin Sodium 5 mg Tablet PO HS. 4. Aspirin 81 mg PO QD. 5. Hydralazine HCl 100 mg PO TID. 6. Isosorbide Mononitrate Extended Release 60 mg PO QD. 7. Atenolol 150 mg PO QD. 8. Furosemide 40 mg PO Qod. Please give first dose on [2172-8-1]. Please hold off if patient is dehydrated. 9. Atorvastatin 40 mg PO QD. Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: 1. Acute on chronic renal failure. 2. New right water-shed cerebrovascular infarction. 3. congestive heart failure Discharge Condition: No CP/SOB/DOE, ambulating with walker & PT assistance. Discharge Instructions: You will be going today to an acute rehab for further monitoring and for some physical therapy treatment. It is important that you stay on your current medicine regiment. You need to follow up with your PCP (Dr. [Last Name (STitle) ]. You are scheduled to see Dr. [Last Name (STitle) ] on [8-15]. I have updated Dr. [Last Name (STitle) ] with your hospital stay. You need to follow up with at the CHF (cardiology clinic) on [8-17]. You also need to follow up in [Month (only) ] at the [Month (only) ] clinic for your suprapubic catheter. In the meantime, it is important that you return to the emergency department you develop any weakness, decrease energy level, chest pain, shortness of breath, fever, or any other concerns. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] ICD9 Codes: 5849, 4254, 4271, 4280, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6307 }	Medical Text: Admission Date: [2171-10-19] Discharge Date: [2171-10-20] Date of Birth: [2145-4-23] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 3984] Chief Complaint: Intoxication / Intubated Major Surgical or Invasive Procedure: Intubation, successful extubation [2171-10-19] History of Present Illness: Per report, patient is a 26 yo M who was drinking EtOH and ?other drug use. He reported possible head trauma over the course the night with an altercation with 5 other men and lead pipe to his head. While in the ED, he became agitated and was threatening staff, prompting use of Haldol 5mg IM to for his personal safety. He then had his RR drop to < 8, and became hypoxic. Given this, he was intubated wtin the ED with Propofol. He then had CT Head which revealed no acute intracranial abnormality. He also had a soft tissue density in posterior [Last Name (un) ]/oropharynx may be related to intubation. Other tox screens negative. No vomiting while in the ED. Alcohol level 269. Upon transfer, VS 91 148/74 12 100% AC 40% Fi02 TV 560 PEEP 5. Past Medical History: Depression PTSD Social History: (Unable to obtain, no OMR, patient intubated) Family History: (Unable to obtain, no OMR, patient intubated) Physical Exam: VITAL SIGNS 97.1, 88, 150/83, 12, 100% on CMV Gen: Sedated HEENT: Symmetric, PERRL, pinpoint at 2mm, 3 slight excoriations L cheek CV: RRR without m/g/r Resp: CTAB without w/r/r ABD: Flat, active bowel tones, no masses Ext: WWP, 2+ pulses DP b/l, no edema Neuro: sedated on Fentanyl/Midazolam Pertinent Results: [2171-10-19] 04:35AM BLOOD WBC-7.0 RBC-5.24 Hgb-16.4 Hct-44.9 MCV-86 MCH-31.2 MCHC-36.5* RDW-12.9 Plt Ct-238 [2171-10-20] 04:08AM BLOOD WBC-11.7# RBC-4.61 Hgb-14.5 Hct-40.2 MCV-87 MCH-31.5 MCHC-36.1 RDW-12.9 Plt Ct-208 [2171-10-20] 04:08AM BLOOD Glucose-101 UreaN-16 Creat-0.9 Na-139 K-3.8 Cl-103 HCO3-28 AnGap-12 [2171-10-19] 04:35AM BLOOD ASA-NEG Ethanol-269* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2171-10-20] 04:08AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1 IMAGING CT HEAD IMPRESSION: No acute intracranial abnormality. CT C SPINE IMPRESSION: 1. No evidence of acute traumatic injury of the cervical spine. Please note that CT does not provide spinal cord detail comparable to MRI. 2. Opacification of the nasal cavity, and visualized oropharynx with tissue attenuation material, likely related to intubation. CXR: SUPINE PORTABLE VIEW OF THE CHEST: The endotracheal tube has been advanced, with the tip now located at the superior border of the clavicular heads, 5.2 cm above the carina. The lungs remain clear. Cardiac size and pulmonary vasculature remain normal. IMPRESSION: Endotracheal tube now at the superior border of the clavicular heads, 5.2 cm above the carina. Brief Hospital Course: 26 yo M, presenting to the ED with intoxication, who became increasingly agitated prompting Haldol use, which caused respiratory distress prompting intubation. # Respiratory failure: Likely [1-26] to Haldol effect in combination with EtOH. No intracranial pathology on CT. CXR without abnormalitiy. EtOH level 269 on admission. Initially on Fenatnyl and Versed for sedtaion, changed to Propofol to prompt quick wean and was extubated successfully [10-19]. # EtOH intoxication: EtOH level 269 at 0430 [10-19], likely sober by 1030. No known history of withdrawal in the past. Remained intubated until [10-19]. Maintained on CIWA but did not require. treated with Thimaine and folate. # S/p Assault: CT head / neck clear. C spine cleared. # Depression: On Buproprion. Consider psychiatry follow up. Medications on Admission: ? Bupropion per OMR Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever > 101. 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Should continue Bupropion if was previously taking Discharge Disposition: Home Discharge Diagnosis: Primary: Alcohol intoxication, respiratory failure Secondary: Depression, PTSD Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were evaluated in the ED after calling 911. There was concern you had been assaulted and you were also intoxicated. Imaging revealed no evidence of fracture or bleeding in your head. You were given medication for you personal safety. This medication caused your breathing to slow down, and you were intubated to protect your airway. Once improved, the breathing tube was removed. You were monitored for further signs of withdrawal but none were seen. Once improved, you were discharged home. Keep all outpatient appointments and take all medications as prescribed. Return to your alcohol treatment program and resume your sobriety. Seek medical advice if you develop severe headache, difficulty walking, breathing, chest pain, fever or any other symptom which is concerning to you. Followup Instructions: Please follow-up with your regular VA provider [Last Name (NamePattern4) ] [12-26] weeks to discuss your hospitalization and your ongoing treatment for alcohol dependence. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] ICD9 Codes: 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6308 }	Medical Text: Admission Date: [2182-8-14] Discharge Date: [2182-9-5] Date of Birth: [2106-2-27] Sex: M Service: ICU HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old man with COPD, hypertension, who has been complaining of shortness of breath for several days prior to admission. The patient presented to the [Hospital 191] Clinic where he was found to be tachypneic and wheezing. He was referred to the ED where he was found to have profound respiratory distress to the point he was unable to speak in full sentences. He also had the complaint of a productive cough consisting of clear sputum. The patient was also having significant wheezing. He had no chest pain, no fever, no chills. In the Emergency Department, he was placed on continuous Albuterol nebulizers and initial vitals revealed a blood pressure of 210/120, heart rate in the 140s, respiratory rate of 38, and saturation of 92%. EKGs showed new atrial fibrillation. The patient was given Diltiazem 20 mg IV with heart rate decreasing down to 90. The patient was placed on BIPAP for about two hours which was then removed and the patient was noted to have nonlabored breathing. His saturations were 94 on 4 liters of nasal cannula. His x-ray at that point revealed pulmonary edema and he was given 40 mg of IV Lasix. Several hours later, the patient was noted to be agitated and received 4 mg of Ativan and a half an hour later was found to be more agitated and was, therefore, intubated for agitation. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of upper GI bleed from esophagitis. 3. Barrett's esophagus. 4. Osteopenia. 5. Hyponatremia secondary to SIADH. 6. History of alcohol abuse about 25 years ago. 7. Carotid stenosis. 8. COPD with pulmonary function tests revealing an FVC of 53%, FEV1 57, preserved ratio, and decreased DLCO. ADMISSION MEDICATIONS: 1. Albuterol. 2. Amlodipine 5 mg b.i.d. 3. Labetalol 200 mg p.o. b.i.d. 4. Protonix 40 p.o. q.d. 5. Lisinopril 20 mg p.o. q.d. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: He is a smoker with 70 pack years, quit about ten years ago. Alcohol: Past heavy use, quit 25 years ago. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 99, blood pressure 106/40, pulse 95, respiratory rate 18, saturating 99% on a ventilator. General: The patient was an intubated gentleman, sedated. HEENT: The mucous membranes were moist. The neck was supple, unable to assess JVD. Cardiovascular: Irregular, S1, S2 with no murmurs. Lungs: Rhonchi in the upper lung zones bilaterally with coarse breath sounds. There were no wheezes or crackles. Abdomen: Soft, nontender, nondistended with hyperactive bowel sounds. Extremities: There was 1+ pitting edema. LABORATORY/RADIOLOGIC DATA: The initial laboratories showed a white count of 10, hematocrit 35, platelets 380,000. Sodium 122, potassium 4.7, chloride 87, bicarbonate 23, BUN 11, creatinine 0.7. HOSPITAL COURSE: 1. RESPIRATORY FAILURE: The patient's initial presentation was somewhat unclear. [Name2 (NI) ] was treated initially for a COPD flare with a combination of tachycardia, hypertension; findings of pulmonary edema on x-ray suggest most likely that he had flash pulmonary edema to explain his hypoxia. Our approach, therefore, was more tailored to relieving pulmonary congestion. This was unfortunately extremely difficult as during the first several days the patient was profoundly hypotensive. He received more fluids in the context of the hypotension as well as the concern that this might be sepsis which led to worsening of his volume overload. He was initially somewhat difficult to oxygenate requiring high B pressures to maintain good 02 saturations. He then remained relatively stable for about ten days and about the middle of the second week developed a fever, a white count, and productive sputum. The sputum grew Enterobacter cloacae. He was, therefore, now believed to have a ventilator associated pneumonia. He was treated for this with levofloxacin and gentamicin. After about three weeks, with improvement in his cardiovascular function and decrease of total body overload, the patient was able to do well on pressure support ventilation and was eventually extubated. He is currently requiring face mask with saturation between 90-92. Of note, given the patient's COPD and chronic C02 retention, he will require 02 saturations in 88-92%. 2. CARDIOVASCULAR: The patient initially presented in atrial fibrillation. This is apparently a new diagnosis for him as he has no history of that. He was placed on IV heparin and multiple attempts to slow down his heart rate were unsuccessful. He was placed on Esmolol and Diltiazem drip and the combination of these were only able to maintain the heart rate at about 150. A consultation with EP was obtained. The patient underwent a TEE as well as DC cardioversion with no success. His medical regimen was eventually maximized to a beta blocker, a calcium channel blocker and Amiodarone which led to a decent control of the heart rate between 90 and 100. Two echocardiograms, one transthoracic and one transesophageal, both revealed normal left ventricular function, thus making the diagnosis of diastolic dysfunction much more likely. His left atrium at 6 cm is enlarged and probably is the explanation of his continuing atrial fibrillation. There is no evidence of significant valvular disease on echocardiogram as well as no evidence for any abnormal wall motions. It is, therefore, most likely that he has diastolic dysfunction which with improvement in heart rate and diuresis led to improvement in his clinical status. 3. INFECTIOUS DISEASE: As mentioned previously, the patient had Enterobacter ventilator-associated pneumonia. Secondary to this, he also developed Enterobacter sepsis with hypotension requiring frequent amounts of IV boluses as well as pressors. He, however, recovered without significant consequences of his sepsis. 4. NEUROLOGICAL: During week number two, the patient was noted to have jerking myoclonal motions in his right arm and right leg as well as decreased movements in his left arm and left leg. Consultation with Neurology was obtained. Of note, the patient has been on Dilantin for ten years and this was discontinued in [2177] for unknown reasons. The neurologist's opinion was that the patient might be seizing as the antibiotics and the stress of the admission may have lowered his seizure threshold. The patient was started on Dilantin and he soon dramatically improved. His jerking monoclonal movements resolved and he had symmetric movements in both extremities. He did, however, still have some weakness on the left side that his daughter attributes to a tremor in the past. He will probably require an MRI to evaluate for the possibility of central nervous system lesion which may be contributing to his left-sided weakness. 5. NUTRITION: The patient was receiving tube feeds and tolerated this very well. 6. ENDOCRINE: On initial admission, the patient's Cortisol was found to be low in the context of what was believed to be hypotension of sepsis. He was, therefore, presumably diagnosed with adrenal failure and was started on Hydrocort. This is currently being weaned as he has been on this medication for about three weeks. CONDITION ON DISCHARGE: Currently, the patient is sitting in a chair, although was quite deconditioned, able to talk in short sentences. He was not complaining of shortness of breath. DISPOSITION: He was discharged to a regular medical floor. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease. 2. Congestive heart failure with diastolic dysfunction. 3. Hypoxic respiratory failure requiring intubation. 4. Ventilator-associated pneumonia. 5. Enterobacter sepsis. 6. Adrenal insufficiency. 7. Possible seizure disorder. 8. Atrial fibrillation. [Name6 (MD) ] [Last Name (NamePattern4) 5837], M.D. [MD Number(1) 8285] Dictated By:[Name8 (MD) 5094] MEDQUIST36 D: [2182-9-5] 02:09 T: [2182-9-5] 16:29 JOB#: [Job Number 29208] ICD9 Codes: 4280, 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6309 }	Medical Text: Admission Date: [2159-1-31] Discharge Date: [2159-2-10] Date of Birth: [2108-11-3] Sex: M Service: SURGERY Allergies: Bactrim / Aspirin Attending:[First Name3 (LF) 5569] Chief Complaint: Central venous occlusion right SVC and Right IJ Major Surgical or Invasive Procedure: [2159-2-1]: Right femoral temporary dialysis line placed [2159-2-8]: Right femoral tunneled dialysis line placed History of Present Illness: 50M with HIV, ESRD s/p failed renal transplant , who has had numerous access problems in the past including a history of SVC syndrome on the left side requiring ligation of left access. Pt now presents with likely central venous thrombus of the right side extending into the subclavian, brachiocephalic, SVC and bilateral IJs. Patient was diagnosed with new central clot today during attempted thrombectomy of his right AVG. He has a known stent in Right brachiocephalic and has had repeat thrombectomy and angioplasty of his current graft. Patient was amidst thrombectomy when patient acutely became SOB with O2 saturations in the high 80s. Per report patient was given heparin 3000, 1gr ancef, 2mg versed and 100mcg Fentanyl" during the thrombectomy. The procedure was terminated. He was urgently transferred by EMS to [Hospital1 18] on a non-rebreather with O2 sats registering 92%. He improved over the next 1/2 hour, and is now off oxygen 100% on ra. Pt denies symptoms of hand swelling, arm pain, sob or facial swelling prior to today's procedure. He was last dialyzed [Name (NI) 766] unclear if full run. He does not void. He refuses to answer further questions throughout the interview limiting history. He is now off o2 with O2 sat of 100% on ra, but still subjectively feels SOB. Initial triage vitals: 98.4 80 80/60 20 92% (unk if nonrebreather or ra) Past Medical History: 1. HIV diagnosed in [2139] 2. End-stage renal disease status post ECD transplantation on [2156-5-21], episode of acute rejection which was aggressively treated, currently has nephrotic syndrome, biopsy showed collapsing GN 3. History of disseminated TB in [2140] with right peritonitis 4. History of pyelonephritis 5. Hypertension 6. Osteoarthritis 7. Status post gunshot wound to the abdomen (per records; patient denies) 8. History of depression 9. SVC syndrome requiring stent placement, status post occlusion of the left innominate vein stent, status post angioplasty of the left arm fistula, status post ligation of the left arm fistula, [11/2156] 10. Upper GI bleed with duodenal ulcers 11. Recent lower GI bleed from the internal hemorrhoids 12. Circumcision for HPV penile lesions - followed by [Hospital ] clinic Social History: Lives alone in an apartment in JP. Married, wife lives in area with 2 sons- aged 10 and 17-who are HIV negative. Denies ETOH, IVDU but smokes marajuana daily. Has a past smoking history but states he quit ~ 2 years ago. Disabled on SSDI since [2140]. Came to the US in [2124], first having lived in [State 531] and since in [Location (un) 86]. His wife also has HIV. Family History: Non-contributory. Both parents are deceased. Patient is unable to contibute any information about his FH. Physical Exam: 86 143/106 17 100%NonRb GEN: NAD, A&o X 3 Speaking without difficulty. CVS: RRR no m/r/g Pulm: Clear anteriorly HEENT: prominent veins right UE, Shoulder, chest, and right IJ engorged. Swelling of Left parotid area and inferior portion of face. ABD: Well healed kidney transplant scar, Midline incision . No hernias, soft, NT, ND. Deferred rectal per patient EXT: 2+ pulses bilaterally, graft RUE without thrill/bruit. Pertinent Results: LABS: 12.6 7.2>-----< 178 39.0 N:76.1 L:19.1 M:3.3 E:1.1 Bas:0.4 PT: 12.8 PTT: 47.1 INR: 1.1 Fibrinogen: 268 134 91 35 -------------<88 5.4 26 7.6 Brief Hospital Course: Mr [Known lastname 10133] was admitted to the Transplant Surgery service directly from AV Care. On [2159-1-31], HD1, he underwent angiogram which showed significant thromboses and stenoses of central and peripheral upper extremity veins. See Dr[Name (NI) 10136] report for further details. A TPA infusion catheter was left in place with continuous TPA running overnight while he was monitored in the surgical ICU. The following day, HD2, he underwent balloon angioplasty and further thrombolysis, again with Dr [Last Name (STitle) ]. His RUE graft could not be fully opened, so a temporary hemodialysis line was placed in his right groin to facilitate HD. He was monitored closely in the SICU with serial cardiac enzymes sent which remained unchanged during hospitalization. He was begun on a heparin drip to attempt chemical thrombolysis of his extensive clots. On [2159-2-4], HD5, he was transferred from the SICU to the floor. He remained afebrile with stable vital signs and underwent HD per his home schedule. He was maintained on his home tacrolimus dose of 2mg/2mg, with levels ranging from 2.9 and <2.0. His hematocrit was stable at 25.0 after leaving the SICU; he was transfused 2u PRBC with dialysis on [2159-2-9]. His blood pressure remained mildly elevated so he was begun on metoprolol while in house and instructed to continue with Toprol once returning home. On [2159-2-8], HD9, he returned to interventional radiology for another attempt at thrombolysis of RUE AVG. This was again unsuccessful, so his temporary right femoral HD line was exchanged for a tunneled HD line. He tolerated this procedure well and underwent dialysis the following day. Following dialysis on the evening of the 25th (during which he received 2u PRBC), he was fatigued so was kept overnight for observation. On the day of discharge, he was tolerating a regular diet, ambulating without assistance, and in good understanding of his condition and plan of care. His previously established home RN was contact[Name (NI) ] prior to discharge and was in agreement with the discharge plan. Medications on Admission: Dapsone 100 mg Tab Epivir HBV 100 mg Tab Remeron 15 mg Tabq hs Aldara 5 % Topical Packet three times per week use after showering Plavix 75 mg Tab Sustiva 600 mg Tab Ziagen 600 mg Tab Pantoprazole 40 mg Tab, Delayed Release Prograf 2 mg Cap" Crestor 5 mg Tab Sensipar 90 mg Tab Renvela 1600 mg Tab'" Prednisone 5 mg Tab Zolpidem 10 mg Tabqhs Docusate Sodium 100 mg Cap" Oxycodone 5 mg Cap [12-17] Capsule(s) by mouth q4-6 hr Zidovudine 300 mg Tab qpm Nephrocaps 1 mg Cap daily Discharge Medications: 1. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. imiquimod 5 % Cream in Packet Sig: One (1) Topical 3x per week: three times per week use after showering. 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 10. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 16. zidovudine 100 mg Capsule Sig: Three (3) Capsule PO QPM (once a day (in the evening)). 17. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 18. oxazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 19. oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 20. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: ESRD s/p failed renal transplant [5-23] currently on HD Thrombosed RUE AVG Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] for fever, chills, increased right arm or leg pain, swelling or redness. Report nausea, vomiting, diarrhea, inability to take or keep down medications, food or fluids. Report any swelling in legs, face or abdomen. Followup Instructions: LM [Hospital Unit Name ], [Location (un) ], Transplant Medicine [2159-2-27] 11:00a DR [Last Name (STitle) ] [2159-2-27] 10:20a DR [Last Name (STitle) 970] ICD9 Codes: 5856, 4241, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6310 }	Medical Text: [ ] Date: [2117-1-2] Discharge Date: [2117-1-5] Date of Birth: [2080-3-21] Sex: M Service: MEDICINE Allergies: Aspirin / Penicillins Attending:[First Name3 (LF) 5810] Chief Complaint: weakness and vomiting Major Surgical or Invasive Procedure: Arterial line placement and removal History of Present Illness: Mr. [Known lastname 44129] is a 36 year old gentleman with no PMH presenting to the ED with weakness and vomiting. For the last week, he has felt worn out and runs out of energy by the end of the day. He also noted polydipsia and polyuria as well as nocturia. The day prior to [Known lastname ], he developed nausea and had 3 episodes of non-bloody, non-bilious vomiting. He came to the ED because he felt he could not keep his food down. . In the ED, vitals were: 98.1 100 155/73 24 100% RA. On initial labs, he had a blood sugar of 396 and a bicarbonate of 7. He was given 2-3 liters of fluid, antiemetics, 10 unit regular insulin bolus and was started on an insulin gtt. ABG done 7.15/11/33. He had symptomatic improvement with the interventions and was admitted to the [Hospital Unit Name 153] for insulin gtt. . On ROS, he denies fevers or chills. No chest pain, vision changes or blurry vision, no cough or sore throat, no abdominal pain or diarrhea. No dysuria. He had some burning in his epigastric area when he first came to the ED, which he attributes to the recent vomiting. He also has a light headache. Past Medical History: s/p laparoscopic cholecystectomy Social History: Lives in [Location 2312] with his girlfriend and their 3yo child. He also had a child who is 18 years old. Has worked as Director for Environmental Services and used to work for [Hospital1 ]. Has been unemployed and had job offer just as his symptoms started. No tobacco, alcohol, or illicits. Family History: Mother has DM, which he thinks she developed in her late 30s. He thinks his father may have DM but he is not sure. Mother also has HTN and hyperlipidemia. Physical Exam: 98.2 154/73 122 15 98% RA Very pleasant, mildly overweight gentleman in no distress, sitting up on edge of bed. EOMI, PERRL, no scleral icterus. Mucous membranes are dry. OP is clear. Neck is supple. No thyroid enlargement or nodule. S1, S2, regular tachycardia, no murmurs or gallops. Lungs are clear b/l without crackles or wheezes. Abd: BS present. Soft, NT, ND. No [Doctor Last Name 515] sign. No hepatomegaly. Alert and oriented with normal speech. Strength 5/5 in UE and LE b/l both proximal and distal. Coordination is intact with F to N b/l. No LE edema. His extremities are warm and well perfused. He is appropriately anxious about his new diagnosis and ICU [Doctor Last Name ]. Pertinent Results: IMAGING: . KUB [2117-1-2]: The lung bases are excluded from the exam. Stool is present throughout the colon, extending to the rectum. No loops of dilated small bowel are seen, although the small bowel is relatively gasless. The stomach is not distended. Cholecystectomy clips are noted in the right upper quadrant. IMPRESSION: Non-obstructive bowel gas pattern. . CXR [2117-1-2]: Lung volumes are low, resulting in vascular crowding. However, there is no consolidation or pleural effusion. There is no pneumothorax. The heart size is normal. There is no hilar or mediastinal enlargement. Pulmonary vascularity is normal. Cholecystectomy clips are noted in the right upper quadrant. There is no free intraperitoneal air. Linear opacities seen on the lateral view are artifactual. IMPRESSION: Low lung volumes, but no acute cardiopulmonary abnormality. . LABS AT [Month/Day/Year ]: [2117-1-2] GLUCOSE-155* UREA N-7 CREAT-0.7 SODIUM-137 POTASSIUM-3.1* CHLORIDE-113* TOTAL CO2-17* ANION GAP-10 CALCIUM-8.0* PHOSPHATE-1.2* MAGNESIUM-2.1 TYPE-ART PO2-95 PCO2-26* PH-7.32* TOTAL CO2-14* BASE XS--10 ALT(SGPT)-22 AST(SGOT)-11 ALK PHOS-76 AMYLASE-53 TOT BILI-0.3 LIPASE-101* ALBUMIN-3.7 URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.025 BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE->1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 URINE HYALINE-8* WBC-10.6 RBC-6.08 HGB-17.5 HCT-51.1 MCV-84 MCH-28.7 MCHC-34.2 RDW-14.6 NEUTS-80.4* LYMPHS-16.3* MONOS-2.7 EOS-0.1 BASOS-0.5 PLT COUNT-268 LABS AT DISCHARGE: [2117-1-5] COMPLETE BLOOD COUNT White Blood Cells 6.7 K/uL 4.0 - 11.0 Red Blood Cells 5.14 m/uL 4.6 - 6.2 Hemoglobin 14.4 g/dL 14.0 - 18.0 Hematocrit 42.4 % 40 - 52 MCV 83 fL 82 - 98 MCH 28.0 pg 27 - 32 MCHC 34.0 % 31 - 35 RDW 14.5 % 10.5 - 15.5 BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 248 K/uL 150 - 440 Glucose 175* mg/dL Urea Nitrogen 5* mg/dL Creatinine 0.6 mg/dL Sodium 143 mEq/L Potassium 4.0 mEq/L Chloride 105 mEq/L Bicarbonate 26 mEq/L Anion Gap 16 mEq/L Calcium, Total 9.6 mg/dL Phosphate 4.2 mg/dL Magnesium 2.2 mg/dL Cholesterol, Total 261* mg/dL Triglycerides 345* mg/dL Cholesterol, HDL 31 mg/dL Cholesterol Ratio (Total/HDL) 8.4 Ratio Cholesterol, LDL, Calculated 161* mg/dL 0 - 129 % Hemoglobin A1c 12.8* % Brief Hospital Course: Mr. [Known lastname 44129] is a 36 year old gentleman with no past medical history who presented with weakness and vomiting from DKA in the setting of newly diagnosed diabetes, which is thought to be Type I, as he presented with diabetic ketoacidosis. He presented with profound acidosis with a AG of 28 on initial labs, which resolved with IV fluids and insulin drip. [Last Name (un) ] was consulted and felt that the patient was most likely to be a type 1 diabetic, however he also has significant insulin resistance which would argue for Type II or a combination of both. The patient was monitored with hourly finger sticks and periodic electrolyte repletion. He was transitioned from an insulin drip to subcutaneous insulin on [1-3]. Nutrition was consulted for diabetic education and he had teaching regarding blood glucose monitoring and Insulin injections. He was transferred to the floor on [1-5] and treated with lantus in the evening (45 units), changed at the time of discharge to 50 units and sliding scale insulin with meals, (sliding scale explained and given to patient). His Hba1c was 12.8%. He also was found to have hyperlipidemia (tchol 261) and hypertriglyceridemia (345) on labs, suspect this is related in part to poorly controlled DM. He was educated by the nurses and doctors during his [Name5 (PTitle) ] regarding his new diagnosis. He will need ongoing education and management as an outpt by pcp and DM specialist. He is being discharged with [Last Name (un) ] follow up appointment on [2117-1-6] as well as new PCP [Name Initial (PRE) 648] (see below). He received a Glucometer for blood sugar monitoring. Medications on [Name Initial (PRE) ]: No medications, no OTCs or herbals Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. Disp:1 vial Refills:2 2. Insulin Syringe-Needle U-100 1 mL 31 x [6-6] Syringe Sig: One (1) needle Miscellaneous four times a day. Disp:120 [Last Name (un) 83721] Refills:2 3. Humalog 100 unit/mL Solution Sig: 1-50 units Subcutaneous four times a day: per sliding scale. Disp:1 vial Refills:2 Discharge Disposition: Home Discharge Diagnosis: new diagnosis of uncontrolled Diabetes mellitus type 1 Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted with new diagnosis of diabetes mellitus. You are being discharged on Insulin. You have been given a glucometer. You will need to measure your blood glucose as instructed. You have an appointment with [Hospital ] clinic. We have made a new primary care docotor appointment for you. Please follow up as instructed. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 32920] at [Hospital ] clinic at 2 pm on [2117-1-6], and the nurse educator at 3 pm the same day. Appointment #2 MD: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 10564] Specialty: Primary Care Date/ Time: Wednesday, [1-20] at 12 noon Location: [Last Name (un) 6424], [Location (un) 86], [Numeric Identifier 6425] Phone number: [Telephone/Fax (1) 798] Special instructions for patient: This appt will be a new patient physical and to go over your inpatient stay. Please arrive 20 mins early to your appt to fill out new pt paperwork.and bring any free care insurance info you have with you. ICD9 Codes: 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6311 }	Medical Text: Admission Date: [2120-7-29] Discharge Date: [2120-8-1] Date of Birth: [2064-7-18] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 11344] Chief Complaint: Status Epilepticus Major Surgical or Invasive Procedure: Endotracheal Intubation with successful extubation History of Present Illness: Mr. [Known lastname 37559] is a 56-year-old right-handed man with history of seizure disorder, hypertension and depression who was transferred from an outside hospital, intubated for multiple seizures. At 5 a.m. yesterday, on [7-28], the patient woke up and felt that he might have a seizure soon because he had the urge to defecate, which often coincides with seizures. Because he felt that he was going to have a seizure, the patient took an extra 500 mg of Depakote. Usually, he takes 500 mg 3 times per day, but that morning, he took 1000 mg and he went back to sleep. At 7:30 in the morning, he woke up again. He was not feeling well. He felt confused and somewhat disoriented. He felt the urge to defecate again and went to the bathroom. His wife said that he was grabbing at the toilet paper, but seemed "out of it." At that time, his wife gave him another 500 mg of Depakote. So, by 7:30 in the morning, he had taken 1500 mg of Depakote. At 8:15, Mr. [Known lastname 37559] had a seizure, which lasted about 20 seconds. His wife states that his upper and lower extremities were both rigid without any shaking. He did not bite his tongue or have urinary incontinence. After the seizure ended, he was confused for about 1-2 minutes. His wife also notes that prior to the seizure, he made a yelping sound, which is typical before a seizure for him. The patient then returned to his baseline. At about 9 o'clock, he had another seizure. Again, his upper and lower extremities were rigid without any jerks. The second seizure lasted about 30 seconds and he was confused for 5 minutes. Again, no tongue biting, no urinary incontinence. He then slept for about 4 hours. At 1 in the afternoon, he woke up and had another seizure, same as the prior two. This one lasted about 1-1/2 minutes. He did bite his tongue and had urinary incontinence. His wife called 911. By the time, EMS arrived, the seizure had terminated on irs own. He was confused for the next 30 minutes or so. In the ambulance, the patient had a generalized tonic-clonic seizure. At that time, he was given 5 mg of IV valium. When he arrived at [Hospital 8125] Hospital ED, he was agitated and combative, so he was given another 5 mg of IV valium. Per outside hospital documentation, this patient is reported to often be combative and agitated when he is post ictal. They attempted to obtain a non-contrast head CT. However, he was too agitated for it. He was given another 5 mg of IV valium but continued to be combative. At that time, he was intubated for airway protection and given another 10 mg of IV valium. He was also given 4 mg of IV Ativan, 1000 mg of fosphenytoin, 2 g of ceftriaxone and then was maintained on propofol for sedation. His valproic acid level at [Hospital 8125] Hospital was 97. He was transferred to [Hospital1 ] for further evaluation. In the ambulance ride on the way over, they ran out of propofol, so he was given 4 mg of midazolam. In the ED here, he was minimally responsive even off propofol, so no attempt was made at extubation, and he was admitted to the neurologic ICU. In the ED, he had a T-max of 101.6, which came down with Tylenol. Overnight, there was concern for an infectious process. He had an LP which showed 4 white cells and 3 RBCs. Prior to results of CSF coming back, he was empirically started on meningitis dosing of ceftriaxone 2 g, vancomycin and acyclovir for HSV. He had a chest x-ray, which did not show pneumonia and he had a UA which was negative for UTI. This morning, propofol was turned off for about 10-15 minutes and the patient woke up. He was quite agitated; however, he was alert, awake and following commands. The patient's wife [Name (NI) ] was present today to provide more history. She said that Mr. [Known lastname 37559] has had cold and has been feeling unwell for the last week or so and on Saturday had subjective fevers and chills. He has not had a productive cough and has not complained of dysuria or frequency of urination. She said that at baseline, he drinks about [1-12] margaritas daily but has not consumed any alcohol for the last several days in the setting of feeling unwell. In terms of his seizure history, he had his first seizure at around age 16 or 18. He has only been treated with Depakote and has not been tried on any other anti epileptics. His seizures are quite well controlled and in the last 10 years, he has only had 3 seizures. His last seizure was 1 year ago and was in the setting of anti-epileptic drug noncompliance. Since then, he has been taking his medications regularly. He does not ever have myoclonic jerks and awakening or light sensitivity. Past Medical History: Seizure disorder, Hypertension, Depression Social History: Worked as contractor in construction, but has not been working very much recently. Tobacco, has smoked about one pack per week for many years since he was a teenager. Alcohol, drinks 2-3 margaritas daily. Illicits: Smokes marijuana daily. Family History: Has 5 siblings. None of them have seizure. Parents did not have seizures. No family history of migraines, stroke or MI. Physical Exam: ADMISSION EXAM: Vitals: T: 100.3 P: 95 R: 12 BP: 127/89 SaO2: 100% on 40% oxygen General: intubated, right after off propofol, patient can track the voice, nod his head, but unable to follow up commands. HEENT: ETT in place Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: patient can track the voice, nod his head, but unable to follow up commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 1.5 to 1mm and brisk. III, IV, VI: unable to test V: unable to test VII: unable to assess with ETT in place VIII: unable to assess IX, X: per nursing report, gag intact [Doctor First Name 81]:unable to asess XII: unable to assess with ETT in place -Motor: Normal bulk, tone throughout. Spontaneous movement of bilateral upper extremities and lower extremities. -Sensory: withdraws somewhat to pain -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was mute bilaterally. -Coordination: unable to assess -Gait: Deferred DISCHARGE EXAM: ************* General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, fluent language with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 1 1 2 1 R 2 1 1 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Per PT/OT - Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Pertinent Results: Labs on Admission: [2120-7-31*] 05:00AM BLOOD WBC-7.8 RBC-4.09 Hgb-12.8* Hct-38.0* MCV-93 MCH-31.4 MCHC-33.8 RDW-13.0 Plt Ct-189 [2120-7-31] 05:00AM BLOOD Plt Ct-189 [2120-7-31] 05:00AM BLOOD Glucose-95 UreaN-7 Creat-0.9 Na-139 K-3.8 Cl-101 HCO3-30 AnGap-12 [2120-7-29] 09:35AM BLOOD CK(CPK)-9452* [2120-7-31] 05:00AM BLOOD CK(CPK)-7728* [2120-7-29] 05:00AM BLOOD CK-MB-11* MB Indx-0.3 cTropnT-0.03* [2120-7-29] 09:35AM BLOOD cTropnT-0.02* [2120-7-30] 02:03AM BLOOD Albumin-3.9 Calcium-8.2* Phos-2.4* Mg-1.9 [2120-7-29] 09:35AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9 [2120-7-31] 05:00AM BLOOD Valproa-51 [2120-7-30] 02:03AM BLOOD Phenyto-5.0* Valproa-78 [2120-7-29] 06:27AM BLOOD Lactate-2.6* [2120-7-28] 09:13PM BLOOD Glucose-96 Lactate-3.7* Na-133 K-6.0* Cl-98 calHCO3-22 Imaging/Studies: CT head w/o contrast [7-29] FINDINGS: There is no evidence of infarction, hemorrhage, discrete masses, mass effect or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. Bilateral mastoid air cells are clear. There are mucosal secretions within the sphenoid sinus as well the nasal cavity, likely representing intubation. There is mucosal thickening involving bilateral maxillary sinuses. The globes are intact. IMPRESSION: 1. No evidence of hemorrhage or infarction. 2. Mucosal thickening involving the sphenoid and maxillary sinuses as well as secretions within the nasal cavity likely representing intubation. EEG Read (ICU) - This telemetry captured no pushbutton activations. The initial diffuse beta activity and background suppression indicate moderate to severe encephalopathy which was possibly due to medication effect, e.g. propofol, or benzodiazepine. During the later half of the recording, the waking background was improved to [5-16] Hz indicating mild encephalopathy. There were no electrographic seizures or epileptiform discharges. Brief Hospital Course: Mr. [Known lastname 37559] is a 56-year-old right handed man with history of seizure disorder, hypertension and depression who was transferred from an outside hospital, intubated and sedated after having multiple seizures. # Neuro: Patient had 4 seizures the day of admission--3 tonic seizures at home and 1 GTCs on ambulance ride to the hospital. At OSH, he was loaded with dilantin prior to transfer. Per patient's wife, he had an upper respiratory tract infection for the last week with subjective fevers and chills. Infectious work up was negative for pneumonia, urinary tract infection, meningitis (see below). He has been compliant with his medications. Of note, the patient usually drinks 2-3 margaritas daily but has not consumed any alcohol for the last several days. Most likely his seizure was triggered by infection versus alcohol withdrawal. So, we did not feel there as a need to obtain further brain imaging with an MRI at this time or to adjust his home anti-epileptics. He was on long term EEG monitoring and did not have any epileptiform activity. Dilantin was tapered off slowly and he was continued on his home dose of Depakote 500mg Delayed Release PO BID. # Cardiac: Was monitored on telemetry and did not have any abnormal rhythms. Continued home metoprolol and lisinopril. Due to BP increases to 180s, Hydralazine IV was administered with good effect. Of note the BP increases were in the setting of likely alcohol withdrawl given his history of [12-11] hard liquor drinks per day for a considerable period. CIWA protocol was initiated and his lisinopril was increased to 30mg qDay with good effect 140-150mmHg SBP for the remainder of his hospitalization. # ID: Patient had a temperature to 101.6 in the ED. He was emperically started on Vancomycin/Ceftriaxone/Acyclovir in meningitis dosing. Chest x-ray with no pneumonia. UA with no UTI. CSF without elevated WBC or RBCs. No source of infection. Leukocytosis most likely in the setting of seizure and and trended down to normal. Discontinued all antibiotics. # Pulmonary: Was intubated prior to transfer. Extubated without difficulty. # RENAL: Cr was 1.3 on admission and CK peaked at ~9000. In setting of mild rhabdo after seizure. CK trended down with hydration. # PSYCH: Social work was consulted on Mr. [Known lastname 37559] for the concern for alcohol withdrawl during his time out of the ICU which was approximately 2-3 days after his last drink where he was noted to be diaphoretic, had increased blood pressure, and some tremor. He was placed on CIWA protocol which improved his symptoms considerably with blood pressures decreased to 140 from 180s. Social work noted there was no bed available for inpatient alcohol rehab which prompted us to offer the patient the option of taking a short course of ativan home for prophylaxis against withdrawl symptoms. The patient agreed to not drink over the course of the four days between discharge and presentation to the inpatient rehabilitation. TRANSITIONS OF CARE: -Code status: Full code Medications on Admission: - Depakote Delayed Release 500 mg [Hospital1 ] - Metoprolol-XL 100 mg daily - Citalopram 40 mg daily - Lisinopril 20 mg daily Discharge Medications: 1. Divalproex (DELayed Release) 500 mg PO BID first now 2. Metoprolol Succinate XL 100 mg PO DAILY Hold sbp <100, hr <60 3. Azithromycin 250 mg PO Q24H Please take 2 pills the first day, then 1 pill each day for the following 4 days. RX azithromycin 250 mg [12-11] tablet(s) by mouth daily Disp #6 Tablet Refills:0 4. Guaifenesin [4-18] mL PO Q6H:PRN sore throat / cough RX guaifenesin 100 mg/5 mL [12-11] tablespoons by mouth every six (6) hours Disp #1 Bottle Refills:0 5. Citalopram 40 mg PO DAILY 6. Lorazepam 1 mg PO Q4H:PRN sweating, palpations Duration: 4 Days RX lorazepam 1 mg 1 tablet(s) by mouth every four (4) hours for the first day, then at most every 6 hours for day 2, then at most every 8 hours for days [2-11] Disp #24 Tablet Refills:0 7. Lisinopril 30 mg PO DAILY hold sbp <100 RX lisinopril 30 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Status Epilepticus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU of [Hospital1 1170] for seizures which lasted an abnormal length of time, known as status epilepticus. On admission, you were intubated for protection of your airway; with improvement of your condition, we were able to extubate you safely. You were further monitored in our ICU then general floor with continuous EEG which did not show any seizures or epileptiform discharges. Please continue your Depakote Delayed Release twice a day as prescribed. You have also been prescribed medications to treat your sinus infection. Please complete your course of antibiotic treatment and follow up with your PCP next week. You were also provided information for alcohol cessation services and a course of medication to help bridge your care from here to rehabilitation services. Please take this medication as necessary for the next four days. It is IMPERATIVE that you do not drink alcohol while on this medication. Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 41415] on Tuesday [2120-8-6] at 2:45pm You will also see Drs. [Last Name (STitle) 851] and [Name5 (PTitle) 86863] on the fourth floor of the [Hospital Ward Name 860] Building ([Hospital Ward Name ]) at 9 a.m. on [2120-8-13]. If you have any problems in the meantime, please call them at [Telephone/Fax (1) 857]. Completed by:[2120-8-1] ICD9 Codes: 4019, 311, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6312 }	Medical Text: Admission Date: [2100-9-20] Discharge Date: [2100-9-23] Date of Birth: [2040-7-1] Sex: F Service: [Hospital1 ] HISTORY OF PRESENT ILLNESS: Patient is a 60-year-old female with a history of type 2 diabetes, bipolar disorder, multiple psychiatric admissions, asthma, hypertension, who was found down at her nursing home at 8 p.m. on the day prior to admission. Per the nursing home staff she had a fingerstick of 289 earlier that evening, and the patient was given permission to administer herself one unit of Humalog insulin. Per the patient, the [Doctor Last Name ] House staff watched her draw the one unit and administer this. She has only given herself insulin injections twice before. She remembers falling asleep, but per the staff she was noted to have three to four generalized tonic-clonic seizures and reportedly had a fingerstick of 10. She was given thiamine, glucose, 8 mg of Ativan with decreased seizure activity, per reports. She was subsequently intubated for airway protection with declining mental status and concern that the patient had aspirated, large food particles were then suctioned from her airway. Patient was treated with Clindamycin for two days in the Medical Intensive Care Unit, has remained afebrile, hemodynamically stable, and was extubated the day prior to being transferred to the floor. The Neurology service consulted on her in the Medical Intensive Care Unit and recommended checking an MRI and an EEG to rule out any structural seizure focus. PHYSICAL EXAMINATION: Temperature is 98.5, heart rate 59 to 85, blood pressure 80 to 124/32 to 82, respirations 18, oxygen saturation 94 to 100% on 2 liters nasal cannula, fingerstick about 300. Generally, she is in no acute distress, alert and oriented times three. HEENT: Mucous membranes are moist with no jugular venous distention, no lymphadenopathy. Cardiovascular: Regular rate and rhythm; no murmurs, rubs, or gallops. Pulmonary is clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended; normoactive bowel sounds. Extremities are without edema with 2+ dorsalis pedis pulses bilaterally. Neurological: Cranial nerves II-XII are intact, moving all extremities well. Sensation grossly intact with bilateral deep tendon reflexes [12-27]. LABORATORY DATA: White count 10.4, hematocrit 26.4, platelets 149, INR 1.0, sodium 138, potassium 4.1, chloride 109, bicarbonate 22, BUN 37, creatinine 1.7, ALT 35, AST 43, alkaline phosphatase 73, total bilirubin 0.2, TSH 4.1, Dilantin level l2.2. ABG 7.38, 76, 39, and 24. HOSPITAL COURSE: 1. Hypoglycemia: The patient admitted with a fingerstick of 10, having generalized tonic-clonic seizures likely secondary to overdose of insulin as patient has very poor vision and had only self-administered insulin one time prior to this event at [Doctor Last Name ] House, where she lives. She was also very insulin sensitive and was seen by the [Last Name (un) ] consult service, who changed her diabetes regimen to Actos 300 mg p.o. q. day and Prandin 0.5 mg t.i.d. with meals without any insulin. She was to follow up with the [Last Name (un) ] service as an outpatient. 2. Generalized tonic-clonic seizures likely secondary to severe hypoglycemia. EEG was without any focal defects. 3. Diabetes: Very insulin sensitive with her regimen changed to Actos and Prandin 0.5 mg three times a day with meals. Patient is not to receive any insulin and to follow up with [Last Name (un) ] after discharge. 4. Bipolar disorder: She was continued on Geodon 30 mg h.s. and Lexapro. 5. Asthma: She continued her Albuterol and Flonase inhalers. 6. Hypertension well controlled on Hydrochlorothiazide and Lisinopril. DISCHARGE CONDITION: Stable. DISPOSITION: Discharged to [Doctor Last Name ] House, where she lives. DISCHARGE MEDICATIONS: 1. Pioglitazone 30 mg p.o. q. day. 2. Famotidine 20 mg p.o. b.i.d. 3. Folic acid 1 mg p.o. q. day. 4. Multivitamin, one, p.o. q. day. 5. Trazodone 20 mg p.o. h.s. 6. Nadolol 80 mg p.o. q. day. 7. Repaglinide 0.5 mg p.o. three times a day with meals. 8. Magnesium oxide 400 mg p.o. b.i.d. for 10 days. DISCHARGE INSTRUCTIONS: 1. The patient is to follow up with Dr. [Last Name (STitle) 8682] in one to two weeks. 2. She is also to follow up with the [Last Name (un) ] service. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (NamePattern1) 5819] MEDQUIST36 D: [2101-1-5] 15:04 T: [2101-1-5] 18:40 JOB#: [Job Number 21237] ICD9 Codes: 5849, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6313 }	Medical Text: Admission Date: [2189-2-19] Discharge Date: [2189-2-27] Date of Birth: [2143-5-24] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5547] Chief Complaint: large cystic mass within the abdomen resulting in abdominal bloating Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Radical resection of cystic intra-abdominal mass en bloc with left hepatic lobe and gallbladder. 3. Intraoperative cholangiogram. 4. [First Name3 (LF) ] History of Present Illness: [Known firstname ] [Known lastname 3646] is a 45-year-old female with a history of progressive abdominal bloating and discomfort. An abdominal ultrasound on [2-5] showed a large cystic mass within the abdomen. This was confirmed with a CT scan of the abdomen obtained on [2-8]. This demonstrated a large complex septated mass centered within the right abdomen and inseparable from the left hemi liver. The lesion measured up to 32 cm in maximum size and was uniform in its attenuation. The findings were most consistent with either a biliary cystadenoma, a mesenteric or peritoneal cyst or a rare sarcoma. The imaging findings and her history were not consistent with hydatid cyst disease. Dr. [Last Name (STitle) 1924] did not feel that further imaging or a preoperative biopsy would be helpful in the management of this lesion and so advised up- front surgery as well as an intraoperative frozen section biopsy of the mass. She understood the rationale for this plan of care as well as the risks and benefits of the procedure and consented to proceed. Past Medical History: PAST MEDICAL HISTORY: 1. Asthma. 2. Nephrolithiasis status post lithotripsy as well as status post ureteroscopy and stone removal in [2184]. 3. Cellulitis of the left leg x2. Past Surgical History: 1. Status post C-sections x2. 2. Status post tonsillectomy at the age 19. 3. Status post a liver biopsy by needle for a small cyst approximately six years ago. The results of this were apparently a benign cyst and she was told that she needed no further followup. Social History: The patient is married and accompanied to the visit today by her husband. She has two children aged 19 and 21. She has a trivial smoking history, having quit several weeks ago. She lives in [Location 9101] and works as an administrative manager of a health care agency. She also works part time as a waitress. She drinks approximately two alcoholic beverages each week. Family History: Remarkable for a mother who is alive and well after treatment for breast cancer. Her father is alive and well with prostate cancer. He also is a survivor of esophageal and stomach cancer. A maternal aunt died of melanoma and a maternal grandmother died of pancreatic cancer. A maternal grandfather died of bone cancer. Physical Exam: At Discharge: Vitals: 98.7, 71, 106/71, 18, 98% on RA GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB ABD: soft, ND, appropriately TTP-RUQ, +BS, +flatus Incision: RUQ-OTA with staples, CDI, JP drains x1 RLQ Extrem: no c/c/e Pertinent Results: [2189-2-27] 07:10AM BLOOD WBC-9.0 RBC-3.41* Hgb-9.7* Hct-30.1* MCV-88 MCH-28.5 MCHC-32.3 RDW-15.1 Plt Ct-322 [2189-2-26] 07:40AM BLOOD WBC-13.1* RBC-3.70* Hgb-10.8* Hct-32.6* MCV-88 MCH-29.1 MCHC-33.0 RDW-15.0 Plt Ct-399 [2189-2-25] 08:15AM BLOOD WBC-10.8 RBC-3.30* Hgb-9.6* Hct-28.6* MCV-87 MCH-29.2 MCHC-33.7 RDW-15.0 Plt Ct-280 [2189-2-22] 07:40AM BLOOD WBC-12.6* RBC-3.25* Hgb-9.5* Hct-28.3* MCV-87 MCH-29.2 MCHC-33.6 RDW-15.3 Plt Ct-197 [2189-2-19] 11:53PM BLOOD WBC-16.5* RBC-3.30* Hgb-9.7* Hct-27.7* MCV-84 MCH-29.3 MCHC-34.9 RDW-15.6* Plt Ct-184 [2189-2-19] 07:12PM BLOOD WBC-19.1# RBC-3.58 Hgb-10.4* Hct-30.8* MCV-86 MCH-29.0 MCHC-33.8 RDW-14.9 Plt Ct-211 [2189-2-24] 08:00AM BLOOD PT-13.5* PTT-23.2 INR(PT)-1.2* [2189-2-26] 07:40AM BLOOD Glucose-93 UreaN-7 Creat-0.7 Na-140 K-3.4 Cl-103 HCO3-29 AnGap-11 [2189-2-25] 08:15AM BLOOD Glucose-95 UreaN-7 Creat-0.5 Na-141 K-3.5 Cl-106 HCO3-28 AnGap-11 [2189-2-19] 11:53PM BLOOD Glucose-222* UreaN-11 Creat-0.6 Na-136 K-4.3 Cl-108 HCO3-21* AnGap-11 [2189-2-19] 07:12PM BLOOD Glucose-158* UreaN-12 Creat-0.7 Na-138 K-4.4 Cl-110* HCO3-19* AnGap-13 [2189-2-27] 07:10AM BLOOD ALT-41* AST-14 AlkPhos-53 Amylase-185* TotBili-0.3 [2189-2-26] 07:40AM BLOOD ALT-54* AST-17 AlkPhos-59 Amylase-216* TotBili-0.4 [2189-2-25] 08:15AM BLOOD ALT-60* AST-18 AlkPhos-52 Amylase-136* TotBili-0.4 [2189-2-27] 07:10AM BLOOD Lipase-265* [2189-2-26] 07:40AM BLOOD Lipase-360* [2189-2-25] 08:15AM BLOOD Lipase-214* [2189-2-27] 07:10AM BLOOD Albumin-3.0* [2189-2-26] 07:40AM BLOOD Calcium-10.0 Phos-2.7 Mg-1.9 [2189-2-25] 08:15AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9 [2189-2-24] 08:00AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.9 [2189-2-22] 09:15AM BLOOD Albumin-2.8* . CT ABDOMEN W/CONTRAST Study Date of [2189-2-23] 6:06 PM IMPRESSION: 1. Status post left hepatectomy with associated postoperative changes. JP drain terminates near the surgical resection site adjacent to segment VIII. 2. Small air-fluid collection within segment V of the liver. This appearance could be consistent with surgical packing material. Correlation with surgical history advised. 3. Small fluid-attenuation collection with a mildly enhancing rim posterior to the gastric antrum may represent postoperative fluid collection or early phlegmon. 4. Mild prominence of the right-sided biliary system. Lack of complete visualization of the CBD which may be related to postoperative inflammatory change. Evidence of intra-abdominal and pelvic free fluid. 5. Pathologically enlarged porta hepatis lymph node, as above, likely reactive. 6. A small amount of free intra-abdominal air consistent with recent surgical history. 7. Left renal hypodense lesion, too small to characterize, likely representing a simple cyst. 8. Right hepatic 7-mm lesion, too small to characterize, likely representing a simple cyst. 9. Probable uterine fibroid. This could be confirmed by pelvic ultrasound on a non-emergent basis, as clinically indicated. . [Date Range ] [2189-2-24] Impression: Normal major papilla. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique .A mild diffuse dilation was seen at the main duct, right main hepatic duct, left main hepatic duct stump and right intrahepatic biliary branches with the CBD measuring 10mm in diameter . Mild extravasation of contrast was noted at the left main hepatic duct stump A 7cm by 10FR Cotton [Doctor Last Name ] biliary stent was placed successfully using a [Company 2267] Rx 10 Fr stent introducer kit . Cytology Report CYST FLUID Procedure Date of [2189-2-19] Diagnosis: NEGATIVE FOR MALIGNANT CELLS. Blood and macrophages consistent with hemorrhagic cyst contents. No epithelial cells present. Brief Hospital Course: Mrs.[Doctor Last Name 33902] operative course was complicated by increased blood loss due to extensive involvement of cyst-like mass within liver. EBL estimated at about 1800cc. She was transfused with 2 units of PRBC, and transferred for closer monitoring. Her vitals, and clinical presentation were otherwise stable. Epidural was initially placed for pain control, but discontinued due to intra-operative blood loss. Patient was managed on a PCA. Serial Hct's were monitored. HCT's stable. No other signs of post-op bleeding noted. She was transferred to Stone 5 for post op care. . Her diet was advanced slowly. RLQ JP drain with bilious ouput. Bilirubin present in fluid. [Doctor Last Name ] arranged for concern for post-op biliary leak. IV Anitbiotics started. Stent placed. Biliary leak stabilized. Diet advanced slowly once again post-[Doctor Last Name ]. Amylase and Lipase elevated related to [Doctor Last Name ]. Labwork re-checked. Both Amylase, Lipase, and WBC decreased. HCT stable. Antibiotics discontinued. Tolerating a regular diet. No N/V. . Post-op recovery otherwise stable. Ambulating independently. Foley removed. Urinating adequates amounts. Passing flatus. Pain well contolled with oral medication. JP drain care & teaching provided to patient. Demonstrated competence with care. Visiting Nurses arranged for discharge to assist with JP care at home. Patient advised to follow-up with Dr. [Last Name (STitle) 1924] in 1 week, and follow-up with [Last Name (STitle) ]/GI will be arranged in near future for possible removal of stent. Medications on Admission: Primatene mist PRN Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:35 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 2 weeks: Take with Hydromorphone. Disp:30 Capsule(s) Refills:0 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/HA for 2 weeks: Do not exceed 4000mg in 24hrs. Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Primary: Large cystic mass arising from the left lobe of the liver, likely biliary cystadenoma or cystadenocarcinoma. Post-op blood loss anemia-treated with tranfusion Post-op biliary leak Post [Hospital3 ] pancreatitis . Secondary: 1. Asthma. 2. Nephrolithiasis status post lithotripsy as well as status post ureteroscopy and stone removal in [2184]. 3. Cellulitis of the left leg x2. Past Surgical History: 1. Status post C-sections x2. 2. Status post tonsillectomy at the age 19. 3. Status post a liver biopsy by needle for a small cyst approximately six years ago. The results of this were apparently a benign cyst and she was told that she needed no further followup. Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow-up appointment with Dr. [Last Name (STitle) 1924]. Steri strips will be applied. -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . JP Drain Care: -Please look at the site every day for signs of infection (increased redness, swelling, odor, yellow or bloody discharge, fever). -Maintain the bulb deflated to provide adequate suction. -Note color, consistency, and amount of fluid in drain. Call doctor if amount increases significantly or changes in character. -Be sure to empty & strip the drain every 4 hours. -You may shower, wash area gently with warm, soapy water. -Maintain the site clean, dry, and intact. -Avoid swimming, baths, hot tubs-do not submerge yourself in water. -Keep drain attached safely to body to prevent pulling Followup Instructions: 1. Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 7508] Appointment should be in [5-29] days 2. Provider: [Name Initial (NameIs) ] 2 (ST-4) GI ROOMS Date/Time:[2189-3-20] 8:00 3. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2839], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2189-3-20] 8:00 Completed by:[2189-2-27] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6314 }	Medical Text: Admission Date: [2124-7-20] Discharge Date: [2124-8-1] Date of Birth: [2071-10-16] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2641] Chief Complaint: left leg swelling Major Surgical or Invasive Procedure: endotracheal intubation bronchoscopy History of Present Illness: Ms. [Known lastname 18654] is an obese, otherwise healthy 52-year-old woman with a history of psoriasis and "seasonal lower leg swelling" referred from [Hospital6 302] for further evaluation of filling defect withing the thoracic aorta at the arch and extending into the descending aorta. She originally presented to [Hospital3 ] ED in early [Month (only) ] with nausea, vomiting, and watery diarrhea and mild left lower extremity pain and swelling in early [Month (only) ]. She was treated with antinausea and antidiarrheal medications and instructed to use hot compresses for the lower leg pain. The diarrhea, nausea, and vomiting resolved after approximately 2 weeks, but the lower extremity pain worsened. Approximately 1 week prior to admission, she reports that her left lower extremity began "swelling up like a helium balloon" and the pain in her calf and thigh worsened to the point where she had difficulty walking. She returned to the [Hospital3 ] ED on [2124-7-19] (1 day prior to admission) with worsening left lower extremity pain and swelling. Per surgery and heme/onc notes in OMR, at [Hospital3 17162] she had elevated D-dimer but initial ultrasound did not show a DVT. CT angiogram performed to evaluate for pulmonary embolism showed a filling defect in the aortic arch extending in to the descending aorta. No evidence of pulmonary embolism. Per the patient, she was then referred to [Hospital1 ] Health for outpatient follow-up. [Hospital1 ] Health referred her to [Hospital1 18] for further evaluation and management by the cardiac surgery service. She was admitted to [Hospital1 18] on [2124-7-20]. In ED, ultrasound was negative for DVT, but chest CT (presumably from [Hospital3 ], not record in OMR) showed evidence of aspiration pneumonia and antibiotics were given (no record). She was tranferred to surgery. Cardiac and vascular surgery were consulted. She underwent a lower extremity duplex ultrasound on [2124-7-20], which showed an acute DVT with occlusive thrombus in the left femoral and popliteal veins and a nonocclusive thrombus seen in the left common femoral vein. No DVT seen in the right leg. Chest MRI showed a filling defect in transverse and proximal descending aorta in the same distribution as seen on the CT scan. No visualized focal dissection. Echo showed mild symmetric left ventricular hypertrophy with preserved global systolic function. [2124-7-20] ECG was read as normal sinus rhythm. Rheumatology was consulted given concern for aortitis, vasculitis. Per OMR, rheumatology stated no clear evidence for systemic vasculitis or connective tissue disorder based on the negative review of systems and exam. Recommended ESR, CRP, anticardiolipin IgM and IgG, bet2 glycoprotein. Recommended against lupus anticoagulant due to heparin gtt. Recommended Heme/onc consult. Heme/onc was consulted for hypercoaguable workup given the finding of aortic arch thrombosis and given her recent history of DVT. For the venous clot, did not recommend testing for inherited thrombophilias as it would not change the management of this patient. Recommended anticoagulatoin for DVT for 3 months. For the arterial clot, recommended testing for antiphospholipid antibodies, testing for lupus anticoagulant once of heparin. Also recommended all age- appropriate cancer screening if not done before (mammograms, colonoscopy). Of note, Ms. [Known lastname 18654] reports previous seasonal experience with lower extremity swelling (L>R), but denies any prior history of DVT or PE. History is significant for remote miscarriage, no further pregnancies. No recent surgeries, trauma. She was relatively bed-bound for of ~2-3 weeks with nausea/vomiting/diarrheain early [Month (only) ]. Past Medical History: - LLE DVT (on coumadin) - descending aortic arch thrombosis - hyperlipidemia - appendectomy Social History: smoking - 1 PPD x 36 years, occassional ETOH 2 drinks/month, no recreation/illicts, widowed without children Family History: mother with DM Physical Exam: PHYSICAL EXAMINATION: GENERAL: Patient is alert, pleasant, obese, no acute distress, appears uncomfortable with movement HEENT: Pupils equal, round, reactive to light. Extraocular muscles intact. Sclerae anicteric. Conjunctivae pink. Oropharynx clear. NECK: Supple, nontender. No thyromegaly. LYMPH NODES: No palpable cervical, supraclavicular, or axillary lymphadenopathy. CHEST: Left clear to auscultation. Expiratory wheezes in right mid posterior lung field. ABDOMEN: Obese, soft, nondistended, diffusely tender to deep palpation. No hepatosplenomegaly appreciated (exam limited by abdominal obesity). EXTREMITIES: Bilateral lower extremity non-pitting edema. Left worse than right. Left warmer than right. Left proximal lower extremity warmer than distal lower extremity. SKIN: Multiple erythematous lesions on all four extremities, back consistent with psoriatic plaques. NEUROLOGIC: Patient is alert and oriented to person, place, time, purpose. Cranial nerves II-XII intact. Pertinent Results: Labs at admission: [2124-7-19] 10:10PM PLT COUNT-381 [2124-7-19] 10:10PM NEUTS-76.0* LYMPHS-17.8* MONOS-3.7 EOS-1.8 BASOS-0.8 [2124-7-19] 10:10PM WBC-11.4* RBC-4.44 HGB-14.3 HCT-44.3 MCV-100* MCH-32.3* MCHC-32.3 RDW-14.3 [2124-7-19] 10:10PM proBNP-58 [2124-7-19] 10:10PM cTropnT-0.01 [2124-7-19] 10:10PM estGFR-Using this [2124-7-19] 10:10PM GLUCOSE-113* UREA N-9 CREAT-0.5 SODIUM-141 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-32 ANION GAP-9 [2124-7-19] 10:37PM PT-13.6* PTT-25.3 INR(PT)-1.2* [2124-7-20] 12:06AM LACTATE-0.9 [2124-7-20] 03:44AM PT-12.2 PTT-21.1* INR(PT)-1.0 ++++++++++++++++++++++++++++++++++++++++++++++ Imaging: ----CT-CHEST w/ CONTRAST FINDINGS IMPRESSION: 1. Pulmonary embolism of the right main pulmonary artery - this finding was discussed with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at 16:13 on [2124-7-28]. 2. Persisting nonocclusive descending aortic thrombus. 3. Prominent mediastinal lymph nodes, likely reactive in nature. 4. Rapid onset of diffuse ground-glass opacities with increased consolidation of the right lower posterior lung and apical segment of the left lower lobe; the differential diagnosis is broad but includes edema/ARDS,infectious/inflammatory causes, hemorrhage, or aspiration. ------DUPLEX VENOUS DOPPLER STUDY OF THE LEFT UPPER EXTREMITY CLINICAL INDICATION: Patient with known left lower extremity DVT and pain in left upper extremity. The left internal jugular, axillary and brachial veins are fully compressible as are the superficial basilic and cephalic veins. Color flow and pulse Doppler assessment of all of the veins in the left upper extremity is normal with no evidence of occlusive or non-occlusive clot. Procedures: Bronchial lavage: --NEGATIVE FOR MALIGNANT CELLS. +++++++++++++++++++++++++++++++++++++++++++++++++++++++ Labs at Discharge: [2124-8-1] 06:40AM BLOOD WBC-9.2 RBC-4.31 Hgb-13.8 Hct-42.2 MCV-98 MCH-31.9 MCHC-32.7 RDW-14.1 Plt Ct-654* [2124-8-1] 06:40AM BLOOD Plt Ct-654* [2124-8-1] 06:40AM BLOOD PT-31.6* PTT-28.5 INR(PT)-3.2* [2124-8-1] 06:40AM BLOOD Glucose-111* UreaN-11 Creat-0.4 Na-137 K-4.3 Cl-101 HCO3-28 AnGap-12 [2124-8-1] 06:40AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.8 Brief Hospital Course: She was admitted to [Hospital1 18] on [2124-7-20]. In ED, ultrasound was negative for DVT, but chest CT (presumably from [Hospital3 ], not record in OMR) showed evidence of aspiration pneumonia and antibiotics were given (no record). She was tranferred to surgery. Cardiac and vascular surgery were consulted. She underwent a lower extremity duplex ultrasound on [2124-7-20], which showed an acute DVT with occlusive thrombus in the left femoral and popliteal veins and a nonocclusive thrombus seen in the left common femoral vein. No DVT seen in the right leg. Chest MRI showed a filling defect in transverse and proximal descending aorta in the same distribution as seen on the CT scan. No visualized focal dissection. Echo showed mild symmetric left ventricular hypertrophy with preserved global systolic function. [2124-7-20] ECG was read as normal sinus rhythm. Rheumatology was consulted given concern for aortitis, vasculitis. Per OMR, rheumatology stated no clear evidence for systemic vasculitis or connective tissue disorder based on the negative review of systems and exam. Recommended ESR, CRP, anticardiolipin IgM and IgG, bet2 glycoprotein. Recommended against lupus anticoagulant due to heparin gtt. Recommended Heme/onc consult. Heme/onc was consulted for hypercoaguable workup given the finding of aortic arch thrombosis and given her recent history of DVT. For the venous clot, did not recommend testing for inherited thrombophilias as it would not change the management of this patient. Recommended anticoagulatoin for DVT for 3 months. For the arterial clot, recommended testing for antiphospholipid antibodies, testing for lupus anticoagulant once of heparin. Also recommended all age- appropriate cancer screening if not done before (mammograms, colonoscopy). Of note, Ms. [Known lastname 18654] reports previous seasonal experience with lower extremity swelling (L>R), but denies any prior history of DVT or PE. History is significant for remote miscarriage, no further pregnancies. No recent surgeries, trauma. She was relatively bed-bound for of ~2-3 weeks with nausea/vomiting/diarrheain early [Month (only) ]. Pt on CT surgery team for several days until the decision was made not to remove the aortic clot surgically. Rheumatology was consulted 2 days after admission for concern for aortitis as the cause of the aortic clot. CXR showed diffuse opacities and CT A/P showed GGO's at lung bases. She was also started on levofloxacin for possible CAP. They did not feel as though her presentation was consistent with a systemic vasculitis as inflammatory markers not significantly elevated as they would be if systemic vasculities. Recommended neoplastic workup, and anticardiolipin ab, complement, [Doctor First Name ]. Heme recommended APA workup, anticaog for 3 months and lupus anticoag. Work up for inherited thrombophilias was negative (factor V Leiden an B-2 glycoprotein). . She was transferred to the medical service. She was noted to have large b/p difference in UE - 60/D on L and 110/s on R. Vascular was aware and did not recommend any intervention. One day after transfer to medicine, she developed a new O2 requirement. CXR showed diffuse pulmonary infiltrates and pulm was consulted for concern for diffuse alveolar hemorrhage. She also had transient hypoxia to 80's while ambulating got bathroom that resolved with rest. She was transferred to the MICU for bronchoscopy MICU Course [Date range (1) 85305]: Patient was admitted from the floor for elective bronchoscopy for increasing O2 requirement and SOB in setting of aortic thrombus, multiple DVT's, GGO's on CT scan and diffuse infiltrates on CXR. Differential was broad - DAH, APA, lupus. Decision was made to intubate given patient's inability to lay flat. She was bronched which showed no evidence of bleeding. She has been started on coumadin prior to transfer and remianed therapeutic while in the ICU. CTA chest showed PE - thought to be embolic from known DVT and not representative of coumadin failure. IVC was considered but not done as she was tolerating her PE without difficulty and therapeutuc on anticoagulation. She was extubated with out difficulty and called out to the floor. On the floor the patient did well. We discussed with vascular the need to continue antiplatelet and anticoagulation given she has VTE and an arterial issue. This was done and the patient was advised of potential risk of clot. Follow up was arranged and she was discharged home. Medications on Admission: Patient denies taking prescribed or OTC medications at home. Denies use of supplements, home remedies, herbs Discharge Medications: 1. Outpatient Lab Work Serial PT/INR Dx: DVT, aortic thrombus Goal INR [3-1] Results to Dr. [First Name8 (NamePattern2) 12041] [Last Name (NamePattern1) ] [Telephone/Fax (1) 85306] 2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Take as directed by Dr. [First Name (STitle) ]. Disp:30 Tablet(s) Refills:2 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Aortic arch arterial thrombosis 2. Deep venous thrombosis in the left lower extremity 3. Pulmonary embolism 4. Hypoxemia 5. vitamin B12 deficiency . Secondary: 1. Psoriasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital due to swelling in your left leg. You were found to have blood clots in the veins of your left leg, in your lungs, and in your aorta. You were started on blood thinning-medications (aspirin and Coumadin) for this. We did some tests to evaluate why you are forming blood clots in several different parts of your body. So far, this testing has not revealed the cause of your blood clots, but further testing will need to be done after you leave the hospital. There was some concern about the blood flow to your left arm due to the blood clot in your aorta. You were followed by the vascular surgery team for this. You should return to the hospital right away if you develop persistent pain in your left arm or hand, or if your left arm becomes cold or blue. There was also concern about your lungs due to a low oxygen level and abnormalities on chest imaging. You were transferred to the ICU due to this and underwent a study called bronchoscopy. This did not reveal the cause of your abnormalities but may need to be repeated in the future. You were briefly intubated for the bronchoscopy, but the breathing tube was removed after the study was done. You should return to hospital emergency IMMEDIATELY if you feel sudden pain/numbness especially in your hands, feet, arms or legs. Return to the emergency room if any extremity turns blue or cold. Talk to your doctor about further evaluation for vitamin B12 defiency. You received a vitamin B12 shot here, and should received further shots from your primary doctor. You have also been started on a vitamin called folic acid. There have been some changes to your medications: START Coumadin (warfarin) to prevent the formation of blood clots. Take this as directed by Dr. [First Name (STitle) ]. You will need frequent blood tests while on Coumadin to prevent serious complications due as bleeding (if your level is too high) and further blood clots (if your level is too low). Your follow-up blood tests will be managed by Dr. [First Name (STitle) ]. Your next blood test will be on [2124-8-3], when you see Dr. [First Name (STitle) ]. START aspirin START simvastatin START folic acid . Follow up as indicated below. Followup Instructions: Please follow up with the following appointments: . PCP [Name Initial (PRE) 648]: Thursday, [8-3] @ 8:45am Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 85307],MD Location: [Location (un) ] CHC Address: [Doctor First Name 85308], [Location (un) ],[Numeric Identifier 62441] Phone: [Telephone/Fax (1) 85306] . Department: RHEUMATOLOGY When: TUESDAY [2124-8-8] at 12:00 PM With: [First Name11 (Name Pattern1) 2890] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 2226] Building: LM [Hospital Unit Name ] [Location (un) 861] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE . Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2124-8-11] at 9:30 AM With: [First Name11 (Name Pattern1) 177] [Initials (NamePattern4) ] [Last Name (NamePattern4) 7801], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Please call the pulmonology clinic at ([Telephone/Fax (1) 513] to make an appointment to see Dr. [Last Name (STitle) ]. You should see Dr. [Last Name (STitle) ] within the next month. . Please call the vascular surgery clinic at ([Telephone/Fax (1) 39970] to make an appointment with Dr. [Last Name (STitle) 24688]. You should be seen by Dr. [Last Name (STitle) 24688] within the next 3 months. ICD9 Codes: 2761, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6315 }	Medical Text: Admission Date: [2120-7-13] Discharge Date: [2120-7-20] Date of Birth: [2065-4-6] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11415] Chief Complaint: transfer from MICU s/p seizures, EtOH withdrawal Major Surgical or Invasive Procedure: left forearm I&D History of Present Illness: 55M with h/o seizures (since [2100], followed by Dr. [Last Name (STitle) ] from Neurology), who presented to the ED after being struck by a brick thrown during a "road rage altercation." He suffered a traumatic mid-shaft open comminuted ulnar fracture ('nightstick'). Per nursing, patient was noted to have EtOH on breath, however BAL never checked. He was admitted to the ortho service initially on [2120-7-13] with plans for washings in the AM. He was placed on a CIWA scale (scores 0-2 overnight), given 200 mg of dilantin at MN, and received Ancef and Gentamycin. . The following morning, the patient was found unresponsive by the phlebotomist at 6:30 am. Per report, he was grinding his teeth, drooling and diaphoretic. VS at that point were BP 93/54, HR 100, RR 24, SaO2 95%/RA, BS 142. He did not open his eyes to commands. At 6:50 am, he had another episode of teeth grinding and was given 2 mg IV ativan with decrease in SaO2 to 69%. At 7:05 am, he had another episode of grinding teeth and eye deviation and was given another 2 mg IV ativan. At 7:20 am, again another similar episode occured and he received 2 mg IV ativan. Neurology and the MICU team were called for evaluation. He was then transferred to the MICU for further evaluation. Course c/b traumatic foley placement on floor, requiring urology evaluation and re-placement of foley. . On MICU arrival, the patient was somnolent and unresponsive to voice, but responsive to painful stimuli. ABG at that time was 7.03/36/285/10 on a NRB. Serum tox was sent and was positive only for EtOH = 70. Dilantin level returned sub-therapeutic at 1.8. He was loaded with 1200 mg IV dilantin per neurology recommendations. After this, the patient was more responsive and awake. Repeat ABG on NRB was 7.28/31/264, lactate 10.8. Also noted to have transaminitis (from ?anti-epileptic meds). While in the MICU, the patient was continued on q2hr CIWA scales and required approximately 7.5-10 mg per day. The patient's mental status improved, vitals stabilized, he had no futher seizure activity, and was transferred to the floor. . On evaluation, the patient complains of a painful left arm. Denies abdominal pain, SOB, CP, diaphoresis, hallucinations, tremulousness, or confusion. Past Medical History: EtOH abuse h/o EtOH withdrawal seizures (last hospitalized [2116] per patient; followed by Dr. [Last Name (STitle) ] from Neurology) Social History: Lives with wife (who is currently in [Name (NI) 108] per the patient). Works as carpenter. Drinks approximately 6-pack beer per day plus occasional vodka. No tobacco or illicits. Family History: noncontributory Physical Exam: General: WDWN black male, soft-spoken, lying in bed, NAD Vitals: T 99.3 BP 120/88 HR 88 RR 20 O2sat 98% RA Skin: warm, no rash HEENT: PERRLA, EOMI, anicteric, OP clear Neck: supple, trachea midline, no LAD Pulm: left basilar fine crackles, no wheezes CV: regular, s1s2 normal, no m/r/g Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: no edema, cyanosis, or clubbing; left arm splinted Neuro: A&Ox3, speech soft but intelligible, CNII-XII intact, mild dysmetria, sensation intact and symmetric bilat, moves all extremities, mild tremulousness, no asterixis Pertinent Results: [2120-7-15] 02:00AM BLOOD WBC-6.2 RBC-3.26* Hgb-11.3* Hct-31.7* MCV-97# MCH-34.7* MCHC-35.7* RDW-14.7 Plt Ct-180 [2120-7-15] 02:00AM BLOOD Neuts-79.7* Lymphs-16.1* Monos-3.5 Eos-0.5 Baso-0.3 [2120-7-15] 02:00AM BLOOD Glucose-102 UreaN-3* Creat-0.7 Na-132* K-3.5 Cl-97 HCO3-25 AnGap-14 [2120-7-14] 09:44AM BLOOD ALT-93* AST-176* LD(LDH)-239 AlkPhos-78 TotBili-0.9 [2120-7-14] 07:02AM BLOOD CK-MB-4 cTropnT-<0.01 [2120-7-15] 02:00AM BLOOD Calcium-8.7 Phos-2.2* Mg-2.3 [2120-7-14] 06:49PM BLOOD Phenyto-18.2 [2120-7-14] 07:02AM BLOOD ASA-NEG Ethanol-70* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . EKG [2120-7-13] - NSR at 70 bpm, normal axis. Slightly prolonged PR interval. No acute ST-T wave changes. Compared to [12-6]. . CXR - Single AP view of the chest is obtained on [2120-7-14] at 19:00 hours and is compared with the prior study performed at 14:47 hours. Again the inspiratory effort is poor. Patchy increased lung markings remain at both bases, particularly on the right side, which may be due to the degree of underinflation. No frank dilatation is identified. . CT head - There is no evidence of hemorrhage. The [Doctor Last Name 352]-white matter differentiation appears preserved. There is no hydrocephalus or shift of normally midline structures. The basal cisterns appear patent. Visualized paranasal sinuses are clear. IMPRESSION: No evidence of hemorrhage. . EEG - This was an abnormal EEG in the waking and drowsy states due to the presence of theta frequency slowing in the left posterior quadrant. This finding suggests an abnormality in the subcortical region. No clear epileptiform activity was seen. Diffuse beta activity seen may be the result of certain medications such as benzodiazepines. . LEFT FOREARM, TWO VIEWS: There is a minimally displaced comminuted fracture through the distal third of the left ulna. There is moderate surrounding soft tissue swelling. The joint spaces of the elbow and wrist appear preserved. No radiopaque foreign bodies are identified. IMPRESSION: Distal left ulnar fracture as described above. Brief Hospital Course: 55 y/o male with h/o seizures, EtOH abuse presented with left ulnar fracture, EtOH withdrawal, and seizures. Patient has been continued on CIWA scales and without further seizure events. Transfer from MICU [2120-7-15] in fair condition. . * EtOH withdrawal - - The patient was placed on aggressive CIWA scales of diazepam 10mg po q4h prn CIWA>8 cover with diazepam 5mg po q2h prn tremulousness, agitation, hallucinations. He was also placed on thiamine IV, folate, and MVI. Neurology also saw the patient was made recommendations. . * Seizures: etiology of seizures likely EtOH withdrawal (possibly supported by EEG findings); also patient on dilantin at home, was subtherapeutic at presentation ?compliance. The patient was initially loaded with 1200 mg IV dilantin. No new seizure activity noted since patient therapeutic on dilantin. The dilantin levels were checked. He was also written for ativan PRN. . * Transaminitis: unclear etiology (?medication, EtOH). The AST:ALT ratio was approximately 2:1 which supports EtOH use. The LFT's were followed daily. . * Ulnar fracture: The patient was brought to the operating room on [2120-7-18] for ORIF of his ulna. See operative note for details. He tolerated the procedure well. He was extubated and brought to the recovery room in stable condition. Once stable in the PACU he was transferred to the floor. He worked with occupational therapy and a an orthoplast splint was made. . * Hematuria - s/p traumatic foley placement on floor. A 22F coudet was placed by urology. . The [Hospital 228] hospital course was otherwise without incident. His pain was well controlled. His labs and vitals remained stable. He is dicharged today in stable condition. Medications on Admission: Dilantin 200/100/200 mg tid Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:50 Tablet(s) Refills:0 2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day): Please take at 6am + 10pm. Disp:60 Capsule(s) Refills:0 3. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO DAILY (Daily): Please take at 2pm daily. Disp:30 Tablet, Chewable(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: L open midshaft ulna fracture Discharge Condition: Stable Discharge Instructions: Please continue to wear splint at all times. Do not bear weight on your left arm. Please keep incision/splint clean and dry. Dry sterile dressing under splint daily as needed. If you notice any increased redness, swelling, drainage, temperature >101.4, or shortness of Please take all medications as prescribed. You may resume any normal home medications. Please follow up as below. Call with any questions. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 1005] in 2 weeks. Call [Telephone/Fax (1) ] to make that appointment. Please follow up with Dr. [Last Name (STitle) ] concerning your seizures. Call [Telephone/Fax (1) ] to make that appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2120-7-31] ICD9 Codes: 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6316 }	Medical Text: Admission Date: [2158-10-10] Discharge Date: [2158-10-16] Date of Birth: [2133-4-11] Sex: M Service: MEDICINE Allergies: Dimetapp Attending:[First Name3 (LF) 348] Chief Complaint: Leg Weakness Major Surgical or Invasive Procedure: None History of Present Illness: 25yoM with no significant [Hospital ] transferred from an OSH with bilateral leg weakness and acute renal failure. On [10-8] he had 3-4 beers, following which he "did [1-11] lines" of cocaine and acknowledges potential snorting of Oxycontin. On [10-9] he woke up upable to stand with weakness and associated numbness on the anterior of his legs R > L. He presented to OSH and was found to be in ARF with elevated CKs. He was transferred to the [Hospital1 18] and admitted to MICU. . In the MICU he had foley placed and was treated for rhabdomylosis with IVF. His labs inititally showed CK of [Numeric Identifier 32925], AST of 1900, ALT of 1400 and Cr of 5.5. Most recently CK of 9000, AST of 800, ALT 600, tbili of 0.7 and cr of 6.4, INR 1.1. Past Medical History: Remote hx of Knee Surgery Social History: Lives with mother, father and sister in [Name (NI) 3494]. Longshoreman in [Location 8391]. [3-14] pack of cigarette daily for 2 years. EtOH on [3-14] beers (up to 10), 3-4x/week since [71] and + coccaine 1x /wk (snorting) for the last year. Denies IVDU or other drug use. Family History: Non-Contriburtory Physical Exam: VITALS: Afebrile. Satting well on room air. Good urine output. GEN: NAD, A0x3 HEENT: PERRLA, EOMI, Anicteric Sclera, seborrheic dermatitis on face NECK: SUPPLE, NO LAD RESP: CTAB b/l. CARD: S1 S2 No Murmurs, Rubs or Gallops. ABD: Soft Mild Tender on deep palpation LLQ, Non-Distended, BS+. Negative Murphys EXTR: No clubbing, cyanosis or edema. 2+ DP. NEURO: A0x3. Pertinent Results: Admission Labs: [2158-10-10] 11:45PM CEREBROSPINAL FLUID (CSF) PROTEIN-21 GLUCOSE-83 [2158-10-10] 11:45PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-3* POLYS-0 LYMPHS-60 MONOS-40 [2158-10-10] 10:14PM URINE HOURS-RANDOM [2158-10-10] 10:14PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [2158-10-10] 10:14PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2158-10-10] 10:14PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [2158-10-10] 10:14PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-<1 [2158-10-10] 10:14PM URINE GRANULAR-0-2 [2158-10-10] 10:14PM URINE AMORPH-FEW [2158-10-10] 05:47PM COMMENTS-GREEN TOP [2158-10-10] 05:47PM LACTATE-1.5 [2158-10-10] 05:35PM GLUCOSE-135* UREA N-57* CREAT-5.5* SODIUM-133 POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-23 ANION GAP-21* [2158-10-10] 05:35PM estGFR-Using this [2158-10-10] 05:35PM ALT(SGPT)-1492* AST(SGOT)-[2086]* LD(LDH)-1843* CK(CPK)-[Numeric Identifier ]* ALK PHOS-82 AMYLASE-47 TOT BILI-0.8 [2158-10-10] 05:35PM LIPASE-31 [2158-10-10] 05:35PM CK-MB-168* MB INDX-0.8 cTropnT-0.15* [2158-10-10] 05:35PM ALBUMIN-4.2 CALCIUM-8.6 PHOSPHATE-2.1* MAGNESIUM-1.8 [2158-10-10] 05:35PM CRP-256.5* [2158-10-10] 05:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2158-10-10] 05:35PM WBC-10.7 RBC-5.00 HGB-16.2 HCT-43.4 MCV-87 MCH-32.3* MCHC-37.2* RDW-13.2 [2158-10-10] 05:35PM NEUTS-92.5* LYMPHS-5.7* MONOS-1.5* EOS-0.2 BASOS-0.1 [2158-10-10] 05:35PM PLT COUNT-132* [2158-10-10] 05:35PM PT-13.0 PTT-26.1 INR(PT)-1.1 [2158-10-10] 05:35PM SED RATE-21* Hospital and Discharge pertinent labs: CBC: [2158-10-16] 05:25AM BLOOD WBC-11.2* RBC-4.37* Hgb-13.9* Hct-37.6* MCV-86 MCH-31.8 MCHC-37.0* RDW-13.4 Plt Ct-232 Coags: [2158-10-12] 03:00AM BLOOD PT-12.6 PTT-29.8 INR(PT)-1.1 ESR: [2158-10-12] 03:00AM BLOOD ESR-30* Chemistry: [2158-10-16] 05:25AM BLOOD Glucose-86 UreaN-95* Creat-10.2* Na-137 K-4.0 Cl-100 HCO3-23 AnGap-18 [2158-10-16] 05:25AM BLOOD Calcium-8.9 Phos-7.5* Mg-2.5 LFTs: [2158-10-16] 05:25AM BLOOD ALT-107* AST-22 LD(LDH)-346* AlkPhos-52 TotBili-0.6 CK: [2158-10-16] CK(CPK)-154 [2158-10-15] 06:00AM BLOOD CK(CPK)-275* [2158-10-11] 11:36AM BLOOD CK(CPK)-7015* [2158-10-10] 05:35PM BLOOD CK(CPK)-[Numeric Identifier ]* Cardiac enzymes: [2158-10-13] 04:25AM BLOOD CK-MB-6 cTropnT-0.42* [2158-10-12] 02:57PM BLOOD CK-MB-9 cTropnT-0.35* Lipids: [2158-10-11] 11:36AM BLOOD Triglyc-277* HDL-22 CHOL/HD-5.3 LDLcalc-40 Hepatitis serologies: [2158-10-11] 11:36AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE, BLOOD HCV Ab-NEGATIVE CRP: [2158-10-12] 03:00AM BLOOD CRP-175.2* HIV AB: [2158-10-12] 02:57PM BLOOD HIV Ab-NEGATIVE Blood tox screen: [2158-10-10] 05:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Lactate: [2158-10-10] 05:47PM BLOOD Lactate-1.5 MRI: Spine IMPRESSION: 1. No evidence for cord compression or spinal canal narrowing. 2. Mild fluid accumulation in the right retroperitoneal space, possibly related to history of rhabdomyolysis. 3. Bilateral lobe opacities concerning for pneumonia. 2. No evidence for aortic dissection on this study, however, this study is inadequate to rule out dissection given significant flow related and pulsation artifacts. Given the patient's acute renal failure, would recommend non- contrast time-of-flight MRA to further evaluate vascular structures. Echo: The left atrium is mildly dilated. The left ventricular cavity is mildly dilated. Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. An aortic dissection cannot be excluded. 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. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mildly dilated left ventricular cavity (probably normal when indexed to patient's body size). Normal global and regional biventricular systolic function. No diastolic dysfunction, pulmonary hypertension or significant valvular disease seen. No evidence of aortic dissection however, the sensitivity of trans-thoracic echo in detection of aortic dissection is low. MRA AB: IMPRESSION: 1. No evidence of aortic dissection. 2. Widely patent appearance of both renal arteries. 3. Multifocal consolidation throughout both lungs but predominantly in the lower lobes, with small right-sided pleural effusion CXR: REASON FOR EXAMINATION: Followup of a patient with rhabdomyolysis and acute renal failure. Portable AP chest radiograph was compared to prior study obtained on [2158-10-10]. The lung volumes are lower compared to the prior study with new bibasal linear opacities that might represent atelectasis or aspiration. The more pronounced opacity is on the right and given it's progression since [10-10], [2158], might represent infection. There is no evidence of failure. There is no pneumothorax. The cardiomediastinal silhouette is stable. Brief Hospital Course: 25M with recent cocaine use now with lower extremity weakess with rhabdomyolysis, ARF, Shock Liver, + Troponins # Rhabdomylosis: CK >20K on admission this AM, 10K overnight. Pt received 5L of fluid prior to coming to the floor. U/A with 0-2 RBCs but large blood indicative of myoglobin. Source is potentially in legs given his focal weakness. However no focal finds indicative of necrosis on exam. Lactate WNL. Pt seen by Nephrology that recommended decreasing from 100ccc/hr and then subsequently d/c'd. CKs eventually trended down without any intervention. Patient was discharged with instructions to follow up in renal clinic and with PCP. . # ARF: Pts Cr up to 5.8 from 5.0 at OSH on presentation from presumed normal levels since no baseline levels availbale. Initial etiology potentially mulit-factorial including: glomerular damage secondary to myoglobinuria, pre-renal secondary to cocaine vasoconstriction, ATN secondary to hypotensive and/or ischemia from cocaine as evident by 0-2 granular casts. Pt was anuric on Sunday/Monday, patient had 20cc/hr during his hospital ICU course, and was given Lasix 20mg IV x 1 without change in UOP. Creatinine increased to 11.2 and started to trend down before discharge. He was making good urine and was not dialysed. He will follow up in the renal clinic. # Transaminitis: AST/ALT in >1000 on admission. Etiologies include shock liver in setting of cocaine use, less likley viral hepatitis. During his ICU cours the patients transaminitis improved, TB and INR remained stable. His hepatitis serologies were negative. LFTs improved and were trending down on discharge. . # + Troponins: Trop 0.15 on admission without CP. Pt without known cardiac disease. Etiology potentially ischemia secondary to cocaine with troponins remaining elevated in setting of ARF. No troponins available found from OSH. The pt's transaminases remained elevated in setting of ARF. TTE was performed and ECHO found to have >60%. Possible that patient had small infarct with global preservation of heart function. . # Metabolic Acidosis: Pt presented with Gap Metabolic Acidosis on presentation to E.D. with gap of 16 which resolved to 11 upon arrival to the ICU. Since lactate not drawn prior to closure unclear the etiology. Lactate WNL. Repeat ABG now with very mild respiratory alkalosis with pt slightly tachypnic. The pts GAP improved . # ?PNA: Pt afebrile, without leukocytosis, or increased sputum. CXR and MR [First Name (Titles) ] [Last Name (Titles) ] demonstrated potential evolving PNA. Pt receive Abx on arrival. Abx were held in the setting of low clinical suspicion for PNA. The pt was given insentive Spirometry and remained afebrile. Given his lack of symptoms clinically he was not treated for pneumonia. . # Neurologic Deficits: Patient complained of R Leg weakness and decreased sensation anteriorly. Seen by neurology that stated his deficits were possibly from lumbar plexopathy or upper cervical involvement and unlikely a central involvement. Pt was given acyclovir for ?HSV which was later held by the MICU team. MR of the [Last Name (Titles) ] revealed a R Psoas fluid collection. His strength in his legs increased although was not back to his baseline upon discharge. # Medication changes: Patient started on Docusate and Senna as needed for constipation Started on Metoprolol 50mg [Hospital1 ]. After discharge he was called and sent a letter instructing him not to take metoprolol. Amlodipine 5mg daily Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:30 Capsule(s) Refills:0 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 3. Dextromethorphan Poly Complex 30 mg/5 mL Suspension, Sust.Release 12 hr Sig: Ten (10) ML PO Q12H (every 12 hours) as needed for cough. 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 --> Instructed to not take after discharge. 6. Outpatient Lab Work Check Chem-10 including creatinine. Please fax results to [Hospital 191] clinic attn Dr. [Last Name (STitle) ] fax #[Telephone/Fax (1) 6309] and Dr. [Last Name (STitle) 4920] Fax #[Telephone/Fax (1) 26643]. Discharge Disposition: Home Discharge Diagnosis: Rhabdomyolysis Acute Renal Failure Cocaine Abuse Alcohol Abuse Discharge Condition: All vital signs stable, kidney function improving. Discharge Instructions: You were admitted with acute muscle breakdown (likely caused by cocaine use) that caused damage to your kidneys. Eventually this your kidney began to heal from this damage without dialysis. You should not take cocaine again. You should also avoid medications such as ibuprofen, Advil, or Naproxen until your kidney function returns to normal. You will need to follow up with a new primary care physician and [Name Initial (PRE) ] kidney doctor. You should also decrease your alcohol intake as you are at risk for becoming and alcoholic. You discussed options for treatment with the social worker. New Medications: 1) Metoprolol 50mg one tab twice a day 2) Amlidpine 5mg one tab daily Please take all your medications as prescribed and attend all your follow up appointments. Please call your doctor or return to the emergency room if you notice a sharp decrease in the amount of urine you make, experience chest pain, shortness of breath or any other symptom that concerns you. Followup Instructions: Provider: [Name10 (NameIs) 2483],[First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 191] MEDICAL UNIT Phone:[Telephone/Fax (1) 250] Date/Time:[2158-11-1] 1:00 ICD9 Codes: 5845, 2762, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6317 }	Medical Text: Admission Date: [2166-4-25] Discharge Date: [2166-5-9] Date of Birth: [2120-4-13] Sex: M Service: MEDICINE Allergies: Keflex Attending:[First Name3 (LF) 2160] Chief Complaint: Shortness of breath, pleuritic chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 46 y/o male who is currently incarcerated who was transferred to [Hospital1 18] for further evaluation and management of PNA, pleural effusion, and cirrhosis. Pt states that about 2 weeks ago, he noticed increasing weakness along with chills, SOB, and pleuritic chest pain. He was sent from jail to the ED for further evaluation of the above-described symptoms. Pt oxygen saturation on RA upon arrival to the ED were in the 80s. Oxygenation improved with NC. Initial CXR revealed a large RLL PNA and pleural effusion. He was started on levofloxacin for CAP. He subsequently underwent a CT chest, abdomen, pelvis which revealed cirrhosis, splenomegaly, and a large right pleural effusion along with an infiltrate in the left lobe. Pt is s/p paracentesis x 2. Pt was transferred to [Hospital1 18] for further evaluation and management. . ROS: Positive for night sweats, denies wt loss. Positive for recen fatigue. Positive for pleuritic chest pain and SOB. Denies N/V/D or abdominal pain. Past Medical History: PMH: 1. Chronic hepatitis C, genotype Ib. 2. Hepatitis B 3. Bipolar disorder 4. Polysubstance abuse . PSH: 1. Ankle fracture in [2162] 2. Eye surgery as a child Social History: Polysubstance abuse including h/o tobacco use, cocaine, and alcohol abuse. He is currently incarcerated for unarmed robbery. Family History: N/C Physical Exam: PE: Vitals: T 100.3 BP 108/64 HR 107 RR 39 93% FT with FiO2 50% General: Comfortable, mild respiratory distress. HEENT: NC/AT. PERRLA. EOMI. MM dry. OP clear. Nasal passages with evidence of dried blood. Anicteric sclerae. Neck: No JVD or LAD. Chest: No evidence of spider angiomata. CV: Normal S1, S2 without m/r/g. Pulm: Significantly decreased BS on right. No wheezes. Abd: Soft, distended, evidence of ventral hernia, no fluid wave. Normoactive BS. Ext: No c/c/e. 2+ DP B/L. Skin: B/L palmar erythema. Neuro: A/O x 3. CNsII-XII grossly intact. Good ROM and strength in all 4 extremities. No asterixis. Pertinent Results: Imaging Studies: . [2166-4-25] CXR Moderate right pleural effusion. . [2166-4-26] Abdominal U/S Normal appearing liver. No focal liver lesions. Large right pleural effusion. Splenomegaly. . [2166-4-26] CXR Moderate-to-large right pleural effusion is again demonstrated and probably unchanged allowing for positional differences from semi-upright on the prior exam to upright on the current study. Adjacent atelectasis is present in the right middle and lower lobes. The left lung is clear except for focal opacity at the left base peripherally, likely due to atelectasis. Hemidiaphragm deformity may potentially reflect a small left pleural effusion. . [2166-4-27] CXR Accumulating right pleural fluid. . Acid Fast Bacilli Stains x3 + BAL specimen, pleural fluid stains- All negative. . CHEST (PA & LAT) [2166-5-7] Small stable right pleural effusion and right apical hydropneumothorax. Opacity at the right lung base which may represent atelectasis versus airspace disease. . LIVER CORE BIOPSY- [2166-5-5] Liver, transjugular biopsy: 1. Fragmented biopsy with wide fibrous septa, bile-duct proliferation, and vague nodularity consistent with cirrhosis, trichrome stain evaluated. 2. Mild septal and lobular mononuclear infiltration with scattered apoptotic hepatocytes (grade 2 inflammation). 3. No prominent cholestasis is seen. 4. No fatty change is seen. 5. No iron is seen on special stain Note: The findings are consistent with chronic viral hepatitis. . TRANSJUGULAR HEPATIC WEDGE PRESSURE [2166-5-5]- 24mmhg (normal <12) . [2166-5-9] 06:30AM BLOOD WBC-8.1 RBC-3.63* Hgb-13.4* Hct-38.9* MCV-107* MCH-37.0* MCHC-34.5 RDW-15.5 Plt Ct-213 [2166-5-6] 05:50AM BLOOD Neuts-64.4 Lymphs-24.3 Monos-6.7 Eos-3.8 Baso-0.9 [2166-5-9] 06:30AM BLOOD PT-16.6* PTT-39.4* INR(PT)-1.5* [2166-5-9] 06:30AM BLOOD Glucose-76 UreaN-10 Creat-0.8 Na-135 K-3.9 Cl-105 HCO3-24 AnGap-10 [2166-5-9] 06:30AM BLOOD ALT-103* AST-121* LD(LDH)-260* AlkPhos-133* TotBili-1.6* [2166-5-9] 06:30AM BLOOD Albumin-2.3* Calcium-8.1* Phos-3.9 Mg-2.0 [2166-5-5] 06:10AM BLOOD calTIBC-217* Ferritn-418* TRF-167* [2166-4-25] 02:46AM BLOOD Folate-10.5 [2166-5-2] 04:00PM BLOOD IgM HBc-POSITIVE [2166-4-25] 10:16AM BLOOD HBsAg-POSITIVE HBsAb-NEGATIVE HBcAb-POSITIVE IgM Hepatititis A NEGATIVE [2166-4-25] 10:16AM BLOOD HIV Ab-NEGATIVE [2166-4-25] 10:16AM BLOOD HCV Ab-POSITIVE Hepatitis Be Antigen Positive Hepatitis Be Antibody negative Brief Hospital Course: Mr. [Known lastname ] is a 46 year old male with history of hepatitis C, hepatitis B, and bipolar disorder who is currently incarcerated who was transferred to [Hospital1 18] for further evaluation and management of PNA and pleural effusion. . MICU Course: Pt was transferred from an outside hospital to the [Hospital1 18] MICU for further evaluation and management of a recurrent right pleural effusion and possible PNA. Pt is s/p thoracentesis x 2 at the OSH which revealed a transudative effusion. Pt was started on [Initials (NamePattern4) ] [Last Name (NamePattern4) 10128] of ABx for CAP on [2166-4-20]. Upon arrival to the MICU, the pt was hemodynamically stable. Since admission, the pt was diuresed with Lasix and spironolactone with significant improvement in his oxygen requirement. He completed a course of levofloxacin for CAP which was stopped on [2166-4-27]. BCx, UCx, and SCx have been NGTD. He is being ruled out for TB with 2 sputum cultures. PPD placed on [2166-4-25] was read as negative on [2166-4-27]. Thoracic surgery was consulted and are planning to pursue a VATS procedure on Tuesday. Etiology of pleural effusion is hepatic hydrothorax vs. parapneumonic effusion. Liver was consulted for Hep C/Hep B/Cirrhosis. Liver is recommending VATS prior to consideration of TIPS procedure. Hepatitis serologies and viral load pending. HIV negative. . Hospital course on the Floor: Pt underwent VATS pleuradesis with chest tube placement with evidence for resolution of the effusion. Chest tube placement was complicated by re-expansion pulmonary edema, which resolved with lasix diuresis and high flow oxygen therapy. The patient did not require intubation. The chest tube was removed three days after placement. He developed recurrent pleural effusion despite pleuradesis. Pleural effusion was transudative in nature. Underwent transjugular biopsy for measurement of his hepatic wedge pressure shown to be 24 (normal <12), with biopsy revealing chronic active viral hepatitis (full path results listed above). Hepatitis Be antigen positive with IGM viral load greater than 200,000 copies indicated acute Hep B infection. The patient was started on Adefovir 10mg daily and should continue until follow up with Dr. [Last Name (STitle) ] in Liver Clinic at [Hospital1 18]. It is likely this patient had underlying chronic liver disease, that was well compensated until acute Hep B infection. Pt was started on Spironolactone 100mg daily and lasix 40mg daily diuresis. He was on higher doses, but developed hypotension, and has since been stable on the above regimen. - Serial Chest xrays should be performed to assess for interval change in effusion. - At time of discharge there was no evidence for recurrence of effusion, the patient may require TIPS in the future should this recur given evidence of elevated portal pressures. - Follow up abdominal ultrasound should be considered in the setting of possible ascites that may develop. . 1) Fever/Possible Pneumonia- (AFB negative x3 as above). Developed fevers [5-4] with loculated effusion (However, s/p pleuradecis last week, s/p chest tube placement) Given recent instrumentation he was started on broad coverage for HAP with Vancomycin and Zosyn for HAP [5-4]. His cultures of pleural fluid, sputum, urine and blood all returned negative and his antibiotics were stopped [5-8]. He has been afebrile x48hours and without leucocytosis at time of discharge. . .. 2) Bipolar disorder - Patient was on Doxepin and Lamictal as an outpatient, and had not been taking it for some time. He was given klonopin 0.5 [Hospital1 ] on admission, this was stopped 10 days prior to discharge today, and the patient has been quite stable from a psychiatric standpoint. . Diet- low sodium Medications on Admission: Medications upon transfer: RISS Senna Protonix Spironolactone 12.5 mg PO daily Levofloxacin 750 mg IV daily Atrovent nebs Albuterol nebs Clindamycin 600 mg PO Q8H Zofran PRN Ativan PRN Toradol PRN . Medications as outpatient: Promethazine 25 mg PO Q6H PRN Loperamide 2 mg PRN Zantac 150 mg PO daily Klonopin 1 mg PO BID Lipitor Lamictal 100 mg PO BID Oxycodone 50 mg PO BID Doxepin 100 mg PO QHS Discharge Medications: 1. Adefovir 10 mg Tablet Sig: One (1) Tablet PO Daily (). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: Acute hepatitis B infection Portal hypertension . History of hepatitis C Discharge Condition: Fair- stable on room air, repeat chest xray without evidence of recurrent effusion. Discharge Instructions: You were admitted for pleural effusion related to acute hepatitis B infection. Please take all of your medications only as prescribed. Call your doctor or 911 if you experience any worsening shortness of breath, chest pain, yellowing hands, skin or eyes, nausea or vomiting, or any other concerning symptoms. Followup Instructions: Please keep the following appointment: Liver Clinic at [Hospital1 18], ([Hospital Unit Name ] on [Hospital Ward Name ]) [Name6 (MD) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2166-5-22] 9:45 ICD9 Codes: 486, 5715, 5180, 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6318 }	Medical Text: Admission Date: [2168-8-4] Discharge Date: [2168-8-15] Date of Birth: [2099-6-5] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 69-year-old male with past medical history of cervical spinal surgery in [2153] after complaints of upper extremity sensory loss and shoulder and neck pain. The patient underwent elective surgery for odontoid process removal and fusion of C3 level. Patient presented on [2168-8-3] complaining of bilateral numbness in palmar area of his hands left greater than right x2-3 months and has also been experiencing pain of the occipital region projecting to the back bilaterally particularly after coughing or taking asthma inhalers. The patient was referred to Dr. [Last Name (STitle) 1327] on [6-22] with x-rays of the neck and has presented for elective surgery. On admission, the patient's vital signs were stable. He was afebrile. Neuro exam revealed 4+/5 muscular strength bilateral upper extremities with a slight right drift. Pupils are equal and reactive to light. Patient's sensory exam was decreased to pin prick in the palmar distribution and decreased proprioception in the left upper extremity. Patient had a soft tissue mass around the odontoid process compressing the spinal cord, otherwise note of odontoid degenerative pannus. Patient had transoral resection of the odontoid and associated soft tissues on [2168-8-5]. Patient had a left iliac crest graft during surgery as well. Estimated blood loss was 1200 cc. Patient was transfused 2 units of packed red blood cells in the OR. Patient remained intubated in the PACU, and was transferred to the ICU. Patient remained intubated on propofol drip status post surgery and ICU. On [2168-8-6], the patient was opening eyes to voice, obeying midline commands. Right deltoids were [3-9], left [3-9], biceps [3-9] bilaterally, triceps [4-9] on the right, [3-9] on the left. Myelopathy and weakness was slightly worse status post surgery. Patient had central line placed on [2168-8-6] without complications. Iliac Hemovac drain was D/C'd on [2168-8-7]. Patient remained on propofol drip and remained intubated. The patient was started on subQ Heparin. Hemovac drain was D/C'd on [2168-8-9]. Patient remained on Ancef for 72 hours after drain D/C'd. Patient extubated on [2168-8-10]. Tube feeds were then started postextubation. Patient pulled out feeding tube on [2168-8-11] and was started on TPN. The patient improved neurologically, and was transferred to floor on [2168-8-12]. Patient was seen by Physical Therapy on the floor. Was moving all extremities on [2168-8-14]. Triceps remained 4+ bilaterally. Patient was D/C'd home with followup with Dr. [Last Name (STitle) 1327] on [8-23] with prior x-rays and follow up with Dr. [Last Name (STitle) 1906] in six weeks at [Hospital1 336]. Patient was D/C'd home on ciprofloxacin one tablet twice a day for 10 days and hydromorphone 2 mg tablets 1-4 tablets q.4-6h. p.o. prn. Patient was taking adequate p.o. at time of discharge. [Name6 (MD) 1339] [Last Name (NamePattern4) 1340], M.D. [MD Number(1) 1341] Dictated By:[Last Name (NamePattern1) 27454] MEDQUIST36 D: [2168-9-12] 12:30 T: [2168-9-14] 05:17 JOB#: [Job Number 47846] ICD9 Codes: 2765, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6319 }	Medical Text: Admission Date: [2124-5-9] Discharge Date: [2124-5-16] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2597] Chief Complaint: Near aortic occlusion with severe disabling claudication. Major Surgical or Invasive Procedure: Right axillary-bifemoral bypass and left profunda plasty. History of Present Illness: This elderly lady is status post a right femoral to anterior tibial bypass in the past for an ischemic ulcer of her right foot. This was done 3 years ago. She has been having severe disabling claudication with inability to walk even a few feet and had loss of femoral pulses on exam. An arteriogram was done and showed a large calcific plaque in the infrarenal aorta nearly occluding the aorta with restricted flow into the iliacs, which were also severely diseased. She has one functional kidney. This lesion was not amenable to angioplasty and because of her advanced age and vascular disease, she is not a candidate for an aortobifemoral graft. She was advised to have an axillary bifemoral bypass. Past Medical History: PMH: Htn,Chol,CAD,MI,EF 40-50%,reversible defect on MIBI , pacer,arthritis,Crohn's,CRI PSH: Rt. Fem-AT, b/l THA, CABG Social History: pos smoker pos alcohol Family History: non contributary Physical Exam: HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [Doctor Last Name ], pt, dp lle - palp fem, [Doctor Last Name ], pt, dp Pertinent Results: [2124-5-16] WBC-10.0 RBC-3.60* Hgb-11.4* Hct-34.0* MCV-94 MCH-31.6 MCHC-33.4 RDW-15.6* Plt Ct-171 [2124-5-16] PT-13.3* PTT-27.5 INR(PT)-1.2* [2124-5-16] Glucose-182* UreaN-33* Creat-1.0 Na-141 K-4.7 Cl-108 HCO3-25 AnGap-13 [2124-5-16] Calcium-8.3* Phos-2.2* Mg-2.3 [2124-5-9] Glucose-114* Lactate-1.4 Na-142 K-3.7 Cl-113* [2124-5-9] Hgb-9.0* calcHCT-27 O2 Sat-75 [2124-5-10] freeCa-1.15 [2124-5-14] 12:44 PM UNILAT LOWER EXT VEINS LEFT PO FINDINGS: Grayscale and color Doppler son[Name (NI) 1417] of the left lower extremity including common femoral, superficial femoral, and popliteal veins was performed. Intraluminal thrombus was not identified. Normal flow, augmentation, and compressibility was demonstrated. IMPRESSION: No evidence for DVT. [2124-5-13] 8:54 PM CHEST (PORTABLE AP) Increased alveolar opacities are seen in the right upper lobe and similar appearance to a lesser extent is seen in the left with some perihilar prominence. These appearances could be probably due to failure but underlying pneumonia could give a similar appearance. There is no evidence of effusion. No pneumothorax is present. IMPRESSION: Probable failure, IJ line in satisfactory position. Cardiology Report ECHO Study Date of [2124-5-10] MEASUREMENTS: Left Atrium - Long Axis Dimension: 4.1 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 6.4 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 6.2 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.7 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.8 cm Left Ventricle - Fractional Shortening: 0.16 (nl >= 0.29) Left Ventricle - Ejection Fraction: 20% (nl >=55%) Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm) Aorta - Ascending: 2.5 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A Ratio: 1.80 Mitral Valve - E Wave Deceleration Time: 199 msec TR Gradient (+ RA = PASP): 36 mm Hg (nl <= 25 mm Hg) INTERPRETATION: LEFT ATRIUM: Mild LA enlargement. