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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6400 }	Medical Text: Admission Date: [2130-2-8] Discharge Date: [2130-2-11] Service: MEDICINE Allergies: Vioxx / Bactrim / Codeine / Aspirin / Gabapentin / Ranitidine Attending:[First Name3 (LF) 2186] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: mesenteric angiography via femoral catheter History of Present Illness: Pt is a 88 year old with history of diverticular bleed, who presents after two episodes of bright red blood per rectum last evening. She became concerned after she felt lightheaded, dizzy and weak and used her life line to call EMS. She denies any abd pain, nausea or vomiting, and has chronic diarrhea. No fever, or chills. Patient had diverticulitis, complicated by abscess in the past, has a history of 8 units of red blood cells transfusion in [2127] for lower gaterointestinal bleed, with negative angiogram. In the ED, initial vitals were: temp 98 pulse 82 blood pressur 160/70 respirations 16 Oxygen sat 100%. Patient was given 3L noramal saline and 2 IVs were place, GI consulted. In the MICU, GI was consulted. She received 2 units of PRBCs on night of admission and hematocrits stabilized without further transfusion. Her EKG was unchanged from baseline. She went to angiogram suite on day of transfer without evidence of active bleed. Surgery was consulted. Vitals on transfer were temp 98.1 pulse 66 blood pressure 156/54 satuation of 97% on roonm air. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, constipation or abdominal pain. No recent change in bladder habits, has chronic [Last Name (un) 940] stools. No dysuria. Denied arthralgias or myalgias. Past Medical History: - diverticulosis [2127] requiring 8 units transfusion with negative angiogram. - grade 1 internal hemorrhoids - sigmoid diverticulitis with an adjacent abscess [9-/2129] - Afib: not on coumadin - Chronic diarrhea - Insulin Dependent Diabtes Mellitus - Hypertension - Asthma - Gout - Recurrent urinary tract infections - gastroesphogeal reflux - Tremor: essential tremor, followed previously by Dr. [Last Name (STitle) 17281] - Chronic Renal Failure - Choledocholithiases/cholangitis ([2126-4-20]): found to have pseudomonas bacteremia, treated with ceftazidime and flagyl, and referred for cholecystectomy but patient refused - Neuropathic pain - Right hip fracture - bilateral knee replacements - right leg pins - cataract repair Social History: No alcohol, tobacco, or other drugs. Currently living with her daughter in [Location (un) 686]. From [State 2690] originally. Three children, six grandkids, 7 greatgrandkids Family History: Father died of MI at 43 yo. Maternal history of breast cancer. Uncle with stomach cancer, uncle with liver cancer, brother with prostate cancer. Brother and 2 daughters with diabetes. Physical Exam: ICU Admission Exam: Vitals: Temp: 98.1 blood pressure: 130/40 Pulse: 94 Resp: 14 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry muccous membranes, oropharynx clear Neck: supple, neck veins not elevated, no masses Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: labs- [2130-2-8] 12:40AM BLOOD WBC-5.7 RBC-3.59* Hgb-10.4* Hct-31.2* MCV-87 MCH-28.9 MCHC-33.3 RDW-16.8* Plt Ct-240 [2130-2-8] 06:00AM BLOOD WBC-8.2 RBC-2.66# Hgb-8.0 Hct-23.7* MCV-89 MCH-30.1 MCHC-33.8 RDW-17.2* Plt Ct-219 [2130-2-11] 01:17AM BLOOD Hct-31.2* [2130-2-11] 07:05AM BLOOD WBC-9.1 RBC-3.78* Hgb-11.5* Hct-32.1* MCV-85 MCH-30.5 MCHC-36.0* RDW-16.4* Plt Ct-113* [2130-2-8] 12:40AM BLOOD Neuts-51.2 Lymphs-41.3 Monos-4.0 Eos-3.3 Baso-0.3 [2130-2-8] 12:40AM BLOOD PT-14.0* PTT-24.9 INR(PT)-1.2* [2130-2-10] 02:55AM BLOOD PT-14.5* PTT-26.9 INR(PT)-1.3* [2130-2-8] 08:16PM BLOOD Fibrino-312 [2130-2-8] 12:40AM BLOOD Glucose-127* UreaN-33* Creat-1.3* Na-139 K-5.1 Cl-106 HCO3-28 AnGap-10 [2130-2-11] 07:05AM BLOOD Glucose-160* UreaN-12 Creat-0.9 Na-140 K-4.2 Cl-107 HCO3-28 AnGap-9 [2130-2-8] 