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Severe global LV hypokinesis. Severely depressed LVEF. TVI E/e' >15, suggesting PCWP>18mmHg. TVI e'<0.08m/s c/w elevated LV filling pressures. LV WALL MOTION: Regional LV wall motion abnormalities include: mid anteroseptal - akinetic; basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; septal apex- akinetic; inferior apex - akinetic; apex - akinetic; RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild to moderate ([12-27]+) MR. TRICUSPID VALVE: Moderate [2+] TR. Mild PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions: 1. The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Tissue velocity imaging demonstrates an e' of <0.08m/s c/w an elevated left ventricular filling pressure (>12mmHg). Resting regional wall motion abnormalities include inferolateral and inferior, apical and anteroseptal along with apical anterior akinesis. 3.Right ventricular chamber size is normal. 4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation seen. 5.The mitral valve leaflets are mildly thickened. Mild to moderate ([12-27]+) mitral regurgitation is seen. 6. Moderate [2+] tricuspid regurgitation is seen. 7.There is mild pulmonary artery systolic hypertension. 8.There is no pericardial effusion. [2124-5-11] 1:52 PM RENAL U.S. Reason: ACUTE RENAL FAILURE, EVAL HYDRO/FLOW. CLINICAL INDICATION: 88-year-old female with acute renal failure. The patient volunteered a history of congenitally absent right kidney and indeed no renal tissue can be seen in the expected right renal fossa. A small right effusion was noted incidentally. The left kidney measures 11.7 cm in length and is relatively normal in appearance. There are no stones, signs of hydronephrosis, or renal masses seen. Color flow Doppler demonstrates flow within the kidney but more precise Doppler cannot be performed due to the lack of the patient's ability to breath-hold. CONCLUSION: History of congenitally solitary left kidney. The left kidney appears to be within normal limits on this portable examination Brief Hospital Course: Pt admitted on [2124-5-9] Pt underwent a Right axillary-bifemoral bypass and left profunda plasty. pt tolerated the procedure, there were no complications. Extubated in the OR. Transfered to the PACU in stable condition. Once recovered from anesthesia. Pt transfered to the VICU in stable condtion Pt had a normal post operative course without complications. On DC pt is stable taking PO / ambulating / urinating / pos bm Medications on Admission: ASA 325, Lasix 20', Coreg 20'', Lisinopril 10", Asacol, Lexapro 10', Simvastatin 10', Betoptic Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H (Every 3 to 4 Hours) as needed. 7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Lexapro 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Renaissance Garden @ [Location (un) ] Discharge Diagnosis: Near aortic occlusion with severe disabling claudication. Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass 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 [1-28] 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: Call Dr[Doctor Last Name ] office and schedule an appointment for 2 weeks. He can be reached at [Telephone/Fax (1) 3121] Completed by:[2124-5-16] ICD9 Codes: 5845, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6320 }	Medical Text: Admission Date: [2140-3-24] Discharge Date: [2140-4-4] Date of Birth: [2056-8-22] Sex: F Service: SURGERY Allergies: Demerol / Droperidol / Penicillamine / Streptomycin / Ampicillin Attending:[First Name3 (LF) 1] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy, extensive lysis of adhesions, small bowel resection with reanastomosis, repair recurrent ventral hernia. History of Present Illness: Mrs. [Known lastname 104299] is an 83yo female with [Hospital 10224] medical and surgical problems. She has a known h/o recurrent ventral hernia. She presented to [Hospital1 18] ED with complaints of abdominal pain, N/V x 3 hours. She reported the pain to be similar to the prior pain that she had with previous small bowel obstructions. She last reports passing flatus the night before presentation to the ED, but no flatus since. She was admitted to the surgery service for further evaluation. . During work-up in ED, the patient was found to have a prolonged QT interval near 600. Of note, patient had dose of Flecanide recently increased. She was also hypokalemic, KCL down to 2.9 on presentation Past Medical History: Hyperlipidemia: [8-/2139] LDL 114 HDL 73 Chol 209 TG 108 Hypertension, labile blood pressure Diastolic left ventricular dysfunction with EF >55% Renal Insufficiency: eGFR 50 Stage 3A (most likely [1-25] HTN) Chronic chest pain, clean coronary arteries by [2127] catheterization Paroxysmal AFib Esophageal spasm Gout Gastroesophageal reflux disease Status TAH-BSO in [2121] for menorrhagia. Chronic vaginal itching, now on Premarin cream. Small Bowel Obstruction in [2123], [2126] and [2138] s/p adhesion lysis in [9-/2139] Migraine headaches H/o hysterectomy (abdominal) H/o abdominal hernia with repair Gallstones Social History: Social history is significant for the absence of current tobacco use and patient states she has never smoked. There is no history of alcohol abuse or illegal substance use. Patient lives in [Location 583], MA. She is a retired dentist and immigrated from [Country 532] and [Location (un) 3156] in the [2110]. Family History: There is no family history of premature coronary artery disease or sudden death. [Name (NI) ] mother had HTN. Physical Exam: At Discharge: Vitals: GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB, decreased bases bilaterally. no w/r/r ABD: soft slightly distended, appropriately TTP Incision: midline abdominal OTA with staples, mild erythema at staples sites with scant dry blood, otherwise CDI GI/GU: diaper in place due to urinary frequency/incontinence. Rectal tube placed on [2140-4-2] for frequent loose brown stool. Intact. no rectal irritation/excoriation noted Skin: perineal skin free of rash and excoriation Extrem: B/L 1+ pedal edema. +DP's Pertinent Results: [2140-3-23] 09:05PM BLOOD WBC-8.1 RBC-4.22 Hgb-11.8* Hct-34.4* MCV-81* MCH-27.9 MCHC-34.2 RDW-15.5 Plt Ct-201 [2140-3-25] 04:43AM BLOOD WBC-7.7 RBC-3.74* Hgb-10.6* Hct-31.1* MCV-83 MCH-28.3 MCHC-34.1 RDW-15.9* Plt Ct-153 [2140-3-27] 04:11AM BLOOD WBC-11.2# RBC-3.84# Hgb-10.9# Hct-33.2# MCV-87 MCH-28.5 MCHC-32.9 RDW-15.2 Plt Ct-175 [2140-3-29] 02:18AM BLOOD WBC-8.5 RBC-3.11* Hgb-9.0* Hct-27.3* MCV-88 MCH-28.9 MCHC-32.9 RDW-15.3 Plt Ct-175 [2140-4-1] 04:49AM BLOOD WBC-7.0 RBC-3.13* Hgb-8.7* Hct-26.7* MCV-85 MCH-27.6 MCHC-32.4 RDW-15.3 Plt Ct-195 [2140-4-3] 03:34AM BLOOD WBC-10.2 RBC-3.49* Hgb-9.8* Hct-28.6* MCV-82 MCH-28.0 MCHC-34.2 RDW-15.7* Plt Ct-255 [2140-4-4] 05:50AM BLOOD WBC-12.0* RBC-3.75* Hgb-10.2* Hct-30.9* MCV-83 MCH-27.2 MCHC-33.0 RDW-15.9* Plt Ct-318 [2140-3-23] 09:05PM BLOOD PT-32.3* PTT-35.4* INR(PT)-3.4* [2140-3-25] 04:43AM BLOOD PT-42.0* PTT-44.0* INR(PT)-4.6* [2140-3-26] 06:20PM BLOOD PT-18.1* PTT-35.0 INR(PT)-1.7* [2140-3-27] 12:40AM BLOOD PT-17.3* PTT-32.7 INR(PT)-1.6* [2140-3-28] 02:03AM BLOOD PT-15.7* PTT-37.3* INR(PT)-1.4* [2140-3-23] 09:05PM BLOOD Glucose-109* UreaN-77* Creat-2.1* Na-137 K-2.9* Cl-90* HCO3-33* AnGap-17 [2140-3-24] 08:51PM BLOOD Glucose-118* UreaN-65* Creat-1.6* Na-144 K-4.0 Cl-105 HCO3-28 AnGap-15 [2140-3-26] 02:25AM BLOOD Glucose-104 UreaN-41* Creat-1.1 Na-150* K-3.3 Cl-109* HCO3-32 AnGap-12 [2140-3-28] 03:29PM BLOOD Glucose-106* UreaN-31* Creat-1.1 Na-152* K-3.7 Cl-114* HCO3-31 AnGap-11 [2140-3-29] 02:18AM BLOOD Glucose-105 UreaN-29* Creat-1.0 Na-153* K-3.7 Cl-116* HCO3-30 AnGap-11 [2140-3-29] 12:46PM BLOOD Glucose-128* UreaN-27* Creat-0.9 Na-152* K-3.8 Cl-116* HCO3-28 AnGap-12 [2140-4-2] 04:03AM BLOOD Glucose-94 UreaN-17 Creat-0.8 Na-141 K-3.5 Cl-104 HCO3-29 AnGap-12 [2140-4-3] 06:53AM BLOOD Glucose-80 UreaN-16 Creat-0.7 Na-141 K-3.5 Cl-103 HCO3-30 AnGap-12 [2140-4-4] 05:50AM BLOOD Glucose-101 UreaN-12 Creat-0.8 Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [2140-3-23] 09:05PM BLOOD Albumin-4.1 [2140-3-24] 04:30AM BLOOD Calcium-8.5 Phos-6.2# Mg-2.4 [2140-3-24] 08:51PM BLOOD Calcium-8.1 Phos-4.7* Mg-3.2* [2140-3-27] 12:13PM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1 [2140-3-28] 02:03AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.4 [2140-3-28] 03:29PM BLOOD Calcium-8.3* Phos-4.2 Mg-2.5 [2140-4-2] 04:03AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.0 [2140-4-3] 06:53AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.8 [2140-4-4] 05:50AM BLOOD Calcium-7.9* Phos-3.8 Mg-2.2 . CDIFF culture negative x 2 on [4-3] & [2140-4-4] . MRSA culture negative x 2 on [3-24] & [2140-3-26] . Urine culture negative on [2140-3-23] . CT ABDOMEN W/O CONTRAST Study Date of [2140-3-24] 12:43 AM IMPRESSION: 1. Findings consistent with small bowel obstruction at the level of the ventral abdominal wall outpouching (likely attenuation of peritoneum rather than true hernia), with distal decompression. No perforation. 2. Cholelithiasis without cholecystitis. 3. Atherosclerotic calcification. . Pathology Examination Procedure date [2140-3-26] DIAGNOSIS: Small bowel, segmental resection: Segment of small bowel with fibrous adhesions, one incorporating synthetic mesh material, and focus of ischemic necrosis. Tissue at margins appears viable. Clinical: Bowel obstruction. . CHEST (PA & LAT) Study Date of [2140-3-31] 4:16 PM IMPRESSION: New left perihilar region faint ground-glass opacity concerning for aspiration. Persistent bibasilar atelectasis with bilateral pleural effusions. . [2140-4-1]-Video swallow completed via CT scan Brief Hospital Course: Mrs. [Known lastname 104299] was underwent a CT scan in the ED for c/o abdominal pain. Her CT scan revealed a small bowel obstruction near her known ventral hernia which was reducible at the beside. General surgery was consulted, and she was admitted to the ICU found to have junctional brady rhythm with prolonged QT (QTc near 600) in context of recent increase in Flecainide dose per PCP. [Name10 (NameIs) ] was monitored in the ICU for a few days. Cardiology was consulted, and recommended holding beta blocker, and flecanide. Coumadin was also held in case of need for surgical intervention. In addition, her Potassium of 2.9 and Magnesium were aggressively repleted. Her cardiac status stabilized after undergoing diuresis with Diamox, however, her abdominal exam worsened over the following 48 hours after a few days of conservative management with NPO/NGT for decompression and IV antibiotics. . She was taken to the OR, and underwent lysis of adhesions and small bowel resection. Her operative course was uncomplicated, routinely observed in the PACU, and transferred back to [Hospital Unit Name 153] where cardiac monitoring and electrolyte correction occurred. She was transfused post/op with 2 U PRBC. HCTs remained stable thereafter. She was extubated and wean off pressors, and transferred to Stone 5. . Physical therapy was consulted upon transfer to Stone 5 for expected discharge to REHAB due to physical deconditioning. Remained NPO until bowel function resumed. Electrolytes checked and repleted daily. Hyponatremia resolved gradually. Started on sips of water, advanced to clear liquids. Noted to have difficulty swallowing and clearing secretions. Bedside Swallow study conducted. She was taken for Video swallow, and cleared for regular diet with thick liquids, and whole pills in puree. Patient reported passing flatus, and incontinent of loose, brown stools. Rectal tube inserted on [2140-4-2] due to frequencey of bowel movements, and risk for compromise of perineal skin. Rectal tube should be removed by Friday [2140-4-8] to prevent rectal breakdown. Diet advanced to regular food. Reported intermittent nausea and lack of appetite which has persisted throughout post-op recovery. Foley was removed. She was able to urinate, incontinent of urine. UA and urine cultures negative. . Mobility compromised. She requires [1-26] people for ambulation and transfer. Requires aggressive physical Rehab, and monitoring of Nutritional, bowel, and cardiac status. She should follow-up with PCP (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2450]), and cardiology to address cardiac events (prolonged QT interval) during this admission. [Hospital 197] clinic at [Hospital1 18] manages the patients coumadin dosing for PAF. Coumadin 2mg Po given at [2140-4-4]. INR should be checked on [2140-4-5], and daily until therapeutic. Goal INR [1-26]. . She will require to have the incisional staples removed in another week. This can be done per REHAB facility after authorization per Dr. [Last Name (STitle) ] (surgeon). Medications on Admission: Allopurinol 100', lipitor 20', colchicine prn, DiltSR 240', Flonase 50", Lasix 80", Diazepam 5 prn, Gabapentin 600HS/300AM/300PM Hydralazine 50 TID, ToprolXL 100 daily, Nitroglycerin prn, prilosec 40 daily, zoloft 100', Spironolactone 25', ASA 81', Coumadin 1mgMWF 2mg other days Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO Q 12H (Every 12 Hours). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough for 2 weeks. 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Gout flare/pain. 7. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 12. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 13. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 16. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain for 2 weeks: Do not exceed 4000mg in 24hrs. 19. Coumadin 1 mg Tablet Sig: Titrate dose per INR Tablet PO once a day: Goal INR [1-26]. Usual dosing MWF-1mg,other days 2mg. 20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. 21. Zofran 2 mg/mL Solution Sig: Two (2) Intravenous every eight (8) hours as needed for nausea for 1 weeks. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Primary: Pre/op prolonged QT interval-managed in ICU & cardiology consulted Recurrent incisional hernia reduced intestine post-op dysphagia-evaluated per Speech & Swallow Specialist post-op blood loss anemia . Secondary: Hx of SBOx3, Hchol, HTN, labile blood pressure,[Last Name (un) 6043] LV dysfn, CRI, Chronic chest pain, Paroxysmal AFib, Esoph spasm, Gout, GERD, migraines, gall stones Discharge Condition: Stable Tolerating a regular diet with Ensure supplements. Tolerating oral medications, whole, if purees. Adequate pain control with oral medication. Discharge Instructions: For REHAB: Weigh patient every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: none. Contact PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2450], with any concerns. . Please call Dr. [Last Name (STitle) ] or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * 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. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow-up appointment with Dr. [Last Name (STitle) ]. Staples may be removed at Rehab facilit. Please contact Dr.[Name (NI) 10946] office to authorize removal. Steri strips will be applied. -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Medications: 1. Coumadin: Continue to dose patient daily according to INR level. Goal INR [1-26]. Usual home dosing is 1 mg MWF, and 2mg other days of week. Patient is followed per [Hospital 18] [Hospital 197] clinic. Followup Instructions: 1. Please follow-up with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 9] in [12-25] weeks for removal of staples. 2. Follow-up with PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2450], [Telephone/Fax (1) 250], 1-2 weeks after discharge from REHAB. 3. Follow-up with [Hospital 197] Clinic([Telephone/Fax (1) 10844]-[Hospital1 18] [Location (un) 86]-after discharge from REHAB for continued management of COUMADIN. . Previous appointments: 1. Provider: [Name Initial (NameIs) 703] (H3) GENERAL 2 [Name Initial (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2140-4-5] 9:30 2. Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2140-4-7] 8:00 3. Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2140-4-7] 8:15 Completed by:[2140-4-4] ICD9 Codes: 5849, 2761, 2760, 2851, 2724, 4280, 2768, 5859, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6321 }	Medical Text: Admission Date: [2111-5-16] Discharge Date: [2111-5-18] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: 84 year old female with recent diagnosis of adeno CA of pancreatic biliary origin with pulm and liver mets, history of diverticulosis and colonic polyps, AF and recently d/c'd off coumadin, presents from [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] after having large amount of bleeding (500cc) with clots per rectum; son elected to send in; would want transfusion; DNR/DNI status per prior hospitalization. . In the ED, HCT 18 and passing large BRBPR (450cc), Right groin line placed. 1 Liter, and 1 u PRBC. BP 80's HR 120's. unknown UO. Mentation, speaking with son. EKG . After family meeting in [Hospital Ward Name 332] MICU today it was decided that she and the family would not want aggressive measures including excessive medications, endoscopy, lines, or surgery. Pt. transferred to floor with goals of care CMO. Past Medical History: 1. Colon Polyps - s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [10-26] --Sigmoid polyp, (biopsy): Adenoma. --Grade 1 internal hemorrhoids. --Diverticulosis of the entire colon. 2. Diverticulosis 3. Type 2 DM 4. S/P CVA - on coumadin 5. Tachybrady s/p pacer (EF >55%, [11-24]+ MR, 1+TR, mod pulm HTN - [5-26]) 6. Glaucoma 7. Cataracts 8. OSA 9. Anemia-source thought to be genitourinary Social History: The patient lives alone. She has a caretaker overnight and goes to daycare during the day. She walks with a cane. She does not have a history of alcohol/tobacco use. Family History: Unknown if GI malignancy, no CAD/DM Physical Exam: Physical Exam: Deferred exam as pt. resting comfortably CMO, many family members at her bedside Pertinent Results: [2111-5-16] 11:04PM WBC-24.1* RBC-4.06# HGB-11.2# HCT-32.9* MCV-81* MCH-27.4# MCHC-33.9# RDW-19.6* [2111-5-16] 11:04PM PLT SMR-LOW PLT COUNT-82* [2111-5-16] 05:12PM POTASSIUM-5.0 [2111-5-16] 05:12PM CALCIUM-7.9* [2111-5-16] 05:12PM HCT-31.4* [2111-5-16] 05:12PM PT-16.9* PTT-31.4 INR(PT)-1.6* [2111-5-16] 12:54PM LACTATE-4.0* [2111-5-16] 06:20AM GLUCOSE-339* UREA N-57* CREAT-1.3* SODIUM-134 POTASSIUM-6.1* CHLORIDE-100 TOTAL CO2-20* ANION GAP-20 [2111-5-16] 06:20AM ALT(SGPT)-45* AST(SGOT)-75* ALK PHOS-402* AMYLASE-20 TOT BILI-1.5 [2111-5-16] 06:20AM LIPASE-5 [2111-5-16] 06:20AM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-2.5* MAGNESIUM-3.2* Brief Hospital Course: # GIB: likely lower either from diverticular bleed or colonic polyp -initially transfused to support hct and BP, but family decided they did not want lines/pressors/endoscopy/surgery so pt. was made CMO in the [Hospital Unit Name 153]. -plan for CMO per family meeting in [Name (NI) 153], pt. deceased [5-17] with family at bedside . # Hypotension: In setting of GIB. CMO -no further vitals . #Zoster: Morphine IV gtt to control pain . #Pulm edema: scopolamine patch prn -can add additional patches prn . # Biliary CA: CMO, goals discussed with family at bedside -morphine gtt to control pain -scopolamine patch -Palliative care consult in am * Pain: Morphine gtt prn -Palliative care consult . FEN: NPO, mouth care and swabs prn Access: Fem line: . Code Status: DNR/DNI and full CMO, no further transfusions/blood draws, control pain with morphine . Communication: multiple family members at bedside, no formal HCP, but in event of death contact son, [Name (NI) ] [Name (NI) ], at [Telephone/Fax (1) 36520] (cell), or [Last Name (LF) 36521], [First Name8 (NamePattern2) 36522] [Known lastname ], at [Telephone/Fax (1) 36523] (cell) Medications on Admission: Lopressor 25mg po BID Colace 100mg po BID ASA 81mg po qd MOM [Name (NI) 36524] 15mg [Name2 (NI) ] qd RISS Gabapentin 300mg TID Off Coumadin x 10days. Discharge Medications: deceased Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Lower Gastrointestinal Bleed Herpes Zoster Rash Metastatic Adenocarcinoma Congestive Heart Failure Discharge Condition: deceased Discharge Instructions: patient deceased, family made patient comfort measures only Followup Instructions: patient deceased, family made patient comfort measures only [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] ICD9 Codes: 5789, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6322 }	Medical Text: Admission Date: [2118-12-15] Discharge Date: [2119-1-4] Date of Birth: [2052-6-27] Sex: M Service: CHIEF COMPLAINT: Hypothermia. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old gentleman who was found outside his home with a core temperature of 82 degrees. He was transferred to the [Hospital1 188] Emergency Department for further resuscitation. The patient was initially treated in the Trauma Bay. A three-way bladder irrigation system was set up. A left chest tube was placed, and a nasogastric tube was placed. The nasogastric tube, chest tube, and three-way bladder irrigation system was used to lavage warm water in order to rewarm the patient. During the patient's resuscitation, he became agitated and he was intubated for airway protection. During the placement of the three-way catheter there was concern of a false passage. Urology was called to evaluate the situation. They performed a bedside ureterocystoscope which showed two to three false passages. The urethralcatheter was left in place, and the Foley was placed to gravity. PAST MEDICAL HISTORY: 1. Ethanol abuse. 2. History of poor nutrition. 3. Questionable baseline dementia. PAST SURGICAL HISTORY: None. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Initial physical examination revealed the patient's temperature was 29.9 Celsius, his pulse was 100, his blood pressure was 107/67, his heart rate was 116, his respiratory rate was 26, and no oxygen saturations recorded on 6 liters by face mask. Cardiovascular examination revealed a regular rate and rhythm. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. There was questionable cyanosis. There was no edema. The pupils were equal and reactive. The extraocular muscles were intact. The tympanic membranes were clear. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's initial hematocrit was 27. Coagulations revealed his prothrombin time was 13, his partial thromboplastin time was 28, and his INR was 1.2. Initial arterial blood gas was 7.3/16/347/8 and -15. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Trauma Service with the initial diagnosis of hypothermia. After transfer to the Intensive Care Unit, the patient was noted to have a rigid and distended abdomen with the findings of a large amount of ascites/free fluid within in the intraperitoneal cavity and free air within the space of Retzius and/or intraperitoneal. It was decided the patient would go to the operating room for an exploratory laparotomy. In the operating room, the bowel was noted to be normal. The fluid was clear with no signs of pus, succus, and/or blood. Urology was consulted for the evaluation of a possible bladder injury. A dye study and retrograde cystogram were performed which did not show any signs of extravasation within the peritoneum and/or retroperitoneal space. The abdomen was left opened. The patient was transferred back to the Intensive Care Unit in stable condition. On hospital day four, the patient was brought back to the operating room and had an exploratory laparotomy and closure of his abdominal wall. The patient's metabolic acidosis improved over time. The patient's bladder pressure following the abdominal closure was 8 cm of water. The Podiatry Service was also consulted at this time for debridement of a keratotic lesion on his left foot which was done without complications. At the end of the removal of the keratotic lesion, Podiatry signed off. The patient was started on total parenteral nutrition for nutrition while his bowel function returned. The patient also had a bronchoscopy to evaluate his pulmonary function which showed purulent secretions from the left lower lobe. A bronchoalveolar lavage was performed. On [12-20], a chest tube was placed in the right chest to relieve an increasing effusion. The procedure was done under sterile technique without complications. Throughout the patient's hospitalization, he intermittently dropped his PO2 into the 60 to 40 range. The patient had a computed tomography angiogram which was negative and multiple chest x-rays which showed a diffuse interstitial pattern versus pneumonia. The patient was started on Zosyn as the bronchoscopy washings were growing gram-negative rods. On postoperative days seven and eight, the patient continued to improve his respiratory status. The patient was transfused several units of packed red blood cells for a hematocrit of less than 30. On postoperative day eight, the patient was extubated. The patient was then transferred to the floor and had a bedside swallow evaluation which concluded that the patient should remain nothing by mouth at this time with an nasogastric tube for nutrition. On the floor, the patient became tachypneic and required suctioning, chest physical therapy, and face mask. The patient's oxygen saturations dropped into the 80s with a nonrebreather. At this time, the patient was transferred to the Intensive Care Unit for further monitoring and possible intubation. An arterial line was placed at this time. The patient was given Ativan for agitation. He was continued on a pulmonary toilet as well as chest physical therapy. Tube feeds were on hold. Intravenous fluids were started. A chest x-ray showed a diffuse interstitial pattern; acute respiratory distress syndrome versus pneumonia. Shortly after transfer to the Intensive Care Unit, the patient was intubated. During that time, the patient spiked a temperature and was pan-cultured. His white blood cell count also went from 8 to 15. It was thought that the patient may have aspirated and/or had a continuing process from his initial insult. At that time, the patient was evaluated for tuberculosis and also for Legionella. The tuberculosis was negative. The Legionella was still pending at the time of this dictation. The patient was also started on Levophed for presumed systemic inflammatory response syndrome versus sepsis. The patient's tachycardia which started prior to his Intensive Care Unit admission (in the 130 range) continued. It did not respond to fluid boluses or sedation but did respond to diltiazem as a rate control [Doctor Last Name 360]. The patient was ruled out for a myocardial infarction. An electrocardiogram was normal. His troponin was less than 0.03. Also, with a question of line sepsis, the patient's central line was removed and a new pulmonary artery catheter line was placed with a new site. The patient was started on broad spectrum antibiotics; particularly vancomycin 1000 mg and Zosyn 4.5 mg three times per day. During the patient's Intensive Care Unit stay, he required Levophed for blood pressure control to keep his mean above 60. He also remained tachycardic which then responded to propofol and/or diltiazem. The patient's urine output during the entire time remained brisk. Urine electrolytes and sodium electrolytes were not consistent with diabetes insipidus. During this time, the patient was also checked for adrenal insufficiency and pheochromocytoma; both of which were within the normal range. The patient had a repeat echocardiogram done by the anesthesia cardiologist which showed no valvular dysfunction and a normal ejection fraction. The patient was continued on broad spectrum antibiotics. His respiratory function improved over the next several days. On [12-29], the Swan-Ganz catheter was changed to a triple lumen catheter. The patient's propofol was weaned. He remained tachycardic in the 100 to 120 range. As his Levophed was also weaned, his mean reached a plateau of between 55 and 60 range. On [1-1], a Medical Intensive Care Unit consultation was obtained to evaluate his tachycardia, hypotension, and brisk urine output as all tests had been negative. On [1-2], the patient was extubated without incident. The patient remained extubated and continued to do well. During this time, the patient was continued on tube feeds. After the patient was to goal with the tube feeds, he had an increased amount of diarrhea. Clostridium difficile was negative times five. At this time, Imodium was added to the tube feeds to decrease the diarrhea. If this does not work, he will have his tube feeds decreased to half strength. On [1-3], the patient was stable enough to be transferred to the floor. The patient was off all pressors, and his agitation was controlled with Ativan. Physical examination on transfer to the floor revealed the patient's temperature maximum was 100.3 degrees Fahrenheit, 98, his blood pressure was 104/54, his heart rate was 119, his respiratory rate was 20, and his oxygen saturation was 96%. Ins-and-outs revealed 2900 in and 2800 out. Laboratories revealed the patient's white blood cell count was 8.4. His hematocrit was 31.3. Chemistry-7 revealed the patient's sodium was 141, potassium was 4.1, chloride was 113, bicarbonate was 19, blood urea nitrogen was 15, creatinine was 0.7, and his blood glucose was 112. His calcium was 7.8, his magnesium was 2.4, and his phosphate was 2.1. The patient was alert and followed commands throughout his extremities. The pupils were equal and reactive. Respiratory examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm with tachycardia. The abdomen was soft, nontender, and nondistended. There were positive bowel sounds. The incision was clean, dry, and intact. There was 1+ edema. Over the course of the [Hospital 228] hospital course, his platelets also were low in the range of 40 to 50. The patient had a heparin-induced thrombocytopenia which was sent and was negative. Within several days of the initial hospitalization, his platelets drifted up to the 50 to 100 range and were not an issue throughout the remainder of his hospitalization. DISCHARGE DIAGNOSES: 1. Hypothermia. 2. Status post chest tube placement for warm water lavage. 3. Status post three-way Foley placement for warm water lavage. 4. Status post right chest tube placement for effusion. 5. Acute respiratory distress syndrome with pneumonia. 6. Hypotension. 7. Status post exploratory laparotomy with retrograde cystogram which was normal. 8. Status post exploratory laparotomy with closure of the abdomen. 9. Poor nutrition. 10. History of alcohol abuse. 11. Questionable dementia. [Last Name (LF) ],[First Name3 (LF) ] E. M.D. [MD Number(1) 10637] Dictated By:[Last Name (NamePattern4) 959] MEDQUIST36 D: [2119-1-4] 07:39 T: [2119-1-4] 07:46 JOB#: [Job Number 52401] ICD9 Codes: 5119, 5185, 486, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6323 }	Medical Text: Admission Date: [2123-6-29] Discharge Date: [2123-7-4] Date of Birth: [2058-7-31] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: This is a 64-year-old male with a known history of three vessel coronary artery disease which was confirmed by cardiac catheterization in [2123-6-3] who was referred for coronary artery bypass graft procedure. The patient has an extensive history of dyspnea on exertion, fatigue, and episodes of paroxysmal nocturnal dyspnea and abnormal EKGs dating back to at least [2120-10-4]. The patient first documented catheterization on [2120-10-23] which demonstrated three vessel coronary artery disease, for which the patient elected to undergo medical therapy only. Follow-up cardiac catheterization in [2122-12-4] demonstrated persistent and advancing coronary artery disease; at this point, the patient again declined bypass surgery, stating that he preferred to wait for the introduction of coated stents. Repeat cardiac catheterization on [2123-6-17] demonstrated once again persistent three vessel coronary artery disease with 60-70% stenosis of the left anterior descending artery at its origin, 40% proximal narrowing in the obtuse marginal, up to 70% stenosis in the midvessel portion of the right coronary artery. Calculated ejection fraction was noted to be 40%. Following this procedure, the patient subsequently changed his mind regarding surgical intervention and consented to undergo coronary artery bypass graft procedure on [2123-6-29]. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Diabetes. 4. Gastroesophageal reflux disease. 5. Hepatitis as a child. 6. Diabetic retinopathy. 7. Anemia. 8. History of alcohol abuse in the past. 9. Extremity arthritis. 10. Prostate cancer, awaiting surgery. 11. Myelodysplasia. ADMISSION MEDICATIONS: 1. Aspirin, enteric coated 81 mg q.d. 2. Lantus insulin 30 units q.p.m. 3. Sliding scale Novalog insulin panel with meals. 4. Cardia XT 240 mg q.d. 5. Enalapril 20 mg p.o. q.d. 6. Protonix 40 mg p.o. q.d. 7. Roxicet t.i.d. 8. MS Contin 15 mg p.o. b.i.d. 9. Plavix 75 mg p.o. q.d. 10. Neurontin 300 mg p.o. q.d. SOCIAL HISTORY: The patient is single and lives alone. The patient works as a mechanical estimator. HOSPITAL COURSE: On [2123-6-29], the patient underwent a quadruple coronary artery bypass graft procedure. Anastomosis included from the LIMA to the LAD, from the aorta via saphenous vein graft to the right PDA, and saphenous vein graft to the distal LAD and saphenous vein graft to the OM. Bypass time was noted to be 85 minutes and cross clamp time was noted to be 71 minutes. The patient's pericardium was left open; lines placed included an arterial line and a Swan-Ganz catheter; both ventricular and atrial wires were placed; both mediastinal and left pleural tubes were placed. The patient was subsequently transferred to the Cardiac Surgery Recovery Unit, intubated, for further evaluation and management. On transfer, the patient's mean arterial pressure was 85, P80 18, [Doctor First Name 1052] 25. The patient was noted to be in normal sinus rhythm with a heart rate of 88 beats per minute. Drips on transfer included propofol, Neo-Synephrine, and aprotinin. Shortly following arrival in the CSRU, the patient was successfully weaned and extubated without complication and was subsequently advanced to oral intake without incident. While in the CSRU, the patient was noted to demonstrate progressively diminishing platelet counts, after which all heparin products were ceased and the patient was sent for heparin-induced thrombocytopenia antibody screen which subsequently proved negative. The patient thereafter demonstrated a gradually increasing platelet count for the duration of his stay without any further dips in his values. On postoperative day number two, the patient's lines and chest tubes were removed without complication and the patient was subsequently cleared for transfer to the floor. The patient was thereafter admitted to the Cardiothoracic Service under the direction of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. While on the floor, the patient progressed well clinically to the time of his discharge. The patient was evaluated by Physical Therapy, who cleared the patient for eventual discharge to home following resolution of the acute medical issues. The patient's Foley catheter was removed without complication and he was subsequently noted to be independently productive of urine for the duration of his stay. The patient's pacer wires were removed without incident and the patient was noted to have adequate pain control via oral pain medications following a consultation from the Chronic Pain Service. On postoperative day number four, the patient was noted to demonstrate a gradual dip in his hematocrit to 22.7, for which he received 1 unit of packed red blood cells which was irradiated and rendered leukopoor. Discussions were with the Hematology/Oncology service. The patient subsequently demonstrated an adequate bump in his hematocrit and demonstrated no evidence of active bleeding. Following clearance by Physical Therapy, the patient was subsequently cleared for discharge to home on postoperative day number five, [2123-7-9], with instructions for follow-up. CONDITION ON DISCHARGE: The patient is to be discharged to home with instructions for follow-up. STATUS AT DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d. 2. Lasix 20 mg p.o. b.i.d. times ten days. 3. Potassium chloride 20 mEq p.o. q.d. times ten days. 4. Enteric coated aspirin 325 mg p.o. q.d. 5. Colace 100 mg p.o. b.i.d. 6. Percocet one to two tablets p.o. q. four to six hours p.r.n. pain. 7. Morphine sulfate 30 mg p.o. b.i.d. 8. Vioxx 12.5 mg p.o. q.d. DISCHARGE INSTRUCTIONS: The patient is to maintain his incisions clean and dry at all times. The patient may shower but should pat dry incisions afterwards; no bathing or swimming until further notice. The patient has been instructed to resume a cardiac diet. The patient has been advised to limit physical activities; no heavy exertion. No driving while taking prescription pain medications. The patient is to follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in one to two weeks; the patient is to call to schedule an appointment. The patient is to follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in four weeks; the patient is to call [Telephone/Fax (1) 170] to schedule an appointment. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 1053] MEDQUIST36 D: [2123-7-3] 04:43 T: [2123-7-3] 17:24 JOB#: [Job Number 32637] ICD9 Codes: 2875, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6324 }	Medical Text: Admission Date: [2120-3-15] Discharge Date: [2120-3-31] Date of Birth: [2075-2-10] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: This is a 45 year old female patient with a history of bipolar disease and idiopathic tachycardia who was transferred to [Hospital6 649] from [Hospital6 19155] where she presented with left lower quadrant and left flank pain, nausea and thrombocytopenia. The patient initially presented to the outside hospital with a three day history of [Location (un) 2452] urine and loose [Location (un) 2452] stools with a more recent development of a lower extremity rash. In addition, the patient noted fatigue with increasing dyspnea on exertion over the last three to six weeks. She also endorsed a one day history of nausea with a development of crampy searing left lower quadrant and flank pain associated with [Location (un) 2452] loose stools. The patient denied any fever, chills, nightsweats, upper respiratory tract symptoms, sore throat. She also denied any epistaxis or bleeding gums. The patient similarly denied any new medications or changes in her medications. At the outside hospital, the patient's laboratory data was notable for a platelet count of 7, INR 1.2, and large blood on a urinalysis. An abdominal computerized tomography scan was performed which showed no evidence of hydronephrosis, no renal stones and a cyst in the right kidney. The patient was given 1 gm intravenously of Solu-Medrol and was transferred to [Hospital6 256]. PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. Tachycardia. MEDICATIONS: 1. Seroquel 75 mg q.h.s. 2. Topamax 100 mg. 3. Mirtazapine 15 mg. 4. Verapamil 80 mg p.o. b.i.d. 5. Oral contraceptives. 6. Flonase. 7. Echinacea started one month ago. ALLERGIES: Demerol leads to anaphylaxis. SOCIAL HISTORY: The patient denies any tobacco, alcohol or drug use. She currently lives alone in [Location (un) 8957] and is not currently sexually active. FAMILY HISTORY: Positive for coronary artery disease. No family history of hematologic disorders. PHYSICAL EXAMINATION: On physical examination temperature was 99.7, heart rate 104, blood pressure 123/83, respirations 10, oxygen saturation is 100% on room air. General: The patient is in mild distress, lying on her back. Head, eyes, ears, nose and throat: Oropharynx is clear. Pupils equal, round and reactive to light. Extraocular movements intact. Dry mucous membranes. Neck: No evidence of supraclavicular lymphadenopathy. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. Abdomen: Obese, normoactive bowel sounds. Mild tenderness to palpation in the right upper quadrant. Negative [Doctor Last Name 515] sign. No evidence of hepatosplenomegaly, no rebound tenderness or guarding. Extremities: There are petechiae evident on the patient's lower extremities bilaterally, right more than left, no evidence of edema or cyanosis. Back: Scattered petechiae, no costovertebral angle tenderness. Neurologic: Alert and oriented times three, bilateral upper and lower extremity strength is symmetric and [5-1]. Cranial nerves II through XII are intact. Sensation is intact to light touch throughout. LABORATORY DATA: White blood cell count 18.2, hematocrit 35.4, platelets 13, MCV 79. Chemistries, sodium 138, potassium 3.9, chloride 104, bicarbonate 28, BUN 38, creatinine 1.2, glucose 158, anion gap of 14, ALT 18, AST 46, alkaline phosphatase 120, amylase 33, total bilirubin 2.2, lipase 35, albumin 3.6. PT 13.5, PTT 21.1, INR 1.2. Fibrinogen 611. Urinalysis: Red, protein over 300, trace glucose, moderate bilirubin, red blood cells over 50, white blood cells [3-1], few bacteria. HOSPITAL COURSE: 1. Heme - The patient was transferred to [Hospital6 256] from an outside hospital with a platelet count of 7 there and 13 on admission here. She was admitted to the General Medicine Service with a diagnosis of thrombotic thrombocytopenic purpura. A hematology and transfusion medicine consult was obtained and the patient was initiated on plasmapheresis for idiopathic thrombotic thrombocytopenic purpura. The patient had stool cultures sent which were negative for Escherichia coli and Shigella. Her heme studies were consistent with a hemolytic anemia in addition to her thrombocytopenia. The patient underwent five cycles of plasmapheresis which were uncomplicated and her platelet count eventually increased to 244. During the patient's sixth plasmapheresis she experienced hives on her face and upper chest which were treated with Benadryl and steroids. On the following day, during her seventh plasmapheresis the patient was premedicated with Benadryl and Tylenol. The first 45 minutes of the patient's pheresis were uneventful but the patient subsequently began to cough continuously and became acutely short of breath. The patient was given an additional intravenous dose of Benadryl and 200 mg of Hydrocortisone and was noted to have an oxygen saturation of 87% on room air. The patient was placed on 5 liters of nonrebreather and her oxygen saturations increased only to 93%. Respiratory therapy was called and gave the patient a Combivent nebulizer treatment and the patient began coughing up pink frothy sputum. A Code Blue was called and the patient became more uncomfortable appearing with expiratory grunting and paradoxical movements. The patient was urgently transported to the Emergency Department where she was intubated for respiratory failure. While in the MICU the patient was continued on plasmapheresis per the recommendations of the transfusion medicine consult service and the hematology consult service. The patient's platelet count remained relatively stable for several days in the MICU and the hematology service recommended Rituximib which the patient received on [2120-3-27]. The patient's platelet count subsequently increased with subsequent plasmapheresis. In addition, her other markers of hemolytic anemia including LDH, total bilirubin and haptoglobin improved. 2. Respiratory failure - As noted earlier, the patient became acutely short of breath with expiratory grunting and paradoxical breathing patterns during her seventh plasmapheresis and was urgently transferred to the Emergency Department where she was intubated. The etiology of the patient's respiratory failure was considered likely secondary to Trali with adult respiratory distress syndrome. The patient was initiated on pressure control ventilation with several recruitment maneuvers and was paralyzed due to continuous difficulty oxygenating and ventilating. Over her stay in the MICU the patient's oxygenation and ventilation improved and she was eventually switched over to assist control ventilation which she tolerated quite well. Over her MICU course, the patient's driving pressures and positive end-expiratory pressure as well as her FIO2 were titrated down. The patient was continued on unprotected ventilation for adult respiratory distress syndrome. With large volume diuresis with CVVH the patient's respiratory status improved dramatically and at the time of dictation, the patient is tolerating pressure support, ventilation of [5-1] and oxygenating quite well. 3. Septic shock - The patient was noted on transfer to the MICU to be in septic shock requiring pressors and large fluid boluses. The etiology of the patient's septic shock is not entirely clear at this time but is considered likely secondary to her transfusion-related acute lung injury associated with a massive cytokine release. The patient was placed on Ceftriaxone, Vancomycin, Flagyl and Levofloxacin for broad empiric coverage. She had blood, urine and sputum cultures which are all negative to date. She received a even day course of steroids for relative adrenal insufficiency. The patient was noted to have an elevated lactate on admission to the MICU likely secondary to hypoperfusion of tissues. Her lactate level and metabolic acidosis improved through her extended stay in the MICU and she had an improving white blood cell count with increased bandemia. Once stable, the patient was taken for a chest and abdominal computerized tomography scan on [2120-3-26] for continuing low-grade fevers. This computerized tomography scan revealed no nidus of infection. There became a concern for sinusitis, given the use of nasal packing for epistaxis and evidence of fluid on her head computerized tomography scan. Otorhinolaryngology was consulted and removed the nasal packing and the patient was started on Afrin for subsequent oozing from her nares. At the time of dictation the patient has been afebrile for over 72 hours. On transfer to the MICU the patient's Apache score was calculated at 31 and a trial of Xigris was considered but was eventually not used secondary to the patient's DIC. 4. Acute renal failure - The patient was admitted to the General Medical Service with a creatinine of 1.2, felt likely secondary to her thrombotic thrombocytopenic purpura. On transfer to the Medical Intensive Care Unit after the Code Blue, the patient's creatinine was 2.2 and eventually increased to 4.4. The Renal Consult Service was contact[Name (NI) ] and the etiology of the patient's acute renal failure was considered likely from hypotension given her severe septic shock. The patient was initiated on CVVH dosed and managed by the Renal Consult Service. Over the course of her stay in the MICU the patient has had modest improvement in her creatinine and a gradual increase in her urine output. The patient's acid base status was consistent with metabolic acidosis, likely secondary from septic shock as well as a metabolic alkalosis that was considered likely secondary to large infusions of bicarbonate in her CVVH dialysate. 5. Cardiovascular - In the setting of the patient's Trali and septic shock her cardiac enzymes were noted to bump. The patient had a peak creatinine kinase of 1001 which eventually trended down and a peak troponin of 0.92 which also trended down. The patient had no electrocardiogram changes and this was considered likely cardiac enzyme leak in the setting of demand ischemia. As noted earlier, the patient was acutely hypotensive in septic shock and was placed on Levophed and Vasopressin for maintenance of her blood pressures. Over the course of her MICU stay, these pressors were titrated off and the patient became hemodynamically stable and normotensive. 6. Gastrointestinal - In the setting of the patient's septic shock and adult respiratory distress syndrome, her liver enzymes became elevated. Consistent with shock liver, the patient's liver function tests eventually decreased to within normal limits. 7. Fluids, electrolytes and nutrition - The patient was started on tube feeds on her second day in the MICU which she tolerated at goal. Her electrolytes were repleted aggressively. The patient was placed on a calcium gluconate drip with frequent ionized calcium checks given the citrate in her plasmapheresis and multiple blood transfusions. The remainder of the [Hospital 228] hospital course as well as her discharge medications and follow up plans will be dictated at the time of discharge. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7585] Dictated By:[Last Name (NamePattern1) 4950] MEDQUIST36 D: [2120-3-31] 17:15 T: [2120-3-31] 16:44 JOB#: [Job Number 54610] ICD9 Codes: 5849, 0389, 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6325 }	Medical Text: Admission Date: [2150-2-9] Discharge Date: [2150-2-12] Date of Birth: [2080-6-5] Sex: F Service: NEUROLOGY Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 2569] Chief Complaint: Slurred speech, facial droop Major Surgical or Invasive Procedure: none History of Present Illness: 69 year old right-handed woman with hx HTN, CHF, afib on coumadin p/w slurred speech and right facial droop. Patient, as per son, had recently been D/Ced ([1-23]) from [Hospital ] Hospital due to rapid afib requiring ICU admission. She was currently at [Hospital3 ], recovering. She woke-up at 6am and was found to have slurred speech (some descriptions of difficulty speaking as well) and she had difficulty to move the R side; with R facial weakness as well. She was taken to OSH. BP was 230/111 with an INR 2.0; found to have a L basal ganglia bleed 1.9 x 1.8 cm with no shift. She was given 2U FFP, vitamin K 10mg x1 and several doses of labetolol 20/40/40/60 and she was transferred here. Her speech improved over time but not the weakness. BP here was 174/111 HR 88 and she was started on labetolol gtt. She received another unit FFP as INR 1.8; repeat CT head was stable. Past Medical History: -HTN -rapid afib on coumadin -cardiomyopathy -CHF -[Female First Name (un) 564] infection -diarrhea Social History: clerk, smoker, divorced, smoker (20PPD); she drinks 2-4 shots/day Family History: dather died of stroke 84 yo; ? mother had cancer Physical Exam: T-98.4 BP-174/111 HR-88 RR-18 100O2Sat Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: irregular Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender. Erythema around vaginal area ext: mild edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, decreased affect. Oriented to person, place, and month and year nut not date. Innatentive ; could not say [Doctor Last Name 1841] backwards. Speech is slurred with normal comprehension and repetition; naming intact. Dysarthria. [Location (un) ] was intact; could not write due to weakness. Registers [2-8], recalls [2-8] in 5 minutes. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation is decreased to light touch, pinprick and temperature V1-V3 R face. R facial weakness. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Tongue midline, movements intact Motor: Decreased tone on R side [Doctor First Name ] Tri [Hospital1 ] WF WE FE FF IP H Q DF PF TE TF R 0 0 0 0 0 0 0 0 0 --------------- L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Decreased to light touch, pinprick on R side, including face Reflexes: B T Br Pa Pl Right 2 2 1 0 Left 1 1 1 0 L upgoing toe Coordination: normal f-n on L side. Could not test on R due to weakness Gait: not tested Pertinent Results: [2150-2-10] 02:00AM BLOOD WBC-8.4 RBC-3.19* Hgb-10.5* Hct-32.4* MCV-101* MCH-32.9* MCHC-32.5 RDW-13.6 Plt Ct-217 [2150-2-9] 11:40AM BLOOD Neuts-64.3 Lymphs-25.2 Monos-5.6 Eos-4.5* Baso-0.3 [2150-2-10] 02:00AM BLOOD PT-15.9* PTT-29.8 INR(PT)-1.4* [2150-2-9] 11:40AM BLOOD PT-19.7* PTT-33.2 INR(PT)-1.8* [2150-2-10] 02:00AM BLOOD Glucose-100 UreaN-8 Creat-0.7 Na-144 K-4.0 Cl-108 HCO3-26 AnGap-14 [2150-2-9] 11:40AM BLOOD ALT-48* AST-57* LD(LDH)-235 CK(CPK)-28* AlkPhos-97 TotBili-0.7 [2150-2-9] 11:40AM BLOOD cTropnT-<0.01 [2150-2-10] 02:00AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.7 [2150-2-10] 02:00AM BLOOD Digoxin-0.9 [2150-2-9] 11:40AM BLOOD WBC-7.5 RBC-3.33* Hgb-10.8* Hct-33.8* MCV-101* MCH-32.5* MCHC-32.0 RDW-13.6 Plt Ct-250 [2150-2-11] 01:48AM BLOOD WBC-8.6 RBC-3.05* Hgb-10.0* Hct-30.6* MCV-101* MCH-33.0* MCHC-32.8 RDW-13.7 Plt Ct-221 [2150-2-12] 04:25AM BLOOD WBC-7.9 RBC-3.14* Hgb-10.4* Hct-32.3* MCV-103* MCH-33.0* MCHC-32.1 RDW-13.6 Plt Ct-233 [2150-2-12] 04:25AM BLOOD Plt Ct-233 [2150-2-12] 04:25AM BLOOD PT-15.9* PTT-30.9 INR(PT)-1.4* [2150-2-11] 01:48AM BLOOD PT-15.4* PTT-31.2 INR(PT)-1.3* [2150-2-10] 02:00AM BLOOD PT-15.9* PTT-29.8 INR(PT)-1.4* [2150-2-11] 01:48AM BLOOD Glucose-92 UreaN-8 Creat-1.0 Na-142 K-3.7 Cl-109* HCO3-24 AnGap-13 [2150-2-12] 04:25AM BLOOD Glucose-85 UreaN-8 Creat-1.0 Na-141 K-4.0 Cl-105 HCO3-29 AnGap-11 [2150-2-9] 11:40AM BLOOD ALT-48* AST-57* LD(LDH)-235 CK(CPK)-28* AlkPhos-97 TotBili-0.7 [2150-2-9] 11:40AM BLOOD cTropnT-<0.01 [2150-2-12] 04:25AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.2 [2150-2-11] 01:48AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.7 [2150-2-12] 04:25AM BLOOD TSH-3.8 [2150-2-10] 02:00AM BLOOD Digoxin-0.9 urine studies [2150-2-9] MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp 50 >1000 MANY NONE 0-2 Urine culture URINE CULTURE (Final [2150-2-12]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. Imaging: CT [2150-2-9]: 1. Left basal ganglia hemorrhage with surrounding vasogenic edema. No new foci of acute hemorrhage. 2. Hyperdense extra-axial calcified round lesion at the left frontoparietal vertex, which likely represents a meningioma. Further characterization with MRI is recommended if clinically indicated and if there is no contraindication to use MRI. CT [2149-2-10]: Again noted is a small focus of acute hemorrhage within the left thalamus. It currently measures 18 x 16 mm which is essentially unchanged in size from prior keeping in account differences in technique. There is mild-moderate surrounding vasogenic edema, unchanged. Though these are likely to be related to hypertension, underlying lesion cannot be excluded Again noted is a right maxillary mucous retention cyst and basilar and bilateral middle cerebral artery calcifications. There is an unchanged left frontoparietal (near the vertex) ossified lesion, likely representing an ossified meningioma. There are multiple periventricular and subcortical white matter hypodense foci noted likely related to sequelae of small vessel ischemic disease. Atherosclerotic vascular calcifications are noted. The paranasal air sinuses and mastoid air cells are unremarkable. IMPRESSION: Stable appearance of small focus of acute hemorrhage in the left thalamus with some surrounding edema.Though this is likely to be related to hypertension, underlying lesion cannot be excluded. MR can be considered, if clinically indicated, after resolution of the hemorrhage. CXR [2150-2-9]: No previous images. The heart is substantially enlarged and there is haziness at both bases consistent with some pleural fluid. There is mild elevation of pulmonary venous pressure. The dichotomy raises the possibility of cardiomyopathy or right pleural effusion. No evidence of acute focal pneumonia. Brief Hospital Course: Ms. [Known lastname ] was admitted to neuro ICU for evaluation and treatment of stroke. She was transfered from OSH with speech difficulty , right hemiplegia and facial droop and CT head demonstrating a left basal ganglia bleed- 1.9 x 1.8 cm. She was on coumadin with INR 2 and her blood pressure was 230/110 at OSH. Prior to transfer to [Hospital1 18] she was reversed with FFP, and vitamin K 10 mg and several doses of labetalol for blood pressure control. She was transfered out of ICU on [2150-2-11] on stroke neurology floor for further care. Neuro She was closely monitored for neurological signs and improvement. She was noted to have non fluent aphasia with nearly intact comprehension, with right hemiplegia and facial droop. She underwent CT scan which showed left basal ganglia bleed with some edema. She was monitored closely for signs of raised ICP which she did not develop. She was evaluated by PT/OT/Speech therapy for assesment of function and rehab. We stopped her coumadin and aspirin for 3 days after bleed. She has been started on aspirin 81 mg on [2150-2-12]. we will hold coumadin for 2 weeks after bleed. She should have repeat CT scan which should be reviewed by her doctor and then decision for starting couamdin should be made. Cards She was in afib with controlled ventricular rate. She was ruled out for myocardial ischemia with EKG and cardiac enzymes. TSH was 3.8 to exclude underlying hyperthyroidism . Her blood pressure was high 190-200 sysolic and was on labetalol drip for blood pressure control initially which was later stopped. She was on carvedilol and metoprolol. We decided to stop carvedilol and continue on metoprolol in increased dose. Her blood pressure was closely monitored and controlled less than 140 systolic. This should be followed closely and controlled to less than 140 systolic. ID She was noted have U/A suggestive of UTI. She was started on cipro empirically. Cultures grew enterococci with sensitivities pending at this point. This should be followed and antibiotic regime should be chosen appropriately. General care Initially for first 48 hours we held on SC heparin for DVT proph. Then it was started. Chest xray did not reveal any pna. she was advised about smoking cessation. Issues pending at discharge Repeat urine cultures as initial culture could be a contaminent HbA1C and lipid profile for risk factor assesment Neuro exam at DC has some difficulty in getting words out- non fluent aphasia, comprehension largely preserved, right hemiplegia and facial droop on right side. Medications on Admission: -Senna 8.6 mg Cap Oral daily -Dulcolax 10 mg Rectal Suppository Rectal -Fleet Enema 19 gram-7 gram/118 mL Rectal -Aspirin 325 mg Tab Oral -Captopril 25 mg Tab Oral TID -Coreg 25 mg Tab Oral [Hospital1 ] -Digoxin 125 mcg Tab Oral daily -Folic Acid 1 mg Tab Oral -Lasix 20 mg Tab Oral -Lopressor 50 mg Tab Oral [Hospital1 ] -Prilosec OTC 20 mg Tab Oral daily -Aldactone 25 mg Tab Oral daily -Thiamine 100 mg Tab Oral daily -Albuterol Sulfate 2.5 mg/0.5 mL Neb Solution Inhalation -Robitussin-DM 10 mg-100 mg/5 mL Syrup Oral -coumadin (unknown dose) Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 14. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 17. CT head, non contrast please schedule on [2150-2-23] ( 2 weeks after BG bleed on [2150-2-9]) Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: acute hemorrhage in the left thalamus , most likely hypertensive Discharge Condition: Activity Status:Bedbound Discharge Instructions: You were admitted for evaluation of stroke. You had CT scan of head which revealed acute hemorrhage in the left thalamus with some surrounding edema. You were initially admittd to ICU for close monitoring and then transfered to neurology stroke floor. We have stopped your coumadin due to recent intracranial bleed. You should start it in after 2 weeks after repeating a CT scan after 2 weeks. Meanwhile you will be on aspirin 81 mg. You had UTI for which you are on ciprofloxacin 500 [Hospital1 ]. (started on [2150-2-11]. You should follow up with urine culture- Enterococcus sensitivities (pending at this time ) and your antibiotic regime should be adjusted by your doctor as per the sensitivity results. You should get repeat CT scan of your head 2 weeks after the bleed, that is on [2150-2-23]. This should be reviewed by your doctor before starting on coumadin for anticoagulation. Please take your medicines as advised. please call your doctor/911 if you have any questions. Followup Instructions: Please follow up in neurology clinic with- Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 162], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2150-3-24] 10:00 Pleaae follow up With your primary care doctor- Provider: [Name10 (NameIs) ] [Name8 (MD) 18200], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2150-3-4] 1:45 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] ICD9 Codes: 4254, 5990, 4019, 4280, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6326 }	Medical Text: Admission Date: [2148-2-9] Discharge Date: [2148-2-11] Date of Birth: [2091-6-16] Sex: F Service: MEDICINE Allergies: Gold Salts Attending:[First Name3 (LF) 3513] Chief Complaint: palpitations Major Surgical or Invasive Procedure: upper endoscopy History of Present Illness: This is a 56 year old woman with history of peptic ulcer disease status post an upper endoscopy in [2141] and [2138](?), rheumatoid arthritis and hypertension who presented with palpitations on day of admission. Patient was concerned because she had palpitations with her prior episodes of GI bleeding. In the ED, she was found to have melena and her Hct was 25 down from her baseline of 31-33. NG lavage was negative and she was given IV fluids. Her heart rate decreased from 130's to 100's. GI was consulted and recommended transfusion 2U PRBCs, PPI and admission to the unit for close monitoring. . Patient denied nausea, vomitting, constipation, chest pain, shortness of breath, abdominal pain. Past Medical History: 1. rheumatoid arthritis 2. peptic ulder disease w/EGD in [2141] and [2138]? 3. hypertension Family History: NC Physical Exam: T97.8 HR 96 BP 108-122/68-72 O2Sat 100% RR 21 GEN pleasant, NAD, looking younger than actual age HEENT PERRL, mmm, OP clear, JVP 9cm CV RRR, nl s1 s2, no murmur/rubs/gallops LUNG CTA b/l at bases, no w/r/r ABD soft ntnd +bs no rebound/guarding EXT nonedematous, 2+ DP pulses, warm NEURO AOx3 nonfocal Pertinent Results: notable for hct drop from 31 (baseline) to 25 . Labs on admission: WBC-7.7 RBC-3.02* Hgb-9.0* Hct-26.5* MCV-88 MCH-29.7 MCHC-33.9 RDW-16.2* Plt Ct-363 . Neuts-84.6* Lymphs-13.1* Monos-1.7* Eos-0.3 Baso-0.3 . Glucose-121* UreaN-35* Creat-0.9 Na-143 K-4.7 Cl-104 HCO3-29 AnGap-15 . PT-12.3 PTT-23.9 INR(PT)-1.1 . Ret Aut-1.5 . URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.008 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG . . EGD [2-10]: Esophagus: Normal esophagus. Stomach: Mucosa: Erythema and congestion of the mucosa with no bleeding were noted in the antrum and pylorus. These findings are compatible with mild gastritis. Excavated Lesions A single cratered non-bleeding ulcer was found in the antrum. Cold forceps biopsies were performed for histology at the ulcer periphery. Duodenum: Normal duodenum. Impression: Erythema and congestion in the antrum and pylorus compatible with mild gastritis. Non-bleeding ulcer in the antrum. Clean-based, non-bleeding ulcer likely secondary to patient's ibuprofen use. Biopsy results: Mild hyperplasia of gastric pits . . EKG: Sinus tachycardia with supraventricular extrasystoles. Normal ECG, except for rate. Since the previous tracing of [2141-12-27] supraventricular extrasystoles are seen. Intervals Axes Rate PR QRS QT/QTc P QRS T 106 130 70 298/360 67 -2 62 Brief Hospital Course: Briefly, this is a 56 year old woman with a history of PUD, RA and HTN who p/w melena and Hct drop. Patient status post upper endoscopy [2-10] which revealed gastritis and nonbleeding ulcer in antrum c/w NSAID use. Hct was stable and patient was subsequently transferred to the floor on [2-10]. . . #. Gastrointestinal bleed: Hematocrit drop and melena were suggestive of an upper gastrointestinal bleed or possible but less likely a lower gastrointestinal bleed. Patient received two units of packed red blood cells with a bump in her hematocrit from 25 to 27.7. GI was consulted and performed an upper endoscopy on [2-10] which showed mild gastritis and a nonbleeding ulcer in antrum which was the likely source of the GI bleed. Patient's Hct stabilized and she was transferred to the floor. Patient's diet was advanced as tolerated. She was continued on protonix PO QD and held all NSAIDs. Patient's Hct remained stable and she was discharged home with follow-up with a repeat upper endoscopy in [Hospital ] clinic in 8 weeks time. She will also need to have her biopsy results checked either when she follows up with her primary care physician or at [Hospital ] clinic. . . #. Rheumatoid arthritis: Continued prednisone and enbrel. Continued methotrexate at 10mg every Monday. Held all NSAIDs. . . #. Hypertension: Held outpatient hydrochlorothiazide per unstable blood volume. Resumed blood pressure medication when hematocrit was stable 24-36 hours. . . #. Prophylaxis: Continued Protonix PO daily per GI recs and pneumoboots . . #. FEN: Advanced diet as tolerated. . . #. Code: Full Medications on Admission: 1. prednisone 5 daily 2. methotrexate 10 mg q mon?? f/u with attg 3. leukovorin 4. enbrel 25 mg q mon + friday Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Enbrel 25 mg Kit Sig: Twenty Five (25) mg Subcutaneous q monday and friday () as needed for rhuematoid arthritis. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 6. Methotrexate 2.5 mg Tablet Sig: Four (4) Tablet PO QMON (every Monday). Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: upper GI bleed NSAID induced gastritis . secondary diagnosis: rheumatoid arthritis hypertension Discharge Condition: Hct stable Hct stable Discharge Instructions: Please take medications as prescribed. Do not take your blood pressure medication (hydrochlorothiazide) until you follow-up with Dr. [First Name (STitle) 3510] on Tues [2148-2-13]. . Please keep follow-up appointments. . If you have any palpitations, lightheadedness, black tarry or blood stools (guaiac positive), chest pain, abdominal pain or the emergency department. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 3510] on [2148-2-13] for a blood level and blood pressure check. Please call to confirm the time of the appointment. Phone: [Telephone/Fax (1) 3511] . Please call Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] office (Gastroenterology) and schedule a follow-up appointment 8 weeks from discharge date. Phone: [Telephone/Fax (1) 904] Completed by:[2148-6-14] ICD9 Codes: 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6327 }	Medical Text: Admission Date: [2183-1-17] Discharge Date: [2183-1-27] Date of Birth: [2131-8-29] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old with known cardiomyopathy and dilated ascending aorta, found to have a question of aortic dissection on catheter on [1-3]. One year history of chest pain. The patient admits to multiple episodes of palpitations and heart racing associated with shortness of breath and dizziness and syncope. Catheterization on [2183-1-3] showed a pulmonary capillary wedge pressure of 23, LVEDP of 28, ejection fraction of 24%, 1+ mitral regurgitation, no coronary artery disease. Admitted today for need for further imaging studies. PAST MEDICAL HISTORY: Remarkable for hypertension, tobacco use greater than 35 pack years, alcohol of four plus beers plus two to three shots per day, depression with several admissions in the past for suicidal ideation/depression, previous suicide attempts, panic disorder. PHYSICAL EXAMINATION: Pleasant 51-year-old, in no acute distress. Vital signs: Pulse 70, sinus rhythm, blood pressure 130/76, respiratory rate 12, oxygen saturation 97% on room air. Cardiovascular: Regular rate and rhythm, positive heave. Respiratory: Breath sounds with scattered rales at the bases. Gastrointestinal: Positive bowel sounds, palpable liver 3 cm below the costal margin, no masses, no tenderness, no distention. LABORATORY DATA: Preoperatively, hematocrit 43.6, creatinine 0.9, AST 31, ALT 16, alkaline phosphatase 105. HOSPITAL COURSE: Patient brought into the hospital preoperatively for testing on [2183-1-17], at which time he was admitted to the Cardiothoracic Surgical service. The patient was brought to the operating room on [2183-1-18] for a repair of ascending aortic aneurysm, aortic valve replacement with 25 mm [Last Name (un) 3843]-[Doctor Last Name ], 28 mm dacron aortic and 8 mm dacron innominate resection of right non-coronary leaflets and vein plaque, right coronary. Cardiopulmonary bypass time was 266 minutes, cross-clamp time was 218 minutes. The patient tolerated the procedure well, and was subsequently taken to the Intensive Care Unit, where an attempt for extubation failed secondary to increased agitation, at which time he had to be sedated and switched to SIMV with pressure support. On postoperative day two, the patient converted to atrial fibrillation with first degree AV block, and was placed on amiodarone drip as will as a nitrite drip. The patient remained sedated with propofol, and extubated. Sedation also included ______________. On postoperative day one, the patient received Ativan around the clock for delirium tremens prophylaxis, and the patient was weaned for attempted extubation. Urine output continued to be excellent, and BUN and creatinine remained stable at 17 and 1 respectively. On postoperative day three, the patient converted back to normal sinus rhythm, at which time the amiodarone drip was stopped. On postoperative day number five, the was stable enough to be transferred to the Surgical floor, at which time he continued to be not engageable and confused and disoriented, which is not a change from Intensive Care Unit. At that time, it was thought that the patient was suffering from delirium, and a Psychiatry consult was obtained. Other tests came out negative, including electrocardiogram, electrolytes and CBC, which were all within normal limits. An Addiction consult was also obtained. The team suggested that the patient was in delirium and the patient should be maintained on Haldol at least three times a day to decrease the agitation. The Psychiatry team also agreed with administration of Haldol and doses of benzodiazepine to decrease any possibility of alcohol withdrawal which, at that point, was unlikely. The patient's waxing and [Doctor Last Name 688] mental status was noted by the nursing staff as well as Physical Therapy, who tried to walk the patient, with occasional success. At one point, the patient was able to walk in the [Doctor Last Name ] unassisted and was, in fact, dancing by himself with complete coordination, and then reverted back to stumbling around. On postoperative day number nine, the patient was more oriented and able to tell us where he was and was engageable. The patient was discharged to rehabilitation for further monitoring, as there is no metabolic reason for his mental status change. CONDITION AT DISCHARGE: Good DISCHARGE STATUS: To rehabilitation DISCHARGE DIAGNOSIS: 1. Status post aortic dissection repair 2. Delirium DISCHARGE MEDICATIONS: 1. Haloperidol 3 mg by mouth three times a day 2. Protonix 40 mg by mouth once daily 3. Multivitamin one capsule by mouth once daily 4. Folic acid 1 mg by mouth once daily 5. Thiamine 100 mg by mouth once daily 6. Clonazepam 0.5 mg by mouth twice a day 7. Amiodarone 200 mg by mouth once daily 8. Aspirin 325 mg by mouth once daily 9. Colace 100 mg by mouth twice a day 10. Potassium chloride 20 mEq by mouth every 12 hours 11. Furosemide 20 mg by mouth twice a day 12. Metoprolol 25 mg by mouth twice a day FO[Last Name (STitle) ]P PLANS: The patient is to follow up with his primary care physician in one week, and to follow up with Dr. [Last Name (Prefixes) ] in four weeks. The patient is to follow up with the patient's cardiologist in one to two weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 17480] MEDQUIST36 D: [2183-1-26] 22:48 T: [2183-1-27] 01:17 JOB#: [Job Number 17481] ICD9 Codes: 4254, 4240, 311, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6328 }	Medical Text: Admission Date: [2130-10-23] Discharge Date: [2130-10-24] Date of Birth: [2083-4-10] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 695] Chief Complaint: Hypotension, sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 47M with chronic hepatitis B virus associated cirrhosis and delta hepatitis suprainfection on the liver transplant list (baseline MELD 27). EMS was called this morning at 4am for 3 days of worsening abdominal pain, double vision and weakness. Upon arrival to his home: HR 100, BP 60/30's, O2 sats 84%, FS 46. Oriented x 4. Taken to [Hospital 1474] Hospital for stabilization, and the transplant center was notified. At [Hospital1 1474], he was started on lactulose, Neo-Synephrine, octreotide, and midodrine, he was intubated, started on a D10W gtt. Once a bed was available, he was transferred to the [Hospital1 18] SICU. Past Medical History: - congenital Hepatitis B - Hep D positivity - Cirrhosis, decompensated by ascites and jaundice - Anemia - Psoriasis - Internal hemorrhoids . Social History: Married, 2 children 4,9, worked as social case manager in the past, now works as PCA 8h per week. Has not smoked or drank EtOH since age of 15. No IVDU. . . Family History: Mother: HBV, DM Physical Exam: PE: Neo 0.35, Vaso 2.4, Phenylephrine 1.5 112 91/44 CVP 17 27 96% CMV 100% +12 PEEP NAD, unresponsive. On no sedation, but received IV Ativan for transfer Jaundiced and icteric Diminished breath sounds on the Right Tachy Abd distended, dull to percussion, +fluid shift. No response to deep palpation 1+ LE edema Pertinent Results: [2130-10-23] 05:24PM WBC-1.7* RBC-2.29* HGB-9.1* HCT-27.4* MCV-120* MCH-39.6* MCHC-33.1 RDW-14.6 [2130-10-23] 05:24PM GLUCOSE-85 UREA N-40* CREAT-2.8# SODIUM-122 POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-11* ANION GAP-20 [2130-10-23] 05:24PM NEUTS-18* BANDS-14* LYMPHS-30 MONOS-3 EOS-18* BASOS-0 ATYPS-0 METAS-10* MYELOS-6* PROMYELO-1* NUC RBCS-10* [2130-10-23] 05:24PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-2+ BURR-2+ STIPPLED-1+ [2130-10-23] 05:24PM PLT SMR-VERY LOW PLT COUNT-49* [2130-10-23] 05:24PM PT-38.7* PTT-54.8* INR(PT)-4.0* [2130-10-23] 05:24PM ALT(SGPT)-52* AST(SGOT)-78* LD(LDH)-191 ALK PHOS-68 TOT BILI-17.7* [2130-10-23] 05:44PM TYPE-ART PO2-87 PCO2-32* PH-7.19* TOTAL CO2-13* BASE XS--14 Brief Hospital Course: Patient was transferred from [Hospital 1474] Hospital after 3 days of worsening abdominal pain, severe hypotension and lactic acidosis. He was admitted to [Hospital 1474] hospital on [2130-10-23] morning, was intubated, started on pressors and antibiotics and after notifying the transplant center, he was transferred in the afternoon and admitted to the surgical ICU of [Hospital1 18]. Patient was started on neo-synephrine, norepinephrine and vasopressin, continued of broad spectrum antibiotics and attempted to correct his coagulopathy with blood products prior to perform a diagnostic paracentesis with hepatology. This showed 500 WBC and 25,500 RBC, but no microorganisms on the gram stain. A right chest thoracentesis for a large right pleural was also performed by the SICU to improve his ventilatory settings and improve his oxygenation, which drained 1,5 L of fluid. Patient tolerated both procedures well initially, but was never stable enough to bring him to CT scan. At midnight he started with increasing pressure requirement and was maximized on neo-synephrine, levophed and vasopressin. His profound lactic acidosis with a worsening lactate up to 11.3 was attempted to be corrected with sodium bicarb, with no improvement on his pH of 7.10. His wife was [Name (NI) 653], who decided to continue measures and after giving 5L of fluids including crystalloids, colloids, blood and at a maximum dose of 3 pressures, he was not able to hold his BP. Patient expired on [2130-10-24] at 01:40 am, after his the pastor of his church arrived to the SICU. His wife [Doctor First Name 1785] was [Doctor First Name 653] while she was on her way. The admitting office was notified and the Medical Examiner waived the case. His family consented for an autopsy which will be done at [Hospital1 18]. Medications on Admission: [Last Name (un) 1724]: clobetasol clotrimazole 10mg 5x/day Vit D 50,000 units weeks lactulose 15mg q4hrs Viread 300mg daily Mag oxide 400mg [Hospital1 ] Lasix 80mg [Hospital1 ] rifaxamin 550mg [Hospital1 ] spironolactome 200mg [Hospital1 ] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary Arrest Septic Shock Multiorgan failure (Renal, Liver, Neurologic, Cardiac) End-Stage Liver Disease Congenital Hepatitis B Discharge Condition: expired Discharge Instructions: autopsy to be performed [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2130-10-24] ICD9 Codes: 0389, 5119, 2762, 5715, 4275, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6329 }	Medical Text: Admission Date: [2112-1-19] Discharge Date: [2112-2-3] Date of Birth: [2050-3-12] Sex: M Service: MEDICINE CHIEF COMPLAINT: Shortness of breath and chest pain HISTORY OF PRESENT ILLNESS: The patient, Mr. [Known firstname 449] [Known lastname 109917], is a 61-year-old white male with a history of anxiety, coronary artery disease status post coronary artery bypass graft x2, end stage renal disease on dialysis, type II diabetes, ischemic cardiomyopathy with one patent vessel and ejection fraction of 15%, was presented to [Hospital6 1760] after complaint of shortness of breath and chest pain. The patient reported shortness of breath for about a month in which sitting around the house would cause breathing difficulties. The patient reported that his breathing is relieved by breathing from a paper bag, as recommended by her friend. It initially occurred in less frequency, but now patient reported symptoms approximately eight times daily. Furthermore, the patient reported episodic nonradiating, sharp, chest pain lasting a few seconds. On the day of admission, the patient called his primary care physician and was advised to come to the Emergency Department for evaluation/treatment. While in the Emergency Department, the patient's symptoms of chest pain and shortness of breath were improved with oxygen supplement. At interview, the patient denied chest pain, shortness of breath, fever, chills, nausea, vomiting, diaphoresis. The patient reported similar episodes in [2111-11-24] with the same symptoms of shortness of breath and chest pain. The patient was admitted for two days that subsequently ruled myocardial infarction. A Persantine MIBI stress test was performed which showed superior and inferior wall fixed defect/moderate lateral wall defect and ejection fraction of 15%. There was no acute electrocardiogram change at that time. The working diagnosis at that time was that the patient was under dialyzed as a result of lower dry weight. The patient was dialyzed again during admission and the symptoms improved. The patient reported increased anxiety, in which he thinks that he is about to die because of all these medical problems. The patient lives alone with only one friend that he can really talk to and has been separated from his wife and [Name2 (NI) 8526]. The patient has been out of work since the age of 46 due to renal and cardiac problems. PAST MEDICAL HISTORY: 1. Diabetes 2. End stage renal disease 3. Coronary artery disease, status post coronary artery bypass graft x2 in [2089] and [2097] 4. Gastritis 5. Anemia 6. High cholesterol status post right cerebrovascular accident 7. Cardiomyopathy 8. Hypertension 9. Anxiety ALLERGIES: The patient has no known drug allergies. INITIAL MEDICATIONS: 1. Zestril 25 qd 2. Imdur 60 mg 1 tablet qd 3. Nitroglycerin prn 4. Neurontin 100 mg 1 tablet qd 5. Nephrocaps 1 tablet qd 6. Prilosec 40 mg qd 7. Lopressor 50 mg [Hospital1 ] 8. Pravachol 40 mg qd 9. Xanax 0.25 mg [Hospital1 ] 10. Reglan 10 mg tid 11. Glyburide 2.5 mg qd 12. ASA 325 mg qd SOCIAL HISTORY: The patient admits to smoking half pack a day for the past 20 years. Denies use of alcohol and intravenous drugs. The patient is separated from his wife, lives alone, has a [Hospital1 8526]. FAMILY HISTORY: Both the father and the brother have type II diabetes and also coronary artery disease. ADMISSION VITALS: Blood pressure 97/60, pulse 89, respiration 20, O2 saturation 100% on 2 liters. PHYSICAL EXAMINATION: GENERAL: The patient is a 61-year-old male who appeared older than stated age, no apparent distress, awake, alert and oriented to time, place and person, was unhappy that he has returned to the hospital for his symptoms. HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular eye movements intact bilaterally. Mucous membranes moist. Oropharynx benign. No lymphadenopathy bilaterally. CARDIOVASCULAR: The patient has regular rate and rhythm with 3/6 holosystolic ejection murmur appearing loudest at the left upper sternal border. Jugular venous distention was normal at 8 cm. PULMONARY: The patient's lung fields are clear to auscultation bilaterally without wheezing or crackles. ABDOMEN: Soft and nontender with active bowel sounds in all quadrants. There was no mass, no bruit, no rebound tenderness or guarding. EXTREMITIES: There is 1+ bilateral lower extremity edema. There was no upper extremity edema. Overall, there is no clubbing or cyanosis. There is an AV shunt on the left arm. NEUROLOGIC: Cranial nerves II through XII are intact bilaterally. The motor exam was [2-26] for all muscle groups and deep tendon reflex was 2+ at all points. MINI MENTAL EXAM: The patient feels lonely from living by himself and has been agitated and very unhappy with the fact that he has to come to the hospital quite often. The patient has no suicidal or homicidal ideation. ADMISSION LABS: CBC: White count 8.0, hematocrit 41.6, hemoglobin 13.9, platelets 140. Chemistries: Sodium 136, potassium 4.1, chloride 92, bicarbonate 27, BUN 41, creatinine 7.1 with glucose of 188. PT 15.1, PTT 29.4, INR 1.6. Electrocardiogram showed no acute changes, has the evidence of old left bundle branch block. IMAGING STUDIES: The patient had a chest x-ray which showed mild chronic failure and bilateral basilar atelectasis. HOSPITAL COURSE: In summary, this is a 61-year-old white male with a history of coronary artery disease, status post coronary artery bypass graft x2, diabetes, end stage renal failure on hemodialysis, severe ischemic cardiomyopathy with one patent vessel and an ejection fraction of 10% who was admitted with shortness of breath and chest pain. The pertinent issues are as follows: 1. CARDIOVASCULAR: The patient ruled out for myocardial infarction with the cycled enzyme of CK and also troponin, all of which are within normal limits. The patient was also initially placed on telemetry but was subsequently discontinued since there were no events recorded. The patient's cardiac medication of Zestril, Imdur and nitroglycerin were held because the blood pressure was in the 80s and the patient was asymptomatic. On hospital day #3, the patient was seen by the congestive heart failure service for evaluation in hopes to provide better treatment plan for his cardiac status. The patient was found to be an ideal candidate for the placement of a ventricular pacemaker and on [2112-1-25], the patient was brought to the Operating Room and the pacemaker was successfully placed. The patient's blood pressure has been in the 80s to 90s during the earlier part of the admission and after the cardiac medications were discontinued, the pressure was hovering in the 70s on the day before pacemaker placement. After the pacemaker was placed on [1-25], the blood pressure remained low in the 60s and 70s and four boluses of 250 cc normal saline were given to boost up the blood pressure. On the next hospital day, the patient did not tolerate the increase in fluid well and had obtunded and complained of discomfort. A stat echocardiogram was ordered which showed ejection fraction to be less than 10%. However, there was no pleural effusion. At this point, the patient was given dopamine to increase his blood pressure, but was subsequently discontinued after about 10 minutes or so because the patient was complaining of [6-1] chest pain with radiation to the left arm. The patient was brought to the coronary cardiac care unit for monitoring of these episodes of hypertension and the patient did well in the unit with no improvement in the blood pressure, but asymptomatic with the patient able to function both physically and mentally. After the patient was returned to the floor, the patient was given cardiac rehabilitation by ambulating with nurse 3x a day. The patient was also given a trial of Midodrine which increased his blood pressure and at the same time caused no symptoms. The EP service and the congestive heart failure service has followed the patient throughout. 2. PULMONARY: The patient has been doing well after the initial complaint of shortness of breath in the Emergency Room. The patient's oxygen saturation has been between 97% and 100% on room air and lung auscultation has been essentially clear without evidence of crackles or wheezing. The patient will be discharged with instructions that if he gets short of breath again, do not exhale into the paper bag like he did before. The patient's symptoms of shortness of breath is most likely contributed by his anxiety of his medical conditions and this can be hopefully alleviated by placing the patient on Celexa. 3. RENAL: The patient has been getting hemodialysis on a Monday, Wednesday, [Date Range 2974] schedule and has been doing well with that. It was found that if more fluids were taken out, the patient's blood pressure actually responds better and the patient's subjectively feels better. The amount of fluid that has been taken out during this admission has been between 2 kg to 3 kg. 4. DIABETES: During this admission, the patient was given Glyburide 2.5 mg qd as well as the regular insulin sliding scale. The patient's fingerstick glucose check 4x a day has been fairly stable. 5. GASTROINTESTINAL: The patient with history of gastritis was placed on Reglan and also on Protonix on admission. The patient's Reglan was discontinued because it was suspected that it was one of the causes for hypotension. The patient has been doing well just on Protonix without gastrointestinal complaints. 6. PSYCHIATRY: The patient has been emotionally up and down throughout admission, but more stable towards the end. The patient was very distressed about having to go to dialysis 3x a day and that is essentially his whole life and he really cannot do anything else. After hospital day 10, the patient has been emotionally more stable. The patient has not had any episodes of crying. This is unclear as to whether this is from the effect of Celexa or because the patient has become accustomed to the medical team and has built trust in the care. A psychiatric hospital was obtained initially in the beginning of the admission. The recommendation was that the patient is baseline and could obtain help from SSRI. DISCHARGE CONDITION: Stable DISCHARGE DIAGNOSES: 1. Diabetes 2. End stage renal disease on dialysis 3. Coronary artery disease 4. Gastritis 5. Anemia 6. High cholesterol 7. Status post right cerebrovascular accident 8. Cardiomyopathy 9. Hypertension 10. Anxiety 11. Ischemic cardiomyopathy DISCHARGE MEDICATIONS: 1. Midodrine 10 mg po tid while awake, with the last dose given before 6 p.m. to prevent hypertension 2. Glyburide 2.5 mg 1 tablet po qd 3. Nephrocaps 1 tablet po qd 4. ASA 325 mg qd 5. Pravachol 40 mg qd 6. Protonix 40 mg 1 tablet po qd 7. Tylenol 650 mg 1 tablet po q 4 to 6 hours prn pain/fever 8. Celexa 20 mg 1 tablet po qd FOLLOW UP APPOINTMENTS: The patient is to follow up with: 1. The electrophysiology team which right now, he has an appointment on [Last Name (LF) 2974], [2112-3-21] at 11 a.m. This is a six week follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] who has already done a follow up 10 days after the placement of the pacemaker. 2. The patient is also to follow up with the congestive heart failure service with Dr. [Last Name (STitle) ] at the [Hospital1 ] Hospital Cardiology Department. 3. The patient should also follow up with his primary care doctor. DR.[Last Name (STitle) 313],[First Name3 (LF) 312] 12-766 Dictated By:[Doctor Last Name 109918] MEDQUIST36 D: [2112-2-3] 13:33 T: [2112-2-3] 13:49 JOB#: [Job Number 32990] ICD9 Codes: 4280, 4254
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6330 }	Medical Text: Admission Date: [2176-6-7] Discharge Date: [2176-6-17] Service: HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old female with mitral stenosis, mitral regurgitation, chronic atrial fibrillation/atrial flutter, admitted for preoperative heparinization in preparation for mitral valve replacement-tricuspid valve replacement. In brief, the patient has an extensive history of mitral stenosis with treatment 14 years prior with mitral valvuloplasty. The patient since has noted increased dyspnea on exertion with shortness of breath and lower extremity edema. The patient originally planned for mitral valve replacement on [2176-5-31]; however, patient was noted to exhibit hypercapnia. Pulmonary consult was obtained and surgical intervention at that time was deferred pending pulmonary function tests. Since then patient's pulmonary function tests were determined to be FEV-1 of 33%. Given patient's chronic Coumadin and chronic atrial flutter/fibrillation, patient was admitted on [2176-6-7], for heparinization in anticipation of surgical intervention. PAST MEDICAL HISTORY: 1. Mitral stenosis (MVA 0.9, MR +3 and ejection fraction 56%). 2. Hypertension. 3. Status post transient ischemic attack with residual left-sided weakness. 4. Neuropathy. 5. Ventral hernia. 6. Chronic diarrhea. MEDICATIONS AT HOME: 1. Atenolol 50 mg p.o. q. day. 2. Zestril 10 mg p.o. q. day. 3. Digoxin 0.125 p.o. q. day. 4. Chronic Coumadin. 5. Mevacor 10 mg p.o. q. day. 6. Zaroxolyn 5 mg p.o. q.o.d. 7. Lasix 40 mg p.o. b.i.d. 8. Potassium chloride 10 mg p.o. q. day. 9. Creon. 10. Ativan. 11. Vitamin B12. 12. Imodium. 13. Equalactin. ALLERGIES: No known drug allergies. PERTINENT LABORATORIES: As of [2176-6-17], white blood cell 12.9, hematocrit 26.2, platelet count 178,000. Sodium 135, potassium 4.3, chloride 92, bicarb 35, BUN 21, creatinine 1.0 and glucose 98. PT 16.6, PTT 47.9 and INR of 1.8. HOSPITAL COURSE: The patient is a 79-year-old female with history of mitral stenosis, chronic atrial flutter/fibrillation admitted for mitral valve replacement/tricuspid valve replacement on [2176-6-7], with preoperative heparinization. During the preoperative evaluation it was noted that patient was hypercapnic and, therefore, pulmonary function tests were obtained which revealed FEV-1 of 33%. On [2176-6-10], the patient underwent an uncomplicated mitral valve replacement and tricuspid valve replacement with MVR using Mosaic porcine heart valve and tricuspid valve replaced with MC3 annuloplasty SYS model 4900 Size T32 mm. Postoperatively patient was doing well, weaning off of Milrinone but exhibiting respiratory metabolic acidosis. The patient was maintained in the Cardiac Surgical Intensive Care Unit for close observation postoperatively. By postoperative day two Milrinone was discontinued. The patient's digoxin was initiated along with captopril. The patient's chest tube was also discontinued. By postoperative day three the patient's chest tube had been removed and the patient was extubated maintaining good saturation on nasal cannula. At this time Lasix was re-initiated and patient's Coumadin restarted. By [2176-6-14], patient was transferred to the floor and Physical Therapy evaluation was placed. Subsequently patient continued to do well with good diuresis with Lasix and tolerating intermittent ambulation with physical therapy. Because patient was advancing faster than anticipated with physical therapy, decision was made to discharge the patient on [2176-6-17], to home. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: Status post mitral valve replacement, tricuspid valve replacement. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Digoxin 0.125 mg p.o. q. day. 3. Captopril 12.5 mg p.o. t.i.d. 4. Lasix 40 mg p.o. b.i.d. 5. Potassium chloride 10 mg p.o. q. day. 6. Coumadin 2.5 mg times one on [2176-6-17], with repeat INR check on [6-19], 13th and 15th, with INR to be sent to Dr. [Last Name (STitle) 49676] [Name (STitle) 49677]. FO[Last Name (STitle) ]P INSTRUCTIONS: Patient is to follow up with Dr. [Last Name (Prefixes) 2545] in four weeks after discharge. Patient is also to follow up with Dr. [Last Name (STitle) 49676] [Name (STitle) 49677] in one week after discharge. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 12370] MEDQUIST36 D: [2176-6-17] 09:47 T: [2176-6-17] 08:50 JOB#: [Job Number 49678] cc:[Name (STitle) 49679] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6331 }	Medical Text: Admission Date: [2142-5-15] Discharge Date: [2142-5-25] Date of Birth: [2067-8-3] Sex: M Service: MEDICINE Allergies: Penicillins / Barbiturates / Tricyclic Compounds / Phenothiazines Attending:[First Name3 (LF) 1253] Chief Complaint: Hypothermia Major Surgical or Invasive Procedure: R PICC line placement History of Present Illness: Mr. [Known lastname 284] is a 74 year old gentleman with history of Alzheimer's dementia, hypothyroidism, pituitary adenoma s/p resection, and prior episodes of hypothermia, who presented to [Hospital6 2910] from his nursing home after it was noted he only ate a small amount of his lunch which was highly unusual for him per report. At that time, his blood pressure was measured and found to be low at 90/50, with a heart rate in 40's-50's, and unmeasurable temperature. . He was taken to [Hospital6 2910], where meansured rectal temperature was 89, and remainder of vital signs were: HR 52, BP 132/80, 100%sat. While at [Hospital6 ], he received 125mg Solumedrol, 2 L warmed IV fluids, 500 mg Levofloxacin, 500 mg Flagyl, and warm blankets. It was decided in conjunction with nursing home physician that pt should be transfered to [Hospital1 18] given there were no ICU beds available elsewhere. Around that time, per report his family stated he was similar to prior admissions. . In the [Hospital1 18] ED, initial vital signs were: temperature 90 axillary, heart rate 48, blood pressure 161/91, respiratory rate of 16, and oxygen saturation of 100%. A fingerstick at triage was 139. During his stay in the ED, Patient was given 1 gram of vancomcyin and warmed with a Bair hugger. A CT abdomen and pelvis was completed as noted below. At time of transfer, vital signs were: 0130: 35.8C 81 136/67 16 98%RA . On the floor, patient was not arousable and further history was not obtainable. Past Medical History: - Dementia (Alzheimer's) - Hypothyroidism - Far-advanced pituitary adenoma s/p resection - History of CVA - Renal insufficiency - Anemia - H/o syphilis - Prostatic enlargement - Depression - Hyperlipidemia - GERD - Amputation of fingers of left hand Social History: Tobacco, ETOH and IVDU hx unavailable. Lives at [Hospital 10246] nursing home. Health care proxy is sister ([Telephone/Fax (1) 85722]) and [Doctor Last Name ], and legal guardian is sister and [Name (NI) ]. Family History: Unavailable Physical Exam: Vitals: T:95.2 (axillary)/ BP: 135/75 / P: 48 / R: 18 / O2: 99% on RA General: Laying in bed, lookinig around, not responsive to questioning, occasional gutteral noises HEENT: Sclera anicteric, moist membranes with poor dentition, oropharynx clear. Pupils 1mm, minimally reactive bilaterally. Neck: supple Lungs: Bilateral airmovement, exam limited by poor effort CV: Regular rate and rhythm, normal S1 + S2, S4 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. Left hand status-post amputation of [12-22] digits Neuro: Opens eyes occasionally, responds to some noxious stimuli Pertinent Results: Admitting Labs: [2142-5-15] 09:39PM SODIUM-144 POTASSIUM-4.9 CHLORIDE-119* [2142-5-15] 09:39PM HCT-25.6* [2142-5-15] 01:42PM GLUCOSE-91 UREA N-19 CREAT-1.2 SODIUM-142 POTASSIUM-5.7* CHLORIDE-115* TOTAL CO2-21* ANION GAP-12 [2142-5-15] 10:03AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2142-5-15] 04:24AM calTIBC-213* FERRITIN-895* TRF-164* [2142-5-15] 04:24AM calTIBC-213* FERRITIN-895* TRF-164* [2142-5-14] 08:40PM TSH-2.9 [2142-5-14] 08:40PM CORTISOL-52.1* [2142-5-14] 08:40PM WBC-6.9 RBC-3.76* HGB-11.2* HCT-36.3* MCV-96 MCH-29.7 MCHC-30.8* RDW-14.8 [2142-5-14] 08:40PM PLT COUNT-170 [2142-5-14] 08:40PM PT-12.0 PTT-32.6 INR(PT)-1.0 [2142-5-14] 08:51PM GLUCOSE-132* LACTATE-1.8 NA+-140 K+-5.0 CL--105 TCO2-25 [2142-5-14] 08:40PM GLUCOSE-133* UREA N-23* CREAT-1.0 SODIUM-138 POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-22 ANION GAP-14 . . Other Studies: FINAL REPORT [2142-5-20] Blood Culture, Routine (Final [2142-5-20]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Numeric Identifier 85723]) REQUESTED SENSITIVITIES [2142-5-17]. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S . [2142-5-14] 9:03 pm BLOOD CULTURE FINAL REPORT [2142-5-20] Blood Culture, Routine (Final [2142-5-20]): NO GROWTH. . [2142-5-14] 11:00 pm URINE Site: CATHETER FINAL REPORT [2142-5-15] URINE CULTURE (Final [2142-5-15]): NO GROWTH. . [2142-5-18] 6:00 am BLOOD CULTURE #2. FINAL REPORT [2142-5-24] Blood Culture, Routine (Final [2142-5-24]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final [2142-5-19]): GRAM POSITIVE COCCI IN CLUSTERS. . Blood Cx Pending from [Date range (1) 85724]: [2142-5-24] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2142-5-23] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2142-5-22] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2142-5-22] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2142-5-21] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2142-5-20] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2142-5-18] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram Stain-FINAL INPATIENT [2142-5-15] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2142-5-14] URINE URINE CULTURE-FINAL EMERGENCY [Hospital1 ] [2142-5-14] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [Hospital1 ] [2142-5-14] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram Stain-FINAL . ECHO - [2142-5-24]: GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - patient unable to cooperate. Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 65%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve is not well seen. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. . PICC placement [5-22]: IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4 French single lumen PICC line placement via the right brachial venous approach. Final internal length is 38 cm, with the tip positioned in SVC. The line is ready to use. . R Thigh Xray [5-21]: HISTORY: Staph in blood culture, to assess source of infection. FINDINGS: No previous images. There is exuberant callus formation about a healed fracture of the proximal femur. Metallic screw is in place. There is no evidence of gas in soft tissues or erosive change to suggest this as a source of spreading infection. . CT abdomen/pelvis w/ contrast [5-14]: IMPRESSION: 1. Bibasilar aspiration versus atelectasis. 2. No acute intra-abdominal process. 3. Mild colonic diverticulosis without acute diverticulitis. 4. Enlarged prostate. Please correlate with serum PSA level. Focal hypodense area within the prostate adjacent to the urethra, correlate with history of prior TURP. If none, findings may represent prostate lesion. . CXR [5-15]: HISTORY: Altered mental status with hypothermia and fluid resuscitation. FINDINGS: In comparison with study of [5-14], the patient has taken a somewhat better inspiration. There is still some indistinctness of pulmonary vessels, which could reflect some elevated pulmonary venous pressure. No definite discrete pneumonia is appreciated at this time. . Discharge Labs: Na 141 / K 4.1 / Cl 103 / HCO3 29 / BUN 20 / Cr 1.5 / 85 Ca 8.6 / Mg 1.9 / P 3.2 CBC 7.2 / Hgb 9.9 / Hct 31.3 / Plts 257 / MCV 94 Brief Hospital Course: #) Hypothermia. The differential for hypothermia includes hypopituitarism, hypothyroidism, hypoadrenalism, hypoglycemia, sepsis, vasodilation/impaired regulation from medication, or environmental among other causes. Given history of pituitary adenoma status-post resection, central cause appeared likely on admission. The patient only had hypothermia to fit SIRS criteria. Significantly he had two similar admissions one to [Hospital 882] Hospital, the other to [Hospital1 112] with similar symptoms and without clear etiology. An EEG in the MICU demonstrated only encephalopathy. The patient was given a Bair-Hugger and temperatures were persistently 95-97F. Follow-up with the patient's nurse [First Name (Titles) ] [Last Name (Titles) ] (SNIF)on [2142-5-16] revealed that his temperatures run low at baseline (never more than 96F). A toxicology screen was negative. A TSH, cortisol and blood cultures were ordered. A stress dose of steroids was administered on [2142-5-12] and continued throughout hospitalization with tapering to home level of 5mg Prednisone daily by time of discharge. When pt came out of the ICU he continued to have intermittent hypothermia into the 93-96 degree range. Pt always warmed back up to 95-97 on next vital sign check and never had any symptoms related to his hypothermia. Concern for Endocrine or Neurologic basis of low temps, BP, and HR prompted a consult to both services. Endocrinology recommended increasing levothyroxine to 75mcg/day and keeping baseline prednisone at or above 5mg/day. Free T4/total T4 levels were check which showed both WNL. Antithyroglobulin and Anti-TPO antibodies were ordered - those results are pending. Neurology noted that vital signs abnormalities could be [12-19] to autonomic dysfunction or a parkinson-plus type syndrome, but that further work-up would likely not change management and that work-up would also be difficult [12-19] to patient's demented state. . #) Hypotension/Hypertension: The patients blood pressure was labile upon arrival to MICU, with SBP 170->70. Given labile nature, sepsis appears less likely. Other possibilities considered were adrenal insufficiency, volume depletion, cardiogenic, autonomic dysregulation. Two IV fluid boluses for blood pressure elevation were given and broad antibiotic coverage for hospital acquired pna were administered(vancomycin and Levofloxacin) in the ICU. On the morning of [2142-5-16], the patient appeared much improved, he was afebrile, without leukocytosis with two normal chest xrays. Antibiotic therapy was discontinued. The hypotension resolved and pt later became hypertensive while on the medicine floor. His home lasix dose of 20mg/day was restarted and after 1-2 days BPs came back down to the high-normal range. No further episodes of hypotension were noted during the hospitalization. . # Bradycardia:Pt presented with significant bradycardia but after treatment in the ICU his heart rates came back up into normal range. Once patient was transferred to the floor, his heart rate drifted down to the 30-50 range where it stayed for the next week without any symptoms. During the evening of [5-20] pt was noted to have pseudonormalization of his T segments in a diffuse distribution on EKG. Cardiology was contact[Name (NI) ] and was not inclined to think these changes were dangerous. One set of cardiac enzymes were negative and pt was placed on ASA and ACS dose of a statin for precautionary reasons. Pt continued to be brady in the 30-50s for the rest of admission with his EKG showing sinus rhythm with a prolong PR interval. A very occasional pause of 2 seconds was noted on tele, but was not deemed warrant further intervention or work-up. Pt remained asymptomatic during all these episodes. . #) Coag Negative Staph bacteremia: After abx were stopped in the ICU, Blood Cx from [5-15] ultimately came back with 1/4 bottles positive for CONS. ID was asked what to do about this finding and recommended putting back on Vanco until initial cultures at [Hospital6 2910] and F/U culture form [5-18] at [Hospital1 18] came back negative. Pt then lost IV access which could not be regained for 5 days. ID recommended switching to PO Linezolid in replacement of vanco until culture results obtained. While the [Hospital6 2910] cultures came back negative, one bottle from [5-18] at [Hospital1 18] came back positive for coag negative staph with sensativities identical to the earlier specimen. A xray of the R thigh found that pt indeed had hardware in the form of a metal screw in an old fracture in his R femur. An TTE ECHO of the heart was done that was a very poor quality study because patient was moving. Valves could not be adequately visualized to assess for possibility of endocarditis. Although ID was suspicious that these cultures were both contaminants, they recommended antibiotics (either Vanco or Linezolid) be continued to finish a 14 day course from the 7/2 blood culture (finishing day [5-31]). Multiple blood cultures are still pending from [Date range (1) 85724]/[2141] (see pertinent results). Pt was discharge on Vancomycin when sent home to nursing facility as a PICC line had been placed later in his admission and the nursing facility was inclined to use Vanco over Linezolid for cost-efficiency reasons. . #) Altered Mental Status. There was a question of mental status changes on admission, the patient reportadly ate only 40% of his dinner which is highly unusual for him. On [5-15] and [2142-5-16], discussions with the patients family and health care providers revealed that that patient at baseline is similar to his appearance on the morning of [2142-5-16]. He is A&Ox1 incontinent, non verbal, unable to feed himself but loves to eat and laugh. As his appetite and mood were restored by [5-16] the patient was transferred to the floor in preparation for discharge. A serum and urine toxicology screen were negative. Pt quickly returned to what family described as baseline mental status as he was transfered out of the ICU. Pt unable to respond to questioning and just looking around his environment without much tracking. Responsive to noxious stimuli. . #) IV access: pt a very difficult venous stick and after a few days on the floor also lost both of his peripheral IVs. IV team was unable to obtain PIV or PICC placement despite multiple attempts. IR could not take to place PIC for 5 days so patient spent 5 days on the floor without access. Blood was only drawn intermittently because phlebotomy was often unable to access a vein. Once PICC was placed blood draws resumed and Abx were okayed to transition to IV to finish the 14 day course. . #) Bright red blood per rectum: Initially there was some concern that patient was haivng rectal bleeding as there was note documentation of BRBPR and a Hct drop after admission. However, upon further investigation, it was determined that this had been inadvertently added to the medical record from an old hospital admission and that patient was not actually bleeding during this admission. Initial Hct drop was attributed to the ressucitiation fluids the patient was given at ICU presentation. His Hct stayed stable the rest of the admission and on evidence of rectal bleeding was ever observed. . #) Hypothyroidism, s/p pituitary resection: The patient was continued on his home dose of Synthroid until endocrine recommended that the dose be increased from 50mcg -> 75mcg each day. Free T4, Total T4, and TSH were all found to be WNL during admission. AntiTPO and Anti Thyroglobilin antibodies were ordered but were pending at time of diagnosis. . #) Dementia: Pt with diagnosis of AD, as well as s/p CVA (remote). Baseline mental status poor, likely multifactorial. Aricept was continued as an inpatient. . #) Anemia: Normocytic anemia in a patient with chronic disease. Given iron studies (Ferritin 895, TIBC 213, TRF 164) and clinical picture, his anemia is likely a mixed picture of anemia of chronic disease, iron deficiency, and hemodilution. Downward trending hct in-house most likely secondary to hemodilution. He does not seem to be bleeding as guaiac neg and imaging neg and hemodynamically stable. . #) Hyperlipidemia: The patient was continued on his home dose of Zocor. It was initially increased to a ACS dose during one evening where there was concern over EKG changes. However, enzymes and clinical situation did not indicate any ACS type event so patient was returned to home Zocor dose at discharge. . Medications on Admission: -Artificial Tears -Aricept 10mg qday -Colace 100mg [Hospital1 ] -Prednisone 5mg qday -Trazadone 50mg q6h -Iron 325mg [Hospital1 ] -Synthroid 50 mcg qday -Zocor 20mg qday -Lasix 20mg PO qday Discharge Medications: 1. Aricept 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [11-18] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Trazodone 50 mg Tablet Sig: 0.5mg Tablet PO twice a day: and in addition 75mg qhs. 8. Vancomycin in 0.9% Sodium Cl 1 gram/250 mL Solution Sig: One (1) Intravenous twice a day for 7 days. 