06:00AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8 [2130-2-10] 02:55AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.0 [2130-2-8] 01:02PM BLOOD pH-7.26* [2130-2-8] 04:05PM BLOOD Type-ART pH-7.37 [2130-2-8] 01:02PM BLOOD freeCa-1.08* [2130-2-8] 04:05PM BLOOD freeCa-1.22 [2130-2-8] 6:00 am MRSA SCREEN NASAL SWAB. FINAL REPORT [2130-2-9] MRSA SCREEN (Final [2130-2-9]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. Reports- EKG [2130-2-8] Atrial fibrillation. There is a late transition with tiny R waves in the anterior leads consistent with possible prior anterior infarction. Non-specific ST-T wave changes. Compared to the previous tracing atrial fibrillation is new. Read by: [Last Name (LF) 2194],[First Name3 (LF) ] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 87 0 84 346/393 0 -10 79 ------------------- EKG [2130-2-8] Sinus rhythm. Compared to the previous tracing of [2129-9-12] ectopy has resolved. Read by: [Last Name (LF) ],[First Name3 (LF) ] Intervals Axes Rate PR QRS QT/QTc P QRS T 80 172 78 358/393 23 -12 70 [2130-2-8] cxr HISTORY: New central line, check position or complications. IMPRESSION: AP chest compared to [2129-9-11]. Tip of the new right internal jugular line projects low over the SVC. No pneumothorax, mediastinal widening or pleural effusion. Heart size is top normal. Lungs are clear. Angiogram- mesenteric -no active source of bleeding visible -------------------- Doppler LE INDICATIONS: 88-year-old female with GI bleed status post angiographic procedure and right-sided groin bruits. Please rule out hematoma or fistula. FINDINGS: Limited arterial and venous duplex was performed in the right femoral location. The common femoral artery is patent with biphasic waveforms and uniform color saturation. The profunda and proximal superficial femoral artery also patent with biphasic waveforms. The common femoral and proximal saphenous are patent without any evidence of fistula. There is no evidence of pseudoaneurysm and no significant hematoma. IMPRESSION: Essentially normal Duplex of the right femoral vessels. No source of the bruits identified. Brief Hospital Course: ICU Course: The patient was admitted with hypotension and ongoing bright red blood per rectum. Hematocrit on admission was 23.7. She was bolused with IV fluids and transfused 2 units of packed red blood cells, and her blood pressure stabilized. Her post-transfusion hematocrit was 37.2. GI and surgery were consulted upon admission. On hospital day one, per GI/interventional radiologist, she was taken directly to angiography, but no bleeding source was found. Upon removal of her femoral sheath, she developed groin pain and a bruit. Ultrasound was obtained, which showed no atriovenous fistula or pseudoaneurysm, with patent vessels. She was prepped for colonoscopy, but as she had no more bleeding over 36 hours. Therefore, GI decided not to pursue a scope during this admission. Given her prior history of diverticular bleed, it is likely that this episode was also from diverticula. Her hematocrit at the time of floor transfer was 31.0, stable over 36 hours. Her blood pressure had also stabilized and was increasing to SBPs 150s, with a plan to restart home BP medications on the floor. Medicine floor course: After transfer to the floor, the patients blood pressure increased overnight to the 170s. She was given captopril and metoprolol short acting. Her hematocrit remained stable overnight at 32.2 and then she was restarted on her home blood pressure medications of lisinopril and verapamil ER. She had no abdominal pain and her vitals remained stable, but with an improved blood pressure to the 130s. She was seen by PT and was able to ambulate and climb stairs independently. She had complaint of gas and was started on simethicone PRN. She also had complaint of skin irritation under her left breast and was instructed to use a zinc oxide containing powder twice a day. She was discharged home and will have follow up with her PCP and the [Hospital ] clinic. Medications on Admission: Insulin NPH SS Albuterol 2puffs prn Allopurinol 100mg PO Atorvastatin 1mg Duloxetine 20mg Fluticasone 110 mcg 2puffs Lisinopril 10mg Pantoprazole 40mg Verapamil 120mg Montelukast 10mg ASA mg Discharge Medications: 1. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) units Injection ASDIR (AS DIRECTED): use as before admission. 3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO TID (3 times a day) as needed for gas: for gas. Disp:45 Tablet, Chewable(s) Refills:3 6. over the counter powder with zinc oxide, apply under the breasts twice a day, avoid inhalation 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation three times a day. 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Tablet(s) 10. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) Inhalation once a day: use as before. 11. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day as needed for shortness of breath or wheezing. 12. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 14. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: primary: acute blood loss anemia lower gastrointestinal bleed secondary: type 2 diabetes gout hypertension chronic diarrhea Discharge Condition: stable, afebrile Discharge Instructions: You were admitted for blood in your stool complicated by anemia. You received 2 units of blood while you were here. You were initially monitored in the ICU. There, your blood pressure and blood counts were stable. You had a scan to detect bleeding in your colon. The results of that were negative. Please see your gasteroenterologist to schedule a colonoscopy. Please follow up with all of your appointments and take all of your medications as directed. If you should have further bleeding, lightheadedness/dizzyness, weakness, chest pain, or shortness of breath, please call your primary care physician or present to the emergency department. Followup Instructions: You have the following appointments. Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7145] ORTHOPEDIC PRIVATE PRACTICE Phone:[Telephone/Fax (1) 11262] Date/Time:[2130-3-22] 11:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2967], [Name12 (NameIs) 280] Phone:[Telephone/Fax (1) 250] Date/Time:[2130-3-1] 10:10- Please recheck HCT as pt had recent admission for lower GI bleeding. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1941], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 1942] Date/Time:[2130-2-20] 12:45 Call Dr. [Last Name (STitle) 174], your gasterenterologist, for an appointment, ([Telephone/Fax (1) 22346]. You will need to discuss your need for a colonscopy. Completed by:[2130-2-12] ICD9 Codes: 2851, 2749, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6401 }	Medical Text: Admission Date: [2182-7-4] Discharge Date: [2182-7-9] Date of Birth: [2144-1-6] Sex: M Service: CARDIOTHORACIC Allergies: Wellbutrin Attending:[First Name3 (LF) 1267] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD, SVG->PDA) [2182-7-5] History of Present Illness: 38 y/o male w/ significant cardiac risk factors and history who presented to OSH w/ 3 weeks of chest pain. Pt. was ruled in w/ enzymes and had Cath on [2182-7-2] which revealed severe 3 vessel disease. Medically managed and then transferred to [Hospital1 18] on [7-4]. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction 8 yrs ago w/ PCI/Stenting to LAD Hypertension Hypercholesterolemia Social History: Married w/ 4 children +Tobacco x 17 yrs- 1/2ppd Occ. ETOH, -IVDA Family History: Father alive, MI at age 36, Uncles x 4 w/ MI's (all deceased at age 50-60's) Physical Exam: VS: 98.4 51 121/72 20 99%RA General: NAD, awake, alert, comfortable HEENT: NC/AT, PERRLA, EOMI, O/P clear Neck: Supple, -LAD, -thyromegaly, -carotid bruits Lungs: CTAB, -w/r/r Heart: RRR, poss. diastolic blowing murmur w/ SEM @ LUSB Abd: Soft, NT/ND +BS Ext: Trace Edema -c/c, DP [12-9]+ Neuro: 5/5 