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 12. Labs weekly CBC, CHEM10 LFTS while on antibiotics 13. Vanco trough Will need to check Vancomycin trough before 4th dose (AM dose on [5-27]). This assumes pt gets dose on PM of [5-25], and gets AM and PM dose on [5-26]. If trough <15 or >20, vanco dose will need to be adjusted. Discharge Disposition: Extended Care Facility: Roscommon on the Parkway - [Location 1268] Discharge Diagnosis: Primary Diagnosis: 1. Questionable coag negative staph bacteremia 2. Questionable autonomic dysregulation with hypothermia, low blood pressure, and bradycardia. . Secondary Diagnosis: - Dementia (Alzheimer's) - Hypothyroidism - Far-advanced pituitary adenoma s/p resection in [2135] - History of CVA - Renal insufficiency - Anemia - H/o syphilis - Prostatic enlargement - Depression - Hyperlipidemia - GERD - Amputation of fingers of left hand Discharge Condition: Mental Status: Confused - always. Activity Status: Bedbound. Level of Consciousness: Lethargic but arousable. Discharge Instructions: Mr. [Known lastname 284], it was a pleasure taking care of you during your stay. . You were admitted after a transfer from [Hospital6 17390] to [Hospital3 ]. Your nursing facility had sent you to [Hospital6 ] with concerns for low heart-rate, low temperature, low blood pressure, and concerns that you only ate a small amount of your lunch. At [Hospital6 ] you were given steroids, warm IV fluids, antibiotics, and warming blankets. . Upon arrival at the [Hospital3 ] emergency department your temperature was still low and you were sent to the ICU. Antibiotics were started and you were warmed with a Bair hugger. Your potassium was high and you were treated for this. A study of your brain waves were ordered showing encephalopathy. Your blood pressure was maintained with IV fluids and as you improved we were able to give you food which you tolerated. Although they were briefly stopped, we re-started you on antibiotics because two different blood cultures grew a bacteria called coag negative staph. The infectious disease team helped us manage your antibiotics and you will be sent home with an antibiotic called vancomycin to complete a 14 day course (ending on [5-31]). An ultra-sound of your heart showed no evidence of endocartitis. Your temperatures came back up to a low/normal range where they stayed for the rest of the admission, with occasional hypothermia into the 94 degree range. . The endocrinology team and neurology team both saw you during your hospital stay. Endocrinology increased your levothyroxine dose to 75mcg each day and recommended your prednisone dose stay at or above 5mg each day. Neurology indicated that you may have some nerve dysfucntion causing low blood pressure, low heart rate, and low temperatures or that you may have some parkinsons type symptoms. However, they said the diagnosis would not change how you are cared for and no further tests were run. . Your heart rate ran low in the 30-50s for the last week of your admission. You never showed symptoms from this and were carefully monitored. Your urine function was found to be slightly abnormal with a creatinine of 1.5 at discharge. In the past your creatinine has also been slightly high in the 1.1-1.4 range. A PICC line was also placed in your R arm to allow IV access because it is difficult to achieve IV access on your veins. This PICC line can be used to complete the course of your IV antibiotic. New Medications to take at discharge: - Vancomycin 1000mg IV Q12 - Levothyroxine 75mcg PO daily - Prednisone 5mg PO daily - ASA 81mg PO daily . Pt should also supplement diet with one Ensure shake at each meal. . You will follow up with your PCP per your normal pattern. Followup Instructions: PCP as per protocol No need to follow up as an outpatient with infectious disease, endocrinology, or neurology. . Will need to check Vancomycin trough before 4th dose (AM dose on [5-27]). This assumes pt gets dose on PM of [5-25], and gets AM and PM dose on [5-26]. If trough <10 or >20, vanco dose will need to be adjusted. . Pt should have each meal supplement with one Ensure shake. ICD9 Codes: 7907, 5849, 2760, 2767, 5859, 2724, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6332 }	Medical Text: Admission Date: [2113-10-6] Discharge Date: [2113-10-13] Date of Birth: [2044-1-29] Sex: M Service: ORTHOPAEDICS Allergies: Iodine Attending:[First Name3 (LF) 3190] Chief Complaint: back pain, radiating leg pain Major Surgical or Invasive Procedure: anterior lumbar interbody fusion, L1-L5, posterior spinal fusion T10-L5. History of Present Illness: 69 year old male with degenerative scoliosis and axial back pain Past Medical History: CABG, CAD, HTN, anxiety Social History: denies tobacco Family History: non contributory Physical Exam: back non-tender neuro intact abd soft, non tender chest clear heart regular Pertinent Results: [2113-10-6] 10:32AM PO2-114* PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-1 [2113-10-6] 10:32AM HGB-13.4* calcHCT-40 O2 SAT-97 [2113-10-6] 08:34AM PO2-178* PCO2-36 PH-7.42 TOTAL CO2-24 BASE XS-0 [2113-10-6] 08:34AM GLUCOSE-96 LACTATE-1.9 NA+-136 K+-3.7 CL--108 [2113-10-6] 08:34AM O2 SAT-99 CARBOXYHB-0.7 [2113-10-6] 08:34AM freeCa-1.06* Brief Hospital Course: 69 year old male, underwent ALIF with partial vertebrectomies L1-L5. Tolerated procedure well. Underwent posterior fusion T10-L5 with significant blood loss and transfusion requirement. No major complications postoperatively. Pain controlled with oxycontin and percocet. DVT prophylaxix achieved mechanically. Discharged to rehab on [10-13] Medications on Admission: atenolol atorvastatin folate niaspan tamsulosin tolterodine ramipril olopatadine alprazolam Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Niaspan Oral 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 9. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 11. Olopatadine 0.1 % Drops Sig: One (1) Ophthalmic [Hospital1 ] (). 12. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 18. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every twelve (12) hours. Discharge Disposition: Extended Care Facility: [Hospital3 ] Discharge Diagnosis: Degenerative scoliosis Discharge Condition: Stable, foley catheter in place, incisions clean and dry Discharge Instructions: Use pain pills as directed. Keep your brace on whenever you are out of bed. You do not need the brace while you are in bed. Keep the incisions dry when you bathe. Call the office if you have increasing drainage or fevers over 101F. Do not lift anything heavier than a gallon of milk, no bending or twisting. Physical Therapy: wt bearing as tol all extremities, must wear TLSO brace when out of bed. No lifting anything heavier than a gallon of milk, no bending or twisting Treatment Frequency: dry gauze dressing to back, change daily, no dressing necessary on thoracotomy Followup Instructions: Dr. [Last Name (STitle) 363] in 2 weeks, [Telephone/Fax (1) 3573] ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6333 }	Medical Text: Admission Date: [2198-5-21] Discharge Date: [2198-6-6] Date of Birth: [2198-3-14] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: This is the third [Hospital1 346] admission for [Known lastname ] [Known lastname ]. [Known lastname ] is the former 28 and [6-1] week gestation infant, birth weight 1.015 kilograms, mother is 29 year-old G1 P0->1 woman. Prenatal screens were O positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative and group beta strep status unknown. The mother has a history of bipolar mood disorder and has been treated with Prozac. This pregnancy was complicated by pregnancy induced hypertension and insulin dependent diabetes mellitus since [2194]. She was induced with Pitocin, but delivered by cesarean section for worsening pregnancy induced hypertension. The baby had [Name (NI) ] scores of 7 at one minute and 8 at five minutes. He was initially treated in the Neonatal Intensive Care Unit from [3-14] until [2198-4-2] when he was transferred to [Hospital ] Hospital for Level II care. Please see the previously dictated summary for that portion of his Neonatal Intensive Care Unit admission. He was transferred from [Hospital ] Hospital to [Hospital3 1810] for management of medical necrotizing enterocolitis. He returned to the [Hospital1 1444] on [2198-4-23]. He was diagnosed with a colonic stricture secondary to the necrotizing enterocolitis, was transferred to [Hospital3 18242] and underwent a resection and end to end anastomosis on [2198-5-17]. Please see the previously dictated summary for his [4-23] to [2198-5-17] [Hospital1 18] Neonatal Intensive Care Unit admission. He returned to the [Hospital1 346] on [2198-5-21]. This dictation covers the remainder of his Neonatal Intensive Care Unit admission through discharge. HOSPITAL COURSE: 1. Respiratory: [Known lastname ] was extubated the day prior to admission. He has been in room air since readmission from [Hospital3 1810]. His oxygen saturations are greater then 95%. At the time of discharge he is breathing comfortably with a respiratory rate of 30 to 50. 2. Cardiovascular: [Known lastname 13291] had previously had two cardiac echocardiograms. A patent foramen ovale was noted. At the time of discharge he continues to have a soft intermittent murmur. 3. Fluids, electrolytes and nutrition: [Known lastname ] returned postoperatively on 10 cc per kilogram of Pregestamil formula feeds. A Broviac cathether had been placed in the right internal jugular vein. He was maintained on total parenteral nutrition fluids as he advanced to full enteral feedings. Feedings were advanced without problems. At the time of discharge he is taking [Known lastname 37112] 24 calories per ounce with a minimum of 130 cc per kilogram per day. His actual intake is 150 to 200 cc per kilogram per day. Serum electrolytes were checked postoperatively twice and were within normal limits. His discharge weight is 2.645 kilograms with a length of 47.5 cm and a head circumference of 34 cm. 4. Infectious disease: [Known lastname ] was treated initially for his presumed return of necrotizing enterocolitis. He received a 14 day course of antibiotics that completed on his third postoperative day. There have been no other infectious disease issues since his return from [Hospital3 1810]. 5. Gastrointestinal: As previously noted [Known lastname ] had a sigmoid stricture diagnosed by barium enema on [2198-5-15] and had an end to end anastomosis. His surgeon at [Hospital3 18242] is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 732]. He would like to follow up with [Known lastname ] two months after discharge. 6. Hematological: [Known lastname ] is blood type A positive, antibody negative. His most recent hematocrit was 27% on [2198-5-23]. He has not received any further transfusions of blood products. 7. Neurology: [Known lastname ] had a normal head ultrasound on [2198-3-21]. There was no evidence of intraventricular hemorrhage or periventricular leukomalacia. A repeat head ultrasound on the day of discharge at corrected age of 40 and 4/7 weeks was within normal limits. [Known lastname ] returned from [Hospital3 1810] on a Fentanyl drip for pain control. The Fentanyl drip was weaned. Due to evidence of neonatal abstinence, he was started on oral morphine solution. He continued a seven day wean of the oral morphine solution, which was discontinued on [2198-6-4]. [Known lastname ] has appeared comfortable since coming off the morphine without any episodes of narcotics habituation. 8. Sensory: Audiology, hearing screening was performed with automated auditory brain stem responses. [Known lastname ] passed in both ears. Ophthalmology, retinas were most recently examined on [2198-5-16] and were found to be mature. Recommended follow up at eight months with ophthalmology at [Hospital3 1810]. 9. Psycho/social: Mother has been actively involved in [Known lastname 53343] care. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 2184] [Last Name (NamePattern1) 53334], [State 53344], [Location (un) 14663]. Phone number [Telephone/Fax (1) 53335]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding: Ad lib po [Telephone/Fax (1) 37112] 24 calories per ounce. 2. Medications: No medications. 3. Car seat position screening was performed. [Known lastname ] was observed for 90 minutes in his car seat without any episodes of bradycardia or oxygen desaturation. 4. Two additional state screens were sent on [4-28] and [2198-5-23] with no abnormal results. 5. Immunizations, second hepatitis B was given on [2198-6-2]. Initial doses of Diphtheria acellular pertussis, hemophilus influenza B, injectable polio vaccine, and pneumococcal 7 valet conjugate vaccine were all administered on [2198-6-2]. Immunizations recommended, Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria. First [Month (only) ] at less then 32 weeks, second [Month (only) ] between 32 and 35 weeks with two of three of the following, day care during RSV season, smoker in the household, neuromuscular disease, airway abnormalities or school age siblings or thirdly with chronic lung disease. Influenza immunizations is recommended in the fall for all infants once they reach six months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home care givers. FOLLOW UP: 1. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 732] Pediatric Surgery at [Hospital3 1810] two months after discharge. Phone number is [Telephone/Fax (1) 38454]. [Hospital3 1810] also has a surgical clinic at [Hospital ] Hospital, [Last Name (un) 53345]with the same phone number for scheduling ([Telephone/Fax (1) 38454]). 2. Pediatric ophthalmology at eight months of age outpatient clinic at the [Hospital3 52563] at [Location (un) 1456], [Location (un) 53346], [Location (un) 1456]. Scheduling phone number [Telephone/Fax (1) 53347]. 3. Pediatrician on [6-7]. 4. VNA visit on [6-11]. 5. Early Intervention Referral made. 6. [Hospital3 1810] Infant Follow Up Clinic Referral made. DISCHARGE DIAGNOSES: 1. Prematurity at 28 and 5/7 weeks gestation now 40 4/7 weeks. 2. Status post respiratory distress syndrome. 3. Multiple suspicions for sepsis ruled out. 4. Necrotizing enterocolitis. 5. Colonic stricture status post resection. 6. Anemia of prematurity. 7. Iatrogenic neonatal abstinence, treated. 8. Patent foramen ovale. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37233], M.D. [MD Number(1) 36463] Dictated By:[Last Name (Titles) 37548] MEDQUIST36 D: [2198-6-6] 07:30 T: [2198-6-6] 07:37 JOB#: [Job Number 53348] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6334 }	Medical Text: Admission Date: [2143-9-14] Discharge Date: [2143-9-27] Date of Birth: [2143-9-14] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname 915] [Known lastname 23096] delivered at 35 1/7 weeks gestation weighing 2110 grams and was admitted to the newborn intensive care nursery for management of prematurity and respiratory distress. Mother is a 33 year-old gravida III, para I, now II mother with estimated date of delivery [2143-10-14]. Prenatal screens included blood type O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune, and group B strep unknown. Pregnancy was completed by pregnancy-induced hypertension. Labor was induced at 35 1/7 weeks for oligohydramnios and maternal hypertension. There was no maternal fever. Membranes were ruptured less than 2 hours prior to delivery for clear fluid. There was no fetal tachycardia. Delivery was by spontaneous vaginal delivery. The infant emerged with a spontaneous cry with good tone and color, was routine bulb suctioned, dried and stimulated. Apgars were 9 and 9 at one and five minutes respectively. PHYSICAL EXAMINATION ON ADMISSION: Anterior fontanelle open, soft, flat. No dysmorphic features. Palate intact. Neck supple with intact clavicles. Lungs fair to good aeration. Clear with mild grunting when disturbed. Cardiovascular showed regular rate and rhythm without murmur. Abdomen soft, no hepatosplenomegaly no masses. Bowel sounds present. Normal male genitalia. Testes descended bilaterally. Extremities pink and well perfused. Good tone and activity. Birth weight 2110 grams, 25th to 50th percentile. Length 43.5 cm, 25th percentile and head circumference 32 cm, 50th percentile. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Had grunting, flaring, retracting on admission without oxygen requirement. The respiratory distress subsided within a few hours and [Known lastname 915] has been in room air since with comfortable work of breathing. His respiratory rate ranges in the 30s to 50s. He has not had any apnea of prematurity. CARDIOVASCULAR: There has no murmur, normal heart rates and blood pressures. Most recent blood pressure 82/40 with a mean of 61. FLUIDS, ELECTROLYTES AND NUTRITION: Started ad lib feeding on day of birth with Enfamil 20 with iron. Required gavage feeding as was unable to take all feeds by nipple. Has been on all p.o. feeds for the past 24 to 48 hours with good intake. He is discharged home on Infacare 24 calories per ounce with weight gain. Discharge weight GASTROINTESTINAL: Was treated with phototherapy for physiologic jaundice. Bilirubin peaked on day of life 3. Phototherapy was discontinued on [2143-9-19] and problem is resolved. HEMATOLOGY: Infant's hematocrit on admission was 41%. INFECTIOUS DISEASE: A CBC and blood culture was drawn on admission. Did not receive antibiotics. The blood culture was negative. The CBC was normal. NEUROLOGY: Examination is age appropriate. SENSORY: Hearing screening was performed with automated auditory brain stem responses. Results are pending. CONDITION ON DISCHARGE: Stable. Infant now 37 weeks gestational age. DISCHARGE DISPOSITION: Discharged home with parents. Name of primary pediatrician, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 22484] at [Hospital6 ] of [Hospital1 ]. Telephone number [Telephone/Fax (1) 26408]. CARE AND RECOMMENDATIONS: 1. Feeds: Infacare 24 ad lib. Monitor weight gain and wean calories as indicated. 2. Medications: None. 3. Car seat position screening was done and he passed. 4. State Newborn Screen was drawn on [2143-9-17] and results are pending. 5. Immunizations received: Hepatitis B immunization on [2143-9-25]. 6. Follow up appointment schedule recommended. VNA referral has been made. Parents will make appointment with pediatrician for beginning of week on [10-1] or [10-2]. DISCHARGE DIAGNOSES: 1. AGA preterm infant at 35 1/ weeks gestation. 2. Transitional respiratory distress, resolved. 3. Physiologic jaundice, resolved. 4. Sepsis ruled out without antibiotics. [First Name8 (NamePattern2) 1154] [Last Name (NamePattern1) ], MD [MD Number(2) 56585] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2143-9-26] 18:40:52 T: [2143-9-26] 19:28:48 Job#: [Job Number 62422] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6335 }	Medical Text: Admission Date: [2191-5-29] Discharge Date: [2191-6-4] Date of Birth: [2109-10-13] Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins / Bactrim Attending:[First Name3 (LF) 5827] Chief Complaint: Vaginal Bleeding Major Surgical or Invasive Procedure: Central Line PICC Line History of Present Illness: 75 F NH resident h/o breast CA, CVA, admitted from ED for sepsis because of elevated lactate. The patient was noted at the [Hospital3 537] to have vaginal bleeding x 2days and was sent to the ED for further evaluation. The patient was started on Cipro empirically at the NH. In the ED, the pt was found to have WBC 29.3, lactate 5.6, though stable vitals. Initial VS: T97.4 p 85 187/1 30 93% 3L. Because of the lactate, sepsis protocol was initiated. R IJ SvO2 catheter was placed. The patient was given 3L IVF, as well as empiric levo/flagyl to cover urine and pulmonary pathogens. CTA chest was done to rule out PE given the low level O2 requirement and CT abdomen was done to evaluate the vaginal bleeding and hematuria. This revealed no PE, though was otherwise unrevealing. The patient was admitted to MICU Green for further management. Past Medical History: Past Medical History: 1. Hypokalemia. 2. Breast cancer, status post radiation therapy with lumpectomy in [2179]. 3. Cerebrovascular accident. 4. History of falls. 5. Arthritis. 6. Status post hysterectomy. 7. Hypertension. 8. Recurrent urinary tract infections. 9. Cardiomegaly seen on chest x-ray. 10. Osteoporosis. Social History: pt is a resident of [Hospital3 ] nursing home. no tob, occasional etoh, no drugs Family History: nc Physical Exam: Physical Exam: VS: T 96.5 P 96 BP 130/60 o2 100 on RA GEN: pleasant, awake, alert oriented to self and place HEENT: PERRL, MMM NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e Neuro: oriented to self and follows simple command, moves all ext when asked, smile symetric Pertinent Results: EKG: SR 100 with PACs. LAD. isolated Q in V1. CT ABD W&W/O C Study Date of [2191-6-1] 8:38 PM No evidence of bladder mass, as clinically questioned. Diffuse bladder wall thickening that may represent cystitis. Interval, partial decompression of the collecting system. Horseshoe kidneys with multiple hypoattenuating lesions, many of which are too small to characterize but most likely represent cysts. Multiple hypoattenuating lesions in the liver, likely cysts. Diffuse osteopenia and deformity and ankylosis of lumbar spine. CTA CHEST W&W/O C&RECON Study Date of [2191-5-29] 10:55 PM No evidence of pulmonary embolism. Horseshoe kidneys with multiple hypodense lesions, the largest of which represent cysts but most of which are too small to fully characterize. Additionally, the ureters are mildly dilated with small filling defects which may represent clot. Hyperdense material within the bladder likely represents blood in setting of gross hematuria. Enlargement of the right adrenal gland may represent adenoma though this is unclear in setting of prior malignancy. Recommend correlation with outside studies if available before pursuing followup/ further evaluation. 4mm right lower lobe nodule requires 3 month followup to ensure stability unless outside studies have demonstrated stability of this lesion over a number of years. Hypodense hepatic lesions, too small to characterize and not definitively representing cysts in the setting of prior malignancy. Hypodense pancreatic lesion too small to carachterize. Diffuse osteopenia with deformity and ankylosis of the lumbar spine and canal narrowing likely. CT HEAD W/O CONTRAST Study Date of [2191-5-29] 6:16 PM No acute intracranial pathology, including no sign of intracranial hemorrhage. [2191-5-29] 11:16PM LACTATE-5.8* [2191-5-29] 10:17PM GLUCOSE-200* LACTATE-4.8* [2191-5-29] 10:17PM HGB-9.5* calcHCT-29 [2191-5-29] 09:09PM LACTATE-4.5* [2191-5-29] 09:09PM O2 SAT-68 [2191-5-29] 08:10PM URINE COLOR-Red APPEAR-Cloudy SP [Last Name (un) 155]-<=1.005 [2191-5-29] 08:10PM URINE BLOOD-LG NITRITE-POS PROTEIN->300 GLUCOSE->1000 KETONE->80 BILIRUBIN-MOD UROBILNGN-4* PH-7.0 LEUK-LG [2191-5-29] 08:10PM URINE RBC->1000 WBC->50 BACTERIA-MOD YEAST-RARE EPI-0 [2191-5-29] 07:44PM CK(CPK)-21* [2191-5-29] 07:44PM CK-MB-NotDone cTropnT-0.01 [2191-5-29] 07:32PM LACTATE-5.3* [2191-5-29] 07:25PM PT-11.9 PTT-23.4 INR(PT)-1.0 [2191-5-29] 06:21PM LACTATE-5.6* [2191-5-29] 06:18PM HGB-12.5 calcHCT-38 [2191-5-29] 05:10PM GLUCOSE-250* UREA N-31* CREAT-1.6* SODIUM-147* POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-19* ANION GAP-21* [2191-5-29] 05:10PM estGFR-Using this [2191-5-29] 05:10PM ALT(SGPT)-31 AST(SGOT)-22 LD(LDH)-324* ALK PHOS-93 AMYLASE-73 TOT BILI-0.5 [2191-5-29] 05:10PM LIPASE-14 [2191-5-29] 05:10PM ALBUMIN-3.6 CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-2.2 [2191-5-29] 05:10PM CORTISOL-128.4* [2191-5-29] 05:10PM WBC-29.3# RBC-4.46 HGB-12.2 HCT-36.4 MCV-82 MCH-27.3 MCHC-33.4 RDW-16.2 [2191-5-29] 05:10PM NEUTS-64 BANDS-22* LYMPHS-2* MONOS-9 EOS-0 BASOS-0 ATYPS-0 METAS-3* MYELOS-0 [2191-5-29] 05:10PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-2+ SCHISTOCY-1+ BURR-1+ ACANTHOCY-2+ [2191-5-29] 05:10PM PLT SMR-NORMAL PLT COUNT-353 Brief Hospital Course: Whie in the MICU, her lactate improved and her blood pressure remained stable. She was found to have horseshoe kidneys and what appears to be blood clot in renal pelvis as well as in bladder. CT also reveals very enlarged bladder c/w retention of chronic nature. UA on admit c/w UTI (+nitrites, mod bacteria).on CT of chest/abd. Urology was consulted. She was started on CBI due to hematuria. She was started on empiric vanco/cipro/aztreo (given PCN allergy) and [3-9] GNR in her blood. Pt was subsequently transfered to CC7, where she continued empiric vanco/cipro/aztreo until Blood and Urine Cx results revealed PROVIDENCIA STUARTII which was resistanst to Cipro, and Sensitive to azotreonam. ID was consulted, and recommended continuation of azotreonam for 14 day course (first dose 6/25); a PICC was placed and central line was D/Ced. CBI with clear drainage on [5-30], and repeat CT urogram on [6-1] showed no evidence of bladder mass, diffuse bladder wall thickening c/w cystitis and itnterval, partial decompression of the collecting system, multiple hypoattenuating lesions in liver and horseshoe kidney, most likely cysts. On [6-1], pt found to have drop in hct from 25.1 to 21.9. LDH was normal and haptoglobin was elevated indicating DIC with intravascular hemolysis unlikely, pt was guaiac negative. 1 unit PRBC was transfused, and hct rose to 25.4. PI Pt's hct has been stable since, and is 27.4 at discharge. Because the pt was admitted with urosepsis which likely arose [1-7] diabetic atonicity of the bladder and subsequent reflux into the collecting system, Urology recomended that pt be discharged with indwelling foley catheter to decompress the urinary system. While admitted the pt has been hypokalemic, hypophosphatemic, and hypomagnesemic on multiple occasions, requiring repletion. Pt has continued to have low grade fevers (100.8 on [6-2] and 100.6 on [6-4]). Pt already has defined pathogen on culture, known to be sensitive to azotreonam so plan is to continue full course of azotreonam with no need to reculture unless fevers become high grade. On day of discharge pt given potasium phosphate 40 mEQ and Neutraphos packets upon discharge due to K 3.1 and Ph 2.5. At rehab lytes should continue to be checked and repleted twice a week. Pt has been evaluated by speech and swallow, and pt to recieve gorund solids, thin liquids and Ensure TID. Medications on Admission: cipro 250 [Hospital1 ] started [5-27] asa 81' metoprolol 25" lisinopril 2.5' actonel 35 qweek fluticasone nasal tramandol 25" aricept 10' namenda 10" senna/dulcolax/fleets os-ca; prilosec Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection QACHS. 2. Namenda 10 mg Tablet Sig: Two (2) Tablet PO twice a day. 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Sodium Chloride 0.9 % 0.9 % Solution Sig: Ten (10) ML Injection DAILY (Daily) as needed: Flush PICC. 6. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: followed by 10 mL NS flush. 7. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours): Last dose 7/9 to complete 14-day course. 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week. 12. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Nasal once a day. Disp:1 30 day supply Refills:2 13. Tramadol 50 mg Tablet Sig: One (1) half Tablet PO twice a day. 14. Os-Cal 500 + D 500-125 mg-unit Tablet Oral 15. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 16. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal once a day as needed for constipation. 17. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day. 18. Milk of Magnesia Oral Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: Urinary tract infection Sepsis Anemia Dementia Diabetese mellitus II Acute renal failure Discharge Condition: Occasional low-grade fever. Vital signs stable. Discharge Instructions: You were admitted with a urinary tract infection and sepsis. You are being treated with IV aztreonam with plan to complete a 14-day course. Followup Instructions: You should follow-up with your primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1266]. Please call [Telephone/Fax (1) 608] to schedule follow-up. ICD9 Codes: 0389, 5990, 5849, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6336 }	Medical Text: Admission Date: [2157-6-23] Discharge Date: [2157-6-27] Date of Birth: [2099-5-10] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 898] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Intubated in medical ICU. History of Present Illness: Patient is a 58 y/o F w/ RA on prednisone, h/o GI bleed, and recent admit to [Hospital1 2025] neuro ICU w/ meningo-encephalitis who presents with hypotension. Patient presented to ED via ambulance with SBPs in 70s-> 80s and a waxing and [Doctor Last Name 688] mental status that corresponded to the blood pressure. Also there was some report of diarrhea. Work-up included a CXR, UA, CT ABD, CT Head, Surgery c/s that was relatively unremarkable. A right femoral line was placed, 7 Liters IVFs given, Levophed and Decadron with improvement in SBPs to 120s. Given Vanco, Levo, Flagyl. Patient also intermittently hypoxic. An ABG was sent and was 7.10/75/112 and then 7.10/70/55. Patient then intubated for hypercarbic respiratory failure. A CTA chest was then performed and was negative for PE (preliminarily). When patient arrived in ICU she was intubated, but awake and able to communicate appropriately. She complained only of chronic back pain and naseau. On further questioning, it is unclear what precipitated this event. On one occasion, patient reports that she was walking near her home when a stranger grabbed her and pulled her into a car. She screamed and then they pushed her out of the car. She was then brought in by EMS. On subsequent occasions, she claims to have been in a meeting at work, became light-headed and then awoke in the ICU intubated. She does not recall any further details. She states that she has had diarrhea, nausea and some emesis over the past month. Past Medical History: Meningo-Encephalitis (Neuro ICU at [Hospital1 2025], discharged [2157-5-17]) Anemia Sleep apnea Occult GI bleeding Rheumatoid arthritis Fibromyalgia s/p right elbow replacement surgery [9-6] Diverticulitis 25 years ago Migraines HTN Hyperlipidemia s/p lap cholecystectomy Depression Paraesophageal hernia with gastric ulceration s/p lap paraesophageal hernia repair with Nissen fundoplication ([12-6]) Social History: Denies tobacco, alcohol or drug use. She is divorced. She has three daughters. [Name (NI) 1403] as P.A. in adult primary care clinic. She is lebanese/palestinian in background. Family History: Father died of MI at 85. Mother had MI at 75. There is family history of CAD and diabetes. Physical Exam: EXAM: T 98.9 BP 136/90 HR 84 RR 18 O2sat 96% on Room air GEN: Awake in bed. Pleasant and comfortable. NAD HEENT: PEERL, mild peri-orbital discoloration and swelling NECK: Supple. No cervical lymphadenopathy. CV: RRR. Normal S1 and S2. No murmurs, rubs, or gallops. LUNGS: CTA bilaterally with no wheezes or decreased breath sounds. ABD: Soft with slight distention. Active bowel signs in all four quadrants. Slightly uncomfortable on deep palpation. EXT: No lower extremity edema. 2+ dorsalis pedis and radial pulses. Pertinent Results: [2157-6-25] 08:00AM BLOOD WBC-7.8 RBC-3.31* Hgb-9.9* Hct-29.1* MCV-88 MCH-29.9 MCHC-34.0 RDW-15.4 Plt Ct-208 [2157-6-22] 05:20PM BLOOD WBC-14.6# RBC-3.96 Hgb-12.0 Hct-35.5* MCV-90 MCH-30.4 MCHC-33.9 RDW-15.4 Plt Ct-264 [2157-6-22] 05:20PM BLOOD Neuts-80.2* Bands-0 Lymphs-11.3* Monos-5.9 Eos-2.3 Baso-0.2 [2157-6-22] 05:20PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL Tear Dr[Last Name (STitle) 833] [2157-6-25] 08:00AM BLOOD Plt Ct-208 [2157-6-22] 05:20PM BLOOD PT-12.1 PTT-23.1 INR(PT)-1.0 [2157-6-25] 08:00AM BLOOD Glucose-95 UreaN-18 Creat-0.7 Na-142 K-3.9 Cl-107 HCO3-27 AnGap-12 [2157-6-22] 05:20PM BLOOD Glucose-134* UreaN-32* Creat-2.1* Na-138 K-4.6 Cl-102 HCO3-23 AnGap-18 [2157-6-23] 03:20AM BLOOD Glucose-213* UreaN-26* Creat-1.2* Na-139 K-4.6 Cl-109* HCO3-19* AnGap-16 [2157-6-22] 05:20PM BLOOD ALT-18 AST-23 CK(CPK)-48 AlkPhos-84 Amylase-77 TotBili-0.4 [2157-6-22] 05:20PM BLOOD Lipase-68* [2157-6-23] 12:27PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2157-6-23] 03:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2157-6-22] 05:20PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2157-6-25] 08:00AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 [2157-6-22] 05:20PM BLOOD Albumin-3.4 Calcium-8.4 Phos-8.6# Mg-2.4 [2157-6-22] 05:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2157-6-23] 03:41AM BLOOD Type-ART pO2-159 pCO2-40 pH-7.30* calHCO3-20* Base XS--5 [2157-6-23] 12:57AM BLOOD Type-ART Rates-12/ Tidal V-550 PEEP-8 pO2-219* pCO2-66* pH-7.14* calHCO3-24 Base XS--7 -ASSIST/CON Intubat-INTUBATED [2157-6-22] 10:08PM BLOOD pO2-55* pCO2-70* pH-7.15* calHCO3-26 Base XS--5 [2157-6-22] 08:41PM BLOOD Type-ART pO2-112* pCO2-75* pH-7.10* calHCO3-25 Base XS--7 [2157-6-23] 12:47PM BLOOD Lactate-1.3 K-4.5 [2157-6-23] 03:41AM BLOOD Lactate-2.7* [2157-6-22] 06:10PM BLOOD Glucose-136* Lactate-1.8 Na-140 K-4.6 Cl-103 calHCO3-30 [2157-6-23] 03:42AM BLOOD Hgb-12.0 calcHCT-36 O2 Sat-64 [2157-6-22] 08:41PM BLOOD Hgb-11.3* calcHCT-34 [2157-6-23] 12:47PM BLOOD freeCa-1.16 Brief Hospital Course: A/P: 58 year old female, with rheumatoid arthritis on daily prednisone presented to ED with hypotension and hypoxic/hypercarbic respiratory failure and transferred to the floor with HTN. . 1) Hypotension: Decreased blood pressure likely secondary to sepsis and relative adrenal insufficiency, due to chronic steroid use for treatment of RA. LLL PNA is possible source of infection, but no elevated white count or sustained fever, so unlikely. Broad spectrum antibiotics were initiated, but discontinued after negative cultures. . 2)Diarrhea: Patient reported episode of C. dificile following admission to outside hospital. Treated with PO flagyl and completed course 2 weeks before current admission. During this admission, watery diarrhea developed. Sent two C. dificile cultures and will discharge on prophylactic Flagyl. Duration of antibiotic course will be determined by test results. Will send 3rd sample and test for C. dificile toxin-B. . 3) HTN: Patient's blood pressure has remained elevated throughout time after transfer to floor on [2157-6-24]. As there was concern that regimen of ACE-I and BBlocker may have contributed to hypotensive episode, caution was used to control BP. Patient finally titrated to 100mg [Hospital1 ] metoprolol and 40 mg [Hospital1 ] of lisinopril. Patient will be discharged home on this regimen. (Of note, previous elbow fracture in her right elbow predisposes to elevated HTN. Thus, measurements on this side may cause spurious results). . 4) Respiratory failure: Hypoxic and hypercarbic failure. LLL PNA initially thought responsible due to possible hypoventilation due to mental status/pain meds/OSA, but less likely. In the MICU, broad spectrum antibiotics started and sputum culture sent. Weaned FiO2 and good oxygenation saturation achieved on room air. . 5) ARF: Baseline creatinine is 1.1, but with ample fluids repleted, Cr has continued to decrease. Likely pre-renal etiology, as urine output has remained ample. . 6) Guiaic positive stool: Has history of GI bleed [2-3] ulcers in paraesophogeal hernia. HCT was stable throughout hospitalization. Will continue PPI. . 7) RA: Continue regimen of dolasetron. Pain was well controlled with pain regimens. . 8) Fibromyalgia: Hold Neurontin, Flexeril, Morphine for now. Use Fentanyl/Versed for sedation and pain control. . 9) Depression: Continue Effexor, Trazodone. . 10) F/E/N: Appetite was good throughout admission. Placed on a diabetic diet. . 11) PPx: SQ heparin for DVT prophylaxis and PPI. . 12) Comm: with patient and mother PCP: [First Name4 (NamePattern1) ] [Name (NI) 1728] -> [Telephone/Fax (1) 96662] [Hospital1 2025]: Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 97764] [0-0-], pager # [Numeric Identifier ]. [Hospital1 2025] MR# [Medical Record Number 97765] Medications on Admission: Prednisone 10 Daily Metoprolol 150 mg TID Atorvastatin 20 mg DAILY Pantoprazole 40 mg Q24H Cyclobenzaprine 30 mg TID Trazodone 100 mg HS Lorazepam 4 mg Tablet HS Gabapentin 1200 mg TID Morphine SR 30 mg Q8H Oxycodone-Acetaminophen 5-325 mg Q4-6H prn Venlafaxine 225 mg DAILY Triamteren/HCTZ 37.5/25 Lisinopril 20 ASA Discharge Medications: 1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3) Capsule, Sust. Release 24HR PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 7. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:42 Tablet(s) Refills:0 13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day: Hold if HR<60 and systolic BP<100. Discharge Disposition: Home Discharge Diagnosis: Hypotension, hypoxic/hypercarbic respiratory failure. Discharge Condition: Good. Discharge Instructions: Please call your physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 1728] ([Telephone/Fax (1) ]) or come to the emergency department if you develop any shortness of breath, unexpected weakness, or any other concerning symptoms. When at your visit with Dr. [Last Name (STitle) 1728], have him check the C. dificile test results and discuss whether your metronidazole (Flagyl) regimen should be continued. Followup Instructions: Please return home today and schedule an appointment with Dr. [Last Name (STitle) 1728] for later this week. ICD9 Codes: 4589, 2762, 5849, 311, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6337 }	Medical Text: Admission Date: [2150-10-29] Discharge Date: [2150-11-16] Date of Birth: [2094-4-5] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is a 56 year-old male with positive ETT and hypertension, hypercholesterolemia admitted with elective catheterization, which showed a left main coronary artery disease of 60 to 70% occlusion, left anterior descending coronary artery moderate calcification, left circumflex normal, right coronary artery and distal chronic aortic dissection. Ejection fraction at the time was estimated to be 60%. PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia and alcohol abuse. MEDICATIONS AT HOME: Lopressor, nitroglycerin and Lipitor. HOSPITAL COURSE: The patient underwent coronary artery bypass graft times three on [2150-10-30] by Dr. [Last Name (STitle) 70]. There was a left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to obtuse marginal one, and saphenous vein graft to right posterior descending coronary artery. Postoperatively, the patient was extubated and weaned off drips in the Intensive Care Unit. However, the patient developed delirium tremor postoperatively and was placed on Ativan protocol. Psychiatry was consulted. The patient was placed on the Ativan protocol and was weaned off and the patient was stabilized and was doing well and transferred to the floor on [11-4] postoperative day five. Once transferred to the floor the patient was found to have a cold left lower extremity. It became acutely ischemic and arteriogram at that time showed no satisfactory vascular arteriole target that was able to be bypassed. Vascular surgery was consulted and recommended below the knee amputation of left lower extremity. The patient underwent below the knee amputation of left lower extremity on the [11-9]. Following that the patient did well and was subsequently extubated and weaned off drips and transferred to the floor without incidence. Also, the sputum culture on [11-3] was positive for Pseudomonas and hemophilias and ________ growth. The patient was placed on a ten day course of Cipro and Ceptaz. Upon discharge the patient finished a ten course of Cipro and Ceptaz and subsequent culture was negative. The patient was afebrile and was stable. Upon transfer to the floor the patient was able to work with physical therapy. Foley was discontinued without incidence. However, immediately postop the patient did require a standing dose of Haldol due to confusion and agitation. Prior to discharge the sitters have been discharged and the patient has not required Haldol prior to discharge and the patient is alert and oriented times three and the patient was cooperative and working with physical therapy in ambulation. DISCHARGE MEDICATIONS: Lopressor 75 mg po t.i.d., Captopril 12.5 mg po t.i.d., Thiamine 100 mg po q.d., heparin subQ 5000 units b.i.d., Neurontin 300 mg po q.d., Motrin 800 mg po t.i.d., aspirin 81 mg po q.d., folate 1 mg po q.d., Zantac 150 mg po b.i.d, Percocet one to two tabs po q 4 to 6 h prn, Colace 100 mg po b.i.d. and Lipitor 10 mg po q.d. DISCHARGE CONDITION: The patient was stable and afebrile. Vital signs were stable. chest was clear to auscultation. Heart rate was regular rate and rhythm, normal sinus. Sternum was stable. Left stump clean, dry and intact. It had some minimal serosanguinous drainage. Vascular was consulted and it was recommended just wrapping the stump with Kerlix bandage. The stump looks clean. No erythema. No inflammation. No pus drainage. The patient was alert and oriented times three. The patient will be discharged to a rehab facility and was told to follow up with Dr. [Last Name (STitle) 70] in three to four weeks. Also is to follow up with the Vascular Service in two to three weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Name8 (MD) 186] MEDQUIST36 D: [2150-11-16] 08:40 T: [2150-11-16] 09:15 JOB#: [Job Number 36499] ICD9 Codes: 4111, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6338 }	Medical Text: Admission Date: [2125-5-11] Discharge Date: [2125-5-15] Date of Birth: [2065-11-22] Sex: F Service: MEDICINE Allergies: Penicillins / Clindamycin / Celery / Bee Sting Kit Attending:[First Name3 (LF) 1257] Chief Complaint: Hypoxia. Major Surgical or Invasive Procedure: None. History of Present Illness: 59 y/o with OSA, asthma, severe pulmonary hypertension, cor pulmonale on 3-4L home O2 who was admitted after presenting to PCP [Name Initial (PRE) 151] O2 saturation of 78% in the absence of increased dyspnea. She describes several weeks of feeling "heavy", with a 10 pound weight gain and swelling in her thighs. She went to a preschedueld appointment with her PCP on the day of admission and was found to be hypoxic with O2 saturation of 78%, for which they referred her to the ED. She was not more SOB than usual and denies any cough, chest pain, palpitations, PND, orthopnea, or lower extremity edema. She denies any change in diet or increased salt intake, but attributes fluid overload to medication adjustments associated with recent hospitalizations, including a change in her diuretic and a recent course of prednisone. . On arrival to ED, VS: 97.2 80 116/71 20 88% on 4L. Exam with crackles and diffuse wheeze, decreased BS at bases. Given 50mg prednisone and nebs and lasix 80mg IV x 1 with 100cc UOP. CXR with vascular congestion, not much different than baseline. EKG with RVH and unchanged. Given persistent hypoxia to 87-97% on 4L, pt went to the ICU. She was treated with 120mg furosemide x2. Repeat CXR suggested possible developing consolidation in left mid lung zone. . On the floor, she reports shortness of breath consistent with her baseline and describes feeling as if much of the extra weight has been taken off. Her baseline O2 sat is 92-93% on 3L at rest and 4L with ambulation, but she notes that it often dips to 70% without her becomign symptomatic. She is able to perform all IADLs at home and go grocery shopping without being short of breath. No longer able to walk around [Country ] Pond. . Review of systems: (+) Per HPI. Also reports increased chronic knee pain and new aching back pain x3 weeks, which she attributes to carrying around the extra water weight. Notes rhinorrhea, congestion secondary to seasonal allergies. (-) Denies fever, chills, night sweats, recent weight loss. Denies headache, sinus tenderness. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - morbid obesity s/p gastric bypass, hernia repair [6-1] - OSA on nocturnal BIPAP (18/15) and 3-4L home O2 - obesity hypoventilation syndrome, baseline bicarb 40s, pCO2 80s - pulmonary HTN thought from OSA and obesity hypoventilation - right heart failure secondary to pulmonary hypertension - asthma Last PFTs in [12-6]: FEV1 - 0.54 liters (32% predicted) FVC - 0.67 liters (29% predicted) FEV1/FVC - 80.47 Impression: These PFTs are consistent with severe restrictive ventilatory deficit. Compared to her previous PFTs obtained on [2124-7-17] her FVC has decreased from 0.77 liters and her FEV1 has decreased from 0.6 liters. Over the past 15 years dating back to [2109-12-24] there has been an overall decrease in her spirometry with her FEV1 having decreased from 1.86 liters over that timeframe. - h/o iron deficiency anemia - Osteoarthritis of bilateral knees Social History: The patient has five children and lives with two her two sons. Not currently working. Alcohol socially, not in >1 year. No tobacco or illicit drug use. Family History: Father died of cerebral aneurysm Mother had breast cancer and hypertension No family history of lung disease except for a sister with asthma. Another sister with DM. One brother with newly diagnosed unknown [Last Name ] problem. Gout: uncle. [Name (NI) ] disease: aunt/uncle Physical Exam: Physical exam on admission to ICU: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not visualized, no LAD Lungs: Quiet breath sounds given body habitus. No wheezing/rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, NTND, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 1+ pulses, trace edema Physical Exam on transfer to floor ([5-12] 8pm): Vitals: T: afeb BP: 95/58 P: 77 R: 20 O2: 92% 3L General: Alert, oriented, no acute distress, speaking full sentences HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP ~10 cm, no LAD Lungs: Quiet breath sounds given body habitus. No rales/wheezing/rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, NTND, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pedal pulses, trace edema Pertinent Results: [2125-5-11] 02:50PM WBC-10.3 RBC-4.21 HGB-12.1 HCT-38.7 MCV-92 MCH-28.8 MCHC-31.4 RDW-15.7* NEUTS-79.8* LYMPHS-14.8* MONOS-3.2 EOS-1.9 BASOS-0.4 [2125-5-11] 02:50PM PT-12.6 PTT-28.0 INR(PT)-1.1 [2125-5-11] 02:50PM GLUCOSE-98 UREA N-32* CREAT-1.2* SODIUM-144 POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-43* ANION GAP-9 [2125-5-11] 04:10PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.010 [2125-5-11] 04:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2125-5-11] 04:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0-2 . [2125-5-15] 05:15AM BLOOD UreaN-31* Creat-1.3* Na-140 K-4.3 Cl-92* HCO3-43* AnGap-9 Brief Hospital Course: 59yo F with obesity hypoventilation, pulmonary HTN, asthma, and cor pulmonale admitted with worsening of baseline hypoxia and weight gain in the context of medication adjustments most consistent with CHF exacerbation. . # Hypoxia: The patient was admitted with SpO2 of 94% on 3-4L, which is consistent with her baseline. Chest radiograph revealed vascular congestion and pulmonary edema. The patient was diuresed with IV furosemide, approximately 640mg over the first two days, and then switched to po torsemide 40mg TID. Metolazone 5mg po BID was added prior to discharge. She is a chronic retainer with baseline bicarb 40s, pCO2 80s. During admission, her bicarb and creatinine transiently increased to 43 and 1.3 respectively, likely due to overdiuresis. She was given 80mg of oral potassium supplementation; potassium remained within normal limits. She remained asymptomatic and without complaints throughout admission. Discharge weight 118.8 kg. . # OSA: She continued to use BiPAP at 18/15, though with some problems due to lack of humidification on the hospital machine. . # Pulm HTN: Her sildenafil was continued at its usual dose. . # Asthma: She continued to use albuterol and fluticasone as at home and also received prn albuterol/ipratropium nebs daily. . Medications on Admission: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for constipation. 5. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Torsemide 40 mg PO TID 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Medications: 1. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:1 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: Primary: CHF exacerbation Secondary: Pulmonary hypertension Obesity hypoventilation syndrome Obstructive sleep apnea Asthma Discharge Condition: Hemodynamically stable, satting >93% on 3L at rest, able to shower and ambulate without assistance. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 69] for evaluation of your low oxygen saturation. There was no evidence of infection and given your 10 lb weight gain and recent change in medications, your hypoxia was most likely due to fluid overload(heart failure.) You were treated with IV furosemide (Lasix) to get rid of the extra fluid and then were changed back to your oral regimen of Torsemide 40mg three times a day. Your oxygen saturation improved to >93% on [3-1] liters of oxygen. You should continue your medications as prescribed. The following changes were made to your medications: --start METOLAZONE 5mg twice a day You should have your blood drawn on Thursday or Friday and have the lab results faxed to Dr. [Last Name (STitle) 3029] at [Telephone/Fax (1) 101569]. You should limit the amount of fluid and salt you take in(<1.5L/day). Weigh yourself every morning on the same scale and [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Dr. [Last Name (STitle) 3029]: Tuesday [5-22] 2:20pm [Telephone/Fax (1) 250] Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2125-6-18] 1:40 Provider: [Name10 (NameIs) ] [Last Name (STitle) ] & DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2125-6-18] 2:00 Completed by:[2125-5-15] ICD9 Codes: 4280, 4168, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6339 }	Medical Text: Admission Date: [2126-9-13] Discharge Date: [2126-9-18] Date of Birth: [2055-3-28] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7223] Chief Complaint: atrial fibrillation Major Surgical or Invasive Procedure: external cardioversion History of Present Illness: Patient is a 71 yo F without known cardiac disease who presented today to have a routine colonoscopy. When initially given medications for sedation, she developed rapid atrial fibrillation with RVR as well as hypotension. She was given IV fluids and transferred to the ER. In the ER, she was given IV diltiazem 20 mg and found to have ST depressions on ECG. Additional dilt 20 mg and then gtt was started but patient persisted in AF with RVR and hypotension. Patient was aggressively given IV fluids. Despite this the patient remained in AF with RVR and hypotensive and was cardioverted with 100J-->200J and converted to NSR at 65 BPM. However, hypotension persisted and the patient was started on phenylephrine via a newly placed right IJ. . While in the ED, initial vitals were HR 136 BP 84/53 RR 18 02Sat 100%. In total she received 5L normal saline, dilt 20 mg x 2, dilt gtt, magnesium, and potassium. Upon arrival to the unit she was noted to be in NSR and did not complain of CP, palpitations, lightheadedness, or dizziness on my interview. Past Medical History: Osteoporosis Lipids tobacco use Social History: Originally from [Location (un) 6847]. Lives with 1 of her 2 sons in [Name (NI) ]. Smokes [12-18] cigarettes per day x 30 years. No EtOH/illicits. Walks every day for exercise. Family History: No family history of heart disease Physical Exam: PHYSICAL EXAMINATION: VS: T: 97.1 BP: 93/53 P: 75, regular RR: 21 Sat O2: 97% RA Gen: pleasant, NAD, A+O x 3 HEENT: NC/AT, MMM. PERRLA, sclerae anicteric. Neck: Jugular veins flat, no HJR. No thyroid nodules appreciated Cor: RR, tachycardic. no m/r/g, no extra sounds appreciated Resp: inspiratory crackles at bases bilaterally R>L Abd: S/NT/ND, + BS Ext: WWP, no C/C/E. R groin no buits or hematoma. Pulses 2+ at radial and DP Skin: no lesions Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [2126-9-13] ADMISSION LABS CBC: WBC-9.1 RBC-3.82* Hgb-11.4* Hct-34.5* MCV-90 MCH-29.8 MCHC-33.0 RDW-13.6 Plt Ct-203 . CHEMISTRY: Glucose-47* UreaN-11 Creat-0.6 Na-145 K-3.2* Cl-115* HCO3-16* AnGap-17 Calcium-6.6* Phos-3.1 Mg-2.8* . CEs: CK(CPK)-91 cTropnT-<0.01 . UCx, Blood Cx pending . [9-13] CXR: IMPRESSION: Edema-like pattern, likely cardiogenic edema given history. Repeat imaging after diruresis recommended to exclude underlying infection and/or lung disease. . [9-13] ECHO: Conclusions: The left atrium is normal in size. The left ventricular cavity is small. 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. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Impression: small, hyperdynamic left ventricle Brief Hospital Course: 71F smoker with new onset A-fib in setting of colonoscopy prep, s/p cardioversion followed by persistent hypotension, briefly on phenylephrine but now off all pressors and HD stable. . 1. Paroxysmal atrial fibrillation - No prior cardiac history and few risk factors so unlikely to be ischemic in origin. No known pulmonary disease or thyroid disfunction. A fib likely related to hypovolemia in the setting of her colonoscopy prep. Has maintained NSR since cardioversion with resolution of ST depressions on EKG. Patient put on anticoagulation for 1 month. on Lovenox while bridging to coumadin in hospital, and she is to get her INR f/u as outpatient, low chads2 score, so 1 month is sufficient. She will f/u with her PCP to monitor her INR . 2. bactermia: Patient has had several episodes of low grade fevers during hospitalization. Grew coag negative staph from blood on admission, started on vanco. spiked low grade fever (Tmax 100.5) several times during hospitalization, but subsequent blood cx and urine cx negative. 8 days of vanco, PICC was placed before discharged for the last 2 days of vanco treatment. . 3. Hypotension - unknown baseline BP, but no past h/o any hypertension. Was likely volume depleted in the setting of colonoscopy prep and received 5L IVF in the ED. Was on phenylephrine briefly, but was weaned off quickly. CXR showed some pulmonary congestion, but no symptoms of fluid overload. . 4. Elevated troponins: patient had slight troponin leak with EKG changes in the setting of a fib. risk factors low, and patient asymptomatic at baseline. Patient to have stress MIBI as outpatient, [10-8]. Will f/u with Dr. [Last Name (STitle) 2232]. . 5. Lipids: continued Zocor Medications on Admission: Boneva Calcium + D Zocor Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TIDAC (3 times a day (before meals)). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime: Next dose to be taken on the evening of [9-20]. Disp:90 Tablet(s) Refills:2 6. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours for 3 days. Disp:6 grams Refills:0 7. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:90 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) ] home therapy Discharge Diagnosis: Atrial fibrillation . secondary: HTN hyperlipidemia CAD Discharge Condition: stable. normal sinus rhythm. Discharge Instructions: You were admitted to the hospital with an abnormal heart rhythm called atrial fibrillation. You were defibrillated to correct your heart from beating irregularly. This stress on your heart produced some changes on your EKG, for which we recommend that you have a stress test and nuclear imaging study to further evaluate your heart. . Since your heart rhythm occasionally reverted back into atrial fibrillation, wou will need to to take coumadin for the next month (beginning this Friday), and have the level checked at your doctor's appointment. You should also take a 325mg Aspirin everyday. . Finally, you were febrile while you were here. A blood culture grew out a bacteria that we are treating with IV antibiotics. You will go home with an IV that can be used to give you antibiotics for the next few days. A visiting nurse can come to your home to give you the antibiotics. . Please call your doctor or return to the hospital if you have chest pain, lightheadedness, palpatations or any other concerning symptoms. Followup Instructions: You have an appointment with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] [2126-9-20] at 11am to have your INR checked. INR is a measurement of the coumadin level in your blood. His office is ([Telephone/Fax (1) 33678]. . You are to have a Stress test on [2126-10-8] at 1130am. This will be on the forth floor of the [Hospital Ward Name ] building at [Hospital3 ] Medical Center. They will send you a mailing with more information. The scheduling number is [Telephone/Fax (1) 33679]. . You also have an appointment with Dr. [Last Name (STitle) 2232]: [2126-10-14] at 11am. [Hospital Ward Name 23] Building [Location (un) ]. [Telephone/Fax (1) 33680] Completed by:[2126-9-19] ICD9 Codes: 7907, 4019, 2724, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6340 }	Medical Text: Admission Date: [2128-1-30] Discharge Date: [2128-2-4] Date of Birth: [2046-3-23] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4765] Chief Complaint: Chest pain, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. [Known lastname 31769] is an 81F with hx of AS (valve area 1.0-1.2 cm2), AR, HTN, DVT x3, dyslipidemia, COPD, PMR, mild pulmonary HTN, initially admitted to [Hospital1 1516] for chest pain and new atrial fibrillation, now transferred to CCU for hypotension. . See nightfloat admission note for full details of initial presentation. Briefly, the patient developed substernal chest pain that awoke her from sleep about 24 hours ago. The pain has an aching quality and is non-exertional and non-pleuritic. She has not previously had this type of chest pain, so she presented to the [Hospital1 18] ER for further evaluation. . In the ED, the patient had bradycardia at 44bpm. Her HR initially ranged 42-44 and she was asymptomatic at that time. She then went into atrial fibrillation with HR in the 90's with associated decrease in BP of 80's-90's. She was given multiple 250cc boluses for a total of 1.75L in the ED to maintain her BP between 80's-100's systolic. She remained asymptomatic throughout. CTA was negative for a PE. CXR was negative. She had a positive UA and was given Cipro IV x1 and Lovenox in the ED. Ce's were neg x1. Overnight she continued to have intermittent episodes of hypotension with SBP's in the 80's, so her antibiotic coverage was broadened to unasyn, and planned to be transferred to the CCU for a TEE and cardioversion once a bed became available. Prior to transfer to the CCU her blood pressure again dropped to the 80's systolic and she required another 250cc bolus. . On arrival to the CCU her initial VS were: 75, 99/37, 24, 95% on RA, she is well appearing and denies shortness of breath, lightheadedness, nausea, palpitations, or other symptoms. She does report continued mild chest pain that has improved throughout her stay. She says that she is not excited about her upcoming procedures but is willing to undergo the TEE and cardioversion. She says that she has never been in A.fib before. Shortly after arrival to the CCU she spontaneously converted to NSR with ectopy. . On review of systems, she denies any prior history of stroke, afib, fevers, cough, dysuria, polyuria or increased frequency, diarrhea. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - Aortic stenosis - Moderate with peak gradient 73mmHg, mean 39mmHg [Location (un) 109] 1.1 cm2 ([10-14]). - Mild aortic regurgitation. 3. OTHER PAST MEDICAL HISTORY: 1. COPD 2. Polymyalgia rheumatica/seronegative rheumatoid arthritis 3. 3 DVTs in the context of plane rides 4. Large ventral hernia Social History: Currently smoking 1 pack per day since college in [2062], stopped for 5 or 6 years at one time but restarted when he daughter got divorced 20 years ago, no history of drug or alcohol abuse. Patient is married and is a former biochemist. The patient's weekly exercise regimen consists of walking briskly. Patient usually tries to adhere to a sensible diet and manages ADLs well. Family History: Mother died of a ruptured AAA at age 70. Father died of leukemia. There is no family history of premature coronary artery disease, unexplained heart failure, or sudden death. Physical Exam: ADMISSION PHYSICAL: VS: 75, 99/37, 24, 95% on RA GENERAL: Alert, interactive, appropriate, comfortable, NAD. HEENT: Pupils equal and round, EOMI, MMM. NECK: Supple, JVD ~10cm CARDIAC: Irregularly irregular, III/VI late peaking systolic murmer at RUSB without audible S2, GII holosystolic murmer at LSB, II/VI diastolic murmer at RUSB radiating to LSB. LUNGS: CTAB but poor air movement, no wheezes, rhonchi. ABDOMEN: Soft, NTND, large ventral hernia. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ Left: DP 2+ . DISCHARGE PHYSICAL: Pertinent Results: ADMISSION LABS ([Date range (1) 31771]): BLOOD WBC-10.5 RBC-4.10* Hgb-12.3 Hct-37.4 MCV-91 MCH-30.0 MCHC-32.8 RDW-12.7 Plt Ct-202 Neuts-76.3* Lymphs-16.7* Monos-5.8 Eos-0.5 Baso-0.7 PT-12.9 PTT-35.6* INR(PT)-1.1 Glucose-159* UreaN-34* Creat-1.3* Na-135 K-4.3 Cl-99 HCO3-27 AnGap-13 ALT-7 AST-19 LD(LDH)-209 CK(CPK)-50 AlkPhos-73 TotBili-0.7 Calcium-9.0 Phos-3.3 Mg-2.2 TSH-0.28 Lactate-1.4 . Cardiac Markers: [2128-1-29] 06:45PM BLOOD cTropnT-<0.01 [2128-1-30] 02:45AM BLOOD cTropnT-<0.01 [2128-1-30] 09:05AM BLOOD CK-MB-2 cTropnT-<0.01 . DISCHARGE LABS: WBC-6.8 RBC-3.16* Hgb-9.8* Hct-28.5* MCV-90 MCH-31.1 MCHC-34.4 RDW-12.6 Plt Ct-194 PT-16.1* INR(PT)-1.4* Glucose-99 UreaN-27* Creat-1.4* Na-139 K-3.8 Cl-104 HCO3-28 AnGap-11 Calcium-8.5 Phos-3.6 Mg-1.9 . STUDIES: CXR [2128-1-29]: IMPRESSION: Interval slight enlargement of the cardiac silhouette likely indicating cardiomegaly, although pericardial effusion remains within the differential diagnosis. No acute pulmonary process. . CTA [2128-1-29]: IMPRESSION: 1. No acute pulmonary embolism or aortic pathology. 2. 8-mm right thyroid nodule. If clinically indicated, recommend non-emergent thyroid ultrasound to further characterize. . TTE [2128-1-31]: Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to moderate ([12-7]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2127-10-9], the degree of AS calculated is now severe. . MICRO: Time Taken Not Noted Log-In Date/Time: [2128-1-30] 7:12 am URINE Site: NOT SPECIFIED 2005F. URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: HOSPITAL COURSE: Pt is a 81F with hx of AS (valve area 1.0-1.2 cm2), AR, HTN, DVT x3, dyslipidemia, COPD, PMR, mild pulmonary HTN who presented with chest pain, now with new onset of atrial fibrillation with hypotension when her rates increase to the 90's. She briefly converted spontaneously to SR, but returned to atrial fibrillation and was started on Amiodarone [1-30] initially with bolus therapy . ACTIVE ISSUES: # ATRIAL FIBRILLATION: The patient was admitted from [Hospital1 ] to the CCU for TEE cardioversion for hypotension in setting of atrial fibrillation. The patient flipped into sinus on admission to the CCU floor and was normotensive. She was loaded with IV amiodarone. Given persistent heart rates in the 50s with brief bradycardic epsiodes to 30s and frequent ectopy the patient was monitored overnight in the CCU. She remained in sinus overnight, with heart rates stable in the 50-60s with normal blood pressures. The following morning she flipped back into atrial fibrillation and stayed normotensive. The onset of AF was thought to possibly be secondary to her UTI, and in the setting of predisposition to afib given her valvular abnormalities likely causing possible dilation of her cardiac [Doctor Last Name 1754], although her LA was 3.9cm on her most recent echo. She is asymptomatic with the afib and may have been in paroxysmal afib prior to this admission. She was started on amiodarone [1-30] with improvement in her heart rate however with significant ectopy w/ ventricular trigeminy that improved overnight. TSH normal. CHADS2 score 2. She reverted back into AF, but remained HD stable. TTE demonstrated worsened AS with valve area 0.8-1. Her HR into 120s with ambulation, though asymptomatic, and started on low dose Metoprolol which was later stopped due to bradycardic episodes. Pt also spontanous converted out of AF on [2-2] and stayed in sinus rhythm until discharge. EP was consulted, and recommended TEE/[Name (NI) 24170], pt refused this intervention and was managed on Amiodarone. She was continued on Heparin gtt, and started on Coumadin. At time she left the hospital her INR was not yet therapeutic and pt was placed on lovenox as an outpt to bridge to theraputic INR . # AS: As above, TTE demonstrated now severe AS, with valve area 0.8-1cm. Symptoms of CP on admission possibly related to AS, though may have also been demand in setting of AF. Pt refused cardiac surgery consult in inpt setting although agreed to see CT surgery service in clinic. . # URINARY TRACT INFECTION: Urinary tract infection on admission to ED, she was started on Ciprofloxacin and changed to IV Unasyn on the floor. She was changed back to ciprofloxacin. UCx grew E. coli pan-sensitive, and she completed a 3 day course for uncomplicated UTI. . # CORONARIES: No evidence of active ischemia. Her cardiac enzymes were cycled and negative. Her ECG's initially showed AF but after spontaneous conversion to sinus showed sinus bradycardia with atrial premature beats. Q-T interval prolongation. Low amplitude T waves. . # PUMP: Patient had EF 55% and AS with valve area 1.0-1.2 which she has been tolerating well prior to this admission. She appeared mildly volume overloaded to euvolemic with mildly elevated JVP, difficult to assess volume status by lung exam given significant COPD and poor air movement, no LE edema. TTE yesterday with EF 55% again. At time of discharge pt was relatively euvolemic. . #. HYPERTENSION: Home anti-hypertensives were initially held in setting of low BP's (atenolol, HCTZ, Lisinopril). Low dose metoprolol 12.5mg [Hospital1 ] was started on [2-1] for rate control but then stopped as above due to bradycardia. ACEI was no restarted in the hospital due to slightly elevated Cr. Pt will need f/u of Cr as outpt and addition of ACE-I when normalizes. . INACTIVE ISSUES: #. DYSLIPIDEMIA: Continued home pravastatin. . #. COPD: Stable. On no home medications. . #. Polymyalgia rheumatica/seronegative rheumatoid arthritis: Stable Continued hydroxychloroquine. . #. Smoking cessation: Continued home bupropion. Tobacco cessation discussed with patient at bedside yesterday. She endorsed desire to quit and belief that she would succeed. Offered nicotine patch/nicorette gum at time of d/c for assistance w/ continued cessation. . # Thyroid nodule: noticed 8mm thyroid nodule on CTA. [Month (only) 116] need further workup as outpatient. . TRANSITIONAL CARE: 1. CODE: FULL 2. MEDICAL MANAGEMENT: 3. FOLLOW-UP: *As above, thyroid nodule noted on CTA, may need further workup as outpatient Medications on Admission: HOME MEDICATIONS: ATENOLOL - 25 mg daily BUPROPION SR- 150 mg twice a day HYDROCHLOROTHIAZIDE - 25 mg daily HYDROXYCHLOROQUINE [PLAQUENIL] - 200 mg twice a day LISINOPRIL [ZESTRIL] - 20 mg once a day PRAVASTATIN [PRAVACHOL] - 20 mg once a day ASPIRIN - 81 mg once a day CALCIUM CARBONATE [CALCARB 600] - 600 mg (1,500 mg) Twice a day ERGOCALCIFEROL (VITAMIN D2)- 1,000 unit daily CENTRUM SILVER - 1 Tablet daily OMEGA-3 FATTY ACIDS [FISH OIL] -1,000 mg once a day . MEDICATIONS ON TRANSFER: ASPIRIN 81mg daily ACETAMINOPHEN 325-650mg Q6H PRN:PAIN AMPICILLIN-SULBACTAM 3G Q8H BUPROPION SR 150mg [Hospital1 ] CALCIUM CARBONATE 1500mg [Hospital1 ] DOCUSATE SODIUM 100mg [Hospital1 ] ENOXAPARIN 30mg SC Q24H FISH OIL 1000mg Daily HYDROXYCHLOROQUINE SULFATE 200mg [Hospital1 ] MULTIVITAMIN 1 Tablet Daily PRAVASTATIN 20mg Daily SENNA 1 Tablet [Hospital1 *]:PRN Constipation VITAMIN D 1000 Units Daily Discharge Medications: 1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 2. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 7. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 8. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s)* Refills:2 10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 weeks. Disp:30 Tablet(s) Refills:0 11. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). Disp:5 syringes Refills:2 12. Outpatient Lab Work Please check chem-7 and INR on Friday [2-6] with results to Dr. [Last Name (STitle) 713] at [Telephone/Fax (1) 719] Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Atrial fibrillation and rapid ventricular response urinary tract infection Aortic Stenosis Hypertension Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had an irregular heart rhythm called atrial fibrillation and needed to be started on a new medicine, amiodarone. This medicine eventually converted you back into a regular rhythm. As Atrial fibrillation increases your risk of a stroke, we started you on coumadin to decrease the risk. You will need to take this medicine every day and use Lovenox injections once a day until your INR is > 2.0. Dr. [Last Name (STitle) 713] will tell you how much coumadin to take every day and when it is OK to stop using the Lovenox. You had a urinary tract infection that was treated with 3 days of an antibiotic. You had some chest pain but did not have a heart attack. You also had a 8 mm thyroid nodule that was found. This nodule is probably not serious but you will need an ultrasound that Dr. [Last Name (STitle) 713] can arrange to further evaluate the nodule. There is no sign that your thyroid function is affected. . We made the following changes to your medicines: 1. Stop taking Atenolol, Lisinopril and Hydrochlorothiazide 2. Start taking coumadin (warfarin) to prevent blood clots and strokes 3. Start taking Lovenox injections once daily until your INR is more than 2.0 3. Start taking amiodarone to keep your heart rhythm regular. You will take two tablets daily for 2 weeks, then decrease to one tablet daily. Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [2128-2-6] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4511], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GERONTOLOGY When: MONDAY [2128-2-9] at 11:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RNC [Telephone/Fax (1) 719] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: WEDNESDAY [2128-2-4] at 1:30 PM [Telephone/Fax (1) 327] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: FRIDAY [2129-1-28] at 10:40 AM With: ECHOCARDIOGRAM [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 5990, 4241, 4019, 2724, 496, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6341 }	Medical Text: Admission Date: [2197-1-23] Discharge Date: [2197-3-13] Date of Birth: [2197-1-23] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby girl [Known lastname 39602] was a 32 and [4-18]-week gestation female born to a 33-year-old G3/P2 (now 3) mother with prenatal screens of blood type A+, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, and group B strep status unknown. [Hospital ] MEDICAL HISTORY: Remarkable for condylomatous with cone biopsy of the cervix, maternal substance abuse with ethanol and cigarette smoking during this pregnancy. Prenatal imaging revealed mild ventriculomegaly and a small cerebellum by ultrasound. Fetal MRI was performed and confirmed findings. A follow-up ultrasound revealed only left ventriculomegaly. Mother was initially referred to [Hospital1 1444] from [Hospital6 2561] at 27 and 6/7 weeks gestation with preterm labor and a shortened cervix. She was treated with betamethasone at that time. She presented to [Hospital3 ] in active labor with spontaneous rupture of membranes. Delivery was by precipitous vaginal route. There was placental abruption noted at the time of delivery. The baby emerged with no respiratory effort and poor tone and was bradycardic. She was treated with suctioning and bag mask ventilation. She required bag and mask ventilation for 3 to 4 minutes prior to spontaneous cry and then had good respiratory effort. The baby was transferred to the NICU in oxygen for admission. Of social concern, mother's other 2 children are in DSS custody. Mother declined [Name2 (NI) ] screening on her last admission. PHYSICAL EXAMINATION ON ADMISSION: Weight was 1405 grams (25th percentile), length was 39 cm (10th percentile), head circumference was 29 cm (25th percentile). In general, baby girl [Name (NI) 39602] was a pink, appropriate for gestational age preterm female infant. HEENT exam revealed an anterior fontanel that was soft and flat, mild frontal bossing, epicanthal folds present, normal red reflex bilaterally, and an intact palate. Respiratory exam revealed mild retractions, fair air entry, and occasional mild grunting. Cardiovascular exam revealed a regular rate and rhythm with normal intensity, S1 and S2, and no murmurs. Her abdomen was soft with normal bowel sounds, and no organomegaly. Her genitourinary exam revealed a normal female. Her hips were stable. Neurologic exam was symmetric with some mild occasional myoclonic jerks noted initially and a normal cry. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: Baby girl [Known lastname 39602] required CPAP in her first 24 hours of life. Then actually was intubated for about 24 hours. She was extubated to room air. Then she developed an oxygen requirement which persisted, requiring nasal cannula until day of life 5. At that time she was able to transition to room air and remained in room air until day of life 21. On day of life 21, she was noted to have decreasing oxygen saturations and was placed back in 50 cc nasal cannula. She remained unable to wean off nasal cannula until the middle of [Month (only) 404]. On [2-28], Diuril was begun at 20 mg/kg/day. This did not effect her oxygen requirement, and her electrolytes remained stable. Her electrolytes remained normal, and her Diuril was increased on [3-3] to 30 mg/kg/day. In room air on [3-5]. At present she remains on Diuril 30 mg/kg/day plus KCL supplementation. She initially had oxygen saturations which would drift into the high 80s for the first few days after weaning flow cannula, but at the time of discharge she had been completely stable in room air. Baby girl [Known lastname 39602] has had some apnea of prematurity but never required treatment with caffeine. Her last spell of bradycardia occurred on [3-5] with a heart rate decreased to 78. She has had no episodes of apnea or bradycardia since that time. 1. CARDIOVASCULAR: Baby girl [Known lastname 39602] was noted to have a murmur on day of life 1. She had a cardiac echo at that time which revealed a small-to-moderate patent ductus arteriosus. Because of her advanced gestational age and clinical stability, this was not treated with indomethacin but was followed for spontaneous resolution. A follow-up echocardiogram on [2-22] showed that the duct was entirely closed. She had no other cardiovascular issues. 1. FLUIDS, ELECTROLYTES, NUTRITION: Baby girl [Known lastname 39602] was initially held n.p.o. on parenteral nutrition until day of life 2. Breast milk 20 by day of life 9. Her calories were then advanced to a maximum of Premature [Known lastname 37112] 30 with ProMod by day of life 17. She has had episodes of emesis with gavage feeds and required them to run over 1.5 hours at times. She started oral feeds on day of life 19 and advanced to full p.o. feeds by day of life 33. Her ProMod was discontinued on [2-27]. Her electrolytes have been normal throughout her hospitalization. Were checked on [3-12] to follow up her potassium level secondary to potassium supplementation, and they were _______________. 1. RENAL: Baby girl [Known lastname 39602] was noted to have a dysplastic ear on the right. A renal ultrasound was performed in light of known association with ear and kidney anomalies. This was done on [2-16] and was normal. 1. HEMATOLOGY: Her initial hematocrit was 38.9%. She was begun on iron and vitamin E on day of life 11. On [2-20] a repeat hematocrit was 21.5% with a reticulocyte count of 5.3%, so she was transfused with 20 cc/kg of packed red blood cells. Repeat hematocrit on [3-6] was 34.6% with a reticulocyte count of 1.4%. Her vitamin E was discontinued at the time of discharge. She required phototherapy from day of life 3 to 8. Her maximum bilirubin was 9.3 with a direct component of 0.3, and her rebound was 5.5 with a direct component of 0.2. 1. INFECTIOUS DISEASE: Baby girl [Known lastname 39602] was treated with ampicillin and gentamicin for sepsis rule out after delivery. Her initial CBC was benign with a white count of 8.3 (with 15% poly's and no bands), hematocrit of 38.9% and platelets of 326,000. Her culture remained negative for infectious issues. 1. NEUROLOGIC: Baby girl [Known lastname 39602] was known to have a prenatal history of ventriculomegaly and a small cerebellum. Head ultrasound on day of life 3 revealed asymmetric ventricles with the left greater than the right, but no evidence of intraventricular hemorrhage. Follow-up ultrasound on [2-21] again revealed mild asymmetry, unchanged, with the left ventricle again larger than the right. There was also a small right geranium with no intraventricular hemorrhage seen. She will follow up with the Neonatal [Hospital 878] Clinic 6 weeks after discharge and will need a brain MRI at that time. 1. SENSORY: Hearing screening was performed with automated auditory brain stem responses and was passed bilaterally. Baby girl [Known lastname 39602] did not qualify to need retinopathy of prematurity screening. 1. PSYCHOSOCIAL: A urine toxicology screen was done on this infant on admission and was negative. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home with both parents in a car seat. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 64569] in [Location (un) ], [State 350]. Her phone number is ([Telephone/Fax (1) 64570]. CARE/RECOMMENDATIONS: 1. At the time of discharge baby girl [Name (NI) 39602] is feeding [Name (NI) 37112] 26 calories per ounce by concentrate and then an additional 2 calories per ounce added by corn oil. 2. Her medications at discharge include iron supplementation, potassium chloride supplements at 2 mEq/kg/d and Diuril 30 mg/kg/day divided b.i.d.. 3. Baby girl [Known lastname 39602] underwent car seat position screening and passed. 4. She had an initial state screen with elevated tyrosine and amino acid profile while on parenteral nutrition., Thought to be reflective of TPN. A repeat screen was sent on [2-18] and is pending at this time. IMMUNIZATIONS RECOMMENDED: Baby girl [Known lastname 39602] received hepatitis B vaccine on [3-8] and Synagis vaccine just prior to discharge. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: (1) born at less than 32 weeks; (2) born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or (3) with chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out of home caregivers. __________Boston in 6 weeks. DISCHARGE DIAGNOSES: 1. Prematurity at 32 and 3/7 weeks gestation. 2. Right dysplastic ear. 3. Chronic lung disease. 4. Asymmetry of brain ventricles. 5. Patent ductus arteriosus - resolved. 6. Hyperbilirubinemia. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Doctor Last Name 56593] MEDQUIST36 D: [2197-3-10] 16:42:50 T: [2197-3-10] 18:18:56 Job#: [Job Number 64571] ICD9 Codes: 769, 7742, 2859, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6342 }	Medical Text: Admission Date: [2171-10-21] Discharge Date: [2171-10-23] Service: MEDICINE Allergies: Codeine / Penicillins Attending:[Male First Name (un) 4578] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization with successful PCI of the SVG to PDA History of Present Illness: HPI: Pt is an 83 yo man s/p CABG in [2151] (SVG-LAD, SVG-D1, SVG-LAD and numerous subsequent caths with stenting admitted to OSH with non-radiating, substernal CP, both exertional and non-exertional, without sweating/ dizziness, nausea. Pt had negative enzymes at that time as well as an EKG unchanghed from baseline. Pt felt pain was similar to past episodes of chest pain requiring hospitalization. Pt was transferred to [Hospital1 18]. Pt was shown to have patent stents in his [Last Name (LF) 8714], [First Name3 (LF) ] occluded SVG-D1, a patent stent to the SVG-LAD, and severe stenosis of his SVG-PDA. Successful PCI was performed on the SVG-PDA. Transient no-flow of the stented vessel was treated successfully with vasodilators. Past Medical History: PMH: CAD CABGX3 with multiple subsequent PCIs HL DM CRI Social History: The patient has a history of 30+ pack years of tobacco use. He quit 12 years ago. He uses alcohol occasionally. He has no history of recreational drug use. He lives with his wife. Family History: Father had a myocardial infarction at age 70. Mother had cancer and myocardial infarction. Brothers have diabetes. Physical Exam: PE: 97.4 BP: 140/89 hr:80 rr:18 99% RA Gen: mildly uncomfortable, nad heent: no jvd, no carotid bruits neck: supple with no thyromegaly cv: s1s2 rrr no mrg lungs: ctab no wheezes/rales/rhonchi abd: soft/nt/nd/+BS ext: no edema, peripheral pulses palapble and symmetric neuro: non-focal Pertinent Results: [2171-10-21] 09:03PM GLUCOSE-172* UREA N-50* CREAT-2.1* SODIUM-140 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-31 ANION GAP-13 [2171-10-21] 09:03PM CK(CPK)-74 [2171-10-21] 09:03PM CK-MB-NotDone cTropnT-0.10* [2171-10-21] 09:03PM CALCIUM-8.3* PHOSPHATE-4.1 MAGNESIUM-1.8 [2171-10-21] 09:03PM WBC-3.4* RBC-3.85* HGB-11.1* HCT-30.1* MCV-78* MCH-28.8 MCHC-36.9* RDW-15.0 [2171-10-21] 09:03PM PLT COUNT-100* Brief Hospital Course: A/P: 83 yo male with h/o CABGX3 with multiple subsequent PCIs stabilized s/p cath with stenting of SVG-RCA. 1) Ischemia/CAD??????As above, the pt was treated with PCI to his SVG-PDA. However, post-cath the pt had [7-5] elevation in leads III and avF c/w inferior MI. The pt??????s CKs were elevated. This was felt to be [2-27] to debris loosened downstream of stenting. Post-cath there was no PCI indicated. His pain was treated with a nitro drip and morphine. He was weaned off the drip and placed on his home nitro dose. During this period his CKs peaked and began to fall. His CP resolved as did his ST elevations on EKG. Throughout his hospitalization he was continued on his home BB, ASA, and statin dose. Given his h/o DM an ACE-I was also added. 2) rhythm??????The pt remained in NSR throughout his admission. 3) pump??????The pt was given a stat ECHO post-cath as there was concern for PDA perforation/tamponade. However that ECHO showed no sign of perf/tamponade. A more complete Echo was later performed and showed and EF 50%. 4) renal failure??????The pt has a h/o CRI by report. This was felt to be likely [2-27] to contrast nephropathy overlying baseline CRI related to DM. He maintained a CR. At 2-2.3 throughout his hospital stay. For his cath he was pre and post-cath treated with mucormyst and bicarb. His Cr was followed throughout his stay and remained stable. Given his DM he was started and d/c??????d on an an ACE-I. 5) DM2??????Throughout his admission he was kept on an ISS and diabetic/card/renal diet. He was d/c??????d on his home glipizide. 6)ppx??????The pt was placed on sq hep throughout his admission. 7)FEN--DM/card/renal diet. His lytes were repleted as necessary. He was on IV bicarb pre- and post his cath. Medications on Admission: plavix asa atenolol simvastatin folic acid amlodipine isosorbide dinitrate MVI glipizide Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Isosorbide Dinitrate 20 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:360 Tablet(s) Refills:2 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:30 Tablet(s) Refills:2 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Myocardial infarction Discharge Condition: Stable Discharge Instructions: Pt should contact PCP or go to [Name (NI) ] if: experiences chest pain or shortness of breath Pt should follow-up with PCP and cardiologist as below. Followup Instructions: Pt will be contact[Name (NI) ] by cardiologist to set up follow-up appointment. Pt has appt with PCP [Last Name (NamePattern4) ]. [Doctor Last Name 8715] [2171-11-1] at 11:30 am. ICD9 Codes: 9971
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6343 }	Medical Text: Admission Date: [2179-10-29] Discharge Date: [2179-11-26] Service: Vascular CHIEF COMPLAINT: Ischemic left first toe HISTORY OF PRESENT ILLNESS: This is an 81-year-old male transferred from [Last Name (un) 4068] Emergency Room with a two day history of painful left great toe and ischemic changes of his left forefoot. He has a history of transient ischemic attacks with work up at [Hospital3 1280], unclear if carotid duplex was obtained. Denies history of coronary artery disease. Has a history of hyperlipidemia. The patient has known end stage renal disease secondary to hypertension. Last dialysis was [2179-10-29]. The patient is inactive and can rarely walk with assistance and does not use a walker. There is no respiratory pain. He was not on aspirin for any medication. He is now admitted for further evaluation and treatment. PAST MEDICAL HISTORY: 1. Hypertension 2. End stage renal disease on hemodialysis 3. Status post right shoulder surgery 4. Subdural hematoma two years ago status post fall 5. History of cataracts 6. History of transient ischemic attacks, multiple 7. Bilateral vessel visual symptoms 8. Drooping of mouth but no residual 9. Left AV fistula three years ago ALLERGIES: He has no known drug allergies. MEDICATIONS: 1. Hydralazine 100 mg tid 2. [Last Name (un) ] 240 mg [Hospital1 ] 3. Lisinopril 40 mg qd 4. PhosLo 3 tablets tid 5. Avapro 300 mg qd 6. Renagel 800 mg tablets 2 3x a day 7. Epogen with dialysis PHYSICAL EXAM: VITAL SIGNS: Temperature 97.8??????, 64, 180/70, 95% on 2 liters of O2. CHEST: Clear to auscultation bilaterally. HEART: Regular rate and rhythm with normal S1 and 2 and a 4/6 systolic ejection murmur radiating to the carotids and to the pericardium. There are no carotid bruits. ABDOMEN: Soft, nontender, nondistended with a prominent abdominal aorta, but it is not aneurysmal. PULSE EXAM: Femoral pulses are palpable bilaterally. Popliteals are palpable bilaterally. The right DP is palpable. The right PT is monophasic dopplerable signal. The left DP is palpable, but diminished in intensity. The left PT is a monophasic dopplerable signal. ADMITTING LABS: CBC: White count was 7.0, hematocrit 36.0, platelets 130,000, normal differential. BUN 19, creatinine 3.3, potassium 3.6. IMAGING: Electrocardiogram normal sinus rhythm, first degree AV block, normal axis, no acute changes, left ventricular hypertrophy. Chest x-ray unremarkable. HOSPITAL COURSE: The patient was admitted to the vascular service. He was intravenous hydrated and began on intravenous heparin. Beta blockers were began. Carotid ultrasound was obtained which demonstrated 60% to 69% left internal carotid artery stenosis and less than 40% on the right internal carotid artery. Renal service was consulted to manage his hemodialysis needs. He was dialyzed on Mondays, Wednesdays and Fridays. He underwent an arteriogram on [2179-11-1] which demonstrated atherosclerotic changes to the abdominal aorta. There is severe stenosis of the right proximal renal artery. There is multiple stenosis of the left SFA and popliteal artery. There are two focal stenoses severe of the proximal AT. There is occlusion of the PT and peroneal. The DP is patent. He was given a Mucomyst protocol for this. There was no bump in his BUN and creatinine post angio. He continued to be dialyzed. Echocardiogram was done to assess a ventricular function for valvular disease. The left atrium was markedly dilated. The right atrium was moderately dilated. There was symmetrical left ventricular hypertrophy. The left ventricle cavity was moderately dilated. There was severe global hypokinesis with relative sparing of the septum. The ................ ventricular systolic function is severely depressed. The right ventricular chamber size is normal. The systolic function appears depressed. The ascending aorta is mildly dilated. The aortic valve three leaflets were mildly thickened. There was mild aortic stenosis and 1+ aortic regurgitation. The mitral valve leaflets are mildly thickened with 1+ mitral regurgitation and 2+ tricuspid regurgitation. There was moderate pulmonary systolic hypertension. There is no pericardial effusion. Ejection fraction was calculated at 25%. The patient underwent on [2179-11-5] a left profunda femoris to anterior tibial bypass with situ saphenous vein. He tolerated the procedure well. He was transferred to the PACU in stable condition with a palpable DP. At the conclusion of the procedure, he required 2 units of packed red blood cells intraoperatively. He was extubated to the SICU for hemodialysis. His PA pressures were 55/18. Cardiac output was 6.18, SVR 1500, CVP 1. Blood pressure was 204/64. He required neomycin during his hemodialysis for low systolic PA pressures. His electrocardiogram postoperatively was unremarkable. His blood gas was 7.27, 58, 125, 28, minus 1. He was continued on a heparin drip and remained in the SICU for continued care. Postoperative day #1, there were no overnight events. He was dialyzed, maintained his systolic pressure between 160 and 180. His PA pressure 75/32. Cardiac index was 4.3. Cardiac output was 7.7. SVR could not be measured. O2 saturations were 96%. Postoperative hematocrit 33.9 down from 36.5, white count 15.3 up from 13.0. BUN 25, creatinine 5.1 which is stable, potassium 5.0. PT/INR were normal with a PTT of 38.1. His physical exam was unremarkable. His graft pulse was palpable. His morphine and Benadryl were discontinued because of sedation and he was placed on a fentanyl prn patch. Ambien was discontinued. He remained NPO on Protonix. Intravenous fluids were Hep-Locked. He remained in the SICU. Postoperative day #2, he was in the SICU. His swan was discontinued. A triple lumen was placed. He continued on hemodialysis. A knee immobilizer was placed to protect the graft. His postoperative hematocrit was 34.3 up from 33.9. BUN 17, creatinine 3.9 which is down from 5.1. His abdomen was with bowel sounds. His lower extremity incisions were clean, dry and intact. The distal pulses were dopplerable. Feet were warm. He had good capillary refill. Chest x-ray was without pneumothorax. Haldol was given for agitation. Narcotics, opiates and antilytics were held. Protonix was continued and he was transferred to the VICU for continued monitoring and care. Postoperative ultrasound of the graft was done which showed an area of high velocity in the upper groin. The patient returned to the Operating Room on [2179-11-8] and underwent a venotomy with excision of competent valve. He tolerated the procedure well. He had a 2+ DP pulse and graft pulse at the end of the procedure. He was transferred to the PACU in stable condition. He had CK/MB cycled. Electrocardiogram was without changes. His cycled enzyme totals were flat. He continued to be followed by the renal service for dialysis needs. His diet was advanced as tolerated and ambulation was began on postoperative day 4 and 1. He was transferred to the floor. Ambulation was begun on postoperative day [4-8]. Kefzol was completed once the patient was .............. The remaining hospital course was remarkable for intermittent episodes of confusion requiring a sitter or small doses of Haldol. He did require a blood transfusion on [2179-11-10] for his hematocrit with improvement of hematocrit of 26.5 to 28.4 post transfusion. Case management followed the patient for screening and speech swallow requested to see the patient for bed side swallow evaluation. It was difficult to assess his swallowing mechanisms because of his severe lethargy throughout the trials. Their recommendations were to continue diet as tolerated, would recommend small sips versus straw sips when given liquids. Encourage po's. Do not attempt to feed the patient while he is drowsy. Put him at a 90 degree angle upright for all meals. Make his medications pureed and will follow for further assessment. Diet was tolerated and was advanced to soft solids and thick liquids. On [11-20], the patient had a low grade temperature of 102??????. Blood cultures and chest x-ray obtained which were both negative. Physical therapy strongly recommended that the patient had impaired balance and functional mobility and strength and severely deconditioned, will recommend rehabilitation facility once medically stable. The patient was transferred to rehabilitation. Remaining hospital course is unremarkable. Awaiting appropriate rehabilitation facility for transfer. The patient was discharged on [2179-11-26] in stable condition. Wounds were clean, dry and intact. The skin sutures removed from the DP incision. The wound was Steri-Stripped. The patient should follow up with Dr. [Last Name (STitle) 1476] in three weeks. DISCHARGE MEDICATIONS: 1. Losartan 50 mg qd, hold for systolic blood pressure less than 100 2. Nephrocaps 1 qd 3. Hydralazine 4. Hydrochlorothiazide 100 mg tid, hold for systolic blood pressure less than 120 5. Lisinopril 40 mg qd 6. Colace liquid 100 mg [Hospital1 ] 7. Allopurinol 1 mg [Hospital1 ], to give the afternoon dose at 3 p.m. 8. Allopurinol 0.5 to 1 mg intravenous q4h prn 9. Protonix 40 mg qd 10. Metoprolol 50 mg [Hospital1 ], hold for systolic blood pressure less than 110, heart rate less than 50 11. Aspirin 325 mg qd 12. Thiamine 100 mg qd 13. Folic acid 1 mg qd 14. Acetaminophen 325 to 650 mg po pr q 4 to 6 hors prn for pain 15. Mupirocin cream 2% [Hospital1 ] to rectal area for a total of five days. This was started on [11-8] and was discontinued on [2179-11-13]. 16. Nitroglycerin ointment 2% 1 inch topical q6h prn for systolic blood pressure greater than 150, wipe off for systolic blood pressure less than 125. 17. Calcium acetate 3 tablets tid with meals DISCHARGE DIAGNOSES: 1. Ischemic left first toe status post left PFA to AT bypass with in situ saphenous vein 2. Graft stenosis, status post venotomy, valvulectomy 3. Postoperative confusion improved 4. End stage renal disease on dialysis 5. Hypertension treated and controlled 6. Coronary artery disease asymptomatic 7. Blood loss anemia corrected [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1477], M.D. [MD Number(1) 1478] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2179-11-25] 11:04 T: [2179-11-25] 11:10 JOB#: [Job Number 47262] ICD9 Codes: 2851, 2767, 4254, 2930, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6344 }	Medical Text: Admission Date: [2163-5-3] Discharge Date: [2163-5-6] Date of Birth: Sex: F Service: CCU CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: A 41-year-old female with a history of coronary artery bypass graft x3 in [2156] who has experienced substernal chest pain over the past two days. Patient initially attributed her discomfort to a cold. This afternoon pain worsened then spread to her arms and neck. She planned to see her doctor tomorrow, but due to this worsening of the pain, the patient decided to come to the Emergency Department. At [Hospital1 69], the patient was brought to the Catheterization Laboratory. At cardiac catheterization, patient was found to have three vessel coronary artery disease. The LMCA had a distal 50% stenosis. The left anterior descending artery was totally occluded after giving off S1 and D1. The distal left anterior descending artery stent refilled via the left collaterals. The left LCA was totally occluded proximally. The right coronary artery was severely diffusely diseased proximally and totally occluded in its mid segment. Selective graft vessel angiography revealed a totally occluded saphenous vein graft to OM after giving off the free LIMA to distal left anterior descending artery. The distal left anterior descending artery supplied by the LIMA graft had mild-to-moderate diffuse disease, but had no flow limiting lesions. The saphenous vein graft to distal RVA was widely patent, but with TIMI-I flow and injection, and supplied diminutive distal right coronary artery. Resting hemodynamics revealed elevated right and left sided filling pressures. There was mild pulmonary hypertension. Cardiac index is mildly reduced at 2.2. The distal right coronary artery occlusion just beyond the saphenous vein graft, right coronary artery anastomosis was successfully treated by thrombectomy, angioplasty, and stenting with no residual stenosis, no intergraphic evidence of dissection, and TIMI-III flow. During procedure, the patient required administration of dopamine due to systolic blood pressures in the 70's. She was transferred to the CCU for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft x3 in [2156]: LIMA to LAD, saphenous vein graft to OM, saphenous vein graft to PDA. 2. Sternal wound infection. 3. Hypothyroidism. 4. Nephrolithiasis. 5. Obesity. 6. Anemia. 7. Depression. 8. Gestational diabetes. 9. Repair of triple hernia. ALLERGIES: Penicillin, succinylcholine, and sulfa. MEDICATIONS: 1. Hydrochlorothiazide 25 mg po q day. 2. Triamterene 37.5 mg po q day. 3. Lasix 40. 4. Levoxyl 50. 5. Omeprazole 20. 6. Folic acid 1. SOCIAL HISTORY: The patient lives in [Location 4288] with her husband. She smokes half a pack a day. She is currently not employed. FAMILY HISTORY: Mother died at age 50 of a myocardial infarction. Multiple family members on her mother's side died in their 50's of coronary artery disease. Father has diabetes mellitus. PHYSICAL EXAMINATION: General: Obese female lying in bed in no apparent distress. Vital signs: Temperature 96.9, blood pressure 120/79, heart rate 74, respiratory rate 24, and O2 saturation 98% on 2 liters. Weight 104.3 kg. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Mucous membranes moist. Oropharynx clear. Neck is supple, difficult to assess jugular venous distention. Heart: Regular, rate, and rhythm, S1, S2, no murmurs, rubs, or gallops. Chest: Sternotomy scar present. Lungs are clear to auscultation anteriorly. Abdomen is soft, nontender, nondistended, positive bowel sounds. Midline abdominal scar. Extremities: Lower leg scar from SV harvest site. Neurologic is alert and oriented times three. Cranial nerves II through XII are grossly intact. Examination is otherwise negative. LABORATORY DATA: White count was 8.1, hematocrit 46.2. Chemistries were significant for a potassium of 3.3 and a magnesium of 1.4. ALT was elevated at 58, AST was elevated at 86, alkaline phosphatase, and total bilirubin were within normal limits. Initial CK was 94 with a troponin of 18.2, second CK was 399 with a troponin of 16.5, third CK was 910. ELECTROCARDIOGRAM: Normal sinus rhythm at 80 beats per minute, normal intervals, right axis deviation, 2 mm ST segment elevation in II, 1 mm ST segment elevation in lead III, 2 mm ST segment elevation in aVF, Q's in I and II, right sided leads, no ST elevation in V4 R. CHEST X-RAY: Probable mild fluid overload, no evidence for pneumonia. IMPRESSION: A 41-year-old female with history of CABG x3 in [2156] and a strong family history of coronary artery disease admitted with chest pain and electrocardiogram changes consistent with inferior myocardial infarction. Patient is status post Angio-Jet thrombectomy to distal right coronary artery with placement of stent to right coronary artery beyond PDA. The patient is admitted to the CCU for further management. HOSPITAL COURSE: The patient was maintained on beta blocker, aspirin, Plavix in the CCU. She was also administered Integrilin for 18 hours. Her homocysteine level was sent off to workup patient's workup etiology of coronary artery disease in this young woman. Creatinine kinase was followed and was noted to be peak at 910. The patient remained in normal sinus rhythm and was monitored on Telemetry. ACE inhibitor was titrated up as patient tolerated. Patient remained chest pain free during her hospital stay. On [5-5] she underwent echocardiogram which disclosed the following: 1) Mild dilatation of the left atrium, 2) left ventricular cavity size is normal, overall left ventricular systolic function is mildly depressed, inferior akinesis is present, 3) trace aortic regurgitation is seen, 4) the mitral valve leaflets were mildly thickened, 5) trivial mitral regurgitation is seen. During hospital stay, it was emphasized to this patient that she must quit smoking. The patient was administered nicotine patch and gum during her hospital stay. The patient expressed a desire to quit smoking. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Three vessel coronary artery disease. 2. Occluded saphenous vein graft to obtuse marginal. 3. Mild systolic and diastolic left ventricular dysfunction. 4. Acute inferior myocardial infarction managed by acute PTCA. 5. Successful Angio-Jet and stenting of the distal right coronary artery beyond the saphenous vein graft-right coronary artery anastomosis. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Atenolol 25 mg po q day. 3. Plavix 75 mg po q day. 4. Folic acid 1 mg po q day. 5. Protonix 40 mg po q day. 6. Levothyroxine 50 mcg po q day. 7. Pravastatin 20 mg po q day. 8. Lisinopril 5 mg po q day. 9. Nicotine gum 2 mg one gum q1h as needed. 10. Nicotine patch 7 mg. DISCHARGE INSTRUCTIONS: Patient instructed to followup with her primary care physician. DR.[Last Name (STitle) ],[First Name3 (LF) 2064] 12-ABZ Dictated By:[Dictator Info 13504] MEDQUIST36 D: [2163-5-9] 15:45 T: [2163-5-11] 05:42 JOB#: [Job Number 13505] ICD9 Codes: 9971, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6345 }	Medical Text: Admission Date: [2131-6-4] Discharge Date: [2131-6-14] Date of Birth: [2067-5-26] Sex: M Service: THORACIC SURGERY ADMISSION DIAGNOSIS: 1. Recurrent right pleural effusions/trapped right lung. 2. Insulin-dependent diabetes mellitus-steroid-induced. 3. BOOP. 4. Coronary artery disease, status post coronary artery bypass graft/postoperative Dressler's syndrome. 5. Status post AVR-Bovine. 6. Basal cell carcinoma of the jaw. 7. Squamous cell carcinoma of the skin, chest, and back. 8. History of Hodgkin's disease, 3B, status post radiation therapy and chemotherapy. 9. History of vertigo. DISCHARGE DIAGNOSIS: 1. Recurrent pleural effusion/trapped right lung-status post right pleural decortication. 2. Intraoperative cardiopulmonary arrest, asystole-status post pacemaker insertion. 3. Insulin-dependent diabetes mellitus-steroid-induced. 4. BOOP. 5. Coronary artery disease, status post CABG/postoperative Dressler's syndrome. 6. Status post AVR-Bovine. 7. Basal cell carcinoma of the jaw. 8. Squamous cell carcinoma of the skin, chest, and back. 9. History of Hodgkin's disease, stage III-B, status post radiation therapy and chemotherapy. 10. History of vertigo. HISTORY OF THE PRESENT ILLNESS: The patient is a 64-year-old male with an extensive past medical history, as noted above in the admission and discharge diagnoses, who has been having recurrent right pleural effusions postoperatively after his coronary artery bypass grafting and aortic valve replacement in [2129-10-15]. Initially, this was attributed secondary to Dressler's syndrome which he had postoperatively which was treated successfully with Lasix and prednisone. These effusions continued to return. He had them tapped in [2129-12-16] and [2131-3-15] which initially relieved his symptoms of dyspnea. The patient did undergo a cardiac echocardiogram which did not show evidence of CHF as the etiology of this. From his pleural taps, his fluid analysis was negative. The patient continues to have some dyspnea on exertion which is worsening and chest CT which was obtained to evaluate this showed a loculated right effusion. He presents for evaluation of the etiology of this by lung biopsy and possible decortication. PHYSICAL EXAMINATION ON ADMISSION: The patient is 5' 8" tall and his weight is 175 pounds. Vital signs: Temperature 95.2, pulse 86 and regular, sinus rhythm, respiratory rate 20, SP02 97% on room air, otherwise blood pressure 155/76. General: The patient was alert and oriented. HEENT: The pupils were equal, round, and reactive to light. The extraocular movements were full. The oropharynx was nonerythematous. The neck revealed scars consistent with previous biopsies but there were no palpable nodes and there was no JVD. The chest was notable for prior sternotomy scar and right posterior incision from prior surgery. The breath sounds were dull and decreased from the right base to the midfield on the right. The left was clear. Cardiac: He was in regular sinus rhythm without any murmur, gallop, or rub appreciated. Abdomen: Soft, nontender. There was no mass or hepatosplenomegaly palpable. Extremities: The lower extremities revealed mild bilateral edema on the right and there was a scar consistent with a prior right vein harvest. LABORATORY/RADIOLOGIC DATA: On the date of admission, the patient's white count was 6.5 with a hematocrit of 33.4, platelet count 203,000. The urinalysis was without evidence of infection. His admitting potassium was 4.0 with a BUN and creatinine of 33 and 1.3. HOSPITAL COURSE: The patient was admitted to the hospital on [2131-6-4] preoperatively. The patient was taken to the Operating Room on the date of admission, [2131-6-4], but the notable EKG changes of T wave inversion and ST segment depression in II and aVF with ST segment elevation in V1 and V2 forced the surgery to be cancelled and the patient was evaluated by Cardiology to rule out MI. Cardiology had the patient undergo MI protocol and serial enzymes were obtained which did not evidence an acute ischemic event. He also underwent an ETT-MIBI the next day which was performed and did not show any evidence of ventricular wall abnormality or ischemia and subsequently Cardiology cleared this patient for surgery. He was subsequently taken to the Operating Room on [2131-6-6] where intraoperatively, the patient went into sudden asystole which was treated by intraoperative atropine and chest compressions. Epinephrine was subsequently given. It was noted that the patient subsequently went into a third-degree AV block and blood pressure returned to a rebound hypertension which required redosing of nitroglycerin. The patient continued to remain in a heart block and bradycardiac and, therefore, transcutaneous pacing was initiated to which the patient did respond. V pace was placed and the patient was V paced at 90 beats per minute and remained stable. This occurred towards the end of the procedure and the incision was subsequently closed and the patient was taken to the Cardiac Surgery Recovery Unit where he remained intubated, sedate, and V paced with a stable blood pressure. He did have an intraoperative TEE to guide the treatment which showed an EF of 40-45% with question of dyskinesis of the septum and anterior septal walls which was difficult to determine if it was related to previous cardiac surgery. There was note of mild right ventricular systolic dysfunction and moderate MR. Cardiology evaluated the patient immediately postoperatively in the Cardiac Surgery Recovery Unit and discussed his complete heart block. Notably, the overall time for CPR was 2-3 minutes. When the patient arrived to the CSRU, he was in normal sinus rhythm at 80 beats per minute with a blood pressure of 120/70. While in the CSRU, the patient continued with temporary pacing wires pending further evaluation by the Electrophysiology Service. These were switched to stable 6F pacer wires on the evening of postoperative day number zero. The patient remained stable in the Cardiac Surgery Recovery Unit on postoperative day number two and three. He did have an episode of acute renal insufficiency which was thought to be prerenal secondary to dehydration in which the patient's creatinine did subsequently recover after hydration was given. The patient remained clinically stable through postoperative day number five on which the patient had a pacemaker inserted. This was a [Company 1543] pacemaker, [Company 1543] Sigma SDR 303. There was note of intraprocedural complication and the patient was subsequently transferred to the floor from the Cardiac Intensive Care Unit the next day. He did not have any further episodes of asystole and he remained on telemetry on the floor. As the patient had been doing well postoperatively and subsequent to his pacemaker insertion it was determined that he could be discharged to home with proper follow-up as outlined previously with Cardiology and with Thoracic Surgery. At the time of discharge, his hematocrit was 27.1 with a white count of 5.3 and platelet count of 255,000. His potassium was 4.4 with a BUN and creatinine of 24 and 1.4. Blood cultures remained negative throughout the course of his hospitalization. The patient's chest x-ray showed some bilateral pleural effusions but these were described as small to moderate and noted to be improved. FOLLOW-UP: He is set to follow-up with the [Hospital ] Clinic on [2131-6-21] and he is to follow-up with Dr. [Last Name (STitle) 175] in one week from the date of discharge. DISCHARGE MEDICATIONS: 1. Protonix 40 mg once a day. 2. Lipitor 20 mg once a day. 3. Prednisone 5 mg once a day. 4. Percocet 5/325 one to two tablets every four to six hours as needed. 5. Colace one tablet twice a day as needed. 6. Continue on Fosamax 70 mg once per week, aspirin 81 mg once a day, and his Novolin 30 units, 20 in the morning, 10 in the evening, and Humalog 8 units, 4 units in the morning, 4 units in the evening for his diabetes. DISPOSITION: At the time of discharge, the patient is doing quite well clinically. He has tolerated insertion of his pacemaker without any notes of arrhythmia. He is ambulating, respiring well. As mentioned, he will follow-up with Dr. [Last Name (STitle) 175] in the [Hospital ] Clinic. [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 178], M.D. [MD Number(1) 179] Dictated By:[Last Name (NamePattern1) 26688] MEDQUIST36 D: [2131-6-14] 12:30 T: [2131-6-22] 19:14 JOB#: [Job Number 48274] ICD9 Codes: 5119, 4275, 2765, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6346 }	Medical Text: Admission Date: [2100-7-16] Discharge Date: [2100-8-12] Service: NEUROLOGY Allergies: Bactrim Attending:[First Name3 (LF) 618] Chief Complaint: Left sided weakness, neglect, and global aphasia Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: History obtained from speaking with the patient's family and review of OMR. Ms. [Known lastname 5021] is a 89 year-old right-handed [Known lastname 595] speaking woman with past medical history significant for hypertension, anemia, hypothyroidism, chronic renal insufficiency, renal cell cancer s/p right nephrectomy and left frontal stroke in [2100-5-11] with no residual deficits who presents with left sided weakness, neglect and aphasia. She was first found this morning at 1030hrs on [2100-7-16] on the floor, by her husband. It was unknown how long she was down for. At that time, she was able to communicate and said she couldn't hear or see well. She did say that she tripped and fell and that was why she was on the floor. She was also confused when she was found; she was asking how to get to the bathroom. EMS came to her house; by that time, she was walking, talking and reportedly oriented, so she remained at home. During the afternoon, there is a question if she had a visual field cut. She was napping on and off all afternoon, but was reportedly talking to her husband at times and it was thought she may have not been completely acting like herself. She was also thought to still be confused; an example given was that she may have had trouble telling time. Her granddaughter went to check on her at 1700hrs and at that time, she was again found on the floor, moaning, not speaking and nor moving her left arm (unclear if moving left leg). Her husband had reportedly went to the bathroom just prior to this and when he left, she was not on the floor, though no one know with certainity if she was moving her left arm and when the last time was that she actually spoke. EMS was called again and brought the patient to [Hospital1 18]. EMS notes upon finding the patient, the left arm was plegic, but she began moving it en route. Upon arrival to [Hospital1 18], a CODE STROKE was called. Neuro ROS: unable to obtain from patient. Past Medical History: -left frontal stroke ([2100-5-11]) -HTN -B12 deficiency -anemia -hypothyroidism -chronic renal insufficiency -renal cell carcinoma s/p right nephrectomy Social History: - She lives with her husband. - No Tobacco, EtOH, or Illicit substance use. Family History: Non-contributory, no known family hx of strokes. Physical Exam: Physical Exam on Admission: Vitals: P: 63 R: 21 BP: 143/72 SaO2: 100% General: Awake, agitated HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no carotid bruits appreciated Pulmonary: lcta b/l Cardiac: RRR, S1S2, III/VI systolic murmur Abdomen: soft, NT/ND, +BS Extremities: warm, pitting edema b/l NIH Stroke Scale score was: 21 1a. Level of Consciousness: 0 1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 2 3. Visual fields: 2 4. Facial palsy: 2 5a. Motor arm, left: 3 5b. Motor arm, right: 0 6a. Motor leg, left: 3 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 2 10. Dysarthria: 1 11. Extinction and Neglect: 2 Mental Status: Awake, alert. She does not produce any comprehensible speech (per her grandaughter who was speaking with her in [Year (4 digits) 595]) and does not follow any commands. She does not mimic. She has a dense left sided neglect. Cranial Nerves: PERRL. Right gaze preference and she does not cross midline to look to the left. She resists attempted Doll's maneuvers to get her to cross midline. She appears to have a left hemianopia as she blinks to threat on the right but not on the left. Left lower facial droop. Motor: Normal tone. She moves the right side more spontanenously compared to the left and more antigravity. She is able to move her left side and is frequently reaching across her body with her left arm though does not maintain it off antigravity. She is also able to hold her left leg antigravity briefly, but it will drift to bed. She would not cooperate with formal strength testing. Sensory: She grimmaces to noxious simulation throughout. DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 3 0 R 2 2 2 3 0 Plantar response was extensor on L>>R. Coordination: she would not cooperate with coordination testing, but no ataxic movements noted on observation. Gait: deferred Physical Exam on Discharge: Pertinent Results: Labs on Admission: [2100-7-16] 06:00PM WBC-6.2 RBC-2.90* HGB-8.8* HCT-27.3* MCV-94 MCH-30.5 MCHC-32.4 RDW-14.3 [2100-7-16] 06:00PM PT-10.9 PTT-25.7 INR(PT)-1.0 [2100-7-16] 06:00PM UREA N-51* CREAT-2.2* SODIUM-141 POTASSIUM-5.0 CHLORIDE-114* TOTAL CO2-17* ANION GAP-15 [2100-7-16] 06:00PM ALT(SGPT)-25 AST(SGOT)-17 ALK PHOS-169* TOT BILI-0.2 Relevant Labs: [2100-7-16] 06:00PM %HbA1c-5.6 eAG-114 [2100-7-16] 06:00PM ALBUMIN-3.9 [2100-7-16] 06:00PM cTropnT-0.02* [2100-7-16] 06:00PM BLOOD cTropnT-0.02* [2100-7-17] 05:45AM BLOOD CK-MB-5 cTropnT-0.08* [2100-7-17] 11:20AM BLOOD CK-MB-5 cTropnT-0.16* [2100-7-17] 07:10PM BLOOD CK-MB-6 cTropnT-0.17* [2100-7-18] 04:17AM BLOOD CK-MB-5 cTropnT-0.14* [2100-7-22] 05:18AM BLOOD CK-MB-15* MB Indx-2.6 cTropnT-0.17* [2100-7-17] 11:20AM BLOOD VitB12-1256* [2100-7-17] 05:45AM BLOOD Triglyc-85 HDL-44 CHOL/HD-3.1 LDLcalc-75 [2100-7-17] 11:20AM BLOOD TSH-2.1 [2100-7-25] 04:00PM BLOOD Phenyto-12.6 Phenyfr-2.3* %Phenyf-18* [2100-7-26] 02:21AM BLOOD Phenyto-13.5 Imaging: NCHCT, Perfusion CT [2100-7-17] 1. Markedly motion-limited head CT without evidence of gross acute hemorrhage. 2. CT perfusion study is slightly limited, but demonstrates a large area of ischemia in the right middle cerebral artery territory and in the right occipital lobe. An infarction also appears to be present, at least in the superior right middle cerebral artery territory, likely smaller in size than the area of ischemia. Chest x-ray [2100-7-17] Heart size is enlarged, unchanged. Mediastinal contour is stable. Lungs' assessment demonstrates mild volume overload but no overt pulmonary edema. Right upper quadrant surgery is redemonstrated. MR/A head and neck [2100-7-17] 1. Extensive right MCA territory infarcts and also a small focus in the right PCA territory, without mass effect, new since the prior study. 2. Occlusion of the right middle cerebral artery in the distal M1 segment and nonvisualization of the rest of the middle cerebral artery branches. TTE [2100-7-19] IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Minimal aortic valve stenosis. Mild-moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. No definite structural cardiac source of embolism identified. Compared with the prior report (images unavailable for review) of [2093-1-20], the severity of mtiral regurgitation and the estimated PA systolic pressure are now higher. Chest x-ray [2100-7-21] The ET tube tip is 5 cm above the carina. Heart size and mediastinum are grossly unchanged. There is newly developed left retrocardiac opacity that may reflect atelectasis, but infectious process or aspiration cannot be excluded. No pulmonary edema, pneumothorax or appreciable interval increase in pleural effusion seen. NCHCT [2100-7-21] Extensive right MCA territory ischemic infarction without evidence of hemorrhagic conversion. Subtle hemorrhage or extension of the infarction may be better assessed by MRI if indicated. EEG [2100-7-22] IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of frequent electrographic seizures arising from the right occipital region and spreading to the right posterior quadrant. There are a total of 15 seizures, lasting 1-2 minutes, most in a cluster between 17:00 and 19:03. In addition, there is continuous focal slowing with intermixed theta and delta range frequencies, attenuation of faster frequencies, and absent alpha rhythm in the right hemisphere. These findings are indicative of an epileptogenic focal structural lesion in the right hemisphere, and are consistent with the clinical history of right MCA stroke. Some of the focal attenuation may be secondary to postictal effects. Background activity is slow with a slow alpha rhythm on the left, indicative of more widespread cerebral dysfunction, which is etiologically nonspecific, but may in part be secondary to sedating medications. EEG [7-27] IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of continuous focal slowing and attenuation of faster frequencies in the right posterior region. These findings are indicative of a focal structural lesion in the right hemisphere and are consistent with the clinical history of right MCA stroke. Background activity shows continuous generalized background slowing in mixed theta and delta range frequencies suggestive of moderate encephalopathy which is etiologically non-specific. No epileptiform discharges or electrographic seizures are present. Compared to the prior day's EEG, faster frequency activities have started to appear in the right posterior region indicating improving dysfunction in the right posterior quadrant. PORTABLE HEAD CT W/O CONTRAST - [2100-7-27] 8:58 AM IMPRESSION: Normal changes consistent with evolution of a right MCA infarction. No definitive evidence of hemorrhagic transformation. No evidence of new infarction. Chronic changes as indicated above. EEG [7-28] IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of continuous focal slowing with absent alpha rhythm and attenuation of faster frequencies in the right hemisphere, maximal in the posterior quadrant. These findings are indicative of a focal structural lesion in the right hemisphere and are consistent with the clinical history of right MCA stroke. Background activity shows continuous generalized background slowing in mixed theta and delta range frequencies along with frequent and prolonged runs of triphasic waves indicative of moderate encephalopathy which is etiologically non- specific. Compared to the prior day's EEG, there is no significant change Brief Hospital Course: 89yo RHF ([Month/Year (2) 595] speaking only) h/o L Frontal Stroke, HTN, Hypothyroid, Anemia, Chronic Renal Insufficiency c/b RCC s/p R nephrectomy p/w L weakness, neglect, and global aphasia with imaging suggestive of dual R MCA and R PCA distribution thus likely secondary to embolic event given pt with paroxysmal AFib while inpatient. Course further complicated by status epilepticus. # Neuro: On admission, patient had left neglect, aphasia (both productive and receptive), right gaze preference with seeming inability to cross the midline, left hemianopia and left hemiparesis. tPA not given since recent stroke and [Last Name (un) 5487] onset of symptoms time as well as recent frontal stroke. The etiology of her right MCA stroke was likely thromboembolic given the extent of infarct and likely secondary to paroxysmal atrial fibrillation which she was found to be in on the floor. Patient initially had some improvement neurologically and was following commands, answering questions appropriately with short words/phrases and moving her left side to antigravity. For her stroke, she was continued on full dose ASA and started on statin. Initially on high dose statin, but as LDL <100, will discharge on Atorvasatin 40 mg daily. On [7-21] in the afternoon, pt had rhythmic shaking of LUE and LLE; however, she was awake, alert, speaking and answering questions appropriately. At ~1700, pt had a generalized tonic-clonic seizure with unresponsiveness, L gaze preference. Was given ativan 1mg IV x2 with no response. Loaded with Keppra 1000mg x1 which resulted in transient arrest of the seizure for 1min, but then seizure activity resumed. Started Dilantin, and placed prophylactic NRB with O2 sats in the high 90s. Remained in status through 1800. BP was 95/48, started NSD5W bolus. At that time after confirming change in codes status with family (pt had been DNR/DNI), called anesthesia for elective intubation, pt was transferred to Neuro ICU. Patient was transferred to ICU for further management after ictal episode requiring intubation for airway protection. Initially, she was maintained on Fentanyl/Versed which limited evaluation of neurologic function. Continuous EEG monitoring revealed electrographic seizures despite any change in mental status of the patient, or evident convulsions. Of note, during AM examination, the patient was noted to have no abnormal movements or change in status from previous exams, but was reported to have rhythmic epileptiform activity on EEG. Versed was held and propofol used due to patient's chronic renal insufficiency. The patient on [7-22] was also started on Dilantin (bolused to bring to theraputic levels). Repeat measurements of her Dilantin level, corrected for hypoalbuminemia, fell between 18 and 21 Ms. [Known lastname 5021] was weaned from propofol over [Date range (1) 5488], and was more active bilaterally in upper and lower extremities. During this period, EEG monitoring continued to reveal no electrographic seizures. She opened eyes spontaneously but remained unresponsive to command (in [Date range (1) 595]). Propofol was used for sedation to agitiation between [Date range (1) 5489], during which patient was less responsive in examination. Baseline agitation was maintained also with Seroquel / Zyprexa. After evaluation by anesthesia and a successful spontaneous breathing trial, Ms. [Known lastname 5021] was extubated on [7-27] without event. She remained globally aphasic not responding to commands from relatives who are [Name (NI) 595] speaking. On the subsequent morning, the patient was responding with garbled phrases to her granddaughter. However, she remained unresponsive to command in the morning and only opened her eyes to repeat stimulation. Lethargy was attributed partially to sedating effects of antiepileptics (on Keppra and Dilantin [Hospital1 ]). Also, had fevers attributed to Dilantin as infectious w/u was neg. Discontinued Dilantin, started Vimpat 50mg PO bid instead. Decreased Keppra dose. She was started on Modafinil to help with her level of alertness. She was also started on Fluoxetine as her mood appeared depressed and given that Fluoxetine can improve 3 month outcome after a stroke. # Cardiopulmonary: Overnight on admission, pt's HRs were in the high 30s to low 40s while asleep. On [7-17] at ~9am, HR was 140s and she was in new onset atrial fibrillation. She was treated with metoprolol 5mg IV and tachycardia resolved. ECG was obtained and showed 1mm depressions in V3-V6. Cardiac enzymes, trops 0.02-->0.08-->0.06, MB 5, 5. Cardiology was consulted for evaluation for ACS as well as new onset afib. Cardiology felt that troponin leak was secondary to demand ischemia, not ACS. Recommended metoprolol 12.5mg [Hospital1 ] for rate control and titrate up as needed as well as atorvastatin 80mg qd. While in the ICU, the patient was persistently bradycardic in the 40-50 bpm range, which per her family is baseline for the patient. She was able to autoregulate her pressures within normal physiologic range without medication or intervention. On [7-26], the patient per the multidisciplinary ICU team was ready for extubation; however, concern for a swollen tongue and potential obstruction caused a delay for one day to [7-27]. Per conversations with the family, the patient will be DNR/DNI upon extubation. She was administered decadron to decrease the glossal swelling on [7-28]. After evaluation by anesthesia and a successful spontaneous breathing trial, Ms. [Known lastname 5021] was extubated on [7-27] without event. On discharge, she was restarted on her home BP meds, except Diltiazem ER (she will be d/c on low dose Metoprolol for rate control, though she is often bradycardic, this should be held for pulse less than 60). # Renal: The patient's known renal insufficiency was factored into decisions regarding her medical management, knowing that excretion of some medications would be compromised. # GI: The patient had a nasogastric tube placed early during her ICU stay for tube feeds. This got dislodged and was replaced by a Dobhoff tube (placed by interventional neuroradiology). She was also maintained on H2 Blockers for reflux. # Endo: She was on Synthroid as an outpatient. She did not receive this for part of time during admission. TSH was checked prior to discharge and was elevated at 8.3. She is restarted on Synthroid at time of discharge. # Goals of care: Had discussions with family about code status. After initial status epilepticus, said they would not want to intubate pt and that she was DNR/DNI. Wanted to wait if she would become less sedated with weaning AEDs prior to making decision about PEG vs. comfort care. Palliative care was consulted. Plan to go to LTACH with Dobhoff for feeding and determining if she will wake up more and tolerate PO intake/rehab. 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL =75) - () No 5. Intensive statin therapy administered? (for LDL > 100) (x) Yes - () No (if LDL >100, Reason Not Given: ) 6. Smoking cessation counseling given? () Yes - (x) No (Reason (x) non-smoker - () unable to participate) 7. Stroke education given? (x) Yes - () No 8. Assessment for rehabilitation? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No (if LDL >100, Reason Not Given: ) 10. Discharged on antithrombotic therapy? (x) Yes (Type: () Antiplatelet - (x) Anticoagulation) - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - (x) No - () N/A. Oral anticoagulation not started given age/fall risk. Will continue ASA 325 mg daily. Medications on Admission: -Mavik 1 mg daily (brand name only) -Vitamin B12 1000 mcg IM or SQ q 2 months -Diltiazem ER 360 mg daily -HCTZ 25 mg daily -Synthroid 50 mcg daily -Ammonium Lactate 12% topical cream -ASA 325 mg daily Discharge Medications: 1. Atorvastatin 40 mg PO DAILY 2. Famotidine 20 mg PO Q24H 3. Fluoxetine 10 mg PO DAILY 4. modafinil NF 100 mg Oral Daily Reason for Ordering: Pt lethargic weeks out from stroke; data exists that modafinil can be beneficial in such cases 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Lacosamide 50 mg PO BID 7. LeVETiracetam Oral Solution 750 mg PO BID 8. Lorazepam 1 mg IM Q4H:PRN seizure > 3 minutes or 3+ events in one hour 9. Heparin 5000 UNIT SC BID 10. Quetiapine Fumarate 25 mg PO QHS:PRN Agitation Please administer suspension via doboff 11. Senna 1 TAB PO BID:PRN constipation hold for more than 1 bowel movement [Last Name (un) 5490] 12. Aspirin 325 mg PO DAILY 13. Hydrochlorothiazide 25 mg PO DAILY 14. Levothyroxine Sodium 50 mcg PO DAILY 15. Metoprolol Tartrate 12.5 mg PO BID Hold for pulse less than or equal to 60 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: right MCA territory ischemic stroke atrial fibrillation status epilepticus Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Neurology exam at discharge: Drowsy,lethargic, open her eyes to calling her name, moves her limbs to painful stimulileft leg more than left arm, does not speak , in response to painful stimuli makes some [Hospital6 ] words, spastic tone in left arm. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2100-8-12] ICD9 Codes: 5990, 2859, 2449, 5859, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6347 }	Medical Text: Admission Date: [2122-6-4] Discharge Date: [2122-6-18] Date of Birth: [2065-9-20] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2763] Chief Complaint: Hypoxia, Increased Work of Breathing Major Surgical or Invasive Procedure: nasopharyngeal intubation PICC line Arterial line Oropharyngeal Intubation with Mechanical Ventilation Tracheostomy History of Present Illness: Ms. [Known lastname 17315] is a 56 y/o F with a h/o morbid obesity, metabolic syndrome and restrictive lung disease who initially p/w weakness and dehydration. On admission she was found to be hypoxic by EMS to 78% on RA. She was also found to have LE cellulitis, a UTI, [Last Name (un) ] and an elevated BNP and troponin. She was admitted to the medical floor, where she was started on ceftriaxone for her UTI and vancomycin for her cellulitis. An echo was done for further evaluation of her hypoxia, which showed a dilated right ventricle and right ventricular volume overload. Given her echo findings, elevated BNP/troponin the floor team was concerned that she may have a PE so she was empirically started on a heparin gtt as she was unable to get a CTA because of her [Last Name (un) ] and radiology felt a V/Q scan would not be useful in the setting of her poor baseline CXR. . She initially was stable but with worsening renal function, when on the day of transfer she was found to be somnolent, confused and with an oxygen saturation of 87% on 4LNC. She was placed on 6LNC with improvement in her oxygen satuartion improved to 92% but she remained tachypneic. ABG done at that time was 7.22/59/70, she was placed on her nighttime bipap for her respiratory distress. A CXR was done that was unchanged from prior, she was also noted to be febrile to 102.5 at that time. Given her need for bipap, a transfer to the ICU was initiated. VS on arrival to the ICU were: 100.4, 80, 105/43, 20, 99% on bipap with 6L. Shortly after her arrival to the ICU she desaturated to the low 80's, at that time we transferred her to NIPPV with settings of [10-19] and an FiO2 of 100%, her oxygen saturations improved quickly on the new bipap settings. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Obesity DM HTN Hyperlipidemia Hypothyroidism Lymphedema Urinary Incontinence Osteoarthritis Sinusitis Carpal tunnel Social History: - Tobacco: None - Alcohol: None - Illicits: None Lives independently at home with the help of a home health aid. She uses a wheelchair when going out, but a walker when at home. Family History: 3 sisters with hypertension, father died of ischemic stroke, Mother died of gallstone perforation, No history of heart disease, diabetes or cancer. Physical Exam: Tmax: 37.3 ??????C (99.1 ??????F) Tcurrent: 37 ??????C (98.6 ??????F) HR: 69 (66 - 78) bpm BP: 146/57(83) {114/40(62) - 178/67(101)} mmHg RR: 16 (13 - 21) insp/min SpO2: 98% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 145.4 kg (admission): 164 kg General Appearance: Well nourished, Overweight / Obese, Anxious Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, bipap mask Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), diminished heart sounds Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bibasilar , Diminished: throughout ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: bilateral lymphedema with accompanying erythema Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, place, time , Movement: Purposeful, Tone: Not assessed Pertinent Results: = = = = = = = = = = = ================================================================ ADMISSION LABS ============================= [2122-6-4] 07:25PM ALT(SGPT)-30 AST(SGOT)-48* LD(LDH)-297* ALK PHOS-67 TOT BILI-0.4 [2122-6-4] 07:25PM cTropnT-0.18* [2122-6-4] 05:39PM URINE HOURS-RANDOM CREAT-239 SODIUM-25 POTASSIUM-90 CHLORIDE-20 TOT PROT-314 PROT/CREA-1.3* [2122-6-4] 05:39PM URINE OSMOLAL-398 [2122-6-4] 12:10PM URINE HOURS-RANDOM [2122-6-4] 12:10PM URINE UCG-NEGATIVE [2122-6-4] 12:10PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.016 [2122-6-4] 12:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-LG [2122-6-4] 12:10PM URINE RBC-4* WBC-144* BACTERIA-MANY YEAST-NONE EPI-3 [2122-6-4] 12:10PM URINE HYALINE-24* [2122-6-4] 12:10PM URINE MUCOUS-FEW [2122-6-4] 11:54AM TYPE-[Last Name (un) ] PO2-87 PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-0 COMMENTS-GREEN TOP [2122-6-4] 11:54AM GLUCOSE-170* LACTATE-1.7 K+-4.7 [2122-6-4] 11:45AM GLUCOSE-178* UREA N-47* CREAT-2.6* SODIUM-144 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-18 [2122-6-4] 11:45AM estGFR-Using this [2122-6-4] 11:45AM CK(CPK)-321* [2122-6-4] 11:45AM cTropnT-0.30* [2122-6-4] 11:45AM CK-MB-6 proBNP-6419* [2122-6-4] 11:45AM WBC-26.2# RBC-3.94 HGB-11.5* HCT-35.5* MCV-90 MCH-29.2 MCHC-32.5 RDW-14.5 [2122-6-4] 11:45AM NEUTS-87* BANDS-6* LYMPHS-4* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2122-6-4] 11:45AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2122-6-4] 11:45AM PLT SMR-NORMAL PLT COUNT-389 [2122-6-4] 11:45AM PT-14.5* PTT-24.2 INR(PT)-1.3* = = = = = = = = = = = ================================================================ DISCHARGE LABS ============================= COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2122-6-18] 02:30 7.5 3.04* 9.0* 27.8* 91 29.4 32.2 14.1 440 PT PTT INR(PT) [2122-6-18] 02:30 16.1* 83.2* 1.4* Glucose UreaN Creat Na K Cl HCO3 AnGap [2122-6-18] 02:30 1871 72 2.2* 144 3.5 94* 412 13 Calcium Phos Mg [2122-6-18] 02:30 9.8 5.1 2.2 = = = = = = = = = = = ================================================================ MICRO DATA ============================== URINE CULTURE (Final [2122-6-7]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ESCHERICHIA COLI \| \| AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 16 I 16 I CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S = = = = = = = = = = = ================================================================ IMAGING/PROCEDURES ======================= ======================= CT Chest abdomen pelvis w/o contrast [2122-6-5]: ======================= FINDINGS: The major airways are patent to subsegmental levels bilaterally. No pulmonary consolidation, masses or pulmonary nodules are detected. Linear subsegmental and dependent atelectasis is seen in both lung bases. There are no pleural or pericardial effusions. The heart is mildly enlarged. The thoracic aorta is unremarkable, except for scattered atherosclerotic calcification, without aneurysmal dilation. Mild coronary arterial calcifications are seen. Mild dilation of the main pulmonary artery measuring 4 cm, consistent with pulmonary arterial hypertension. Few mediastinal lymphnodes are seen, which do not meet CT criteria for significant adenopathy. CT OF THE ABDOMEN WITH ORAL CONTRAST: Limited non-contrast evaluation of the liver, spleen, adrenal glands and pancreas are normal. A 3.2 cm gallstone is seen within the gallbladder, without evidence of acute cholecystitis. Both kidneys are unremarkable, without hydronephrosis, stones or large renal masses. There is dilatation of the left ureter up to 1.7cm from the renal pelvis to approximately 2cm above the UVJ. No obstructing cause is noted. Few sub- centimeter left renal lesions are seen, consistent with simple renal cysts. The stomach, small and large bowel are normal, without evidence of bowel wall thickening or obstruction. The appendix is normal. There is no intra-abdominal free fluid or air. The abdominal aorta has scattered calcification, without aneurysmal dilation. No significant retroperitoneal or mesenteric lymphadenopathy is seen. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is empty with a Foley catheter in place. The rectum and sigmoid colon are normal. The uterus and adnexa are unremarkable. BONES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are seen. Chronic deformity of both femoral necks, is unchanged. A femoral nail traversing both femoral necks are seen. The femoral nail traversing the left femoral neck impinges on the acetabular articular surface. IMPRESSION: 1. No acute pulmonary pathology, especially no evidence of pneumonia or pulmonary edema. Pulmonary arterial hypertension. 2. Left hydroureter measuring up to 1.7cm from the renal pelvis to approx 2cm above the left UVJ. No obstructing cause is visualized and this may represent congenital megaureter, further evaluation with retrograde ureterogram is recommended for confirnation. 3. Cholelithiasis without evidence of acute cholecystitis. ===================== LENI [2122-6-5]: ===================== IMPRESSION: Non-diagnostic evaluation for DVT in either the left or right leg. ===================== Chest X-ray ([2122-6-6]): ===================== FRONTAL CHEST RADIOGRAPH: Study is markedly limited by underpenetration. The degree of vascular congestion has worsened. There is no definite new focal consolidation. Small effusion are unchanged. IMPRESSION: Worsening pulmonary vascular congestion. ===================== Chest X-ray ([2122-6-18]): ===================== FINDINGS: Tracheostomy tube terminates 4.1 cm above the carina. NG tube courses in the stomach, its tip out of view. Left PIC catheter is seen coiling in the brachiocephalic veinor in azygos vein, unchanged in position. Low lung volumes. Widened mediastinum can be attributed to mediastinal lipomatosis, as seen on [2122-6-5] CT exam. Moderate right pleural effusion is increased in size priom prior exam. Heart size is moderately enlarged. No pneumothorax. Pulmonary vascular congestion persists. IMPRESSION: 1. Moderate right pleural effusion, increased in size from [2122-6-16] exam. 2. Persistent pulmonary vascular congestion. ===================== Echocardiogram: ===================== The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is dilated with probably depressed free wall contractility. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve is not well seen. The mitral valve leaflets are not well seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2114-12-19], the right ventricle is now dilated with probably depressed free wall motion . Labs Pending at time of discharge: 2 blood cultures and 1 Urine culture Brief Hospital Course: Hypoxic and Hypercarbic respiratory failure: The etiology of her hypoxemia is likely multifactorial, including obesity-related hypoventiliation syndrome, pulmonary edema, and possible PE. A heparin infusion was initiated for a presumptive diagnosis of pulmonary embolism. Definitive imaging was unable to be obtained based on patient's body habitus and renal function precluding her from VQ scan or CT scan. A heparin drip was empirically started. She required nasal intubation in the ICU due to poor oropharyngeal anatomy, begining on [2122-6-6], and was unable to be successfully extubated as she developed post extubation stridor. She was oropharyngeal reintubated. Tracheostomy was pursued with good results on [2122-6-17]. Additionally, given possible pulmonary edema aggressive diuresis was initiated with a lasix infusion and metolazone, resulting in a net negative diuresis of about 10 liters for her length of stay. Patient was started on oral coumadin prior to discharge. At time of discharge, her INR was still subtherepeutic. She will require at least 6 months of oral anticoagulation. Acute Tubular Necrosis: She had muddy brown casts in her urine on admission. Her creatinine peaked at 3.2. Etiology thought to be related to hypoxia with presentation. She was treated with a furosemide infusion and metolazone. A nephrology consultation was obtained. Her creatinine improved and stabilized at a value of about 2.7 upon discharge. This will likely be her new post-ATN creatinine. Her medications should continue to be renally dosed. Of note, her Valsartan and Lisinopril were held given renal compromised. Complicated Urinary Tract Infection: On admission her urine culture grew two speciations of E.Coli, both sensitive to ceftriaxone. She was treated with ceftriaxone for 7 days. Cellulitis: She was treated for cellulitis of the right lower extremity with vancomycin for a total of 14 days. Goal vancomycin serum levels were 15-20. Her cellulitis improved. She continued to have evidence of venous stasis changes in both lower extremities post antibiotic course. Diabetes Mellitus II: She was treated with subQ insulin, which resulted in suboptimal glucose control. An insulin infusion was initiated, resulting in improved glycemic control. Her insulin was titrated to glargine 8 U qday with a regular insulin sliding scale every 6 hours. As the patient was only receiving tube feeds upon discharge, this will most likely require adjustment, specifically changes to short acting insulin and meal time dosing. Hypertension: Her home medications of HCTZ, lisinopril and valsartan were initially held. Once she was stabalized, she was started on amlodipine 5mg daily with adequate blood pressure control. Given multiple antihypertensives prior to admisison, will most likely require reinstitution of additional antihypertensive agents if goal of <130/80 mmHg is not acheived. . Obstructive Sleep Apnea: her family brought in her home bipap machine. After tracheostomy, patient did not require any positive pressure ventilation, only trach mask for saturations around 96%. She will most likely require positive airway pressure when tracheostomy closes up as lots of redundant oral pharyngeal soft tissue. Hyperlipidemia: Last measured in [10/2121] and LDL was 118. Continued Fenofibrate nanocrystallized 150 mg daily and Crestor 40 mg daily Hypothyroidism: TFT??????s were normal in house. Continued Levothyroxine 137 mcg daily Urinary Incontinence: chronic issue. Continued Detrol LA 4 mg qHS. Sinusitis: chronic issue that is currently stable. Continued visine drops for allergy symptoms. Depression: currently stable. Continued Venlafaxine 75 mg [Hospital1 ]. Carpal tunnel: Gets intermittent numbness and tingling in her digits bilaterally per report. Given admission gabapentin was subtherepeutic, held given renal dysfunction. . Labs Pending at time of discharge: 2 blood cultures and 1 Urine culture Medications on Admission: Fenofibrate nanocrystallized 145 mg daily Fexofenadine 180 mg daily Fluocinonide 0.05% cream Fluticasone 50 mcg [Hospital1 ] Gabapentin 200 mg [Hospital1 ] HCTZ 25 mg daily Humalog Levothyroxine 137 mcg daily Lisinopril 30 mg daily Crestor 40 mg daily Detrol LA 4 mg qHS Vaslartan 40 mg daily Venlafaxine 75 mg [Hospital1 ] Aspirin 81 mg daily MVI daily Omega-3 Fatty Acids Discharge Medications: 1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 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. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 6. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. desonide 0.05 % Cream Sig: One (1) Appl Topical TWICE A DAY () as needed for dry skin. 9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [1-11] Drops Ophthalmic PRN (as needed) as needed for Dry eyes. 10. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO Daily (). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fevers/pain. 12. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for fungal infection. 14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for Hypoxia. 15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 16. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 17. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP<100. 18. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. heparin (porcine) in NS 10,000 unit/1,000 mL Parenteral Solution Sig: SLIDING SCALE Intravenous SLIDING SCALE: Please continue heparin drip while achieving therepeutic INR on oral coumadin. Heparin drip may be discontinued once INR is [2-12] for >48 hours. ==================== HEPARIN SLIDING SCALE . Initial Infusion Rate: 3000 units/hr Target PTT: 60 - 100 seconds . PTT <40: 6000 units Bolus then Increase infusion rate by 700 units/hr . PTT 40 - 59: 3000 units Bolus then Increase infusion rate by 350 units/hr . PTT 60 - 100: GOAL . PTT 101 - 120: Reduce infusion rate by 350 units/hr . PTT >120: Hold 60 mins then Reduce infusion rate by 700 units/hr . 20. insulin glargine 100 unit/mL Solution Sig: Eight (8) Units Subcutaneous once a day. 21. insulin regular human 100 unit/mL Solution Sig: SSI Injection every six (6) hours: Sliding Scale -------------------- 71-100 mg/dL 0U 101-150 mg/dL 2U 151-200 mg/dL 4U 201-250 mg/dL 6U 251-300 mg/dL 8U 301-350 mg/dL 10U 351-400 mg/dL 12U > 400 mg/dL Notify M.D. . 22. 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. 23. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 24. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Hypoxic Respiratory Failure Pulmonary Embolism . Secondary: Diabetes Mellitus Hypertension Obesity Hyperlipidemia Hypothyroidism 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: Ms. [Known lastname 17315], You were admitted to the hospital because of respiratory distress. Your breathing became so poor that you required mechanical intubation to help you breathe. Attempts were made to take you off the ventilator, however you were unable to safely have the tube removed due to airway swelling. As a result, you had a tracheostomy performed. There was concern that your difficutly breathing was due to a blood clot in your lungs. You were started on a heparin drip to keep your blood thin, as well as another medication called "Warfarin (aka Coumadin)" to keep your blood thin. This will help your body dissolve any possible clots and prevent clots from recurring. Additionally, you had a urinary tract infection in the hospital as well as lower leg cellulitis, both which were treated with antibiotics. Lastly, your kidney function was impaired upon admission. This is likely due to the low blood oxygen you experienced on initial presentation. Your kidney function improved, but should continue to be monitored by your physician. [Name10 (NameIs) ] had some medications changed. Please refer to your new medication list attached in this packet. Of note, the following medications were discontinued. Please speak with your doctor before making any changes in your medication regimen. . STOP TAKING: Valsartan 40 mg daily HCTZ 25 mg daily Gabapentin 200 mg twice daily Lisinopril 30 mg daily . You will be going to [Hospital 100] Rehab facility for further strengthening and care. It has been a pleasure taking care of you Ms. [Known lastname 17315]! Followup Instructions: PLEASE ASSIST PATIENT WITH ARRANGING PCP FOLLOW UP PRIOR TO LEAVING REHAB You have the following follow up appointments scheduled: . Department: MEDICAL SPECIALTIES When: FRIDAY [2122-10-23] at 10:00 AM With: DR. [First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . You mentioned your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3441], will be graduating from her residency program. If you would like to continue to receive your care at the [Hospital 191] clinic at [Hospital1 18], please call [Telephone/Fax (1) 250] to schedule an appointment after you are discharged from rehab. In the hospital, you were seen by resident physicians Drs [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17316], [Name5 (PTitle) ] Piccarillo, and Nishan Tchekmedyian. You can arrange follow up with them or any of the residents at the [Hospital 191] clinic. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] ICD9 Codes: 5845, 5990, 4280, 4168, 2449, 5859, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6348 }	Medical Text: Admission Date: [2158-9-26] Discharge Date: [2158-9-27] Date of Birth: [2098-8-17] Sex: F Service: MEDICINE Allergies: Aspirin / lisinopril Attending:[First Name3 (LF) 99] Chief Complaint: Throat swelling Major Surgical or Invasive Procedure: Endoscopic air way evaluation History of Present Illness: 60yo F with PMHx of HTN on lisinopril and 1 prior episode of laryngoedema in setting of ibuprofen use per pt presenting with OP edema with out airway compromise. . Pt reports that she and her husband ate chicken sandwiches for lunch. She said there was just salad in the [Location (un) 6002]; she was not sure if there were nuts. She then walked to work and started to feel that the Right side of her face was starting to swell and she felt she was having some difficulty breathing in. She went to the Shapirio building and a First Aid was called. An epi pen was administered and she reports that the "clogged" feeling improved slightly. She was then brought to the ED via EMS. . She reports that this is the second time this is happened. The first is about 1 year prior and was attributed to ibuprofen. She did not require intubation at that time and reports that her symptoms were similar to current. She was started on lisinopril in 4/[2157]. She reports only an allergy to peaches (rash). She has a historical h/o allergy to ASA but tolerates a daily baby ASA. . In the ED inital vitals were, 99 74 138/66 18 98%. She was given solumedrol 125 mg IV x1 as well as famotidine 20 mg and benedryl 50 mg x2. She was treated with a one time nebulizer of racemic epi. She was never in respiratory distress during her ED evaluation and has remained able to manage her secretions. ENT was called. She underwent a nasolaryngoscopy to evaluate the cords, which were found to be nonedematous and the airway was widely patent. Edema was seen in the posterior pharynx and it was decided that the patient should be admitted to the ICU for airway monitoring. Upon transfer her vitals were stable. . On the floor, the patient appears to be breathing comfortably. She continued to report that she feels that her throat is "clogged". She denies overt difficulty swollowing or breathing but reports that they both feel slightly abnormal and uncomfortable. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: HTN HLD - diet control DMII - diet control Social History: - Tobacco: denies - Alcohol: denies - Illicits: denies Pt lives in [Location (un) 18293] with her husband, they have 3 children and 5 grandchildren. She works as a dishwasher at [Hospital1 18]. Family History: Mother DM+CAD, Father deceased, unknown Physical Exam: Admission Physical Exam: Vitals: T: 98 BP: 121/61 P: 74 R: 16 O2: 97%RA General: Alert, oriented, no acute distress, able to easily manage secretions HEENT: Sclera anicteric, MMM, posterior oropharynx edematous, +swelling below the jaw line (R>L), mildly tender, no appreciable cervical LAD. Neck: supple, JVP not elevated, Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Physical Exam: VS: 97.4 105/53 58 17 100% General: Alert, oriented, no acute distress, able to easily manage secretions HEENT: Sclera anicteric, MMM, posterior oropharynx very slightly edematous, +swelling below the jaw line (R>L) that is reduced compared to yesterday, not tender, no appreciable cervical LAD. Neck: supple, JVP not elevated, Lungs: CTAB, no wheezes, rales, ronchi, no accessory muscle use. 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 Pertinent Results: Admission Labs: [2158-9-26] 01:50PM BLOOD WBC-8.1# RBC-4.02* Hgb-13.3 Hct-35.7* MCV-89 MCH-33.1* MCHC-37.2* RDW-12.6 Plt Ct-330# [2158-9-26] 01:50PM BLOOD Neuts-46.6* Lymphs-47.1* Monos-3.7 Eos-2.2 Baso-0.4 [2158-9-26] 01:50PM BLOOD Glucose-123* UreaN-21* Creat-0.8 Na-139 K-3.9 Cl-99 HCO3-26 AnGap-18 Discharge Labs: [2158-9-27] 09:56AM BLOOD WBC-10.6 RBC-3.87* Hgb-12.6 Hct-34.7* MCV-90 MCH-32.6* MCHC-36.3* RDW-12.1 Plt Ct-243 [2158-9-27] 09:56AM BLOOD Neuts-90.6* Lymphs-7.7* Monos-1.3* Eos-0.3 Baso-0.1 [2158-9-27] 09:56AM BLOOD Glucose-253* UreaN-15 Creat-0.6 Na-138 K-3.9 Cl-105 HCO3-22 AnGap-15 [2158-9-27] 09:56AM BLOOD Calcium-8.8 Phos-2.4# Mg-2.0 Brief Hospital Course: 60 yo F with h/o HTN, HLD and DM presenting with laryngeal edema without respiratory distress. Pt is being admitted to the ICU for airway monitoring. # Laryngeal edema Most likely angioedema secondary to lisinopril and less likely food allergy. Prior to her ED visit and hospitalization, pt recieved an epi pen. She then recieved solumedrol, famotidine, benedryl in the ED. ENT consulted in the ED, found posterior pharygeal edema with no involvement of the vocal cords and widely patent airway. They recommended continuous O2 monitoring and continued decadron 10mg IV q8hrs x 3 days (day 1 [2158-9-26]) and standing benadryl and zantac x 3 days. Also request nasal trumpet be at bedside at all times. All her po meds, including lisinpril were held. She reported a sensation that her benadryl capsule was stuck her her throat, however she did not report breathing difficulties and remained comfortable. As a precaution she was kept on a full liquid diet over night. In the morning, she reported significant improvement and she tolerated a full diet for breakfast. She continued to remain slightly edematous, but given her improvement and lack of any airway compromise during the duration of her symptoms she was discharged home. It seemed most likely that this was secondary to lisinopril. The time line of her previous incident was reviewed and both occasions occured after she had started taking her lisinopril. She was told to stop taking this medication and her allergy list was updated in OMR. She was provided with an script for hydrocholorthiazide and an epi pen. Inactive Issues: HTN -Her BP meds were held overnight as above. She was d/c on HCTZ alone. Her BP remained wnl during her hospitalizations. DMII -Pt is diet controlled at home, however, given her steroid load, she was placed on a humalog sliding scale while in the hospital. HLD -Pt is diet controlled at home and no interventions were taken during this hospitalization. Medications on Admission: Lisinopril/HCTZ ASA Discharge Medications: 1. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection Intramuscular Once as needed: Inject once as needed for anaphylaxis Inject at 90 degress, hold for 10 seconds and then release. . Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Laryngeal edema Secondary Diagnoses: Hypertension Dyslipidemia Diabetes Mellitus Type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 76050], It was a pleasure taking care you during this hospitalization. You were admitted because you felt your throat was swollen. You were evaluated by the ENT physicians who felt that your airway was swollen but not closing. You monitored overnight in the Intensive Care Unit in case the swelling was to increase, but it did not. We feel that this is most likely due to medication called lisinopril. You should follow up with your primary care physician with in 1 week. We should you continue to feel better. Medications: STOP: Lisinopril/Hydrocholorthiazide START: Hydrocholorthiazide 12.5 mg by mouth daily Continue all other medications as directed. Followup Instructions: Department: BIDHC [Location (un) ] When: MONDAY [2158-10-9] at 12:30 PM With: [First Name11 (Name Pattern1) 3295] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3296] [Last Name (NamePattern1) 3297], MD [Telephone/Fax (1) 608] Building: 545A Centre St. ([Location (un) 538*], MA) None Campus: OFF CAMPUS Best Parking: ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6349 }	Medical Text: Admission Date: [2191-3-30] Discharge Date: [2191-4-4] Date of Birth: [2138-8-5] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2751] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 1005] is a 52yo F with history of leukocytoclastic vasculitis recently diagnosed and completed steroid taper about a week ago who presented to her PCP's office complaining of fatigue, vomiting and subjective fevers for the past 3 days. She was found to be hypotensive with systolics in the 90s and hyponatremic and received 2 liters of NS before being referred to the ER. . In the ED, initial vs were: 99, 95, 96/46, 16, 100% RA. She was febrile to 101 and received tylenol. CXR was negative for infection, and urinalysis was benign. She received stress dose steroids for concern for adrenal insufficiency and ceftriaxone. Given her continued borderline blood pressures of systolics in the 80s-90s despite total of 4 liters of NS, she was admitted to the MICU for further monitoring. . In the ICU, she complains of generalized fatigue and malaise for the past few weeks and nightly fevers at home for the past couple weeks. Patient has had decreased PO intake for the past week in the setting of this fatigue and malaise. She has had intermittent headaches, occasional blurry vision, frequent nausea and morning diarrhea. She had some non-bloody, non-bilious emesis yesterday and has had persistant pruritis. She feels her rash has progressively worsened to cover more of her body surface now. No sick contacts. . Review of systems: (+) Per HPI (-) Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, dysuria, frequency, or urgency. Past Medical History: # Leukocytoclastic Vasculitis -- diagnosed in [2191-2-15] with skin biopsy -- presented with rash # DM Type 2 -- last A1C 6.7 # Hypertension # Hyperlipidemia # Scoliosis # Fatty liver -- mild on US in [2188] # OSA -- denies needing CPAP # Major Depressive Disorder # Appendectomy # C-section # Osteoarthritis Social History: She was born in the [Country 13622] Republic and moved to the US in the early [2159]. She was vaccinated with BCG as in grade school and has had a positive PPD since. Last travel to DR [Last Name (STitle) ] [Name (STitle) ] and has not travelled since. She has never smoked and drinks 2 margaritas/week. No illicit drug use. Family History: MI, CVA and stomach cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.7 BP: 95/54 P: 94 R: 19 O2: 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, PERRL, MM dry, oropharynx clear without lesions Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Diffuse, blanching, macular, erythematous rash covering chest, scattered across back, arms and legs. Bilateral lower cheeks and neck with macular erythema. Hyperpigmented plaque across upper back consistent with acanthosis nigricans. DISCHARGE PHYSICAL EXAM: VS: T 98.9, BP 146/96, HR 91, RR 20, SpO2 94 on RA Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Resting in bed. HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign. Neck: Supple. JVP not elevated. No cervical lymphadenopathy. CV: RRR. Normal S1, S2. No M/R/G appreciated. Chest: Respiration unlabored, no accessory muscle use. Bibasilar crackles right>left. No wheezes or rhonchi. Abd: BS present. Soft, NT, ND. Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+. Skin: Flat, erythematous rash worst over chest Neuro: Moving all four limbs. Pertinent Results: ADMISSION LABS: [2191-3-30] 05:26PM BLOOD WBC-7.6 RBC-3.26* Hgb-10.5* Hct-30.1* MCV-93 MCH-32.4* MCHC-35.0 RDW-13.4 Plt Ct-280 [2191-3-30] 05:26PM BLOOD Neuts-79.3* Lymphs-13.1* Monos-1.8* Eos-5.6* Baso-0.2 [2191-3-30] 05:26PM BLOOD Glucose-113* UreaN-49* Creat-2.3* Na-131* K-4.3 Cl-98 HCO3-20* AnGap-17 [2191-3-30] 05:26PM BLOOD ALT-54* AST-72* AlkPhos-74 TotBili-0.3 [2191-3-30] 05:24PM BLOOD Lactate-1.9 Na-132* K-4.2 Cl-99* DISCHARGE LABS: [2191-4-4] 05:35AM BLOOD WBC-13.1* RBC-2.69* Hgb-8.9* Hct-25.2* MCV-94 MCH-33.1* MCHC-35.3* RDW-13.6 Plt Ct-390 [2191-4-4] 05:35AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-141 K-4.3 Cl-106 HCO3-26 AnGap-13 [2191-4-4] 05:35AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.1 STUDIES: # CXR ([2191-3-30]): IMPRESSION: No acute intrathoracic process. # ECHO ([2191-3-31]): The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality due to body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. Mild mitral regurgitation. Mildly elevated pulmonary artery systolic pressures. # CXR ([2191-4-1]): IMPRESSION: 1. New mild-to-moderate volume overload. 2. Bibasilar opacities may represent atelectasis, although infection cannot be excluded. Brief Hospital Course: Ms. [Known lastname 1005] is a 52yo F with history of leukocytoclastic vasculitis presenting with malaise, hypotension, fever, and hyponatremia. . # Hypotension: Appeared dry on admission exam with history consistent with decreased PO intake and suspected dehydration. She also likely had insensible losses due to her rash, fevers and AM loose stools. Adrenal insufficiency was also a concern given her history of steroid use and development of fevers, malaise, hyponatremia and vague abdominal discomfort after steroid d/c. However, her cosyntropin stim test was WNL (although on the low end of normal). We felt that sepsis was also a possibility but no clear source or concerning leukocytosis (at least initially - see below). She was given IVF and stress dose steroids for 1 day and improved. . # Fever: She reported nightly subjective fevers at home and was febrile to 101 in the ER on admission. No leukocytosis or clear localizing symptoms on exam or by history to suggest infection on admission. Initial CXR and urinalysis were reassuring. Blood cultures on [2191-3-30] grew Strep viridans in one set, and urine culture grew coag negative staph. CXR on [2191-4-1] showed bibasilar opacities and could not exclude pneumonia. Fever could also be due to underlying inflammation from her vasculitis. Drug fever was also a possibility given that she started Plaquenil the day PTA but this did not fit the time course she had suggested. Later in the admission she developed leukocytosis but based on clinical improvement and time course this was felt to be [1-19] steroids. She remained afebrile for the remainder of her stay. She was treated with Vancomycin and Cefepime during her stay and discharged on Levofloxacin 750 mg PO for three days to complete a 7 day course of antibiotics. . # Acute kidney injury: Her baseline creatinine is 0.6 according to Atrius records and was elevated to 3.4 at her PCP's office. Creatinine improved to 2.3 by admission to [Hospital1 18] ER after receiving 2L of NS at PCP's office which was reassuring for pre-renal etiology that improved with fluids. However, intrinsic renal disease was also a possibility given her vasculitis, but less likely, given Cr trended down to 0.8 with more IVF. . # Volume Overload: On exam she had bibasilar crackles which likely represented volume overload. She was initially hypovolemic, but received significant IV fluids early in her stay. Her CXR on [2191-4-1] showed new mild-to-moderate volume overload with bibasliar atelectasis and effusions, and an infectious process could not be excluded. TTE showed normal LVEF and diastolic function. She was given Furosemide 20 mg IV once prior to discharge and prescribed Furosemide 20 mg PO daily for 4 days after discharge. . # Rash: Her current rash appears almost confluent and erythrodermic across her chest with some scattered areas on the back and extremities. Although this may be her underlying leukocytoclastic vasculitis, drug rash from Plaquenil was also a possibility (new med started the day PTA). We held Plaquenil and there was clinical improvement. . # Leukocytoclastic vasculitis: We continued sarna and hydroxyine for itch, held Plaquenil. After her low-normal response to [Initials (NamePattern4) ] [Last Name (NamePattern4) 104] stim test, steroids were held for several days. She was restarted on Prednisone 10 mg PO daily on [2191-4-3]. . Medications on Admission: Hydroxychloroquine 200 mg Oral Tablet 1 tablet twice daily Clobetasol (TEMOVATE) 0.05 % Topical Cream apply to itchy areas [Hospital1 ] prn Hydroxyzine HCl 25 mg Oral Tablet Take 1 tablet three times daily as needed Desonide 0.05 % Topical Lotion apply to affected area Prednisone 10 mg Oral Tablet take 5 pills tues-wed-thurs, then 4 pills friday-sat, decrease by one pill every 2 days 5-5-5-4-4-3-3-2-2-1-1 Lisinopril-Hydrochlorothiazide (ZESTORETIC) 20-25 mg Oral Tablet 1 by mouth once daily Propranolol (INDERAL LA) 120 mg daily Omeprazole 20 mg daily Citalopram 20 mg Oral Tablet 1 and [12-19] tablet daily Simvastatin 40 mg Oral Tablet 1 TABLET PO DAILY Discharge Medications: 1. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three times a day as needed for itching. Disp:60 Tablet(s) Refills:0 2. desonide 0.05 % Lotion Sig: One (1) Topical once a day: Apply to affected area. 3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:10 Tablet(s) Refills:0 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:4 Tablet(s) Refills:0 9. clobetasol 0.05 % Cream Sig: One (1) Topical twice a day as needed for itching: Apply to affected areas. Do not apply to face, underarms, or groin. . Discharge Disposition: Home Discharge Diagnosis: Primary: Hypotension, Vomiting, Fevers Secondary: Leukocytoclastic Vasculitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital for vomiting, fevers, and low blood pressure. You were initially sent to the ICU to help stabilize your blood pressure. Your symptoms improved and you were transferred to a regular medical floor after receiving IV fluids, antibiotics, and steroids. Your chest X-ray was concerning for possible pneumonia, and you will need to complete a course of antibiotics after discharge. You were also started on a short course of Furosemide to help remove excess fluid from your body. Since it may have been contributing to your rash, your Plaquenil was stopped. Because of your low blood pressure on admission, you have not been receiving your usual blood pressure medications. You should stop taking them until restarted by your PCP. We made the following changes to your medications: START: Levofloxacin 750 mg once a day for 3 days START: Furosemide 20 mg once a day for 4 days START: Prednisone 10 mg once a day STOP: Plaquenil (Hydroxychloroquine) STOP: Lisinopril-Hydrochlorothiazide (ZESTORETIC) until restarted by your PCP [Name Initial (PRE) ]: Propranolol (INDERAL) until restarted by your PCP Please continue to take your other medications as prescribed. If you experience any of the below listed Danger Signs please call your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Please see your PCP, [Name10 (NameIs) ] [First Name8 (NamePattern2) ] [Name (STitle) ], for followup at the appointment you have scheduled this week. The office can be reached at [Telephone/Fax (1) 2261]. You should also see your Dermatologist and Rheumatologist for followup at the appointments you have scheduled this week. ICD9 Codes: 486, 5849, 2761, 4589, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6350 }	Medical Text: Admission Date: [2139-8-3] Discharge Date: [2139-8-7] Date of Birth: [2079-8-6] Sex: M Service: MEDICINE Allergies: Iron Attending:[First Name3 (LF) 2195] Chief Complaint: Nausea, Vomiting, Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 59 year old male with PMH significant for CKD s/p renal transplant, DM-II, chronic pancreatitis, HCV without cirrhosis, and HTN who was admitted earlier this afternoon for nausea, emesis and abdominal pain felt to be due to an acute on chronic pancreatitis flare-up. Patient explains that he had several non-bloody emesis episodes and nausea for about 5 hrs leading up to admission. Also several episodes of diarrhea (non-bloody). He also had more intense epigastric area pain after eating a meal yesturday afternoon. States recent ETOH use was 4-5 days ago. He states his abd pain is similar to his prior episodes of pancreatitis. No fevers, chills, CP, SOB, H/A, numbness/weakness/tingling. In the ED this morning his initial VS were: T99 HR67 BP227/66 18 100 % on RA. Lipase was 148, Cr was 1.8 (near usual baseline), AST 41/ALT 21. He was given GI cocktail, maalox, IV morphine, PO zofran and IV compazine. He was also given 50 mg oral metoprolol and 1L IVF. He had missed his AM dose of metoprolol today. . When he arrived to the medical floor he had 215/90, HR 80, RR18, 100% on RA. On exam, He was alert, fully oriented and without headache / visual changes. Neurologically intact. Abd pain well controlled with percocet x 1. On the floor, patient's BP range was: 150-210/80-98. He was given 5 mg metoprolol IV, 50 mg PO metoprolol, 10 mg IV labetalol and 20 mg IV labetalol. His SBP remained 189-214 with these interventions. Transfer to MICU was initiated for better BP control. On arrival to the [Hospital Unit Name 153], initial vs were: T98.6F, P80, BP195/79,RR 15 O2 sat 100% RA. Patient was given additional 10mg Labetolol IV and BPs came down to 180s systolic range. Past Medical History: 1. ESRD s/p Renal Transplant [6-/2135] (baseline Cre 1.8-2.5) - complicated by CMV Viremia 2. Erectile Dysfunction 3. Hx of detached retina - [2132], surgically repaired 4. h/o infected sebaceous cyst 5. Pancreatitis -chronic 6. Diabetes Mellitus Type II - on Insulin 7. h/o Knee arthritis 8. h/o Hepatitis C - followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11455] ([Hospital1 2177]) 9. Hypertension - controlled on metoprolol Social History: Home: Lives alone in apartment on [Location (un) ] avenue. On disability, not currently working. EtOH: Had [1-31] pint hard liquor 2 days PTA. Denies any other EtOH use since [Month (only) 547]. Notes drank regularly ([1-31] pint to pint until mid 90s, when decreased dramatically). No history of withdrawl noted by patient. Drugs: Denies illicits. Tobacco: Denies Family History: Mother - Type 2 Diabetes Mellitus, hypertension Father - Type 2 Diabetes Mellitus Physical Exam: Vitals: T 98.6F, P80, BP195/79,RR 15 O2 sat 100% RA. General: Alert, oriented, somewhat slow speech at times ncomfortable. Slightly irritable. HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, no LAD and JVP 8cm Lungs: Clear to auscultation bilaterally. CV: Regular rate and rhythm, tachycardic, normal S1 + S2. No murmurs, rubs, gallops. Abdomen: soft, tender over mid-epigastrium. Normoactive BS. No rebound tenderness or guarding. No organomegaly. Refused rectal exam. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: No sensation deficits to light touch. CNs [3-13] in tact. [6-3] UE and LE strength. No tremors. No asterixis. Gait assessment deferred. GU: no foley Pertinent Results: CBC [2139-8-3] 06:15AM BLOOD WBC-11.3# RBC-4.96 Hgb-11.1 Hct-35.7* MCV-72* MCH-22.4* MCHC-31.1 RDW-15.3 Plt Ct-142* [2139-8-4] 03:57AM BLOOD WBC-6.6 RBC-5.46 Hgb-12.2* Hct-40.1 MCV-73* MCH-22.4* MCHC-30.5* RDW-15.3 Plt Ct-160 [2139-8-3] 06:15AM BLOOD Plt Ct-142* [2139-8-4] 03:57AM BLOOD Plt Ct-160 [2139-8-6] 04:31PM BLOOD WBC-4.0 RBC-4.10* Hgb-9.3* Hct-30.7* MCV-75* MCH-22.6* MCHC-30.1* RDW-15.5 Plt Ct-116* [2139-8-7] 11:00AM BLOOD WBC-4.8 RBC-4.37* Hgb-9.6* Hct-32.4* MCV-74* MCH-22.0* MCHC-29.7* RDW-15.6* Plt Ct-179# CHEM 7 [2139-8-3] 06:15AM BLOOD Glucose-97 UreaN-25* Creat-1.8* Na-142 K-4.1 Cl-107 HCO3-20* AnGap-19 [2139-8-4] 03:57AM BLOOD Glucose-124* UreaN-20 Creat-1.4* Na-135 K-5.9* Cl-100 HCO3-21* AnGap-20 [2139-8-6] 05:45AM BLOOD Glucose-137* UreaN-54* Creat-2.5# Na-136 K-4.8 Cl-101 HCO3-26 AnGap-14 [2139-8-6] 04:31PM BLOOD Glucose-159 UreaN-51* Creat-2.3* Na-137 K-4.8 Cl-105 HCO3-17* AnGap-20 [2139-8-7] 11:00AM BLOOD Glucose-170* UreaN-41* Creat-1.9* Na-142 K-4.1 Cl-108 HCO3-25 AnGap-13 OTHER LABS [2139-8-3] 06:15AM BLOOD ALT-21 AST-41* AlkPhos-86 TotBili-0.6 [2139-8-3] 06:15AM BLOOD Lipase-148* [2139-8-6] 05:45AM BLOOD Lipase-153* [2139-8-4] 03:57AM BLOOD tacroFK-4.7* [2139-8-7] 11:00AM BLOOD tacroFK-PND Brief Hospital Course: Brief Hospital Course Mr. [Known lastname ] is a 59yo male with h/o CKD s/p renal transplant, and DM-II who was admitted with an acute flare of chronic pancreatitis and HTN urgency, also found to have acute on chronic renal failure improved back to baseline with hydration. #Acute on chronic pancreatitis: Unclear whether this is a new flare or residual sx prior flare last week, which never fully resolved. [Month (only) 116] have been in setting of eating large bolus of meat (possible outdated) on [8-2], prior to admission. - Pain well controlled on percocet 1-2 mg q4h PRN throughout admission. - Tolerating full diet without issue by the time of discharge. - No hx of bloody emesis on this admission. - Pt reports that he has pain clinic appt next Wednesday. - Diarrhea and nausea resolved on admission. #Hypertensive urgency: Patient has had chronic elevated BPs in the 170-190s range (systolic). - Was briefly in ICU on this admission for hypertensive urgency (SBPs 215-220, uncontrolled by PO metoprolol, IV metoprolol and IV labetalol) No neurologic or visual changes at any time. - Received additional dose of IV labetalol as well as amlodipine in the ICU, with SBP down to < 160. - On the floor, pressures were well controlled (SBP < 150, and generally 120s-140s) on oral metoprolol 50 mg po bid and amlodipine 5 mg po qd. - Patient instructed to continue PO metoprolol and amlodipine on discharge. # Acute on chronic renal failure: Patient with baseline renal function with Cr 1.8, during hospital found to have acute worsening of Cr up to 2.5 on [2139-8-6] thought to be prerenal in setting of being NPO and having flare of pancreatitis. - Given 1L bolus and Cre down to 2.3 on recheck on [2139-8-6]. afternoon. - Given 2L fluids overnight with return of Cre to baseline value of 1.9 upon discharge. #h/o ESRD, s/p transplant: Likely had renal failure secondary to HTN although patient seems to be limited historian in this Medical Center, Dr. [First Name (STitle) ]. -continued Prednisone 2.5mg daily -continued Mycophenolate Mofetil 750 mg PO DAILY -continued Tacrolimus 1 mg PO QPM / 2 mg PO QAM -has followup appointment with Dr. [First Name (STitle) ] at [Hospital1 2177] on discharge #DM-II: Longstanding history of type II diabetes. - HbA1c=6.1% - QID fingersticks with SSI - Home glargine restarted once patient was taking full POs. #Alcohol Abuse: Patient strongly denied use between prior discharge and current admission. Had CIWA scale in the MICU but did not require ativan. No e/o withdrawal on exam, so CIWA scale was d/c'd without issue. #Recent GI Bleed: Recent coffee-ground emesis on prior admission. He could have possible varices given his HCV and ETOH history although no documented cirrhosis. Also may be gastritis related as he has h/o GERD. Hct stable on this admission; refused EGD on prior admission and rectal exam on this admission. - HCt stable at patient's baseline on this admission - Patient agreed to consider outpt EGD -- he will discuss with his [Hospital1 2177] PCP. [Name Initial (NameIs) ] PPI dose was increased to 40 omeprazole [Hospital1 ]. # IV access/blood draws: Of note, patient with difficult access. We were able to obtain an antecubital R PIV during this admission (although in past has had PICC lines, we wanted to avoid this due to infection risk). Phlebotomy was challenging, but when MD order allowed patient to be drawn on left side where patient had his old fistula, phlebotomy was able to obtain blood from left hand. Medications on Admission: Insulin SC (per Insulin Flowsheet) Morphine Sulfate 2-4 mg IV Q6H:PRN abdominal pain Metoclopramide 10 mg IV Q6H:PRN nausea Pantoprazole 40 mg IV Q24H gastritis Mycophenolate Mofetil 750 mg PO DAILY PredniSONE 2.5 mg PO/NG DAILY Tacrolimus 1 mg PO QPM Tacrolimus 2 mg PO QAM Metoprolol Tartrate 50 mg PO/NG [Hospital1 ] Discharge Medications: 1. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. 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:0 5. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 6. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 7. Mycophenolate Mofetil 250 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Two (22) UNITS Subcutaneous at bedtime. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for abdominal pain : Please contact your primary care provider who normally prescribes this medication for any refills. Disp:0 Tablet(s) Refills:0 11. Humalog 100 unit/mL Cartridge Sig: Four (4) UNITS Subcutaneous WITH EVERY MEAL. 12. Outpatient Lab Work Please have CHEM7 panel and CBC drawn on [2139-8-10]. Results should be faxed to Dr. [Doctor Last Name 11456] at [Telephone/Fax (1) 11454]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute pancreatitis Secondary Diagnoses: Acute on chronic renal failure Hypertensive urgency End-Stage Kidney Disease, status-post kidney transplant 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 to participate in your care. You were diagnosed with hypertension and pancreatitis. When you came into the hospital you had abdominal pain similar to your prior episodes of pancreatitis. When you arrived on the Medical Floor, your blood pressure was very high (as high as 215 systolic). You were given several medications but your blood pressure remained high. Therefore you were transferred to the medical intensive care unit, where your blood pressure was controlled with labetalol, metoprolol, and amlodipine. Subsequently, on the medical floor, your blood pressure remained well controlled on oral metoprolol and oral amlodipine. Your abdominal pain was controlled with Percocet. Your diet was slowly advanced until you were tolerating a full diet by the time of your discharge. You should avoid alcohol and foods that trigger worsening of your pancreatitis. . Please note the following changes to your medications: MEDICATIONS ADDED: Amlodipine 5 mg by mouth every day MEDICATION DOSE CHANGES: Dose increased to Omeprazole 40 mg by mouth twice a day. MEDICATIONS REMOVED: None . Thank you for allowing us to participate in your care. Followup Instructions: You have an appointment with your Primary Care Physician (Dr. [Doctor Last Name 11456]) on [8-12] at 3:45 PM. At this appointment, please discuss your blood pressure medications and the risk factors that may cause or worsen your pancreatitis. Please mention the new dose of omeprazole, which has been increased. You should also discuss the possibility of having an upper endoscopy as an outpatient procedure. ------- You have an appointment with your Renal Transplant Doctor, Dr. [First Name (STitle) ] at [Hospital6 ] on [8-19] at 8:20AM. At this appointment, please discuss your kidney function and your current transplant drug regimen. ICD9 Codes: 5849, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6351 }	Medical Text: Admission Date: [2190-9-5] Discharge Date: [2190-9-9] Date of Birth: [2132-10-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2782] Chief Complaint: Nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 57M w/PMHx IDDM, heavy EtOH use who presented to [Hospital1 18] [Location (un) 620] with nausea, emesis and abdominal pain found to be in DKA. He reported that he developed nausea after eating a [Location (un) 6002] on his night shift 1.5 days ago. Subsquently he has vomited >15 producing nb/nb emesis. He denies fevers. He reports suprapubic abdominal pain that was well controled with advil. He denies changes in his bowels or bladder habbits. After arriving to [Hospital1 18] [Location (un) 620], initially had a lactate of 15, WBC 15.8 with potassium of 5.7 and AG metabolic acidosis of 39. Received 3L IV NS, Insulin gtt started and Vanc, Zosyn IV received. Last FSG 328 mg/dL. His lipase was nearly 1100. He was then transferred to [Hospital1 18] for futher management. On arrival to [Hospital1 18], he was continued on Insulin gtt [First Name8 (NamePattern2) ] [Last Name (un) 387] protocol, D5 NS +40 mEq and electrolytes were repleted. He was quickly transfer to the MICU for futher managmenet of his DKA, presume pancreatitis, and alcohol withdrawal. His inital vitals in the ED were 99.8 110 138/78 18 98% RA. Past Medical History: 1. Diabetes mellitus type 2. 2. Dyslipidemia. 3. Psoriasis. 4. Gout. 5. Elevated transaminases. 6. Anemia (macrocytic) 7. Vitamin D deficiency. 8. History of right rotator cuff injury. 9. History of carpal tunnel syndrome. 10. Last colonoscopy in [2188-4-7] at which time the patient was noted to have a colon polyp and diverticulosis. Pathology was consistent with a hyperplastic polyp. 11. Status post right and left inguinal hernia repairs. Social History: The patient is married. He has 2 children He states that he does not smoke cigarettes. Last drink Friday, [5-14] drinks daily, sometimes more. He acknowledges that he drinks "heavily." He works for the highway system for the state. He denies use of illicit drugs. Family History: The patient's mother died from ovarian cancer he believes in her early 70s. The patient's father died from heart disease in his 70s. The patient has 4 sisters who he believes are in goodhealth. He is not aware of any family history of iron overload. Physical Exam: MICU EXAM T 37.7 HR: 104 BP: 132/66 RR: 25 SpO2: 96% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, horizontal nystamus MMM, oropharynx clear Neck: supple CV: Regular rate normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, ttp suprapubic, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, tremor in hands bilaterally Discharge Exam: VS: 98.8 117/97 90 18 100 ra General: Sitting up in bed, NAD, aoX3 HEENT: Sclera anicteric, PERRL, OP clear Neck: supple, no JVD CV: RRR, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, nontender, nondistended, no rebound/guarding, no CVA tenderness Ext: WWP, 2+ DP/PT/radial, no edema, psoriasis patches on wrists, and left calf, no asterixis Neuro: CNII-XII intact, moving all extremities, no asterixis, AOx3, [4-10] recall, gait not observed Pertinent Results: Admission Labs: [2190-9-4] 11:55PM BLOOD WBC-5.5 RBC-2.30* Hgb-7.8* Hct-23.8* MCV-104* MCH-34.0* MCHC-32.8 RDW-12.8 Plt Ct-133* [2190-9-4] 11:55PM BLOOD Neuts-90.6* Lymphs-4.6* Monos-4.5 Eos-0.2 Baso-0.1 [2190-9-4] 11:55PM BLOOD PT-13.2* PTT-26.6 INR(PT)-1.2* [2190-9-4] 11:55PM BLOOD Glucose-236* UreaN-29* Creat-1.7* Na-138 K-4.0 Cl-103 HCO3-17* AnGap-22* [2190-9-5] 02:50AM BLOOD ALT-61* AST-96* AlkPhos-55 Amylase-511* TotBili-1.8* [2190-9-5] 02:50AM BLOOD Lipase-1251* [2190-9-5] 06:39AM BLOOD CK-MB-3 cTropnT-<0.01 [2190-9-4] 11:55PM BLOOD Calcium-5.9* Phos-1.6* Mg-1.1* [2190-9-5] 02:50AM BLOOD VitB12-1273* [2190-9-5] 02:50AM BLOOD Triglyc-77 [2190-9-5] 12:12AM BLOOD Type-[Last Name (un) ] Temp-37.1 O2 Flow-2 pO2-35* pCO2-30* pH-7.39 calTCO2-19* Base XS--5 Intubat-NOT INTUBA Vent-SPONTANEOU [2190-9-5] 12:02AM BLOOD Lactate-3.6* [2190-9-5] 03:07AM BLOOD Lactate-2.2* [2190-9-6] 04:33AM BLOOD Lactate-1.1 [2190-9-4] 11:55PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.013 [2190-9-4] 11:55PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-300 Ketone-80 Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [2190-9-4] 11:55PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE Epi-1 [2190-9-4] 11:55PM URINE CastHy-17* Relevent MICU Labs: [2190-9-6] 03:55AM BLOOD WBC-5.2 RBC-2.97* Hgb-10.4* Hct-30.2* MCV-102* MCH-34.8* MCHC-34.3 RDW-13.0 Plt Ct-109* [2190-9-7] 04:17AM BLOOD WBC-3.8* RBC-2.60* Hgb-8.8* Hct-28.0* MCV-107* MCH-33.7* MCHC-31.4 RDW-12.7 Plt Ct-103* [2190-9-6] 03:55AM BLOOD PT-12.0 PTT-27.7 INR(PT)-1.1 [2190-9-6] 03:55AM BLOOD Plt Ct-109* [2190-9-7] 04:17AM BLOOD PT-12.2 PTT-30.3 INR(PT)-1.1 [2190-9-7] 04:17AM BLOOD Plt Ct-103* [2190-9-6] 03:55AM BLOOD Glucose-152* UreaN-18 Creat-1.1 Na-135 K-3.8 Cl-98 HCO3-23 AnGap-18 [2190-9-7] 04:17AM BLOOD Glucose-546* UreaN-9 Creat-1.0 Na-132* K-3.1* Cl-97 HCO3-25 AnGap-13 [2190-9-6] 03:55AM BLOOD ALT-53* AST-72* LD(LDH)-251* CK(CPK)-104 AlkPhos-62 Amylase-517* TotBili-1.0 [2190-9-7] 04:17AM BLOOD ALT-57* AST-86* LD(LDH)-218 AlkPhos-75 TotBili-1.0 [2190-9-6] 03:55AM BLOOD Lipase-1303* [2190-9-7] 04:17AM BLOOD Lipase-1337* Discharge Labs; [2190-9-9] 08:00AM BLOOD WBC-4.2 RBC-2.99* Hgb-10.2* Hct-30.5* MCV-102* MCH-34.0* MCHC-33.3 RDW-13.1 Plt Ct-169 [2190-9-9] 08:00AM BLOOD Glucose-176* UreaN-16 Creat-1.0 Na-137 K-3.4 Cl-103 HCO3-25 AnGap-12 [2190-9-9] 08:00AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.6 [2190-9-8] 07:00AM BLOOD %HbA1c-8.3* eAG-192* Micro: Blood culture [9-4]- PENDING x 2 Imaging: EKG [2190-9-5]: Sinus tachycardia. RSR' pattern in lead V1 (normal variant). Left atrial abnormality. Non-specific ST segment changes. No previous tracing available for comparison. Rate 114, QTc 424 CXR [2190-9-5]: Lung volumes are low and there are patchy bibasilar opacities which may reflect patchy lower lobe atelectasis, although aspiration or pneumonia cannot be entirely excluded. Clinical correlation is advised. No pneumothorax. No evidence of pulmonary edema. No acute bone abnormality appreciated. CT abd/pelvis [2190-9-5]: 1. Peripancreatic fluid and fat stranding suggestive of pancreatitis. No evidence of organized fluid collection. 2. Hepatic steatosis. 3. Diverticulosis without evidence of diverticulitis Brief Hospital Course: 57 yo Male with history of poorly controlled DM, transferred from [Hospital1 ] [Location (un) 620] for managment of DKA, pancreatitis and EtOH withdrawal #DKA- came in with gap of 18, glucose of 230s. Patient endorse medication non-compliance. While in the ICU, patient was treated with fluid and electrolyte resuscitation and subcutaneous insulin, with good response. [Last Name (un) ] Diabetes Center was consulted. His insulin drip was stopped on [2190-9-7]. He was called out to the medicine floor where he remained quite stable. He was seen by PT on whose recommendation he was dc-ed to rehab. # Acute pancreatitis- Nausea and abdominal pain were present on admission, as well as a lipase to 1098 at [Hospital1 ] [Location (un) 620] 1251 at [Hospital1 18]. He was treated conservatively with NPO diet, pain control with tylenol. A CT abdomen showed uncomplicated pancreatitis, without pseudocyst, necrosis, or fluid collection. Pt improved quickly and was toelrating regular diet, with pain controlled on tylenol at dc to rehab. # Alcohol withdrawal- Patient reports his last drink was on friday morning before admission. Patient reports that he drinks [5-14] hard alcoholic drinks daily. He denies any withdrawal symptoms in the past, however while in the ICU he required more than 100mg of PRN Diazepam on a CIWA scale. He was treated with Diazepam and breakthrough lorazepam per CIWA protocol, and given thiamine and multivitamin supplementation. A social work consult was placed regarding his substance abuse, as well. He did not score on CIWA after transfer to floor. #Anemia: HCT has remained stable throughout MICU stay. Has macrocytic anemia consistent with history of alcohol abuse. He did not require transfusion, and had guaiac negative stools. We continued home b12 and added on folate supplementation. #[Last Name (un) ]- Presented with serum Cr of 1.9 on admission, which is elevated from baseline. Was given aggressive fluid resuscitation and responded well with normalization of serum Cr. Normalised at time of dc. Transitional Issues: - Will need ETOH abuse council if amenable - f/u with [Last Name (un) 387] as outpt-set up as high risk through care connection seen w/in 2 days of discharge; decision to refer to [Last Name (un) ] deferred to PCP Medications on Admission: Lisinopril 10 mg daily simvastatin 40 mg daily Levemir Flexpen [Hospital1 ] (10 units, but patient is unsure) Spectravite Senior multivitamin Discharge Medications: 1. Simvastatin 40 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Levimir 8 Units Bedtime 6. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Doctor Last Name 5749] [Doctor Last Name ] Village - [Location (un) ] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. ACUTE PANCREATITIS 2. DIABETIC KETOACIDOSIS SECONDARY DIAGNOSIS: 1. TYPE 2 DIABETES MELLITUS 2. HYPERLIPIDEMIA 3. PSORIASIS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [Known lastname ], It was a pleasure participating in your care while you were admitted to [Hospital1 69]. As you know you were admitted because you were experiencing abdominal pain and were ultimately found to have pancreatitis. This was caused by drinking too much alcohol and it is very important that you decrease the amount you are drinking. Your blood sugars were also extremely high and you develop a condition called Diabetic Ketoacidosis. This can be extremely dangerous and it is very important that you take insulin as instructed. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) 6715] H. Location: [Hospital1 ] FAMILY MEDICINE OF [Location (un) ] Address: [Street Address(2) 31531], [Location (un) ],[Numeric Identifier 31532] Phone: [Telephone/Fax (1) 31529] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. ICD9 Codes: 5849, 2875, 2859, 2724, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6352 }	Medical Text: Admission Date: [2180-4-28] Discharge Date: [2180-5-18] Date of Birth: [2147-8-13] Sex: F Service: MEDICINE Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine / Neurontin / Heparin Agents / IV Dye, Iodine Containing Attending:[First Name3 (LF) 2181] Chief Complaint: Joint Pain, Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 32 y/o F with SLE, ESRD s/p failed transplant on HD, cerebral hemorrhages with resultant seizure d/o, restrictive lung disease, who presents with SOB, generalized body/joint pains similar to those from her prior admission. Has been taking more than her prescribed home dose of dilaudid over the past few days. Went to HD yesterday. Pain improved with 1mg IV dilaudid x 1. Patient recently diagnosed with fibromyalgias on last admission and having pains in neck, arms, legs. Had full session of [First Name3 (LF) 2286] on Wed. . In the ED, initial VS: 99.0 100 138/97 18 100 Given dilaudid 1mg IV x 6 over 12 hours. Admitted for pain control and shortness of breath. Past Medical History: #. Systemic Lupus Erythematosus: diagnosed [2166] complicated by lupus nephritis, anemia, serositis and ascites, vascular stenosis resulting in facial edema and subclavian steal #. Pulmonary HTN #. ESRD s/p failed renal transplant in [2174] requiring explant -HD T/Th/Sat #. HTN #. GERD #. Multiple hospitalizations for line sepsis #. S/p R BKA for chronically infected non-healing fracture (R Tib-fib fracture in [2176]) #. H/o MSSA endocarditis c/b embolic stroke and resultant seizure disorder #. Seizure disorder- complication of embolic strokes from mitral valve endocarditis in [2177] #. H/o VSD s/p surgery at age 13 #. HTN #. ITP #. Sickle cell trait #. S/p left oophorectomy related to IUD associated infection, s/p TAH/RSO for right pelvic abscess #. Restrictive lung disease Social History: Lives at home with husband and 16 year old son. Denies any past history of smoking, alcohol or other drugs. Originally from [Country ]. Used to work at [Hospital1 18] as a patient care technician, currently on disability. She has used a walker for about 2.5 years since amputation of her right foot. She lives in an apartment on the [Location (un) 448], has to climb about 15 stairs to get to the apartment. Family History: Brother with SLE and DM Physical Exam: Vitals - T: 97.3 (100.5) BP: 102/84 HR: 96 RR: 18 02 sat:92/RA GENERAL: thin African-American woman with round swollen-appearing faces in NAD and thin extremities. Alert and Oriented x3. Tearful. HEENT: NCAT. Sclera anicteric but injected bilaterally. Eyelids and lips largely swollen; lower lip angio-edema appearing but pt states it is chronic. EOMI. oropharynx clear. tongue is midline and not swollen. CARDIAC: RR, split S1, normal S2. no murmurs appreciated. CHEST: HD line tunneled in place right side, nontender at insertion site, dressing in place. LUNGS: Resp unlabored, no accessory muscle use. Crackles bilaterally. ABDOMEN: Soft, mildly distended, nontender currently. BACK: diffusely tender to palpation over muscles of lower, mid, and upper back and spine EXTREMITIES: No peripheral edema of lower extremities, very thin. Right arm with scar from old AV graft or fistula site. Right foot amputated. Left foot warm w good pulses. Knees and elbows not erythematous or swollen, not any warmer than rest of extremities; good range of motion, pain with motion. Elbows nontender, but knees tender to palpation. NEURO: [4-12] right hip flexor strength and [3-13] Left Hip Flexor strength. Left arm also with mildly decreased strength s/p stroke. SKIN: Dark oval-shaped macular spots 2-3cm in width on arms and legs. Pertinent Results: Admission Labs: [2180-4-27] 09:57PM BLOOD WBC-6.9 RBC-4.46 Hgb-12.8 Hct-41.2 MCV-93 MCH-28.7 MCHC-31.0 RDW-22.5* Plt Ct-111* [2180-4-27] 09:57PM BLOOD Neuts-60.4 Lymphs-33.3 Monos-3.4 Eos-2.1 Baso-0.8 [2180-4-29] 06:05PM BLOOD ESR-90* [2180-4-27] 09:57PM BLOOD Neuts-60.4 Lymphs-33.3 Monos-3.4 Eos-2.1 Baso-0.8 [2180-4-27] 09:57PM BLOOD Glucose-92 UreaN-28* Creat-7.1# Na-133 K-3.9 Cl-92 HCO3-34* AnGap-11 [2180-4-27] 09:57PM BLOOD Calcium-7.4* Phos-2.4* Mg-2.6 [2180-4-29] 06:05PM BLOOD CRP-41.5* [2180-4-28] 12:45PM BLOOD C3-23* C4-8* CXR [2180-4-28]: 1. Confluent left lower lobe opacity, potentially due to pneumonia in the appropriate clinical setting. Lupus pneumonitis is an additional consideration, as well as atelectasis. 2. Interstitial edema. 3. Massive enlargement of central pulmonary arteries consistent with pulmonary arterial hypertension. Plain film L shoulder [2180-4-29]: FINDINGS: The alignment is normal without fracture or dislocation. Please note that these films were taken to assess the shoulder. The lung visualized in the image demonstrates increased lung markings and hazy vasculature that has probably increased compared to the study from the prior day. The study and the report were reviewed by the staff radiologist MRI L Shoulder [2180-5-3]: 1. Tendinopathy of supraspinatus and infraspinatus tendons without tear. 2. Mild glenohumeral and acromioclavicular joint degenerative change. 3. Slightly limited by patient motion. Portable AP chest [2180-5-7]: Single view of the chest demonstrates enlargement of the heart, prominent mediastinum, patchy multifocal airspace disease with underlying interstitial changes. There is a probable small left-sided pleural effusion. Right-sided [Month/Day/Year 2286] catheter is present. Interval worsening of the appearance of the chest since prior study from [2180-4-28]. Brief Hospital Course: #. Arthralgias/joint pain/left shoulder immobility: Initially there was concern that this pain may represent a lupus flare, versus continuing chronic pain. Serum C3, and C4 were low and rheumatology was consulted. Plaquenil was stopped, and she was treated with three days of prednisone 20mg PO daily. She did not have significant improvement with this regimen and she was put back on her home dose of 5mg PO daily. She had difficulty moving her left shoulder, but could mover her fingers and hand, and sensation and pulses remained intact. An MRI was performed of her left shoulder, which showed supraspinatus tendonitis. Her dose of dilaudid was decreased from 1mg IV q 2 hrs, to 8 mg PO q 4 hr over several days. She gradually complained of less pain and reported improved mobility of her shoulder. . #. Opacities on CXR. Patient presented with a complaint of shortness of breath and had a temperature of 100.3 on the day of admission. Chest x-ray showed new RLL opacity suggestive on PNA. She was treated with one day of vancomycin and meropenem for HCAP. She clinically improved and antibiotics were stopped. Repeat CXR showed improvement. However she began spiking fevers, a repeat CXR and CT scan were concerning for HAP, and the patient defervesed on broad spectrum abx. - complete 8 day course of Vancomycin and Ceftaz. . #. Face/neck swelling. Patient had notable facial and neck swelling, slightly more prominent on the left. Per prior notes, this appeared stable from prior admissions. Transplant surgery was consulted and recommended no further intervention. . #. ESRD - Transplant nephrology was consulted, and patient received hemodialysis on M/W/F. She was also treated wth epogen twice weekly, nephrocaps and calcium acetate. She was noted to have low serum calcium, and her calcinet was stopped. A [Year (4 digits) 2286] session was stopped early on [2180-5-5], due to seizures and hypotension. She received and extra [Date Range 2286] session on [2180-5-6]. She tolerated [Date Range 2286] well thereafter with BP support from midodrine. . # Seizure disorder - Patient was continued on her current doses of topamax 100mg PO every day, with the dose given after [Date Range 2286] on [Date Range 2286] days, and keppra 500mg PO bid on non [Date Range 2286] days, and 1000mg PO daily on [Date Range 2286] days given AFTER [Date Range 2286]. Patient was noted to have short period of myoclonic jerking and unresponsiveness while at hemodialysis on [2180-5-6]. [Date Range ] session was stopped, and she was given her anti-epileptics. Her serum calcium was noted to be low, and she was repleted 4g of calcium gluconate. Her outpatient neruologist was contact[Name (NI) ] ([Name (NI) ]/[Doctor Last Name ]), who recommended a 24 hour video EEG. This was performed and showed no epileptiform activity. . # Hypotension - Patient blood pressure baseline is 90s/60s. Several times her dilaudid was held for SBP < 90. At [Doctor Last Name 2286] on [2180-5-6] her blood pressure decreased to 70s/50s and [Date Range 2286] was stopped. On the morning on [2180-5-8], she was noted to be somnolent and persistently hypotensive in the 70s/50s. She was bolused 1 liter of NS and her pressure increased to 80s/50s. She was tranferred to the intensive care unit for further management. In the ICU, the patient's pressures remained stable. She was started on Midodrine 10mg TID. TSH and Cortisol were WNL. She was started on Vancomycin on [2180-5-7], which was to be d/c'd if the BCx remained negative for 48hrs. She was called out the next morning to the floor. Midodrine was continued. . # Stage II decubitis ulcer: Ulcer was present on admission, and was treated with standard wound care measures. . # Constipation: Patient was consistently constipated. She was treated with a progressively more aggressive bowel regimen. . # CODE: FULL . #. Vaginal bleeding - Pt is s/p TAH, but has recent vaginal bleed. Patient needs outpatient follow-up with her gynecologist. Medications on Admission: - Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QMOWEFR (Monday -Wednesday-Friday) -- immediately after [Date Range 2286]. - Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID ON SAT/SUN/TUES/THURS - Topiramate 100 mg Tablet Sig: One (1) Tablet PO (After HD on [Date Range 2286] days). - Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). - Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). - B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). - Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. - Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. - Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). - Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. - Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). - HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day - Epo-alfa at HD . Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO MWF (Monday-Wednesday-Friday): Take AFTER [Date Range 2286]. Disp:30 Tablet(s) Refills:2 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take like this on NON-HD days, i.e. SA-[Doctor First Name ]-TU-TH. Disp:30 Tablet(s) Refills:2 3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 Capsule(s) Refills:2 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 capsules Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for consitpation. Disp:60 Tablet(s) Refills:0 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-11] Drops Ophthalmic PRN (as needed) as needed for dry eyes. Disp:1 dropette Refills:3 10. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 11. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 14. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:30 Suppository(s) Refills:0 16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO TID (3 times a day) as needed for constipation. Disp:30 packet Refills:0 17. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:30 Tablet(s) Refills:2 18. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol). 19. Ceftazidime 1 gram Recon Soln Sig: One (1) Gram Injection QHD (each hemodialysis). 20. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:100 Tablet(s) Refills:0 21. Pantoprazole 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 22. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Location (un) 86] Center for Rehab & Sub-Acute Care - [Location (un) 2312] Discharge Diagnosis: Joint Pain Health Care Associated Pneumonia Lupus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted for worsening pain and shortness of breath. An x-ray of your chest and shoulder were performed. The chest x-ray showed evidence of possible pneumonia which was confirmed on CT and you are currently being treated for this. The shoulder x-ray did not show a fracture. Fluid removed from your knee showed neither inflamation nor infection. You were initially treated with antibiotics for the possible pneumonia, but these were stopped as your breathing improved. Hemodialysis was performed on schedule. Rheumatology saw you and did not think your pain was related to a lupus flare. Pain management was consulted and recommended you start an new medication, lyrica. Your pain was otherwise controlled with the medication dilaudid. Your pain gradually improved and your dose of dilaudid was decreased. Psychiatry saw you while you were here, and recommended you start the anti-depressant medication cymbalta. During [Location (un) 2286] you had a seizure. You were placed an video electroencephalography (EEG) monitoring for one day, and no further seizures were observed. Your antiseizures were continued. Your stay was complicated by low blood pressures which were treated with the medication midodrine. Please note the following changes in your medications: You were started on topamax 100mg every evening You were started on duloxetine 60mg daily You were started on artificial tears as needed for dry eyes You were started on Lyrica(pregabalin) 75mg twice per day for pain You were started on calcium supplements (calcium carbonate) 500mg three times per day You were started on miralax which you can take upto three packets per day as needed for constipation. You were started on bisacodyl suppositories which you may use as needed up to twice per day for constipation Dr. [Last Name (STitle) ] will attempt to get you a prior authorization for lidoderm patches. . Your hydroxychloroquine was stopped. Please review all change in your medications with your primary care doctor. It is very important that you only take all medications as prescribed. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: RHEUMATOLOGY When: WEDNESDAY [2180-5-24] at 9:30 AM With: [First Name11 (Name Pattern1) 2890] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 2226] Building: LM [Hospital Unit Name ] [Location (un) 861] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE Department: NEUROLOGY When: MONDAY [2180-5-22] at 4:00 PM With: DRS. [Name5 (PTitle) ] & [Doctor Last Name 5284] [Telephone/Fax (1) 5285] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: THURSDAY [2180-5-18] at 10:10 AM 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 Completed by:[2180-5-18] ICD9 Codes: 486, 5856, 2761, 4589, 4168, 4019, 2767, 2875, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6353 }	Medical Text: Admission Date: [2109-4-3] Discharge Date: [2109-4-10] Date of Birth: [2059-9-23] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: Carciniod of the lung Major Surgical or Invasive Procedure: S/p L pneumonectomy History of Present Illness: 49 F found to have a mass in her L lung. She was worked up and found to have a carcinoid tumor of the lung. She underwent pre-op Chemo/radiation and was scheduled for a resection. Past Medical History: Hypothyroid C section Chin Surgery Social History: None Family History: None Physical Exam: AVSS NAD CTA(b) RRR Soft/NT/ND BS present No C/C/E Pertinent Results: [2109-4-3] 03:59PM TYPE-ART TEMP-37.7 RATES-/20 O2-50 PO2-184* PCO2-47* PH-7.34* TOTAL CO2-26 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-FACE TENT [2109-4-3] 03:59PM O2 SAT-98 [2109-4-3] 03:04PM GLUCOSE-118* UREA N-12 CREAT-0.5 SODIUM-141 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15 [2109-4-3] 03:04PM CALCIUM-8.4 PHOSPHATE-4.5 MAGNESIUM-1.6 [2109-4-3] 03:04PM WBC-12.2* RBC-3.87* HGB-11.0* HCT-32.2* MCV-83 MCH-28.3 MCHC-34.0 RDW-15.9* [2109-4-3] 03:04PM PLT COUNT-316 [2109-4-3] 01:53PM TYPE-ART TIDAL VOL-520 PO2-189* PCO2-37 PH-7.44 TOTAL CO2-26 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED [2109-4-3] 01:53PM GLUCOSE-108* LACTATE-0.8 NA+-139 K+-3.7 CL--108 [2109-4-3] 01:53PM HGB-11.0* calcHCT-33 [2109-4-3] 01:53PM freeCa-1.15 [2109-4-3] 12:37PM TYPE-ART O2-100 PO2-203* PCO2-39 PH-7.44 TOTAL CO2-27 BASE XS-2 AADO2-483 REQ O2-80 INTUBATED-INTUBATED [2109-4-3] 12:37PM GLUCOSE-106* LACTATE-0.6 NA+-139 K+-3.8 [2109-4-3] 12:37PM HGB-10.7* calcHCT-32 [2109-4-3] 12:37PM freeCa-1.17 [2109-4-3] 11:31AM TYPE-ART RATES-/8 TIDAL VOL-550 PO2-175* PCO2-40 PH-7.44 TOTAL CO2-28 BASE XS-3 INTUBATED-INTUBATED VENT-CONTROLLED [2109-4-3] 11:31AM GLUCOSE-105 LACTATE-0.8 NA+-139 K+-4.0 CL--107 [2109-4-3] 11:31AM freeCa-1.17 Brief Hospital Course: Pt was taken to the OR on [4-3] for a resection. Intraoperatively, it was found that the tumor could not be resected without a complete pneumonectomy therefore this was done. Post operatively she was transferred to the PACU and then to the ICU. An epidural was placed pre-op which provided pain relief. The Acute Pain Service followed her throughout her hospital course. She had a tube placed in the OR however it was removed immediately post-op. She was transferred to the floor. PT was consulted and she ambulated well. She had an episode of orthostatic hypotension which resolved with fluids. Her Hct was stable throughout her hospital stay. Serial CXR showed that her surgical side was healing well and slowly filled with fluid. On POD#6 she was tolerating a regular diet and her pain was controlled with PO medications and she was deemed safe for D/C. She was also given a course of 5 days of Levofloxacin for peri-operative pulmonary coverage. This was completed prior to her D/C. Medications on Admission: Synthroid 112' Ativan prn Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:50 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:60 Tablet(s) Refills:2 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:1000 ML(s) Refills:0 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:50 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Lung cancer Discharge Condition: Stable Discharge Instructions: No heavy lifting with L arm. Continue PT for L arm. Ambulate as tolerated Followup Instructions: F/U with Dr. [Last Name (STitle) ] in [9-13] days. Please call for an appointment. Completed by:[2109-4-10] ICD9 Codes: 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6354 }	Medical Text: Admission Date: [2171-1-17] Discharge Date: [2171-1-29] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 17683] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: s/p exploratory laparotomy and right colectomy History of Present Illness: Patient is an 85 year old female who presented to the emergency department with recurrent rectal bleeding. The patient has a history of hypertension, high cholesterol, and stroke. The patient was recently discharged after an admission for lower GI bleeding ([1-5]) which required transfusion of 6 units of packed RBC's. She has had two admissions prior to this for the same complaint. During her most recent admission she had a tagged red blood cell scan which showed bleeding at the hepatic flexure, but subsequent angiograms were negative. A colonoscopy revealed diverticulosis but no active bleeding. The nursing home where the patient resides reported that the patient had 240cc of hematochezie with a negative lavage. The patient reported some crampy abdominal pain prior to the onset of the bleeding. Past Medical History: 1. H/O GI bleeds in [2168] and as above 2. HTN 3. Hypercholesterolemia 4. S/P MCA CVA on [2171-1-28]- Since this time, pt has suffered from residual aphasia and left hemiparesis. 5. Depression 6. S/P cholecystectomy 7. H/O nocturia 8. Recurrent UTIs Social History: Pt lives in the [Hospital3 9475] Home in [Location (un) 3146]. She is able to bathe and dress herself. She ambulates using a walker. Pt does receive assistance with eating. Her daughter lives in the area and is involved. No tobacco, ETOH, or drugs. Family History: No family history of CAD, CVA, or bleeding disorders. Physical Exam: Vitals pulse 88, bp 149/47, respiratory rate 16, 100% O2 sats on room air General: awake, alert, n acute distress, pale Pulm: clear to auscultation bilaterally CV: regular rate/rhythm Abd: slightly distended, soft, mild diffuse tenderness Rectal: normal tone, no masses, positive hematochezia Ext: warm, well-perfused Pertinent Results: [2171-1-17] 03:46PM BLOOD Hgb-12.2 calcHCT-37 [2171-1-17] 06:07PM BLOOD Hgb-12.7 calcHCT-38 [2171-1-18] 09:57PM BLOOD Hgb-10.5* calcHCT-32 [2171-1-18] 11:23PM BLOOD Hgb-11.2* calcHCT-34 [2171-1-18] 09:57PM BLOOD Glucose-135* Lactate-0.9 Na-141 K-3.6 Cl-111 [2171-1-18] 11:23PM BLOOD Glucose-145* Lactate-1.2 Na-140 K-3.7 Cl-110 calHCO3-27 [2171-1-17] 03:46PM BLOOD Type-[Last Name (un) ] Comment-GREEN TOP [2171-1-18] 09:57PM BLOOD Type-[Last Name (un) ] pO2-50* pCO2-44 pH-7.37 calHCO3-26 Base XS-0 [2171-1-18] 11:23PM BLOOD Type-[Last Name (un) ] pH-7.37 [2171-1-17] 02:54AM BLOOD Albumin-3.3* Calcium-9.2 Phos-3.3 Mg-1.8 [2171-1-18] 04:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.6 [2171-1-19] 04:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-3.4* [2171-1-20] 05:50AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.2 [2171-1-22] 05:07AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.1 [2171-1-23] 05:32AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.9 [2171-1-24] 06:19AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.7 [2171-1-25] 05:40AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.5* [2171-1-29] 05:20AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.9 [2171-1-17] 02:54AM BLOOD CK-MB-2 cTropnT-<0.01 [2171-1-20] 05:50AM BLOOD CK-MB-4 cTropnT-<0.01 [2171-1-17] 02:54AM BLOOD ALT-11 AST-23 LD(LDH)-315* CK(CPK)-37 AlkPhos-53 Amylase-60 TotBili-0.3 [2171-1-20] 05:50AM BLOOD CK(CPK)-910* [2171-1-17] 02:54AM BLOOD Glucose-131* UreaN-21* Creat-0.7 Na-139 K-4.9 Cl-108 HCO3-24 AnGap-12 [2171-1-18] 04:00AM BLOOD Glucose-149* UreaN-13 Creat-0.6 Na-143 K-4.1 Cl-112* HCO3-22 AnGap-13 [2171-1-18] 12:35PM BLOOD Glucose-138* UreaN-14 Creat-0.6 Na-143 K-3.6 Cl-112* HCO3-25 AnGap-10 [2171-1-19] 12:01AM BLOOD Glucose-147* UreaN-11 Creat-0.5 Na-143 K-3.4 Cl-111* HCO3-27 AnGap-8 [2171-1-19] 04:00AM BLOOD Glucose-102 UreaN-11 Creat-0.5 Na-143 K-3.6 Cl-111* HCO3-28 AnGap-8 [2171-1-20] 05:50AM BLOOD Glucose-101 UreaN-10 Creat-0.5 Na-142 K-4.1 Cl-108 HCO3-26 AnGap-12 [2171-1-21] 05:30PM BLOOD Glucose-113* UreaN-7 Creat-0.4 Na-142 K-3.9 Cl-106 HCO3-30* AnGap-10 [2171-1-22] 05:07AM BLOOD Glucose-111* UreaN-6 Creat-0.4 Na-139 K-3.7 Cl-104 HCO3-30* AnGap-9 [2171-1-23] 05:32AM BLOOD Glucose-124* UreaN-8 Creat-0.4 Na-140 K-4.3 Cl-104 HCO3-31* AnGap-9 [2171-1-24] 06:19AM BLOOD Glucose-119* UreaN-8 Creat-0.4 Na-139 K-3.8 Cl-106 HCO3-29 AnGap-8 [2171-1-25] 05:40AM BLOOD Glucose-102 UreaN-7 Creat-0.4 Na-138 K-3.6 Cl-102 HCO3-28 AnGap-12 [2171-1-28] 02:00PM BLOOD Glucose-96 UreaN-5* Creat-0.5 Na-139 K-3.4 Cl-106 HCO3-29 AnGap-7* [2171-1-17] 02:54AM BLOOD PT-12.9 PTT-22.9 INR(PT)-1.0 [2171-1-17] 02:54AM BLOOD Plt Ct-369# [2171-1-18] 04:00AM BLOOD Plt Ct-219 [2171-1-18] 12:35PM BLOOD PT-13.7* PTT-23.6 INR(PT)-1.2 [2171-1-18] 12:35PM BLOOD Plt Smr-NORMAL Plt Ct-226 [2171-1-18] 09:47PM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.2 [2171-1-19] 04:00AM BLOOD Plt Ct-188 [2171-1-20] 05:50AM BLOOD Plt Ct-208 [2171-1-21] 05:30PM BLOOD Plt Ct-248 [2171-1-17] 02:54AM BLOOD Neuts-65.1 Lymphs-27.0 Monos-4.3 Eos-3.4 Baso-0.2 [2171-1-18] 12:35PM BLOOD Neuts-91.5* Bands-0 Lymphs-4.8* Monos-3.6 Eos-0 Baso-0 [2171-1-17] 02:54AM BLOOD WBC-6.6 RBC-2.83* Hgb-9.0* Hct-26.4# MCV-93 MCH-31.7 MCHC-33.9 RDW-15.0 Plt Ct-369# [2171-1-17] 11:00PM BLOOD Hct-32.2 [2171-1-18] 04:00AM BLOOD WBC-18.4# RBC-3.52 Hgb-10.7* Hct-31.4* MCV-89 MCH-30.5 MCHC-34.3 RDW-16.6* Plt Ct-219 [2171-1-18] 06:40PM BLOOD Hct-26.3* [2171-1-19] 12:01AM BLOOD Hct-33.6# [2171-1-20] 05:50AM BLOOD WBC-15.2 Hct-32.1* Plt Ct-208 [2171-1-21] 05:30PM BLOOD WBC-11.3* RBC-3.41* Hgb-10.2* Hct-31.1* MCV-91 MCH-30.0 MCHC-32.9 RDW-15.2 Plt Ct-248 [2171-1-24] 01:30PM BLOOD Hct-31.0* [2171-1-25] 05:40AM BLOOD WBC-8.5 RBC-3.22* Hgb-9.4* Hct-29.3* MCV-91 MCH-29.2 MCHC-32.1 RDW-14.8 Plt Ct-345 Brief Hospital Course: The patient was originally admitted to the medicine service at [Hospital1 18]. Blood was transfused to a goal hematocrit of 30. SMA embolization was performed on HD 2. Neurology was consulted due to the patient's history of stroke and mental status changes on admission. It was thought that these changes were most likely related to sedative drugs and a urinary tract infection. The infection was treated appropriately with antibiotics, and the use of narcotic medications was minimized. The patient subsequently developed ischemic bowel with peritoneal signs and an elevated WBC thought to be a complication from the embolization procedure. On HD 2 the patient underwent an exploratory laparotomy and right colectomy for ischemic colitis. She tolerated the procedure well with slow return of bowel function. Physical therapy worked with her, and it was planned that she would be discharged to rehab when clinically ready. She demonstrated some irregularity in cardiac rhythm on post-op day 2, and was monitored by telemetry to follow this rhythm. She was placed on flagyl for a two-week course due to the development of some diarrhea. Her foley was discontinued on post-op day 10, and although the patient successfully voided, she subsequently put out little output. It was decided that if she had not voided again by the time of discharge that she would be discharged with a foley in place. The patient has a history of stroke and was placed on aspiration precautions. She was not to have any thin liquids - all liquids were thickened. She required encouragement in taking po's, and her rehab facility was informed of this. In addition, her rehab facility was advised to check her electrolytes several times per week due to the need for repletion in the hospital. Medications on Admission: celexa 20 qd vicodin 1 tab [Hospital1 ] xanax 0.25 [Hospital1 ] doxepin 10 qd ferrous sulfate 325 [Hospital1 ] folic adic 1 qd vitamin B12 1000mcg qd lipitor 10 qd colace 100 [Hospital1 ] senna 1 tab [Hospital1 ] lisinopril 20 qd protonix 40 qd Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 more days (end on [2171-2-8]) days. 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Senokot 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 12. FerrouSul 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 13. Doxepin HCl 10 mg Capsule Sig: One (1) Capsule PO at bedtime. 