Strength, sensation intact throughout Pertinent Results: [2182-7-4] 07:52PM BLOOD WBC-9.0 RBC-5.38 Hgb-15.6 Hct-44.4 MCV-82 MCH-29.1 MCHC-35.3* RDW-13.2 Plt Ct-171 [2182-7-7] 06:22AM BLOOD WBC-10.8 RBC-4.10* Hgb-12.0* Hct-34.0* MCV-83 MCH-29.3 MCHC-35.2* RDW-13.1 Plt Ct-124* [2182-7-9] 06:25AM BLOOD Hct-32.2* [2182-7-4] 07:52PM BLOOD PT-13.6* PTT-26.9 INR(PT)-1.2 [2182-7-6] 04:11AM BLOOD PT-14.3* PTT-28.4 INR(PT)-1.4 [2182-7-4] 07:52PM BLOOD Glucose-107* UreaN-12 Creat-0.7 Na-139 K-4.5 Cl-101 HCO3-31 AnGap-12 [2182-7-7] 06:22AM BLOOD Glucose-131* UreaN-14 Creat-0.7 Na-135 K-4.4 Cl-99 HCO3-28 AnGap-12 [2182-7-9] 06:25AM BLOOD K-3.8 [2182-7-4] 07:50PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.025 [2182-7-4] 07:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG Brief Hospital Course: As mentioned in the HPI, pt was admitted on [7-4], and consented to surgery. On HD #2 pt was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see op note for surgical details. Pt. tolerated the procedure well with no complications and was transferred to the csru in stable condition only on a Propofol gtt. Later on op day pt was weaned from mechanical ventilation and Propofol and was extubated. He was awake, alert, MAE and following commands. On POD #1 was only on a Insulin gtt, his Swan-Ganz catheter was removed and he was doing well and transferred to telemetry floor. Diuretics and B-blockers were initiated per protocol. On POD #2 both his chest tubes and Foley catheter were removed. On POD #3 his epicardial pacing wire were removed. Pt. appeared to be recovering well with no complications and physical exam was unremarkable. Pt was ambulating well with PT and at level 5 by POD #4. His labs were stable and he was discharged home with the appropriated f/u appointments. Medications on Admission: 1. Crestor 10mg qd 2. Toprol XL 50mg qd 3. ASA 81mg qd 4. Lisinopril 10mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. Disp:50 Tablet(s) Refills:0 4. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA Care [Location (un) 511] Discharge Diagnosis: Coronary artery disease (w/ h/o Myocardial Infarcation 97 & PCI to LAD) s/p Coronray Artery Bypass Graft x 3 Hypertension Hypercholesterolemia Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Do not use lotions, creams, or powder on wounds. Call our office for sternal drainage, temp.>101.5 Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 56487] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Completed by:[2182-7-24] ICD9 Codes: 4280, 4240, 412, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6402 }	Medical Text: Admission Date: [2131-9-18] Discharge Date: [2131-9-19] Date of Birth: [2047-6-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: Transfer for ERCP Major Surgical or Invasive Procedure: ERCP [2131-9-18] History of Present Illness: 84 year old male with a history of of coronary artery disease, sick sinus syndrome s/p pacemaker, chronic kidney disease and recent prolonged hospitalization for gangrenous cholecystitis s/p open cholecystectomy complicated by bile leak requiring external drainage in [2131-8-1]. The initial surgery was performed on [2131-8-11]. On entering the abdomen he was noted to have gangrenous cholecystitis. He had extensive adhesions and it was difficult to dissect the fascial planes. It was not possible to remove the entire gallbladder and the gallbladder was instead divided 1 cm above the takeoff of the cystic duct. He was ultimately discharged to Blueberry [Doctor Last Name ] nursing home on [2131-8-24]. Per notes his subhepatic drain was removed on [2131-9-14]. . He represented to [Hospital ] hospital on [2131-9-16] with right upper quadrant pain and chills. On arrival to [Hospital ] hospital he was afebrile with a HR of 78, BP of 98/57, O2 saturation 95% on RA. WBC count on presentation was 20.4 with normal transaminases. CT scan done on admission showed a distended gallbladder with