14. Lopressor 50 mg Tablet Sig: half tablet Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 9475] Care Center - [Location (un) 3146] Discharge Diagnosis: 1. s/p SMA embolectomy 2. s/p exploratory laparotomy and right colectomy 3. recurrent lower GI bleeds 4. hypertension 5. stroke with residual left hemiparesis 6. depression 6. recurrent UTIs 7. reflux Discharge Condition: stable; tolerating regular diet; out of bed daily Discharge Instructions: Please call ER or surgery clinic if you observe increased pain, swelling, bleeding, drainage, temperature > 101.5, or other symptoms which are concerning to you Avoid directly soaking wound. [Month (only) 116] shower, but cover with dressing at these times Followup Instructions: 1. Follow-up with Dr. [Last Name (STitle) ] in 1 week for wound evaluation 2. Follow-up with your primary care provider as needed for medication management [Name6 (MD) 843] [Name8 (MD) 844] MD [MD Number(1) 845] ICD9 Codes: 5990, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6355 }	Medical Text: Admission Date: [2164-6-4] Discharge Date: [2164-6-7] Date of Birth: [2113-6-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 50 year old man with hypercholesterolemia, hypertension, cigarette smoking, FHx of early MI presented with CP to OSH; found to have inferior STEMI, was transferred to [Hospital1 18] for emergent cardiac catheterization. . Patient developed SSCP [6-17] while working on his motorcycle, assoc w/ diaphoresis and right arm numbness. His wife called EMS and he was brought to [Hospital3 3583] where he received NTG and ASA. He was found to have inferior ST elevations on EKG was started on Plavix, a Heparin gtt, and Integrillin gtt. . Next, patient was transferred to [Hospital1 18] for cath. Cardiac cath showed a RCA and LCX dz with 80% OM1 and 100% OM2 lesions. His OM2 was stented with a DES, resulting in resolution of his chest pain. He is now admitted to the CCU for monitoring. . Currently, he feels well w/ only mild lingering chest pressure. No chest pain, dyspnea, palpitations, abd pain, leg pain, or leg weakness or numbness. Past Medical History: - HTN - hyperlipidemia - depression Social History: significant for tobacco use, > 20 pack-years, currently [1-10] ppd. There is no history of alcohol abuse. No cocaine or IVDU. Family History: - CAD: father died of MI at 61, brother had MI at 40. Physical Exam: VS: T , BP 120/77, HR 79, RR 12, O2 sat 99% RA Gen: healthy appearing man lying flat in bed, pleasant and conversational, NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear w/ MMM. Neck: Supple with no JVD. CV: reg s1/s2, no s3/s4/m/r Pulm: CTA b/l, no crackles or wheezes. Abd: obese, +BS, soft, NT. Left fem puncture site w/ no oozing, tenderness, or bruit. Ext: warm; 2+ DP b/l, no edema, no femoral bruits. Neuro: a/o x 3 Pertinent Results: [2164-6-4] 11:37PM WBC-13.8* RBC-4.54* HGB-14.0 HCT-40.3 MCV-89 MCH-30.7 MCHC-34.7 RDW-13.9 . EKG [2164-6-4] - demonstrated ST elevations in II, III, aVF, V5, V6 and ST depressions in aVR, AvL and V1, V2. Sinus rhythm. Actue inferolateral ST segment elevation myocardial infarction with reciprocal depressions in lead aVL and V1-V2. No previous tracing available for comparison. . CARDIAC CATH performed on [2164-6-4] demonstrated: 40% mid, 80% distal RCA, LCX with 80% OM1 and 100% OM2, as well as 30% LMCA lesion RA 11, RV 46/7, PA 49/19/32, PCWP 20 CI 2.26, CO 4.52 . Cardiac ECHO performed [2164-6-5] Conclusions: The left atrium is normal in size. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal half of the inferolateral wall and basal inferior wall. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse.The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. Brief Hospital Course: Patient is a 50 year old man with multiple cardiac risk factors admitted to CCU for monitoring after inferior ST-elevation myocardial infarction, treated with a drug eluting stent to the second obtuse marginal branch off of the left circumflex artery. . 1) Coronary artery disease: He has multiple risk factors including hyperlipidemia, hypertension, smoking and family history. Cath showed significant RCA disease and distal LCX disease. Peak CK/troponin were 3656/5.59. After placement of the OM2 stent (Taxus) the patient was treated with ASA 325 daily, plavix 75 daily, atenolol 50BID, Lisinopril 5 daily, and lipitor 80 daily. The patient was on an integrillin gtt for 18 hours after stent placement. He had several asymptomatic 10 beat runs of ventricular tachycardia after catheterization. These had completely resolved for over 24 hours prior to discharge. An ECHO demonstrated left ventricular ejection fraction of 45% to 50%. . 2) HTN: managed with atenolol and lisinopril as above. . 3) Hyperlipidemia: start lipitor 80 mg as above. . 4) Tobacco use: We started a nicotine patch and the patient was counseled regarding the need for smoking cessation. Medications on Admission: - ASA 81mg qd - Lisinopril/HCTZ 10/12.5mg daily - Lipitor 10mg daily - Prozac 40mg/80mg alternating daily Discharge Medications: 1. Aspirin 325 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). Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: STEMI Hypertension Smoking Hyperlipidemia Coronary artery disease Discharge Condition: Vital signs stable. Chest pain free. No longer short of breath. Discharge Instructions: Please take your medications as prescribed. Please follow up with the appointments as documented below. . Again, we understand that quitting smoking is very difficult, but we also must emphasize that with your hypertension, high cholesterol and family history, smoking has the propensity of worsening your heart disease and increasing the likelyhood of another heart attack. Followup Instructions: Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 128] Date/Time:[2164-7-23] 10:00 Please followup with Dr. [Last Name (STitle) 171] at 10:00 am on [7-23]. His office can be reached at ([Telephone/Fax (1) 1987] Please call your primary care physician to make [Name Initial (PRE) ] follow up appointment in the next two weeks. [Last Name (LF) ],[First Name3 (LF) 177] G. [Telephone/Fax (1) 18696] Completed by:[2164-6-7] ICD9 Codes: 4271, 4019, 2720, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6356 }	Medical Text: Admission Date: [2161-12-17] Discharge Date: [2161-12-24] Date of Birth: [2090-11-19] Sex: M Service: [Last Name (un) ] ADMISSION DIAGNOSIS: Descending thoracic aortic pseudoaneurysm. HISTORY OF PRESENT ILLNESS: This is a 71-year-old gentleman with a history of peripheral vascular disease and COPD with hypertension and coronary artery disease, who presented to the Emergency Department with 10 days of cough, shortness of breath, and chest pain. Patient had been seen earlier in the week and started on Zithromax for presumed respiratory infection. However, he returned on the day prior to admission with recurrent cough. CTA done at that time showed a partially thrombosed pseudoaneurysm or penetrating ulcer of the aortic arch approximately 2.5 cm distal to the takeoff of the left subclavian artery with diffuse emphysematous changes, no pulmonary embolus. He was started on esmolol for blood pressure control, given an elevated pressure of 175/48 when he was admitted. He had appropriate monitoring placed including an A line and a Foley catheter, and admission laboratories were significant for a hematocrit of 41.4 and a BUN and creatinine of 26 and 1.4. His EKG did not show ischemic changes and his CK's and troponins were negative initially. Vascular Surgery and Cardiothoracic Surgery services were consulted and he was admitted to the Intensive Care Unit on the Vascular Surgery service. PAST MEDICAL HISTORY: Right cerebrovascular accident. Coronary artery disease. Hypertension. Prostate cancer. History of hepatitis C. Hypercholesterolemia. Hypertension. Asthma. PAST SURGICAL HISTORY: Left carotid endarterectomy in [2161-8-16]. Right carotid endarterectomy in [2161-6-16]. Five vessel CABG in [2152]. Right upper lobectomy for lung cancer in [2154]. Left vertebral artery stent in [2161-6-16]. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Albuterol. 2. [Doctor First Name ]. 3. Lipitor 20 mg by mouth every day. 4. Cartia XT 300 mg by mouth every day. 5. Ecotrin 325 mg by mouth every day. 6. Hydrochlorothiazide 25 mg by mouth every day. 7. Protonix 40 mg by mouth every day. 8. Serevent every day. SOCIAL HISTORY: The patient is a former smoker. He quit in [2160-5-15] with a greater than 30 pack year history. Denies ingestion of alcohol. INITIAL PHYSICAL EXAMINATION: Temperature 96.9, heart rate 64, blood pressure initially 131/73 down to 110/57 after institution of esmolol, 93 percent. He was alert and in no acute distress. His heart was regular with no murmurs, rubs, or gallops. His chest was clear to auscultation with diminished breath sounds in the bases. His abdomen was moderately obese with normoactive bowel sounds, soft, and nontender. Extremities were warm without clubbing, cyanosis, or edema. He had palpable femoral pulses bilaterally and Dopplerable popliteal, DP and PT bilaterally with monophasic DP and PT on the left. STUDIES: CTA: No pulmonary embolus. A 3 cm partially thrombosed pseudoaneurysm versus penetrating ulcer of aortic arch 2.5 cm distal to the takeoff of the left subclavian artery, diffuse emphysematous changes. Chest x-ray: No new infiltrate. BRIEF HOSPITAL COURSE: As stated above, Mr. [Known lastname 13029] was admitted to the ICU for blood pressure control on an esmolol drip. He remained without recurrent chest pain and he had a MRI/MRA done of his chest to further delineate his anatomy. Of note, there were two small outpouchings of contrast from the lumen of the inferior portion of the aortic arch surrounded by large thrombus component with some thickening of the aortic wall and no evidence of active bleeding or free fluid. There were additionally multiple irregularities in the aortic wall throughout the entire thoracic and abdominal aorta that was visualized. This was thought to represent an unusual appearance of a penetrating ulcer with a large thrombus component. He additionally had a cardiac catheterization to evaluate for any underlying coronary artery disease should he need operative repair. This revealed 90 percent stenosis of his right coronary artery, saphenous vein graft with patent vein grafts to the OM and patent LIMA to the LAD with diffuse disease in the distal LAD. A Heparin-coated stent was placed in the vein graft to the right coronary artery. Other findings from his catheterization revealed an 80 percent instent stenosis of the left vertebral artery and an 80 percent right brachiocephalic ostial lesion. He tolerated the procedure well and there were no bleeding or groin complications. He returned to the Intensive Care Unit for continued blood pressure monitoring and his esmolol drip was eventually weaned off. Given the patient's multiple medical problems including his severe pulmonary disease, underlying coronary artery disease, and overall debilitated condition, the decision was made to proceed with medical management as the postoperative management of this likely penetrating ulcer. He was transitioned to oral agents. His diltiazem dose was increased and Lopressor was added for additional rate control. He remained off drips for greater than 48 hours. Decision was made to send him home with close followup. Of note, his hematocrit remained stable. His creatinine remained within its baseline of around 1.4 and he was tolerating a regular diet and able to ambulate without difficulty. Of note, because of his complaint of cough, a sputum sample was sent, which grew out Pseudomonas that was [Last Name (LF) 7384], [First Name3 (LF) ] he was started on ciprofloxacin on [2161-12-22]. Follow-up chest x-ray revealed bilateral lower lobe changes concerning for pneumonia. He remained afebrile with normal white count. DISCHARGE DIAGNOSES: Penetrating ulcer versus thrombosed pseudoaneurysm of the descending thoracic aorta. Coronary artery disease status post right coronary artery saphenous vein graft stent with Heparin-coated stent. Bilateral lower lobe pneumonia. DISCHARGE MEDICATIONS: 1. Salmeterol. 2. Flovent. 3. Lipitor 20 mg by mouth every day. 4. Tylenol as needed. 5. Aspirin 325 mg by mouth every day. 6. Hydrochlorothiazide 50 mg by mouth every day. 7. Diltiazem sustained release 360 mg by mouth every day. 8. Lopressor 12.5 mg by mouth twice a day. 9. Ciprofloxacin 500 mg by mouth every 12 hours times seven days additional. DISCHARGE INSTRUCTIONS: Patient is to have his blood pressure checked 3-4 times per week and communicate these results with Dr. [Last Name (STitle) ] and his primary care doctor. He should call if his systolic blood pressure is greater than 110 or less than 90. Complete a 10 day course of ciprofloxacin to take seven additional days and to call Dr. [Last Name (STitle) ] should he have recurrent chest discomfort. Follow up with Dr. [Last Name (STitle) ] in one month with a CTA of his chest, with Dr. [First Name4 (NamePattern1) 1169] [Last Name (NamePattern1) ], his primary care doctor in two weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 5697] Dictated By:[Last Name (NamePattern1) 13030] MEDQUIST36 D: [2161-12-24] 10:45:31 T: [2161-12-24] 11:59:21 Job#: [Job Number 13031] ICD9 Codes: 486, 496, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6357 }	Medical Text: Admission Date: [2118-6-27] Discharge Date: [2118-7-18] Date of Birth: [2052-9-12] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: Rectal bleeding Major Surgical or Invasive Procedure: [2118-6-28] Colonoscopy [2118-7-7] Left Colectomy,Mobilization of Splenic Flexure History of Present Illness: 65yoM with h/o CAD with IMI s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] 2, ADD who initially presented to [Hospital1 ]-N on [6-26] with bloody diarrhea. Patient was in USOH until [6-26] when he developed diarrhea. On 5th or 6th BM, he noticed bright red blood. States that it was solely blood with clots and no brown or tarry stool. Was otherwise asymptomatic. Specifically denied dizziness, LH, CP, SOB, abdominal pain, nausea, vomiting, fevers, chills, recent travel or food exposure. Given his symptoms he presented to [Hospital1 ]-N for evaluation. At [Hospital1 ]-N, initial Hct was 37. NGL was negative blood. Patient continued to have BRBPR (~100cc per BM). Serial Hct drifted downward to 29. Patient was given 2L GoLYTEly for preparation of colonoscopy. Patient was transfused 2 units of pRBCs. SBPs trended downward to 90s and decision was made to transfer patient to [Hospital1 18] for further management. On arrival to the MICU, patient appears in no acute distress. Stated that he felt well. Denied prior episodes. Was hungry. Past Medical History: 1. CARDIAC RISK FACTORS: + Dyslipidemia 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - ADD - L sided weakness from mild anoxia at birth - Only has a R sided kidney - nephrolithiasis Social History: - Tobacco history: denies - ETOH: quite > 1 year ago, previous drank approx 10 ETOH/ week - Illicit drugs: denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: Vitals- Temp: 38.6, HR: 60, BP: 104/71, RR: 25, O2sat: 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Rectal: mostly empty rectal vault with specks of BRB mixed with brown stool. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2118-7-13] 05:34AM BLOOD WBC-5.4 RBC-2.98* Hgb-8.7* Hct-26.6* MCV-89 MCH-29.2 MCHC-32.7 RDW-14.7 Plt Ct-349 [2118-7-12] 06:00AM BLOOD WBC-5.3 RBC-2.90* Hgb-8.6* Hct-25.9* MCV-89 MCH-29.7 MCHC-33.3 RDW-14.3 Plt Ct-341# [2118-6-29] 12:10PM BLOOD Hct-25.0* [2118-6-28] 09:00AM BLOOD Hct-24.9* [2118-6-27] 08:08AM BLOOD WBC-4.1 RBC-3.67* Hgb-11.0* Hct-32.9* MCV-90 MCH-29.9 MCHC-33.4 RDW-13.8 Plt Ct-139* [2118-6-30] 07:15AM BLOOD Neuts-61.0 Lymphs-29.5 Monos-6.6 Eos-2.6 Baso-0.3 [2118-7-13] 05:34AM BLOOD Plt Ct-349 [2118-7-13] 05:34AM BLOOD Glucose-102* UreaN-9 Creat-0.7 Na-138 K-3.3 Cl-101 HCO3-28 AnGap-12 [2118-6-28] 04:28AM BLOOD ALT-19 AST-16 AlkPhos-45 TotBili-0.3 [2118-7-13] 05:34AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.2 [2118-7-7] 04:49PM BLOOD Glucose-142* Lactate-1.5 Na-141 K-3.0* Cl-109* [2118-7-7] 04:49PM BLOOD O2 Sat-99 [2118-6-27]: CTA abdomen: IMPRESSION: 1. No active extravasation to identify the source of bleeding. Possible AVM in the descending colon. 2. Moderate sigmoid and descending colon diverticulosis without diverticulitis [2118-6-27]: chest x-ray: FINDINGS: In comparison with the study of [2117-12-28], there is little interval change. The suspected opacification at the left base has cleared. No pneumonia, vascular congestion, or pleural effusion. [2118-6-30]: GI bleeding study: IMPRESSION: No evidence of active GI bleeding. Findings were discussed with Dr. [First Name (STitle) ] at 10pm on [2118-6-30] via telephone by Dr. [Last Name (STitle) ] [2118-7-4]: GI bleeding study: IMPRESSION: Moderately brisk bleeding over a short interval in the region of the descending colon [2118-7-5]: IR study: IMPRESSION: Selective inferior mesenteric as well as superior mesenteric angiographies with no evidence of active bleeding, vascular malformation or dysplasia [2118-7-5]: angio: IMPRESSION: Selective inferior mesenteric as well as superior mesenteric angiographies with no evidence of active bleeding, vascular malformation or dysplasia [2118-7-5]: lower abdominal pelvis, abd. angio: IMPRESSION: Selective inferior mesenteric as well as superior mesenteric angiographies with no evidence of active bleeding, vascular malformation or dysplasia Brief Hospital Course: The patient was admitted to the hospital with rectal bleeding. Prior to admission, he was reported to be hypotensive and required 2 units of packed red blood cells. Upon arrival to the hospital, he was hemodynamically stable despite having bright red blood/maroon blood per rectum with a stable hematocrit. His vital signs and hematocrit were closely monitored. He was reported to have a decreased hematocrit to 25 and received 1 unit of packed red blood cells. On hospital day #2, he underwent a colonoscopy which did not visualized any bleeding source. He continued to bleed and was transfused 1 unit of blood. A tagged RBC scan was performed, which was also unsuccessful in appreciating any bleed. Multiple units of packed red blood cells were transfused over the next couple days as his hematocrit continued to drop and rebound post infusion. His bleeding increased from 600cc to 1000cc daily. A left descending colon bleed was discovered during the latest test and the patient was scheduled for IR embolization the following day. Unfortunately the patients bleeding decreased over the evening prior to surgery and the IR team was unable to visualize or fix the bleed. Bleeding resumed the following day and the acute care service was notified. On HD #11, he was taken to the operating room for an extended left hemicolectomy with mobilization of the splenic flexure. The operative course was stable. He had a 400cc blood loss and required 275cc of platelets. [Initials (NamePattern4) ] [Last Name (NamePattern4) 406] drain was placed in the left retroperitoneum. He was extubated after the procedure and monitored in the recovery room. His post-operative course has been stable. On POD #1, his [Last Name (un) ]-gastric tube and Foley catheter were removed. During this time, he had an isolated episode of decreased oxygenation to 82% on room air. The patient was encouraged to use the incentive spirometer and his oxygen level gradually improved. He reported nausea with emesis on POD #3 and he was made NPO and had the [Last Name (un) ]-gastric tube inserted. He was also reported to have an isolated episode of hematuria which was though to be related to manipulation of the Foley catheter. His abdominal distention gradually resolved and his and the [Last Name (un) ]-gastric was removed on POD #6 as well as his Hemovac. He was introduced to clear liquids with advancement to a regular diet. The regular diet progressed well until POD #8, when the patient had a recurrence of nausea and vomiting. A x-ray of the abdomen was done which showed dilated loops of small bowel suggestive of an ileus. A [Last Name (un) ]-gastric tube was inserted, and motility agents added to his medical regimen. Over the course of the next 1-2 days his symptoms improved and the ng tube was removed. His diet was slowly advanced and he was able to tolerate this without any difficulties. At time of discharge he was also having bowel movements. During his hospital course, he was evaluated by physical therapy because of his long hospitalization and deconditioning. After evaluation, recommendations were made for discharge home. His vital signs have been stable and he has been afebrile. He has been tolerated a regular diet. His pain has been controlled with oral analgesics. His hematocrit has stabilized at 27. His Plavix was resumed on POD #7. His prior anti-platelet medication,Prasugrel was discontinued. Aspirin was resumed on POD #8. He was discharged to home with instructions to follow-up with the acute care surgery clinic, Cardiology, and Gastroenterology. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Patient. 1. Prasugrel 10 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. BuPROPion (Sustained Release) 150 mg PO QAM 4. Fluoxetine 40 mg PO DAILY 5. Nitroglycerin SL Dose is Unknown SL PRN chest pain 6. Metoprolol Succinate XL 50 mg PO DAILY 7. methylphenidate NF 18 mg Oral qday 8. Pravastatin 80 mg PO DAILY 9. Ascorbic Acid 1000 mg PO DAILY 10. Fish Oil (Omega 3) 1000 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 81 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #21 Tablet Refills:0 5. HYDROmorphone (Dilaudid) 2-6 mg PO Q3H:PRN pain hold for increased sedation, resp. rate <10 RX hydromorphone 2 mg 1 tablet(s) by mouth EVERY 3 HOURS Disp #40 Tablet Refills:0 6. BuPROPion (Sustained Release) 150 mg PO QAM 7. Fluoxetine 40 mg PO DAILY 8. methylphenidate NF 18 mg Oral qday 9. Multivitamins 1 TAB PO DAILY 10. Pravastatin 80 mg PO DAILY 11. Cyanocobalamin 1000 mcg PO DAILY 12. Fish Oil (Omega 3) 1000 mg PO DAILY 13. Ascorbic Acid 1000 mg PO DAILY 14. TraMADOL (Ultram) 50 mg PO QID RX tramadol 50 mg 1 tablet(s) by mouth four times a day Disp #30 Tablet Refills:0 15. Nitroglycerin SL 0.4 mg SL PRN chest pain take 1 TABLET EVERY 5 MINS. X 3 ....PLEASE NOTIFY YOUR PCP OR call for ride to emergency [Apartment Address(1) 91781]. Docusate Sodium 100 mg PO BID hold for diarrhea 17. Senna 1 TAB PO BID:PRN constipation 18. Metoclopramide 10 mg PO QIDACHS Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal bleeding 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 rectal bleeding. You were given several blood transfusions to maintain your blood level. You underwent several tests to determine the cause of your bleeding [Doctor First Name ] you were found to have bleeding in the descending colon. You were taken to the operating room where you part of your left colon removed. You are slowly recovering from your surgery. Your vital signs and blood work have been normal. You are preparing for discharge home with the following instructions: ACTIVITY: Do not drive until you have stopped taking pain [Doctor First Name ] and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your [Doctor First Name 5059] at your next visit. Don't lift more than 20-25 lbs for 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.) You may start some light exercise when you feel comfortable. 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. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. You may resume sexual activity unless your doctor has told you otherwise. HOW YOU [Month (only) ] FEEL: You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. 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: Your incision may be slightly red aroudn the stitches or staples. This is normal. You may gently wash away dried material around your incision. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing r clothes. If the staining is severe, please call your [Month (only) 5059]. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Ove the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of [Month (only) ] such as Percocet or codeine. 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]. After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluitds and see if it goes away. If it does not go away, or is severe and you feel ill, please 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 [Name2 (NI) ] to take by mouth. It is important to take this [Name2 (NI) ] as directied. Do not take it more frequently than prescribed. Do not take more [Name2 (NI) ] at one time than prescribed. Your pain [Name2 (NI) ] 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 [Name2 (NI) ]. Please don't take any other pain [Name2 (NI) ], including non-prescription pain [Name2 (NI) ], unless your [Name2 (NI) 5059] has said its okay. IF you are experiencing no pain, it is okay to skip a dose of pain [Name2 (NI) ]. 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. In some cases you will have a prescription for antibiotics or other medication. If you have any questions about what [Name2 (NI) ] 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: GENERAL SURGERY/[Hospital Unit Name 2193] With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD When: Tuesday [7-26] at 3pm With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], MD Specialty: CARDIOLOGY Location: [Hospital1 ]-[Location (un) ] Address: [Street Address(2) ] [Location (un) ], [Numeric Identifier 3002] Phone: [Telephone/Fax (1) 4105] Appointment: Thursday [7-28] at 1pm Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 88349], MD Specialty: Primary Care When: Wednesday [8-3] at 3:50p Location: [Location (un) ] [University/College ] FAMILY [University/College 662] PC Address: [Street Address(2) ]., [Apartment Address(1) 35387], [Location (un) 35388],[Numeric Identifier 3471] Phone: [Telephone/Fax (1) 17203] You do not need to follow up with the GI service here, but if you develop any further problems, such as recurrence of bleeding. Please feel free to schedule an appointment with the GI service by calling # [Telephone/Fax (1) 682] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2118-7-20*] ICD9 Codes: 5789, 2851, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6358 }	Medical Text: Admission Date: [2156-12-27] Discharge Date: [2156-12-30] Date of Birth: [2111-12-11] Sex: M Service: CCU CHIEF COMPLAINT: Status post ethanol ablation. HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old white male with hypertrophic cardiomyopathy presenting today status post ethanol septal ablation procedure. Mr. [Known lastname 36365] was diagnosed with hypertrophic subacute severe aortic stenosis in [2156-2-12] after presenting to EMMC with severe chest pain in the setting of several years of dyspnea on exertion and anginal chest pain. After a series of negative enzymes and negative ETT [Last Name (LF) 1608], [First Name3 (LF) ] echocardiogram showed marked systolic anterior motion with a dynamic outflow obstruction with a peak gradient of 32. On catheterization, the patient had a systolic gradient of 130 post premature ventricular contractions and 96 post Valsalva. Despite a trial of medical therapy, the patient continued to have symptoms of dyspnea on exertion that were significantly debilitating. He was thus referred to [Hospital6 649] for ethanol ablation. In the catheterization laboratory, patient's resting gradient was not significantly elevated but a dobutamine induced gradient was between 160-200 mmHg. He underwent an ethanol ablation without complications and was sent up to the Coronary Care Unit in stable condition. When patient was seen in the Coronary Care Unit, he complained of mild right sternal discomfort, but no shortness of breath, headache, palpitations, lightheadedness, cough, groin pain or leg weakness, numbness. PAST MEDICAL HISTORY: 1. Idiopathic hypertrophic subaortic stenosis. 2. Catheterization on [2156-2-23] revealed no significant coronary artery disease. 3. Hyperlipidemia. 4. Hypertension. MEDICATIONS: 1. Verapamil 240 mg po b.i.d. 2. Aspirin 325 mg po q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Quit tobacco 45 years ago. He is married. He drinks about two cases of beer per week. History of cocaine and marijuana abuse as recently as 15 years ago. FAMILY HISTORY: Unknown. PHYSICAL EXAMINATION: General: Well-appearing 45-year-old white male in no apparent distress. Vital signs: Heart rate 87. Blood pressure 150/97. Respiratory rate 12. Oxygen saturation 100%. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Neck supple. Chest: Clear to auscultation anteriorly. Cardiovascular normal, S1, S2 normal with 2/6 systolic ejection murmur at left lower sternal border radiating to apex, rate increasing with Valsalva. Abdomen soft, nontender with normal bowel sounds. Extremities: No cyanosis, clubbing or edema. LABORATORIES: On [2156-12-22]: White blood cell count 9.6, hematocrit 41.6, platelets 333,000. Sodium 141, potassium 4, chloride 101, bicarbonate 27, BUN 19, creatinine 1.2, glucose 64, INR 0.97. Electrocardiogram: Baseline normal sinus rhythm with septal hypertrophy, left axis deviation. Post catheterization normal sinus rhythm. Septal hypertrophy, slight ST depression and T wave inversion in aVL. Catheterization results: Left ventricular pressures 147/6 with dobutamine 342. After ablation with dobutamine 180/14. ASSESSMENT: Patient was a 45-year-old white male with hypertrophic cardiomyopathy who presented now status post ethanol ablation. HOSPITAL COURSE: By systems: Pump: 1. Cardiac: The patient had septal ablation with ethanol to improve his idiopathic hypertrophic subaortic stenosis. He tolerated the procedure well. He was sent to the Coronary Care Unit after the ethanol ablation because of the risk for developing bradyarrhythmias. He had a temporary wire placed in the catheterization laboratory in case he became bradyarrhythmic. His calcium channel blocker was held in the setting of this situation. The aspirin was still continued. He had been mildly hypertensive after the procedure. He was started on Captopril 12.5 mg po t.i.d. in the setting of his hypertension since his verapamil and beta-blockers were held in the setting of possible development of bradyarrhythmias. After the ablation therapy, his left ventricular outflow gradient was improved. It will need some time to determine how well his exertional tolerance will be. Because of the fear for lowering his after load reduction, he was switched to metoprolol. His Captopril was discontinued. His telemetry events only showed premature ventricular contractions, but no evidence of bradyarrhythmias. On the third day of admission, his metoprolol was increased to 25 mg po t.i.d. and he was restarted on his calcium channel blocker as the window of developing bradyarrhythmias is narrowed. He had been tachycardiac and the beta-blocker was started and increased and the verapamil was restarted to improve his heart rate control. His blood pressure improved and he was no longer hypertensive. His murmur also decreased likely from improved hemodynamics and decreased heart rate. His pacemaker was removed on the third day of admission. On the fourth day of admission, he was transferred to the floor. On the fourth day of admission, it was felt that his risk for developing arrhythmias was significantly decreased. He had improved hemodynamics and his murmur was much reduced. Rate was under improved control between 70 and 90. His blood pressure was also improved and he was no longer hypertensive. His CK was done after the procedure with first CK of 588, MB of 22, index of 4.3. His second one was 244 and his third one was only 155, MB of 4. Subsequently, he did have an acute increase in his CKs, status post ablation which was expected, however, and on discharge his CKs were trending downward. 2. Pain: The patient was started on Percocet for his pain and had adequate pain control with Percocet prn on a prn basis. 3. Pulmonary: On the second day of admission, the patient had an oxygen desaturation while sleeping. He normally was in the mid 90s to upper 90s on oxygen saturation, however, he decreased to 91% while sleeping. It was felt that the patient who has a thick neck may have sleep apnea and may benefit from further work-up of that condition. Patient was discharged back to home on the following medications: DISCHARGE MEDICATIONS: 1. Verapamil 180 mg po q.d. 2. Metoprolol 25 mg po t.i.d. 3. Aspirin 325 mg po q.d. FOLLOW-UP: He is to follow-up with his cardiologist at home. Patient actually left without a prescription for the medications. His local clinic was notified and he received his prescriptions through them. DISCHARGE DIAGNOSES: 1. Hypertrophic cardiomyopathy. 2. Hypertension. DISCHARGE STATUS: Patient is to be discharged back to home. DISCHARGE CONDITION: Patient was in fair condition. [First Name8 (NamePattern2) 2053] [Last Name (NamePattern1) 2052], M.D. [MD Number(1) ] Dictated By:[Name8 (MD) 4523] MEDQUIST36 D: [2157-3-22] 11:26 T: [2157-3-22] 11:26 JOB#: [Job Number 36366] ICD9 Codes: 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6359 }	Medical Text: Admission Date: [2116-1-30] Discharge Date: [2116-2-2] Date of Birth: [2038-1-3] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 78F with h/o HTN, PVD, COPD, osteoporosis, TCC of bladder, presenting with worsening dyspnea x 4 days. History obtained from husband revealed URI x 2 days with productive cough. Night PTA, worsening sx's and agitation. Husband called 911. In ambulance, noted to have poor air movement, given combivent and nebs. Last seen by PCP [2105], but records from outside pulmonologist in [2114] reveal FEV1 0.7. On arrival to ED, HR 130, BP 140/100, RR 38, SaO2 97% on NRB. In ED, received Solumedrol 125mg IV, Combivent nebs, Levoflox 500mg IV x 1. Given terbutaline 0.25mg SC. Decision made to intubate for worsening O2 sat to 67% on NRB, and failed CPAP. Received succinylcholine, etomidate, and propofol peri-intubation. Post-intubation ABG 7.22/75/423 with lactate 2.1. Post-intubation, VS improved to 99.8F HR 120, BP 146/81, RR 18. Past Medical History: 1) COPD: [2114-12-19]: FVC 1.46 (57%) FEV1 0.7 (39%) no bronchodilator response Resid vOl 215% of predicted Diffusion 37% predicted High lung volumes - no restrictive component on interpretation. Baseline ABG 7.37 \| 42 \|80 \| 24 on RA, SpO2 93% on RA. Baseline HCT 44. Maintained on albuterol and spireva. 2) HTN 3) PVD, s/p L fem-[Doctor Last Name ] [2103] 4) TCC of bladder - s/p TURBT and local BCG treatments, no evidence of recurrence at last urology f/u 6 months ago 5) Osteoporosis 6) Hyperlipidemia 7) Cataract surgery [9-10] Social History: 50 p-y hx, quit smoking 7ya, no EtOH, lives at home with husband. [Name (NI) 1403] as film archivist at [Last Name (un) ] Family History: Mother with lung CA Physical Exam: BP T 99.6 124/52 HR 103 sinus RR 14 O2 100% SIMV Fi02 50% 500 rr16 peep 5 not overbreathing Gen: intubated, sedated nad HEENT: mmm, perrla, Lungs: diminished bs, low pitched expiratory wheezes, no rales Heart: distant hs, no m/r/g, rrr Abd: distended but soft, no organomegaly, hypoactive bs Ext: distal pulses present, lle cool, scar on lle from fem [Doctor Last Name ], no le edema Neuro: unable to assess due to sedation Pertinent Results: Initial [1-30] CXR: The heart size and mediastinal contours are normal. The lungs are hyperinflated with attenuation of the pulmonary vascularity, particularly in the right upper lobe, consistent with emphysema. No focal pulmonary parenchymal consolidation or pleural effusions identified. No pneumothorax. Initial ECG: Sinus tachycardia. Biatrial abnormality. P pulmonale with very tall P waves in leads II, III and aVF. Compared to the previous tracing of [2115-9-12] tachycardia has appeared. Left atrial abnormality is more pronounced. TTE [1-31]: Conclusions: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. Aortic stenosis is present but could not be quantitated. An aortic valve vegetation/mass cannot be excluded. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is severe mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. The absence of a vegetation by 2D echocardiography does not exclude endocarditis if clinically suggested. Blood Cultures: [1-30]: Coag negative staph 2/2 bottles [1-31] and [2-1]: Pending at time of death Spurum Cultures: [1-31]: Rare oropharyngeal flora [2-2]: No growth Urine Culture: [1-30]: No growth Rapid respiratory virus screen: Positive for influenza A antigen [2116-1-30] 08:19AM BLOOD WBC-16.6* RBC-4.51 Hgb-14.6 Hct-42.5 MCV-94 MCH-32.3* MCHC-34.3 RDW-12.9 Plt Ct-246 [2116-2-2] 04:46AM BLOOD WBC-7.9 RBC-3.88* Hgb-12.3 Hct-36.4 MCV-94 MCH-31.7 MCHC-33.8 RDW-12.7 Plt Ct-227 [2116-1-30] 08:19AM BLOOD Neuts-93.3* Bands-0 Lymphs-3.8* Monos-2.7 Eos-0.1 Baso-0.1 [2116-1-31] 03:57AM BLOOD PT-11.6 PTT-26.6 INR(PT)-1.0 [2116-1-30] 08:19AM BLOOD Glucose-150* UreaN-35* Creat-1.1 Na-137 K-4.1 Cl-92* HCO3-25 AnGap-24* [2116-2-2] 04:46AM BLOOD Glucose-109* UreaN-55* Creat-1.1 Na-138 K-3.7 Cl-100 HCO3-30 AnGap-12 [2116-1-30] 08:19AM BLOOD CK(CPK)-315* [2116-1-30] 08:19AM BLOOD CK-MB-9 [2116-1-30] 08:19AM BLOOD TotProt-6.4 Calcium-8.8 Phos-6.6* Mg-3.2* [2116-1-31] 03:57AM BLOOD Albumin-3.2* Calcium-8.3* Phos-5.3* Mg-2.3 Cholest-191 [2116-1-31] 03:57AM BLOOD Triglyc-137 HDL-72 CHOL/HD-2.7 LDLcalc-92 [2116-1-30] 07:22AM BLOOD Type-ART pO2-473* pCO2-75* pH-7.22* calHCO3-32* Base XS-0 [2116-1-31] 02:47AM BLOOD Type-ART Temp-36.7 Rates-20/ PEEP-5 FiO2-40 pO2-113* pCO2-43 pH-7.36 calHCO3-25 Base XS--1 -ASSIST/CON Intubat-INTUBATED [2116-2-1] 03:04PM BLOOD Type-ART Temp-36.2 Rates-[11-9] Tidal V-500 PEEP-5 FiO2-40 pO2-157* pCO2-51* pH-7.31* calHCO3-27 Base XS--1 -ASSIST/CON Intubat-INTUBATED [2116-1-30] 07:22AM BLOOD Lactate-2.1* [2116-1-30] 10:24PM BLOOD Lactate-1.3 [2116-1-30] 07:40AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.020 [2116-1-30] 07:40AM URINE Blood-TR Nitrite-NEG Protein-500 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2116-1-30] 07:40AM URINE RBC-0-2 WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0-2 Brief Hospital Course: Mrs. [Known lastname ] was admitted to the [Hospital Unit Name 153], intubated. She was continued on her COPD regimen of prednisone, levofloxacin, and albuterol/atrovent MDIs. There were initial difficulties finding an appropriate ventilatory mode due to problems triggering breaths. This was present on several modes tried, and it was decided to keep the ventilator on AC mode, with appropriate levels of propofol for sedation. The day after her admission, initial blood cultures grew GPC in pairs and clusters in [1-9] bottles. This was unexpected, given infrequent hospital exposure and lack of infiltrate on CXR that might suggest a staph PNA. It was suspected that this was contamination from placement of PIVs in the ED, but vancomycin was started to cover until speciation and sensitivities returned. A TTE was also done to assess for evidence of endocarditis. Thickened AV were noted, but no clear evidence of vegetations. The team decided that, while a TEE may be clinically indicated, her wishes, as clearly conveyed by her son [Name (NI) 382] and husband, were that minimal invasive testing be done, and a TEE was deferred. Mrs. [Known lastname ] also had a nasopharyngeal aspirate done for respiratory viruses, which was positive for influenza A. Droplet precautions were instituted; however, since her URI symptoms had been occurring for several days prior to admission, it was not felt that antiviral therapy would be beneficial, and supportive measures were continued. Several conversations were held with Mrs.[Known lastname 96174] husband and son, both physicians. They clearly indicated that Mrs. [Known lastname ] would want to be DNR and, if her clinical course did not rapidly improve within 24-48h of admission, that she would want to be placed on comfort measures, and the endotracheal tube removed. While stable from a hemodynamic and respiratory perspective, she did not demonstrate any increasing ability to be weaned from the ventilator over this time frame. It was thought by the primary team that her respiratory failure was probably reversible, given the likely exacerbation by her inluenza, but that her underlying COPD was severe enough that it may take 1-2 weeks to wean from the ventilator. The family decided that Mrs. [Known lastname ] would not want this extended course, and decided to switch the goals of care to comfort measures only. She was given morphine IV prn, and her endotracheal tube was removed. Over the next several hours, her SaO2 was in the 60s-70s on face tent, and morphine IV was given prn for respiratory distress. Housestaff was called to the bedside at 9:25pm to pronouce the patient. On examination, she had no palpable pulse for two minutes. She had no auscultated breaths or heart sounds over that span. She was pronounced dead at 9:25pm, and her husband and PCP [Name Initial (PRE) 13109]. The family declined an autopsy. A/P: Patient is a 78 yo female with PMH of copd, htn, pvd, and bladder cancer who is admitted s/p copd exacerbation requiring intubation. COPD exacerbation- fev 1 0.70, cxr with hyperinflation but no infiltrate, possibly exacerbated by influenza. -Having difficulties triggering breaths. Currently trying PS trial 15/5. -cont prednisone 40mg qD as part of 2 week taper. -cont levofloxacin 250mg IV qD D4 -cont albuterol q2h and ipratropium q6h. -Will plan on extubating today, with no reintubation if fails. Family states pt would want to be CMO. Coag negative staph bacteremia - BCx growing coag negative staph in blood, and GPC in sputum. Bacteremia could be due to possible contamination from placement of PIV, but continuing with vanc 1gm IV q48h due to concommitant finding in sputum.. - TTE showing no vegetations, but does not severely thickened/deformed AV, may need TEE if pt does well post-extubation. HTN- treated in the past with aldactazide with evidence of borderline lvh on ekg. Last cardiac wkup in '[03], nl. -Holding HCTZ in setting of worsening renal function. Would treat HTN with standing norvasc for now. Bladder ca- Appears to be stable, s/p BCG topical therapy [5-13] years ago. Last urologist appt 6 months ago, reportedly normal. Access: 2 20ga PIVs, a-line Code: DNR. Would not want to be intubated for long-term, would not want reintubated if unsuccessful extubation. Verfied with son/HCP Contact: [Name (NI) 4906], [Name (NI) 6339]: [Telephone/Fax (1) 96175] HCP and POA: [Name (NI) ]: [Telephone/Fax (1) 96176] (cell) Medications on Admission: Aldactazide 25mg/25mg qD Zocor 20mg qHS -?taking Fosamax Ca supplements Albuterol Spiriva Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Influenza Respiratory failure Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A ICD9 Codes: 496, 5849, 4019, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6360 }	Medical Text: Admission Date: [2151-3-9] Discharge Date: [2151-4-8] Date of Birth: [2109-2-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: abdominal pain, transfer from OSH with pancreatitis Major Surgical or Invasive Procedure: Endotracheal intubation Peripherally inserted central catheter Subclavian vein central venous line Internal jugular vein central venous line Arterial line Tracheostomy Percutaneous gastro-jejunostomy tube History of Present Illness: 42M with h/o hypertension, otherwise healthy now transferred form [Location (un) ] for severe pancreatitis. He presented initially to [Location (un) ] on [2151-3-7] with 1 day h/o nausea and non-bilious, non-bloody vomiting and intense mid epigastric pain. There was diarrhea on the day PTA as well. He noted fevers and chills. In the ED at [Location (un) ], he was noted to be hypotensive, though rapidly responded to aggressice IVF and his BP was soon in the 90s and tachy to 130s rr 20 96% RA. Initial labs showed WBC 19.4, hct 48.2, plt 269. amylase 3228, lipase [Numeric Identifier ]. transaminases nl and t bili 0.8. Of note, cr up to 1.6 from a normal baseline. ABG 7.33/45/52. CT Abd showed pancreatic edema with extensive pancreatic inflammation, no free air, pseudocyst. ABD US showed no gallbladder thickening, stones, or ductal dilatation. Pt was admitted to ICU for aggressive IVF. His hospital course was otherwise unremarkable. Past Medical History: HTN Tobacco abuse Asthma Social History: smoking 1ppd x 20 years, rarely drinks alcohol nothing recently. no drug use. Family History: pt was adopted. Physical Exam: VS: Temp: 99 BP: 183/102 HR: 129 RR: 20 O2sat: 93 5L NC GEN: appearing uncomfortable HEENT: MM dry, OP clear RESP: CTAB CV: RR, S1 and S2 wnl, no m/r/g ABD: distended abd, TTP diffusely. typanitic to percussion. EXT: non-pitting LE edema Genital: scrotal edema. Pertinent Results: Admission labs: 143 110 17 --------------< 163 4.0 26 0.8 Ca: 7.4 Mg: 1.9 P: 1.5 ALT: 19 AP: 58 Tbili: 1.1 Alb: 3.1 AST: 50 LDH: 850 [Doctor First Name ]: 345 Lip: 490 . 13.1 15.3 >----< 180 38.0 PT: 14.0 PTT: 28.6 INR: 1.2 . Discharge Labs: [2151-4-8] 04:40AM BLOOD WBC-9.6 RBC-3.25* Hgb-8.8* Hct-29.0* MCV-89 MCH-27.1 MCHC-30.5* RDW-14.9 Plt Ct-344 [2151-4-8] 04:40AM BLOOD PT-14.8* PTT-61.9* INR(PT)-1.3* [2151-4-8] 04:40AM BLOOD Glucose-107* UreaN-15 Creat-0.6 Na-142 K-3.6 Cl-102 HCO3-29 AnGap-15 [2151-4-8] 04:40AM BLOOD ALT-57* AST-31 AlkPhos-90 Amylase-49 TotBili-0.3 [2151-4-8] 04:40AM BLOOD Lipase-28 [2151-4-8] 04:40AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.1 . Micro: [3-13], [3-20], [3-21] blood cultures: coag neg staph [3-29], [3-30], [4-4] sputum: MSSA other blood, urine, and sputum cultures NGTD c diff negative x 6 . Radiology: CXR [2151-3-9]: Interval development of mild-to-moderate pulmonary edema. KUB [2151-3-9]: Nonspecific bowel gas pattern. . CT Abd [2151-3-7] OSH: Pancreatic edema with extensive pancreatic inflammation, no free air, pseudocyst. . ABD US [2151-3-8]: no gallbladder thickening, stones, or ductal dilatation [3-10] ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [3-26] ECHO: no vegetations . [3-11]: CT abdomen/pelvis: 1. More than 50% areas of non-enhancement within pancreatic bed consistent with necrosis. No pseudocyst or abscess is seen within the pancreatic bed. No biliary ductal dilatation of pancreatic dilatation is seen. 2. Non occlusive thrombus of superior mesenteric vein is noted. 3. Extensive fluid accumulation within the abdominal cavity predominantly anterior to the stomach and in the anterior pararenal space. . [3-24]: CT abdomen/pelvis: 1) Pancreatic pseudocyst measuring 13.7 cm x 5 cm with significant inflammation and fat stranding noted in the peripancreatic area. 2) Bilateral pleural effusions with associated atelectasis. 3) Sigmoid diverticulosis without evidence of diverticulitis. 4) Bilateral inguinal hernias. . [3-31]: CT chest/abdomen/pelvis: 1. Extensive pancreatic necrosis with large pancreatic fluid collection, probably slightly increased since the prior study. 2. Bilateral moderate pleural effusions with compressive atelectasis. 3. Multiple lower lobe lung nodules some of which are tree-in-[Male First Name (un) 239] in configuration and may represent an infectious process versus aspiration. 4. Stable bilateral large fat containing inguinal hernias. 5. Filling defects versus contrast mixing in the bilateral internal jugular veins. Ultrasound could be performed to exclude thrombus. 6. Fluid collection next to the left adrenal gland versus small adrenal lesion. . [4-6]: CXR: Interval decrease in the bibasilar pleural effusion. Otherwise, stable as compared to yesterday. . [4-8]: CT abdomen/pelvis: pending Brief Hospital Course: 42M h/o hypertension, presents with idiopathic acute necrotizing pancreatitis with pseudocyst. Hospital course by problem: . # Pancreatitis: Etiology unclear on presentation (no h/o EtOH abuse, no stones on RUQ U/S, normal Ca2+, only mildly elevated TG, no trauma). Perhaps medication related (lisinopril, HCTZ) or viral. CT abdomen as above demonstrated extensive pancreatitis. Followup film showed pseudocyst formation. There was no abscess seen in either film. Patient was followed closely/daily by both the GI service and pancreatic surgery service. They participated actively in his management. His disease, although severe, was not deemed necessary for surgical repair. Instead, we provided supportive care with respiratory ventilation, nutritional needs, and prophylactic management. Amylase and lipase normalized by [3-13]. He aggressively treated with IVF early in his hospital course. We maintained his UOP greater than 100cc/h. He then mobilized his third-spaced fluid and we assisted with his diuresis. The prolongation of his ventilatory requirements was largely [3-5] elevated intraabdominal pressures and significant pulmonary edema. PEG-J tube was placed by IR for tube feeds. After extubation, he was started on POs which he tolerated well with no increase in serum pancreatic enzymes. Consider pancreatic enzyme replacement if develops steatorrhea. A repeat abdominal CT scan was performed prior to discharge per surgery. Followup with Dr. [Last Name (STitle) ] in 2 weeks (he would like to be called if not tolerating POs, develops abdominal pain, or requires re-admission to the hospital). . # Hypoxic Respiratory Failure: Patient was intubated on [3-10]. Given bilateral infiltrates seen on CXR, he was initially ventilated under ARDS-net protocol with use of an esophageal balloon pump to monitor pleural pressures and a triadyne bed for rotational support. His PEEP was initially high but we weaned down gradually over the course of several weeks. It was thought that his PEEP requirements were [3-5] large abdominal girth from third spacing. This improved with diuresis and we weaned him down to more typical vent settings. Received diamox transiently for metabolic alkalosis. He also developed VAP and completed a 7 day course of vanc/cefepime with improvement in his secretions. Noted to have wheezing and was given combivent inhalers and nebulized steroids with improvement. Given the prolonged intubation a tracheostomy was performed by thoracic surgery. He was succesfully weaned off of the ventilator. . # ID: Patient spiked temperatures as high as 103.9 intermittently throughout his hospital course. Given concerns for GNR assoc with his pancreatitis, he was treated with meropenem on [3-10] for a seven day course. This was discontinued. Superinfected pseudocyst also possible but abd CT unchanged. Thereafter he had three blood cultures which grew coag neg staph thought to be [3-5] a central line infection. We pulled the right IJ and treated with vancomycin for a 14 day course. We also repeated an echo which showed no evidence of vegetations. His fever curve improved but then developed increased secretions and fever likely due to VAP. Sputum eventually grew MSSA. He completed a 7 day course of vanc/cefepime and remained afebrile with decraesed secretions and his respiratory status improved significantly. . # SMV Thrombosis: Noted incidentally on CT scan ([3-15]) and heparin gtt started. Data suggests that the SMV thrombosis is commonly associated with severe pancreatitis and often resolves with resolution of the pancreatic inflammation. We treated with heparin gtt with strict parameters (ptt goal of 55-60). Coumadin started [4-5] (Goal INR [3-6]), continue to follow INR at rehab facility. Will need 6 months anticoag per surgery. Repeat CT abdomen performed prior to discharge and will followup with surgery. . # Functional bowel obstruction: On [3-20], patient was given lactulose for no stool output. He then had bilious vomitting. It was promptly noted that his rectal tube was poorly positioned. It was replaced and he had significant stool output. His feeding tube had to be repositioned and we restarted his tube feeds without issue. . # Tachycardia: The patient was persistently tachycardic in the 100-110s. His HR was greater than 130s on admission and responded to IVF as he was intravascularly dry. Once euvolemic, he was treated with metoprolol to control tachycardia and hypertension (baseline HTN at home with mx meds). This was discontinued in the setting of aggressive diuresis and he remained largely in the HR of 100-110s. . # Hypertension: On multiple BP meds at home which were discontinued. As his clinical status improved, he became more hypertensive and was started on metoprolol with good effect. Given that his pancreatitis was possibly BP med-related, would avoid thiazides and ACEi. . # Anemia: Patient had drop in his hct to low 20s in setting of acute illness and aggressive IVF. On [3-23], his Hct dropped to 19. He had no obvious source of bleeding. He was transfused with improvement. His heparin was held for several days until hct stabilization. We also urgently obtained a CT abdomen to assess for intraabdominal fluid/blood collection which was not seen. Hct remained stable throughtout the rest of the hospital stay. . # Sedation: Patient required significant doses of versed and fentanyl for sedation. As we weaned down on the PEEP, we also weaned down on the sedation and was started on fentanyl patch to avoid withdrawal. He tolerated this well. The fentanyl patch can be weaned off slowly. . # Transaminitis: He developed elevated LFTs on [3-25]. Thought [3-5] meds vs tube feeds. We limited his tylenol intake and did not see other med source for hepatotoxicity. We trended this over several days with improvement. Likely [3-5] tube feeds vs. meds. LFTs normalized. . # Hyperglycemia: Elevated blood sugars, possibly due to pancreatic endocrine dysfunction. Initially on insulin gtt then transitioned to standing NPH and RISS with good control. . # FEN: Trophic tube feeds were started. The patient recieved PEG-J by IR [4-1]. He will need to have the T-clips surrounding the PEG-J tube removed on [4-11] (see sheet included with d/c summary for instructions). He was restarted on POs slowly on [4-5] with good tolerance and can be increased to soft regular diet [4-9] as tolerated. Tube feeds should be discontinued once PO intake is adequate. . # Access: PICC . # Contact: Wife [Name (NI) 8513] [0-0-], [Name (NI) 5321] [Name (NI) 71501] (mom) [Telephone/Fax (1) 71502] Medications on Admission: asa 81 atenolol 100" felodipine 10' HCTZ 25' lisinopril 20' zantac 50' Discharge Medications: 1. Acetaminophen 325 mg Tablet [Telephone/Fax (1) ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol [Telephone/Fax (1) ]: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 3. Clonazepam 0.5 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 50 mg/5 mL Liquid [Telephone/Fax (1) ]: Two (2) PO BID (2 times a day). 5. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 6. Fentanyl 50 mcg/hr Patch 72HR [Telephone/Fax (1) ]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. 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. 8. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution [Telephone/Fax (1) ]: One (1) sliding scale Intravenous ASDIR (AS DIRECTED): goal PTT 55-60, discontinue when INR [3-6]. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol [Month/Day (3) ]: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Lactulose 10 g/15 mL Syrup [Month/Day (3) ]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO BID (2 times a day). 13. Budesonide 0.5 mg/2 mL Solution for Nebulization [Last Name (STitle) ]: One (1) ML Inhalation [Hospital1 ] (2 times a day). 14. Quetiapine 25 mg Tablet [Hospital1 ]: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 15. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 16. Warfarin 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily): goal INR [3-6]. 17. Insulin NPH Human Recomb 100 unit/mL Suspension [Month/Day (3) ]: Thirty Eight (38) units Subcutaneous qam: 36 units qpm. 18. Insulin Regular Human 300 unit/3 mL Insulin Pen [Month/Day (3) ]: One (1) sliding scale Subcutaneous four times a day. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Primary: Necrotizing pancreatitis with pseudocyst Acute respiratory distress syndrome Ventilator associated pneumonia Superior mesenteric vein thrombosis . Secondary Hypertension Asthma Hyperglycemia Discharge Condition: Good, afebrile, stable respiratory status, tolerating food Discharge Instructions: Please take all medications as prescribed. . Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, or other concerning symptoms. Followup Instructions: You are scheduled for the following appointments. Please contact the [Name2 (NI) 11686] provider with any questions or if you need to reschedule. Surgery: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 2833] Date/Time:[2151-5-7] 8:00. ICD9 Codes: 7907, 5119, 4019, 3051, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6361 }	Medical Text: Admission Date: [2117-2-6] Discharge Date: [2117-2-17] Date of Birth: [2035-9-12] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 2009] Chief Complaint: Rectal bleeding Major Surgical or Invasive Procedure: None History of Present Illness: 81F with atrial fibrillation on coumadin, Hep B without ESLD, s/p colonoscopy 8 days PTA, presenting with 7 days of mild rectal bleeding with 2 days of heavier bleeding and finding of low hematocrit as an outpatient. She had routine outpatient colonoscopy at [Hospital1 112] on [2116-1-30]. Daughter reports polyps removed, but report not yet available. She had stopped coumadin prior to procedure, and resumed use the day following her procedure. Since the procedure she has noted small amounts of red blood in her stools. Then two day ago she had a large bowel movement which was basically all red blood. Since then she has had 5 similar bowel movements. No abdominal pain, but notes a gassy feeling. Has felt fatigued with activity and daughter notes she slept in today. Has had decreased PO intake and little interest in food since colonoscopy, but most notably in past 2 days since larger bleeding started. Also notes a feeling of her heart pounding earlier today. No chest pain or dyspnea. No fever. No lightheadedness or presyncope. She presented to her PCP today, thought ?related to colonoscopy vs. viral. Prescribed lomotil and took one dose today. Labs returned with hematocrit of 24.1. She was therefore referred to the ED. . In the ED, initial vs were: T98.1 P71 123/34 16 100% on RA. Vital signs remained stable throughout ED course. BRB on rectal exam. Hct 21.9 and INR 2.4. Given 5 mg IV vitamin K, ordered for FFP and typed and crossed for 2 units PRBCs. GI paged but have not yet called back. Admitted to MICU given severity of anemia, age, unclear how fast she is bleeding. . On the floor, patient reports feeling well, just fatigued. No abdominal pain. Past Medical History: - Atrial fibrillation, most recently in sinus. On beta blocker and coumadin. - Hepatitis B. No evidence of cirrhosis ever. Recent labs ([1-30]) with viral load of 431 and normal LFTs. - Hypertension - ?Past CVA or TIA (had weakness of fingers of one hand, which resolved) - Hyperlipidemia - Osteopenia/osteoporosis - ?Elevated fasting glucose - "being watched" per daughter. - s/p cataract surgery [11/2116], no complications. Social History: Lives with daughter and granddaughter. [Name (NI) ] works full time. - Tobacco: remote history of occasional smoking, quit > 45 years ago. - Alcohol: none - Illicits: none Family History: Daughter with kidney stones. Physical Exam: Admission exam: General: Appears younger than stated age, alert, oriented, no distress. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVD 2-3 cm ASA, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, some decrease at bases. CV: Regular rate and rhythm, normal S1 + S2, soft SM at RUSB and at apex. No significant radiation to carotids. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Neuro: CN II-XII intact. Strength 5/5 in UEs and LEs. Pertinent Results: Admission labs: [2117-2-6] 08:55PM BLOOD WBC-6.7 RBC-2.36* Hgb-7.4* Hct-21.9* MCV-93 MCH-31.3 MCHC-33.7 RDW-13.6 Plt Ct-216 [2117-2-6] 08:55PM BLOOD Neuts-53.0 Lymphs-40.0 Monos-4.7 Eos-1.3 Baso-1.1 [2117-2-6] 08:55PM BLOOD PT-25.4* PTT-34.1 INR(PT)-2.4* [2117-2-6] 08:55PM BLOOD Glucose-132* UreaN-24* Creat-0.8 Na-139 K-3.8 Cl-107 HCO3-23 AnGap-13 [2117-2-6] 08:55PM BLOOD ALT-11 AST-20 LD(LDH)-182 AlkPhos-32* TotBili-0.2 [2117-2-8] 06:48AM BLOOD CK-MB-4 cTropnT-0.02* (subsequent .01) [2117-2-7] 06:43AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.1 [2117-2-6] 08:55PM BLOOD Albumin-3.4* [2117-2-6] 10:00PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.008 [2117-2-6] 10:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Discharge and other labs: [2117-2-12] 07:05AM BLOOD TSH-0.59 [2117-2-17] 06:10AM BLOOD WBC-7.3 RBC-4.26 Hgb-12.2 Hct-36.8 MCV-86 MCH-28.7 MCHC-33.2 RDW-17.0* Plt Ct-264 [2117-2-17] 06:10AM BLOOD PT-17.5* INR(PT)-1.6* [2117-2-17] 06:10AM BLOOD Glucose-92 UreaN-17 Creat-0.8 Na-143 K-3.9 Cl-108 HCO3-25 AnGap-14 [2117-2-11] 07:00AM BLOOD CK(CPK)-140 [2117-2-17] 06:10AM BLOOD Calcium-8.6 Phos-3.2# Mg-2.1 Studies: [2-10] R ankle x-ray Five total images of the right foot and lower leg are submitted. The bones are osteopenic. There is a small ankle joint effusion. There are mild degenerative changes at the tibiotalar joint and talonavicular joint. No acute abnormality is noted. Five total images of the right foot and lower leg are submitted. The bones are osteopenic. There is a small ankle joint effusion. There are mild degenerative changes at the tibiotalar joint and talonavicular joint. No acute abnormality is noted. [2-16] CXR Transvenous right atrial and right ventricular pacer leads follow their expected courses from the left axillary pacemaker. No pneumothorax or mediastinal widening is present. Lateral view shows a very small pleural effusion collected posteriorly. Heart size normal, probable small pericardial effusion projects to the left of the cardiac apex, but there is no mediastinal vascular engorgement to suggest that this is hemodynamically significant. Vascular deficiency in the right upper lobe is probably due to emphysema. No focal pulmonary abnormality is seen elsewhere. Brief Hospital Course: 81 yo F with atrial fibrillation on Coumadin, chronic HBV without ESLD, presenting with BRBPR s/p colonoscopy one week ago. . # BRBPR. Presenting with 2 days of painless rectal bleeding, in the setting of having a colonoscopy one week ago - high suspicion for post-polypectomy bleed in the setting of re-starting Coumadin as an outpatient, particularly since pt had been having smaller amounts of bleeding since the procedure. No evidence of ischemic colitis. Patient was admitted overnight to the MICU and made NPO while trending her hematocrit. Her INR was reversed with vitamin K and FFP. GI saw her and recommended continued supportive management at this time. We obtained OSH records that confirmed polypectomy x3 in the cecum. Patient was stable throughout the day in the MICU and transferred to the floor. Patient had one additional episode of bloody BM on the general medicine floor in the setting of PTT >150 while on Heparin drip bridging to Coumadin, and this resolved when Heparin was discontinued. Hct was stable and patient did not require any transfusions. She did not have any additional BRBPR during her hospital stay. . # Atrial fibrillation. On coumadin. Patient's anticoagulation was initially held in the setting of acute bleed, but then restarted by the time of patient's discharge from the MICU. She was started on Metoprolol 25mg [Hospital1 ] (increased from home dose of Metoprolol 25mg daily) and was paroxysmally in and out of a fib/flutter throughout her stay on the medicine wards. Patient's HR was in the 140's during episodes of a fib/flutter. Heart rate responded to IV Metoprolol and IV Diltiazem, but the patient was seen to have [3-28] second pauses on telemetry with IV nodal agents. She was seen by her outpatient cardiologist and was scheduled to have a pacemaker placed which was done on [2-15]. Given the patient was only symptomatic from her a fib/flutter was during the initial episode on the floor, and remained asymptomatic with stable BPs during her subsequent episodes of a fib/flutter, it was decided to hold off on attempt to rate control prior to placement of pacemaker. After the pacemaker was placed she continued to have afib with RVR without a good response to Metoprolol. Diltiazem was started with good response. Amiodarone loading with 400mg [Hospital1 ] was also started on day of discharge. Her INR was not therapeutic at discharge however there was concern of bleeding into the pacemaker pocket if she were bridged with Heparin. . # Hypertension. Normotensive in the MICU. BP meds were held in the setting of acute bleed. . # Osteoporosis versus osteopenia. Fosamax was held while patient was in-house and started at discharge. . #Next of [Doctor First Name ]: [Known lastname ],[First Name3 (LF) ] Relationship: DAUGHTER Phone: [Telephone/Fax (1) 83954] Other Phone: [Telephone/Fax (1) 83955] # Code: Full Medications on Admission: - Coumadin 2.5 mg Tue/Fri, 2 mg other days - Avapro 150 mg daily - Metoprolol 25 mg daily - Fosamax 70 mg weekly - Simvastatin 20 mg daily - Multivitamin daily - vitamin D 1000 units daily - Fish oil 1000 mg daily Discharge Disposition: Home With Service Facility: Americare at Home Inc Discharge Diagnosis: Bright red blood per rectum Atrial fibrillation/flutter . Secondary Diagnosis: - Hypertension - Diet controlled Diabetes Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You presented to the hospital for bloody bowel movements after having a colonoscopy with removal of polyps. You were on blood thinners during this time, which were held initially while you were in the hospital. You were monitored in the intensive care unit and transfused 4 units of blood to bring your blood counts back up. After your blood count stabilized and you did not have any further bleeds, you were transferred to the floor. While on the general medicine floor, you went into atrial fibrillation/flutter, and were given medications to control your heart rate. Your blood thinners were re-started. A pacemaker was placed in your chest on [2-15] since the medications for the atrial fibrillation were causing your heart to beat too slowly. You heart is now beating normally. While you were here some of your home medications were changed. You should CONTINUE taking: Avapro 150 mg daily Fosamax 70 mg weekly Simvastatin 20mg daily multivitamin daily Vitamin D 1000U daily Fish oil 1000U daily You should CHANGE: Coumadin should now be 2mg every day and NOT 2.5mg. You should follow the coumadin dosing as prescribed by your coumadin clinic. You should START: -Cephalexin, an antibiotic which is given to prevent infection after a procedure. Finish the pills in the prescription. -Diltiazem 120mg daily -Amiodarone 400mg twice a day. Take this pill until told to stop by Dr. [First Name (STitle) ]. -Tylenol as needed for pain. If that doesn't work you can take Oxycodone as prescribed, however do not drive when using this medication. If you have any palpitations or feel your heart is beating funny you should call you Dr. [First Name (STitle) ] at the number below. Followup Instructions: An appointment has been scheduled for you with your cardiologist, Dr. [Last Name (STitle) 83956] [Name (STitle) ], on [2-22] at 2pm. Your pacemaker will be checked at that time. Telephone number [Telephone/Fax (1) 2258]. You should have your INR checked your lab or PCP's office on Friday [2-19]. You should follow-up with your primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 644]) on [2-22] at 11am. ICD9 Codes: 2851, 4019, 2724, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6362 }	Medical Text: Admission Date: [2113-1-5] Discharge Date: [2113-1-13] Date of Birth: [2113-1-5] Sex: F Service: NEONATOLOGY HISTORY: Baby Girl [Name2 (NI) 12101] is the 2275 gram product of a 35 [3-24] week gestation, born by cesarean section for complete previa and pre-term labor to a 36-year-old GII PI now II mother. Prenatal screens: A negative, antibody negative, rubella immune, hepatitis surface antigen negative, RPR vaginal bleeding three weeks prior to delivery, treated with betamethasone and magnesium sulfate. In the delivery room, the infant emerged with good cry, suctioned, dried, given blow-by oxygen. Apgars were assigned at 8 and 8. Subsequently started grunting, flaring and retracting. Admitted to the Newborn Intensive Care Unit for further management of respiratory distress. PHYSICAL EXAMINATION: Unremarkable, anterior fontanel open and flat, palate intact, bilateral red reflex. Chest with moderate retractions, pink, fair aeration. Normal S1 and S2, no audible murmur. Pulses 2+, no hepatosplenomegaly, three vessel umbilical cord, normal external female genitalia, hips stable, clavicles intact. Spine straight, without defects. Moves all extremities well. Birth weight 2275 grams, head circumference 31.5 cm. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: Chest x-ray obtained demonstrated moderate surfactant deficiency. The infant was intubated, received one dose of surfactant, and was extubated by 24 hours of age. Her maximum ventilatory settings were 22/6 with a rate of 25. She was extubated to CPAP, where she remained for 24 hours, at which time she transitioned to nasal cannula oxygen, remaining in nasal cannula for about 48 hours, and she has since been in room air with saturations greater than 95%, and no further issues. 2. Cardiovascular: Has had no hemodynamic issues during this hospital course. 3. Fluids, electrolytes and nutrition: Birth weight was 2275. Initially started on 60 cc/kg/day of D-10-W. Enteral feedings were initiated on day of life number two. The infant achieved full enteral feedings by day of life number five, and the infant is currently ad lib feeding, taking in a minimum of 130 cc/kg/day, and her discharge weight is 2030g. 4. Gastrointestinal: Peak bilirubin was 13.4/0.4 on day of life number four. She received phototherapy for a total of two days, and her most recent ([1-12]) bilirubin is 11.3. 5. Hematology: Her hematocrit on admission was 41.7. The infant has not required any blood transfusions. 6. Infectious Disease: A CBC and blood culture were obtained on admission. CBC was benign. Antibiotics were initiated for a total of 48 hours, at which time blood cultures remained negative and antibiotics were discontinued. 7. Neurology: Has been appropriate for gestational age. 8. Sensory: Hearing screen was performed with automated auditory brain stem responses, and the infant passed both ears. 9. Psychosocial: A social worker has been involved with the family and can be contact[Name (NI) ] at [Telephone/Fax (1) 8717]. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 4468] [Last Name (NamePattern1) 18412], telephone number [Telephone/Fax (1) 47109]. CARE RECOMMENDATIONS: 1. Feedings: Continue ad lib feeding of Enfamil 20 or breast milk 20. 2. Medications: Not applicable. 3. Car seat position screening has been performed, and the infant 4. State newborn screen has been sent per protocol, and has been within normal limits. 5. Immunizations received: The infant received hepatitis B vaccine on [2113-1-9]. DISCHARGE DIAGNOSIS: 1. Premature infant, born at 35 3/7 weeks gestation 2. Mild respiratory distress syndrome treated with surfactant 3. Status post rule out sepsis with antibiotics 4. Mild hyperbilirubinemia [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 35940], M.D. [MD Number(1) 35941] Dictated By:[Last Name (NamePattern1) 38294] MEDQUIST36 D: [2113-1-12] 23:04 T: [2113-1-13] 00:13 JOB#: [Job Number 47110] ICD9 Codes: 769, 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6363 }	Medical Text: Admission Date: [2164-2-1] Discharge Date: [2164-2-5] Date of Birth: [2108-11-16] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 922] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: [2164-2-1] Coronary bypass grafting x4: Left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to first diagonal coronary artery; reverse saphenous vein single graft from aorta to the ramus intermedius coronary artery; reverse saphenous vein single graft from aorta to posterior descending coronary artery History of Present Illness: This is a 54 yo Spanish-speaking male diagnosed with 3VD in [2163-2-21] after abnormal stress test led to cardiac catheterization. Since that time, he has been managed medically. But despite medical therapy, he has continued to experience exertional chest pain and dyspnea. He denies chest pain at rest. He denies orthopnea, PND, pedal edema, syncope, presyncope, and palpitations. He was referred by Dr. [Last Name (STitle) 5543] for surgical revascularization. Past Medical History: Coronary artery disease Hypertension Dyslipidemia History of positive PPD 5-6 years ago - s/p ABX for one year Colon polyps s/p cholecystectomy s/p polypectomy Social History: Race: Guatamalan, has lived in US for last 25 years Lives with: Uncle Occupation: [Name2 (NI) 8551] Tobacco: remote, Quit 25 yrs ago ETOH: Social, no history of abuse Family History: Denies premature coronary artery disease Physical Exam: HR:51 Resp:18 O2%:100/RA BP LEft:236/94 Right:238/83 Height:145cm Weight:130 lbs General: WDWN male in no acute distress Skin: Warm[x] Dry [x] intact [x] HEENT: NCAT[x] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None Neuro: Grossly intact Pulses: Femoral Right: dressing in place Left: 2 DP Right: 1 Left: 1 PT [Name (NI) 167]: 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit Right: none Left: none Pertinent Results: [2164-2-1] Echo: PRE-CPB: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. No thoracic aortic dissection is seen. Mild intimal thickening is seen in descending aorta. Mild focal calcifications is seen in the aortic root. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) central mitral regurgitation is seen. POST-CPB: LV systolic function remains normal. There is no new wall motion abnormality. MR remains mild. There is no evidence of dissection. Brief Hospital Course: Mr. [Known lastname ] was a same day admit after undergoing pre-operative work-up prior to admission. On [2-1] he was brought directly to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later that day he was weaned from sedation, awoke neurologically intact and extubated. Beta-blockers and diuretics were started and he was gently diuresed towards his pre-op weight. Amiodarone was given due to atrial ectopy with good effect. On post-op day two he was transferred to the step-down unit for further care. Chest tubes and epicardial pacing wires were removed pre protocol. During his post-op course he worked with physical therapy for strength and mobility. He continued to make good progress and on post-op day four he was discharged home with the appropriate medications and follow-up appointments. Medications on Admission: Imdur 30 daily Metoprolol 50 daily Aspirin 81 daily Simvastatin 20 daily Nitro prn Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:7 Tablet, ER Particles/Crystals(s) Refills:0 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take 400mg twice daily for 5 days. Then 200mg twice daily for 7 days. Then 200mg daily until stopped by Dr. [Last Name (STitle) ]. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 4 Past medical history: Hypertension Dyslipidemia History of positive PPD 5-6 years ago - s/p ABX for one year Colon polyps s/p cholecystectomy s/p polypectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with narcotics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema: trace Discharge Instructions: Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Please come to [Hospital Ward Name 121] 6 on Wednesday, [2-15] at 10AM for wound check You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) 914] [2-28] at 2:30PM Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5543] [2-23] at 4PM Please call to schedule appointments with your Primary Care in [3-27] 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:[2164-2-6] ICD9 Codes: 4111, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6364 }	Medical Text: Admission Date: [2122-4-22] Discharge Date: [2122-4-25] Date of Birth: [2056-1-4] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: s/p Aortic valve replacement with a 25-mm [Company 1543] Ultra aortic valve bioprosthesis History of Present Illness: 66 yo M with past medical history significant for hypertension and family history of coronary artery disease with known aortic stenosis who presents for cardiac catheterization to evaluate coronary anatomy and cardiac surgery evaluation for aortic valve replacement. Past Medical History: Prostate CA s/p brachytherapy 2 yrs ago Hypertentension Hypertrophic Cardiomyopathy Past Surgical History: s/p tonsillectomy Social History: Race:Caucasian Last Dental Exam:winter [2121] Lives with:wife Occupation:retired tv producer Tobacco:denies ETOH:2 drinks/day Family History: Father s/p MI age 62 s/p CABG Physical Exam: Pulse:58 Resp:18 O2 sat: 100%RA B/P Right:133/81 Left: 135/81 Height:5'[22]" Weight:154 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 III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema 0 Varicosities +1 Neuro: Grossly intact Pulses: Femoral Right: Dressing in place Left: +2 DP Right: [Year (2 digits) ] Left: [Name (NI) ] PT [Name (NI) 167]: [Name (NI) ] Left: [Name (NI) ] Radial Right: +2 Left: +2 Carotid Bruit Right/Left: transmitted murmur Pertinent Results: [2122-4-23] 02:04AM BLOOD WBC-9.7 RBC-3.30* Hgb-10.1* Hct-29.8* MCV-90 MCH-30.7 MCHC-34.0 RDW-12.8 Plt Ct-179 [2122-4-22] 12:20PM BLOOD WBC-6.6 RBC-2.94# Hgb-9.1# Hct-26.5# MCV-90 MCH-30.8 MCHC-34.2 RDW-12.8 Plt Ct-154 [2122-4-23] 02:04AM BLOOD Glucose-111 UreaN-17 Creat-0.8 Na-140 K-4.3 Cl-111* HCO3-23 AnGap-10 Brief Hospital Course: On [2122-4-22] Mr.[Known lastname 73692] was taken to the operating room and underwent Aortic valve replacement (#25-mm [Company 1543] Ultra aortic valve bioprosthesis) with Dr.[Last Name (STitle) ]. Cross clamp time=67 minutes, Cardiopulmonary Bypass time= 51 minutes. Please see operative report for further details. He tolerated the procedure well and was transferred to the CVICU intubated, sedated, requiring pressors to optimize cardiac function. He awoke neurologically intact and was extubated without difficulty. All lines and drains were discontinued in a timely fashion. Beta- Blocker and diuresis was initiated. He was kept in the intensive care unit on post operative day 1 due to hypotension. His Percocet was discontinued on day #2 due to hallucinations and visual tracting after taking this medication. He continued to progress and on POD#2 was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. The remainder of his hospital course was essentially uneventful. On POD# 3 he was cleared by Dr.[Last Name (STitle) 914] for discharge. All follow up appointments were advised. Medications on Admission: Atenolol 50mg po daily Simvastatin 10mg po daily Terazosin 5mg po daily Aspirin 81mg po daily 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. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:5 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5 days. Disp:5 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 976] VNA Inc Discharge Diagnosis: Aortic stenosis Prostate CA s/p brachytherapy 2 yrs ago Hypertentension Hypertrophic Cardiomyopathy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month, and while taking narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 914] in 4 weeks ([Telephone/Fax (1) 170]) [5-26] at 1:00 PM Dr.[First Name (STitle) ] [First Name8 (NamePattern2) ] [Doctor Last Name ],[Telephone/Fax (1) 86792] in 1 week Dr. [First Name (STitle) ] [Name (STitle) 2257] in [2-18] weeks Please call for appointments Wound check appointment [Hospital Ward Name 121] 6 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2122-4-25] ICD9 Codes: 4241, 4254, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6365 }	Medical Text: Admission Date: [2164-12-23] Discharge Date: [2164-12-29] Date of Birth: [2118-1-6] Sex: F Service: [Hospital1 212] CHIEF COMPLAINT: New myocardial infarction. HISTORY OF PRESENT ILLNESS: This is a 46 year old Caucasian female with a past medical history of coronary artery disease, three vessel disease with a recent myocardial infarction in [2164-10-16], and an echocardiogram revealing questionable mural thrombus who presented to [Hospital6 3426] on [2164-12-22], with left sided chest pain and dizziness. She was found by her mother the morning of presentation and brought to [Hospital6 33] for further evaluation. At [Hospital6 33], the patient was noted to have a blood sugar of 1200 and laboratories consistent with diabetic ketoacidosis, acute renal failure with creatinine of 2.4, baseline creatinine of 1.5. Her electrocardiogram was notable for new right bundle branch block, inferior ST depression, anterior T wave changes, new as compared to recent electrocardiogram. She was admitted to the Intensive Care Unit there where she was treated for diabetic ketoacidosis with intravenous fluids and insulin drips. She was treated for the new non ST elevation myocardial infarction with Aspirin but no beta blocker secondary to her low blood pressure. At that point, the hospital course was complicated for new altered mental status. She has chronic anticoagulation with Coumadin and CT of the head was conducted to rule out intracerebral hemorrhage. The first CT had questionable changes along the tentorium cerebelli and thus the Heparin was held until [2164-12-23], when repeat head CT was negative. Lumbar puncture and electroencephalogram were not done. Neurology was consulted and they suggested that the altered mental status was secondary to toxic metabolic causes. Of note, the patient's peak CK was 498, MB 86 and troponin 3.16 at the outside hospital and repeat electrocardiogram showed resolution of the inferior depressions. Of note also at the outside hospital, she was on intravenous Vancomycin and Tequin for questionable infection of her outer ear as a cause of her diabetic ketoacidosis. PAST MEDICAL HISTORY: 1. Coronary artery disease, three vessel, myocardial infarction in [2163-11-17], and [2164-10-16]. Echocardiogram in [2164], showed a questionable mural thrombus. 2. Congestive heart failure with an ejection fraction of 15 to 25% and 1+ mitral regurgitation. 3. Diabetes mellitus type 1, times thirty-six years, brittle, complicated by retinopathy and nephropathy and neuropathy. 4. Asthma. 5. Osteoporosis, multiple tibial fibular fractures, the last one and one half years prior to admission which has failed to heal. 6. Chronic skin infections. 7. Iron deficiency anemia. 8. Glaucoma. 9. Irritable bowel syndrome. 10. Gastroparesis. 11. Dermatitis herpetiformis. 12. Chronic hyponatremia. ALLERGIES: Amoxicillin and injected cortisone. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: No alcohol, tobacco or drug use. MEDICATIONS ON TRANSFER: 1. Aspirin. 2. Heparin. 3. Tequin 200 mg once daily. 4. Clarinex 5 mg once daily. 5. Neurontin 600 mg four times a day. 6. Doxepin 200 mg once daily. 7. Celexa 20 mg once daily. 8. Niacin 500 mg p.o. three times a day. 9. Digoxin 0.125 mg p.o. once daily. 10. Synthroid 137 mcg once daily. 11. Prednisone drops, Trusopt drops. 12. Protonix. 13. Serevent. 14. Flovent. 15. Xalatan. 16. Atropine. 17. Vancomycin. LABORATORY DATA: On admission, the patient had a chest x-ray that showed poor inspiration, small bilateral effusions. She had a head CT at the outside hospital which showed bilateral symmetric postthalamic calcifications but no hemorrhage. She had the following laboratories apparently on admission to [Hospital1 69]: Sodium 124, potassium 4.7, chloride 93, bicarbonate 21, blood urea nitrogen 47, creatinine 1.7, glucose 193, calcium 8.4, phosphorus 4.6. She had an AST of 26, ALT 22, alkaline phosphatase 165, total bilirubin 0.2. CK on admission was 381, MB 57, albumin 3.1, troponin 3.16. Prothrombin time was 31.3, partial thromboplastin time 45.4 and INR 4.4. Her white blood cell count was 12.1, hematocrit 33.7, platelet count 310,000. She had an echocardiogram in [2164-9-16], which showed severe regional wall left ventricular dysfunction with an akinetic distal one half septum, distal one third of anterior inferior wall. The apex is akinetic. There was question for small mural thrombus, 1+ mitral regurgitation, and ejection fraction of 25%. Electrocardiogram on [2164-12-22], which showed normal sinus rhythm at 76 beats per minute, normal PR interval, QRS greater than 120, right bundle branch block, right axis deviation, T wave inversion V1 through V3, questionable ST depressions in V4 through V6. Compared with [2164-10-6], she had new right bundle branch block, T wave inversions and ST depressions and new right axis deviation. The patient had other studies of significance including the following: Repeat echocardiogram on [2164-12-26], showed no mural thrombus. The echocardiogram also demonstrated left ventricular ejection fraction of 20 to 25%, basically unchanged from [2164-10-16], and without further akinesis or hypokinesis. In addition, the patient underwent an x-ray of her left lower leg which demonstrated a continuous nonhealing fracture of the tibia and fibula. Two days prior to discharge, the patient had the following laboratory values: White blood cell count 8.6, hematocrit 32.9. Chem7 revealed sodium 132, potassium 4.7, chloride 95, bicarbonate 23, blood urea nitrogen 24, creatinine 1.0, glucose 236, calcium 9.0, magnesium 2.1, phosphorus 5.7 and the day of discharge she had an INR of 1.5. HOSPITAL COURSE: 1. Cardiovascular - The patient was treated conservatively with beta blockers, ace inhibitors, Heparin and Aspirin and remained chest pain free the majority of her remaining hospital stay. As mentioned previously, her repeat echocardiogram showed no change in her cardiac function and demonstrated no mural thrombus. She gradually became volume overloaded through the course of her hospital course and required diuresis for the last three hospital days. 2. Endocrine - The patient presented to the outside hospital with blood sugar in the 1200 range. She was treated conservatively with intravenous fluids and insulin drip and her blood sugar gradually came into the 200 to 300 range the remainder of her hospital stay. Her blood sugar is extremely brittle and very difficult to control but she had no further complications from the diabetes through the hospital stay. 3. Hematology - The patient had previously been anticoagulated for akinesis related to her previous myocardial infarction and she remained stable through the course of her hospital stay. Per cardiology, she had a target INR of 1.8 for three months following discharge and then a goal of 1.5 following those three months. In addition, she has a chronic anemia likely secondary to iron deficiency and chronic renal insufficiency. She is to be treated with Ironist 2.5 mg injections once a week. 4. Dermatology - The patient has a history of dermatitis herpetiformis recently controlled with Niacinamide and Minocycline and Ultravate cream. She was treated with these medications during her hospital stay and the rash remained stable. The patient also had a lesion on her right anthelix which was biopsied and showed subcellular atypia and needs to be rescheduled for biopsy by dermatology as an outpatient. 5. Renal - The patient has a baseline renal insufficiency with a creatinine of roughly 1.5. She was hydrated through the course of her hospital stay and her creatinine was at baseline the day of discharge. She had intermittent rise in her creatinine during the hospital stay presumed due to a prerenal state as it corrected with volume repletion. She also has chronic hyponatremia and her sodium remained around 130s through her hospital stay. 6. Gastroenterology - The patient has a history of gastroparesis and irritable bowel syndrome. She tolerated p.o. through her full stay in the hospital. 7. Psychiatric - The patient has a history of depression. She was seen by psychiatry who recommended continuing her Celexa at 40 mg p.o. once daily and adding Trazodone for sleep. They also mentioned they would consider additional low dose benzodiazepine for short term treatment of anxiety or Buspirone. They also recommended adding Tox therapy for the patient. 8. Orthopedic - The orthopedic service saw the patient for persistent right leg pain related to her cast bowing. They reshot films and noted continued failure of her tibia/fibula fracture on the right to heal and changed the cast and recommended follow-up with orthopedics in one to two weeks following discharge. CONDITION ON DISCHARGE: The patient was in fair condition at discharge. DISCHARGE STATUS: To home with services. DISCHARGE DIAGNOSES: 1. Status post myocardial infarction. 2. Diabetes mellitus, status post diabetic ketoacidosis. 3. Dermatitis herpetiformis. 4. Sacral decubitus. 5. Right eye hemorrhage. 6. Neuropathy. 7. Congestive heart failure. 8. Tibia/fibula fracture of right. 9. Depression. 10. Hypercholesterolemia. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 mg p.o. once daily. 2. Insulin NPH 12 units q.a.m. and 11 units q.p.m. 3. Humalog sliding scale. The patient has her scale and should resume upon rehospitalization. 4. Atropine Ophthalmic Solution 1% one drop both eyes twice a day. 5. Latanoprost 0.005% Ophthalmic Solution one drop both eyes q.h.s. 6. Flovent 110 mcg two puffs inhaled twice a day. 7. Serevent two puffs inhaled twice a day. 8. Protonix 40 mg p.o. twice a day. 9. Prezolimide 2% Ophthalmic Solution one drop right eye four times a day. 10. Prednisolone Acetate 1% Ophthalmic Solution one drop to the right eye four times a day. 11. Synthroid 137 mcg p.o. once daily. 12. Digoxin 0.125 mg p.o. once daily. 13. Niacin 500 mg p.o. three times a day. 14. Celexa 40 mg p.o. once daily. 15. Ferrous Sulfate 325 mg p.o. three times a day. 16. Neurontin 600 mg p.o. four times a day. 17. Colace 100 mg p.o. twice a day. 18. Albuterol one to two puffs MDI p.r.n. shortness of breath. 19. Zestril 10 mg p.o. once daily. 20. Fentanyl patch 25 mcg per hour q72hours. 21. Coumadin 3 mg p.o. q.h.s. to be adjusted twice a week to a goal INR of 1.8 for three months and thereafter a goal of 1.5. 22. Bactroban 2% cream twice a day to skin ulcers. 23. Ultravate cream to skin twice a day. 24. Lasix 120 mg p.o. twice a day. 25. Trazodone 50 mg p.o. q.h.s. 26. Minocycline 100 mg p.o. once daily. 27. Claritin 10 mg p.o. once daily. 28. Plavix 75 mg p.o. once daily. 29. Livostin eyedrops one drop O.D. four times a day times two weeks. 30. Ironist 2.5 mg intramuscular q.week. FOLLOW-UP PLANS: The patient is to follow-up with Dr. [First Name (STitle) ] of orthopedics. The patient is to follow-up with ophthalmology at the [Hospital ] Clinic. She is to follow-up with dermatology and also with her primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) ]. The patient has all the numbers for these follow-up appointments and indicated that she would call and do so. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 15868] Dictated By:[Last Name (NamePattern1) 11801] MEDQUIST36 D: [2165-1-7] 16:05 T: [2165-1-14] 19:59 JOB#: [Job Number 25526] ICD9 Codes: 5849, 2765, 2761, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6366 }	Medical Text: Admission Date: [2139-8-31] Discharge Date: [2139-9-8] Service: MEDICINE Allergies: Feldene / nitroglycerin / Penicillins / piroxicam Attending:[First Name3 (LF) 1515] Chief Complaint: severe aortic stenosis, exaccerbation of diastolic heart failure here for corevalve Major Surgical or Invasive Procedure: transcutaneous aortic valve replacement (Corevalve) permanent pacemaker- [Company 1543] Model: SENSIA SESR01 History of Present Illness: Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [First Name (Titles) ] [Last Name (Titles) ]: Dr. [First Name (STitle) ] [Name (STitle) ], MD Referring Physician: [Last Name (NamePattern4) ]. [Last Name (STitle) 110614] [Name (STitle) 110615] PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. Reason for admission: severe aortic stenosis, exaccerbation of diastolic heart failure Chief Complaint: shortness of breath, chest pressure HPI: Patient is an 89yo caucasian male with known aortic stenosis and CAD s/p CABGx4([2123])with postop course complicated by deep sternal wound infection, occluded SVG graft to RCA s/p bare metal stent to RCA ([2138]), diabetes, CKD, hypertension and hyperlipidemia who presented with c/o worsening shortness of breath and chest pressure. He reports that he feels vague chest pressure with ambulation or climbing a flight of stairs, if he continues with the activity, he experiences blurred vision, urinary incontinence, and confusion. He was evaluated at [Hospital1 2025] for aortic stenosis. Cardiac surgery deemed him at extreme risk for surgical aortic valve replacement. He was also evaluated for the TAVI/[Doctor Last Name ] [Last Name (un) 30978] valve and was found to have an annulus too large for the device. He was referred here for aortic valve treatment options. He again was found to be of prohibitively extreme risk for conventional surgical AVR. He was scheduled for elective cardiac cath but cancelled due to illness. He was later admitted for shortness of breath and diaphoresis. He underwent urgent cardiac cath and was found to have patent grafts and stent. On [2139-7-25] he was againg admitted with chest pain, exaccerbation of diastolic CHF and NSTEMI. He was transferred to [Hospital1 18] for stabilization and BAV. He was then screened for Corevalve TAVR after extensive discussion with patient and family and informed consent was obtained. He met all inclusion criteria and did not meet exclusion criteria. He now returns for Corevalve/TAVR. Coumadin was discontinued 4 days prior to admission. NYHA Class: III Past Medical History: Cath on [7-31] showed 2VD, with patent 3 grafts, pulm htn CAD - s/p CABG x 3 ( [2123])- postop deep sternal wound infection PCI bare metal stent to RCA ([5-/2138]) severe aortic stenosis s/p valvuloplasty with [Location (un) 109] 0.82cm2 afib on coumadin hypertension hyperlipidemia Type II DM, diet controlled CKD, basline Cr looks to be 2.5 renal calculi obesity GERD BPH colon polyps s/p left cataract surgery bilateral rotator cuff repair skin cancer left inguinal hernia repair left wrist fracture [First Name9 (NamePattern2) ] [Hospital Ward Name 4675] cyst Active Medication list as of [2139-7-14]: Medications - Prescription AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day DOXAZOSIN - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth once a day GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule - 2 Capsule(s) by mouth three times a day HYDROCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth q4-6 hrs as needed for prn METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth twice a day SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day Medications - OTC ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg Tablet Extended Release - 1 Tablet(s) by mouth once a day ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth once a day CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a day CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider) - 1,000 mcg Tablet - 1 Tablet(s) by mouth once a day --------------- --------------- --------------- --------------- Allergies: Penicillin - rash piroxicam - photosensitivity bee stings - anaphylaxis feldene NTG - syncope Social History: Retired worked in contruction company making steel [Doctor Last Name ]. Married with two children, 4 grandchildren. Lives in single level home, one flight of stairs to enter in [Location 110611]. Family History: Father deceased age [Age over 90 ], CHF. Mother deceased age 36, brain abcess. Physical Exam: Pulse: 65 B/P: 110/66 Resp: 18 O2 Sat: 100% Temp: 97.8 Height: 74 inches Weight: 209 lbs General: Alert pleasant male seated in chair in NAD at rest. Skin: color pale pink, skin warm and dry. No lesions. HEENT: normocephalic, anicteric, conjunctiva pale pink. Good dentition, oropharynx moist. Neck: Neck supple, trachea midline, carotid bruit vs. referred murmer. Chest: decreased bases bilat. Essentially CTA, no rales/whz. Anterior chest wall deformity superior portion of sterum. Irregularly healed sternal scar. Depressed area mid-upper sternum. Heart: murmer RSB, radiating. Abdomen: round, soft, nontender, nondistended, (+)BS Extremities: Trace lower extremity edema, L>R. Well healed surgical scars bilateral ankles to mid thighs. Neuro: alert and oriented, pleasant, gross FROM. Gait slow but steady. Pulses: palpable peripheral pulses. Pertinent Results: [2139-8-31] 01:58PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.012 [2139-8-31] 01:58PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR [2139-8-31] 10:40AM GLUCOSE-107* UREA N-32* CREAT-2.1* SODIUM-142 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14 [2139-8-31] 10:40AM estGFR-Using this [2139-8-31] 10:40AM ALT(SGPT)-13 AST(SGOT)-26 CK(CPK)-41* ALK PHOS-54 TOT BILI-0.5 [2139-8-31] 10:40AM proBNP-[Numeric Identifier 35706]* [2139-8-31] 10:40AM ALBUMIN-4.3 [2139-8-31] 10:40AM WBC-5.0 RBC-3.62* HGB-11.3* HCT-35.4* MCV-98 MCH-31.1 MCHC-31.9 RDW-17.0* [2139-8-31] 10:40AM PLT COUNT-158 [2139-8-31] 10:40AM PT-11.8 PTT-34.0 INR(PT)-1.1 STS SCORE: Procedure Name Is[Name (NI) 88959] [Name2 (NI) 88960] Risk of Mortality 15.261% Morbidity or Mortality 49.370% Long Length of Stay 31.219% Short Length of Stay 5.950% Permanent Stroke 3.205% Prolonged Ventilation 39.894% DSW Infection 0.353% Renal Failure 29.457% Reoperation 12.900% EUROSCORE: 32.11 % MMSE-2 SCORE: GRIP STRENGTH TEST: RIGHT: LEFT: WALK TEST: (Wheelchair dependent? no ) Time in Seconds: 12.2, 11.2 Cardiac Catheterization:([2139-7-31]) ASSESSMENT 1. Two vessel coronary artery disease; patent SVG to OMB; patent SVG to LAD; patent LIMA to the diagonal branch 2. Severe aortic stenosis 3. Successful Balloon valvuloplasty reducing gradient from 55.34 mmHg to 45.32 and aortic valve area increase from 0.69 to 0.82. 4. Elevated right and left heart filling pressures Echocardiogram: Done [2139-8-3] at 9:54:24 AM FINAL Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 30% >= 55% Left Ventricle - Stroke Volume: 59 ml/beat Left Ventricle - Cardiac Output: 3.89 L/min Left Ventricle - Cardiac Index: 1.80 >=2.0 L/min/M2 Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Aortic Valve - Peak Velocity: 4.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 94 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 63 mm Hg Aortic Valve - LVOT VTI: 17 Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: 0.5 cm2 >= 3.0 cm2 Findings This study was compared to the prior study of [2139-7-30]. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate regional LV systolic dysfunction. Estimated cardiac index is depressed (<2.0L/min/m2). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Trivial MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Tricuspid valve not well visualized. PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. Conclusions There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the anterior wall, septum, and apex. The estimated cardiac index is depressed (<2.0L/min/m2). Right ventricular chamber size is normal with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets are severely thickened with critical aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing from the aortic valve and MAC, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonic valve leaflets are thickened. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with anterior/septal wall motion abnormalities and depressed overall left ventricular systolic function. Moderately depressed right ventricular free wall systolic function. Critical aortic stenosis. Mildly dilated ascending aorta. EKG: Study Date of [2139-8-19] 10:36:12 AM Intervals Axes Rate PR QRS QT/QTc P QRS T 61 154 96 468/469 10 6 132 CT chest w/o contrast: ([2139-6-17] [First Name8 (NamePattern2) ] [Hospital3 6783] hospital) FINDINGS: A 4mm nodule is noted at the right lung base. A 6mm nodule is noted at the right posterior costophrenic angle. A possible 6mm nodule is noted in the right lung base. Increased markings are present at the [Doctor Last Name ] bases suggesting atelectasis. No pleural fluid is seen. The heart is enlarged. Extensive ahterosclerotic changes are noted. Nomediastinal or hilar adenopathy is seen. Scans through the upper abdomen demonstrate no evidence of an adrenal mass. Left renal atrophy is present. Calcifications are noted in upper pole calyces suggesting stones. No definite hydronephrosis is seen. The visualized portion of the right kidney is unremarkable. The gallbladder is filled with stones. No obvious abnormality is seen in the visualized portions of the liver or spleen. IMPRESSION: Lung nodules as described. PFT's: ([2139-8-3]) FEV1 2.16L/86% DLCO 59% Carotid dopplers: ([2139-7-7]) Significant plaqueis not noted, doppler shows mild spectral broadening compatible with less than 29% stenosis in the internal carotid arteries bilaterally and good flow was seen with colorflow. Brief Hospital Course: 88yo male with severe symptomatic aortic stenosis, with history of CAD s/p CABG with postop course complicated by extensive deep sternal wound infection, occluded SVG graft s/p bare metal stent to RCA, diabetes, and CKD, repaeat cardiac cath with 2 vessel CAD/patent grafts,recurrent acute on chronic diastolic heart failure, recent NSTEMI, and now s/p BAV. ACUTE ISSUES #symptomatic severe aortic stenosis - ([Location (un) 109] 0.8cm2, mean gradient 63mmmHg: The patient was admitted to the hospital electively for the procedure on [8-31]. He was Plavix loaded at 300mg. A Corvalve/TAVR was done on [2139-9-1]. The patient's beta blocker and diuretic were held the day of procedure. The patient developed a hypotensive episode after the procedure to a BP 50 systolic that required epinephrine 300 mcg IV bolus. His pressure responded to > 200 systolic with improvement in his wall motion (LVEF = 30%). He developed atrial fibrillation but remained hemodynamically stable. Echocardiography demonstrated no evidence of pericardial perforation and no change in his left or right ventricular function. There was 2+ mitral regurgitation by echocardiography. An intraaortic balloon pump was placed from the left femoral artery without complications for hemodynamic support. The patient was transported to the CCU in stable condition on norepinephrine and dobutamine. He was rapidly weaned from both pressors and his balloon pump was discontinued. He continued to maintain an excellent blood pressure off pressors and his heart rate did not drop below the high 50s. His repeat echo on [9-2] showed a well-seated replacement valve with minimal leak. His ejection fraction, mitral regurgitation, and pulmonary hypertension were unchanged. On [2139-9-3], his transvenous pacing wire was removed and his femoral sheath was pulled. Later that day, he had several four second pauses on EKG, during which time he was asymptomatic. On the evening of the 26th, the patient had two 10 second pauses separated by an escape beat. During the second pause he became unresponsive and required chest compressions before regaining consciousness. Isoproterenol was started at 1mcg/min per electrophysiology recommendations. He had a pacemaker placed without complications. He was transferred to the floor and subsequently discharged. #Fever: while here patient had a fever of Tm 101 after pacemaker placed. It was believed this was likely transient bactermeia in setting of pacemaker being placed. He was treated for a possible hospital aquired pneumonia bc he had a cough. He was started on [9-4] started on vanc and zosyn which was d/c'don [9-6] switched to levofloxacin for respiratory infection, end date is [9-10] so he will have 2 more days to complete while at rehab. # CKD: The patient has known chronic kidney disease with a baseline creatinine of approximately 2.5. His admission creatinine this hospitalization was 1.9. After his recent NSTEMI, he suffered contrast nephropathy after catheterization that brought his creatinine to 3. As such, he received pre-catheterization hydration to minimize contrast nephropathy. The patient's creatinine gradually increased to 2.9 and then trended back down to 2.2 by day of discharge. # Anemia, thrombocytopenia: The patient's admission Hct 35.5 to 25.5 on [9-3], concomitant with a platelet drop from 150 (admission) to 100 ([9-3]). Hemolysis labs were done but found negative. The patient received two units packed red blood cells given his recent NSTEMI and the desire to avoid a low hematocrit in a recent post-MI patient. His coags were elevated due to the heparin and coumadin that he received, but consumptive coagulopathy (DIC, TTP) were considered extremely unlikely. His numbers were followed. HIT was considered but the time course, degree of platelet depression, and absence of known thrombosis argued against this hypothesis. Platelet counts improved on their own and were 196 at day of discharge. #Confusion: The morning following his procedure, Mr. [Known lastname 52455] was initially confused as to the date and which hospital he was in; this improved the following day. At time of discharge still slightly confused regarding some details, but was close to or at home baseline. #CAD - s/p RCA stent [2138], NSTEMI, ccath-Two vessel coronary artery disease; patent SVG to OMB; patent SVG to LAD; patent LIMA to the diagonal branch. We continued ASA held her beta blocker for the Corevalve procedure but restarted it soon after. We also decreased his statin due to current antibiotic therapy with erythromycin for lip lesion prescribed by DMD. #Atrial arrhythmia: The patient has a known history of atrial arrhythmia that may be atrial fibrillation with an abnormally regular ventricular response or atrial flutter. The exact nature of this was unclear but he has been treated anticoagulated (goal INR [3-13]) and rate controlled with beta blocker. His coumadin was stopped on [8-27] in anticipation of the procedure, after which his heparin was continued as a bridge to coumadin and resumption of his pre-hospitalization anticoagulation. He was transitioned back to warfarin and had an INR of 1.5 at time of discharge. Since he was also on ASA and Clopidogrel, this was thought adequate INR to discharge off heparin. He will continue uptitration of his warfarin as an outpatient and will need INR checks every 2-3 days until he achieves a stable INR goal of [3-13]. Once INR is > 1.8, his plavix should be discontinued. CHRONIC ISSUES # DM type II: The patient was maintained on an insulin sliding scale while he was in the hospital. His blood sugars were appropriately controlled. # Lip lesion: The patient presented with a lip lesion sustained during a recent dentist visit for which he had briefly received erythromycin (which was not continued while hospitalized). TRANSITIONAL ISSUES # Atrial fibrillation: the patient was bridged back onto coumadin with a heparin drip while in the hospital although had not yet achieved therapeutic INR at time of discharge but this felt okay as he is also on ASA and plavix. He should receive his INR checks as regularly scheduled and his plavix should be stopped once his INR > 1.8. # Aortic stenosis now s/p core valve: should follow up with Dr. [Last Name (STitle) ] on an outpatient basis. Plan to discontinue his plavix once INR > 1.8 # Anemia, thrombocytopenia: Largely resolved. Will need one f/u CBC as an outpatient. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Gabapentin 200 mg PO TID 4. Ascorbic Acid 500 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Torsemide 20 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Metoprolol Tartrate 25 mg PO BID 9. Warfarin 3 mg PO 3X/WEEK (TU,TH,SA) 10. Warfarin 2 mg PO 4X/WEEK ([Doctor First Name ],MO,WE,FR) Discharge Medications: 1. Warfarin 2 mg PO 4X/WEEK ([Doctor First Name ],MO,WE,FR) 2. Warfarin 3 mg PO 3X/WEEK (TU,TH,SA) 3. Atorvastatin 80 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Clopidogrel 75 mg PO DAILY 6. Ascorbic Acid 500 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. Aspirin 81 mg PO DAILY 9. Gabapentin 200 mg PO Q24H 10. Metoprolol Tartrate 25 mg PO BID 11. Guaifenesin-CODEINE Phosphate 5 mL PO HS:PRN bad cough, hard time sleeping please do not give if somnalant RR<12 12. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 14. Furosemide 40 mg PO DAILY 15. Acetaminophen 1000 mg PO Q8H:PRN pain/temp > 38.0 16. Bisacodyl 10 mg PR ONCE Duration: 1 Doses notify NP if no results after 2 hours 17. Guaifenesin [6-18] mL PO Q6H:PRN cough 18. Senna 1 TAB PO BID Discharge Disposition: Extended Care Facility: [Hospital ] Rehab Discharge Diagnosis: -Severe Aortic stenosis s/p Corevalve placement [2139-9-1] -Complete heart block s/p permanent pacemaker placement [2139-9-4] -CAD - s/p CABG x 3 ( [2123])- postop deep sternal wound infection (EF35%) -PCI bare metal stent to RCA ([5-/2138]) -Hypertension -Hyperlipidemia -Type II DM -Chronic kidney disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Groin precautions - no lifting > 10lbs Discharge Instructions: Dear Mr. [Known lastname 52455], It was a pleasure caring for you while you were hospitalized at the [Hospital1 ]. As you know, you were admitted for severe symptomatic aortic stenosis and were treated with a percutaneous transcatheter aortic valve replacement (Corevalve). Postoperatively, you experienced a very slow heart rate and had a permanent pacemaker placed without difficulty. Your kidney function was temporarily impaired (as Dr. [Last Name (STitle) ] had mentioned would probably happen), but this improved. Your blood counts were low (anemia) so you received one unit of red blood cells. You have continued to progress well and are now ready for discharge. Weigh yourself every morning, call Dr. [Last Name (STitle) ] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Followup Instructions: INR should be checked regularly and plavix should be stopped once INR > 1.8 Department: ECHO LAB When: WEDNESDAY [2139-10-7] at 11:00 AM With: ECHOCARDIOGRAM [Telephone/Fax (1) 62] Building: GZ [Hospital Ward Name ] BUILDING (FELBEERG/[Hospital Ward Name ] COMPLEX) [Location (un) 1951] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: WEDNESDAY [2139-10-7] at 12:00 PM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23*] Garage ICD9 Codes: 4241, 486, 4275, 7907, 4280, 5859, 2724, 4168, 2859, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6367 }	Medical Text: Admission Date: Discharge Date: [2175-6-29] Date of Birth: [2175-6-8] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: [Known lastname ] [Known lastname 5311] was born at 34 and 1/7 weeks gestation to a 26 year old, Gravida IV, Para 0 now I woman. Mother's prenatal screens were blood type AB positive, antibody negative, Rubella immune, RPR nonreactive. Hepatitis surface antigen negative and group B strep unknown. The mother's prenatal history is remarkable for systemic lupus erythematosus, treated with Prednisone and Imuran, possibly as late as seven weeks gestation. Her previous medical history is also remarkable for gastritis, treated with Pantoprazole. The mother had spontaneous onset of labor. Rupture of membranes occurred at delivery. She did receive intrapartum antibiotics. The infant delivered via spontaneous vaginal delivery. Apgars were eight at one minute and nine at five minutes. The birth weight was 1,560 grams. The birth length was 41 cm. The birth head circumference was 28 cm, all at approximately the 10th percentile for gestational age with the head circumference being less than the 10th percentile. The admission physical examination reveals a vigorous, mildly dysmorphic, preterm, small for gestational age infant. Anterior fontanel open and flat. Palate intact. Breath sounds are clear and equal. Heart was regular rate and rhythm. Grade I over VI systolic murmur. Abdomen soft, no masses. Premature male. External genitalia. Testes descended bilaterally. Patent anus. No sacral anomalies. Clavicles intact. Stable hips. Age appropriate tone and reflexes. He does have some mildly dysmorphic features. He has a very prominent occipital protuberance (inion), depressed nasal bridge, and shortened fingers. HOSPITAL COURSE: Respiratory status: [Known lastname ] remained in room air. He has comfortable respirations. He has had no episodes of apnea or bradycardia. Cardiovascular status: He has had an intermittent grade I over VI systolic ejection murmur, heard at the left mid sternal border, consistent with a flow murmur or peripheral pulmonic stenosis. On examination, he is pink and well perfused. He has remained without cardiorespiratory signs or symptoms throughout his Neonatal Intensive Care Unit stay. This should be investigated further if persistent. Fluids, electrolytes and nutrition: At the time of discharge, his weight is 2,165 grams; his length is 42.5 cm and head circumference is 31.5 cm. Enteral feeds were begun on the day of delivery and advanced without difficulty to full volume feedings. At the time of discharge, he is taking formula 26 calories per ounce, 4 calories per ounce made from concentration and two calories per ounce made from corn oil. He is eating on an ad lib schedule with consistent weight gain. Gastrointestinal status: He was treated with phototherapy for hyperbilirubinemia on day of life number two until day of life number three. His peak bilirubin occurred on day of life number two and was total of 10.9 and direct of 0.1. Hematology status: [Known lastname 58159] last hematocrit on [2175-6-10] was 48.7. He is receiving supplemental iron. He has never received any blood product transfusions. Infectious disease: He was started on Ampicillin and Gentamicin at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours when the infant was clinically well and the blood cultures were negative. He remained off antibiotics since that time. On [2175-6-27], he was started on Nystatin ointment for a monilial diaper rash and continues on that at the time of discharge. Neurology: Head ultrasound on [2175-6-12] was completely within normal limits and head ultrasound on [6-26] was within normal limits with the finding of a small choroidal plexus cyst. He was evaluated by [Hospital3 1810] neurosurgery for the prominent inion and it was felt that it was not concerning and could be followed clinically without need for further neurosurgical involvement. Sensory: Audiology: Hearing screen was performed with automated auditory brain stem responses and he passed in both ears. Genetics: [Known lastname ] was followed by Dr. [Last Name (STitle) ] of [Hospital3 18242] genetics. He did have a normal karyotype of 46XY. They would like to see him in the genetics clinic six to eight weeks after discharge. Telephone number is [Telephone/Fax (1) 58160]. Genitourinary: The infant was circumcised on [2175-6-28]. The area is healing nicely. Psychosocial: Parents have been very involved in the infant's care throughout his Neonatal Intensive Care Unit stay. They have been followed by [Hospital1 190] social worker, [Name (NI) 42593] [Name2 (NI) 6861], [Hospital1 346] beeper number [Serial Number 36451]. Occupational therapy: [Known lastname ] has been followed by the Neonatal Intensive Care Unit occupational therapist for lower extremity dorsiflexion contractures and hip external rotation. The mother has been trained in proper exercise for this and demonstrates good ability to do these exercises. He will be followed by early intervention for this. The infant is discharged in good condition, to home with his parents. PRIMARY PEDIATRIC CARE: South [Hospital 12162] Health Center, telephone number [Telephone/Fax (1) 58161]. RECOMMENDATIONS: Feedings: Formula: 26 calories per ounce; 4 calories per ounce made from concentration, 2 calories per ounce from added corn oil, on an ad lib schedule to maintain consistent growth. The infant is discharged on two medications: Iron sulfate (25 mg per ml) 0.2 ml p.o. daily. Nystatin ointment topically to diaper area four times daily. State newborn screen was sent last on [2175-6-11]. [Known lastname ] received his hepatitis B vaccine on [2175-6-25]. RECOMMENDED IMMUNIZATIONS: Synagis RSV prophylaxis should be considered from [Month (only) 359] to [Month (only) 547] for infants who meet any of the following three criteria: 1. ) Born at less than 32 weeks. 2.) Born between 32 and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings. Or, 3.) With chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 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: 1. Dr. [Last Name (STitle) ] of [Hospital3 1810] Genetics, six to eight weeks after discharge. Telephone number [Telephone/Fax (1) 58162]. 2. Early intervention of the Bay Cove Early Intervention. Telephone number [Telephone/Fax (1) 43091]. 3. Care Group [Hospital6 407]. Telephone number [Telephone/Fax (1) 37503]. DISCHARGE DIAGNOSES: 1. Prematurity at 34 and 1/7 weeks gestation. 2. Small for gestational age. 3. Sepsis ruled out. 4. Intermittent murmur, consistent with peripheral pulmonic stenosis. 5.Status post hyperbilirubinemia of prematurity. 6. Choroid plexus cyst. 7. Monilial diaper rash. 8. Mild dysmorphism. 9. Prominent inion. 10. Status post circumcision. Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2175-6-29] 01:46:58 T: [2175-6-29] 04:42:27 Job#: [Job Number 58163] ICD9 Codes: 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6368 }	Medical Text: Admission Date: [2129-4-26] Discharge Date: [2129-5-6] Date of Birth: [2044-3-5] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2181] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: PICC placement X2 (second placement was IR-guided) History of Present Illness: 85 yo M with vascular dementia, HTN, NIDDM, found to be lethargic by family today. Labs at nursing home showed hypernatremia, hyperglycemia. At the nursing home, the patient was given insulin SC 6 units x 3, with no improvement in hyperglycemia. . In the ED, initial vital signs were T 98.3 BP 104/62 HR 96 RR 40 Sat 100%/10L NRB. EKG showed new ST depressions inferolaterally < 1 mm. CXR, head CT negative. He was given 2L of NS and 10 units of regular insulin. Vitals on transfer, T 99.5 HR 87 BP 129/55 RR 18 Sat 97%/RA. . Review of systems is unobtainable. Past Medical History: DM2 hypertension hypercholesterolemia vascular dementia with prominent frontal lobe findings and behavioral problems and wandering hepatitis B deafness asbestosis glaucoma cataract essential tremor psoriasis Social History: Lives at nursing home. Prior to his recent hospitalizations, he was living with his wife and participating in daycare. More recently, he has been at [Hospital 37] Nursing Home. As noted in prior admits, he has had a notable decline in his level of functioning over the past few months. Tob: quit one year ago EtOH: none recently IVDA: family denies Family History: non-contributory Physical Exam: Vital signs: T 95.6 BP 148/85 HR 90 RR 18 Sat 93%/RA Derm: Decreased skin turgor General: Not speaking. Moving around in bed. HEENT: Anicteric. Dry mucous membranes. Neck: JVP 4 cm above RA. Resp: CTAB. CV: RRR. Normal s1, s2. No M/G/R. Abd: +BS. Soft. NT/ND. Ext: Warm extremities. Radial pulses 2+. No edema. Neuro: Not speaking. Moving around in bed. Moving all extremities. PERRL. Left eye deviated laterally. Pertinent Results: Admission labs: [2129-4-26] 04:00AM BLOOD WBC-10.4# RBC-3.74# Hgb-11.4# Hct-37.1# MCV-99 MCH-30.5 MCHC-30.7* RDW-15.1 Plt Ct-236 [2129-4-26] 04:00AM BLOOD Neuts-82.5* Lymphs-12.7* Monos-2.5 Eos-0.6 Baso-1.6 [2129-4-26] 04:00AM BLOOD PT-17.2* PTT-24.8 INR(PT)-1.5* [2129-4-26] 04:00AM BLOOD Glucose-653* UreaN-77* Creat-2.2# Na-177 K-3.9 Cl-130* HCO3-37* AnGap-14 [2129-4-26] 04:00AM BLOOD cTropnT-0.03* [2129-4-26] 04:00AM BLOOD Calcium-10.3 Phos-3.2 Mg-3.4* [2129-4-26] 04:14AM BLOOD Glucose-551* Lactate-2.3* Na-177* K-3.9 Cl-122* calHCO3-38* [2129-4-26] 04:14AM BLOOD freeCa-1.35* . CT head w/o contrast [2129-4-26]: 1. No evidence of an acute intracranial process. 2. Small chronic infarct in the right caudate head, new since [2123]. . CXR (portable AP) [2129-4-26]: Mild pulmonary vascular congestion, unchanged. No acute intrathoracic process. . . MICRO: [2129-4-26] 8:00 am URINE FINAL REPORT [2129-4-28] URINE CULTURE (Final [2129-4-28]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S . MRSA Screen Positive . DISCHARGE LABS: Brief Hospital Course: 85 yo M with DM2, HTN, vascular dementia, presents with lethargy in the setting of severe dehydration, hyperglycemia, and hypernatremia, consistent with hyperosmolar hyperglycemic state. . # Hyperosmolar hyperglycemic state/DM2: The patient presented with marked hyperglycemia and was started on an insulin drip. With improvement in his hyperglycemia, he was transitioned to subcutaneous insulin. Metformin was held. He was started on lantus while needing D5W. When his D5W was stopped after his sodium was corrected, his insulin was adjusted and his sugars were mildly well-controlled. Insulin sliding scale was eventually stopped and patient was restarted on metformin. He was switched to metformin 500mg twice a day. . # Hypernatremia: The patient presented with profound hypernatremia, with sodium 177-180. His free water deficit was greater than 10 L. During a period of several days, his free water deficit was gradually repleted with good effect. Last serum sodium checked prior to discharge was 140. As patient's labs were stable, they were not checked daily. . # Acute renal failure: The patient presented with creatinine 2.2, significantly elevated from his baseline of 0.9. This was felt to be pre-renal in setting of severe dehydration. However, given the patient's history of urinary retention, obstruction may have also contributed, a Foley catheter was placed. The patient was treated with IV fluids and Foley placement and his creatinine slowly improved. At the time of discharge his creatinine was 1.2. His mixed picture has resolved and he will need to follow up with Urology. . # Urinary tract infection: U/A was positive. The patient was started on empiric ceftriaxone and Vancomycin given gram positive cultures in the past. Cultures grew out coagulase positive staph aureus. Blood cultures were negative. He was continued on vancomycin until he was able to tolerate oral medications and then switched to bactrim for a total of 14 days. Last dose is on [2129-5-9]. . # Constipation: Patient appeared to be having some abdominal discomfort and hard bowel movements. He was started on a more aggressive bowel regimen and received a tap water enema the day prior to admission. He should receive all constipation medications until he is having soft, regular bowel movements. If he does not have a bowel movement after 2 days, he should receive a tap water enema. . # EKG changes: The patient had some lateral ST depression, which were reviewed with cardiology and felt to be most consistent with left ventricular hypertrophy with strain. . # Goals of care: Patient will be transitioned to hospice care when he returns to [Hospital3 2558]. . # CODE STATUS: DNR/DNI Medications on Admission: terazosin 10 mg QHS latanoprost 0.005% 1 drop each eye QHS finasteride 5 mg PO daily mirtazepine 15 mg PO QHS lactulose 30 cc TID PRN constipation senna 8.6 mg PO BID PRN constipation polyethylene glycol 17 grams daily PRN constipation lactulose 15 cc PO daily colace 100 mg PO daily senna 1 tab PO QHS trazodone 25 mg Q6H PRN agitation ciprofloxacin 250 mg PO BID x 7 days lactobacillus 1 cap [Hospital1 ] x 7 days trazodone 50 mg PO QHS metformin ER 1000 mg QPM simvastatin 20 mg QHS colace 100 mg [Hospital1 ] PRN constipation Tylenol 650 mg PO Q6H PRN pain vitamin D 50,000 units Qweekly x 8 weeks Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [12-5] Drops Ophthalmic PRN (as needed) as needed for red, dry eyes. 2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days: last dose [2129-5-9]. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 7. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO three times a day as needed for constipation. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. lactobacillus acidoph & bulgar 1 million cell Tablet Sig: One (1) Tablet PO twice a day. 13. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 16. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary Diagnoses: # Hypernatremia # Hyperglycemia # Acute Renal Failure # Vascular Dementia . Secondary Diagnosis: # Type II diabetes mellitus # Hypertension # Hypercholesterolemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You are being discharged from [Hospital1 1170]. It was a pleasure taking care of you. You were admitted for high sugar levels and high sodium levels. You were initially admitted to the intensive care unit (ICU) and then transferred to the regular medical floor for further management. Your sugars were better controlled and your sodium came down by giving you back enough water. You mental status improved and you were more cooperative and ready for discharge to your nursing home. . We made the following changes to your medications: - STARTED artificial tear drops as needed - STOPPED terazosin (as recommended by your urologist at your last visit) . You will need someone to sit and feed you until you have completed meals. You should also always have access to water (cup with straw in front of you). You were not getting enough nutrition or water at your nursing home, which is why you ended up in the hospital. It is imperative that the nursing staff address this. Please take your other medications as prescribed and keep your follow up appointments. Followup Instructions: Name: [Last Name (LF) 770], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 ] Address: [Last Name (LF) ], [First Name3 (LF) ] 440, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 5727] We are working on a follow up appointment in Urology within 1 week. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call the office. Completed by:[2129-5-6] ICD9 Codes: 5849, 2760, 5990, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6369 }	Medical Text: Admission Date: [2199-9-3] Discharge Date: [2199-9-14] Date of Birth: [2144-12-14] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: CC:[CC Contact Info 44741] Major Surgical or Invasive Procedure: liver transplant [2199-9-3] ex lap, cystic duct leak repair [2199-9-7] History of Present Illness: This is a 54 y/o male with history of hepatitis C cirrhosis and hepatocellular carcinoma. He is currently on the liver transplant waiting list with most recent Meld score of 25 points. He underwent RFA of solitary HCC lesion [3-30], however repeat CT scan showed evidence of tumor recurrence which measured approximately 4.7 x 4.8 cm. He was referred to GI Oncology for chemoembolization and he underwent CE on [7-11] to his right lobe but had no chemoembolization of the tumor. On [7-23] he underwent CE of the left lobe of liver as bridge to liver transplantation. His liver transplant evaluation was completed and includes recent colonoscopy with an extraction biopsy in the cecum which showed benign-appearing adenoma. He also has had endoscopy, which showed grade 1 varices. Recent cardiac catheterization with normal left and right heart filling pressures. He has fully recovered from his CE, his only complaint being pain with inspiration in his RUQ which he has treated at home with PO Dilaudid for which he has a script. On presentation today he reports feeling well. He denies fevers, chills, SOB or chest pain. He has had no episodes of ascites (has never been tapped) denies symptoms of encephalopathy or liver failure. Patient brought up issue of positive screen for methadone last week. He flatly denies use of any drugs legal or illegal except the dilaudid and ultram for the RUQ pain that he has been prescribed for. He states his last Marijuana use was [Month (only) 547] of this year. States he does not smoke or drink. . Past Medical History: Hypertension BPH Hepatitis C cirrhosis Hepatocellular carcinoma Liver transplant [2199-9-3] Ex lap, t tube placement, ligation of cystic duct, cholangiogram, intraop bx [2199-9-7] Social History: Denies any alcohol in the past six years. He denies any history of IV drug use. He lives in [Hospital1 1562] with his wife, who is very supportive and he has twin daughters, aged 19, and he is working odd jobs on [Location (un) ]. Family History: No h/o hepatic disease, no familial cancers Physical Exam: VS: 97.5, 80, 104/72, 20, 97%RA 83.3kg HEENT: sclera non-icteric, slight white coating to tongue, moist mucous membranes, no oropharyngeal redness. Lungs: CTA bilaterally Card: RRR, no M/R/G Abdomen: Soft, sl obese, non-distended, non-tender except over RUQ which is not new. + BS, no scars Extr: No C/C/E, 2+ pulses DP Pertinent Results: [2199-9-3] 10:50AM FIBRINOGE-203 [2199-9-3] 10:50AM PT-14.8* PTT-39.3* INR(PT)-1.3* [2199-9-3] 10:50AM PLT COUNT-72* [2199-9-3] 10:50AM WBC-1.8* RBC-4.13* HGB-13.6* HCT-38.9* MCV-94 MCH-33.0* MCHC-35.0 RDW-14.6 [2199-9-3] 10:50AM ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-1.6 [2199-9-3] 10:50AM ALT(SGPT)-69* AST(SGOT)-96* ALK PHOS-74 TOT BILI-1.0 [2199-9-3] 10:50AM GLUCOSE-147* UREA N-11 CREAT-0.7 SODIUM-142 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-31 ANION GAP-13 [2199-9-3] 12:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.0 LEUK-NEG Brief Hospital Course: On [2199-9-3] he underwent liver transplant from a 49 y.o. donor after cardiac death. Surgeon was Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] assisted by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Please see operative report for details. Two [Doctor Last Name 406] drains were placed. He received standard immunosuppressive induction consisting of solumedrol and cellcept. EBL was 25 liters for which he was replaced with crystalloid, PRBC, FFP and plts. He was sent to the SICU immediately postop intubated. An u/s showed fully patent hepatic vasculature with high velocities noted in the main portal vein near the region of anastomosis. A small left subhepatic fluid collection was noted. LFTS trended down. His hct stablized. He was weaned off the vent on pod 2. Diet was advanced and tolerated. The drains were noted to have bile in JP. The medial JP bilirubin was 157. Serum bilirubin was 3.2. On POD 4 an ERCP was done to evaluate bile leak. A bile leak was noted at the common duct. On [9-7] he was taken back to the OR for bile peritonitis. He had ex lap with repair of cystic duct with placement of t.tube, cholangiogram and liver biopsy. Postop, he did well. IV dilaudid was used for pain control. This was converted to po dilaudid, but he required IV breakthru medication given his higher tolerance from chronic pain medication. Diet was slowly advanced. [Last Name (un) ] followed for management of hyperglycemia. Lantus insulin and sliding scale insulin qid were used. LFTs trended down. Prograf was started on pod 2 and adjusted per levels. Steroid were tapered per protocol. Cellcept remained at 1 gram [Hospital1 ]. On POD 4 ([9-11])from cystic duct repair a tube cholangiogram was done revealing no bile leak with patent anastomosis. The T tube was capped. The lateral JP was d/c'd on [9-12] (pod [8-27]). The medial JP remained in place with outputs in 200 range. He was to go home with the medial JP and was taught to self empty and record. PT cleared him for home safety. Vital signs were stable. He was tolerating a regular diet. The incision was faintly pink at the incision staple sites. He was started on unasyn on [9-7] after the cystic duct repair. He remained on this until [9-12] when this was changed to Keflex. The plan was for him to take this for 1 week. The JP was to remain in place until the next outpatient visit. He was discharged in stable condition, ambulatory and tolerating a carb consistent diet. Medications on Admission: Tamsulosin 0.4 Daily,Hydrochlorothiazide 25 mg daily, Omeprazole 40 mg daily, Hydromorphone 4 mg q 4 hours PRN pain, Mycelex Troches (buccal) five times daily. Ultram PRN pain . Discharge Medications: 1. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times a day for 1 weeks. Disp:28 Capsule(s) Refills:0 3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours) as needed. Disp:75 Tablet(s) Refills:0 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28) units Subcutaneous once a day. Disp:1 bottle Refills:1 14. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. Disp:1 bottle Refills:1 15. syringes low dose insulin syringes for qam lantus and qid sliding scale regular insulin supply:1 box refill:o 16. Lancets 1 box for qid glucose monitoring refill:1 17. Test Strips One touch Ultra-qid accuchecks 1 box refill: 1 Discharge Disposition: Home With Service Facility: vna of [Hospital3 635] Discharge Diagnosis: HCV cirrhosis HCC s/p liver transplant bile leak Steroid induced hyperglycemia Discharge Condition: good Discharge Instructions: Please call Transplant office [Telephone/Fax (1) 673] if you develop any fevers, chills, nausea, vomiting, inability to take any of your medication, increased abdominal pain, jaundice, incision redness/bleeding/drainage at incision or JP site Empty JP when half full. Record output. Bring record of outputs to next MD appointment Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) 156] TRANSPLANT SOCIAL WORK Date/Time:[2199-9-18] 10:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2199-9-18] 11:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2199-9-25] 11:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] ICD9 Codes: 5715, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6370 }	Medical Text: Admission Date: [2180-4-17] Discharge Date: [2180-4-21] Date of Birth: [2105-12-29] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 458] Chief Complaint: syncope Major Surgical or Invasive Procedure: temporary ppm RIJ CVL Permanent PM History of Present Illness: 74 F, creole speaking, unclear PMH p/w palpitations and DOE. Pt came to the USA on [2180-4-1]. Her son states that she was having episodes of suncope in [Country 2045]. Here he noticed that she was feeling SOB while walking upstairs. Last night she woke up in middle of night feeling SOB. Hence he brought her to the ER. In the ED, initial vitals 98.2 42 174/37 98/RA. EKG showed complete heart block. EP was consulted. She was admitted to CCU for monitoring with a plan to doa PPM tomorrow AM. She has a +ve UA and was given ciproflox 500 PO x 1. In the CCU she denies any CP, SOB, dizziness, palpitations. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. She c/o increased urinary frequency but denied dysuria Cardiac review of systems is notable for absence of chest pain, orthopnea, ankle edema, palpitations. Past Medical History: Unclear although possibly a seizure disorder according to her daughter in law. Cardiac Risk Factors: unclear but was told in past that she needed three vessel CABG Social History: She is from [Country ]. MOved to the States on [2180-4-1]. Lives with her son. [Name (NI) ] tobacco, no ETOH. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - 98 176/61 34 98/RA Gen: WDWN old female 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 JVD at angle of jaw. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No pitting edema but legs look swollen. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [2180-4-17] 04:06PM TYPE-ART PO2-164* PCO2-54* PH-7.33* TOTAL CO2-30 BASE XS-1 [2180-4-17] 04:06PM LACTATE-1.1 K+-4.1 [2180-4-17] 03:40PM TYPE-ART PO2-51* PCO2-56* PH-7.31* TOTAL CO2-30 BASE XS-0 INTUBATED-NOT INTUBA [2180-4-17] 03:33PM GLUCOSE-98 UREA N-24* CREAT-1.1 SODIUM-141 POTASSIUM-8.3* CHLORIDE-109* TOTAL CO2-26 ANION GAP-14 [2180-4-17] 03:33PM ALT(SGPT)-22 AST(SGOT)-62* LD(LDH)-852* ALK PHOS-72 TOT BILI-0.5 [2180-4-17] 03:33PM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.5 [2180-4-17] 03:33PM WBC-7.4 RBC-4.38 HGB-12.1 HCT-35.9* MCV-82 MCH-27.5 MCHC-33.6 RDW-14.4 [2180-4-17] 03:33PM PLT COUNT-227 [2180-4-17] 03:33PM PT-11.5 PTT-21.8* INR(PT)-1.0 [2180-4-17] 11:50AM URINE BLOOD-SM NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2180-4-17] 11:50AM URINE RBC-0-2 WBC-[11-17]* BACTERIA-MANY YEAST-NONE EPI-[3-2] [2180-4-17] 11:50AM URINE HYALINE-0-2 [2180-4-17] 11:35AM GLUCOSE-117* UREA N-25* CREAT-1.3* SODIUM-143 POTASSIUM-7.1* CHLORIDE-108 TOTAL CO2-27 ANION GAP-15 [2180-4-17] 11:35AM CK(CPK)-231* [2180-4-17] 11:35AM cTropnT-<0.01 [2180-4-17] 11:35AM CALCIUM-9.2 PHOSPHATE-3.6 MAGNESIUM-2.5 [2180-4-17] 11:35AM WBC-7.4 RBC-4.94 HGB-13.1 HCT-40.8 MCV-83 MCH-26.6* MCHC-32.1 RDW-14.2 [2180-4-17] 11:35AM NEUTS-49.3* LYMPHS-41.1 MONOS-6.7 EOS-2.1 BASOS-0.8 [2180-4-17] 11:35AM PLT COUNT-255 [2180-4-17] 11:35AM PT-11.9 PTT-23.1 INR(PT)-1.0 EKG demonstrated complete heart block and RBBB. TTE [2180-4-17]: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-31]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No intracardiac thrombus seen. Diffuse, but non-mobile aortic atheromata. EEG [2180-4-20]: FINDINGS: ABNORMALITY #1: There were intermittent bursts of left fronto-temporal theta frequency slowing. BACKGROUND: Showed a well-formed 8 Hz alpha frequency posterior predominant rhythm in wakefulness. The anterior-posterior voltage gradient was preserved. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: The patient progressed from wakefulness through drowsiness and achieved stage II sleep. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 60 bpm. IMPRESSION: This is an abnormal routine EEG in the waking and sleeping states due to the left fronto-temporal slowing indicative of a subcortical abnormality in this region. Vascular disease is among the most common causes in this age group. There were no epileptiform features noted. P-MIBI [2180-4-20]: The image quality is satisfactory although there is attentuation from the patient's left arm. Left ventricular cavity size is mildly dilated with a calculated EDV of 99 ml. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal mild global hypokinesis. The calculated left ventricular ejection fraction is reduced at 44%. IMPRESSION: Normal myocardial perfusion. Mildly dilated LV with ejection fraction of 44%. Brief Hospital Course: # Complete heart block: Patient presented with CHB. Unclear if prior syncopal/seizure episodes were related to this. Developed episode of seizure-like activity one hour after admission and temporary pacemaker was placed. TTE showed likely ischemic cardiomyopathy which may have contributed to CHB versus age-related calcification/fibrosis. Had PPM placed later in admission. Will follow up with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 5448] in the [Hospital ] clinic. Will follow up for ppm check in 1 week. Will be on keflex for 3 days post-procedure for prophylaxis. # HTN: Stopped CCBs given the heart block and initiated captopril. Was also started on beta blocker for presumed CAD given WMA on TTE. Prior to discharge BPs were well controlled and patient was transitioned to once daily ACE and beta blocker. # Seizure: Patient had witnessed generalized seizure with right-sided tonic/clonic movements and tongue smacking. On tele there were no associated pauses suggesting CHB as cause and patient had history of seizures in past. Ativan was given and patient stopped seizing. Neurology was consulted. Keppra was started. EEG showed left frontal temporal lobe abnormalities. Neuro thought this was likely [1-31] old CVA which could have been focus for seizure. Patient will follow up with neuro as an outpatient. # UTI: Had c/o urinary frequency on admission. UA positive. Started initially on cipro but after seizure changed to bactrim given cipro lowers seizure threshold. Urine culture showed pan-sensitive ecoli and patient was continued on bactrim for 7 days. # CAD: Patient had WMA consistent with CAD on TTE. Given the history of a physician telling the patient she needs CABG it was thought the most likely cause of her lv dysfunction would be ischemic and she was thus risk stratified with ldl/stress test. P-mibi showed mild lv systolic dysfunction and no perfusion defects. LDL was above goal at 151 so statin was started. She was continued on asa and started on ACE and beta blocker as above. She will follow up with Dr. [Last Name (STitle) 5448] and [Doctor Last Name ] in cardiology clinic. # Cough: Patient was recent immigrant from [Country ] and c/o dry cough chronically. PPD was ordered but was not placed prior to discharge. Patient will follow up with new pcp in [Name9 (PRE) 191] clinic and have ppd placed there. # Emergency contact: [Name (NI) ] # Code: full Medications on Admission: Amlodipine 5mg daily NIfedipine 20mg daily ASA 81 daily Discharge Medications: 1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 2. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:45 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:8 Tablet(s) Refills:0 6. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:6 Capsule(s) Refills:0 7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: Complete Heart Block Seizure disorder Urinary Tract Infection Discharge Condition: stable Discharge Instructions: You had complete heart block and a pacemaker was inserted. Do not take a shower until after you have your device clinic appt. You may bathe in a tub but do not get the dressing wet. Do not lift your left arm over your head or carry more than 5 pounds for 6 weeks. You will be on an antibiotic for the next several days to treat your urine infection and prevent the pacer site from becoming infected. Medication changes: 1. STOP taking all of your old medicines except aspirin 2. Metoprolol: to increase the pumping function of your heart 3. Lisinopril: to lower your blood pressure 4. Bactrim: an antibiotic for the urine infection and the pacemaker 5. Keflex: an antibiotic to prevent an infection near your pacemaker 6. Simvastatin: to lower your cholesterol 7. Keppra: an anti-seizure medicine . Please call the device clinic if you have any fevers, bleeding, swelling, increasing pain at the pacemaker site. Call Dr. [Last Name (STitle) ] if you have any further episodes of fainting, chest pain, trouble breathing, nausea or any other concerning symptoms. . You have an appt with Dr. [Last Name (STitle) ] on [5-12]. We were unable to book an interpreter at that time. Please come with a family member to interpret or reschedule the appt. Followup Instructions: DEVICE CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2180-4-27] 11:30. [Hospital Ward Name 23] Clinical Center, [Location (un) 436], [Hospital Ward Name 516], [Hospital1 18] [Location (un) ], [Location (un) 86] . Primary care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and Dr. [First Name (STitle) ] Phone: [Telephone/Fax (1) 250] Date/time: [5-12] at 1:30pm. No interpreter was able to be booked. [Hospital Ward Name 23] Clinical Center, [Hospital Ward Name 516], [Location (un) ], [Location (un) 86] . Cardiology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5448] and Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone: [Telephone/Fax (1) 62] Date/time: [5-26] at 9:00am. [Hospital Ward Name 23] Clnical Center, [Location (un) ]. . Neurology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 18530] and Dr. [Last Name (STitle) ] Phone: ([Telephone/Fax (1) 5088] Date/Time: Office will call you with an appt in [4-3] weeks. Completed by:[2180-4-21] ICD9 Codes: 5849, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6371 }	Medical Text: Admission Date: [2111-4-5] Discharge Date: [2111-4-22] Date of Birth: [2064-1-18] Sex: M Service: SURGERY Allergies: Nsaids Attending:[First Name3 (LF) 473] Chief Complaint: GI Bleed Pancreatic Pseudocyst Hypotension Major Surgical or Invasive Procedure: EGD and stent removal Embolization - Left gastric artery Subtotal pancreatectomy with splenectomy, Primary takedown of gastro-cystic fistula with gastrohorrhaphy repair. History of Present Illness: This is a 47 year old male with a pancreatic pseudocyst and he had endoscopic drainage of the pseudocyst on [2111-3-26] by Dr. [Last Name (STitle) ]. He was recently readmitted and discharge on [2111-4-2] with fever and pseudocyst infection, in which he was discharge home on Fluconazole and Augmentin. He now returns with abdominal pain, and weakness. Past Medical History: pancreatitis thought to be due to NSAID use in mid [2092]'s, hernia repair EGD and pseudocyst-gastrostomy [2111-3-26] Social History: He is a mental health worker. Smokes, drinks alcohol one to two times a month. No prior history of heavy alcohol ingestion. Denies drug use. Family History: Family History: Positive for colon cancer in the patient's maternal aunt. She was diagnosed with cancer in her 70's, otherwise negative for colon cancer, rectal cancer or other HNPCC related cancers in first or second degree relatives. Physical Exam: 98.8, 94, 110/70, 22, 100% RA Gen: NAD CV; RRR Pulm: Clear to ausc. bilat. Abd: soft, distented, mild discomfort to deep palpation difusely Pertinent Results: [2111-4-5] 02:25AM BLOOD WBC-24.9# RBC-3.92 Hgb-11.7* Hct-33.5* MCV-85 MCH-29.8 MCHC-35.0 RDW-13.0 Plt Ct-635# [2111-4-5] 08:50AM BLOOD WBC-11.1# RBC-2.82# Hgb-8.5# Hct-24.3# MCV-86 MCH-30.1 MCHC-34.9 RDW-13.1 Plt Ct-369 [2111-4-5] 02:09PM BLOOD WBC-10.7 RBC-3.30 Hgb-9.9* Hct-28.0* MCV-85 MCH-29.9 MCHC-35.3* RDW-14.0 Plt Ct-335 [2111-4-7] 06:15AM BLOOD WBC-9.2 RBC-3.34* Hgb-10.0* Hct-27.9* MCV-84 MCH-30.1 MCHC-36.0* RDW-13.9 Plt Ct-370 [2111-4-5] 02:25AM BLOOD Glucose-224* UreaN-22* Creat-1.4* Na-142 K-4.3 Cl-103 HCO3-25 AnGap-18 [2111-4-7] 06:15AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-143 K-4.0 Cl-107 HCO3-27 AnGap-13 [2111-4-5] 02:25AM BLOOD ALT-137* AST-106* CK(CPK)-41 AlkPhos-80 Amylase-44 TotBili-0.1 [2111-4-5] 02:25AM BLOOD Lipase-49 [2111-4-7] 06:15AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.6 [2111-4-5] 02:36AM BLOOD Lactate-3.3* [2111-4-5] 08:59AM BLOOD Lactate-1.2 . EGD Impression: 1. Large adherent clot in the fundus of the stomach at the site of the cyst gastrostomy site. 2. Distal aspect of the two pigtail stents were seen in the gastric antrum. 3. Fresh blood was seen emanating at the cyst gastrotomy site. 4. These pigtail stents were removed with a snare. Otherwise normal EGD to third part of the duodenum Recommendations: 1. Continue management in ICU 2. Consult IR for angio embolization of the bleeding source. . ABDOMINAL AORTA [2111-4-5] 4:57 PM INDICATION: Upper GI bleeding with the source at the gastric fundus by upper endoscopy. Based on the findings on endoscopy with the bleeding site at the gastric fundus, it was decided to proceed with embolization of the left gastric artery. A microcatheter was then advanced into the left gastric artery with the help of a guidewire. Another arteriogram was performed, demonstrating no evidence of active extravasation, pseudoaneurysm or neovascularity. Four cc's of Gelfoam slurry were then slowly injected through the microcatheter into the left gastric artery until stagnation of flow. The microcatheter was then pulled back and another arteriogram was performed demonstrating no opacification of the peripheral branches of the left gastric artery at the gastric fundus. The microcatheter was then removed and another arteriogram was performed from the main catheter engaged into the celiac trunk. Once again no active extravasation was documented and there was no opacification of the peripheral branches at the gastric fundus. The catheter was removed. A guidewire was advanced through the sheath and the sheath was then removed from the common femoral artery. An Angio-Seal closure device was then deployed at the femoral artery puncture site and hemostasis achieved. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: No evidence of active extravasation or detectable pseudoaneurysm in the celiac trunk territory. Prophylactic embolization of the left gastric artery with Gelfoam based on the endoscopic findings of the bleeding site at the gastric fundus. . CT ABDOMEN W/CONTRAST [2111-4-5] 3:35 AM IMPRESSION: 1. Unchanged size of pseudocyst with slightly decreased surrounding stranding. Double pigtail drainage catheter is in unchanged position. 2. No other new pathology in the abdomen is identified as a possible source of infection. 3. Large filling defect in the stomach is most likely representing food. However, if the patient did not recently eat the possibility of hemorrhage into the stomach should be considered. . CHEST (PORTABLE AP) [2111-4-6] 4:15 AM INDICATION: Question of atelectasis. As compared to the previous radiograph, the endotracheal tube has been removed. There is moderate motion artifacts that inhibit a closer morphologic analysis of the lung parenchyma. The subtle area of hypoventilation in the right lung apex could be unchanged. No evidence of newly occurred areas of atelectasis. . CT ABDOMEN W/CONTRAST [2111-4-9] 11:19 AM IMPRESSION: 1. No significant interval change in the hyper dense pseudocyst noted in the pancreatic tail. There has been interval removal of double pigtail drainage catheter. The air noted in the pseudocyst is most likely related prior connection with stomach. 2. Stable absence of pancreatic neck and stable distal pancreatic atrophy with distal ductal dilatation. 3. Multiple hypodense liver lesions are consistent with cysts/hemangiomas. . SPECIMEN SUBMITTED: distal pancreas and spleen. Procedure date Tissue received Report Date Diagnosed by [2111-4-10] [2111-4-11] [2111-4-17] DR. [Last Name (STitle) ] [Last Name (NamePattern4) 7001]/cma?????? DIAGNOSIS: Pancreas and spleen, distal pancreatectomy and splenectomy: 1. Pancreas with hemorrhagic pseudocyst and marked acute-on-chronic pancreatitis with necrosis and peripancreatic abscess formation; no residual in-tact pancreatic acinar tissue identified. 2. Spleen with incidental littoral cell angioma and simple epithelial cyst (see note). 3. Small fragment of unremarkable adrenal tissue. 4. No malignancy is identified. . CT PELVIS W/CONTRAST [2111-4-17] 11:07 AM IMPRESSION: 1. Interval decrease in size of a now low-density fluid collection adjacent to the greater curvature of the stomach. 2. Status post subtotal pancreatectomy and splenectomy. . Brief Hospital Course: This is a 47 year old male who had EGD and pancreatic pseudocyst gastrostomy and 2 stents placed on [2111-3-26]. He returned with hypotension and a GI Bleed. He went for CT ABD showing The pseudocyst unchanged measuring approximately 6.6 x 6 cm in the axial plane. There is mild surrounding stranding, slightly decreased since the prior study. There are again mixed attenuation material within the pseudocyst, with increased air components. A large filling defect in the stomach most likely represents food, although hemorrhage into the stomach cannot be excluded. He was admitted to the ICU and had hematemesis and NG aspirate revealed frank blood. He received 4 units of PRBC for blood loss anemia and aggressive IVF. He was electively intubated for urgent EGD and therapy. He went for EGD and and stent removal, with bleeding at the site of the tube (fundus). He had a suspected He then went to IR and no bleeding source found, left gastric embolized prophylactically. He was extubated the next day and moved to the floor. His diet was advanced to clears on HD 3. He continued on antibiotics for pseudocyst infection. He was doing well on the floor and able to advance his diet. On [2111-4-9], the patient became diaphoretic and briefly unresponsive on the floor. He maintained a pulse and blood pressure. He was transferred to the ICU. He had a HCT drop from 30.7 to 22.9. NGT lavage revealed BRB. He received 2 Units of RBC and his HCT was stable at 28.1. He went to the OR on [2111-4-10] for: Subtotal pancreatectomy with splenectomy, Primary takedown of gastro-cystic fistula with gastrohorrhaphy repair. He did well post-operatively. Pain: He had an epidural for pain control and was followed by APS. The epidurla was removed on POD 5. He was started on a PCA and once taking adequate orals, was switched to PO meds. GI/ABD: He was NPO, with IVF and TPN, and a NGT. The NGT was removed on POD 4 after clamp trials revealed low residuals. He was started on clears on POD 5. His diet was slowly advanced and he was tolerating a regular diet at time of discharge. His abdomen was soft, nondistened and appropriately tender. His incision was opened on the left side for a post-op wound infection and packed with wet to dry gauze. The staples were removed and steri strips applied Medications on Admission: cipro, percocet prn Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:40 Tablet(s) Refills:0 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA Southeastern Mass Discharge Diagnosis: 1. Chronic pancreatitis. 2. Pancreatic pseudocyst. 3. Gastro-cystic fistula causing recurrent life-threatening hemorrhage from pancreatic pseudocyst into the stomach. . abd pain, fevers, and hypotensive Hypotension Post-op Wound infection Discharge Condition: Good Discharge Instructions: You were admitted pain, fevers, and hypotensive Please return to the ED or call the doctor if: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * 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. * Continue to increase activity daily * No heavy lifting (>[9-23] lbs) for 6 weeks. * Continue with wound dressing changes. Followup Instructions: Provider: [First Name8 (NamePattern2) 251] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 476] Date/Time:[2111-5-8] 9:45 Completed by:[2111-4-22] ICD9 Codes: 5789, 2851, 4589, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6372 }	Medical Text: Admission Date: [2135-2-8] Discharge Date: [2135-2-14] Date of Birth: [2052-1-30] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[Doctor First Name 2080] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: Reason for MICU Admission: hypoxia respiratory distress . Primary Care Physician: [Name10 (NameIs) 585],[Name11 (NameIs) 586] [Name Initial (NameIs) ]. [Telephone/Fax (1) 589] . CC: cough, shortness of breath . HPI: 83yo female Russian with history of CLL presenting with respiratory distress. . Per patient she reports 6 days of productive cough and progressive dyspnea. She reports associated fevers up to 100.2 and sore throat. Two days prior to admission prescribed bactrim by her son who is a physician. [Name10 (NameIs) ] [Name11 (NameIs) 3010] worsened and she presented to her PCP [Name Initial (PRE) 3011]. There vital signs notable for O2 sat 89% RA, improved to 92% on 2L NC. CXR with right increased effusion and possible left sided infiltrate. She was referred to ED for further eval. . In the ED, initial VS: 99.3 81 118/46 20 96% NRB. Labs notable for WBC of 33.2, 61% lymphocytes; K: 5.2, creatinine 2.7, lactate 1.3. Blood cultures obtained. CXR performed which demonstrated interval increase in moderate - large right pleural effusion as well as opacity lateral to left hilum. Patient received PO Tylenol 650mg x1, IV Ceftriaxone and Levofloxacin. The patient was attempted to be weaned to NC, but desated to 90%. She was placed back on a NRB and transferred to [Hospital Unit Name 153] for further evaluation and management. . In the [Hospital Unit Name 153] the patient states that her breathing has improved. . ROS: +: as per HPI -: denies any chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, orthopnea, PND, lower extremity edema, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Past Medical History: # Oncologic History Chronic Lymphocytic Leukemia - Diagnosed in [2125]: Rai stage 0 in [2125] - s/p 5 cycles of fludarabine ending in [2130-5-29]. - recurrent anemia and advancing peripheral blood lymphocytosis and lymphadenopathy, prompted 4 additional 3-day cycles of fludarabine from [3-9] to [6-6]. # PMH 1. Macular degeneration; legally blind. 2. Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [2121-2-26] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [2133-6-29], she was admitted to hospital with respiratory infection due to H1N1 influenza A. She received 6 days of Tamiflu and Levaquin with improvement in symptoms. Myelosuppression during her viral illness improved. . SURGICAL HISTORY: Hysterectomy at age 43. Appendectomy. Right thyroidectomy Social History: Lives with her husband. [Name (NI) ] two children. Retired teacher. Originally from [Country 532] Tob: none EtOH: none Family History: Father - h/o esophageal cancer Mother - h/o skin cancer Sister - h/o breast cancer Physical Exam: On Admission: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, II/ VI SEM, no M/G/R, normal S1 S2, radial pulses +2 PULM: diminished BS at the right base, otherwise no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymo Pertinent Results: [2135-2-8] 05:30PM WBC-33.2* RBC-4.31 HGB-12.5 HCT-36.5 MCV-85 MCH-29.1 MCHC-34.3 RDW-15.9* [2135-2-8] 05:30PM PLT SMR-NORMAL PLT COUNT-164 [2135-2-8] 05:30PM NEUTS-34* BANDS-0 LYMPHS-61* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2135-2-8] 05:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2135-2-8] 05:30PM GLUCOSE-134* UREA N-48* CREAT-2.7# SODIUM-136 POTASSIUM-5.2 CHLORIDE-102 TOTAL CO2-20* ANION GAP-19 [2135-2-8] 10:28PM PT-13.6* PTT-28.0 INR(PT)-1.2* [2135-2-8] 05:30PM CK(CPK)-89 [2135-2-8] 05:30PM cTropnT-<0.01 [2135-2-8] 05:35PM LACTATE-1.3 [2135-2-8] 10:28PM PT-13.6* PTT-28.0 INR(PT)-1.2* [2135-2-8] 05:30PM CK-MB-4 proBNP-1345* [2135-2-8] 11:09PM URINE HOURS-RANDOM UREA N-390 CREAT-52 SODIUM-37 POTASSIUM-30 CHLORIDE-16 [2135-2-8] 11:09PM URINE OSMOLAL-270 [2135-2-8] 11:09PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.008 [2135-2-8] 11:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2135-2-8] 11:09PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [2135-2-8] 11:09PM URINE MUCOUS-RARE [2135-2-8] 11:09PM URINE EOS-NEGATIVE . IgG IgA IgM [2135-2-10] 05:57 963 52* 66 . Micro: Legionella Urinary Antigen (Final [2135-2-9]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [2135-2-9] 2:33 pm PLEURAL FLUID GRAM STAIN (Final [2135-2-9]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Final [2135-2-11]): NO GROWTH. URINE CULTURE (Final [2135-2-10]): <10,000 organisms/ml Pleural Pathology: pending CT chest: FINDINGS: Bulky lymphadenopathy is present in the imaged portion of the lower neck, superior mediastinum, throughout the intrathoracic mediastinum, bilateral hila, and to a lesser extent within the axillary regions. Large right pleural effusion is dependent in location and measures simple fluid density. A small amount of loculated fluid is also present within the major fissure and in the anterolateral portion of the right lower chest. Extensive consolidation is present within the right lower and right middle lobes. Peribronchiolar abnormalities are present in both upper lobes with a combination of ground glass and consolidation accompanied by bronchial wall thickening and small peribronchial nodules. A dominant peribronchial nodule in the left upper lobe measures 2.2 cm and is surrounded by a halo of ground-glass opacity (26, series 3A). This corresponds to a rapidly growing focal opacity on serial chest x-rays between [2135-2-8] and [2135-2-10]. Additional peribronchiolar abnormalities are present to a lesser extent within the left lower lobe. Exam was not tailored to evaluate the subdiaphragmatic region, but note is made of retroperitoneal or intra-abdominal lymphadenopathy as well as incompletely imaged splenomegaly. Lucent spine lesions within the lower thoracic spine (image 53, series 3A and image 48, series 3A) are probably hemangiomas. Degenerative changes are also noted at multiple levels throughout the spine. IMPRESSION: 1. Multifocal lung abnormalities most suggestive of a widespread infectious process. Nodular opacity with ground-glass halo in left upper lobe is nonspecific, but this appearance may be associated with angioinvasive Aspergillus infection in the setting of neutropenic fever. 2. Large simple right pleural effusion. 3. Extensive lymphadenopathy, likely related to the provided history of CLL. Splenomegaly is also in keeping with this diagnosis. 4. Two lucent thoracic vertebral body lesions in the lower thoracic spine which probably reflect hemangiomas. . TTE The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. No clinically significant valvular regurgitation. Borderline pulmonary artery systolic hypertension. An area of echodensity measuring 7.4 cm x 4.9 cm (clip [Clip Number (Radiology) ]) is seen that appears to be contained within a small right pleural effusion. Clinical correlation and consideration of a chest CT for further characterization suggested. . LENI: FINDINGS: Color and [Doctor Last Name 352]-scale son[Name (NI) ] was performed on the bilateral lower extremities. The bilateral common femoral, superficial femoral and popliteal veins are normal in compressibility, augmentation, and Doppler waveforms. The calf veins are patent and compressible. There is no deep vein thrombosis in either lower extremity. . Brief Hospital Course: This is a 83 year-old female with a history of CLL who presents with respiratory distress. . # Respiratory Distress. Etiology likely secondary to worsening effusion as well as new infiltrates concerning for multifocal pneumonia. Patient with known malignancy and therefore at risk for hypercoagulable state. [Doctor Last Name 3012] score appears to be low -1 (+1 for malignancy, -2 for other cause of dyspnea). LENIs negative. Biomarkers flat. TTE with normal systolic and diastolic function. Patient underwent uncomplicated thoracentitis on [2-9], 500cc was removed. Fluid largely transudative. Gram stain with no growth. Cytology pending. CXR with LUL infiltrate. Urine legionella negative. Blood cx: NGTD. CT scan consistent with multifocal pneumonia; though question of fungal per radiology, clinical suspicion higher for pneumococcal pathogen. Patient continued on Ceftriaxone and Levofloxacin with plan for 8-10day course. Patient's respiratory status improved on these antibiotics and O2 was weaned as tolerated. At time of transfer to floor on [2-11], oxygen saturation was >94% on 3L NC. Narrowed to Levofloxacin alone prior to discharge . PENDING CYTOLOGY NEEDS FOLLOW UP. ALSO RECOMMEND CT CHEST AFTER TREATMENT COMPLETED. . # [Last Name (un) ]. Patient with history of chronic renal insufficiency with baseline creatinine 1.5. Creatinine on admission 2.7. Etiology pre-renal, AIN in setting of recent bactrim usage. UA and urine culture without sign of infection. Urine eosinophils negative. FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3. at time of transfer to the medical floor. Trending daily. It was lowered to 1.7 prior to discharge. . # CLL. Patient diagnosed in [2125]. Patient last treated with fludarabine in [2133-5-29]. Labs notable for elevated WBC >20 since 4/[2134]. Patient without anemia or thrombocytopenia. IgG levels checked. IgG level wnl. Dr [Last Name (STitle) ] followed patient closely. No plan for IVIG infusion. . # Diabetes. Last HgA1c: 9.0. Patient states she does not take any meds for diabetes and her daughter said she eats whatever she wants. Monitoring QID FS, ISS. . # Hypothyroid. Continued Synthroid . # FEN: IVF, replete prn, diabetic/cardiac diet . # Access: PIV . # PPx: subQ heparin, home PPI . Medications on Admission: See [Hospital Unit Name 153] admission note Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO Q12H (every 12 hours). 2. tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO BID (2 times a day). 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 doses. Disp:2 Tablet(s) Refills:0 7. Home Oxygen 2 liters continuous pulse dose for portability. dx: pleural effusion 8. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Community acquired pneumonia with parapneumonic effusion Chronic kidney disease stage III CLL Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for treatment for severe pneumonia as well as fluid in the lung. The fluid in the lung was sampled. You were started on antibiotics with improvement in your symptoms. Please continue your antibiotics to complete the full course. Please take all other medications as prescribed. You need to see you PCP in close follow up. Lung fluid cytology is PENDING at discharge and will need to be followed up. Also, we recommend a follow up CT scan of the chest once your symptoms resolve. START: Levofloxacin 750mg every 48 hours Albuterol inhaler as needed Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] as soon as possible Department: [Hospital3 1935] CENTER When: WEDNESDAY [2135-2-23] at 8:20 AM With: [First Name11 (Name Pattern1) 354] [Last Name (NamePattern4) 3013], M.D. [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2135-3-22] at 1:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3014], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [2135-5-19] at 9:30 AM With: [First Name11 (Name Pattern1) 312] [Last Name (NamePattern4) 3015], M.D. [Telephone/Fax (1) 1803] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 486, 5845, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6373 }	Medical Text: Admission Date: [2155-7-3] Discharge Date: [2155-7-9] Date of Birth: [2107-5-6] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: ESRD [1-13] HTN presents for renal transplant Major Surgical or Invasive Procedure: renal transplant [2155-7-3] History of Present Illness: 48M with ESRD [1-13] HTN presents for deceased donor kidney transplant. Patient reports he has been in good health recently. He last underwent HD today via his LUE AV fistula. ROS negative for fevers/chills, nausea, vomiting, chest pain, shortness of breath, changes in bowel or bladder habits. Past Medical History: ESRD on HD Tu/Th/Sat since [2150] HTN Hyperlipidemia Hyperparathyroidism, secondary osteoporosis. GERD Thyroid nodules +Lupus Anticoagulant [2155-7-3] Cadaveric renal transplant Social History: Lives at home with his wife, son, and two daughters. Retired chef. Prior h/o heavy smoking. No ETOH. Family History: HTN Physical Exam: Weight 79.8kg VS: 98.7 82 139/95 18 100%RA Gen: NAD CV: RRR Chest: CTAB Abd: S/NT/ND, no scars Ext: WWP, no edema; LUE with AV fistula +thrill; 2+ distal pulses in arms/legs b/l Labs: 6.2 > 45.6 < 211 141 97 24 --------------< 4.0 32 7.1 Ca 9.8 Mg 2.2 Phos 3.6 AST 10 ALT 8 Alb 5.2 PTT 33.5 INR 1.1 Studies: [7-3] EKG - no evidence of ischemia, moderately elevated T waves in lateral chest leads [7-3] CXR - no acute cardiopulmonary process Pertinent Results: [2155-7-9] 04:55AM BLOOD WBC-4.5 RBC-3.73* Hgb-11.4* Hct-34.5* MCV-93 MCH-30.5 MCHC-32.9 RDW-18.8* Plt Ct-166 [2155-7-7] 05:39AM BLOOD PT-15.3* PTT-37.2* INR(PT)-1.3* [2155-7-3] 07:40PM BLOOD UreaN-24* Creat-7.1# Na-141 K-4.0 Cl-97 HCO3-32 AnGap-16 [2155-7-9] 04:55AM BLOOD Glucose-104 UreaN-80 Creat-8.6* Na-133 K-4.7 Cl-97 HCO3-21* AnGap-20 [2155-7-9] 04:55AM BLOOD Calcium-9.5 Phos-6.2* Mg-2.1 [2155-7-9] 04:55AM BLOOD tacroFK-8.8 Brief Hospital Course: On [2155-7-3], he underwent pediatric cadaveric renal transplant to right iliac fossa. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Induction immunosuppression was administered (cellcept, solumedrol and ATG). A ureteral stent was placed. Please refer to operative note. An u/s of the kidney was done on [7-4] showing no hydronephrosis, no large perinephric collection (trace fluid) and normal arterial/venous flow. Postop, he was hypertensive and required monitoring in the SICU for a labetalol drip to keep sbp <130 given pediatric kidney. Labetalol was weaned off and lopressor po was started tid. Norvasc was started. Blood pressure improved and he was transferred out of the SICU. Urine output was low initially, but increased daily to 1.5 liters per day. Creatinine remained in the 7-8 range. A total of 4 doses of ATG (100mg each)were given as well as cellcept 1gram [Hospital1 ] and steroid taper. Prograf was started and dose increased to 6mg [Hospital1 ] for a level of 8.8. Medication teaching was done and VNA arranged to continue teaching/monitor medication administration. Diet was advanced and tolerated. Many of his home meds were resumed. PT evaluated and recommended PT at home. The incision was intact with scant serosanuinous drainage. Vital signs were stable. He was discharged to home in stable condition. Medications on Admission: - Sensipar 30mg PO daily - Folate 1mg PO daily - Lasix 80mg PO daily - Metoprolol XL 50mg PO daily - Nifedipine (sustained release) 180mg PO daily - Omeprazole 20mg PO daily - Renagel 3200mg PO TID with meals - Simvastatin 20mg PO daily - ASA 81mg PO daily - Vit D - Calc/VitD - MVI Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,FR). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sevelamer HCl 400 mg Tablet Sig: Eight (8) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:1 12. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 13. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 14. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: esrd htn s/p renal transplant Discharge Condition: good Discharge Instructions: please call the Transplant office [Telephone/Fax (1) 673] if fever, chills, nausea, vomiting, incision redness/bleeding, decreased urine output, weight gain of 3 pounds in a day or edema Labs at [Last Name (NamePattern1) 439] [7-10] by 9am then every Monday and Thursday. Do not take prograf prior to lab work. Take after blood drawn. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2155-7-15] 2:35 Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2155-7-21] 3:10 Completed by:[2155-7-10] ICD9 Codes: 5856
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6374 }	Medical Text: Admission Date: [2121-4-17] Discharge Date: [2121-4-21] Date of Birth: [2046-11-18] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Reason for consult: Left frontal lobe hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 74yo RHF with HTN, DM, HL presenting with headache upon awakening this AM. She noted the headache as soon as she woke up and describes it as frontal and "just a pain." She did not have any nausea and vomiting. She went to her daughter's house to baby sit around 815am and was complaining of mild HA but was otherwise at baseline. Her daughter returned home around noon and found her mother confused and unable to recount what had happened that morning. She also called her daughter by the wrong nams. She was still complaining of the HA so her daughter called EMS. She was taken to [Hospital3 1280] Hosp where she was noted to be confused, but otherwise had a non-focal exam. Her SBP was in 150's. She had a head CT which showed a left frontal hemorrhage and she was transfered to [Hospital1 18] for further care. She denies any symptoms such as vision changes, numbness or weakness. She does note that it is harder to find words at times. She denies any recent illnesses, trauma, change in medications. Review of systems: No change in vision, hearing. No weakness, numbness. No change in gait. No fever, rhinorrhea, cough, SOB. No chest pain, palpitations. No nausea, vomiting, abdominal pain, diarrhea. No arthralgia, rash. No change in appetite, recent weight loss. No change in behavior. No history of trauma. Past Medical History: HTN HL DM TIA in [2119] - few hours of right arm/hand numbness Social History: Contact is [Name2 (NI) ] O'Shae [Telephone/Fax (1) 109637] Lives alone indenpently, able to do all ADL's on her own. Widowed with two daughters. Formerly worked as secretary. Remote history of smoking, rare EtOH use FULL CODE Family History: Mother had small stroke? No seizures. No DD, LD. No migraines. No stroke. No neuromuscular conditions. Physical Exam: T 97.3 HR 77/min, reg RR 18/min BP 168/94 mmHg Gen: Awake, alert, not in distress, lying in bed. Non-toxic appearance. Skin: No rash, skin stigmata such as hemangioma, pigmentation, dyspigmentation. HEENT: Normocephalic, no conjunctival injection, nares patent, mucous membranes moist, oropharynx clear. Neck: Supple, no meningismus. No cervical bruit. Resp: Clear to auscultation bilaterally CV: Regular rate, normal S1/S2, no murmurs, rubs, or gallops Abd: Bowel sounds present, abdomen soft, non-tender, and non-distended. Extrem: Warm and well-perfused. No arthralgia. ROM full. Neuro: MS - Awake, alert, interactive. Oriented to person, hospital (with prompting), and date. Attentions is mildly abnormal, able to do days of the week backwards but not months. Ok naming high frequency objects, struggles with low frequency. Repetition intact. Has difficulty recounting own history, with some word finding difficulty. Memory registers [3-12] 0/3 at 5min [2-12] with prompting; no left-right confusion. Cranial Nerves ?????? Pupils equal and reactive (5 to 3mm); EOM smooth and full, no diplopia; no nystagmus; Visual field full with confrontation test, intact facial sensation, face symmetric with full strength of facial muscles, palate elevation is symmetric, and tongue protrusion is symmetric and full movement. Sternocleidomastoid and trapezius are strong and normal volume. Tone - Slightly increased in LE Strength - Delt [Hospital1 ] Tri WrEx FEx FFlx IO [Location (un) ]/IP Quad Ham DF PF TF R 5 5 5 5 5 5 5 5 5- 5 5- 5 5 5 L 5 5 5 5 5 5 5 5 5- 5 5- 5 5 5 Reflexes - Biceps Triceps Brachioradialis Patellar Ankle R 2+ 2+ 2+ 2+ 2+ L 2+ 2+ 2+ 2+ 2+ Plantar responses flexor bilaterally Sensation - Intact to light touch, temperature, vibration, position throughout. Coordination - No dysmetria and smooth finger to nose. Accurate heel knee tapping. Gait - deferred Pertinent Results: [2121-4-17] 04:45PM GLUCOSE-84 UREA N-15 CREAT-0.6 SODIUM-141 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13 CALCIUM-9.1 PHOSPHATE-2.8 MAG-1.7 WBC-8.1 RBC-3.67* HGB-10.9* HCT-33.3* MCV-91 MCH-29.8 MCHC-32.8 RDW-13.5 NEUTS-72.4* LYMPHS-21.8 MONOS-3.7 EOS-1.4 BASOS-0.6 URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.014 BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILI-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-0-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 PT-11.8 PTT-22.1 INR(PT)-1.0 CTA ([2121-4-17]): LEFT FRONTAL INTRAPARENCHYMAL HEMORRHAGE MEASURING 4.3 X 3.6 CM UNCHANGED IN SIZE WITH MASS EFFECT ON LEFT VENTRICAL FRONTAL [Doctor Last Name ]. SMALL AMOUNT OF SURROUNDING EDEMA. 4MM LEFT TO RIGHT MIDLINE SHIFT IN FRONTAL REGION, UNCHANGED. MRI [Month (only) ] BE OBTAINED TO EXCLUDED UNDERLYING MASS. NO EVIDENCE OF VASCULAR ANEURYSM, DISSECTION, OR HEMODYNAMICALLY SIGNIFIANCT STENOSIS. CALCIFICATION OF THE CAVERNOUS CAROTIC ARTERIES. MRI ([2121-4-18]): Findings: 1. Large left frontal parenchymal hematoma with associated subarachnoid blood products, as well as small left frontotemporal subdural hematoma. Mass effect and rightward shift of the normally midline structures is stable. Though underlying amyloid angiopathy is a prime consideration, the presence of multicompartmental hemorrhage raises the possibility of post-traumatic injury, though there is no evident injury to the extra-calvarial soft tissues, and, apparently, no known history of trauma. 2. Punctate focus of susceptibility artifact in the right parietal lobe, though non-specific, may represent microhemorrhage (no calcification is seen at this site on CT), and support the diagnosis of amyloid disease. 3. Moderate chronic microvascular ischemic white matter disease, and central and cortical atrophy. 4. Sinus disease as described above, the activity of which is to be determined clinically. COMMENT: As discussed with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], the requesting physician, [Last Name (NamePattern4) ] 1:15 PM on [2121-4-18], recommend follow-up enhanced MR study in [6-17] weeks' time, with expected resorption of blood products, to more fully exclude an underlying mass. Brief Hospital Course: A/P: Pt is a 74yo RHF with HTN, DM, and HL presenting with headache and confusion found to have a left frontal hemorrhage. Her exam is notable for a mild inattention and an expressive aphasia. Etiology of the hemorrhage is unclear at this point but includes amyloid angiopathy, ischemic infarct with hemorrhagic conversion, underlying mass or vacular malformation or hypertension. The location is more suggestive of amyloid angiopathy or underlying mass as it is not in a particular vascular territory for a ischemic infarct with conversion and also not a typical location for hypertensive bleed. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Hospital Course: Ms. [Known lastname 1391] was admitted to the Neurology ICU for close monitoring. She was loaded with Keppra, and placed on a standing dose of 750mg [Hospital1 ] to be continued for 1 month. She underwent an MRI which showed her large hemorrhage and a distinct punctate area of microhemorrhage, suggestive of amyloid angiopathy. There were no underlying masses or arteriovenous malformations seen; note, however, that a large hemorrhage frequently obscures such predisposing structural lesions. On [4-18] she was transferred out of the ICU to the floor, where she had an uneventful period of staging for rehab placement. The only changes to her home med regimen were the increase of lisinopril from 10 to 20mg qDay and the discontinuation of her Aggrenox. She would be stable to restart ASA 81mg 4 weeks following her bleed, at the discretion of her PCP. [Name10 (NameIs) ] only new medication is the previously mentioned Keppra, which she will continue for at least three months. Medications on Admission: Aggrenox 25/200mg Lipitor 20mg Metformin 850mg Glyburide 5mg Lisinopril 10mg atenolol 50mg Allergies: No known any allergies. Discharge Medications: 1. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day: Plan to take this medication for at least three months, and perhaps longer pending the evaluation of your Neurologist. 6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [Location (un) 582] at [Location (un) 620] Discharge Diagnosis: Parenchymal cerebral hemorrhage (a bleed within the brain) Discharge Condition: Making occasional paraphasic errors, especially word finding and grammatical structure. Sequencing and planning skills are poor. She demonstrated interval improvement in each of these deficits over the last three days of hospitalization. Speech is fluent. Alert, awake, interactive. Ambulating independently Slight pronator drift in the L. hand, otherwise strength full and symmetrical Discharge Instructions: You were evaluated following a period of confusion and were found to have a hemorrhage within your brain (left frontal lobe). We evaluated you for causes of such a bleed, such as a tumor, a malformation of your blood vessels, or a trauma, and found no evidence for these causes of bleed. We suspect that you have a condition called amyloid angiopathy, which is a condition of elderly persons in which the small arteries in the brain become fragile and prone to bleeding. Because your bleed was quite large, it is impossible to see the area immediately around the bleed. Therefore, you need an MRI in [6-17] weeks to assess for any of the above-mentioned causes of hemorrhage. We have stopped one of your home medications (Aggranox) - you can substitute aspirin 81mg for this medication in four weeks. Followup Instructions: Upon discharge from rehab - 1. Contact Dr. [Last Name (STitle) 12997] for a rapid follow-up appointment, within 1-2 weeks of leaving rehab. Plan to restart aspirin 81mg four weeks following your bleed. 2. Request a follow-up MRI in [6-17] weeks. This study is to evaluate the area of your hemorrhage for any causative structural lesions that we are unable to see on the current study. 3. Request follow-up with an Atrius Neurologist in 3 months to evaluate the need for further anti-seizure medication. This visit will likely include an EEG, a test of brain activity. Continue taking Keppra until this appointment. This Neurologist will make the decision about whether to continue this medication. Completed by:[2121-4-21] ICD9 Codes: 431, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6375 }	Medical Text: Admission Date: [2104-4-16] Discharge Date: [2104-4-25] Date of Birth: [2026-9-9] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Positive stress test Major Surgical or Invasive Procedure: [2104-4-21] Two Vessel Coronary Artery Bypass Grafting utilizing a free left internal mammary artery to left anterior descending artery with saphenous vein graft to obtuse marginal. History of Present Illness: Mr. [Known lastname 110616] is a 77 year old male with multiple cardiac risk factors and known cardiomyopathy. He recently underwent ETT which revealed a large fixed anterior wall defect, suggestive of prior MI with an overall LVEF of 35%. He was subsequently referred for cardiac catheterization which revealed a 90% left main lesion. He remained pain free on medical therapy and was transferred to the [Hospital1 18] for surgical revascularization. Past Medical History: Coronary artery disease Non-insulin Dependent Diabetes Mellitus Chronic Systolic Heart Failure Chronic Wenckebach rhythm Abdominal Aortic Aneurysm s/p Herniorrhaphy [2036] Social History: Race: Caucasian Lives: Alone Occupation: Works in a wine store Cigarettes: Quit 27 years ago ETOH: [2-26] drinks/week Illicit drug use: Denies Family History: Denies premature coronary artery disease Physical Exam: ADMIT EXAM BP 142/86 Pulse: 90 Resp:18 O2 sat: 96% on RA Height: 74" Weight: 93.4 kg General: WDWN male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: cath site Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [2104-4-16] WBC-5.0 RBC-4.03* Hgb-12.9* Hct-41.2 MCV-102* RDW-12.1 Plt Ct-206 [2104-4-16] PT-11.4 PTT-28.0 INR(PT)-1.1 [2104-4-16] Glucose-109* UreaN-21* Creat-0.9 Na-139 K-4.5 Cl-104 HCO3-30 [2104-4-16] ALT-18 AST-29 LD(LDH)-179 AlkPhos-51 Amylase-107* TotBili-0.8 [2104-4-16] %HbA1c-5.8 eAG-120 . [2104-4-17] Echocardiogram: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is severely depressed with global hypokinesis and a relative sparing of the basal inferolateral segment (LVEF= 15 %). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mildly dilated left ventricle with normal wall thickness and severe global left ventricular hypokinesis. Mildly dilated aortic root and aortic arch. No clinically signficant valvular regurgitation or stenosis. Normal pulmonary artery systolic pressure. . [2104-4-17] Carotid Ultrasound: Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. Right ICA <40% stenosis. Left ICA <40% stenosis. . [2104-4-18] Cardiac MR: 1. Moderately increased left ventricular cavity size. Global left ventricular hypokinesis with severe hypokinesis to akinesis of the mid to distal anterior wall, apex, and entire inferior wall. Abnormal motion of the septum and left ventricular intraventricular dyssynchrony. The LVEF was severely depressed at 23%. 2. No CMR evidence of prior myocardial scarring/infarction. 3. Normal right ventricular cavity size with normal global and regional systolic function. The RVEF was normal at 49%. 4. Mild tricuspid regurgitation. 5. Mild biatrial enlargement. . [2104-4-24] 05:48AM BLOOD WBC-7.4 RBC-2.64* Hgb-8.5* Hct-25.4* MCV-96 MCH-32.3* MCHC-33.6 RDW-11.8 Plt Ct-116* [2104-4-24] 05:48AM BLOOD Glucose-130* UreaN-15 Creat-0.7 Na-137 K-4.0 Cl-99 HCO3-33* AnGap-9 Brief Hospital Course: Mr. [Known lastname 110616] was admitted to cardiac surgical service and underwent further preoperative evaluation. Echocardiogram confirmed severely depressed LV function with an EF 15%. There was no aortic valve disease with only trivial mitral regurgitation. Cardiac MR [First Name (Titles) 654] [Last Name (Titles) 110617] myocardium. He remained pain free on medical therapy, and was eventually cleared for surgery. On [4-21], Dr. [Last Name (STitle) ] performed two vessel coronary artery bypass grafting. For surgical details, please see operative note. Given his prolonged hospital stay, Vancomycin was used for perioperative antibiotic coverage. Following surgery, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the floor on postoperative day one. He remains on Imdur for his free left internal mammary artery graft for three months. Low dose beta blocker was started and the Electrophysiology Service was consulted due to his chronic Wenchebach block. This was changed to Carvedilol due to his systolic dysfunction. An echocardiogram prior to discharge demonstrated a left ventricular ejection fraction of 20% (v. 10-15% immediaetly off bypass). Medications on Admission: Actos 22.5mg daily, Metformin 500mg [Hospital1 ], Glipizide ER 5mg daily, Lovastatin 40mg daily, Aspirin daily, Multivitamin daily, Fish oil 100mg daily, Vitamin D [2092] units daily, Vitamin b complex daily Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain, fever. 4. pioglitazone 15 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily) for 3 months. 8. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. omega-3 fatty acids Capsule Sig: [1-21] Capsules PO DAILY (Daily). 11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Location (un) ] House Nursing Home - [Location 9583] Discharge Diagnosis: Coronary Artery Disease s/p coronary artery bypass grafts Chronic Systolic Congestive Heart Failure Non-insulin Dependent Diabetes Mellitus Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Provider: [Last Name (NamePattern4) ].[First Name (STitle) ] R. [Doctor Last Name ] ([Telephone/Fax (1) 170]) on [2104-5-28] at 1:45 Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office will call with an appointment. Please call to schedule appointments with your Primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 68100] in [4-24] 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:[2104-4-25] ICD9 Codes: 4280, 4111, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6376 }	Medical Text: Admission Date: [2200-12-30] Discharge Date: [2201-1-7] Date of Birth: [2152-1-8] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 12174] Chief Complaint: Tylenol overdose Major Surgical or Invasive Procedure: None. History of Present Illness: -- per admitting MICU resident -- 48 F with a history of depression, PSA, migraines who has been abusing pain medications for several years. The history is obtained from her significant other [Name (NI) 25368] as patient is encephalopathic. Per his report patient took 100 of his Percocets and took those throughout the weekend and to the best of his knowledge her last ingestion was Monday. Patient has a recent T11 compression fracture suffered at work which triggered increased use. Denies suicide attempt. Was taken to ER by [Location (un) 25368] after she became progressivelly confused over the weekend. She was started on NAC after a Tylenol level of 52 at 1530. AST 2725, ALT 2620, bili 2.3. CTH at OSH was per report negative. In the ICU patient states her name but otherwise confused. ABG in the ER with pH 7.47. Around midnight the patient had coffee ground emesis which was guiaic positive. NGT was placed and was lavaged with 2500cc, would clear but subsequently marroon liquid would be suctioned. Liver fellow was present and given HD stability decision to defer endoscopy until AM was made. Past Medical History: Depression PS abuse Migraines Social History: Smokes unknown quantity, No ETOH per significant other. [Name (NI) ] illicit drug use other than prescription meds. Works as CNA at a nursing home. Family History: Non-contributory Physical Exam: -- on arrival to floor -- VS: 99/98.7 87 BP 87-132/54-80 12 98-100% RA GEN: somnolent but arousable, oriented x 3 CV: RRR s mrg RESP: CTA on limited exam ABD: TTP on RUQ > LUQ, no rebound, guarding, or rigidity. Hyperactive BS, no distention. EXT: WWP, 2+ pulses, no c/c/e NEURO: Could not assess asterixis as limited patient cooperativity. Pertinent Results: [2201-1-6] 05:23AM BLOOD WBC-6.1 RBC-2.97* Hgb-8.7* Hct-26.4* MCV-89 MCH-29.4 MCHC-33.0 RDW-18.2* Plt Ct-169 [2201-1-6] 05:23AM BLOOD Glucose-84 UreaN-8 Creat-0.5 Na-142 K-3.8 Cl-107 HCO3-28 AnGap-11 [2201-1-6] 05:23AM BLOOD ALT-165* AST-39 AlkPhos-114* TotBili-0.6 [2201-1-6] 05:23AM BLOOD Albumin-3.0* Calcium-8.2* Phos-3.8 Mg-1.9 [2200-12-31] 05:22PM BLOOD Cryoglb-NEGATIVE [2200-12-30] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-31.7* Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2200-12-30] 10:40PM BLOOD Acetmnp-21.7 [2200-12-31] 03:44AM BLOOD Acetmnp-13.3 [2200-12-31] 11:38AM BLOOD Acetmnp-5.5* [2200-12-31] 05:22PM BLOOD Acetmnp-NEG [2201-1-1] 03:01AM BLOOD Acetmnp-NEG [2200-12-31] 05:22PM BLOOD RheuFac-13 [2200-12-30] 10:40PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE HAV Ab-POSITIVE [2200-12-31] 11:38AM BLOOD TSH-0.30 [2200-12-31] 05:22PM BLOOD RheuFac-13 [2200-12-30] 10:40PM BLOOD HCV Ab-POSITIVE* [2200-12-30] 08:10PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-8* pH-6.5 Leuks-NEG URINE CULTURE (Final [2201-1-2]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S HCV VIRAL LOAD (Final [2201-1-3]): THIS IS A CORRECTED REPORT ([2201-1-3] AT 3PM). 1,370,000 IU/mL. [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgG AB (Final [2201-1-1]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS EBNA IgG AB (Final [2201-1-1]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgM AB (Final [2201-1-1]): NEGATIVE <1:10 BY IFA. CMV IgG ANTIBODY (Final [2201-1-2]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 183 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [2201-1-2]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. [12-30] RUQ U/S: 1. Unremarkable ultrasound of the liver. 2. A 1.1 cm predominantly hyperechoic lesion incidentally noted within the upper pole of right renal cortex with features most compatible with angiomyolipoma. [12-31] EEG: IMPRESSION: This is an abnormal routine EEG due to a discontinuous background consisting of seconds of diffuse high voltage delta frequency slowing and triphasic waves alternating with equal periods of global attenuation approaching a burst suppression pattern. There was also 14 and 6 Hz positive spikes, which is a variant pattern reported in severe hepatic failure. This EEG pattern is indicative of a severe diffuse encephalopathy. [12-31] TTE: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. [12-31] CT head: No intracranial hemorrhage. Mild diffuse cerebral edema without herniation. Given patient's intoxication history, the differential includes reversible hepatic encephalopathy versus progressive hypoxic-ischemic encephalopathy. Recommend MR to distinguish between these two etiologies. [1-1] MR/MRA head 1. Subtle T2 hyperintensity and mild diffusion restriction in the bilateral basal ganglia and central thalami. Diffuse mild cortical edema. These findings are suggestive of metabolic encephalopathy. 2. Intact intracranial circulation, with possible infundibulum at the origin of the right PComm. Brief Hospital Course: Briefly, the patient presented with AMS and was started on NAC given a h/o ingestion of "100 percocets" per patient's SO. Tylenol level found to be 52 in ED with AST/ALT [2190]+ and bili 2.3. CT head @ OSH negative. Patient was admitted to MICU on NAC drip and had a hospital course complicated by coffee ground emesis leading to NGT placement. With lavage the patient cleared, but she did require blood transfusion. Began to develop decerebrate posturing, and a CT head showed e/o cerebral edema. EEG showed evidence of diffuse encephalopathy with no epileptiform activity. Neuro recommended mannitol and hyperventilation, after which patient's neuro exam improved. MRI of the head was consistent with metabolic encephalopathy. She was continued on NAc/lactulose and had interval improvement in awareness, mental status. Incidentally, pt was found to have UTI and completed a 3 day course of Macrobid. At time of transfer, patient was oriented x 3 but still significantly drowsy. . She was continued on lactulose on the floor and her mental status cleared. As her liver enzymes were returning to normal, the N-acetylcysteine drip was discontinued. . The patient was placed under Section 12 by Psychiatry with plan to transfer to inpatient psychiatry unit after discharge. At time of discharge, patient is medically stable with evidence of resolving liver damage warranting no further inpatient workup or management. Her mental status has cleared with no current evidence of ongoing encephalopathy. Her upper GI bleed earlier in her hospital course spontaneously resolved and her hematocrit remained stable. She will need to continue a proton-pump inhibitor for at least 4-8 weeks. As an outpatient, she will need an EGD to further work up the source of the bleed, but as there is no evidence of ongoing bleeding for several days, this does not warrant inpatient workup. . She was also noted to be Hep C positive during this admission with an viral load of 1,370,000 IU/mL. This should be followed up as an outpatient. Medications on Admission: Trazodone 100mg Methadone 10mg PO BID Valium Percocet abuse Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: 1. tylenol-induced hepatitis 2. substance abuse 3. suicidal ideations 4. metabolic encephalopathy Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were seen at [Hospital1 18] for altered mental status thought due to an overdose. You were placed on a detoxification regimen and admitted to the intensive care unit. You had evidence of brain dysfunction, but this resolved after several days in the unit. You also had a bleed from your stomach which spontaneously resolved, but you required a blood transfusion. The following medications were changed; ADDED pantoprazole to treat you after a history of bleeding from your stomach Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 86616], four weeks after you are discharged. You can contact his office at [Telephone/Fax (1) 75627]. Completed by:[2201-1-7] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6377 }	Medical Text: Admission Date: [2171-9-23] Discharge Date: [2171-10-2] Date of Birth: [2102-11-12] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor Last Name 19844] Chief Complaint: s/p Pedestrian struck by auto Major Surgical or Invasive Procedure: [2171-9-30] 1. Open reduction internal fixation pelvic ring fracture left and right side with cannulated 7.3 mm screws. 2. Open reduction internal fixation left ankle with medial shear antiglide plating. History of Present Illness: 68 year old male with unknown past medical history who has been transferred from [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital who presents with spinal and pelvic fractures status post pedestrian struck. He reportedly was struck by a motor vehicle traveling approximately 30-35 miles per hour. There was significant front end damage to the vehicle. The patient was thrown approximately 15-20 feet and had a loss of consciousness during the accident. EMS arrived on scene and found the patient to be conscious but confused and complaining of hip and leg pain. He was taken by EMS to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] hospital, where he was found to have spinal and pelvic fractures by CT imaging. His pelvis was stabilized, and he was transported to [Hospital1 18] for further surgical evaluation. The patient did not receive any pain medication or sedation, and complains now of 1 out of 10 pelvic pain. Past Medical History: EtOH abuse, HTN, anxiety Social History: +EtOH Family History: Noncontributory Physical Exam: Upon presentation to [Hospital1 18]: HR: 85 BP: 130/ O(2)Sat: 98 Normal Constitutional: GCS 15 HEENT: Left anterior scalp laceration. Small occipital laceration, Pupils equal, round and reactive to light, Extraocular muscles intact Cervical collar in place. No hemotympanum. No bloode in the nares. Chest: Airway patent. Clear breath sounds bilaterally. Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nondistended Pelvic: Pelvis wrapped with sheet GU/Flank: Foley in place, + hematuria Extr/Back: 2+ radial and DP pulses bilaterally. Skin: Skin abrasions over knees, bilaterally Neuro: 5/5 strength throughout the lower extremities, bilaterally. Pertinent Results: [2171-9-23] 01:33PM HCT-31.4* [2171-9-23] 06:37AM CK(CPK)-1810* [2171-9-23] 06:37AM CK-MB-31* MB INDX-1.7 cTropnT-<0.01 [2171-9-23] 01:37AM PH-7.28* COMMENTS-TRAUMA,GRE [2171-9-28] 01:08AM BLOOD WBC-9.0 RBC-2.72* Hgb-9.0* Hct-26.8* MCV-98 MCH-33.2* MCHC-33.8 RDW-14.7 Plt Ct-206 [2171-9-30] 05:51AM BLOOD WBC-9.8 RBC-2.89* Hgb-9.5* Hct-28.4* MCV-98 MCH-32.9* MCHC-33.5 RDW-14.3 Plt Ct-330# [2171-9-30] 07:40PM BLOOD WBC-11.4* RBC-2.90* Hgb-9.7* Hct-28.6* MCV-99* MCH-33.4* MCHC-33.9 RDW-14.2 Plt Ct-381 [2171-10-1] 06:00AM BLOOD WBC-9.1 RBC-2.72* Hgb-9.0* Hct-26.6* MCV-98 MCH-32.9* MCHC-33.6 RDW-14.2 Plt Ct-335 [2171-9-28] 01:08AM BLOOD Glucose-132* UreaN-15 Creat-0.7 Na-140 K-3.6 Cl-105 HCO3-29 AnGap-10 [2171-9-29] 06:12AM BLOOD Glucose-153* UreaN-17 Creat-0.8 Na-139 K-3.6 Cl-104 HCO3-26 AnGap-13 [2171-9-30] 07:40PM BLOOD Glucose-146* UreaN-18 Creat-0.9 Na-138 K-4.5 Cl-104 HCO3-25 AnGap-14 [2171-10-1] 06:00AM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-137 K-4.1 Cl-103 HCO3-25 AnGap-13 CT head, C-spine(OSH)[2171-9-23]: no acute bleed/fracture TIB/FIB (AP & LAT) LEFT([2171-9-23]): There are acute fractures through the medial and lateral malleoli and proximal fibula, all nondisplaced. No knee joint effusion. KNEE 2 VIEW PORTABLE LEFT([2171-9-23]): There are acute fractures through the medial and lateral malleoli and proximal fibula, all nondisplaced. No knee joint effusion. HAND (AP, LAT & OBLIQUE) RIGHT([2171-9-23]): No fracture. WRIST, AP & LAT VIEWS RIGHT([2171-9-23]): Radius and ulna and elbow joint are normal. There are no carpal bone, metacarpo- or phalangeal fractures. The scaphoid appears intact. No fracture. ELBOW (AP, LAT & OBLIQUE) RIGHT([2171-9-23]): There is no evidence right glenohumeral or elbow joint dislocation. There is no acute fracture. No AC joint separation. SHOULDER 1 VIEW RIGHT([2171-9-23]): There is no evidence right glenohumeral or elbow joint dislocation. There is no acute fracture. No AC joint separation. RIGHT HUMERUS (AP & LAT) ([2171-9-23]): There is no evidence right glenohumeral or elbow joint dislocation. There is no acute fracture. No AC joint separation. RIGHT FOREARM (AP & LAT) ([2171-9-23]): Radius and ulna and elbow joint are normal. No fracture. [9-26] CT cystogram ([Last Name (un) ]): filling defect on the CT cystogram. given its appearance and comparing it to the CT from 4 days earlier, differential would be clot versus tumor. given that the foley is expanding pressure upon it, clot is more likely. no evidence of extrav from the bladder. complex pelvic fx. [9-27] CXR: There are persistent low lung volumes. Cardiomegaly is accentuated by the low lung volumes. Minimal bibasilar opacities, likely atelectasis, have increased on the left. There is no pneumothorax or pleural effusion. Dobbhoff tube tip is in the stomach. Brief Hospital Course: He was admitted to the acute care/trauma surgery service and transferred to the trauma ICU for close monitoring. His hospital course as follows by systems: N: He was initially alert and responsive. However, his mental status quickly deteriorated secondary to alcohol withdrawal and he became confused and agitated. He was placed on a CIWA regimen with Ativan and Valium. He was given thiamine for 7 days and a clonidine patch to help with his withdrawal. His mental status eventually cleared over the next few days. At time of transfer from the ICU to the floor he had no requirements for Ativan or Valium. His mental status on day of discharge was alert and oriented x2 without agitation. CV: He was hypertensive initially felt likely secondary to withdrawal and he was given metoprolol and labetalol as well as clonidine. He was also given hydralazine. Eventually as his withdrawal symptoms subsided his blood pressure normalized at and time of discharge his blood pressure was 128/80 with a heart rate of 97. He is being discharged on Lopressor and Clonidine patch. The Clonidine patch can be tapered over the next week if his mental status continues to improve and his blood pressure and heart rate are stable on the beta blockers. Pulm: He had multiple rib fractures and his pain was controlled. He was saturating well on face tent initially and then nasal cannula. Serial chest xrays were followed showing low lung volumes with some atelectasis. He was started on nebulizers and the oxygen was weaned - his saturations are ranging in the high 90's range at time of discharge. GI: He was kept NPO and on IVF while actively withdrawing. A Dobbhoff tube was placed on [9-26] and tube feeds started. Once his mental status improved, speech and swallow evaluated him and he was then given a mechanical soft diet. GU: There was concern for a hematoma near the bladder and urology consult was placed. Urology recommended continuing Foley for 7 days with gentle irrigation for clots. The Foley was removed on HD# 9. Heme: His hematocrits were stable ranging in the mid to high 20's. He is receiving daily Lovenox for DVT prophylaxis. MSK: For his lower extremity and pelvic fractures Orthopedics was consulted and once able to obtain consent he was taken to the operating room for open reduction internal fixation pelvic ring fracture left and right side with cannulated 7.3 mm screws and open reduction internal fixation left ankle with medial shear antiglide plating. He is non weight bearing on both lower extremities. Dispo: He was evaluated by Physical and Occupational therapy and is being recommended for rehab after his acute hospital stay. Medications on Admission: Denies Discharge Medications: 1. Enoxaparin Sodium 40 mg SC DAILY 2. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD 1X/WEEK (MO) 3. Docusate Sodium 100 mg PO BID 4. Bisacodyl 10 mg PO/PR DAILY:PRN no BM 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 6. Metoprolol Tartrate 50 mg PO TID Hold for HR < 60, SBP < 100 7. Senna 1 TAB PO BID:PRN constipation 8. Acetaminophen 325-650 mg PO Q6H:PRN pain 9. Multivitamins 1 TAB PO DAILY 10. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain Discharge Disposition: Extended Care Facility: [Hospital ] Rehabilitation & Skilled Nursing Center - [Location (un) 1456] Discharge Diagnosis: s/p Pedestrian struck by auto Injuries: Right sacral fracture Right inferior/superior pubic rami fractures with displacement Right 2,4,6 rib fractures T12 compression fracture subacute Left medial maleolus fracture Proximal left fibula fracture Secondary Diagnosis: Acute alcohol withdrawal Delirium 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 hopsital after being struck by an auto where you suatined multiple injuries including rib fractures and broken bones in your pelvis, left leg and ankle. Your ankle fracture required an operation to repair this injury. You should avoid bearing any weight on your left ankle for at least the next 4-6 weeks and possibly longer per recommendation of the Orthopedic surgeon. You were also found to have an old compresion fracture of one of the spine bone located near your mid to lower back region. You were seen by the Spine specialists who did not recommend any acute treatments for this. You were seen by the Physical therapists and being recommended for discharge to a rehabilitation facility. Followup Instructions: * Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2171-10-24] at 3:15 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage You will need a chest x-ray prior to this appointment. Please go to [Hospital1 7768], [Hospital Ward Name 517] Clinical Center, [Location (un) ] Radiology 30 minutes prior to your appointment. Department: ORTHOPEDICS When: TUESDAY [2171-10-29] at 8:40 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2171-10-29] at 9:00 AM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2171-10-2*] ICD9 Codes: 5180, 4019, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6378 }	Medical Text: Admission Date: [2152-11-21] Discharge Date: [2152-11-24] Date of Birth: [2101-11-17] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7055] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: Cardiac catheterization, no intervention History of Present Illness: 51 yo male with history of CAD s/p CABG X3 in [2145] (LIMA to LAD, SVG to Diag and OM), HTN, HLD, tobacco use, ITP presents from [Hospital3 3583]. He woke up from sleep at 6am with severe substernal chest pain, radiating to both arms (L>R), with some tingling. HE took one nitroglycerin which helped with the pain initially, but it returned in 15 minutes, he felt as if an "elephant was sitting on his chest." He also complained of some diaphoresis during those episodes, but denied N/V. The patient presented to [Hospital1 3325] this AM with this chest pain. He was found to have elevated BP to 206/126. EKG showed ST depressions. Initial trop was 1.03. He was given SL nitro, total of 8mg IV morphine, 600mg plavix, 325mg aspirin, 50mg metoprolol PO. He was admitted to their CCU where he had recurrent chest pain at 4pm. He was then started on heparin and nitro drips. Most recent troponin prior to transfer was 9.10, CPK > 1000. On transfer, he has no chest pain. He was transferred here for emergent Cath. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Past Medical History: 1. CARDIAC RISK FACTORS:(-)Diabetes,(+)Dyslipidemia,(+)Hypertension 2. CARDIAC HISTORY: -CABG: [2145] X3 LIMA to LAD, SVG to Diag, SVG to OM 3. OTHER PAST MEDICAL HISTORY: ITP - was worked up at OSH, no splenectomy. Appendectomy at age 10 Social History: Lives with his girlfriend named [Name (NI) 53564]. [Name2 (NI) 12694] of water well. Divorced 4 years ago. 3 Children. He states that he quit smoking on and off, but most recently a month ago, but had a few cigarettes while in [Last Name (un) ] last week. Routine EtOH intake [2-10] beers daily. company in [Location (un) 3320] -Tobacco history: (+) -ETOH: (+) -Illicit drugs: none. Family History: Brother CAD with angioplasty, Father -lung CA at 61, Mother - [Name (NI) ]. Physical Exam: On Admission: VS: T=100PM BP= 137/85 HR= 85 RR= 18 O2 sat=98% on GENERAL: WDWN 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 CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . On discharge: VSS. Pertinent Results: [2152-11-21] 09:30PM PLT COUNT-158 [2152-11-21] 09:30PM WBC-12.7* RBC-4.73 HGB-14.3# HCT-41.4 MCV-88 MCH-30.3 MCHC-34.6 RDW-13.9 [2152-11-21] 09:30PM CK-MB-129* MB INDX-8.8* cTropnT-2.44* [2152-11-21] 09:30PM CK(CPK)-1472* [2152-11-21] 09:30PM estGFR-Using this [2152-11-21] 09:30PM GLUCOSE-151* UREA N-17 CREAT-1.2 SODIUM-136 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 ECHO: The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to mid-inferior and inferolateral walls. The right ventricular cavity is mildly dilated with low-normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Regional LV systolic dysfunction consistent with CAD. Mildly dilated RV with borderline normal function. No pathologic valvular abnormality seen. Cardiac Cath: Report not available at time of discharge. Brief Hospital Course: 51M with CAD s/p CABG X3 in [2145] (LIMA to LAD, SVG to Diag and OM), HTN, HLD, tobacco use, ITP presents from [Hospital3 3583] with chest pain. He was transported to the cath lab for emergent cath and then was admitted to the CCU for post-cath care. . # NSTEMI: Based on Cath from [2145], which showed Left main and two vessel coronary artery disease, mild global systolic left ventricular dysfunction, Normal left ventricular diastolic function; patient undergone CABG X3 LIMA to LAD, SVG to Diag, SVG to OM. At OSH EKG showed ST depressions in Lateral leads (I, AvL, V2-3). Patient s/p cath (which demonstrated SVG to OM was occluded, LIMA to LAD was patent, severe LV diastolic heart failur ) with no stenting, with deferred PCI due to likely completed NSTEMI. Also, CK: 1472 MB: 129 MBI: 8.8 Trop-T: 2.44. HE received 160 ml of contrast total. He was started on Aspirin 325 Daily, Eptifibatide 2 mcg/kg/min IV DRIP INFUSION Duration: 18, - Continue Heparin drip 6 hours s/p arterial hemostasis until chest-pain free, with no bolusing. This was stopped on HD#2. Plavix 75mg Daily (was loaded at OSH) for 1 month post MI. Atorvastatin 80mg Daily. Metoprolol titrated to HR of 60-70, as BP tolerates. We maintained O2 saturation above 90% with nasal cannula as needed. His Cardiac Enzymes peaked. Post cath checks without any complications. Echo was done and showed Regional LV systolic dysfunction consistent with CAD. Mildly dilated RV with borderline normal function. No pathologic valvular abnormality was seen. This patient would greatly benefit from total smoking cessation, and this was discussed with him. . . # Hypertensive Emergency/HTN - patient's BP was in 200's at OSH. Patient received Lasix 20, and was on nitro Drip while in cath. While in the CCU his blood pressure was not in the hypertensive. We monitored his blood pressure while in hospital. We stopped his home lisinopril, but he should resume it later if his blood pressure is increased. . # Elevated WBC count - likely post Cath but with low grade fever. This improved prior to discharge, and he was afebrile while in hospital. . #PROPHYLAXIS: Patient was prophylaxed with subcutaneous heparin and pneumoboots while inpatient. Medications on Admission: MEDICATIONS on TRANSFER: Metoprolol 50mg daily Heparin 1500units/hr Nitro 90mcg/min . HOME MEDICATIONS: Aspirin 325 daily Crestor 40mg Daily Lisinopril 20 Daily Multivitamin Cod liver oil Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 4. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:25 Tablets Refills:0 7. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Non ST Elevation Myocardial Infarction Coronary Artery Disease Hypertension Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had chest pain and a heart attack at [Hospital3 3583] and was transferred here for a cardiac catheterization. We found a blockage in one of the bypassed veins. We did not try to fix this artery as it appeared that the heart attack was over. You have done very well after the heart attack and an echocardiogram showed that your heart function is still OK but not quite as strong as before. You will have another echocardiogram at your new cardiologists office. Please follow the instructions of the physical therapist regarding activity until you see Dr. [Last Name (STitle) 5310]. We have made the following changes to your medicines: 1. Start taking Plavix every day to prevent any further blockages in your heart arteries 2. Start taking Imdur to prevent any chest pain and help lower your blood pressure. 3. Start taking Metoprolol to help your heart recover from the heart attack. 4. Continue to take a full (325mg) aspirin, Lisinopril and Crestor as before. 5. Take the nitroglycerin as directed for any chest pain or pressure. Please call Dr. [Last Name (STitle) 5310] if you have chest pain. Call 911 if the nitroglycerin does not relieve the chest pain. . Please talk to Dr. [Last Name (STitle) 5310] about returning to physical activity . You will need to stop smoking entirely to prevent further heart attacks. Smoking is a major contributor to your heart disease. Smoking cessation strategies have been discussed with you. Followup Instructions: Name: [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Specialty: Internal Medicine Address: 3 VILLAGE GREEN NORTH, STE. 321, [Location (un) ],[Numeric Identifier 40624] Phone: [Telephone/Fax (1) 55984] Appointment: Thursday [11-30] at 11:00AM Name: [Last Name (LF) 5310], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Specialist: Cardiology Address: [Doctor Last Name 37166],LOWER LEVEL, [Location (un) ],[Numeric Identifier ] Phone: [Telephone/Fax (1) 5315] Appointment: Tuesday [12-13] at 2:20PM Completed by:[2152-11-24] ICD9 Codes: 4019, 2724, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6379 }	Medical Text: Admission Date: [2130-7-20] Discharge Date: [2130-8-7] Date of Birth: [2057-6-24] Sex: F Service: MEDICINE Allergies: Spironolactone / Oxycodone Attending:[First Name3 (LF) 1377] Chief Complaint: bone biopsy concerning for histoplasmosis Major Surgical or Invasive Procedure: Paracentesis Flexible Sigmoidoscopy NG tube History of Present Illness: The patient is a 73-year-old African-American female with history of sarcoidosis (suggestive of liver involvement but no granulomas seen), cryptogenic cirrhosis complicated by portal hypertension and ascites. Noted onset of left-sided rib pain [2-6] months ago and subsequent imaging revealed a pathologic fracture of the left anterolateral fifth rib. Associated with a mass seen on CT and underwent a CT-guided bone biopsy with results suggesive of histoplasmosis. . Currently, patient feels fine but has felt better. Has had increased abdominal distention and leg swelling over the past two weeks. Related to the abdominal distention is a shooting pain along the lower right abdomen, a pain she often gets when she has a lot of fluid on. Notes that she has had decreased energy for the past two weeks. Has poor appetite as well though that is more chronic. Notes chills but no fevers or night sweats. Denies any headache, vision changes, pain or trouble swallowing, chest pain, cough, shortness of breath, diarrhea, nausea, vomiting. . Of note, patient was discharged on [7-6] after hypokalemia to 2.4 in setting of lasix. . ROS: per HPI, also denies BRBPR, melena, dysuria. Endorses dyspnea on exertion and inability to take deep breath when abdomen is distended Past Medical History: -Type 2 Diabetes, diet controlled -HTN -Cryptogenic cirrhosis (complicated by ascites and coagulopathy) -s/p hysterectomy for fibroids Social History: -Tobacco history: Distant as a teenager, none currently -ETOH: distant, only occasional -Illicit drugs: None -Home: 2 fam house; She lives in 1 unit and grand-daughter in other. Worked as a tutor for 34 years. Divorced and has one daughter who works as a pharmacist in [Doctor First Name 5256] -Grew up in [State 108] and [Doctor First Name 26692] then moved to [Location (un) 86]. Father was in the military. Never been to [State 5111] river valley Family History: -Paternal aunts with cancers of some sort, unclear what kind. -Mom, [Name (NI) ] and Sister all with Diabetes Physical Exam: ADMISSION exam VS: 97.8 127/64 70 18 100%RA GENERAL: Well appearing in NAD. Thin, cachectic appearing, pleasant HEENT: Anicteric sclera, MMM, whitish film over tongue, no lesions CARDIAC: RRR with 2/6 systolic murmur over LUSB, no JVD LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Distended but Soft, tender to palpation only over suprapubic/RLQ. No guarding or rebound. Dullness to percussion over dependent areas but tympanic anteriorly. No appreciable HSM EXTREMITIES: 1+ edema to thighs b/l. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: No asterixis, AOx3, CNs intact, 5/5 strength throughout, gait normal, intact FTN b/l SKIN: no lesions noted LYMPH: no axillary, supraclavicular, cervical, or inguinal LAD Discharge exam 97.9 99/50 59 18 100%ra GENERAL: elderly AA female in NAD HEENT: Anicteric sclera, moist membranes. Small cut on tip of nose CARDIAC: S1, S2 reg rhythm, 2/6 systolic murmur at LUSB and at apex radiating to axilla. LUNGS: CTA b/l with no wheezing, rales, or rhonchi ABDOMEN: Distended and tenser than yesterday, mildly tender. No rebound/guarding. EXTREMITIES: trace b/l LE edema to thighs. Warm and well perfused. NEUROLOGY: no asterixis, CN2-12 intact. Gait steady. A+Ox3 Pertinent Results: ADMISSION labs [2130-7-20] 09:10PM BLOOD WBC-3.4* RBC-3.54* Hgb-9.8* Hct-32.0* MCV-91 MCH-27.8 MCHC-30.7* RDW-17.1* Plt Ct-62* [2130-7-25] 05:21AM BLOOD Neuts-91.0* Lymphs-4.4* Monos-4.1 Eos-0.1 Baso-0.4 [2130-7-20] 09:10PM BLOOD PT-18.2* PTT-37.0* INR(PT)-1.7* [2130-7-20] 09:10PM BLOOD Glucose-118* UreaN-11 Creat-1.0 Na-135 K-4.2 Cl-105 HCO3-26 AnGap-8 [2130-7-20] 09:10PM BLOOD ALT-18 AST-41* LD(LDH)-274* AlkPhos-93 TotBili-1.2 [2130-7-20] 09:10PM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.1 Mg-1.9 [2130-7-25] 11:35PM BLOOD Lactate-2.3* . MICU labs [2130-7-28] 02:05AM BLOOD WBC-8.8 RBC-3.62* Hgb-10.7* Hct-32.0* MCV-89 MCH-29.7 MCHC-33.6 RDW-17.4* Plt Ct-38* [2130-7-28] 02:05AM BLOOD Plt Ct-38* [2130-7-28] 02:05AM BLOOD Glucose-86 UreaN-46* Creat-3.7* Na-135 K-3.9 Cl-100 HCO3-20* AnGap-19 [2130-7-28] 02:05AM BLOOD ALT-15 AST-26 LD(LDH)-210 AlkPhos-46 TotBili-3.1* [2130-7-28] 02:05AM BLOOD Calcium-7.7* Phos-5.2* Mg-2.1 Histoplasma Ag - negative Histoplasma Ab - negative Blood mycolytic cultures - negative rpt Histoplasma Ag - pending rpt bld cx - pending . Discharge labs [2130-8-7] 05:55AM BLOOD WBC-5.6 RBC-3.16* Hgb-9.5* Hct-28.9* MCV-92 MCH-29.9 MCHC-32.7 RDW-19.7* Plt Ct-111* [2130-8-7] 05:55AM BLOOD PT-22.8* PTT-61.0* INR(PT)-2.2* [2130-8-7] 05:55AM BLOOD Glucose-151* UreaN-47* Creat-2.0* Na-141 K-3.8 Cl-107 HCO3-26 AnGap-12 [2130-8-7] 05:55AM BLOOD ALT-16 AST-35 AlkPhos-83 TotBili-2.0* [2130-8-7] 05:55AM BLOOD TotProt-5.7* Calcium-8.9 Phos-3.6 Mg-1.8 . Imaging: Head CT [8-4]: Mildly rotated position of the head is noted. There is no evidence of acute intracranial hemorrhage, discrete masses, mass effect, or shift of normally midline structures. The ventricles and sulci are mildly prominent, consistent with age-related involutional changes. Periventricular and subcortical low-attenuating white matter lesions appear consistent with sequelae of chronic small vessel ischemic disease. There is no evidence of acute major vascular territory infarction. Bilateral mastoid air cells and visualized paranasal sinuses are clear. KUB [8-4]: Radiographs are limited due to motion and patient positioning. Given these limitations, there is a non-obstructive bowel gas pattern with no dilated loops of small bowel visualized and air within the colon. There is no large amount of free air. Osseous structures are grossly unremarkable. IMPRESSION: Non-obstructive bowel gas pattern. CXR [7-28]: Moderate cardiomegaly, severe pulmonary edema, and small bilateral effusions, larger on the left side, are unchanged. There is no pneumothorax. Left PICC tip is in the upper SVC. NG tube tip is in the stomach. Lesion in the lateral aspect of the left fifth rib is better seen in prior CT from [5-3]. . KUB [7-27]: Dilated loops of small bowel and air within the colon, most consistent with partial small-bowel obstruction. NG tube in the stomach. . ECHO [7-27]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is dilated with normal free wall contractility. 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. Mild to moderate ([2-6]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. Dilated right ventricle. Mild to moderate mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary artery systolic hyeprtension. EKG [7-26]: Sinus rhythm. Left axis deviation. Left anterior fascicular block. Non-specific repolarization abnormalities. Compared to the previous tracing of [2130-7-5] there is no diagnostic change. Abd CT [7-25]: 1. Multiple dilated loops of small bowel with collapsed terminal ileum are compatible with a small bowel obstruction. Probable transition point is seen in the left lower quadrant. There is no free air to suggest perforation. 