irregular contour and thickened wall and pericholecystic inflammatory changes suspicious for acute cholecytsitits with possible track from the gallbladder to the skin. He was started on IV antibiotics initially with Unasyn and then Zosyn. He underwent drainage of subhepatic fluid collection on [2131-9-17] with removal of 50mL thicky cloudy bile and a 12 F catheter was placed. He was transferred to this hospital for ERCP and internalization of his biliary drain. . He was transferred to the ERCP suite. He was intubated periprocedure. The procedure was technically uncomplicated and he had two plastic stents placed. During the procedure his blood pressure was labile ranging from the 60s to 130s systolic. He required treatment with neosynephrine at 0.5 mcg/kg. He received 1.5 L IVF and made 120 cc urine. There was minimal blood loss. He was extubated in the PACU and transferred to the medical ICU ([Hospital Ward Name 332]). Neosynephrine was turned off on arrival to the [Hospital Unit Name 153] with blood pressures in the 120s to 130s systolic. In the [Hospital Unit Name 153], he currently had no complaints. He denied fevers, chills, nausea, vomiting, diarrhea, constipation, dysuria, hematuria, leg pain or swelling. He continued to endorse abdominal pain, worst in the right upper quadrant. Past Medical History: Open cholecystectomy for gangrenous cholecystitis [2131-8-11] Coronary artery disease s/p anterior MI in [2126] Cardiomyopathy with congestive heart failure (EF 45-50% in [1-6]) Sick sinus syndrome s/p biventriuclar pacemaker in [2121] Stage IV Chronic Kidney Disease (baseline creatinine 2.0) Cervical spinal fracture with cord compression in [2127] complicated by three month hospitalization with tracheostomy and PEG placement Gastroesophageal Reflux Disease Hypogonadism Hypopituitarism (on 5 mg hydrocortisone at home) Hyperlipidemia Hypertension History of orthostatic hypotension BPH s/p TURP Left pulmonary granuloma History of diverticulosis and diverticulitis Osteoarthritis History of reflux sympathetic dystrophy of left hand Type II Diabetes History of MRSA Social History: Lives with his son in [Name (NI) ] but now coming from rehab. Remote history of smoking (quit 20+ years ago). No current alcohol use but previously drank one per day. No illicit drug use. Retired electrician. Family History: Father died at age 83 of throat cancer. Mother died at age 80 of coronary artery disease. 1 sister died of leukemia. 1 living brother and 2 living sisters. Physical Exam: PE at admission to [Hospital Unit Name 153] [2131-9-18]: Vitals: T: 97.6 BP: 123/66 P: 117 R: 18 O2: 97% on 3L General: Alert, oriented to person, [Month (only) 216], not place or season, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Trace crackles at bases, poor inspiratory effort, no wheezes or ronchi CV: Tachycardic, regular rhythm, normal s1 and s2, II/VI HSM at LLSB, no rubs or gallops Abdomen: soft, tender in RUQ, mildly distended, bowel sounds present, positive guarding, no rebound, cholecystecomy scars well healing, drain in place with green bile, previous g-tube site well healed, no organomegaly GU: Foley with clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . PE at transfer back to [Hospital1 ] [2131-9-19]: Tmax: 99.4 ??????F Tc: 99.4 ??????F HR: 106 BP:136/56(75) RR: 17 SpO2: 94% NC 4L General: Alert, oriented to person, [Month (only) 216], not place or season, no acute distress Lungs: Trace crackles at bases, poor inspiratory effort, no wheezes or rhonchi CV: Tachycardic, regular rhythm, normal s1 and s2, II/VI HSM at LLSB, no rubs or gallops Abdomen: soft, tender in RUQ, mildly distended, bowel sounds present, positive guarding, no rebound, cholecystecomy scars well healing, drain in place with green bile, previous g-tube site well healed, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission [2131-9-18]: Urinalysis [2131-9-16]: Negative Chemistries [2131-9-17]: Na 141, K 4.8, Cl 108, CO2: 