2. Large volume ascites, cirrhosis, and splenomegaly. 3. Trace bilateral pleural effusions. Brief Hospital Course: 73F with cryptogenic cirrhosis c/b recurrent ascites p/w rib lesion suggestive of histoplasmosis admitted for treatment and evaluation, now with abdominal pain and distention concerning for SBO, altered mental status, acute kidney injury, transferred to MICU for closer monitoring, improved and now discharged to rehab. . #[Last Name (un) ]: Patient had rising BUN, Cr since admission, baseline 1.0, up to 3.7 this admission. Multifactorial: likely [3-9] pre-renal (FeNa and FeUrea both low when transferred to MICU) from underresuscitation of SBO/third spacing, two paracentesis, and treatment with ambisome. Prior to transfer to MICU, patient became oliguric and was given an albumin challenge with no immediate results. Diuretics were held and ambisome was discontinued. Patient was given about 2L crystalloid as well as about 125g albumin total. Her Hct was also found to be low, and she was given 2 units of blood. Since early [7-28] am, patient has been making more urine, and it would appear that some of her kidney damage is reversible, from ATN, and the decision was made to hold off dialysis and trend lytes, kidney function, urine lytes. Over the next few days her creatinine trended down and it was determined there would be no need for dialysis. Octreotide was stopped as HRS seemed less likely. Cr 2.0 on discharge. She will get weekly labs per below, including lytes and Cr/BUN. . #SBO: patient states that she has been having abdominal pain for the past week, worst [Date range (1) 34558], and appeared very sick. Lactate was 2.3. KUB and CT confirmed SBO, at ileo-cecal jxn, no free air. Patient a couple of days prior had a flex sig to assess for granulomatous lesions previously seen, although it is unlikely that this could have caused any sort of obstructive process. She also has a hx of TAH many years ago and adhesions may be the cause. No h/o SBO. -NGT was placed, serial abd exams showed large distended abd but soft. Tender to palpation, but no guarding/rebound. Lactulose was held. Patient was deemed not to be surgical candidate by surgery. Patient was started on Cipro/Flagyl and was switched to Zosyn upon arrival to MICU. Pain control with IV tylenol and IV dialudid 0.125 q6h prn pain. While narcotics in treatment of SBO not ideal, patient required some IV analgesic for symptom control. Around the same time that patient's UOP improved, abdominal pain also improved and patient began to start passing gas. She then began to have regular bowel movements. She had no bowel movements despite lactulose while in MICU [2048-8-2], NGT was placed [8-4]. KUB [8-4] showed nonobstructive bowel gas pattern. SBO resolved by time of discharge. . #CIRRHOSIS, with decompensation: Cryptogenic c/b by large volume ascites and grade I varices (EGD in [12/2129]), but no SBP in past or on cell count here. Patient generally had one paracentesis every few months for comfort, but since admission, required 2 paracentesis, one on [2130-7-21] with removal of 5L, and one on [2130-7-26], both of which were NOT consistent with SBP. As patient's SBO and [Last Name (un) ] developed, she appeared to have had a slight hepatic decompensation, as demonstrated by worsening mental status (while lactulose was held, MS improved once SBO and UOP improved prior to initiation of lactulose). In addition to rising Cr, worsening ascites, and encephalopathy, patient also started to exhibit asterixis, coagulopathy. Patient was started on Midodrine and Octreotide for management of possible concominant HRS. However, her renal function improved with decreasing creatinine and octreotide was stopped. In anticipation of discharge to rehab, therapeutic paracentesis was performed with removal of 1.5L of ascitic fluid on [8-3]. Patient became more altered prior to MICU transfer [8-4], head CT negative, lactulose restarted. Her HE was improved at time of discharge, and she is now on lactulose and rifaximin. He got a paracentesis that removed 3.5L on [8-7], w/ 25g albumin IV afterwards. If she has close f/u with the liver clinic, but if she develops ascites before than and tense abdomen, liver clinic should be called to set up paracentesis (([Telephone/Fax (1) 1582]). #Hypotension: Baseline pressures low due to cirrhosis (patient's BP's ranged from 80-100s during initial admission. However, upon transfer to MICU, BPs remained 80-100/40-50s despite treatment with 125g albumin, 2 units of blood, and 2L of crystalloid. Concern for sepsis in setting of SBO. A-line revealed SBP in 120-130s range initially in ICU, which eventually settled out to 100s range. As above, patient was treated with midodrine/octreotide. As patient got first liter of fluids after finishing blood in MICU, she went into flash pulm edema and had mild SOB, and required 1-3L NC. This improved once UOP picked up. All fluids were held at that point. No prior echo records were found, and an echo demonstrated preserved EF but mod TR, MR, and pulm hypertension. Given that BPs had been stable throughout MICU stay, A-line was d/c'ed. When the patient was transferred to the floor, she had stable blood pressures with systolics in the high 80s-90s and was asymptomatic at these pressures. However, on the night of [8-4] the patient became hypotensive to the 70s/30s with dizziness and was transferred to the MICU for pressor support. She did not require pressors while in the MICU as she had been fluid responsive while still on the floor. BP improved and she did not require further fluid boluses before being transferred back to the floor. her BP was stable on the floor, ranging 90-110 systolic. . #FUNGAL INFECTION: Bone biopsy suggestive of histoplasma. Previously had biopsies of GI tract suggestive of granulomatous process thought to be sarcoid but could be c/w histo. Otherwise has no known exposures or systemic symptoms. Fungal culture in blood and peritoneal fluid was negative; Histo Ag, Ab negative as well. Patient was treated with Ambisome with plans for tx for 1-2 weeks followed by Itraconazole for at least a year. Patient developed pancytopenia and renal failure concerning for ambisome effects, and this was stopped. After further evaluation by world's expert on histo, it appears that perhaps bone biopsy's findings were misleading and diagnosis of histoplasma was likely an artifact. Later in her course, new pathology slides were reviewed and it was confirmed that fungal elements truly were seen in the biopsy. Cryptococcus was suggested as the possible cause given its similarity in appearance. A serum cryptococcal antigen was weakly positive at 1:32 (though this can be falsely elevated with cirrhosis) and the patient was started on fluconazole, with the plan to follow up with ID for likely >8 week course. LP was performed [8-4] with negative CSF cryptococcal antigen and 1 WBC. Will need monitoring of CBCw/diff, BUN/Cr, weekly LFTs while on fluconazole, please fax to [Telephone/Fax (1) 1419] attn: [Last Name (un) ]. . #Anemia: Patient with worsening anemia, appeared to be c/w anemia of chronic disease. Smear without schistocytes, but did show abn associated with chronic liver disease so sequestration and damage from spleen may be playing role. Hct stable upon discharge . #DMII - diet controlled, may cover with ISS should patient require . #CODE: Full #CONTACT: sister, HCP is [Name (NI) 41890] [Name (NI) 2072]> Daughter (lives in North [Doctor First Name ]) [Telephone/Fax (1) 93375] =================================== TRANSITIONAL ISSUES # will need monitoring of CBCw/diff, BUN/Cr, weekly LFTs while on fluconazole, please fax to [Telephone/Fax (1) 1419] attn: [Last Name (un) ]. # f/u pending SPEP/UPEP, sent to assess for underlying heme or malignant process that may have predisposed her to crypto infection Medications on Admission: 1. Amiloride HCl 10 mg PO DAILY 2. Estrogens Conjugated 0.625 mg PO DAILY 3. Calcium Carbonate 600 mg PO BID 4. Fluticasone Propionate NASAL 2 SPRY NU [Hospital1 ]:PRN congestion 5. Senna 2 TAB PO DAILY hold for loose stools 6. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain 7. Boost NF (food supplement, lactose-free) 1 unit Oral daily Discharge Medications: 1. Amiloride HCl 10 mg PO DAILY 2. Acetaminophen 325-650 mg PO Q6H:PRN Pain/fever 3. Fluconazole 200 mg PO Q24H 4. Lactulose 30 mL PO TID 5. Midodrine 5 mg PO TID 6. Rifaximin 550 mg PO BID 7. Boost NF (food supplement, lactose-free) 1 unit Oral daily 8. Calcium Carbonate 600 mg PO BID 9. Estrogens Conjugated 0.625 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU [Hospital1 ]:PRN congestion 11. Senna 2 TAB PO DAILY hold for loose stools 12. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Disseminated cryptococcus cryptogenic cirrhosis type 2 diabetes mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms [Known lastname 10935], It was a pleasure taking care of you at [Hospital1 18]. You were found to have an infection from a fungus called cryptococcus. For this, you will be on an anti-fungal medication for a long time (several months at least). Your hospital course was also complicated by having a low blood pressure and altered mental status, which required stays in the ICU. However, you are doing much better now. Please call your doctor or return to medical care if you start to feel sick in any way. Followup Instructions: Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge Name: [Last Name (LF) ],[First Name3 (LF) ] L. Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 11962] Department: INFECTIOUS DISEASE When: TUESDAY [2130-8-8] at 3:30 PM With: [First Name11 (Name Pattern1) 3049] [Last Name (NamePattern4) 14666], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: LIVER CENTER When: WEDNESDAY [2130-8-16] at 8:40 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7128], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: LIVER CENTER When: WEDNESDAY [2130-9-13] at 9:20 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7128], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] ICD9 Codes: 5845, 5715, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6380 }	Medical Text: Admission Date: [2180-7-8] Discharge Date: [2180-7-28] Date of Birth: [2106-8-10] Sex: M Service: PLASTIC Allergies: Morphine / Codeine Attending:[First Name3 (LF) 7733] Chief Complaint: SOB, pleural effusion, sternal wound dihescience s/p sternectomy and CABG Major Surgical or Invasive Procedure: thoracentesis Sternal wound debridement and latissmus dorsi flap closure History of Present Illness: HPI: 73M male with h/o DMII, CAD s/p MI [2167] s/p 4-vessel CABG complicated by fracture of sternal wires and wound dehiscence. Recently was discharged from [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] service here at [Hospital1 18] on [6-30] after 10 day hospital stay. WAs discharged to [Hospital 38] rehab with vac dressing over chest wound. Pt tx'ed to S. [Hospital ] Hosp on [2180-7-5] for SOB, fever to 101.9, HR 119, and found to have large left pleural effusion s/p CT guided thoracentesis with 1200 cc removed and pt's resp status is markedly improved however his wound appears worrisome to them. Sating 93-96% on RA. . Here prior hospitalization was notable for the following: . CAD/CHF. [2180-5-1] with chest and arm pain and found to have non-Q MI. Transferred to Eastern [State 1727] MC on [2180-5-2] for cath, which showed multi-vessel disease. On [5-3] he had a CABGx4. Post-op course was complicated by respiratory failure and fluid overload. He also had paroxysmal afib for which amiodarone and coumadin were started. He later developed L hand weakness and was felt to have had a R MCA ischemic stroke by neurology. Sx improved, and he was admitted to acute rehab at EMMC on [2180-5-11]. . Sternotomy Wound Dehiscence. On [5-13] he was readmitted to medicine service after fracture of his sternal wires and sternal incision dehiscence. He underwent rewiring and debridement but continued to have serous drainage from the mid-portion of his wound. On [2180-5-19] he underwent sternal wound debridement and b/l pectoralis major flaps. On [5-24] he was started on cefuroxime for L-sided infiltrate and bronchospasm. On [6-14] he had another debridement and removal of several sternal wires. . Stroke: On [5-28] he developed L hand weakness and L facial droop was felt to have had a R MCA ischemic stroke by neurology (CT negative at that time); started on aggrenox. Carotid U/S nl on L, incomplete study on R. TEE with PFO with R to L shunting, concentric LVH, mod TR. LE dopplers with no DVT. . Per D/C summary at [Hospital1 34], patient noted to be anemic and was transfused 1 T PRBC, Cr 1.2-->2.0; due to changing Cr, lovenox was switched to Hep gtts. Past Medical History: DM x15 years h/o non-Q wave MI in [2167]; stents placed in [2173] and [2174]; CABGx4 vessel in [2180-4-19]. HTN hyperlipidemia chronic lower back pain; degenerative disk disease R rotator cuff repair umbilical hernia repair L total knee arthroplasty anal fissure repair [2167] appendectomy tonsillectomy nephrolithiasis mild renal insufficiency Social History: Lives in [Location (un) 63982], [State 1727] with wife and daughter. Quit smoking in [2147]. No alcohol. Family History: Father died of heart disease age 78. Father also with DM. Physical Exam: Tc 97.3, 87, 180/100, 20, 98% BSFS 122. Looks comfortable HEENT: PEERL, EOMI, mm moist Neck: supple, no LAD Chest: Mediastinal wound with minimal erythema on superior acpect of wound near sternal notch. Lungs with decreased breath sounds over left lower lobe. Heart: RRR. No M/G/R Abd: NABS, soft, NT, ND Ext: Petichial hyperpigneted rash over lower legs. 1+ pitting edema of feet and ankles. Neuro: alert and oriented. Answers questions appropriately. . Pertinent Results: . . Labs: Pleural Fluid at [Hospital1 34]: GS neg, Cx neg. WBC 63, alb 2.4, LDH 119 Cr 1.2 ([7-5])-->3.4 ([7-7]) --->2.9 ([7-8]) Labs [7-8] at [Hospital1 34]: 135 101 28 3.7 22 2.9 . WBC 6.0, HCT 30.7, plt 304. PTT 76.8 (hep 1250) . Rads at OSH: CT with Contrast: C/W SXternal Dehiscence with surgical packing. no pneumomediastinum but 1.3cm of SQ gas at prox edge. lg Left effusion. . ETT: [5-23]: in [State 1727]: EF 70%, concentric left vent hypertrophy. . [7-10] CXR: 1. Large midsternal lucency corresponding to known open sternal wound in this patient with history of sternal dehiscence. 2. Moderate-to-large left pleural effusion, probably slightly increased in size in the interval. It is difficult to exclude underlying pneumonia in the lingula or left lower lobe. . TTE: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 60%). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. The aortic root 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. The mitral valve leaflets are/present but cannot be quantified. There is no pericardial effusion. . [7-13] CXR: 1. Residual small left pleural effusion, without pneumothorax. 2. New small right pleural effusion. [2180-7-24] 04:55AM BLOOD WBC-7.4 RBC-3.23* Hgb-9.3* Hct-28.9* MCV-89 MCH-28.8 MCHC-32.2 RDW-16.1* Plt Ct-375 [2180-7-23] 11:24AM BLOOD WBC-7.7 RBC-3.14* Hgb-9.3* Hct-27.9* MCV-89 MCH-29.6 MCHC-33.4 RDW-16.2* Plt Ct-359 [2180-7-22] 06:15AM BLOOD WBC-7.6 RBC-3.23* Hgb-9.3* Hct-28.8* MCV-89 MCH-28.7 MCHC-32.2 RDW-16.5* Plt Ct-401 [2180-7-21] 07:57AM BLOOD WBC-10.1 RBC-3.20* Hgb-9.2* Hct-28.2* MCV-88 MCH-28.8 MCHC-32.7 RDW-16.4* Plt Ct-370 [2180-7-21] 03:39AM BLOOD Hct-26.9* [2180-7-20] 01:25PM BLOOD Hct-27.8* [2180-7-20] 05:24AM BLOOD WBC-9.9 RBC-3.22* Hgb-9.0* Hct-28.2* MCV-88 MCH-27.9 MCHC-31.8 RDW-16.2* Plt Ct-330 [2180-7-19] 10:44PM BLOOD Hct-26.0* [2180-7-19] 09:25AM BLOOD Hct-25.4* [2180-7-18] 03:00AM BLOOD WBC-17.2* RBC-3.25* Hgb-9.4* Hct-29.0* MCV-89 MCH-28.9 MCHC-32.4 RDW-14.9 Plt Ct-386 [2180-7-17] 09:50PM BLOOD WBC-13.7# RBC-3.44 Hgb-10.4* Hct-30.5* MCV-89 MCH-30.2 MCHC-34.1 RDW-14.6 Plt Ct-400 [2180-7-17] 05:47AM BLOOD WBC-8.7 RBC-3.29* Hgb-9.4* Hct-29.6* MCV-90 MCH-28.6 MCHC-31.9 RDW-14.9 Plt Ct-428 [2180-7-16] 02:45AM BLOOD WBC-9.8 RBC-3.26* Hgb-9.6* Hct-29.4* MCV-90 MCH-29.4 MCHC-32.6 RDW-15.1 Plt Ct-434 [2180-7-26] 06:15AM BLOOD PT-12.6 PTT-25.8 INR(PT)-1.1 [2180-7-17] 09:50PM BLOOD PT-12.6 PTT-27.4 INR(PT)-1.1 [2180-7-17] 05:47AM BLOOD PT-12.2 PTT-29.1 INR(PT)-1.0 [2180-7-16] 02:45AM BLOOD PT-13.2 PTT-36.3* INR(PT)-1.1 [2180-7-26] 06:15AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-136 K-4.2 Cl-98 HCO3-32 AnGap-10 [2180-7-25] 12:05PM BLOOD Glucose-168* UreaN-8 Creat-0.8 Na-135 K-4.4 Cl-99 HCO3-31 AnGap-9 [2180-7-24] 04:55AM BLOOD Glucose-120* UreaN-8 Creat-0.8 Na-136 K-3.7 Cl-97 HCO3-32 AnGap-11 [2180-7-23] 11:24AM BLOOD Glucose-226* UreaN-8 Creat-0.8 Na-135 K-4.0 Cl-98 HCO3-31 AnGap-10 [2180-7-22] 06:15AM BLOOD Glucose-133* UreaN-6 Creat-0.8 Na-139 K-3.6 Cl-99 HCO3-31 AnGap-13 [2180-7-21] 07:57AM BLOOD Glucose-169* UreaN-7 Creat-0.8 Na-138 K-3.5 Cl-101 HCO3-29 AnGap-12 [2180-7-20] 05:24AM BLOOD Glucose-85 UreaN-11 Creat-0.9 Na-139 K-4.1 Cl-103 HCO3-28 AnGap-12 [2180-7-18] 03:00AM BLOOD Glucose-180* UreaN-13 Creat-0.9 Na-137 K-4.7 Cl-101 HCO3-27 AnGap-14 [2180-7-17] 09:50PM BLOOD Glucose-136* UreaN-12 Creat-0.9 Na-137 K-4.2 Cl-101 HCO3-26 AnGap-14 [2180-7-17] 05:47AM BLOOD Glucose-176* UreaN-17 Creat-1.1 Na-138 K-4.0 Cl-99 HCO3-30 AnGap-13 [2180-7-16] 02:45AM BLOOD Glucose-139* UreaN-23* Creat-1.3* Na-137 K-3.6 Cl-98 HCO3-30 AnGap-13 [2180-7-21] 08:36PM BLOOD CK(CPK)-103 [2180-7-21] 10:57AM BLOOD CK(CPK)-121 [2180-7-21] 03:39AM BLOOD CK(CPK)-133 [2180-7-14] 05:12AM BLOOD LD(LDH)-174 [2180-7-21] 08:36PM BLOOD CK-MB-3 cTropnT-0.08* [2180-7-21] 10:57AM BLOOD CK-MB-4 cTropnT-0.08* [2180-7-21] 03:39AM BLOOD CK-MB-4 cTropnT-0.07* [2180-7-11] 04:54AM BLOOD proBNP-4619* [2180-7-26] 06:15AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.5* [2180-7-25] 12:05PM BLOOD Calcium-7.8* Phos-3.8 Mg-1.6 [2180-7-24] 04:55AM BLOOD Mg-1.3* [2180-7-23] 11:24AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.4* [2180-7-22] 06:15AM BLOOD Calcium-7.8* Mg-1.8 Iron-16* [2180-7-21] 05:40PM BLOOD Mg-1.9 [2180-7-21] 07:57AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.3* [2180-7-18] 03:00AM BLOOD Calcium-8.1* Phos-4.6* Mg-1.9 [2180-7-22] 08:15PM BLOOD VitB12-1158* Folate-7.7 Ferritn-185 [2180-7-22] 06:15AM BLOOD calTIBC-230* Ferritn-206 TRF-177* [2180-7-22] 08:15PM BLOOD TSH-48* [2180-7-22] 06:15AM BLOOD TSH-41* [2180-7-8] 09:19PM BLOOD TSH-55* [2180-7-8] 09:19PM BLOOD Free T4-0.6* [2180-7-18] 03:10AM BLOOD Type-ART pO2-113* pCO2-49* pH-7.40 calHCO3-31* Base XS-4 [2180-7-17] 10:08PM BLOOD Type-ART pO2-73* pCO2-47* pH-7.39 calHCO3-30 Base XS-2 [2180-7-17] 08:44PM BLOOD Type-ART pO2-237* pCO2-41 pH-7.43 calHCO3-28 Base XS-3 [2180-7-17] 07:11PM BLOOD Type-ART pO2-179* pCO2-40 pH-7.47* calHCO3-30 Base XS-5 [2180-7-17] 05:52PM BLOOD Type-ART pO2-209* pCO2-38 pH-7.47* calHCO3-28 Base XS-4 Intubat-INTUBATED [2180-7-17] 03:58PM BLOOD Type-ART pO2-270* pCO2-34* pH-7.53* calHCO3-29 Base XS-6 [2180-7-18] 03:10AM BLOOD freeCa-1.09* [2180-7-17] 10:08PM BLOOD freeCa-1.12 [2180-7-17] 08:44PM BLOOD freeCa-1.09* [2180-7-17] 07:11PM BLOOD freeCa-1.08* [2180-7-17] 05:52PM BLOOD freeCa-1.12 [2180-7-17] 03:58PM BLOOD freeCa-1.08* Brief Hospital Course: Medicine part: [Date range (1) 63984] A/P: 73M with CAD s/p CABGx4 with complication of wound dehiscence. . # Sternal wound: Pt had CABG in [4-23] and has had wound dehiscence s/p repeated debridement/revision with a pec flap done at OSH. VAC dressing was placed during last admission to [Hospital1 18], during which plastic surgery followed closely. On this admission, plastic surgery evaluated the wound and was not concerned for infection. Pt had been on keflex to cover skin flora, and this was continued on admission. VAC was maintained with high density sponge. When it became apparent that the wound would not close quickly enough by secondary intention, plan was for a latissimus flap to close the sternal wound with both plastic surgery and CT surgery involved. . # CHF/pleural effustion: Pt appeared hypervolemic on exam, with large L pl effusion on CXR. TTE was a limited study due to the large, open sternal wound, but showed EF 60% and evidence of diastolic dysfunction. Initially pt was diuresed with lasix 40mg IV BID with a goal of [11-21] L negative per 24h. I/O and daily weights were strictly monitored; fluid restriction of 1500cc per 24h maintained. This improved his respiratory status slightly. On [7-13] pt had a thoracentesis with 1200cc of fluid removed. Pleural fluid had total proten 4.3 (serum 6.4), LDH 134 (174 serum), which was exudative. . # CAD s/p CABG: Pt had CABG [5-3] at OSH. Hospital course was complicated by fluid overload and wound dehiscence. Continued ASA, statin, BB (titrated to HR 60s). ACE was held initially due to ARF, then restarted. Pt was medically cleared for surgery: recent revascularization with CABG in [4-23]. Clinically, no CP or anginal symptoms. Perioperative BB continued. . # Hematuria: Began when foley catheter was removed around the time of transfer from OSH. When the patient began to pass clots in his urine, a 3-way foley was placed with continuous bladder irrigation. Heparin drip was stopped. Hematuria then resolved and hct remained stable. Hematuria did not recur even when lovenox was restarted for anticoagulation. . # Acute Renal Failure: This was likley due to contrast andminstration at outside hospital and quickly resolved. Initially lovenox was held and heparin started instead due to ARF. Likewise ACE-inhibitor was held initially then restarted when creatinine returned to baseline. Creatinine again bumped up slightly, likely due to diuresis. Lasix and ACE-I were again held...??? . # Infection/?PNA: CXR on admission shows that the heart is enlarged. There were no overt signs of failure. Considerable opacification at the left base was present. This may have been related to an effusion, extensive pleural thickening, or consolidation or subsegmental atelectasis. Levofloxacin was started, but discontinued because no clinical signs of infection (no cough, fever, or elevated WBC count). Respiratory status improved following thoracentesis. . # DM2: Continued lantus. Continued FS QID & ISS. [Doctor First Name ] diet. . # HTN: stable, continued metoprolol. ACE was restarted when ARF resolved. . # Hypothyroidism: Continued synthroid. TSH should be rechecked in about 1 month. . # Paroxysmal Afib/Rhythm: Pt is higher risk due to PFO seen on echo done at OSH. Heparin drip on admission (no lovenox initially due to ARF). Anticoagulation was stopped due to hematuria, then lovenox was restarted with no evidence of bleeding. Pt has not been on coumadin so far due to the need for surgical management of his wound. # Anxiety/agitation: On last admission, this was an active issue. Pt is less anxious currently. Trazodone was continued for sleep. Neurontin helped with anxiety. Benzodiazepines were avoided since they apparently made the patient hallucinate/sundown on the last admission. . # R-IJ clot: Heparin drip was started on admission for anticoagulation. Once acute renal failure resolved, switched back to lovenox. Pt has not been on coumadin due to the need for surgical management of his wound. . # FEN: [Doctor First Name ]/cardiac diet. Monitored lytes and repleted as needed. # PPX: pneumoboots, PPI, bowel regimen. # Access: [Name (NI) ], Pt has a RIJ clot visualized on chest CT on last admission. Have avoided line placement in this vessel since then. PRS part [2180-7-17] Underwent sternal wound debridement and latissmus dorsi flap closure on [2180-7-17] without complications. He received one U PRBC. Was tx to SICU. Post op pain and anixety were controlled, B/P was elevated and treated with lopressor and lisinopril. Was on atrovent nebs PRN. Electrolytes were folwed and K and Mg were repleted as needed. lasix was given PRN. He received periop Kefzol. urine output was adeq. Flap was warm with good cap refill and no [Last Name (un) ]. congestion, JPs were SS and draining, and he had minimal edema. He was tx to the floor [7-18]. Flap remained well perfused throughout hospital course with good cap refill, it was warm, and never showed signs of venous congestion. On the floor he amb with the help of PT. His HCT remained stable and lytes were repleted as necess. On [2180-7-21] c/o SOB and felt as if his lungs were filled with fluid. Sympomatic relief when moved to chair. Had basilar crackles on exam and CXR showed fluid in R lung field. EKG and enzymes were negative and he was diuresed with Lasix ande he was placed on O2 NC (initally 5L) and titrated down. Medicine was consulted. O2 sats and symptoms improved with Lasix administration (goal was 500 negative per day) and his last Lasix dose was on [2180-7-26] (40 PO BID had been TID previous days) and it was stopped because his O2 sat was stable off of O2. Wound Cx came back MRSA positive and he was started on Vancomycin on [2180-7-25] for a total of 14 days. On [2180-7-26] he was started on Lovenox (1 mg/kg [Hospital1 ] = 110 mg [Hospital1 ]) and coumadin 5 mg QHS for proph. On [2180-7-28] he is in good condition for discharge to rehab. Medications on Admission: Meds on Transfer: Hep wt based protocol 1250U /hr (PTT 76.8) Zocor 20mg po qd Protonix 40mg po qd Levo 500mg IV qd Zosyn 3.375mg IV q6 hours Isordil--->Imdur 30mg qd ASA 325mg po qd Insulin gtts. Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:10 inhalation Refills:0 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:30 inhalation Refills:0 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:0 Capsule(s) Refills:2 7. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:2 8. Vancomycin HCl 1000 mg IV Q 12H 9. 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. 10. Enoxaparin Sodium 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous [Hospital1 ] (2 times a day). Disp:0 subq Refills:2 11. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:0 Tablet(s) Refills:2 12. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:0 Tablet Sustained Release 24HR(s) Refills:2 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:0 Tablet(s) Refills:2 14. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:0 Tablet Sustained Release 24HR(s) Refills:2 15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:2 16. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for anxiety. Disp:0 Capsule(s) Refills:0 17. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:2 18. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:0 Tablet(s) Refills:0 19. DM control Regular insulin sliding scale Discharge Disposition: Extended Care Facility: [Hospital 63985] Health Center Discharge Diagnosis: sternal wound dehiscence CAD, s/p CABG in [4-23] CHF DM type II HTN Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500cc Please take all medications as directed. Please attend all follow up appointments. If you have fever >101.5, severe pain, chest pain, shortness of breath, if the flap changes color or in sensation, if you have bleeding or discharge, or anything that causes you great concern, please return or go to local hospital. Followup Instructions: Please followup with your PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 3065] [Last Name (NamePattern1) 805] within [11-21] weeks after discharge from the hospital. Please call [Telephone/Fax (1) 63986] for an appointment. Recommend adjusting anti-coag and a TSH in 6 weeks. Call Dr. [Last Name (STitle) 5385] for a follow up appt. ([2179] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 7738] ICD9 Codes: 5119, 5849, 2449, 412, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6381 }	Medical Text: Admission Date: [2173-1-19] Discharge Date: [2173-1-24] Date of Birth: [2099-9-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2745] Chief Complaint: hyperglycemia noted at [Hospital1 1501] Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 73M, h/o seizures, CVA with L sided deficits, HTN, PEG for dysphagia, EMS reported that mental status is near baseline according to [Hospital1 1501] (localizes to pain), DNR/DNI, sent to ED because at [Hospital1 1501], noted to be lethargic and had fsbg of 800. Not a known diabetic and no treatment for this was given at [Hospital1 1501]. Chem7 showed elevated Cr, Na, Glc, and WBC, so he was sent to [Hospital1 18]. EMS witnessed a tonic clonic seizure, 2-3 minutes, seizure activity broke by the time IV access was obtained, and then brought him to ED. On arrival to ED, did not open eyes, now moves arms somewhat and opens eyes. Blood sugar 774, given insulin 10 IV x2, then on drip at 10 for first hour, now on 15, b/c sugar is still critically high. 3rd L of NS hanging now. Also febrile to 102.6 on arrival. CXR clean, Urine clear. Abd soft, nontender. Blood and urine cultures sent. Given vanc and CTX empirically. At time of transfer, T102, HR 120s (sinus), BP 110s, O2 sats 95-97% on 2L RR 18. ROS: pt unable to provide Past Medical History: strokes from ruptured intracerebral aneurysms in [2160] and [2162] or [2163] with residual left sided deficits (has not been able to walk since the stroke in '[63]) and aphasia, PEG for dysphagia h/o seizure do dementia HTN h/o HepC hepatitis, apparently not active h/o neurosyphilis, treated in [2163] hypothyroidism Social History: Nursing home resident ([Hospital3 2558]) since [2163]. Sent here with no personal belongings. Family History: Noncontributory Physical Exam: Vitals: T: 98.1 BP:113/66 HR:114 RR:23 O2Sat:99%2L GEN: chronically ill appearing elderly African American man HEENT: EOMI, surgical pupils with gaze fixed to patient's right, sclera anicteric, no epistaxis or rhinorrhea, MM dry, OP Clear NECK: Supple, able to passively touch chin to chest. No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: II/VI early systolic murmur at RUSB, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: Neg Kernig's and Brudzinski. nonverbal. CN II ?????? XII grossly intact. Moves R arm, L hand contractured. muscle wasting throughout. SKIN: Spotchy hypopigmentation on chest. No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: CHEST (PORTABLE AP) Study Date of [2173-1-19]: UPRIGHT AP VIEW OF THE CHEST: The heart size is normal. The aorta is mildly unfolded. Pulmonary vascularity is normal. Hilar contours are within normal limits. The lungs demonstrate low inspiratory volumes, but otherwise are clear. No pleural effusions or pneumothorax. Thoracic scoliosis convex to the right is again demonstrated. IMPRESSION: No acute cardiopulmonary abnormality. CT HEAD W/O CONTRAST Study Date of [2173-1-19]: FINDINGS: There is no hemorrhage, hydrocephalus, shift of normally midline structures, or evidence of acute major vascular territorial infarct. The [Doctor Last Name 352]-white matter differentiation is preserved. Hypodensities in the periventricular and subcortical white matter reflect chronic microvascular ischemic change. Right frontal and left parieto-occipital lobe encephalomalacia is compatible with old infarcts. Tiny hypodensities in the right subinsular region is consistent with lacunes. The ventricles and sulci are prominent, compatible with age- related involutional change. There has been a right frontal craniotomy. The visualized paranasal sinuses and mastoid air cells are normally aerated. The surrounding soft tissues are unremarkable. IMPRESSION: No intracranial hemorrhage. CHEST (PORTABLE AP) Study Date of [2173-1-21]: Low lung volumes. The tip of the PICC line remains unchanged. No failure or infiltrates are seen. IMPRESSION: No pneumonia. ADMISSION LABORATORY WORK: [2173-1-19] 07:20PM BLOOD WBC-16.3* RBC-5.04 Hgb-15.0 Hct-46.5 MCV-92 MCH-29.8 MCHC-32.3 RDW-12.6 Plt Ct-175 [2173-1-19] 07:20PM BLOOD Neuts-80.2* Lymphs-11.2* Monos-7.8 Eos-0.1 Baso-0.5 [2173-1-19] 07:20PM BLOOD Glucose-774* UreaN-48* Creat-2.1* Na-158* K-3.6 Cl-120* HCO3-20* AnGap-22* [2173-1-19] 07:20PM BLOOD PT-15.5* PTT-33.8 INR(PT)-1.4* [2173-1-19] 07:20PM BLOOD Calcium-10.1 Phos-5.3* Mg-2.4 [2173-1-19] 07:20PM BLOOD Phenyto-3.8* [2173-1-19] 07:14PM BLOOD Glucose-GREATER TH Lactate-9.5* CARDIAC ENZYMES: [2173-1-20] 01:00AM BLOOD CK-MB-7 cTropnT-0.04* [2173-1-20] 05:00AM BLOOD CK-MB-8 cTropnT-0.04* [2173-1-20] 11:23AM BLOOD CK-MB-10 MB Indx-0.2 cTropnT-0.02* [2173-1-20] 06:07PM BLOOD CK-MB-10 MB Indx-0.1 cTropnT-0.02* CPKs: [2173-1-20] 01:00AM BLOOD CK(CPK)-1754* [2173-1-20] 05:00AM BLOOD CK(CPK)-2635* [2173-1-20] 11:23AM BLOOD CK(CPK)-5212* [2173-1-20] 06:07PM BLOOD CK(CPK)-6733* [2173-1-21] 04:00AM BLOOD CK(CPK)-5812* MICROBIOLOGY: [2173-1-21] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING [2173-1-20] MRSA SCREEN MRSA SCREEN-PENDING [2173-1-19] URINE URINE CULTURE-FINAL (NO GROWTH) [2173-1-19] BLOOD CULTURE Blood Culture, Routine-PENDING [2173-1-19] BLOOD CULTURE Blood Culture, Routine-PENDING Brief Hospital Course: MICU COURSE: # Fevers/elevated WBC: CXR clear at presentation. Urine clear except for high glucose. Abdomen was soft and non-tender with no rebound at presentation. No signs of RUQ pathology/cholecystitis on LFTs. History of seizures raised suspicion for CNS infection, although no signs of meningismus on exam; family refused LP to conclusively rule out meningitis. Regardless, patient was treated empirically in first 24 hours with Acyclovir, Vancomycin, Ampicillin, and Ceftriaxone at meningitis dosing. On morning of [2173-1-21], culture data and clinical signs remained unrevealing, and with no specific source of infection identified, on [2173-1-22], ceftriaxone was stopped as well. # Hyperosmolar Hyperglycemic State: Hyperglycemic to 774 at presentation with hypernatremia to 158 (corrected for elevated glc, corrNa was 169). Likely HHS (no ketones in urine, so unlikely DKA). Catalyst is likely infectious process. Hyperglycemia resolved within 12 hours of presentation. Initially treated with insulin gtt, and given his high insulin requirement, D5 1/2NS as well, and then transitioned to subcutaneous insulin on [2173-1-21]. Nutren Pulmonary Full strength tube feedings were started on [2173-1-22], at nutrition's recommendation, and although pt had been on nocturnal cycled tube feeds at his nursing home, [Last Name (un) ] and nutrition consults recommended round the clock tube feedings to simplify blood sugar management. He will therefore receive lantus + RISS for euglycemic control. # Hypernatremia: Goal was to decrease sodium 12 mEQ in 24 hrs. From evening presentation on [2173-1-19] to evening of [2173-1-20], sodium went from 158 to 162. On morning of [2173-1-21], patient's fluids. He continued to receive tube feeds with Q6H 250 mL free water flushes, and Na was down to 148 on [2173-1-22]. # Acute renal failure: Cr was 1.8 on arrival. Likely was prerenal. Creatinine resolved quickly to 0.7 by morning of [2173-1-21]. # Hypertension: Antihypertensives held at presentation due to concern for dehydration and impending sepsis, but since he has been stable, on [1-21], lisinopril 5mg (home dose was 40mg) and metoprolol 50mg [Hospital1 ] (was on 100mg [Hospital1 ] at home). # Seizure disorder: Has history of seizures and upon admission had seizure in setting of fever and dilantin level of 3.8; not clear when last seizure was. Still unsure if meningitis was present but without LP cannot know this. Reloaded with 500mg dilantin IV x 2 and AM dilantin level on [2173-1-21] was supratherapeutic at 28; however, this was not a trough level. A true trough was taken on morning of [2173-1-22] and was 13.8. # Constipation: Patient was without BM from admission to morning of [2173-1-21] and had evidence of stool-filled colon on CXR. Lactulose was given on [2173-1-21] until patient stooled in the afternoon. Medicine Floor course: The patient was evaluated by the [Last Name (un) ] service and his insulin regimen was titrated. New [Last Name (un) ] service recs recommended reverting his tube feeds back to his nocturnal tube feeds and titrating his insulin regimen to that schedule. The patient's lantus was titrated to 10 units qAM with a lispro sliding scale. The patient will need close further insulin titration on an outpatient basis. No clear etiology for the patient's fevers and leukocystosis was discovered (family had refused LP). Perhaps there was a viral infection. The patient's bp meds were uptitrated to his home regimen with strict holding parameters on discharge. Would continue prior TF regimen. Medications on Admission: lisinopril 40mg daily metoprolol 100mg [Hospital1 ] hydralazine 50mg qid milk of magnesia dilantin 25mg [Hospital1 ] colace liquid 100mg [Hospital1 ] Discharge Medications: 1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) cc PO qMWF: Resume prior dosage and frequency of this med. 3. Phenytoin 50 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day): Increased from 25 mg po bid. 4. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day: Hold FOR SBP< 100, HR<55. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day): HOLD FOR DIARRHEA. 6. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a day: Hold for SBP<100. 7. Acetaminophen 160 mg/5 mL Solution Sig: Ten (10) ml PO Q6H (every 6 hours) as needed for pain. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 9. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous qAM. 10. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous at meals: Administer per sliding scale. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Hyperosmolar Hyerglycemic State Seizure Acute Renal Failure Fevers, Leukocytosis Hypernatremia Discharge Condition: Vital Signs Stable Discharge Instructions: Patient to retrun to ED if he is having consistently elevated blood sugars>500 that do not improve with sliding scale insulin, fevers, rigors, hypotension, seizures. Followup Instructions: Patient to f/u with Urban Med PCP [Last Name (NamePattern4) ] 1 week. Will be followed at [Hospital3 2558]. ICD9 Codes: 5845, 2760, 2875, 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6382 }	Medical Text: Admission Date: [2156-8-17] Discharge Date: [2156-8-31] Date of Birth: [2089-12-13] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Indomethacin / Actonel / Reglan / linezolid / meropenem / atenolol / biphosphates / macrolids / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / prazoles / Prochlorperazine / risedronate sodium Attending:[First Name3 (LF) 3624] Chief Complaint: Shortness of breath, chest pain Major Surgical or Invasive Procedure: Transesophageal echocardiogram [2156-8-17] History of Present Illness: 66yoF with h/o chronic diastolic CHF (EF 70%), severe/symptomatic AS (sp valvuloplasty [2156-8-5], gradient 46.44->29.4mmHg and valve area 1.0->1.23cm2, discharged on [2156-8-10]), AFib not on Coumadin, liver/kidney transplant [7-/2154] for ESRD [3-11] diabetic nephropathy and contrast induced nephropathy as well as NASH, hip fracture s/p femoral nail [1-/2156], DM on insulin who presents with increased SOB and chest heaviness x 2 days. Pt reports having chronic SOB associated with her aortic stenosis. 2 weeks prior to arrival she had the valvuloplasty and denied any improvement in her symptoms. She then returned home with the same chronic SOB. One day prior to arrival she noted increased SOB associated with chest heaviness in the middle of the chest. Chest heaviness is worse with deep inspiration. Non positional. She reports that her SOB is similar to prior CHF/aortic stenosis episodes but her chest pain is new. Pt's SOB worsening over the course of the day and went to PCPs office this AM. She was initialy sent to [Hospital 5871] hospital. While at [Hospital 5871] hospital, she was found to be in CHF per CXR and given lasix 40mg IV with 800cc urine output. Also found to have positive UA and given ceftriaxone. She was transferred to [Hospital1 18] for further eval. In the [Hospital1 18] ED, initial vitals were Temp: 100.2 ??????F (37.9 ??????C) (Rectal), Pulse: 71, RR: 28, O2Sat: 98, O2Flow: 3, Bedside u/s showed no evidence of pericardial effusion. Labs and imaging significant for WBC 19 (81 Neut) PLT 634, HCT 31, Hb 9, MCV 103, lactate 2.7, Cr 1.9, trop 1.13. CK MB pending. BNP 27,000. Patient given lorazepam 1mg IV, vancomycin 1 g (OSH: lasix and ceftriaxone) Blood cultures and urine cultures were sent. Vitals on transfer were 98.6, 74, RR 25, 129/55, 100% on 3L Access: has a 20 g Pt was transfered to the CCU for close care and for TEE. On arrival to the CCU, patient is comfortable, denies any chest pain or SOB, she says both have resolved. She reports that ativan and lasix in the ED improved her CP and SOB. Bedside TEE was performed and showed no acute dissection. REVIEW OF SYSTEMS Positive: urinary frequency On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors (does report feeling cool). She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: severe aortic stenosis s/p aortic valvuloplasty in [7-/2156] ([2156-8-6] TTE showed [Location (un) 109] 0.9cm2, pressure gradient 34) Atrial fibrillation - High-degree AV block, s/p PPM [2154-2-5] ([Company 1543] Sensia DDD pacemaker), now pacer dependent - Diastolic heart failure, NYHA II-[Last Name (LF) 1105], [First Name3 (LF) ] >70-75% on TTE [5-/2155] - Moderate mitral annular calcification and mitral regurgitation - Mild tricuspid regurgitation - Moderate pulmonary hypertension 3. OTHER PAST MEDICAL HISTORY: - Diabetes Mellitus Type 2, on Insulin, c/b retinopathy, nephropathy, and neuropathy - End-stage renal disease, [3-11] diabetes & contrast-induced nephropathy, s/p cadaveric transplant [2153-7-21] - Hx frequent MDR UTIs - Dyslipidemia - Hypertension - Non-alcoholic steato-hepatitis cirrhosis (Stage IV, Grade 2), c/b portal HTN, ascites, encephalopathy, grade I-II esophageal varices s/p banding s/p TIPS [8-/2152], s/p OLTx [2153-7-21] - Saphenous vein interposition graft repair of the hepatic artery and harvesting of the left saphenous vein graft [2154-3-14], Hepatic artery s/p stent [2154-4-25] - [3-/2155]: Exploratory laparotomy, evacuation of intra-abdominal blood, exploration of retroperitoneal hematoma, left salpingo-oophorectomy for RP bleeding - s/p VATS decortication [11/2153] - Splenic vein thrombosis, no longer on coumadin - Anemia - Thrombocytopenia - h/o C.diff - h/o Seizures - headaches ?[3-11] occipital neuralgia - Meningioma, small left frontal lobe - GERD - OSA has CPAP at home but does not use - Cervical DJD - Dermoid cyst - Right adrenal mass - osteoporosis - Status post cholecystectomy followed by tubal ligation - Status post left oopherectomy - Status post appendectomy - ? Restless legs syndrome - hypothyroid - gout - hip surgery, discharged [2156-2-8] Social History: Widowed, lives in [Hospital3 ] facility in [Hospital1 6930], MA. Uses a walker for ambulation. Has 4 children, 3 in MA, one in [State 3908]. Previously worked as a nurse [First Name (Titles) ] [Last Name (Titles) ]. No tobacco, alcohol or drugs ever Family History: father died of stroke, mother died of cerebral hemorrhage. Her sister has diabetes. Physical Exam: Admission exam VS: 97.9, HR 80, 141/79, RR 23, 99% 3L GENERAL: NAD. Oriented x3. Mood, affect appropriate. Chronically ill appearing HEENT: NCAT. pale conjunctiva, PERRL, EOMI. Neck: JVP difficult to assess since large neck. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2 systolic murmurs, one murmur heard at right sternal border radiating to carotids late peaking, other murmur is holosystolic at left sternal border. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. few crackles in bases bilaterally ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: radial 2+ Left: radial2+ MOST RECENT EXAM [2156-8-30] VS - 98.2/98.6 134/58 (120s-150s/50s-70s) 73(60s-70s) 95% ra I/O: 2 BMs last night. BG: 75, 230, 208, 68 GENERAL: Well appearing female looks stated age. NAD. Speaking in full sentences appropriately. AAOx3. Flat to depressed affect. HEENT: Upper dentures not in place. Moist mucous membranes. Non distended JVP. Anicteric sclera. Poor dentition. CARDIAC: Irregular, systolic ejection murmur best at RUSB, no extra heart sounds. LUNGS: Unlabored breathing. Good air flow. Minimal crackles at bases b/l. No wheezing. ABDOMEN: BS+, distended, soft, non-tender EXTREMITIES: No Edema in the lower extremities. Warm. NEUROLOGY: no Asterixis. A+Ox3. CN2-12 intact. Pertinent Results: Admission labs [2156-8-17] 10:00PM BLOOD WBC-19.2* RBC-3.01* Hgb-9.6* Hct-31.0* MCV-103* MCH-31.9 MCHC-30.9* RDW-18.6* Plt Ct-634# [2156-8-17] 10:00PM BLOOD Neuts-81 Bands-0 Lymphs-11* Monos-3 Eos-5* Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-6* [2156-8-17] 11:10PM BLOOD PT-13.3* PTT-25.8 INR(PT)-1.2* [2156-8-17] 10:00PM BLOOD Glucose-167* UreaN-51* Creat-1.9* Na-140 K-5.3* Cl-103 HCO3-22 AnGap-20 [2156-8-17] 10:00PM BLOOD ALT-10 AST-17 CK(CPK)-46 AlkPhos-101 TotBili-0.2 [2156-8-17] 10:00PM BLOOD CK-MB-2 cTropnT-1.13* proBNP-[Numeric Identifier 21404]* Cardiac labs [2156-8-17] 10:00PM BLOOD CK-MB-2 cTropnT-1.13* proBNP-[Numeric Identifier 21404]* [2156-8-18] 04:10AM BLOOD CK-MB-2 cTropnT-1.20* [2156-8-19] 05:15AM BLOOD CK-MB-3 cTropnT-0.64* TACRLIMUS TREND: [2156-8-18] 04:10AM BLOOD tacroFK-3.2* [2156-8-19] 05:15AM BLOOD tacroFK-5.1 [2156-8-20] 05:00AM BLOOD tacroFK-6.1 [2156-8-21] 05:05AM BLOOD tacroFK-5.6 [2156-8-22] 05:00AM BLOOD tacroFK-6.6 [2156-8-23] 05:30AM BLOOD tacroFK-6.9 [2156-8-29] 05:05AM BLOOD tacroFK-5.1 [2156-8-31] 05:30AM BLOOD tacroFK-4.3* DISCHARGE LABS ([2156-8-30]) [2156-8-31] 05:30AM BLOOD WBC-12.3* RBC-2.58* Hgb-8.5* Hct-27.5* MCV-107* MCH-32.8* MCHC-30.7* RDW-18.2* Plt Ct-527* [2156-8-31] 05:30AM BLOOD PT-10.0 PTT-29.0 INR(PT)-0.9 [2156-8-31] 05:30AM BLOOD Glucose-88 UreaN-54* Creat-1.5* Na-133 K-4.9 Cl-99 HCO3-23 AnGap-16 [2156-8-31] 05:30AM BLOOD ALT-14 AST-17 AlkPhos-106* TotBili-0.2 [2156-8-31] 05:30AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.1 [2156-8-31] 05:30AM BLOOD tacroFK-4.3* Micro: [8-17] urine and blood cultures x2 negative [8-18] MRSA negative [8-20] urine culture negative [8-21] urine culture pending Studies: [2156-8-17] TEE: Overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the aortic root. 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. No thoracic aortic dissection is seen. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. IMPRESSION: No evidence of aortic dissection. Atheroma throughout aorta with small, calcified atheroma just above the aortic sinus, complex atheroma in the arch and descending aorta. Likely moderate to severe aortic stenosis with mild aortic regurgitation. Moderate to severe mitral regurgitation . [2156-8-17] CXR: The lungs are well expanded and clear. The cardiac silhouette is enlarged. The mediastinal silhouette and hilar contours are normal. No pleural effusion or pneumothorax is present. A left-sided pacer terminates with its leads in the right atrium and right ventricle. IMPRESSION: Mild cardiomegaly, but no acute intrathoracic process. . [2156-8-18] bilateral LE U/S: No evidence of deep vein thrombosis in either leg. . [2156-8-19] hip xray: FRONTAL VIEW OF THE PELVIS AND CONED-DOWN VIEWS OF THE RIGHT HIP: The patient has a gamma nail construct with proximal nail, intramedullary rod and interlocking screw transfixing an intertrochanteric fracture which appears in unchanged alignment with no evidence of hardware-related complications. Fracture line is still visible but less prominent compared to the most recent prior examination. Vascular calcifications are noted. A coil is noted over the left hip and along the left lower abdomen. IMPRESSION: Open reduction internal fixation of right intertrochanteric femur fracture without evidence of hardware-related complications and with fracture line less prominent compared to the most recent prior examination. [2156-8-24] CT pelvis: 1. Unchanged left chronic retroperitoneal hematoma (but decreased from first sighting in [Month (only) 956] of [2155]). This lesion contains some "entrapped" fat lobules and should be followed to resolution to exclude an underlying lesion. If seried, this could be followed by MRI. 2. Appearance of right femoral fracture and hardware. 3. Increased stranding and skin thickening with 2.7cm rounded hematoma in left lower anterior abdominal/pelvic wall could relate to recent injections and trauma to this site. Correlation with exam findings is recommended. 4. Air in the bladder and transplant kidney collecting system could relate to recent Foley catheterization. Brief Hospital Course: Ms [Known lastname ] (goes by [Doctor Last Name 8214]) is a 66yoF with h/o severe aortic stenosis (s/p valvuloplasty [2156-8-5]), diastolic congestive heart failure (EF 70%), paroxysmal atrial fibrillation (not on Coumadin), diabetes mellitus type 2, and End stage liver and renal disease s/p liver/kidney transplant [7-/2154], who presented with 2 days shortness of breath and pleuritic chest heaviness. She is currently pain free with improvement in dyspnea. Transesophageal echocardiogram showed no dissection. Now active Suicidal ideation. ## acute diastolic CHF exacerbation - Patient complained of dyspnea on exertion. Likely acute on chronic diastolic heart failure (dCHF) exacerbation with volume overload in the setting of severe Aortic Stenosis. BNP >[Numeric Identifier ] (baseline 3,000-9,000) on admission. Per OSH, pt's CXR showed pulmonary edema and she was given lasix 40mg IV with good urine output. CXR here showed mild pulmonary congestion. She was diuresed, weaned off oxygen, and put back on her home dose of torsemide 20mg PO daily. She remained euvolemic and was discharged at a weight of 86.4kg. Also, she was restarted on home carvedilol 25mg [Hospital1 ] and lisinopril 5mg. . ## Chest Pain with Troponin Elevation - likely secondary to demand ischemia in setting of dCHF and left ventricular hypertrophy/aortic stenosis. EKG is unchanged and CK-MB is normal. She has 90% stenosis of LAD diagonal branch per [8-5] cath report. A TEE was done in the CCU initially to r/o dissection, and no dissection was found. Troponin trended down. Because of mild persistant chest heaviness, and known 90% stenosis per above, we trialed her on imdur 30mg daily which improved her symptoms. This decrease in preload may facilitate control of pulmonary edema as well. Given known CAD, we continued [Month/Year (2) ], Statin, [Month/Year (2) ]. . ## Psych: Hx of depression, anxiety. Psych was consulted when patient arrived to floors. Determined to be Section 12 as patient was actively suicidal. Admits to trying to recently kill herself w/ insulin and tylenol while at home. She was placed on a 1 to 1 sitter. Psychiatry recommended inpatient psych unit and ETC therapy. Venlafaxine was increased to 225mg and aripiprazole were started. She continues on haldol. Ativan was given for anxiety. She has not contraindications for inpatient pyschiatric facility at this time. . ## Urinary frequency and UA suggestive of UTI - h/o multi drug including ESBL resistant E. coli and VRE UTI in the past. Had a temperature of 100.4 on admission, though afebrile for the remainder of the admission. She was empirically placed on cefipime + tigacycline per ID recs, and received these for 2 days, but they were discontinued after urine culture came back negative. Then started on Fosfomycin 3g once weekly for suppressive therapy, per ID recs. . ## h/o Renal/Liver Transplant - tacro was low, so we increased tacrolimus to 1mg [Hospital1 ], and resultant troughs were within goal range. [2156-8-28] Trough was within Renal guidelines. Recommendation to check Tacro Trough once weekly on Tuesdays. Continued prednisone. Held Bactrim for PCP [Name9 (PRE) ], given recent h/o c diff. Has transplant f/u on [2156-9-9]. . ## Recent C DIFF infection: patient developed watery loose stools on recent admission, C Diff PCR positive. She was started on flagyl 500mg TID for total 14 day course to be completed [8-24]. However, on this admission had episodes of diarrhea with increased frequency, so we started on PO vancomycin for 10 days, completed on [2156-8-31], with improvement in her symptoms. . ## Constipation - resolved with lactulose 15mL in AM, senna, colace, miralax. . ## DM type 2, insulin dependent: on lantus 25 U qhs, and used HISS in house. . ## Hypothyroidism: continued homed levothyroxine. . ## Hx of seizure: continued on home keppra. . ## POST DISCHARGE LABS - Plan to check CBC & Chem7 & Tacro trough weekly on Tuesdays . CODE: full code CONTACT INFO: [Name (NI) ] [Name (NI) ] (son) [Telephone/Fax (1) 50001], [Telephone/Fax (1) 49733] ============================================ TRANSITIONAL ISSUES # Patient is stable and has no medical contraindications for inpatient psychiatric facility # Will need to f/u with cardiology to revaluate for AoValve replacement as recent valvuloplasty does not seem to have improved her functional status # Check labs weekly including Tacro level, chem7, cbc # Follow up imaging of left chronic retroperitoneal hematoma: Per CT report, "This lesion contains some 'entrapped' fat lobules and should be followed to resolution to exclude an underlying lesion. If seried, this could be followed by MRI." # Patient will need psychiatry follow up given her suicidal ideation. ECT has been considered as therapy, as this has reportedly worked in the past. # Patient should follow up with her Cardiologist, Dr. [First Name (STitle) 437] regularly given her diagnosis of heart failure and recent exacerbation in the setting of AS. She should next be seen 1-2weeks into transfer to inpatient unit. Has appt for [2156-9-20] at 1pm. Medications on Admission: 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Albuterol-Ipratropium 2 PUFF IH Q6H:PRN SOB 3. Allopurinol 200 mg PO DAILY 4. Aspirin 325 mg PO DAILY 5. Atorvastatin 10 mg PO DAILY 6. Calcium Carbonate 500 mg PO DAILY 7. Carvedilol 25 mg PO BID 8. Docusate Sodium 100 mg PO BID 9. Clopidogrel 75 mg PO DAILY 10. Haloperidol 0.5 mg PO QAM 11. Haloperidol 1 mg PO HS 12. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 13. LeVETiracetam 500 mg PO BID 14. Levothyroxine Sodium 50 mcg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. PredniSONE 5 mg PO DAILY 17. Ursodiol 300 mg PO BID 18. Venlafaxine 75 mg PO DAILY 19. Vitamin D 400 UNIT PO DAILY 20. Lactulose 30 mL PO Q8H:PRN constipation 21. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 22. Lisinopril 5 mg PO DAILY 23. Torsemide 20 mg PO DAILY 24. HydrOXYzine 12.5-25 mg PO Q6H:PRN itching hold for sedation RX hydroxyzine HCl 25 mg 0.5-1 tablet by mouth every 6 hours Disp #30 Tablet Refills:0 25. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX Flagyl 500 mg 1 Tablet(s) by mouth every 8 hours Disp #36 Tablet Refills:0 26. Sarna Lotion 1 Appl TP QID:PRN pruitis RX Sarna Anti-Itch 0.5 %-0.5 % apply to skin four times a day Disp #1 Container Refills:2 27. Tacrolimus 0.5 mg PO Q12H Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Albuterol-Ipratropium 2 PUFF IH Q6H:PRN shortness of breath or wheezing 3. Allopurinol 200 mg PO DAILY 4. Aspirin 325 mg PO DAILY 5. Atorvastatin 10 mg PO DAILY 6. Calcium Carbonate 500 mg PO DAILY 7. Carvedilol 25 mg PO BID 8. Docusate Sodium 100 mg PO BID 9. Clopidogrel 75 mg PO DAILY 10. Haloperidol 0.5 mg PO QAM 11. Haloperidol 1 mg PO HS 12. HydrOXYzine 12.5-25 mg PO Q6H:PRN itching hold for sedation 13. Lactulose 30 mL PO Q8H:PRN constipation 14. LeVETiracetam 500 mg PO BID 15. Levothyroxine Sodium 50 mcg PO DAILY 16. Lisinopril 5 mg PO DAILY 17. Multivitamins 1 TAB PO DAILY 18. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 19. PredniSONE 5 mg PO DAILY 20. Sarna Lotion 1 Appl TP QID:PRN pruitis 21. Torsemide 20 mg PO DAILY 22. Ursodiol 300 mg PO BID 23. Vitamin D 400 UNIT PO DAILY 24. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY angina consider to continue as outpatient, rec by Dr. [First Name (STitle) 437] 25. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 26. Tacrolimus 1 mg PO Q12H You should have weekly Tacrolimus levels drawn on Tuesdays to monitor your drug level. 27. Venlafaxine 225 mg PO DAILY per Psych. Serotonin syndrome should be observed. 28. Aripiprazole 5 mg PO DAILY 29. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO) Dissolve in [4-11] oz (90-120 mL) water and take immediately 30. Lidocaine 5% Patch 1 PTCH TD DAILY place on right hip please 31. Lorazepam 0.5 mg PO HS:PRN anxiety, insomnia hold for sedation or RR < 12 MAX 1mg/ day 32. Polyethylene Glycol 17 g PO BID constipation 33. Senna 2 TAB PO BID Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY: - acute on chronic diastolic congestive heart failure exacerbation - active suicidal ideation SECONDARY: - Liver/Renal transplant management 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 taking care of you at [Hospital1 18]. You came in for worsening shortness of breath and chest pain. This was found to be from volume overload, and we gave you water pills to get rid of the extra fluid. Upon psychiatric [Hospital1 2742], it was later determined that you pose a significant risk to yourself when alone at home. The psychiatry team recommended inpatient psychiatric admission for ECT, a treatment for depression that you have had in the past. You will be going to an inpatient psychiatric facility for further mental health care. The following changes have been made to your medications: * INCREASE tacrolimus (immunosuppressant) to 1mg twice a day (from 0.5mg twice a day) INCREASE Venlafaxine to 225 mg by mouth daily START Aripirazole 5mg by mouth daily START Imdur 30mg daily START Fosfomycin (antibiotic for UTI) 3gm/week on Mondays indefinitely ADD Senna and Miralax to your daily treatment for constipation STOP Flagyl (Metronidazole) Followup Instructions: Department: MEDICAL SPECIALTIES When: TUESDAY [2156-10-5] at 11:20 AM With: BONE DENSITY TESTING [Telephone/Fax (1) 4586] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2156-9-20] 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: TRANSPLANT CENTER When: THURSDAY [2156-9-9] at 10:20 AM 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 Please discuss with the staff at the facility a follow up appointment with your PCP below when you are ready for discharge. Name: [Last Name (LF) ],[First Name3 (LF) ] S Location: [Hospital1 ] PRIMARY CARE Address: [Street Address(2) 20897], [Hospital1 ],[Numeric Identifier 20898] Phone: [Telephone/Fax (1) 20894] [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970] MD [MD Number(1) 3629] Completed by:[2156-9-1] ICD9 Codes: 4168, 5990, 4280, 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6383 }	Medical Text: Date of Birth: [2064-1-19] Sex: F Service: The patient denies smoking, alcohol or intravenous drug use. FAMILY HISTORY: Remarkable for coronary artery disease. PHYSICAL EXAMINATION: On admission vital signs revealed temperature 97 degrees heartrate of 74, blood pressure 149/54, respiratory rate 16 and the patient was sating at 99% patient was alert and awake in no acute distress. Head, eyes, ears, nose and throat, pupils equally round and reactive to light. Sclera are anicteric, with an nasogastric tube noting dried blood in the tubing. Chest examination was notable for bibasilar rales, no wheezes. Cardiovascular system, S1 and S2, irregular rate and rhythm with III/VI decrescendo systolic ejection murmur, no rubs and no gallops. Abdomen, soft, obese, nontender, nondistended, normal bowel sounds in all four quadrants. No organomegaly. Extremities, no clubbing, no cyanosis and no edema. +2 Dorsalis pedis pulses and warm extremities. Neurological examination, the patient was alert and oriented times three and grossly intact. LABORATORY DATA: Laboratory studies on admission revealed sodium 137, potassium 4.7, chloride 106, bicarbonate 19, BUN 46, creatinine 1.6, glucose of 308, white blood cell count was 7.9, hematocrit 28.2, platelets 84 and MCV 89 with a differential in the complete blood count revealing neutrophils 82%, no bands, lymphocytes 10, monocytes 4 and eosinophils 3. Cholesterol panel revealed a total cholesterol of 144, HDL 45, and LDL 80 and triglycerides at 99. An electrocardiogram at admission to [Hospital 26200] Hospital on [7-18], revealed sinus bradycardia with a 2:1 second degree heartblock, normal axis, prolonged PR, prolonged QRS, QT: Right bundle branch block, ST depressions in AV1, AVL and leads V2 to V5 with T wave inversions. Subsequent electrocardiograms revealed normal sinus rhythm with improvement in ST depressions and continued depressions in V2, V3, AV1 and AVL. Upon admission at [Hospital6 1760] electrocardiogram showed continued ST segment depressions in leads 1, AVL, V2 to VF, and inverted T waves in 1 through V5 with painfree, electrocardiogram revealed improvement of these changes. HOSPITAL COURSE: The patient was admitted to [Hospital6 1760] for impending cardiac catheterization. 1. Cardiovascular - A. Coronary artery disease, the patient was continued on Aspirin and Metoprolol at 12.5, however, her ACE inhibitor was held secondary to the recent elevation in her creatinine. Heparin and Integrilin drips were also held secondary to her gastrointestinal bleed and low platelets. Plavix was held secondary to low platelets as well. The patient was given sublingual nitroglycerin for pain. Cardiac catheterization on hospital day #2 revealed the following findings - 1. Hemodynamics: There was mild gradient across the aortic valve; severely elevated left ventricular end diastolic pressures. Coronary angiography revealed the following - Right dominant system with left main coronary artery a small caliber, left anterior descending artery that was occluded. This was small caliber left anterior descending filled by left internal mammary artery. Left circumflex: Occluded after tiny first obtuse marginal, distal obtuse marginal filled by saphenous vein graft. Right coronary artery: Tiny and mid occluded, posterior descending artery filled by saphenous vein graft. Saphenous vein graft to obtuse marginal and diagonal: Patent, prior stent in this graft. Saphenous vein graft to posterior descending artery: Patent mild tapering origin. Left internal mammary artery to left anterior descending, patent. Given these findings no intervention during [Hospital1 ] time with recommendation of medical treatment including therapy to reduce elevated filling pressures. Therefore the patient was started on calcium channel blocker Norvasc 5 mg p.o. q.d. and increased to 7.5 mg p.o. q.d. by time of discharge. The patient was also continued on Hydralazine at 25 mg p.o. q.i.d. The patient continued to complain of some chest discomfort upon awakening the first two days following the day of admission and was continued on a Nitroglycerin drip until [2132-7-26]. At that time the patient became chest pain/arm pain free throughout the remainder of her hospital stay and is currently stable on her current cardiac regimen, and is asymptomatic. B. Rhythm - Of note, the patient was noted to have runs of Wenckebach's block on her rhythm strip. The patient remains to have occasional Wenckebach's block, the patient is symptom free throughout her hospital stay and given the benign nature of this type of A-V nodal block no intervention is needed at this time. 2. Pulmonary - Upon initial examination the patient was noted to have bibasilar rales on examination. This is believed to be secondary to some fluid overload in the context of severe diastolic dysfunction, with recent history of acute renal failure. On the day of admission the patient was given 80 mg of Lasix intravenously times one. The patient had good response to this diuresis and remained to be oxygenating well. Of note, the patient also has a history of asthma. Her beta agonist medication was held initially on examination given her recent cardiac event and pending catheterization. Throughout the hospital stay as the patient was restarted on nebulizers as needed and remained and upon discharge the patient remains free of any complaints of any of her asthma symptoms. 3. Gastrointestinal - The patient was status post hematemesis with an nasogastric tube upon admission with suspected etiology secondary to hypercricoid state and recent nausea and vomiting in the setting of diabetic ketoacidosis. The patient's hematocrits were followed throughout her hospital course and was transfused one unit of packed red blood cells on hospital day #3. Hematocrits were followed throughout the remainder of the hospital stay and remained stable at discharge. 4. Hematology - Thrombocytopenia, of note the patient had a platelet level of 81 on day #2 at admission, believed secondary to be due to recent heparin use. Platelets were run throughout the hospital stay and remained stabilized and began to increase throughout the remainder of the hospital stay and had increased to a level of 159 two days prior to discharge. As a result basically it is thought the patient can be restarted on Plavix upon discharge. 5. Renal - The patient's creatinine increased to 2.1 on hospital day #2 status post catheterization, and her creatinine continued to elevate to a level of 4.3 on hospital day #7. Urine dip stick was negative except for notable blood believed secondary to trauma to Foley catheter, and urine sediment was noted for many red blood cells, many elastocasts with occasional granular casts. Urine lytes were notable for a prerenal state. Given the patient's fluid status and recent cardiac catheterization it is believed that this acute renal failure was consistent with a contrast nephropathy. The patient's intakes and outputs were followed throughout the hospital stay with decreased intercreatinine starting at two days prior to admission. Upon discharge the patient's creatinine remains at a level of about 3 and we will continue to have her creatinine and electrolytes checked, replaced and removed as needed at rehabilitation. Of note, throughout this time the patient remains symptom-free with no paresthesias, no pruritus, no mental status changes, and the patient was also started on PhosLo throughout her hospital stay. 6. Endocrinology - The patient with a history of insulin dependent diabetes mellitus. The patient was started on NPH insulin sliding scale regimen as needed, and her sugars were difficult to control early throughout the course of her hospital stay. With some adjustment of her insulin requirements, her glucose levels improved and she will be discharged on her outpatient regimen and including a sliding scale of q.i.d. finger sticks at the time of discharge. The patient had increased urine output throughout the last three days prior to discharge. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSIS: Troponin leak in the setting of myocardial ischemia, acute renal failure and chronic renal insufficiency. DISCHARGE STATUS: The patient will be discharged to a rehabilitation facility with physical therapy as needed as per physical therapy consult. DISCHARGE MEDICATIONS: 1. Advair Diskus 2. Norvasc 7.5 mg p.o. q.d. 3. Metoprolol 25 mg p.o. b.i.d. 4. Hydralazine 25 mg p.o. b.i.d. 5. Lipitor 10 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Nitroglycerin sublingual .3 mg sublingual prn 8. Protonix 40 mg p.o. q.d. 9. NPH Insulin 30 units q. AM, 30 units q. PM 10. Regular insulin 30 units q. AM, 15 units q. PM, regular insulin sliding scale with a q.i.d. fingerstick 11. Ambien 5 mg p.o. q.h.s. prn 12. Atrovent nebulizers q. 8 hours prn 13. Plavix 75 mg p.o. q.d. 14. Ciprofloxacin 250 mg p.o. q.d. times four days with a repeat urinalysis and culture status post treatment course The patient should also have creatinine levels followed until they return to baseline. FOLLOW UP: 1. Discharge to rehabilitation as above. 2. Follow creatinine levels until they return to baseline with possible referral to Nephrology as needed. 3. Continue antibiotic course for urinary tract infection with repeat urinalysis and culture pending completion of antibiotic therapy course. DR.[Last Name (STitle) 2052],[First Name3 (LF) 2053] 12-462 Dictated By:[Last Name (NamePattern4) 44315] MEDQUIST36 D: [2132-7-30] 17:04 T: [2132-7-30] 18:20 JOB#: [Job Number ] ICD9 Codes: 5849, 4280, 4241, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6384 }	Medical Text: Admission Date: [2197-3-8] Discharge Date: [2197-3-9] Date of Birth: [2118-11-7] Sex: F Service: [Location (un) 259] HISTORY OF PRESENT ILLNESS: The patient is a 78 year old woman initially transferred from [Hospital6 4620] to the Emergency Department at [Hospital1 188] for management of pneumonia and respiratory failure. The patient has multiple medical problems to include schizophrenia, dementia, Parkinson's Disease, and atrial fibrillation. The patient was status post right above the knee amputation on [2-17], at [First Name8 (NamePattern2) 1495] [Hospital ] Hospital. Following this procedure, she was transferred to [Hospital 110826] Health and Rehabilitation Center. While at the rehabilitation center, the patient was noted to be febrile to 103.2 F., diaphoretic and short of breath. She was then transferred to [Hospital6 4620] for further work-up. At that hospital, she was noted to be hypertensive, tachycardic, tachypneic, with a decreased oxygen saturation. Chest x-ray disclosed evidence for right upper lobe, left lower lobe infiltrates. Therefore, the patient was intubated and pan cultured; given a dose of Zosyn. Her labs were notable for an elevated white blood cell count at 23.8. Chemistries were notable for hypernatremia with a sodium of 155, an elevated BUN and creatinine 48, 1.0. The patient was transferred to [Hospital1 188] for further management of her respiratory failure. On presentation to the Emergency Department at [Hospital1 346], the patient's temperature was 101.2 F. PAST MEDICAL HISTORY: 1. Schizophrenia. 2. Parkinson's Disease. 3. Atrial fibrillation. 4. PEG tube placed [2197-2-8], at [First Name8 (NamePattern2) 1495] [Hospital ] Hospital. 5. Status post cerebrovascular accident. 6. Status post right above the knee amputation for dry gangrene. The procedure was done on [2-17], at [First Name8 (NamePattern2) 1495] [Hospital ] Hospital. 7. Status post cerebrovascular accident. 8. Status post right above the knee amputation for dry gangrene. The procedure was done on [2-17], at [First Name8 (NamePattern2) 1495] [Hospital ] Hospital. 9. Status post third degree burns sustained in the [2153] during an accident. 10. Status post pacer placement. 11. Gastroesophageal reflux disease. 12. Hypertension. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Hydrochlorothiazide 12.5 mg p.o. q. day. 2. Digoxin 0.125 mg p.o. q. day. 3. Catapres 0.1 microgram patch q. week. 4. Colace 100 twice a day. 5. Senna two q. day. 6. Restoril 15 q. h.s. 7. Ativan 0.25 q. h.s. 8. Metoprolol 150 twice a day. 9. Lisinopril 40 q. day. 10. Norvasc 10 q. day. 11. Albuterol and Atrovent nebulizers p.r.n. 12. Prazosin 4 q. day. 13. Jevity tube feeds, 60 cc per hour. 14. Multivitamin, one q. day. 15. Artificial tears. 16. Zyprexa 20 q. h.s. 17. Abilify 10 q. h.s. SOCIAL HISTORY: The patient resides in a rehabilitation. Per son, the patient has an extensive smoking history. The patient's family contact is her son, [Name (NI) 1193] [Name (NI) 1557], [Telephone/Fax (1) 110827]. FAMILY HISTORY: Not known. PHYSICAL EXAMINATION: In general, a chronically ill appearing female lying in bed, intubated. Vital signs were temperature of 101.0 F.; blood pressure 140/80; heart rate 92; respiratory status - the patient on assist control ventilation, total volume 400, respiratory rate 12, FIO2 100%, PEEP 5, O2 saturation 96%. HEENT: The pupils are sluggish, Periorbital burn scar. Endotracheal tube in place. Mucous membranes were dry. Neck with left IJ line in place. Heart is irregularly irregular, S1, S2, no murmurs, rubs or gallops. Lungs with coarse breath sounds anteriorly. Abdomen is soft, nontender, nondistended, positive bowel sounds. G-tube in place. Extremities with right stump, black ulceration, left heel; left pretibial ulcer. Contractures of upper extremities. Neurologic: The patient is intubated and sedated, unable to cooperate with neurological examination. Skin with burn scars present on face, torso and upper extremities. LABORATORY: On presentation, white blood cell count 24.9, hemoglobin 8.7, hematocrit 29.6. Differential 84% neutrophils, 12% bands, 3% lymphs, platelet count 610. PT 13.8, PTT 19.9, INR 1.3. Chemistries with sodium 154, potassium 3.0, chloride 115, bicarbonate 27, BUN 43, creatinine 0.9 with a glucose of 106. Initial CK MB 2, troponin T 0.07, magnesium 1.7, digoxin level 1.0. Initial blood gas 7.40, pCO2 44, pO2 68, lactate 2.7. EKG: Atrial fibrillation at 80 beats per minute, QT 362, QT corrected 391, downsloping ST segments in II, III, AVF, V3 through V6. Normal axis. Consider anteroseptal infarction. RADIOLOGY: Chest x-ray with aspiration versus multifocal pneumonia with consolidations in the left lower lobe and right lower lobe, endotracheal tube in place. Left internal jugular venous catheter tip within the left brachiocephalic vein. IMPRESSION: This is a 78 year old woman with multiple medical problems including atrial fibrillation, dementia, and schizophrenia, transferred from [Hospital3 1196] to [Hospital1 69] for management of respiratory failure. Chest x-ray notable for right lower lobe and left lower lobe infiltrates. Labs significant for hypernatremia and elevated white count. PLAN: 1. RESPIRATORY FAILURE: The patient initially was admitted to the Medical Intensive Care Unit for management of her respiratory failure thought to be secondary to aspiration pneumonia. The patient remained on assist control mechanical ventilation. Sputum culture was obtained. She was continued on Zosyn for broad spectrum coverage. She continued on Albuterol, Atrovent nebulizer treatments. Her sputum culture grew Methicillin resistant Staphylococcus aureus; therefore, on the subsequent day, Vancomycin was added to the patient's regimen. The patient was also noted to have a Klebsiella urinary tract infection. The Klebsiella was initially thought to be beta lactamase resistant, so the patient was changed to meropenem and Vancomycin. The patient self extubated on [3-4], her respiratory status improved. She was weaned off supplemental oxygen. The patient was transferred to the Medical Floor on [3-4]. 2. INFECTIOUS DISEASE: As noted above, the patient was noted to have a Methicillin resistant Staphylococcus aureus pneumonia and a klebsiella urinary tract infection. There was also concern about possible postoperative infection of the patient's right stump. The Infectious Disease Service was involved in managing the patient's antibiotic regimen. As noted above, the patient remained on Vancomycin for her Methicillin resistant Staphylococcus aureus pneumonia. The patient is to complete a three week course of treatment for this pneumonia. Regarding the patient's Klebsiella urinary tract infection, initially it was thought that the Klebsiella was beta lactamase resistant; however, further sensitivities revealed that this organism was sensitive to Ceftriaxone. On [3-4], however, the patient developed a peripheral eosinophilia. The Infectious Disease Service thought that this reaction might be due to beta lactin antibiotics; therefore, the patient was changed from ceftriaxone to Aztreonam. The patient to complete a two week course of Aztreonam for her Klebsiella urinary tract infection. Given persistently elevated white count, the patient underwent a CT scan of her right stump to rule out the presence of a fluid collection. No focal fluid collection was identified within the right lower extremity. Finally, on [3-5], the patient was noted to have Candiduria. The patient's Foley catheter was changed. She was started on a seven day course of fluconazole. 3. FLUIDS, ELECTROLYTES AND NUTRITION: On admission, the patient was noted to be hypernatremic with a sodium of 155. The patient was thought to be volume depleted. She was hydrated and given free water boluses for her PEG tube. The patient was also maintained on her tube feeds and a nutrition consultation was obtained for assistance with tube feeds. The patient started Probalan, 50 cc per hour. The patient was maintained on aspiration precautions during her hospital stay. 4. CARDIOVASCULAR: Pump - On admission the patient's anti-hypertensive medications were initially held; then they were reintroduced and then required further titration during her hospital stay. The patient is currently on Metoprolol 100 three times a day, Lisinopril 40 twice a day, Hydrochlorothiazide 25 q. day; Norvasc 10 q. day; and Clonidine patch 0.2 mg patch weekly. The patient also remains on her digoxin 125 micrograms q. day. Digoxin level was within normal limits during this hospital admission. Coronary artery disease: The patient was noted to have elevated troponin on admission. CK remained flat. It was thought that this elevated troponin was secondary to demand ischemia. Rhythm: The patient has a history of atrial fibrillation with pacer. The patient's heart rate was stable during this admission. She remains on her digoxin and beta blocker. The patient is not on anti-coagulation given history of cerebrovascular hemorrhage. 5. VASCULAR: As noted above, there was concern for a possible postoperative wound infection in the patient's right stump. Vascular Surgery was consulted for evaluation of this area as well as a left pretibial ulcer. Vascular surgery recommended multi-Podis boots to decrease skin breakdown. They also provided recommendations regarding dressing changes. On [3-7], Vascular Surgery took the patient to the Operating Room for revision of the right above the knee amputation stump. The area was debrided and revised. 6. GASTROINTESTINAL: The patient was maintained on a proton pump inhibitor and bowel regimen during her hospital stay. At one point, she was noted to have elevated liver function tests including alkaline phosphatase. These elevated liver enzymes were thought to be secondary to medication or sepsis. Liver function tests have trended down during her hospital stay. 7. PSYCHIATRIC: The patient has a history of schizophrenia. She was maintained on her psychiatric medications during her hospital stay to include Zyprexa, Abilify and Ativan as needed. 8. HEMATOLOGIC: The patient was noted to be anemic during her hospital stay. Iron studies were sent off and it was felt that it was an anemia secondary to chronic disease. Of note, the patient underwent an esophagogastroduodenoscopy at the outside hospital recently. Esophagogastroduodenoscopy disclosed erosive gastritis. 9. PROPHYLAXIS: The patient was maintained on subcutaneous heparin during her hospital stay. She was also maintained on proton pump inhibitor and bowel regimen. 10. ACCESS: The patient had a left internal jugular vein catheter during her hospital stay. A PICC line was placed in the right basilic vein on [3-8]. 11. CODE STATUS: The patient remains full code. CONDITION AT DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Klebsiella urinary tract infection. 2. Methicillin resistant Staphylococcus aureus pneumonia. 3. Candiduria. 4. Possible beta lactate allergy. 5. Hypertension. 6. Atrial fibrillation. 7. Peripheral vascular disease, status post revision of right above the knee amputation stump. 8. Hypertension. 9. Schizophrenia. 10. Dementia. DISCHARGE MEDICATIONS: 1. Albuterol one to two puffs inhaled q. six hours as needed. 2. Atrovent two puffs four times a day. 3. Multivitamin one tablet p.o. q. day. 4. Albuterol one nebulizer q. six hours. 5. Lopressor 100 mg three times a day. 6. Atrovent nebulizer q. six hours p.r.n. 7. Lisinopril 40 twice a day. 8. Hydrochlorothiazide 25 q. day. 9. Norvasc 10 q. day. 10. Clonidine 0.2 patch weekly. 11. Digoxin 0.125 micrograms q. day. 12. Aspirin 325 q. day. 13. Colace 15 ml twice a day. 14. Senna one twice a day. 15. Abilify 10 q. day. 16. Olanzapine 20 q. day. 17. Ativan 0.5 to 1 mg q. four hours p.r.n. 18. Vancomycin 1 gram q. 18 hours times eleven days. 19. Aztreonam 1 gram q. eight hours times four days. 20. Fluconazole 100 mg p.o. times five days. 21. Lansoprazole 30 q. day. 22. Subcutaneous heparin 5000 units twice a day while hospitalized. DISCHARGE INSTRUCTIONS: 1. The patient's son will arrange follow-up with a physician within one week after discharge. 2. Dressings changes right above the knee amputation, gauze dry dressings should be changed daily. 3. For patient's left tibial ulcer, wet-to-dry dressing changes q. day. 4. Tube feeds, Probalan full strength, 50 cc per hour. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Last Name (NamePattern1) 5092] MEDQUIST36 D: [2197-3-8] 16:47 T: [2197-3-8] 17:03 JOB#: [Job Number 110828] ICD9 Codes: 5990, 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6385 }	Medical Text: Admission Date: [2193-6-17] Discharge Date: [2193-6-21] Service: MED Allergies: Bactrim / Fluoxetine Attending:[First Name3 (LF) 905] Chief Complaint: AMS, urosepsis, Acute MI Major Surgical or Invasive Procedure: right internal jugular central venous line placed in ICU History of Present Illness: 82 y.o. F c h/o type 2 DM, HTN, PVD, and CRI (h/o urosepsis, nephrolithiasis), interstitial cystitis presented from OSH ([Hospital3 ]) with confusion/ UTI/ ARF/ hyperkalemia. [Hospital1 ] ED COURSE: Family brought pt in for increasing confusion, [Month (only) ] PO intake. She was feeling depressed about recent eye surgery and eating/drinking less x7d, mild LBP, +dysuria, +f/c, [Month (only) ] UOP over past wk; no n/v/d, no melena, brbpr, abd pain. Pt. presented c acute renal failure (hyperkalemia to 5.8, BUN/Cr.-> 118/34, metabolic acidosis), wbc elevated w/bandemia and UTI on U/A. She was tx w/levoflox 250mg iv x1, ca gluc, kayexelate for K 5.7, 2L NS. Head Ct w/"layering, ?old blood". Bp at OSH 111/78. Xfer to [Hospital1 18]. [Hospital1 18] ED COURSE: T 97.4, p104, bp 95/38 RR 16, 100%/RAlowest bp in ED dropped to 81/40. Labs remarkable for + MI: CK 127, trop T 1.16, MB 8, then rose to CK 404, trop 2.05, CKMB 29, MBI 7.2. Pt tx w/4L NS for ARF, K 5.8 so given D50, insulin iv 10U ?x2, kayexelae 30mg (+bm in ED), bicarb 2amps; then hep gtt and ASA for MI. HOSPITAL COURSE: admitted transiently (2hrs) to [Hospital Unit Name 196], then acidotic by VBG 7.13/20/38, lactate 2.1, concern for urosepsis, difficult fluid status. BP 120-130s, dropped to 100 at 2pm. Given about 250cc of [12-14] NS w/part of an amp of bicarb. Tx w/CTX 1gm IV. Blood cx, repeat u/a +cx drawn, PIV placed. Xfer to MICU. In MICU, fluid resuscitated and given 1amp of bicarb followed by po bicarb for bicarb level of 7. Changed abx to CTX and stopped heparin after normalization of troponin and CK trending down. Creat improved with fluid, almost back to baseline. UCx negative here, but started on Abx before drawn. 2u rpbcs given on admission with stablization hct. Past Medical History: 1. Breast cancer ([2178]) 2. DM2 3. h/o urosepsis 4. interstitial cystitis 5. HTN 6. Fe def. anemia 7. B12 def 8. depression 9. h/o DVT 10. Raynaud's 11. venous insufficiency 12. dyslipidemia 13. carotid stenosis s/p CEA 14. nephrolithiasis s/p R nephrectomy 15. macular degeneration 16. fibroid uterus 17. PVD 18. CRI (baseline 1.1-1.6) 19. Ileal loop neobladder ([2178]) - pt unclear of reason for it Social History: lives alone, independent ADLs, currently visiting son for [Name2 (NI) 108870]; no tob/ivdu/etoh Family History: non-contributory Physical Exam: Vitals (transfer from MICU) T: 98.0 P: 77 BP: 115/75 RR: 20 SaO2:97%RA Gen WNWD, NAD, sitting upright in chair HEENT NC/AT, PERRL, EOMI, MMM Neck Supple, RIJ in place, no bleeding Thorax CTA Bilaterally except for fine rales bilat bases CV reg rate, nl S1/S2, no s3/s4 Abd soft, NT/ND, NABS in all 4 quads Ext Trace-1+ bilat LE edema ankle->mid calf Skin warm and dry w/o rashes Neuro A&Ox3, non-focal Back No CVAT bilat, foley with dark brown urine Pertinent Results: [2193-6-16] 11:53PM BLOOD WBC-11.7* RBC-3.04* Hgb-9.6* Hct-30.2* MCV-99* MCH-31.7 MCHC-31.9 RDW-13.8 Plt Ct-139* [2193-6-17] 06:08AM BLOOD Neuts-70 Bands-12* Lymphs-5* Monos-12* Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2193-6-17] 01:54PM BLOOD PT-14.0* PTT-67.7* INR(PT)-1.3 [2193-6-16] 11:53PM BLOOD Glucose-221* UreaN-118* Creat-3.4# Na-135 K-5.8 Cl-115* HCO3-<5 [2193-6-21] 05:00AM BLOOD Glucose-72 UreaN-37* Creat-1.4* Na-145 K-4.6 Cl-121* HCO3-12* AnGap-17 [2193-6-17] 06:15AM BLOOD freeCa-1.19 Cardiac Enzyme Trend: [2193-6-16] 11:53PM BLOOD CK-MB-8 cTropnT-1.16* [2193-6-17] 06:08AM BLOOD CK-MB-29* MB Indx-7.2* cTropnT-2.05* [2193-6-18] 06:19AM BLOOD CK-MB-41* MB Indx-5.1 cTropnT-2.49* [2193-6-20] 05:31AM BLOOD CK-MB-6 cTropnT-1.73* Radiology: ----CT HEAD W/O CONTRAST [2193-6-17]:There is no evidence of intracranial hemorrhage, hydrocephalus, shift of normally midline structures or edema. The [Doctor Last Name 352]-white matter differentiation appears intact throughout. The paranasal sinuses are well aerated. IMPRESSION: No evidence of intracranial hemorrhage. ----Bedside TTE [2193-6-17]: 1.The left atrium is normal in size. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). 3.Right ventricular chamber size and free wall motion are normal 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. 5. Normal mitral valve leaflets. Mild (1+) mitral regurgitation is seen. 6.There is moderate pulmonary artery systolic hypertension. 7.There is no pericardial effusion. ------EKG [2193-6-17]: Wide complex tachycardia - mechanism uncertain - consider "slow" atrial flutter/ atrial tachycardia with 2:1 response Intraventricular conduction delay/ left bundle branch block pattern Clinical correlation is suggested Since previous tracing of [2190-5-13], sinus rhythm absent and intraventricular conduction delay seen -------RENAL U.S. [2193-6-17] 6:50 AM: The patient is status post right nephrectomy. The left kidney measures 12.6 cm. There is no evidence of hydronephrosis, masses or stones. Brief Hospital Course: Impression: 82 yo F w/DM, htn, cri, R nephrectomy [1-14] nephrolithiasis in past, presents in ARF, hyperkalemia, met acidosis, UTI/pyelonephritis w/ urosepsis, and ruled in for acute NSTEMI. Uncomplicated MICU course and transferred to the floor after 72 hours. PLAN: 1. CAD- NSTEMI in setting of hypotension, stress from ARF and infection. Initially on heparin gtt which was discontinued after enzymes started trending down. Peak CK 910, trop 2.0. Equivalent to positive stress test, therefore assume coronary disease likely. Will need formal evaluation as outpatient in [3-19] weeks. Her ASA and lipitor wer continued throughout her hospitalization. Her BBlocker was held transiently given her hypotension, but then restarted and titrated back to her outpatient dose of lopressor at 25 [Hospital1 ]. 2. Acute on chronic renal failure/metabolic acidosis: FeNa < 1% (prerenal) from dehydration/Urosepsis/MI. Also hx of decreased PO intake prior to arrival. No hx NSAID use, held ACEI until creat normalized. s/p 6.5L IVF, mostly NS, w/improvement in creatinine back to basline of 1.4. Her lasix was discontinued and she will f/u with PCP for reinitiation. 3. Diastolic CHF: Bedside ECHO (done for +trop, volume overload) showed ef >55%, cxr w/mild CHF following fluid resuscitation, thus may have decreased LV compliance [1-14] infarct w/diastolic dysfsn. Once hemodynamically stable, no issues with CHF with Room Air sats high 90s and clear pulmonary exam. Will need repeat TTE as outpatient. Restarted Lisinopril on discharge. 4. UTI/Pyelo/Urosepsis: u/a positive but UCx negative (abx already administered at OSH). UCx at [Hospital1 1774] ultimately grew E. Coli in 10K-100K, senstivities not performed. Patient straight caths [Hospital1 ] at home due to neurogenic bladder which is likely source of infection. Urosepsis improved with abx, IVF while in MICU. Foley d/c'd [2193-6-19] and UOP good without dysuria or back pain. She was continued on ceftriaxone x5 days and then switched to cefpodoxime 200mg [Hospital1 ] to complete a 14 day course. BCx were all negative. 5. Acidosis: bicarb as low as 5 in setting of urospesis, ARF. Patient with history of "RTA" due to baseline low HCO3-. Renal team consulted and initially felt her to have Type I and Type IV RTA given inappropriate wasting of bicarb in urine with metabolic acidosis. However, after discussion with patient, it was discovered that she had ileal neobladder surgery [98] yrs ago which accounts for her bicarb wasting. Her prior diagnosis of "RTA" therefore is likely to be incorrect. She was sent home with sodium bicarb tablets at 1300 TID with goal serum bicarb in the range of 15-17. 6. DM2: she was maintained on outpatient NPH regimen and insulin sliding scale. 7. Anemia: Hct- 30.2 on admission, 26.6 post aggresssive IVF hydration. Known hx of iron deficiency, renal insufficiency. She received 2U prbcs in MICU with stable hct during the rest of her hospitalization. 8. Hyperkalemia: secondary to renal failure. pt. given kayexelate, bicarb, insulin and glucose on admission in ED and develop iatrogenic hypokalemia. K+ stablized x72 hours without replacement 9. Code: Full Medications on Admission: (Home) 1. lipitor 20 2. lisinopril 10 3. NPH 14/8 4. ASA 325 5. vit b12 q month 6. lasix 20 7. lopressor 25 [Hospital1 ] Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Miconazole Nitrate Powder Sig: One (1) Appl Miscell. QID (4 times a day). Disp:1 container Refills:0 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: see below units Subcutaneous twice a day: NPH 14U/8U. 7. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:1 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO twice a day for 9 days. Disp:18 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. Urosepsis 2. Enterococcal UTI/Pyelonephritis 3. Non-ST elevation myocardial infarct 4. Acute Renal failure (due to infection, pre-renal azotemia) on chronic renal failure 5. Diastolic Congestive Heart Failure 6. Metabolic Acidosis from ileo-loop bladder 7. Diabetes 8. Anemia secondary to Chronic renal failure 9. Hyperkalemia Discharge Condition: stable and improved Discharge Instructions: 1. Continue to take all medications as previously prescribed. Check the list below if you have any questions. Do not take your lasix until Dr. [Last Name (STitle) ] instructs you to. 2. You will need to have a stress test scheduled by Dr. [Last Name (STitle) ] in [3-19] weeks. Call his office for more information. 3. Return to ED for fever, chills, pain with urination, chest pain, shortness of breath. Followup Instructions: 1. Please call Dr. [Last Name (STitle) ],[First Name3 (LF) ] A. at [Telephone/Fax (1) 1144] to set up a follow up appointment next week. He will discuss restarting lasix with you and setting up a cardiac stress test as an outpatient. 2. Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY Where: [Last Name (NamePattern4) ] SURGERY Date/Time:[2193-12-19] 10:30 [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] ICD9 Codes: 0389, 4280, 5849
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6386 }	Medical Text: Admission Date: [2197-10-4] [Month/Day/Year ] Date: [2197-10-9] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 13386] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] yo female s/p fall out of bed; + EtOH. She was taken to an area hospital; found to have a sustaining right subdural hematoma and was subsequently transferred to [Hospital1 18] for ongoing care. Past Medical History: Hypothyroid Osteoporosis Social History: +Etoh Resides in [Hospital3 ] facility Family History: Noncontributory Physical Exam: VS T 99.8 P 80 BP 90/41 RR 16 Gen: A&Ox3, NAD Head: NC, AT, no abrasions HEENT: TMs clear, hares clear, PERRLA, EOMI, 2mm L periorbital abrasion Neck: supple, NT CV: RRR Pulm: CTAB ABD: +BS, NT, ND, soft Pelvis: stable Back: NT Rectal: guaiac neg UE: b/l elbow ecchymosis, NT, FROM, +sensation, [4-14] MS, R hand superficial laceration/abrasion LE: NT, FROM, [4-14] MS, +sensation Pertinent Results: [2197-10-4] 11:40PM GLUCOSE-116* UREA N-14 CREAT-0.5 SODIUM-145 POTASSIUM-3.9 CHLORIDE-114* TOTAL CO2-23 ANION GAP-12 [2197-10-4] 11:40PM CK-MB-7 cTropnT-<0.01 [2197-10-4] 11:40PM CALCIUM-7.5* PHOSPHATE-1.3* MAGNESIUM-3.0* [2197-10-4] 11:40PM PLT COUNT-142* [2197-10-4] 11:40PM WBC-10.5 RBC-3.64* HGB-11.3* HCT-34.0* MCV-93 MCH-31.1 MCHC-33.4 RDW-14.0 [2197-10-4] 11:53AM LACTATE-2.5* ECG: [10-5] Sinus bradycardia First degree A-V block Left atrial abnormality rSr'(V1) - probable normal variant Possible right ventricular hypertrophy Low QRS voltages in limb leads Since previous tracing of [2197-10-4], junctional rhythm has reverted to sinus rhythm and ST-T wave abnormalities are resolved Intervals Axes Rate PR QRS QT/QTc P QRS T 56 256 84 462/451.86 82 10 56 CT HEAD W/O CONTRAST Reason: SUDDEN MS CHANGES, EVAL FOR PROGRESSION OF SDH [Hospital 93] MEDICAL CONDITION: [Age over 90 ] year old woman with sudden MS change REASON FOR THIS EXAMINATION: r/o out sdh progression CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: [Age over 90 ]-year-old with sudden mental status changes, history of subdural hemorrhage. TECHNIQUE: CT of the brain without IV contrast. Comparison is made to non-contrast CT performed at 3:00 a.m. today at [Hospital1 18] [Location (un) 620]. FINDINGS: Again seen is a subdural hemorrhage extending along the right parietal and temporal lobe convexities and extending into the middle cranial fossa. This measures 6 mm in greatest dimension over the right parietal lobe and is unchanged from the prior examination. No new hemorrhages identified. There is no new hydrocephalus. There have been no other changes in the seven-hour interval. IMPRESSION: Stable appearance of right subdural hematoma. Findings were discussed at approximately 11:00 a.m. with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3271]. Brief Hospital Course: She was admitted to the Trauma service. She initially required Dopamine in the Emergency room because of hypotension following administration of sedative for agitation. Once stabilized she was transferred to the Trauma ICU for close monitoring. Her Dopamine was weaned off the following day and her blood pressures have remained stable. Neurosurgery was consulted because of her right SDH; this injury was nonoperative. She was loaded with Dilantin which will need to continue for a total of 7 days. Serial head CT scans were performed and were stable. Her Dilantin dose was decreased from 100 mg po tid to 100 mg [Hospital1 ] because felt may be contributing to confusion given level of 17; although therapeutic, in elderly patients this level may be toxic. She will follow up with Neurosurgery in 6 weeks for repeat head imaging. Cardiology was also consulted to rule out cardiac causes of her fall; her troponin level was flat; junctional rhythm on ECG felt may be secondary to CNS event. No clinical evidence of heart failure or tamponade noted. Serial ECG's were performed (see pertinent results); she remained on telemetry with no recorded events. Geriatrics was also consulted because of her age and mechanism of injury; several recommendations were made pertaining to her medications. It was recommended that she be placed on prn Ativan given her alcohol consumption (EtOH level 19 on admission) and Seroquel at hs prn. She did initially require a 1:1 sitter and this was eventually discontinued. Pt was alert although remained slightly confused but easily redirectable for the remainder of her hospitalization. Her labs were stable, she was tolerating a regular diet and had no acute events. Physical therapy was consulted and have recommended a short rehab stay. Case management initiated the screening process for rehab placement. Pt discharged to a rehab facility attached to her prior retirement community and the pt was looking forward to [Hospital1 ]. She was to continue for a total of 10days of dilantin for sz prophylaxis, but then be discontinued for potential CNS toxicity in this elderly lady. She has follow up in 6wks with neurosurgery to assess the resolution of her SDH. She was instructed to follow up with her PCP after [Hospital1 ]. Her TSH was high at 5.2 a few days prior to [Hospital1 ] and rechecked the day of [Hospital1 ] and was still pending at time of [Hospital1 ]. She was discharged on 25mcg of levothyroxine and instructed to follow up with her PCP for any further adjustments of her thyroid medication. Medications on Admission: Syntrhoid Fosmax [Hospital1 ] Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Acetaminophen 650 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 3 days. Disp:6 Capsule(s) Refills:0 9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). Disp:12 Tablet(s) Refills:2 [Hospital1 ] Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] - [Location (un) ] [Location (un) ] Diagnosis: s/p Fall Right subdural hematoma [Location (un) ] Condition: Stable [Location (un) ] Instructions: Retrun to the Emergency room if you develop any severe headaches, dizzines, visual disturbances, seizure activity, fevers; weakness in any of your extremties and/or any other symptoms that are concerning to you. You will need to continue with Dilnatin for a total of 7 days; you have 3 more days to complete this course of medication. Followup Instructions: Follow up with Neurosurgery in 6 weeks with Dr. [Last Name (STitle) 739], 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 with your primary doctor [First Name (Titles) ] [Last Name (Titles) ] from rehab, you will need to call for an appointment. Ask your PCP to follow your thyroid function and medication for you. ICD9 Codes: 2762, 2449, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6387 }	Medical Text: Admission Date: [2198-5-4] Discharge Date: [2198-5-16] Date of Birth: [2138-8-4] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 443] Chief Complaint: Transfer from OSH for STEMI and PNA Major Surgical or Invasive Procedure: Endotracheal intubation Arterial line placment Central line placement History of Present Illness: Mr. [Known lastname ]. [Known lastname ] is a 59 year old man with history of CAD tranferred from OSH following anterior STEMI on [4-29] who is s/p DES to LAD. Course c/b cariogenic shock requiring dual pressors and IABP, both now weaned and pneumonia. Patient presented to [Hospital1 ] MC ER evening of [2198-4-29] with acute excruciating chest pain for about an hour prior to presentation. EKG at that time showed [Known lastname ] elevation in anterior precordial leads. He received ASA, clopidogrel, heparin and IV nitroglycerin. Due to hypotension, nitro was stopped. Noted to have bouts of VT between 10-20 beats periodically. He was taken to catherterization lab and angiography via RFA approach showed normal L main, but an LAD that was thrombotically occluded proximally, and LCx with very small distal vessel occlusion. RCA showed chronic occlusion in proximal portion with TIMI-1 flow into the remaining vessel. Export thrombectomy yieled significant thrombus removal and restoration of flow into LAD with residual 90% lesison. The lesion was then stented with 3mm x 18mm Xience DES. TIMI 3 flow was seen post stent placement. Distal RCA seen to collateralize from LAD. Despite revascularization, patient continued to have chest pain and hypotension. LVEDP was seen to be 35 mmHg at that time and 8 Fr 40 cc intra-aortic balloon pump was placed. Dopamine was started with continual hemodynamic decompensation and phenylepherine was added. Attempts to open the RCA was done at that time as decompensation was thought to have been to subacute closure, but lesion appeared chronic. Patient maintained mentation but continued to become more agitated. Given tenuous status, decision made to intubate at that time. Per report hemodynamics improved dramatically over the ensuing 48 hours. Neo-synephrine and dopamine were weaned within 24 hours, and the balloon pump was also weaned over the subsequent 24 hours. He was started on carvedilol, aldactone, and captopril with continued hemodynamic stability. He was diuresed approximately 3.5 L and TTE noted EF of approximately 25%. His hospitalization was complicated by MSSA pneumonia, and he was started on vancomycin on [5-2] with addition of cefazolin on [5-3]. He remains intubated. His platelets were also noted to decrease over first 48 hours of admission. Heparin dependent antibodies were negative per report and they had recovered to 65 prior to arrival to [Hospital1 18]. At this time, patient's family has requested transfer to [Hospital1 18] for further management. Review of systems was unable to be obtained, as patient was intubated on arrival. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - CABG: None known - PERCUTANEOUS CORONARY INTERVENTIONS: Angioplasty approximately 18-19 years ago. Details unclear. - PACING/ICD: None known 3. OTHER PAST MEDICAL HISTORY: - CAD - HTN - HLD Social History: per OSH Records: Has worked in [Location (un) 86] for [Company 33655] Insurance. - Tobacco history: Remote - ETOH: Unknown - Illicit drugs: Unknown Family History: - Father and 2 brothers with premature CAD Physical Exam: ON ADMISSION VS: T=99.6 BP=103/72 HR=92 RR=16 O2 sat=100% on PS [4-5] FiO2 80% GENERAL: Intubated. Sedated. HEENT: NCAT. PERLL 3-->2mm. ETT and OG in place. Dry MM. No apparent JVD at 45 degrees. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Appears nonlabored on PS. Mechanical breath sounds bilaterally to anterior ausculation without additional adventitial sounds. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, or rashes noted NEURO: Intubated, sedated. Does not respond to voice. Does not withdraw from noxious stimuli. Face appears symmetric and pupils are equally round and reactive from 3->2mm. 1+ ankle jerk and biceps reflexes. Mute babinski . ON DISCHARGE: VS: Temp 99, HR 90-100's, SR/[Known lastname ] with isolated 3-6 beat NSVT, RR 18, BP 90-110/54-68, O2 sat 96% on RA. Weight 83 kg . Gen: alert, oriented, fatigued CV: RRR, no M/R/G Chest: CTAB ant, mild cough ABD: soft, NT, ND, pos hyperactive BS, inc gas EXTR: no edema, feet warm Lines: Right IF TLC, dressing changed [5-15] Leftvest in place, battery changed [5-16] Pertinent Results: ADMISSION LABS: [2198-5-4] 12:40PM BLOOD WBC-12.6* RBC-3.45* Hgb-11.4* Hct-35.3* MCV-103* MCH-33.1* MCHC-32.3 RDW-13.1 Plt Ct-111* [2198-5-4] 12:40PM BLOOD PT-14.1* PTT-27.5 INR(PT)-1.3* [2198-5-4] 12:40PM BLOOD Glucose-126* UreaN-17 Creat-0.9 Na-142 K-3.8 Cl-107 HCO3-26 AnGap-13 [2198-5-4] 12:40PM BLOOD ALT-43* AST-77* LD(LDH)-1210* AlkPhos-58 TotBili-0.7 Microbiology: Sputum culture [2198-5-4]: MSSA Sputum culture [2198-5-7]: NEGATIVE Induced sputum [2198-5-12]: Blood cultures Urine cultures: Cdiff [2198-5-11]: NEGATIVE Imaging: TTE [2198-5-4]: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) secondary to extensive septal, anterior, and apical akinesis. The rest of the left ventricle is hypokinetic with regional variation. The right ventricular free wall thickness is normal. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen (may be underestimated due to the technically suboptimal nature of this study). Tricuspid regurgitation is present but cannot be quantified. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. TTE [2198-5-7]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the distal 2/3rds of the anterior septum and anterior walls and apex. There is hypokinesis of the remaining segments (LVEF = 20-25 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([11-27]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD (prox/mid-LAD distribution). Mild-moderate mitral regurgitation. Compared with the prior study (images reviewed) of [2198-5-4], the overall findings are similar. CT Chest [2198-5-11]: The lung parenchymal findings suggest a combination of pulmonary edema and pulmonary infection. The manifest as ground-glass opacities, crazy paving, interstitial fluid overload and pleural effusions. Several millimetric subpleural bilateral nodules and peribronchial nodules, none of which are suspicious for malignancy. Borderline sized lymph nodes, coronary stent, normal appearance of the heart. Incidental finding several medications are seen in the stomach DISCHARGE LABS: [2198-5-16] 04:39AM BLOOD WBC-13.0* RBC-2.42* Hgb-8.1* Hct-24.5* MCV-101* MCH-33.4* MCHC-33.0 RDW-15.0 Plt Ct-462* [2198-5-16] 04:39AM BLOOD Glucose-89 UreaN-26* Creat-1.2 Na-132* K-4.3 Cl-104 HCO3-19* AnGap-13 [2198-5-16] 04:39AM BLOOD ALT-140* AST-93* Amylase-110* [2198-5-14] 04:40AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION Mr. [Known lastname ]. [Known lastname ] is a 59 year old man with history of coronary artery disease (CAD) tranferred from OSH following anterior STEMI on [4-29] who is s/p DES to LAD. Course complicated by cariogenic shock requiring dual pressors and intra-aortic balloon pump (IABP), both now weaned and methicillin sensitive staph aureus (MSSA) pneumonia. ACTIVE PROBLEMS # [Known lastname ] elevation myocardial infarction (STEMI): Patient with known prior CAD. Presented to OSH with STEMI on [4-29]. Patient is s/p thrombectomy to LAD with placement of 3mmx18mm Xience DES to persistent 90% lesion. His course was complicated by cardiogenic shock requiring dual pressors and IABP. Pressors and pump were weaned over subsequent 48 hours and patient was hemodynamically stable on arrival to [Hospital1 18]. He has persistent STE on admission EKG, but this appears consistent with OSH EKG's done over the preceeding 48 hours. Multiple repeat CK-MB's were noted to be within normal limits. TTE was notable for LVEF= 20% secondary to extensive septal, anterior, and apical akinesis and patient was started on coumadin with heparin bridge for thrombus prophylaxis. We continued his aspirin 81 mg daily, plavix 75 mg daily, atorvastatin 80 mg daily. Captopril was started at OSH and transitioned to lisinopril 5 mg daily. Carvediolol was changed to metoprolol succinate 150 mg daily. # New ischemic systolic heart failure: TTE showed LVEF= 20% secondary to extensive septal, anterior, and apical akinesis. Anticoagulation with coumadin and heparin drip was started as above. Pulmonary edema was apparent on CXR and patient was diuresed with 20-60mg IV lasix as needed for continued gentle diuresis. He was further medically managed with metoprolol and lisinopril as above. He was started on spironolactone 12.5 mg daily as well. He should have a repeat echo in 2 weeks and wear the lifevest external defibrillator until f/u with Dr. [Last Name (STitle) ] for consideration of ICD placement. # Hypoxic respiratory failure: Patient intubated in cath lab [4-29] at OSH in setting of agitation and cardiogenic shock. Course has been complicated by MSSA PNA. Presented from OSH intubated and ventilation was stable on PSV 8/5 and 50% FiO2 early in stay. PNA and CHF were treated as noted elsewhere. On the evening of [5-6] he was noted to develop [Last Name (un) ] [Doctor Last Name 6056] respirations and was sent for non-contrast head CT which was negative for intracranial hemorrhage. Upon return from radiology, patient self-extubated. He maintained sats initially on manual bag masking, however after reintubation his O2 sats were noted to decreased mid 70's on 100% Fi02. He was given 60mg IV lasix and his O2 sats improved over the next 10 minutes. His ventilatory dependence decreased dramitically the following day in the setting of additional diuresis and he was successfully extubated. # Hypertension (HTN): Home regimen included isosorbide and atenolol, which were not used during his stay. He presented following cardiogenic shock at OSH and had recently been weaned off pressors and IABP. Metoprolol and lisinopril were started as above. His blood pressures remained well controlled during stay except for hypotensive episode with SBP from 70-90 in setting of self-extubation, presumed flash pulmonary edema, and reintubation on the evening of [5-6]. # Hyperlipidemia (HLD): Apparently well controlled as lipid panel at OSH revealed TC 98. HDL 47 LDL of 37 on [4-30]. Will continue atorvastatin 80mg daily for now. # Pneumonia (PNA): MSSA on OSH microbiology report. Started cefazolin [5-2] and transitioned to nafcillin planning to complete 14 day course. However, spiked more fevers with leukocytosis and repeat chest CT showed bilateral multifocal pna. Pulmonary was consulted and recommended repeat CT in 8 wks. He had a negative HIV test and sputum cultures were negative so far. He was broadened to cefepime/vancomycin to complete an 8 day course on [5-19]. He was transitioned to cefpodoxime and vancomycin on discharge. # Thrombocytopenia: Dropped from 177 on [4-29] to 47 on [5-2] at OSH. Likely due to critical illness with balloon pump. Recovering per OSH records and platelet dependent antibodies are negative per OSH report. Platelet count was normal during his stay. # Abdominal pain: started on [5-15]. LFTs and amylase/lipase slightly elevated but exam benign. Differential included gallstone pancreatitis, c diff colitis and constipation. Pain went away spontaneously after passing gas and having formed BM. Sample was not sent for c-diff and enzymes trended down somewhat on day of discharge. TRANSITIONAL ISSUES: - He should have a repeat echo in 2 weeks and wear the lifevest external defibrillator until f/u with Dr. [Last Name (STitle) ] for consideration of ICD placement. - Repeat chest CT in 8 weeks Medications on Admission: HOME MEDICATIONS per OSH records, dosing not listed: - Gemfibrozil - Isosorbide - Atenolol - ASA - Simvastatin Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Fever Do not exceed 4g in one day 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 2 Days give 2 doses on [5-18], then d/c 5. Clopidogrel 75 mg PO DAILY Do not stop taking unless Dr [Last Name (STitle) ] says it is OK to do so. 6. Polyethylene Glycol 17 g PO DAILY 7. Furosemide 20 mg PO DAILY 8. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 9. Lisinopril 5 mg PO DAILY Hold for SBP<100 10. Metoprolol Succinate XL 125 mg PO DAILY Please hold for SBP < 100, HR < 50 11. Senna 1 TAB PO BID:PRN constipation 12. Spironolactone 12.5 mg PO DAILY Hold for SBP<90 13. traZODONE 25 mg PO HS:PRN insomnia hold for sedation or rr<10 14. Vancomycin 1250 mg IV Q 12H Duration: 2 Days Give 2 doses on [5-18], then d/c triple lumen 15. Warfarin 3 mg PO DAILY16 please check INR on [5-18] Discharge Disposition: Extended Care Facility: [Hospital ] Hospital for Continuing Medical Care - [Hospital1 8] Discharge Diagnosis: [Known lastname ] elevation myocardial infarction Ischemic heart failure with apical akinesis MSSA pneumonia Dyslipidemia hypertention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ]. [Known lastname ], It was a pleasure taking care of you here at [Hospital1 18]. You were admitted to [Hospital1 18] from another hospital for concern about your heart. You had a severe heart attack and required treatment in the ICU and you developed a very bad pneumonia and needed a breathing tube to help you breath temporarily. After your blood pressures improved to normal range and you no longer required support for your breathing you were transferred to the regular cardiac floor. We determined that part of your heart was injured from the heart attack and was not pumping very well and because this can put you at risk for developing blood clots there so you were started on blood thinners. Because of your type of heart attack you also are at risk for having your heart go into a bad rhythm, and therefore will need to wear a lifevest while you wait for an ICD (implanted defibrillator) to be placed. . Follow-up needed for: 1. ICD placement 2. Anticoagulation 3. Pneumonia Weigh yourself every morning, call Dr. [Last Name (STitle) ] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Stop taking all of your home medicines and start taking the medicines that you have been taking here. Followup Instructions: You will need an echocardiogram in 2 weeks and see Dr. [Last Name (STitle) ] in 4 weeks. Please call [Telephone/Fax (1) 62] if you do not hear from them in the next few days. ICD9 Codes: 5849, 2875, 2760, 4271, 2761, 4275, 4019, 4280, 2859, 2724, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6388 }	Medical Text: Admission Date: [2104-2-17] Discharge Date: [2104-2-23] Date of Birth: [2023-4-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 458] Chief Complaint: transferred from OSH for ? urgent cardiac cath Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 76 yo F with h/o DM, SVT, afib not on anticoagulation who presented to an OSH on [2104-2-16] with weakness, decreased appetitie, cough and increase in chronic back pain. She was found to have an NSTEMI with initial trop I of 1.[Street Address(2) 71258] depressions in precordial leads of 3mm. She was placed on nitro gtt, heparin gtt and given asa, plavix, lopressor. Later in the evening she began to have respiratory distress requring a non-rebreather. She was given lasix for diuresis and had an ABG of 7.46/34/64/23 with an O2 sat of 93% on NRB. She continued to have ST depressions and was transferred to [Hospital1 18] for ? urgent catheterization. Her second set of enzymes showed a troponin I of 2.81. Her hospital course was also complicated by her afib which became rapid with HR to 120-160's. She was rate controlled with IV lopressor. Her digoxin level was 0.4mg on admission. Also of note, her initial blood sugar was 457 but this came down to the 200-300 range with insulin. . Per her daughter, the patient has had SOB, palpitations, syncope, and weakness. She denies CP, DOE, PND or orthopnea. Since arrival to [Hospital1 18], she was in afib with RVR and given IV lopressor 5mg x2 to bring her rate down to the 80's. Past Medical History: DM2 on oral agents hypertension chronic back pain hypothyroidism atrial fibrillation not on anticoagulation given fall history No known CAD - ECHO in [2102] per d/c summary of OSH had LVEF 50-55%, moderate LVG, mild [Name Prefix (Prefixes) ] [Last Name (Prefixes) 13385], trace MR, mild TR, RVSP of 19. dementia urine incontinence s/p appy s/p right eye cataract surgery Social History: retired teacher, lives with daughter. Denies any h/o tobacco or alcohol use. Ambulated with walker at home adn performs ADLs. Greek speaking but understands minimal English. Family History: HTN Physical Exam: T 100.8, BP 136/94, HR 119, RR 20, 95% on NRB General: non English speaking, somewhat sedated, labored breathing HEENT: JVP elevated, PERRL, anicteric sclera, non injected conjunctiva CV: irreg, irreg. harsh systolic murmur Lungs: rales half way up lungs bilaterally Abdomen: +BS, soft NTND Ext: cool. no edema, pulses 2+ DP Pertinent Results: [2104-2-17] CXR: IMPRESSION: Right upper lobe infiltrate. Given the diffuse increased interstitial markings, the chronicity of this process cannot be assessed. . [2104-2-18] CXR: There has been an improvement in the appearance of the chest with decrease in the prominence of the interstitial markings bilaterally. The patchy air space space disease in the right upper lobe has significantly improved. Given the rapidity of the change, this likely represents some clearing of interstitial edema. . [2104-2-19] ECHO: Conclusions: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (given small body size). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([2-5]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [2104-2-19] Cath: 1. Two vessel coronary artery disease with miuld disease in the LAd and chronic total occlusion in the LCX. 2. Left ventriculography was deferred. [LM - no disease; LAD - 50%; LCx - total occulsion; RCA/PDA - 40%] . Admission labs: WBC-10.4 RBC-3.65* Hgb-11.0* Hct-30.5* MCV-84 MCH-30.2 MCHC-36.2* RDW-15.1 Plt Ct-135* Neuts-87.6* Bands-0 Lymphs-9.4* Monos-2.6 Eos-0.2 Baso-0.1 [2104-2-17] 04:52AM BLOOD Glucose-109* UreaN-25* Creat-1.1 Na-135 K-4.4 Cl-98 HCO3-24 AnGap-17 . CK peak 264 with trop T peak at 0.95 . Cholesterol panel Triglyc-85 HDL-46 CHOL/HD-3.7 LDLcalc-105 LDLmeas-112 . TSH 2.1 . HA1C- 8.0 . Discharge labs: WBC-7.3 RBC-3.79* Hgb-11.1* Hct-31.8* MCV-84 MCH-29.2 MCHC-34.8 RDW-14.7 Plt Ct-94* Glucose-157* UreaN-24* Creat-1.2* Na-139 K-3.9 Cl-101 HCO3-29 AnGap-13 Brief Hospital Course: Ms. [Known lastname 33352] is an 80 year old female without documented CAD who presented with demand ischemia and flash pulmonary edema likely from afib with RVR. Transferred from OSH for management of NSTEMI and afib with RVR. . # cardiac: Ms. [Known lastname 33352] presented to the OSH with ST depressions and rising cardiac enzymes in the setting of afib with RVR. Her respiratory status decompensated requiring a non-rebreather for adequate oxygenation at the OSH. She was transferred to [Hospital1 18] for possible urgent catheterization. Upon arrival she was noted to have a questionable RUL infiltrate and definate pulmonary edema in addition to her afib with RVR. It was unclear if a community acquired pneumonia added strain to her heart or if the rapid a fib alone initiated the event. . - Pulmonary edema: She was given furosemide for diuresis and very quickly was weened off of the non-rebreather to a nasal cannula and subsequently to room air. She had an ECHO which showed a LVEF of 60% with some AS and MR and trace AR. She does not appear to have CHF and her pulmonary edema was likely secondary to strain on her heart from the rapid afib. Once she was diuresed, she remained euvolemic and did not require further furosemide doses. She was continued on and ACEI and BB. . - Atrial fibrillation: Her afib was rate controlled by titrating up metoprolol to 150mg TID and adding amlodipine back from her home regimen. She was monitored on telemetry and had no events other than her afib. She was not anticoagulated at home secondary to fall risk. We spoke with her PCP who confirmed this to be true saying that she has had several falls and is quite unsteady on her feet. She was treated with a heparin gtt initially but she is not being sent out on warfarin given her baseline mild dementia and h/o falls giving her a high risk of bleeding complications. She is being treated with ASA for anticoagulation. She was on digoxin for her afib at home. This medication was discontinued in favor of a beta blocker for rate control as it will be beneficial given her CAD as well. . - CAD: For her NSTEMI, she was loaded with plavix and kept on a heparin gtt (also for her a fib). She went to the cath lab and was found to have obstruction of the LCX and mild disease in the LAD and RCA. Her CK peak at 264. The decision was made to medically manage her CAD without intervention. She was continued on aspirin, BB, ACEI and statin along with amlodipine for rate and BP control. . - Cardiac medications: at discharge she was placed back on her combination medication of amlodipine and benzapril as well as fluvastatin. Her new medication includes metoprolol 150mg TID. Digoxin has been discontinued. . # Infection: Ms. [Known lastname 33352]' initial CXR suggested she had a RUL infiltrate suggestive of community acquired pneumonia as well as pulmonary edema. She was treated with levofloxacin. Subsequent CXR showed almost complete resolution of the RUL infiltrate suggesting it was more likely pulmonary edema than infiltrate, but given her initial temp of 100.5 on admission, she was continued on a full 7 day course of antibiotics. All blood cultres and urine cultures showed no growth to date on discharge. . # hypothyroidism: She was continued on her home dose of levothyroxine and her TSH was within normal limits at 2.1 . # DM2: Her oral antihypoglycemic agents were held initially given her disposition to the cath lab and she was treated on a sliding scale with insulin (humalog). 48 hrs after cath, she was restarted on her home doses of metformin and glyburide with an insulin sliding scale for coverage. Her hemoglobin A1C was elevated at 8.0. She will need further adjustments to her diabetes regimen (via medications and/or diet) as an outpatient. . # Demential/delirium: Ms. [Known lastname 33352] was continued on her nemenda during her hospitalization. While in the CCU she did sometimes have sundowning at night; she was often helped with working on her day/night cycle and reorientation. . #PPX: Once the heparin gtt was discontinued, she was given heparin SQ for DVT prophylaxis; she was given a PPI while in house and NPO for procedures. Finally, she was evaluated by physical therapy while in house and it was thought that she would benefit from rehab to build on strength, conditioning and balance training before going home. . #code: DNR but can intubate for reversible causes. . #Dispo: to rehab Medications on Admission: Medications on arrival from OSH: IV heparin gtt nitro gtt at 100mcg/min synthroid 50mcg dialy zestril 5mg daily namenda 10mg [Hospital1 ] lopressor 25mg [Hospital1 ] KCL 40mEq daily ASA 325mg daily lipitor 10mg nightly plavix 75mg daily digoxin 0.125mg daily nexium 40mg daily glyburide 5mg daily . Meds from home: lotrel 5/10mg daily metformin 500mg [Hospital1 ] synthroid 50mcg daily lescol XL 80mg at dinnertime glyburide 5mg daily digoxin 125mcg daily namenda 10mg [Hospital1 ] lisinopril 5mg daily asa 81mg daily Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid (). 4. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Lotrel 5-10 mg Capsule Sig: One (1) Capsule PO once a day. 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. Lescol XL 80 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO at bedtime. 10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other day for 1 doses: Please give last dose (QOD) on [2104-2-25]. Thanks. . 11. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) Subcutaneous QACHS: please follow attached sliding scale. . Discharge Disposition: Extended Care Facility: [Hospital 2971] Rehabilitation and Nursing Center - [Hospital1 1474] Discharge Diagnosis: Primary diagnosis: NSTEMI atrial fibrillation with rapid ventricular rate pulmonary edema HTN community acquried pneumonia . Secondary diagonsis: DM2 hypothyroidism urinary incontinence dementia Discharge Condition: ambulating with assistence and tolerating good oral intake. vital signs stable Discharge Instructions: You were admitted with a rapid and irregular heart rate which likely caused your heart attack and fluid in your lungs. You had a cardiac catheterization which showed some clogged arteries to your heart. Your medications have been optimized to offer the best medical management for your heart rate and rhythm. . You have been given some new medications and should continue to take them as prescribed. . You should notify your physician or go to the emergency room if you have shortness of breath, chest pain, palpitations, nausea or vomiting or bleeding from the cath site or any other symptoms which are concerning to you. . You will need to follow up with a cardiologist in [2-5] weeks. Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 17996] in [2-5] weeks. We were unable to make the follow up appointment for you. Please call [Telephone/Fax (1) 3183] to make the appointment. . Please follow up with your new cardiologist which your daughter has selected within 1-2 weeks as well. ICD9 Codes: 486, 4240, 4280, 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6389 }	Medical Text: Admission Date: [2151-6-28] Discharge Date: [2151-7-1] Date of Birth: [2079-8-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: Right carotid artery stenosis - asympomatic Major Surgical or Invasive Procedure: Stenting of R. Carotid Artery History of Present Illness: 72 yo f with pmh of cad, htn, hyperlididemia, carotid artery disease who was noted to have a bruit on exam while viting family in [Country 11150] in early [2150]. She had an ultrasound which showed right carotid stenosis, was evaluted by Dr. [First Name (STitle) ] for possible carotid intevention. She underwent a carotid MRA wchih showed R carotid stenosis of approximately 70-80%. The pt denied previous history of amaurosis fugax, sensory or motor deficts, and aphasias. Past Medical History: HTN -Hyperlipidemia -[2139] MI -CAD s/p stents in [2139], reportedly done at the [Hospital ] Hospital but no report is available -Right ICA stenosis 70-80% -Uterine fibroids -[2-22] Vaginal bleeding for one day, which started one week after initiating Plavix. Plavix d/c and changed to ASA. A vaginal u/s -[2151-5-5] showed stable cyst 4.9 x 3.9 x 4.8cm and biopsy was normal. Plavix 75mg daily was restarted. -Tubal ligation 40 years ago Social History: Social Hx: Married. Supportive family. Her daughter Dr. [Last Name (STitle) ] (psychiatrist) can be reached at [Telephone/Fax (1) 65960] or [Telephone/Fax (1) 23525]. The pt speaks primarily Indian and some English. Family History: FHx (+) CAD in a couple of cousins and uncles died suddenly of MI but dates and ages are unknown. Brother died suddenly of MI at age 60. Son had MI in his early 30's. Physical Exam: T 98 HR 66 BP 146/67 (60mcg neo) RR 16 O2sat 98%RA. General: Awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. R femoral sheath inplace. Neurologic: -mental status: Alert, oriented x 3. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. Pertinent Results: [2151-6-28] EKG: NSR @ 50 nl axis, sinus brady, lvh with repol changes. . Radiologic Data: [5-25] Carotid u/s with R ica 80-99% stenosis [6-11] Carotid mra - 70-80% R ica. Brief Hospital Course: 72 yo f with h/o htn & cad admitted for stenting of asymptomatic carotid stenosis. -Pt underwent successful stenting of R carotid on [2151-6-28]. During procedure pt became asystolic, which was reversed with atropine. Post-procedure course was uncomplicated. Her SBP was maintained b/t 110-170mmHG with neosynephrine drip, which was weaned of [6-29]. Pt did exhibit signs of "sun-downing" ON with some disorientation to place & people. This resolved after two days. However, her post-procedure neuro exam remained normal. Pt was weaned off of neo gtt without complication. SBP increased appropriately, though her home anti-hypertensives medications were held during the hospitalization. She was started on aspirin & plavix, and continued on atorvastatin. Medications on Admission: Isordil 20mg qam and 10mg qpm Metoprolol 50mg [Hospital1 ] ASA 81mg [Hospital1 ] Plavix 75mg daily Lipitor 20mg daily Acupril 20mg daily Will take ASA 325mg the day before and the day of the procedure. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Stenosis of Right Carotid Artery Discharge Condition: Stable Discharge Instructions: Continue taking the aspirin and plavix as instructed. Do not discontinue these medications before speaking to your cardiologist. Followup Instructions: Please call Dr. [First Name (STitle) ] on Monday ([7-5]) to let him know how you are doing. He will instruct you regarding the resumption of your anti-hypertensives (Acupril & Isordil). -Please schedule an appointment with Dr. [First Name (STitle) ] in one month at his office on the [Hospital Ward Name ] of [Hospital1 18] ([Location (un) 86]). Office #[Telephone/Fax (1) 920]. -Please schedule an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (Neurologist) for the same day as your 1 month appointment with Dr. [First Name (STitle) ]. Office # ([Telephone/Fax (1) 1703] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6390 }	Medical Text: Admission Date: [2154-6-28] Discharge Date: [2154-7-15] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6346] Chief Complaint: colon cancer in transverse colon Major Surgical or Invasive Procedure: laproscopic assisted transverse left colectomy History of Present Illness: Mr. [Known lastname 7356] is an 88-year-old gentleman with a history of anemia who underwent a colonoscopy which demonstrated a cancer in the transverse colon. The risks and benefits of the surgery were offered after a surgical consult was obtained. A CT scan demonstrated no evidence of extracolonic tumor and CEA level was 2.5 which was normal. Past Medical History: restless leg syndrome Social History: Lives with his wife. Daughter lives in area. No tobacco or alcohol use. Family History: No significant history Physical Exam: Vitals: afebrile, hemodynamically stable Chest: CTAB Heart: RRR, -MRG Abdoment: Soft, NT, ND, +BS, no masses appreciated on exam. Ext: peripheral pulses palpable Pertinent Results: [7-5]- atrial fibrillation with RVR [2154-7-5] 09:00PM BLOOD WBC-10.1 RBC-2.97* Hgb-8.6* Hct-24.7* MCV-83 MCH-29.2 MCHC-35.1* RDW-16.2* Plt Ct-255 [2154-7-6] 01:08AM BLOOD WBC-10.6 RBC-3.31* Hgb-9.9* Hct-27.7* MCV-84 MCH-29.8 MCHC-35.8* RDW-16.1* Plt Ct-237 [2154-7-15] 07:21AM BLOOD PT-33.1* PTT-40.0* INR(PT)-3.6* [2154-7-14] 08:55AM BLOOD PT-41.7* PTT-44.1* INR(PT)-4.7* [2154-7-13] 06:00PM BLOOD PT-56.1* PTT-43.4* INR(PT)-6.8* [2154-7-13] 08:05AM BLOOD PT-60.1* PTT-44.7* INR(PT)-7.4* [2154-7-12] 03:00AM BLOOD PT-48.0* PTT-43.7* INR(PT)-5.6* [2154-7-11] 06:05AM BLOOD PT-24.0* PTT-39.4* INR(PT)-2.4* [2154-7-10] 10:28AM BLOOD PT-22.1* PTT-87.8* INR(PT)-2.2* [2154-7-9] 08:30PM BLOOD Glucose-97 Lactate-3.3* Na-127* K-3.9 Cl-103 calHCO3-19* [2154-7-10] 02:59AM BLOOD Lactate-3.6* [2154-7-10] 01:00PM BLOOD Lactate-1.6 [2154-7-10] 08:41PM BLOOD Lactate-1.0 Brief Hospital Course: Mr. [Known lastname 7356] was admitted following a colonoscopy which showed an obstruction colon CA at his splenic flexure. He underwent a lap assisted transverse colectomy without complication. An NGT and PICC were placed following the procedure. On [7-5] he developed atrial fibrillation with rapid ventricular response. He also removed his NGT, PICC line, and Foley at this point. They were then replaced. He taken to the ICU and placed on lopressor and diltiazem for his atrial fibrillation. Also on [7-5] he had a positive C. diff screen and was place on Flagyl. On [7-8] he underwent cardioversion successfully for his atrial fibrillation. He was then transferred to the floor. However, on [7-9] he was taken back to the ICU for the development of shortness of breath and tachypnea. He was found to have an increasing lactate at this time and also a hematocrit of 24. He was transfused with 1 unit of blood and was doing well the following day. On [7-12] he was transfered back to the floor and had an uncomplicated remainder of his hospital stay. Medications on Admission: pamiprexole 25 qhs dihydrochloride Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:30 Tablet(s) Refills:0 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:30 Refills:2 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:5 Refills:2 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 7. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO qhs () as needed for restless legs. Disp:20 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: obstructing adenocarcinoma at splenic flexure Discharge Condition: stable, to extended care facility Discharge Instructions: Please return if: 1. fever > 101 2. pain/pus around wound site 3. nausea/vomitting 4. inability to pass stool or tolerate oral food Followup Instructions: Please follow-up with Dr. [First Name (STitle) 2819] on [8-1] at 3:30PM in [Location (un) 86]. Please do not take your coumadin per Dr. [First Name (STitle) 2819] ICD9 Codes: 9971
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6391 }	Medical Text: Admission Date: [2117-11-26] Discharge Date: [2117-12-8] Date of Birth: [2048-6-22] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 8747] Chief Complaint: Patient found unresponsive Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 69 year old woman with a history of diabetes and high blood pressure now presenting with a left temporal lobe bleed. The patient is unable to give a history so most details are taken from her chart and staff members. She presented to an OSH ED at around 4am after being found down at home by son. She was taken to [Hospital6 2561] where a left temporal intraparenchymal bleed was uncovered. She was given dilantin and factor 7 and transferred to [Hospital1 18] for neurosurgical evaluation. The neurosurgery staff evaluated the patient and did not feel a surgical intervention was warranted. Past Medical History: -IDDM -hypertension -s/p hysterectomy -high cholesterol -hypothyroidism? -COPD - h/o DVT s/p left IVC filter - s/p polypectomy - duodenal AVM - diverticulosis - chronic anemia Social History: -lives with son, [Name (NI) ] [Name (NI) 65377] [Telephone/Fax (1) 65378] -h/o heavy tobacco use Family History: Non-contributory Physical Exam: T: 99.1 BP 120/68 [120-122/62-68] HR 74 RR 18 O2sat: 92-95% on RA Neuro: Oriented to self; she will nod head to hospital when given a choice of places. She has poor attention which improves with progression of exam. She generally answers questions with one or two word sentences. There is very little spontaenous spech. She readily follows 1-step verbal commands. There is no evidence of focal neglect. CN: PERRL, EOMI, no facial droop. Uvula and tongue midline. Motor: L arm extensors [4-13], flexors [5-13], increased tone R arm extensors [4-13], flexors [5-13], mild increase in tone Sensory: difficult to formerly assess [2-10] attention, however clearly responds to LT in all extremities HEENT: PERRL, EOMI, OP clear Resp: very mild crackles at bases b/l, no wheezes CV: RRR, II/VI early SEM at LUSB Abd: obese, soft, ND, NT, no guarding or rebound Extr: no edema. Improved dryness over distal feet. Pertinent Results: [2117-12-8] 08:25AM BLOOD WBC-16.1* RBC-4.26 Hgb-11.0* Hct-31.9* MCV-75* MCH-25.8* MCHC-34.5 RDW-15.2 Plt Ct-309 [2117-12-7] 08:30AM BLOOD WBC-15.1* RBC-4.28 Hgb-11.1* Hct-33.1* MCV-78* MCH-25.9* MCHC-33.5 RDW-15.6* Plt Ct-332 [2117-12-6] 06:30AM BLOOD WBC-14.4* RBC-4.15* Hgb-11.0* Hct-32.5* MCV-78* MCH-26.5* MCHC-33.8 RDW-15.5 Plt Ct-315 [2117-12-5] 07:00AM BLOOD WBC-13.2* RBC-3.93* Hgb-10.0* Hct-31.0* MCV-79* MCH-25.4* MCHC-32.2 RDW-15.7* Plt Ct-309 [2117-12-4] 07:15AM BLOOD WBC-14.8* RBC-3.86* Hgb-9.8* Hct-30.0* MCV-78* MCH-25.4* MCHC-32.6 RDW-15.6* Plt Ct-290 [2117-12-3] 03:00PM BLOOD WBC-13.6* RBC-3.63* Hgb-9.4* Hct-28.0* MCV-77* MCH-25.8* MCHC-33.4 RDW-15.3 Plt Ct-281 [2117-12-3] 04:45AM BLOOD WBC-12.1* RBC-3.59* Hgb-9.4* Hct-28.3* MCV-79* MCH-26.2* MCHC-33.2 RDW-15.5 Plt Ct-298 [2117-12-1] 06:25AM BLOOD WBC-10.9 RBC-3.61* Hgb-9.5* Hct-28.4* MCV-79* MCH-26.2* MCHC-33.4 RDW-15.5 Plt Ct-253 [2117-11-30] 03:28AM BLOOD WBC-12.7* RBC-3.48* Hgb-9.2* Hct-26.5* MCV-76* MCH-26.4* MCHC-34.7 RDW-15.2 Plt Ct-176 [2117-11-29] 02:27AM BLOOD WBC-16.9* RBC-3.69* Hgb-9.4* Hct-27.5* MCV-75* MCH-25.5* MCHC-34.2 RDW-14.9 Plt Ct-230 [2117-11-28] 01:37AM BLOOD WBC-16.7* RBC-3.85* Hgb-10.0* Hct-28.6* MCV-74* MCH-25.9* MCHC-34.8 RDW-14.8 Plt Ct-241 [2117-11-27] 01:03AM BLOOD WBC-20.9* RBC-4.02* Hgb-10.3* Hct-29.7* MCV-74* MCH-25.6* MCHC-34.6 RDW-15.0 Plt Ct-249 [2117-11-26] 08:30AM BLOOD WBC-18.5* RBC-4.62 Hgb-11.8* Hct-34.6* MCV-75* MCH-25.6* MCHC-34.1 RDW-14.9 Plt Ct-270 [2117-12-8] 08:25AM BLOOD Neuts-82.0* Lymphs-14.0* Monos-3.5 Eos-0.4 Baso-0.2 [2117-12-8] 08:25AM BLOOD Plt Ct-309 [2117-12-3] 04:45AM BLOOD PT-13.0 PTT-21.4* INR(PT)-1.1 [2117-11-30] 03:28AM BLOOD Ret Aut-1.6 [2117-12-8] 08:25AM BLOOD Glucose-190* UreaN-11 Creat-0.6 Na-132* K-3.3 Cl-89* HCO3-27 AnGap-19 [2117-12-7] 08:30AM BLOOD Glucose-148* UreaN-12 Creat-0.6 Na-134 K-3.1* Cl-92* HCO3-31 AnGap-14 [2117-12-4] 11:14AM BLOOD ALT-25 AST-20 LD(LDH)-344* AlkPhos-63 Amylase-36 TotBili-0.4 [2117-12-4] 11:14AM BLOOD Lipase-26 [2117-11-27] 12:45PM BLOOD CK-MB-5 cTropnT-<0.01 [2117-11-27] 01:03AM BLOOD CK-MB-5 cTropnT-<0.01 [2117-11-26] 08:30AM BLOOD cTropnT-<0.01 [2117-12-8] 08:25AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.6 [2117-12-7] 08:30AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8 [2117-12-4] 11:14AM BLOOD calTIBC-192* VitB12-590 Folate-15.0 Ferritn-289* TRF-148* [2117-11-27] 01:03AM BLOOD %HbA1c-7.9* [Hgb]-DONE [A1c]-DONE [2117-12-4] 11:14AM BLOOD TSH-0.88 [2117-11-26] 08:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Head CT [11-26]:Intraventricular hemorrhage, predominantly within the left lateral ventricle and expanding the left temporal [Doctor Last Name 534]. No CT evidence for source of this hemorrhage is found. MRI and MRA of the brain is warranted to assess for source of hemorrhage such as aneurysm, tumor, or vascular malformation. Head CT [11-27]: No significant interval change in the previously noted intracranial hemorrhage. Head CT-A [11-29]: No aneurysm or flow abnormality. Head CT [12-5]: Again seen is intraventricular hemorrhage, which is unchanged in extent, with an appearance consistent with evolving hemorrhage. Stable ventricular size. No new foci of intracranial hemorrhage are identified. CT Chest/Abd/Pelvis [2117-12-5]: Small mediastinal and left axillary lymph nodes. Otherwise, no identified pathology within the chest, abdomen, and pelvis to explain persistent fevers. TTE [2117-12-8] :The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. EEG [2117-11-27]:This is an abnormal EEG due to the presence of low voltage slowed background seen throughout the recording. In addition, overlying muscle activity was seen throughout the recording. This EEG is consistent with a severe encephalopathy. Common causes of encephalopathy include medications, metabolic causes, and infections. No focal abnormalities or epileptiform activity was observed. Brief Hospital Course: By systems NEUROLOGY Pt. was tranferred from [Hospital6 ] where her INR was 4.2. She apparently had been coumadin for unclear reasons. Her INR was reversed with vitamin K and factor VII and tranferred to [Hospital1 18]. The patient was admitted to the Neuro ICU with a large left intraventricular hemorrhage with some spill-over into the right lateral ventricle. She was loaded with dilantin and her blood pressure was controlled with PRN IV hydralazine. Repeat CT scans showed no progression of the hemorrhage. An EEG was performed because pt remained sleepy and this was c/w encephalopathy. Pt remained confused, moving all extremities. Her dilantin was discontinued as the hemorrhage is primarily intraventricular. She was transferred to the floor on [11-30] and had remained relatively confused and intermittently agitated often pulling at lines and tubes and requiring Level II restraints. She has since improved with greater alertness, fluent albeit sparse speech and right greater than left weakness. Anti-platelet agents have been held. The work-up for underlying intracranial mass or metastatic lesion has been negative thus far. The etiology of her hemorrhage was unclear and thought to be related to anticoagulation. She did not tolerate a complete MRI because of agitation and may need to have a better study as an outpatient. She will likely require a repeat CT scan in about 3 weeks to look for interval change and/or underlying pathology. HYPERTENSION The patient had persistent hypertension that was difficult to control. She has been relatively well-controlled now on triple therapy of metoprolol, HCTZ, and captopril. She has not required rescue IV medication in several days. RESP Pt. with intermittent atelectasis. She should get chest PT and incentive spirometry. She has a h/o COPD and takes Albuterol nebulized solution q6h. This may possibly be weaned. ID [1-10] botle of Gram positive coci (coag negative) at an outside hospital. Pt was started on Vancomycin. This was subsequently d/c'd as patient was afebrile. She then began to spike fevers. An extensive work-up has been performed in cluding sevral blood cultures, two urine cultures, a CT of the entire torso to lookf or occult abscesses and a TTE to investigate endocarditis. All have been negative. Also found to have a leukocytosis. Her WBC had fallen and over the past few days risen again. The patient has been afebrile for 28 hours and counting. It is possible that some blood has trickled into the 3rd ventricle and irritated the hypothalamic thermostat although this is clearly a diagnosis of exclusion. FEN/GI Had required NGT for much of hosptilization. Over past two days she has become far more alert and awake and is tolerating PO well. SHe has been on PPI for prophylaxis throughout this hospitalization. RENAL The patient has a Foley catheter as she is inattentive and incontinent. Her U/O has been appropriate. She has a slight hyponatremia 132 and a falling Cl-. However, these metabolic derangements may respond to mild free water restriction. Her BMP should be followed in Rehab. HEME Patient has been anemic however CBCs have stabilized. Her latest Hct is 31.9 and she remains asymptomatic. Her WBC did remain elevated and she should be ruled out for clostridium difficile. ENDOCRINE Blood sugars have been controlled on insulin sliding scale. Discharge Diagnosis: Intraventricular Hemorrhage Discharge Condition: Fair The above remaining medical issues were discussed with Dr. [Last Name (STitle) 7108] at [Hospital3 ]. Medications on Admission: atenolol, metformin, lisinopril, coumadin?, Oxygen at home (2L) Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:360 Tablet(s) Refills:2 3. Ammonium Lactate 12 % Lotion Sig: One (1) Topical [Hospital1 ] (2 times a day) as needed for dryness. Disp:1 tube Refills:0 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:1 box Refills:2 8. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). Disp:600 mL Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: Left intraventricular hemorrhage HTN COPD IDDM Discharge Condition: Stable Some disorientation Right sided weakness Discharge Instructions: Please take your medications If you develope chest pain, SOB, new weakness, numbness, if you become confused, please see a physician [Name Initial (PRE) 65379]. Followup Instructions: Please call Neurology/Stroke Service for appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 2574] Please see your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 65380] upon d/c from Rehab. ICD9 Codes: 431, 496, 5180, 2761, 2449, 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6392 }	Medical Text: Admission Date: [2151-6-23] Discharge Date: [2151-7-4] Date of Birth: [2089-7-23] Sex: M Service: MEDICINE Allergies: Ativan / Tetracycline Attending:[First Name3 (LF) 5368] Chief Complaint: Fever Major Surgical or Invasive Procedure: 1. Tunnelled catheter placement 2. [First Name3 (LF) ] History of Present Illness: 61Yo End Stage Renal Disease on HemoDialysis, CAD s/p CABG, PVD s/p bilateral BKAs, recents MRSA line sepsis who presents from HD with fever and suspected recurrent line sepsis. . Patient reports on Wednesday having stomach discomfort. He states he felt like he did with previous line infections. Patiends tunneled line was placed on [4-7]. He checked his temperature which was 101.3. On Thursday he had partial [Month/Year (2) 2286] session (2hours) but was ended early due to his fever/lightheadedness/nausea. His temperature was noted to be 103. In Hemodialysis he recieved Vancomycin was given at HD and he then transfered to [Hospital1 18] ED. . In [Name (NI) ], pt recieved 2 liters IV fluids and was started on gentamycin. His SBP went to 60's so periheral dopa was started with improvement of pressures. Multiple attempts at central access were made but without success. Renal consultation was done with no indication for emergent HD. Renal approved use of HD catheter for temporary access. . In MICU, patient had aggressive fluid, continued on vanco and gent, renal consulted. Heparin started Past Medical History: - ESRD on HD MWF - DM 1 or 2 c/b PVD, CAD, ESRD - bilateral BKAs - CAD s/p CABG - clot in L arm AV graft - no longer functioning - R SC tunnel cath placed - s/p MSSA bacteremia [12-2] - HTN - h/o VRE, MRSA Social History: Lives in [Location 5110] with his mother. A retired pharmacist. Never smoked, rare etoh use. Family History: Mother and father with DM, father with PVD. No h/o CAD. Physical Exam: PE: Temp 98.2 BP 118/62 84 Gen: NAD, obese man, flushed face lungs: CTA no w/r/r chest: Right Subclavian line without evidence of infection heart: RRR no m/r/g abd; soft nontender ext: s/p bilat BKA neuro: CN II-XII intact, Cerbellar function intact Pertinent Results: [2151-6-23] 10:30PM URINE COLOR-Straw APPEAR-Hazy SP [Last Name (un) 155]-1.014 [2151-6-23] 10:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [2151-6-23] 10:30PM URINE SPERM-MOD [2151-6-23] 10:00PM TYPE-ART PO2-187* PCO2-41 PH-7.48* TOTAL CO2-31* BASE XS-7 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP [2151-6-23] 09:50PM GLUCOSE-249* UREA N-48* CREAT-7.2# SODIUM-137 POTASSIUM-5.8 CHLORIDE-95* TOTAL CO2-26 ANION GAP-22* [2151-6-23] 09:50PM ALT(SGPT)-11 AST(SGOT)-15 LD(LDH)-198 CK(CPK)-164 ALK PHOS-70 TOT BILI-0.8 [2151-6-23] 09:50PM CK-MB-2 cTropnT-0.10* [2151-6-23] 09:50PM CALCIUM-8.6 PHOSPHATE-4.6* MAGNESIUM-1.6 [2151-6-23] 09:50PM WBC-14.5# RBC-3.93 HGB-13.1* HCT-36.3* MCV-92 MCH-33.2* MCHC-36.0* RDW-14.6 [2151-6-23] 09:50PM NEUTS-93* BANDS-3 LYMPHS-1* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2151-6-23] 09:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2151-6-23] 09:50PM PLT SMR-NORMAL PLT COUNT-125* [2151-6-23] 09:50PM PT-22.8* PTT-31.1 INR(PT)-3.4 [2151-6-23] 06:25PM LACTATE-4.9* K+-6.8* Brief Hospital Course: 61YO male with ESRD on HD, bilateral IJ clots on coumadin, CAD s/p CABG, MRSA sepsis [4-1] who presents with sepsis. Transferred from MICU to floor on [2151-6-27] . 1) Sepsis- SIRS (initial lactate of 4.9), in MICU pt give IV fluids. Recieved Depo in ED. Switched to Levofed in MICU. Off pressors as of [6-24]. [Date Range ] line resited to right subclavian w/ central access available [6-24]. Gent was D/C on [2151-6-27]. MRSA + in blood cx [6-23], now on vanc and gent for synergy. Dosed gent after HD. HD catheter re-sited on R side. Spiked [6-25] and has GPC's from [6-25] also, most likely [12-30] transient bacteremia during line change. TEE done [2151-6-29] showed no evidence of endocarditi. CT Abodmen Showed Hypo attenuating lesion in the head of pancreas with possible dilatation of the pancreatic duct. This can be further evaluated with MRCP as it could represent IPMT or a cyst. MRCP was ordered, however patient refused study. HE will be scheduled for outpatient MRCP with ourpatient GI follow up. Patient will continue Vanco (level dosed) per ID Rec for 6 wks, 2) Renal - Renal Consulted in ED. Pt got new tempory R SC line [6-25]. Recieved UF on ([6-26]). Perma cath placed Monday [6-28]. Patient continued sevelamer, ca carbonate, nephrocaps. In future plan for Transplant surgery to evaluate pt for possible kidney transplant . 3)FEN- Metabolic alkalosis on admission, recieved over 7L in MICU. Patient was continued cardiac diabetic diet . 4)CAD-Enzymes negative.Continue aspirin, statin. Patient restarted on Metroprolol and Lisinopril with holding parameters systolic <90 . 6)GI- Patient continued anti-emetics for nausea. Patient also recieved PPI. . 7)Hem -Thrombocytopenia-may be due to sepsis. Daily CBC were checked to monitor Platlets. . 9) Bilateral IJ clots- Hep gtt. Patient continued on Heparin. He started coumadin on [2151-6-28]. He remained hospitalized until his Coumadin became theurpetic (INR 2.0-3.0) . 10) Respiratory- In ICU patient has desaturated less than 90 on room air. On floor patient longer required oxygen . 11) DM II- Patient restarted Glipizide on the floor with Sliding Scale . 12) Access: [Date Range 2286] line resited to R subclav [6-24] and replaced over wire [6-25], CXR on [6-27] to check placement of subclavian. Subclavian line to be replaced IR [2151-6-28]. Patient also has peripherial line. . Medications on Admission: 1. Warfarin Sodium 1 mg qd 2. Simvastatin 40 mg qd 3. Insulin Regular Human 100 unit/mL . 4. B Complex-Vitamin C-Folic Acid 1 mg qd 5. Metoprolol Tartrate 25 mg [Hospital1 ] 6. Lisinopril 5 mg qd 7. Glipizide 5 mg [Hospital1 ] 8. Calcium Acetate 667 mg tid with meals 9. Sevelamer HCl 800 mg po tid Discharge Medications: 1. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 3. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)). 4. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous at Hemodialysis for 6 weeks: Have Vancomycin level checked and if level <15 give 1g Vancomycin. Disp:qs Refills:0 11. Outpatient Lab Work Have PT, PTT levels checked. Your doctors [First Name (Titles) ] [Last Name (Titles) 2286] [Name5 (PTitle) ] be adjusting your coumadin based on this. 12. Outpatient Lab Work Have Vancomycin level drawn at HD sessions and if level <15 administer 1 gram Vanco. Discharge Disposition: Home Discharge Diagnosis: 1. Line infection 2. Tunnelled catheter placement Discharge Condition: Stable Discharge Instructions: Continue taking all medications as prescribed. Return to the hospitals if you have any further fevers, nausea, vomiting, shortness of breath or other concerning symptoms. Have your Vanco level checked and dosed at hemodialysis. Have your INR checked each week and called to Dr. [Last Name (STitle) ] to adjust your coumadin dosage. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5085], MD Where: [Hospital Ward Name ] BUILDING ([Hospital Ward Name ] COMPLEX) Phone:[Telephone/Fax (1) 1983] Date/Time:[2151-7-20] 10:00 Provider: [Name10 (NameIs) ] WEST,ROOM TWO GI ROOMS Where: GI ROOMS Date/Time:[2151-7-20] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5377], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2151-8-3] 9:00 Completed by:[2151-7-19] ICD9 Codes: 5180, 2875, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6393 }	Medical Text: Admission Date: [2113-3-19] Discharge Date: [2113-4-6] Date of Birth: [2113-3-15] Sex: M Service: NB ID: Baby [Name (NI) ] [Known lastname ] is a 22 day old former 35 [1-31] wk infant with history of RDS and pneumonia who is being discharged from the [Hospital1 18] NICU. HISTORY OF PRESENT ILLNESS: [Known lastname ] [Known lastname ] is the former 2.375 kg product of a 35 and [1-31] week gestation pregnancy, born to a 39 year-old, G2, P0-1 mother with prenatal screens: [Name (NI) ] type B negative, Ab negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, group b strep status unknown. EDC was [2113-4-17]. Pregnancy was complicated by low amniotic fluid volume. He was taken to elective Cesarean section because of the decreased amniotic fluid volume and breech presentation. Apgar scores were 8 at 1 minute and 8 at 5 minutes. He received blow-by oxygen in the delivery room. He was admitted to the NICU for initial grunting and hypoglycemia. PHYSICAL EXAMINATION: Physical exam upon admission to the Neonatal Intensive Care Unit: Weight was 2.375 kg, 50th percentile. Head circumference 33 cm, 75th percentile. Length 45.5 cm, 50th percentile. General: Non dysmorphic infant in moderate respiratory distress. Head, ears, eyes, nose and throat: Normocephalic, atraumatic scalp. Anterior fontanel open and flat. Red reflex present on the left. Unable to elicit on the right secondary to eyelid edema. Palate intact. Neck supple. Lungs clear and equal bilaterally, no intercostal retractions. Occasional grunting. Cardiovascular: Regular rate and rhythm. No murmur. Femoral pulses 2+ bilaterally. Abdomen: Soft with active bowel sounds, no masses or distention. Spine: Midline, no sacral dimples. Hips stable. Anus patent. Skin: Pink, warm, no lesions. Neuro: Normal suck, gag and tone. HOSPITAL COURSE: 1. Respiratory: [Known lastname ] had escalating respiratory distress with elevated oxygen requirement. He was intubated received 2 doses of Surfactant. He was extubated to CPAP on day of life #2, but due to increased work of breathing and hypercapnia, required reintubation on day of life #3, and he received a third dose of Survanta. His respiratory status worsened and he was changed to the high frequency oscillator/ventilator and remained on that ventilator through day of life number 5 when he was changed back to the conventional ventilator. He was extubated to continuous positive airway pressure on day of life 6. He then transitioned to nasal cannula and remained in nasal cannula through day of life 19. He was then in room air with oxygen saturations greater than or equal to 95% for the 48 hours prior to discharge. Initial CXR showed consolidation, particularly on the left side. He was treated for presumed pneumonia with a 14 day course of antibiotics. 2. Cardiovascular: [Known lastname ] maintained normal heart rates and [Known lastname ] pressures. No hemodynamic support was needed. At discharge, his heart rate is 120 to 160 beats per minute with a recent [Known lastname ] pressure of 64/52 with a mean of 56 mmHg. 3. Fluids, electrolytes and nutrition: [Known lastname ] was initially n.p.o. He was treated with IV fluids and later peripheral parenteral nutrition. Enteral feeds were started on day of life 5 and gradually advanced to full volume. At the time of discharge, he is taking breast milk or Enfamil 20 calorie per ounce and breast feeding. Weight on the day of discharge is 2.495 kg with a length of 46 cm and a head circumference of 33 cm. Serum electrolytes were checked in the first week of life and were within normal limits. He was begun on Multivitamin supplementation as he was receiving predominantly breast milk. 4. Infectious disease: Due to the unknown etiology of the respiratory distress, [Known lastname ] was evaluated for sepsis upon admission to the Neonatal Intensive Care Unit. A complete [Known lastname ] count was within normal limits. A [Known lastname ] culture was obtained prior to starting IV Ampicillin and Gentamycin. Due to the severity of his respiratory illness, he was treated with a 14 day course of Ampicillin and Gentamycin for presumed pneumonia. A lumbar puncture was performed with all results within normal limits. Antibiotics were discontinued on [2113-3-29]. 5. Hematology: [Known lastname ] is [Known lastname ] type B positive and is direct antibody test negative. He did not receive any transfusion of [Known lastname ] products during admission. 6. Gastrointestinal: [Known lastname ] was treated for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life 6 at a total of 11.5 over 0.4 mg/dl for an indirect of 11.1. He received approximately 48 hours of phototherapy. Rebound bilirubin on [2113-3-24] was a total of 6.8 over 0.4 with an indirect of 6.4 mg/dl. 7. Urology: A circumcision was performed on [2113-3-30]. At the time of discharge, it is still not fully healed and is still being treated with Vaseline. 8. Neurology: [Known lastname ] has maintained a normal neurologic exam during admission. He was treated with IV Fentanyl and Versed for sedation during the height of his illness. He has a normal neurologic exam at the time of discharge. 9. Sensory: Audiology: Hearing screening was performed with automated auditory brain stem responses. [Known lastname ] passed in both ears. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 44797], MD, [Apartment Address(1) 66088], [Hospital1 8], [Numeric Identifier ]. Phone number [Telephone/Fax (1) 66089]. Fax number [Telephone/Fax (1) 47151]. CARE AND RECOMMENDATIONS: 1. Ad lib breast feeding or p.o. feeding Enfamil formula. 2. Medications: Goldline baby vitamins, 1 ml p.o. once daily. 3. Car seat position screening was performed. [Known lastname ] was observed in his car seat for 90 minutes without any episodes of oxygen desaturation or bradycardia. 4. State newborn screens were sent on [3-18] and [2113-3-29]. No notification of abnormal results. 5. Immunizations received: Hepatitis B vaccine was administered on [2113-3-29]. Synagis was administered on [2113-4-5], given severity of initial respiratory illness. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW UP: 1. Appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 44797] within 3 days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 35 and 2/7 weeks gestation. 2. Respiratory distress syndrome secondary to surfactant deficiency. 3. Pneumonia. 4. Suspicion for sepsis. 5. Unconjugated hyperbilirubinemia. 6. Status post circumcision on [2113-3-30]. 7. Breech position at birth. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2113-4-6] 02:20:45 T: [2113-4-6] 04:09:17 Job#: [Job Number 66090] ICD9 Codes: 769, 7742, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6394 }	Medical Text: Admission Date: [2185-2-15] Discharge Date: [2185-2-19] Date of Birth: [2109-3-28] Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient was referred from an outside hospital with a chief complaint of increasing shortness of breath and tires easily with exertion. Admitted to [Hospital 4628] Hospital in [2184-10-25] in congestive heart failure at that time. Via echocardiogram, found to have aortic stenosis. Referred to [Hospital1 188] for cardiac catheterization to further evaluate her aortic stenosis. Cardiac catheterization done on [1-10] showed an aortic valve area of .38 cm.sq., with a mean gradient of 62, and a peak gradient of 85. Moderate pulmonary hypertension, PA pressure 48/24, 1+ mitral regurgitation, severe aortic stenosis with an LVEDP of 19 and an ejection fraction of 43%. She was then referred to Cardiothoracic Surgery for aortic valve replacement. PAST MEDICAL HISTORY: 1. Aortic stenosis 2. Diabetes mellitus Type 2 3. Right hip replacement 4. Noninsulin dependent diabetes mellitus MEDICATIONS ON ADMISSION: Include Glucovance 5/500 one tablet twice a day, Univasc 7.5 mg once daily, lasix 20 mg every other day, and aspirin 325 mg once daily. ALLERGIES: No known drug allergies. FAMILY HISTORY: Significant for her father, who died at 50 years from myocarditis. SOCIAL HISTORY: She lives alone in [Location (un) 4628] with five stairs. She has a remote tobacco history, quit in [Month (only) 359], one pack per day for 50 years. No alcohol use. PHYSICAL EXAMINATION: Vital signs: Heart rate 108 and regular, blood pressure 145/76, respiratory rate 20, height 5'2", weight 141 pounds. General: Healthy-appearing woman, in no acute distress. Skin: No lesions or rashes. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light, extraocular movements intact, anicteric, not injected. Oropharynx: Mucous membranes moist. Neck: Supple, no lymphadenopathy, no jugular venous distention, no thyromegaly. Chest: Clear to auscultation bilaterally. Heart: Regular rate and rhythm, S1, S2, with III/VI blowing murmur. Abdomen: Soft, nontender, nondistended, normal active bowel sounds, no hepatosplenomegaly. Extremities: Warm and well perfused, with no cyanosis, clubbing or edema, no varicosities. Neurological: Cranial nerves II through XII grossly intact. Moves all extremities. Strength 5/5 in upper and lower extremities. Sensation intact in all dermatomes. Pulses: Femoral 2+ bilaterally, dorsalis pedis 1+ bilaterally, posterior tibial 1+ bilaterally, and radial 2+ bilaterally. No carotid bruits were noted. LABORATORY DATA: White count 5.3, hematocrit 43, platelets 200. Sodium 138, potassium 4.9, chloride 102, CO2 25, BUN 24, creatinine 0.9, glucose 309. Electrocardiogram: Rate of 91, first degree AV block, intervals .22, .92, .36, with left ventricular hypertrophy. Chest x-ray is pending at the time of physical. HOSPITAL COURSE: The patient was a direct admission to the operating room on [2-15], at which time she underwent an aortic valve replacement. Please see the operative report for full details. In summary, she had an aortic valve replacement with a #21 mosaic porcine valve. She tolerated the operation well, and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. The patient did well in the immediate postoperative period, however, her blood pressure remained somewhat labile. Therefore, she was continued on a Neo-Synephrine drip to maintain a systolic blood pressure greater than 110. In addition, she was slow to awaken after her anesthesia was reversed, and in several attempts to wean from the ventilator, she developed a respiratory acidosis. She therefore remained on the ventilator throughout the day of postoperative day one. On postoperative day two, the patient remained hemodynamically stable. Her Neo-Synephrine drip was weaned to off. She was again weaned from the ventilator, and successfully extubated. Her chest tubes were discontinued and, at the end of the day, she was transferred from the Cardiothoracic Intensive Care Unit to the floor for continuing postoperative care and cardiac rehabilitation. After being transferred to the floor, the patient did well. Over the next several days, her activity level was increased with the assistance of Physical Therapy and the nursing staff. She remained hemodynamically stable. Her respiratory condition remained stable and, on postoperative day four, she was deemed stable and ready to be transferred to rehabilitation for continuing postoperative care and physical therapy. At the time of transfer, the patient's physical examination is as follows: Vital signs: Temperature 98.4, heart rate 78 and sinus rhythm, blood pressure 106/50, respiratory rate 18, oxygen saturation 97% on room air. Weight preoperatively was 67 kg, at discharge is 70.9 kg. Laboratory data on [2-18]: White count 4.1, hematocrit 23, platelets 144. Sodium 141, potassium 4.3, chloride 108, CO2 25, BUN 24, creatinine 0.8, glucose 140. Physical examination: Alert and oriented x 3, moves all extremities, conversant. Respiratory: Scattered rhonchi with diminished breath sounds in the bases. Cor: Regular rate and rhythm, S1, S2, with soft systolic ejection murmur. Sternum is stable. Incision with staples, open to air, clean and dry. Abdomen: Soft, nontender, nondistended, normal active bowel sounds. Extremities: Warm and well perfused, with no cyanosis, clubbing or edema. DISCHARGE MEDICATIONS: Ranitidine 150 mg twice a day, enteric-coated aspirin 325 mg once daily, Glucovance 5/500 one tablet twice a day, metoprolol 25 mg twice a day, Furosemide 20 mg once daily for 14 days, potassium chloride 20 mEq once daily for 14 days, Colace 100 mg twice a day, Niferex 150 mg once daily, Percocet 5/325 one to two tablets every four hours as needed, ibuprofen 400 mg every six hours as needed. DISCHARGE DIAGNOSIS: 1. Aortic stenosis status post aortic valve replacement with a #21 mosaic porcine valve 2. Diabetes mellitus Type 2 3. Right hip replacement CONDITION ON TRANSFER: Stable. DISCHARGE INSTRUCTIONS: She is to have follow up with Dr. [Last Name (STitle) ] in one month, and follow up in the [Hospital 409] Clinic in two weeks. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2185-2-18] 18:35 T: [2185-2-19] 01:03 JOB#: [Job Number 37147] ICD9 Codes: 4241, 4280, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6395 }	Medical Text: Admission Date: [2143-5-9] Discharge Date: [2143-5-10] Date of Birth: [2062-10-19] Sex: M Service: MEDICINE Allergies: ibuprofen Attending:[First Name3 (LF) 2387] Chief Complaint: CHIEF COMPLAINT: claudication REASON FOR CCU ADMISSION: hypertensive urgency Major Surgical or Invasive Procedure: [2143-5-9] lower extremity angiography History of Present Illness: Mr. [Known lastname 3501] is an 80y/o gentleman with CAD s/p CABG [2118], ischemic CM (EF 40%), HTN, HLD, DM2 on oral hypoglycemics, and PAD (ABI R:0.6, L:0.67) who has had ongoing claudication, underwent elective angiography today, and is now admitted to the CCU due to post-procedural hypertension. . With regards to his claudication, he has had progressive bilateral calf pain with exertion relieved with rest. Gets pain even walking 25 feet. He denies chest pain, shortness of breath, palpitations or lightheadedness. He was scheduled for elective RLE angiography, and this morning he had breakfast and held his oral hypoglycemics (Metformin, Glyburide) though he says he took his antihypertensives (Atenolol, Amlodipine, Quinapril, HCTZ, Spironolactone). . During the angiogram, he was found to have severe disease in the bilateral aorto-iliac junction and critical RCFA disease. Kissing stents were placed in the proximal common iliac arteries, and Vascular Surgery was consulted for surgical management of RCFA disease. . Post-procedure, he became nauseated with elevation in SBP 220s, asymptomatic (specifically, no CP, SOB, H/A, worsened vision). He was started on NTG gtt with improvement in BP 170s. Glucose 350. He was admitted to the CCU for BP management and glucose control. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: CAD s/p CABG x 3 in [2118] (LIMA to LAD, SVG to ramus, SVG to RCA) Ischemic cardiomyopathy, LVEF 40% Hypertension Hyperlipidemia PAD Diabetes Type 2 Colon polyps Basal cell carcinoma s/p resection Macular degeneration [2135]: GIB in the setting of Ibuprofen requiring transfusion Hard of hearing (bilateral hearing aids) Remote resection of left testicle Social History: - Home: widowed; lives alone - Occupation: retired; previously worked as an engineer - Tobacco history: quit [2118] - ETOH: [1-14] glasses per week - Illicit drugs: None Family History: No known family history of premature CAD Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=97.8 BP=143/33 HR=61 RR=11 O2 sat=96% 2L NC GENERAL: NAD. Oriented x3. Mood approppriate, affect slightly inappropriate (answers questions but with inappropriate jokes, odd comments) HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no JVD 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: Obese, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Right and left groin cath sites without any hematoma. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, 5/5 strength biceps, hand grip PULSES: 1+ DP and PT pulses bilaterally; 2+ carotid and radial pulses Pertinent Results: ADMISSION LABS: [2143-5-9] 10:11PM BLOOD WBC-9.0 RBC-3.76* Hgb-11.5* Hct-33.9* MCV-90 MCH-30.6 MCHC-34.0 RDW-12.9 Plt Ct-202 [2143-5-9] 10:11PM BLOOD Glucose-359* UreaN-23* Creat-0.9 Na-132* K-4.5 Cl-95* HCO3-26 AnGap-16 [2143-5-9] 10:11PM BLOOD CK-MB-2 [2143-5-10] 03:55AM BLOOD CK-MB-2 [2143-5-9] 10:11PM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1 . DATA: - RLE ANGIOGRAPHY: final report pending Brief Hospital Course: Mr. [Known lastname 3501] is an 80y/o gentleman with CAD s/p CABG [2118], ischemic CM (EF 40%), HTN, HLD, DM2 not on insulin, and PAD (ABI R:0.6, L:0.67) who has had ongoing claudication, underwent elective angiography today with post-procedure hypertension and hyperglycemia and was admitted to the CCU due to hypertensive urgency with SBP to 220s. His BP resolved after taking his home meds and he was discharged home. . ACTIVE ISSUES . #. Hypertension: hypertensive urgency, resolved. Pt was admitted with hypertensive urgency with SBP to 220s. His HTN may have been in the setting of groin pain after the procedure; he denied missing any doses of home meds but this is a possibility. There was no evidence of end-organ damage based on history, exam, EKG, labs. His BP was much better controlled on a low-dose NTG drip and he was quickly weaned to his home oral meds. No change was made to his antihypertensive regimen. . #. PAD: severe aortoiliac and common femoral disease (ABI R:0.6, L:0.67). The aortoiliac disease was treated with kissing stents on [5-9]. He was started on Plavix 75mg daily, continued ASA 81mg daily, statin. Right groin post-cath check was unremarkable. He will follow up with Dr. [Last Name (STitle) ] (Vascular surgery) as an outpatient regarding his right common femoral disease. . #. DM2: hyperglycemia, resolved. His fingersticks was elevated >300, likely in the setting of having breakfast and holding his meds. Also probably a component of stress. ). Small amount of insulin corrected his hyperglycemia. Continued home Glyburide and plan to hold Metformin until Saturday [2143-5-11] (b/c of angio dye). . INACTIVE ISSUES . #. Ischemic CM: EF 40%. Currently euvolemic, well-compensated. Continued ACE, Spironolactone, BB. . #. CAD s/p CABG [2118]: stable. Continued ASA, statin, ACE, BB as above. . #. HLD: stable. Continued statin, fibrate. . TRANSITIONS OF CARE -new medication started: Plavix -follow-up: with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 2912], and Vascular Surgery (Dr. [Last Name (STitle) ] Medications on Admission: HOME MEDICATIONS: [confirmed] ASPIRIN [ECOTRIN LOW STRENGTH] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth every morning ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth every evening FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - (Prescribed by Other Provider) - 145 mg Tablet - 1 Tablet(s) by mouth every morning ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth twice a day AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 (One) Tablet(s) by mouth every morning QUINAPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 (One) Tablet(s) by mouth every morning HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth every morning SPIRONOLACTONE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth daily GLYBURIDE MICRONIZED - (Prescribed by Other Provider) - 3 mg Tablet - 1 Tablet(s) by mouth twice a day METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1 (One) Tablet(s) by mouth every morning ASCORBIC ACID [C-500] - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 400 unit Capsule - 1 Capsule(s) by mouth every morning POLYSACCHARIDE IRON COMPLEX [FERREX 150] - (Prescribed by Other Provider) - 150 mg Capsule - 1 Capsule(s) by mouth every morning VIT C-VIT E-COPPER-ZNOX-LUTEIN [PRESERVISION] - (Prescribed by Other Provider) - 226 mg-200 unit-[Unit Number ] mg-0.8 mg-34.8 mg Capsule - 1 Capsule(s) by mouth daily Discharge Medications: 1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. fenofibrate nanocrystallized 145 mg Tablet Sig: One (1) Tablet PO every morning. 5. atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. quinapril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. glyburide micronized 3 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: restart on Saturday. 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 14. cholecalciferol (vitamin D3) 400 unit Capsule Sig: One (1) Capsule PO once a day. 15. Ferrex 150 150 mg Capsule Sig: One (1) Capsule PO once a day. 16. PreserVision 226-200-5 mg-unit-mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: hypertensive urgency peripheral artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 3501], You came to [Hospital1 18] for a lower extremity angiogram because of leg pain, and were found to have blockages in your leg arteries. One of the blockages was treated with stents (for which you have to start taking Plavix, a blood thinner, in addition to daily Aspirin you take), and the other blockage was evaluated by Vascular Surgery (you will follow up with them as an outpatient, see below for details). . After your procedure, you had very high blood pressure, which was possibly related to pain, so you were observed in the cardiac ICU overnight. Now, on your home medications, your blood pressure is much better controlled. . In addition, you had elevated blood sugar, which was likely related to eating breakfast and not taking your diabetes medications. This has resolved as well. . We made the following changes to your medications -START Plavix 75mg daily -HOLD Metformin until Saturday [2143-5-11] (to avoid complications relating to the dye you received for the angiogram) Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] C. Location: [Hospital1 ] BLDG, [Apartment Address(1) 8540] Address: [Last Name (NamePattern1) 8541], [Location (un) ],[Numeric Identifier 9749] Phone: [Telephone/Fax (1) 8543] When: [Last Name (LF) 766], [5-20], 2:15 PM VASCULAR SURGERY Please call ([Telephone/Fax (1) 10880] within [2-15] business days to arrange a follow-up visit with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6396 }	Medical Text: Admission Date: [2176-2-29] Discharge Date: [2176-3-4] Date of Birth: [2105-3-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: BRBPR/Melena Major Surgical or Invasive Procedure: Endoscopy with Cautery Hemostasis of Duodenal Ulcer History of Present Illness: 70M H/O AF on Coumadin and NSAIDS who presented to the [Hospital1 18] ED with BRBPR and melena for two days. He had no abdominal pain, N/V or diarrhea. In the ED, he remained normotensive with a HCT of 33 (from baseline 39). An NG lavage was performed, which did not clear after 750 cc saline. He was given 4 units FFP for an INR = 2.4, Vitamin k, IV Protonix and was transferred to the unit for urgent endoscopy. This showed 2.5cc clot in duodenal bulb, which was injected w/ epinephrine and removed, revealing a shallow ulcer. This site was injected again and cauterized. He remained hemodynamically stable in the MICU overnight. He received 1 unit of PRBC for HCT = 27. At this time, he feels totally well. There is no abdominal pain, dyspnea, malaise, nausea, vomiting, dizziness, lightheaded ness, chest pain or any other symptoms. Past Medical History: 1. Stroke ([Country 48229] in [2162]) 2. AF on coumadin 3. Hyperlipidemia 4. Elevated PSA 5. LVEF40% with Mild AR/MR (ECHO in 9/[2174]). Social History: He was born in [Country 3587] and then lived in [Country 48229]. He is in close contact [Name (NI) ] his supportive son in area, name [Doctor First Name ] at [Telephone/Fax (1) 48230]. He never smoked and quit social ETOH use in [2162] after his stroke. Family History: No known GIB or cancers. Physical Exam: Tm/c 98.5 BP115/55 (SBP90s-140s) HR55 (50s-70s) RR14 ([7-3]) OS98-100%RA. I/O (since MN) = 1050/3200 GEN - NAD. PLEASANT. UNDERSTAND SOME ENGLISH. SON TRANSLATING [Name2 (NI) ]. HEENT - CLEAR OP. MMM. RESP - CTAB. RLL CRACKLES CLEARED WITH COUGH. CV - [Last Name (un) ] [Last Name (un) ]. MILD BRADY. NML S1/S2. NO MGR. ABD - S/NT/ND. POS BS. EXT - NO CCE. NEURO - A&OX3. Pertinent Results: [2176-3-1] 02:16PM BLOOD Hct-31.4* [2176-3-1] 04:30AM BLOOD WBC-9.1 RBC-3.08* Hgb-9.3* Hct-27.9* MCV-91 MCH-30.1 MCHC-33.2 RDW-13.6 Plt Ct-314 [2176-2-29] 04:00PM BLOOD Neuts-74.3* Lymphs-20.4 Monos-4.3 Eos-0.6 Baso-0.4 [2176-3-1] 04:30AM BLOOD Plt Ct-314 [2176-3-1] 04:30AM BLOOD PT-15.9* PTT-33.4 INR(PT)-1.6 [2176-3-1] 04:30AM BLOOD Glucose-77 UreaN-23* Creat-1.0 Na-141 K-4.3 Cl-107 HCO3-26 AnGap-12 [2176-3-1] 04:30AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.4 [2176-2-29] 10:00PM BLOOD Digoxin-1.4 Brief Hospital Course: 1. UGIB: The patient initially presented to the [Hospital1 18] ED with BRBPR and melana. An NG lavage was performed, which did not clear after 750 cc saline. He was given 4 units FFP for an INR = 2.4, Vitamin k, IV Protonix and was transferred to the medical intensive care unit for urgent endoscopy. The endoscopy demonstrated a 2.5cm clot in duodenal bulb, which was injected w/ epinephrine and removed, revealing a shallow ulcer. This site was injected again and cauterized. He remained hemodynamically stable in the MICU overnight. He received 1 unit of PRBC for HCT = 27. He was then transferred to the floor. The patient was maintained on protonix 40mg [Hospital1 ], serial HCT were checked, antihypertensives were held and his diet was advanced slowly. He remained hemodynamically stable with Hct >30 (given his hx of CAD, his goal Hct was >28). He was re-started on his valsartan and eventually metoprolol 12.5mg [Hospital1 ] was initiated as well. He was discharged home in stable condition without further episodes of BRBPR, melana, hematemsis and close GI follow up. He was scheduled for an outpatient Hct check on Thurs. [2176-3-7] at his PCP's office. . . 2. Tachy/Brady: The patient was monitored on telemetry for his GI bleed and during the admission was found to have episodes of bradycardia to 40s. Although he was asymptomatic, these episodes were occuring when he is awake as well as asleep, and therefore is difficult to attribute to inc. vagal tone at night. This may also be secondary to outpatient medications of digoxin and low dose atenolol. However these medications were discontinued and the patient still had episodes of bradycardia. In addition, he was also found to be tachycardic to 140s with ambulation which indicated he was not appropriately nodal blocked. He was also found to have pauses > 3sec on telemetry monitor. Again, he was asymptomatic during these episodes. EP was consulted regarding, the tachy/brady, the 3sec pauses and afib. They felt this did not warrant a PPM at this time as he was asymptomatic. He was instead started on metoprolol 12.5mg [Hospital1 ] and the digoxin was discontinued altogether. Decision regarding ppm will be re-evaluation by PCP as outpatient. . . 3. AF/Anticoagulation: Given his history of prior stroke, the risk for another episode of stroke is high. His coumadin was held during this admission due to the acuity of the situation. He was instructed to re-start his normal dose of coumadin on Sat [3-9], [2175] (10days after the initial Endoscopy) with follow up with his PCP on [Name9 (PRE) ] [2176-3-11] to titrate his coumadin dose. Given his recent GI bleed, his goal INR is 2. The digoxin was held on admission and discontinued all together after consultation with EP. At the time it was felt that the digoxin was not particularly helpful given the fact that he was in atrial fibrillation. Discussion regarding cardioversion were raised at the initial EP evaluation, however given the acuity of the GI bleed and lack of current anticoagulation, this was deferred until later time at the discretion of the PCP. [Name10 (NameIs) ] was discharged with close follow up with his PCP. . . 4. [Doctor First Name 48]: appears to have been pre-renal as pt responded to IVF with improvements in creatinine back to baseline. Discharged in stable renal function. . 5. Hyperlipidemia: cont to lipitor. . 6. PPx: The patient received DVT prophylaxis with Pneumoboots as well as PPI for GI prophylaxis during his entire hospital stay. . 7. Code: Full. . 8. Communication: His son [Name (NI) ] at [Telephone/Fax (1) 48230]. . Medications on Admission: Naproxen 250 [Hospital1 ] Digoxin 0.25 qd- Valsartan 320 qd- Coumadin 5mg qhs- Lipitor 20mg qd- Doxazosin 4 mg PO QHS- Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Doxazosin Mesylate 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Valsartan 80 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: Please start taking your normal evening coumadin dose on Sat. [2176-3-9]. Please have your INR checked on Mon. [2176-3-11] at Dr.[Name (NI) 11509] office. Thank you. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1) Upper Gastrointestinal Hemorrhage. 2) Duodenal Ulcer. Secondary Diagnoses: 3) Atrial Fibrillation and Bradycardia. 4) Congestive Heart Failure. Discharge Condition: stable Discharge Instructions: 1) Please avoid alcohol and NSAIDs (ie. Naproxen, Ibuprofen, etc.) Consult your doctor before using any medications (even over-the-counter or herbal medications). 2) Call your doctor or return the ER immediately if you are light-headed, dizzy, feel weak, have dark stools, bloody stools, nausea, vomiting, or any other concerning symptoms. 3) Please have your hematocrit (blood level) checked at Dr. [Name (NI) 11978] office on Thursday [2176-3-7]. They have been notified that you will be coming in for a lab test. 4) Please take all of your medications. Please note several changes have been made in your medications. A). Your coumadin is being held until this Sat [2176-3-9] due to your recent bleeding. Please re-start your normal dose on Sat. Goal INR is 2. Have your blood levels of INR checked on Mon [2176-3-11] and your coumadin dose adjusted as necessary. B). Your digoxin was discontinued during this admission. Please discuss whether you really need this medication or not with your PCP. C). You have been started on metoprolol 12.5mg twice daily during this admission. This medication will help slow your heart rate down when you are walking or otherwise active as it has been found to be very high during those times (Heart rate of 140s). Please discuss this with your PCP. D). You have been started on doxazosin for your prostate. Please discuss this with your PCP as well. E). You were also started on protonix 40mg twice daily. This medication will lower the acid in your stomach and help heal the stomach ulcer. Please make sure you take this medication. Followup Instructions: 1) Please see your primary doctor ([Last Name (LF) ],[First Name3 (LF) ] A. [Telephone/Fax (1) 7976]) within one week of discharge. Dr. [Last Name (STitle) 8499] and his nurse [Doctor First Name ] was notified of this admission and is awaiting a phone call from you to schedule an appointment. A). Please have your hematocrit (blood level) checked at Dr. [Name (NI) 11978] office on Thurs [2176-3-7]. B). Please start taking your coumadin on Sat. [2176-3-9] and have your INR (blood level) checked on Mon at Dr.[Name (NI) 11509] office on Mon [2176-3-11]. Your goal INR is 2. Please have your coumadin dose adjusted at the time. C). Speak to your docotor about adjusting your blood pressure medications as necessary D). Your H. Pylori antibody needs to be followed up by your doctor. E). At the time, please have an ECG performed and your heart rate monitored, as your heart rate was found to be very low during your admission. 2) Scheduled Appointments: Provider [Last Name (LF) ],[First Name8 (NamePattern2) ] [Name9 (PRE) 7975] INTERNAL MEDICINE Where: OFF CAMPUS [Hospital1 7975] INTERNAL MEDICINE Phone:[Telephone/Fax (1) 3666] Date/Time:[2176-3-19] 2:30 Completed by:[2176-3-5] ICD9 Codes: 2765, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6397 }	Medical Text: Admission Date: [2185-11-29] Discharge Date: [2185-12-9] Date of Birth: [2139-2-14] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: s/p Motor Vehicle Crash Major Surgical or Invasive Procedure: [11-29] IM nail right femur frature [12-2] ORIF right tibia fracture History of Present Illness: 46 yo restrained driver s/p motor vehicle crash; extensive front end damage with winshield break. No LOC. Past Medical History: Hypertension Hypercholesterolemia Social History: Lives with wife Employed as a Housekeeper Denies tobacco Rare ETOH Family History: Noncontributory Physical Exam: VS upon admission: BP 200/99 HR 80 O2 Sat 96-100% on 100% FM GCS 15 Alert, collared and boarded CTA bilaterally RRR S1 S2 Soft, NT, ND; guaiac negative FAST exam positive Right thigh contusion & deformity; LLE with open deformity Pertinent Results: [2185-11-29] 06:16PM WBC-10.1 RBC-3.58* HGB-10.1* HCT-27.7* MCV-77* MCH-28.2 MCHC-36.5* RDW-14.4 [2185-11-29] 06:16PM PLT COUNT-130* [2185-11-29] 06:16PM PT-13.9* PTT-23.7 INR(PT)-1.3 [2185-11-29] 01:50PM GLUCOSE-191* UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16 [2185-11-29] 01:50PM CALCIUM-7.0* PHOSPHATE-3.9 MAGNESIUM-1.3* [2185-11-29] 09:30AM TYPE-ART PO2-206* PCO2-46* PH-7.34* TOTAL CO2-26 BASE XS--1 [2185-11-28] 11:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2185-11-28] 11:40PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.023 [2185-11-28] 11:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG TIB/FIB (AP & LAT) BILAT [2185-11-29] 12:12 AM FEMUR (AP & LAT) BILAT; KNEE (2 VIEWS) BILAT Reason: ASSESS FX INDICATION: Evaluate for fracture. COMPARISON: None. RIGHT LOWER EXTREMITY, NINE RADIOGRAPHS: There is transverse fracture through the mid portion of the right femur, with medial angulation of the fracture fragment and posterior displacement with bayoneting of the distal fracture fragment. Additionally, there is a fracture of the lateral aspect of the proximal tibia, extending to involve the lateral tibial plateau. There is approximately 1 to 2 mm displacement at the fracture line. No definite fracture of the fibula is identified. Limited images of the right ankle joint demonstrate no definite effusion or associated fracture. LEFT LOWER EXTREMITY, FOUR RADIOGRAPHS: On these single view images of the left lower extremity, no definite fractures are identified. No knee joint effusion is seen. Bony mineralization is normal. IMPRESSION: 1. Transverse fracture of the mid portion of the right femur, as described above. 2. Longitudinal fracture of the proximal portion of the left tibia, extending to the lateral tibial plateau. VENOUS DUP EXT UNI (MAP/DVT) RIGHT [2185-12-7] 4:09 PM VENOUS DUP EXT UNI (MAP/DVT) R Reason: please evaluate for DVT. [Hospital 93] MEDICAL CONDITION: 46 year old man with Right femoral and R tibial plateau fracture s/p ORIF now with cellulitis R shin and edema of thigh and tenderness. REASON FOR THIS EXAMINATION: please evaluate for DVT. CLINICAL INFORMATION: 46-year-old man with right femoral and right tibia plenty of fracture, cellulitis at right shin, and edema of thigh. Evaluate for DVT. PROCEDURE/FINDINGS: Duplex ultrasound was performed at the right lower extremity. The right common femoral, superficial femoral, popliteal, anterior and posterior tibial veins are patent and compressible. No evidence of deep venous thrombosis was identified in the right leg venous system. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity venous system. TIB/FIB (AP & LAT) RIGHT [2185-12-7] 8:39 AM FEMUR (AP & LAT) RIGHT; TIB/FIB (AP & LAT) RIGHT Reason: check hardware [Hospital 93] MEDICAL CONDITION: 46 year old man with REASON FOR THIS EXAMINATION: check hardware STUDY: Right femur, two views performed on [2185-12-7]. HISTORY: 46-year-old man with femur and proximal tibial fractures. FINDINGS: Comparison is made to prior study [2185-12-2]. There is again seen an intramedullary rod with one proximal and two distal interlocking screws fixating a transverse fracture through the proximal right femoral shaft. There is anatomic alignment of the injury. Surgical skin staples are seen laterally. Images of the tibia and fibula demonstrates interval placement of a lateral plate with multiple cortical screws fixating a fracture of the right tibial plateau. Lateral surgical skin staples are also seen. There is no evidence for hardware complications. A brace is seen surrounding the right knee. Brief Hospital Course: Patient admitted to the trauma service. Orthopedics was immediately consulted because of patient's injuries. He was taken to the OR on [11-29] for IM rodding of right femur fracture and on [12-2] for ORIF of tibia fracture and closure of wound left lower extremity. Neurology was consulted due to finding on CT scan; tiny lacunar infarcts noted; felt that motor vehicle crash not likely caused by this. Recommended holding ASA until stable and to restart patient's home antihypertensives and statin. These were restarted. At this time his HCTZ and Atenolol have been on hold secondary to orthostasis and dizziness. His symptoms have slowly improved; his Hct was initially low and this has improved as well. Most recent Hct 28.3 on [12-5]. On [12-7] patient noted with cellulitis of his RLE anterior tibia region; he was started on Ancef 1 GM IV every 8 hours and underwent LENIS which were negative for DVT. He is being discharged to home on Keflex 500 mg po QID. Physical therapy was consulted and have recommended home PT. Medications on Admission: HCTZ 25' Atenolol 50' Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous once a day: Continue for 4 weeks. Disp:30 Refills:0 6. CPM machine as directed 7. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. Disp:40 Capsule(s) Refills:0 8. Wheelchair Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: s/p Motor Vehicle Crash Sternal Fracture Grade IV Liver Laceration Right Femur Fracture Left Anterior Tibia Fracture Wound Cellulitis RLE Discharge Condition: Stable Discharge Instructions: Do not bear any weight on your right leg. Continue to wear your [Doctor Last Name ] brace on your right leg until you follow up with Dr. [Last Name (STitle) 1005] in 2weeks. You will need to continue with your Lovenox injections for 4 weeks. Follow up with Orpthopedic Surgery in 2 weeks. NOT take your blood pressure medications until you see Dr. [Last Name (STitle) 1789]. Return to the Emergency room if dizziness worsens. Followup Instructions: Call [Telephone/Fax (1) 6439] for follow up appointment with Trauma Clinic in 2 weeks. Provider: [Name10 (NameIs) 5865] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2185-12-27] 8:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2185-12-27] 8:40 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2185-12-9*] ICD9 Codes: 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6398 }	Medical Text: Admission Date: [2192-9-28] Discharge Date: [2192-10-29] Date of Birth: [2112-7-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 710] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: Aortic valve replacement Central line access PICC line access Intubation Arterial line Thoracentesis Cardiac catheterization History of Present Illness: 80 year old male with hx, CVA, SBO's, prostate CA, recently discharged after ventral hernia repair who presents with fevers, AMS and hypotension. Per the daughter's report, the patient has been drowsy and delerious since discharge but has become more somnolent over the past 3-4 days. Two nights ago, he began spiking fevers. He was diagnosed with a UTI and given several doses of Levofloxacin. Subsuquently, his blood cultures grew GPC's and he got Vancomycin. Today his blood pressure lowered, with SBP's in 80's. His creatinine increased from 0.9-> 1.3 overnight, and his hemoglobin dropped from 10-.7.6 over the past 6 days. He was transfered to [Hospital1 18] via ambulance from [Hospital 100] Rehab. . Notably on last admission, he was on the surgery service for SBO. This was intially managed conservatively. The patient then developed respiratory distress and hypoxia. He was transfered to the SICU for a question of aspiration PNA vs PE. LENI neg, V/Q scan neg- PE r/o. Eventually, it was decided that he did not have an aspiration PNA and that his tachypnea was [1-7] distended abd. He was taken to the OR and found to have an incarcerated hernia which was repaired. He was discharged on [9-22] to [Hospital 100] Rehab. . In the ED his vital were temp 101.6 pt SBP 97-112/46-67, HR 98 RR 30 SaO2 97% NRB. A CXR was performed with new RUL infitrate. he was tachypnic to 30's and hypoxic. He was given [Doctor Last Name ]/Zosyn/Levo. He received 3liters NS and 1 units pRBC's w/o improvement of BP. Cr 1.4, baseline 0.9. Trop 0.12. EKG w/o ischemia. Lactate 2.0. He was seen by the surgical service who did not think that his presentation was secondary to an abodominal process or related to his recent surgery. . MEDICINE TRANSFER HPI: 80M with PMH of CVA, small bowel obstruction, metastatic prostate CA, who was admitted on [2192-9-28] with fevers, altered mental status and was found to have MRSA bacteremia and aortic valve endocarditis. Prior to his current admission he was admitted from [Date range (3) 77130] for small bowel obstruction which was complicated by incarcerated hernia which also required surgical treatment. . He was initially admitted to the MICU for sepsis as he was febrile and hypotensive. Source was initially thought to be PNA given RUL infiltrate on CXR and hypoxia and he was treated with vanc/zosyn/levo. Her was persistently hypoxic and on an NRB mask for a prolonged period of time. He was also anemic on admission with HCT 22 and guaiac positive stools concerning for GI source. In addition, he had a CT on admission showing early SBO. He was treated with an NG tube and fluids. On [2192-9-30] his blood cultures came back positive for MRSA and pip/tazo + levofloxacin were d/c'd and he was continued on vancomycin alone. Despite treatment with vancomycin, he continued to have positive blood cultures and fevers. He developed a pleural fluid which was concerning for empyema. A pleuroscentesis showed the fluid was transudative. ID was then asked to consult on the pt. All lines were removed. He had an initial TTE showing no definite valvular vegetation and was felt not to be stable enough for a TEE. Gentamicin was started on for synergy given continued bacteremia. A repeat ECHO showed a large aortic valve vegetation and severe AR meeting criteria for surgery. On the evening of [9-8] he was intubated due to increasing oxygen requirements and work of breathing from heart failure due to aortic insufficiency. He was also started on levophed for hypotension. On [2192-10-11] he underwent to surgery for a porcine valve replacement and was transfused 9U pRBC perioperatively for a post op HCT of 30. . Post operatively he was cared for in the cardio-thoracic ICU. Regarding his ongoing bacteremia, he was changed from vancomycin + daptomycin to linezolid on [2192-10-12] due to BCx positive Staph. aureus intermediately resistant to vancomycin and daptomycin. On [2192-10-12] he developed Afib with RBR and was started on amiodarone 400mg [Hospital1 ] following loading with an IV drip. Per cardiology this was decreased to 400mg daily on [2192-10-18]. He is planned to decrease to 200mg PO daily on [2192-10-24] and continue at that dose for a week. Regarding his volume status, he is >18L positive this admission. He was started on lasix 20mg IV BID on [2192-10-12] which was increased to 40mg IV BID on [2192-10-18]. He was extubated on [2192-10-14]. Regarding his abdominal pain, on [2192-10-15] he had a KUB and RUQ u/s for abdominal pain and concern for SBO vs cholecystitis. The KUB showed non obstructive bowel gas pattern with retained contrast c/w delayed transit. His RUQ ultrasound showed no evidence of cholelithiasis or cholecystitis. He had not moved his bowels in several days and did have bowel movement following lactulose. LFT's were slightly elevated on [2192-10-11] but were improved on repeat [2192-10-15] . On tranfer to the medicine service his vital signs were 98.4 121/78 71 18 97% on 3L. He remains delerius but responsive. He had pulled out his NG tube that day so cannot get PO meds or feeds. Otherwise he is stable. He denies pain but winces on abdominal exam. He can answer yes or no and at time speaks full sentances. Past Medical History: PMH: # Prostate CA w/ spinal mets (not active for several years; in remission according to his oncologist) # Gastric volvulus s/p gastropexy # Constipation # Depression # Lacunar infarct # Small Bowel Obstruction # Incarcerated hernia s/p bowel resection . PSH: # Gastropexy # Hiatal Hernia Repair Social History: Widowed, NH resident ([Hospital3 537]). Grew up in [Location (un) 17004], NY and worked as teacher, SW, guidance counselor. Was married and had 2 children; wife passed away in [2158]. Daughter is a psychiatrist in [Location (un) 86] area. Family History: Son died of a brain tumor at age 19 in [2160]. Physical Exam: VITALS: T 99.0 HR90 BP 90/57 RR 20 SAO2 97% NRB, 88% RA and on NC GEN: pale, ill appearing older male HEENT: no JVD, no LAD, no neck stiffness RESP: Clear bilaterally, tachpnic but w/o retractions or pursed lips CARD: tachy, RR, no MRG ABD: well healing midline scar, no distension, no tympany, no TTP, NABS EXTR: warm, well perfused NEURO: AOx1, limited alertness, responds to voice and looks around, answering yes and no but not answering questions SKIN: no rashes . MEDICINE TRANSFER: GEN: NAD, debiliated elderly man VS: 98.4 121/78 71 18 97% 3L HEENT: Very dry MM, no JVD or LAD CV: Distant heart sounds. RR, NL S1S2 no MRG. Pulses 1+ DP bilat and 2+ radial bilat PULM: CTAB, but poor inspiratory effort ABD: BS+, non distended, soft, diffusely tender possibly more on the L. No rebound LIMBS: 3+ LE edema, 1+ UE edema, contractures of the R and and LUE NEURO: PERRLA, reflexes 2+ at the biceps and 1- at the patellas. Toes up bilaterally with clonus on the R. Grasp reflex of the R hand. Difficult to assess otherwise. +Snout, +palmomental Pertinent Results: ADMISSION LABS: [2192-9-28] 01:20PM BLOOD WBC-9.3 RBC-2.45* Hgb-7.5* Hct-22.2* MCV-91 MCH-30.7 MCHC-34.0 RDW-15.5 Plt Ct-184 [2192-9-28] 01:20PM BLOOD Neuts-85.6* Bands-0 Lymphs-10.1* Monos-4.0 Eos-0.2 Baso-0.1 [2192-9-28] 01:20PM BLOOD PT-15.2* PTT-39.9* INR(PT)-1.3* [2192-9-28] 01:20PM BLOOD Glucose-102 UreaN-49* Creat-1.4* Na-140 K-3.9 Cl-106 HCO3-22 AnGap-16 [2192-9-28] 01:20PM BLOOD ALT-36 AST-45* CK(CPK)-160 AlkPhos-111 TotBili-0.5 [2192-9-28] 01:20PM BLOOD Lipase-90* [2192-9-28] 01:20PM BLOOD CK-MB-4 cTropnT-0.12* [2192-9-28] 01:20PM BLOOD Albumin-2.3* Calcium-7.2* Phos-3.4 Mg-1.8 [2192-9-28] 08:21PM BLOOD Type-ART pO2-72* pCO2-27* pH-7.50* calTCO2-22 Base XS-0 Intubat-NOT INTUBA [2192-9-28] 01:28PM BLOOD Lactate-2.0 K-3.8 . DISCHARGE LABS: [2192-10-26] 04:59AM BLOOD WBC-7.7 RBC-2.92* Hgb-8.8* Hct-26.0* MCV-89 MCH-30.1 MCHC-33.9 RDW-15.3 Plt Ct-152 [2192-10-26] 04:59AM BLOOD PT-14.5* PTT-31.3 INR(PT)-1.3* [2192-10-26] 04:59AM BLOOD Glucose-103 UreaN-17 Creat-1.2 Na-143 K-3.3 Cl-107 HCO3-26 AnGap-13 [2192-10-26] 04:59AM BLOOD Calcium-7.4* Phos-3.3 Mg-2.0 . ADDITIONAL LABS: [2192-10-5] 03:25AM BLOOD CRP-209.8* [2192-10-25] 05:38AM BLOOD CRP-92.4* [2192-10-20] 06:01AM BLOOD PSA-1.0 . STUDIES: [2192-10-3] Interventional Radiology - There is no evidence of pneumothorax. Mild decrease in now small right pleural effusion. Left pleural effusion, adjacent atelectasis and pulmonary vascular congestion is stable. Cardiomegaly is unchanged. NG tube tip is in the stomach. Left PICC tip is in the SVC. . [2192-10-7] CT chest, abdomen, & pelvis with contrast - IMPRESSION: 1. Findings compatible with pneumonia, most prominent in the left upper lobe. 2. Moderate bilateral pleural effusions with atelectasis or pneumonia in both lower lobes. 3. Mild ectasia of the ascending aorta. 4. Decreased amount of fluid along the incision in the midline anterior abdominal wall. The left pectineus muscle is mildly enlarged and appears to have some fluid attenuation within it. This is likely due to resolving hematoma. 5. Sclerotic bone lesions suspicious for metastases such as from prostate cancer. Recommend further evaluation. 6. New rectal wall thickening compatible with proctitis. . [2192-10-7] CT head with & without contrast - CT HEAD BEFORE AND AFTER IV CONTRAST: No evidence of hemorrhage, edema, mass effect, hydrocephalus, or recent infarction is seen on the non-contrast study. Prominence of the ventricles and extra-axial CSF spaces are consistent with age-related involutional change. An old lacunar infarct is noted along the left periventricular white matter. Vascular calcifications are noted along the cavernous carotid and vertebral arteries. The patient is status post bilateral lens replacement; otherwise, the soft tissues appear unremarkable. A right nasogastric tube is noted to be in place. A small mucus-retention cyst is noted in the right maxillary sinus. There is partial opacification of the mastoid air cells bilaterally. Small curvilinear calcification along the left posterior fossa is extra-axial and could represent a small meningioma, or dural calcification. No region of abnormal enhancement is noted after administration of IV contrast. There is normal enhancement of the major arteries of the circle of [Location (un) 431]. IMPRESSION: No evidence of acute intracranial abnormality seen. . [2192-10-8] ECHO - The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal half of the lateral wall and distal septum. The remaining segments contract well (LVEF 55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are moderately thickened but aortic stenosis is not present. There is a large, 2.3cm mobile vegetation with central lucency is seen on the LVOT side of the non-coronary leaflet aortic valve. At least moderate to severe (3+) aortic regurgitation. The mitral valve leaflets are mildly thickened. No discrete vegetation is seen. Mild to moderate ([12-7]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2192-10-1], a large vegetation is now visualized on the aortic valve (vs. focally thickened non-coronary leaflet). The severity of aortic regurgitation is slightly increased. The left ventricular systolic dysfunction also appears new ?emboli to coronary arteries? If clinically indicated, a TEE would be better able to define the aortic valve vegetation and to identify a potential abscess. . [2192-10-8] CXR - The right internal jugular line was inserted in the meantime interval. The tip is in mid SVC. There is no pneumothorax. The Dobbhoff tube tip is proximal in the proximal stomach, unchanged compared to the prior study. There is increase in the opacification of the right lung now involving not only the right lower lobe as seen previously but also the right upper lobe which potentially represent a combination of increased pleural effusion and parenchymal abnormality. Given the worsening of the left perihilar opacities these findings may be represented by worsening of bilateral edema or multifocal consolidations. . [2192-10-9] Right Lower Extremity Ultrasound - IMPRESSION: No deep venous thrombosis in the right lower extremity. . [2192-10-10] Cardiac Cath: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed no obstructive disease. The LMCA was normal and widely patent. The LAD, LCx, and RCA all had diffuse irregularities but no significant obstructive stenoses. 2. There was marked ascending aortic enlargement requiring a JL6 catheter. FINAL DIAGNOSIS: 1. No angiographically significant disease. 2. Marked ascending aortic enlargement. . MR HEAD W & W/O CONTRAST Study Date of [2192-10-20] 8:13 PM There is a punctate focus of elevated signal on image 21, series 502 of the diffusion-weighted scans, but which also appears to have slightly elevated signal on the commensurate FLAIR image. Thus, the finding might represent so- called "T2 shine-through" of a previous small vessel infarct. A few additional areas of chronic small vessel infarction, all subcentimeter in size, are seen within the periventricular white matter of both cerebral hemispheres, as well as a few within the right cerebellar hemisphere inferiorly. On diffusion image 15, series 502, there is a punctate area of elevated signal in the right occipital pole that is not seen on the ADC map, and could be an artifact. While many of the provided images are degraded by patient motion, there is no overt sign for the presence of an intracranial mass lesion or shift of normally midline structures. There are no areas of abnormal susceptibility seen within the brain. There is generalized mild brain atrophy. Following the intravenous infusion of gadolinium-DTPA, within the limits of this study, there are no definite signs for the presence of pathological enhancement intracranially. The principal vascular flow patterns are identified. There is extensive high T2 signal within the mastoid sinuses bilaterally, which could indicate an inflammatory process. In turn, this finding could relate to prior intubation. CONCLUSION: Probable chronic small vessel infarction. Extensive bilateral mastoid sinus T2 hyperintensity, which could reflect an inflammatory process. Brief Hospital Course: INITIAL MICU COURSE [Date range (2) 77131]: The patient was initially started on Zosyn, Levofloxacin and Vancomycin, pending identification of the cause of his sepsis. Surgery was consulted on admission and did not feel that the patient had a small bowel obstruction. Zosyn and Levofloxacin were stopped on [9-30] and Vancomycin continued when he was found to have MRSA in his blood, urine, and sputum. MRSA sepsis was associated with fever, hypoxia, and hypotension. Despite treatment with vancomycin, the patient continued to spike fevers and grow MRSA from blood and sputum cultures. He underwent a thoracentesis to drain accumulating pleural fluid due to concern for empyema. The fluid was transudate in nature. An infectious disease consultation was obtained on [10-4] for further assistance. All invasive lines were removed. The patient had a TTE showing no definite valvular vegetation and was felt not to be stable enough for a TEE. Gentamycin was started on [9-7] for synergy given continued bacteremia. He had a repeat ECHO on the same day showing a large aortic valve vegetation. On the evening of [9-8] the patient was intubated due to increasing oxygen requirements and work of breathing. He was started on levophed for hypotension. After discussion with the patient's daughter, surgical service, and gastroenterology, the patient was transfered to the surgical service on the morning of [9-10] for surgery to remove the vegetation and repair the valve. . Hypoxia: Multifactorial with pleural effusions, pulmonary edema, and possible infectious etiology. . RLE Edema: R>L edema was concerning for clot but LENI negative. Patient was on DVT prophylaxis with SC heparin and pneumoboots. . AMS: Likely multifactorial secondary to infection and fever. Per report, he had some degree of altered mental status at rehab following his ventral hernia repair. Head CT was negative for acute intracranial bleed. Venlafaxine was stopped. Initially haldol was given prn agitation, but that too was stopped. . Anemia: Baseline HCT 23-27. No sign of overt bleeding, however, mildly Guiac +. Received 9 units during his MICU course (3 of those the day prior to surgery). . Elevated Troponin: Troponins continuing to rise, no clear ECG changes although some T wave flattening on ECGs. Pt may have septic emboli to coronaries given new wall motion abnormalities and reduced EF on recent echo. . ARF: creatinine increased to 1.4 prior to surgery, like from hypotension, poor perfusion. Pt was given renal protective therapy with sodium bicarb and mucomyst. . On [2192-10-11] The patient was transfered to the surgical service for aortic valve replacement with a porcine valve which was uncomplicated. Post operatively he was cared for in the cardio-thoracic ICU. He was changed from vancomycin + daptomycin to Linezolid on [2192-10-12] as his sensitivities VISA and dapto-intermediate sensitivity. On [10-12] he was started on amiodarone 400mg [Hospital1 ] following loading with an IV drip for rapid Afib, he was decreased to 400mg daily on [10-18]. He was also started on lasix 20mg IV BID on [10-12] which was increased to 40mg IV BID on [10-18]. He was extubated on [2192-10-14]. On [10-15] he had KUB and RUQ u/s for abdominal pain and concern for SBO vs cholecystitis. The KUB showed non obstructive bowel gas pattern with retained contrast c/w delayed transit. His RUQ ultrasound showed no evidence of cholelithiasis or cholecystitis. He had not moved his bowels in several days and did have bowel movement following lactulose . LFT's were slightly elevated on [2192-10-11] but were improved on repeat [10-15]. . He was transferred to the MICU service on [10-18] due to continued delirium. . MICU COURSE [Date range (3) 77132]: The patient was continue on the Lasix 40mg IV BID but this was stopped on [2192-10-19] due to concerns of rising creatinine. He continued to diurese well. An MRI was ordered for further work-up of mental status changes. Mental status waxed and waned but was not markedly changed from admission. Pt would respond to voice occasionally, follow commands sporatically. Moves all extremities. Pt was transferred to the floor on [2192-10-19] for further workup. . MEDICINE COURSE [2192-10-19] to [2192-10-26]: 80M with PMH of CVA, small bowel obstruction, and metastatic prostate CA admitted originally for altered mental status who developed vancomycin and daptomycin intermediate resistant endocarditis with destruction of the aortic valve now s/p valve replacement with persistant delirium. His hospitalization has been complicated by afib with RVR post op. He is also volume overloaded with an estimated 18L positive fluid balance not accounting for error and insensible losses. He is persistently anemic. The DD for his delerium is primary CNS process such as infection, infarct, met, toxic metabolic state, or degenerative process. His bacteremia seems to be cleared and his cardiac status is stable. . # Delirium: Main clinical issue at this point. Likely multifactorial related to toxic metabolic state, medications, possible CNS complications such as infection, infarct, met, or degenerative process. To reduce this we have treated pain with tylenol standing and low dose MS IV if appeared to be in pain. He has not required MS IV in several days. We held sedating and altering medications as much as possible. A head MRI showed no process to explain his delirium. We D/Ced IJ, Foley, and recal tubes. He has a condom cath and an NG tube which he tolerates. The Pt also has ongoing frontal sings including [Last Name (un) 8752]-metal, snout, [Doctor Last Name ], and [Doctor Last Name 77133] as well as pathologic Babinski. Has failed speech and swallow examination. . # Atrial fibrillation - he had Afib with RVR post-operatively for which he was started on amiodarone + metoprolol. He is currently in NSR with rate in the 60-70's. He has no h/o afib prior to surgery therefore may have been isolated event in setting of open heart surgery. Has been monitored on tele with no events. Cards had recommended amiodarone 200mg daily for 6 months but CT [Doctor First Name ] said none is needed since he seems to be in stable sinus rhythm. Holding amio for now. On metoprolol for rate control. . # Anemia: HCT 22 on admission with guaiac positive stools concerning for slow GI bleed. He was transfused 9U pRBC peri-operatively. HCT had been stable ~30 post op. HCT dropping slowly. Likely component of phelbotomy induced anemia in the context of anemia of inflammation. Plan to transfuse if increasingly tachycardic or HCT <21. Could be due to linazolid toxicity. . # UMN signs and possible frontal release signs. Pt with toes up bilat, LE rigidity, reports inability to move legs due to weakness. There is distant concern that he could have epidural abscess [1-7] seeding from his endocarditis. Frontal release sings positive for [Last Name (LF) 77133], [First Name3 (LF) ], palmomenal, and snout. Grasp was positive but less so over time. As noted, MRI of the brain showed nothing to explain his delerium or neuro s/s. Held off on imaging of spine as he was clinically improving and afebrile. Given that some of the signs have fluctuated, this may be a component of his delirium . # Stage III Decubitus Ulcer - located on coccyx, followed by wound consult service. On [Doctor First Name ]-air mattress. Now that he has PO access hopefully improved nutrition will help this. . # Aortic valve endocarditis and bacteremia- now s/p aortic valve replacement with porcine valve. All blood cultures since surgery have been sterile. On strict contact isolation for vancomycin and daptomycin intermediate resistant Staph. aureus. Per ID will continue linezolid to [2192-11-23]. No need for further screening BCx. As Staph can seed and cause abscesses which must remain in the DD for ongoing neuro issues, however MRI of the brain is essentially NL. Spine MRI was not done [1-7] agitation. Held off on additional imaging as clinical status improving. Most recent CRP was 99, down from 200. Will need weekly CRP to confirm imporvement after his endocarditis. . # Volume Overload - Positive fluid balance over his length of stay with significant pleural effusions and lower extremity edema. Now on furosimide 40mg PO daily (was 20mg IV BID) and diuresing actively. Will need [Hospital1 ]-weekly check of electrolytes given on active diuresis. Holding Lasix for now since seems euvolemic. . # Abdominal Pain: Now seemingly resolve. Had KUB and abdominal ultrasound which were unrevealing. Not a clear complaint because could distract pt from it. Amylase and LFTs NL. Cdiff negative x 2. Resolved. He had a large BM after tap water enema on [2192-10-26]. . # Prostate cancer: Known to have metastatic prostate cancer. PSA WNL [2192-10-20] so was holding leuprolide given low PSA. Pt normally received his leuprolide every 4 months of 30 mg IM. He is followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Hospital3 328]. We gave him a dose of 28.25 mg IM on [2192-10-26] (only dose we had here) which is an adequate dose per Dr.[Name (NI) 77134] office. . # Hypotension: Not pathologic. SBP 90-110. Hold metoprolol for SBP<90 . # Depression: prior to his prolonged two hospitalizations here he had been treated for depression with Remeron 45 mg qhs, Effexor XR 150 mg tabs (1.5 tabs daily) and Zyprexa 7.5 mg qhs. He has not been on these doses for a couple of months but prior to his hospital stay at the [Hospital1 18], at the MACU at [Hospital 100] Rehab he was on Effexor 37.5 mg [Hospital1 ] and Haldol. He is currently not on any of these agents. He would benefit from seeing a psychiatrist once his delirium resolves. . # Nutrition: Patient due to delirium has been aspirating thin liquids and is unable to take po. A dubhoff was placed for enteral nutrition. It came out by accident upon transport from getting a PICC line and an NG tube was put back in. Per daughter [Name (NI) 3608], she would like to give him a chance ie two weeks before thinking about a G tube. Medications on Admission: 1. Cholecalciferol 400mg PO DAILY 2. Docusate Sodium 100 mg Two PO BID 3. Senna 8.6 mg PO BID 4. Lupron Subcutaneous 5. Polyethylene Glycol 3350 Oral 6. Aspirin 81 mg PO Daily 7. Calcium Oral 8. Cyanocobalamin Oral 9. Garlic Oral 10. Omega-3 Fatty Acids 1,000 mg PO Daily 11. Haloperidol 1 mg PO TID PRN Agitation. 12. Haloperidol 1 mg Tablet 2.5 Tablets PO QHS 13. Venlafaxine 37.5 mg SR PO BID 14. Ferrous Sulfate 325 mg PO DAILY 15. Heparin SQ 5000 units TID 16. Acetaminophen 325 mg 1-2 Tablets PO Q6H PRN 17. Pantoprazole 40 mg Delayed Release PO Q24H 18. Midodrine 5 mg PO TID 19. Metoprolol Tartrate 25 mg 0.5 Tablet PO BID 20. Bisacodyl 10 mg Suppository Rectal QHS PRN constipation. 21. Docusate Sodium 100 mg PO BID 22. Insulin Regimen Sliding Scale Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Name (NI) ]: 5000 (5000) units Injection TID (3 times a day). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 5. Acetaminophen 325 mg Tablet [Hospital1 ]: Two (2) Tablet PO four times a day: While [Last Name (LF) 77135], [First Name3 (LF) ] not exceed 4g in 24hrs, please give standing for pain. 6. Heparin, Porcine (PF) 10 unit/mL Syringe [First Name3 (LF) ]: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 7. Linezolid 600 mg/300 mL Parenteral Solution [First Name3 (LF) ]: Six Hundred (600) mg Intravenous Q12H (every 12 hours): Please discontinue after [2192-11-22]. 8. Polyethylene Glycol 3350 100 % Powder [Month/Day/Year ]: One (1) PO DAILY (Daily). 9. Lactulose 10 gram/15 mL Solution [Month/Day/Year ]: 30 mL PO once a day: Titrate up more for constipation. 10. Metoprolol Tartrate 25 mg Tablet [Month/Day/Year ]: 0.5 Tablet PO twice a day: Hold for SBP <90 and pulse <60. 11. Leuprolide (4 Month) 30 mg Kit [Month/Day/Year ]: One (1) kt Intramuscular q 4 months: last given on [2192-10-25]. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary diagnosis: Staph endocarditis s/p AVR with porcine valve, delirium, stage III sacral decubitus ulcer, post-op afib resolved . Secondary diagnosis: Metastatic prostate cancer, depression Discharge Condition: Stable vital signs, afebrile Discharge Instructions: You were admitted from rehab for fevers. Ultimately you were found to have Staph growing in your blood. We found evidence that a valve in your heart was infected by this Staph and you required surgery to repain the damage done to your aortic valve. We have treated you with long term antibiotics as a result of this infection as well. You have been more delirius during this hospitalization. The cause of this is multi-factorial. . Please continue to take your medications as prescribed. . Please attend your follow up appointments. . Please call your doctor or come to the emergency department if you experience fevers, shortness of breath, palpitations, chest pain, diarrhea, or other concerning symptoms. Followup Instructions: [Hospital1 18] PCP: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name12 (NameIs) 280] Phone:[Telephone/Fax (1) 719] Date/Time:[2192-11-14] 11:00 - works with PCP [Last Name (NamePattern4) ]. [First Name (STitle) ] [Hospital1 18] ID: [First Name4 (NamePattern1) 8495] [Last Name (NamePattern1) 8496], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2192-12-13] 9:00 Cardiothoracic surgery will call with a follow up appointment Completed by:[2192-10-29] ICD9 Codes: 5849, 9971, 5990, 4241, 4280, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6399 }	Medical Text: Admission Date: [2124-5-11] Discharge Date: [2124-5-22] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: fatigue, chest pain Major Surgical or Invasive Procedure: AVR/CABG on [2124-5-16] History of Present Illness: 81 y/o female with exertional chest pain and fatigue. She's had known AS, followed by echo, recent increase in symptoms. Past Medical History: HTN obesity hypercholesterolemia complete heart block s/p PPM chronic anemia GERD recurrent ventral hernia narcolepsy agorophobia fractured ribs s/p MVA s/p right carotid stent s/p PPM placement s/p hernia repair Social History: remote smoker denies ETOH wodowed, lives with friend retired Family History: non-contributory Physical Exam: Cor: gr IV/VI systolic murmur Abd: + large ventral hernia 1+ peripheral edema pre-operative exam otherwise unremarkable Pertinent Results: [2124-5-20] 05:31AM BLOOD Hct-25.6* [2124-5-19] 03:36AM BLOOD WBC-12.2* Hct-26.8* [2124-5-18] 05:43AM BLOOD Plt Ct-200 [2124-5-22] 05:25AM BLOOD Glucose-102 UreaN-29* Creat-1.2* Na-133 K-4.7 Cl-99 HCO3-25 AnGap-14 Brief Hospital Course: Admitted on [2124-5-11] due to anemia. GI workup revealed duodenitis (by EGD) and diverticulosis and rectal polyp (by colonoscopy). Carotid ultrasound: [Country ]: 40-59% and [Doctor First Name 3098] 60-69% stenosis She was taken to the OR on [2124-5-16] where she underwent an AVR (# 21mm pericardial valve), and a CABG X 1 (SVG>RCA) Post-operatively she was taken to the cardiac surgery recovery unit, and was weaned from mechanical ventilation and extubated the day of surgery. She was noted to be undersensing her P waves by her permanent pacemaker, and the EP service was following her for this. She also has an elevated threshold for her ventricular lead. She was transferred to the telemetry floor on POD # 2, her chest tubes were removed, and she has remained hemodynamically stable. Her epicardial wires were removed on POD # 3 Her creatinine peaked at 1.8 on POD # 3, but has dropped to 1.2 today, POD # 6. She has progressed slowly with ambulation and physical therapy, but has remained hemodynamically stable throughout her post-op course. She is ready to be discharged to rehab today to continue with increasing mobility/physical therapy. Medications on Admission: Benicar/HCTZ 40/25 daily Norvasc 5mg QD Crestor 10mg QD ASA 325 mg QD Acidophilus Cipro Protonix 40mg QD Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: ledge Discharge Diagnosis: s/p AVR(#21 pericardial)CABGx1(SVG->RCA) PMH: HTN, ^chol, CHB s/p PPM, anemia, GERD, recurrent ventral hernia, obesity, narcolepsy Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2124-6-30] 11:00 Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 2934] Date/Time:[2124-6-30] 11:30 Completed by:[2124-5-22] ICD9 Codes: 4241, 2761, 4019, 2724

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