20, BUN: 31, Creatinine 1.9, TBili 0.5, Lipase 138, AP 54, AST 20, ALT 26 INR 1.25 WBC: 14.5 (from 20.4 with 84% PNS), Hct: 36.2, Plts 155 . Labs on transfer to [Hospital1 ] [2131-9-19]: WBC-12.0* RBC-3.73* Hgb-11.2* Hct-34.4* MCV-92 MCH-30.1 MCHC-32.6 RDW-16.0* Plt Ct-191 Neuts-79.8* Lymphs-16.0* Monos-2.5 Eos-1.2 Baso-0.4 PT-13.9* PTT-31.2 INR(PT)-1.2* Glucose-57* UreaN-22* Creat-1.6* Na-142 K-4.1 Cl-111* HCO3-18* AnGap-17 ALT-12 AST-13 AlkPhos-47 TotBili-0.7 Calcium-8.4 Phos-3.3 Mg-2.0 Lactate-0.7 . Micro [9-18] BCx - pending at time of transfer . Imaging: CXR [2131-9-18]: Extremely low lung volumes may account for much of the prominence of the transverse diameter of the heart. Bibasilar atelectatic change without definite acute focal pneumonia. Pacemaker device is in place. No evidence of intubation on this study. Of incidental note is an apparent tube in the right mid abdomen laterally. . ERCP [2131-9-18]: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Normal major papilla Cannulation: Cannulation of the biliary duct was successful and deep with a Autotome 44 using a free-hand technique. Contrast medium was injected resulting in partial opacification. . Biliary Tree: Extravasation of dye was noted at the gallbladder. No filling defects were seen in the CBD. A biliary sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Two 10FR by 9cm Cotton [Doctor Last Name ] biliary stents were placed in tandem successfully using a Microvasive 10FR stent introducer kit. . Impression: Cannulation of the biliary duct was successful and deep with a Autotome 44 using a free-hand technique. Extravasation of dye was noted at the gallbladder. No filling defects were seen in the CBD. A biliary sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Two 10FR by 9cm Cotton [Doctor Last Name ] biliary stents were placed in tandem successfully using a Microvasive 10FR stent introducer kit. Brief Hospital Course: [Hospital Unit Name 153] Course [Date range (3) 29787]: Assessment and Plan: 84 year old male with a history of of coronary artery disease, sick sinus syndrome s/p pacemaker, chronic kidney disease and gangrenous cholecystitis now presenting with fevers, leukocytosis and right upper quadrant pain transferred for ERCP. . Biliary Sepsis: Patient with known bile leak from previous cholecystectomy. On presentation to [Hospital1 ] he was afebrile but with leukocytosis, tachycardia and mild hypotension. He had significant clinical improvement with IV antibiotics and drain placement and is now s/p ERCP with stents with ultimate hope to internalize drain. He was mildly tachycardic but with stable blood pressures. Pt was NPO post procedure, advanced to clears which the patient tolerated well. Carvediolol was restarted but other anti-hypertensives were held and not re-initiated before transfer. Continued zosyn for broad spectrum coverage of biliary pathogens. Pain not adequately controlled with morphine and pt had increased O2 requirement, so changed mediation to dilaudid for better pain management and decreased splinting with improved pain control. . Hypoxia: Patient with 3-4L oxygen requirement post-procedure. Lung exam significant for crackles. Patient does have a history of cardiomyopathy with mildly decreased ejection fraction. Also may have a component of atelectasis and is an aspiration risk. Pt was also splinting due to pain and pain control increased with dilaudid 0.5mg q4h: PRN. . Coronary artery disease: s/p anterior MI in [2126]. No chest pain after procedure. Coreg and Zestril were initially held. Coreg restarted prior to transfer with stable SBP 100s. Statin and fibrate were contrinued. Aspirin was held peri-procedure and continues to be held for 72 post procedure. . Cardiomyopathy: Last ejection fraction 45-50% in [2128]. Currently with new oxygen requirement. No pulmonary edema on CXR although pt had low lung volumes. Carvedilol restarted once BP stable. Zestril continued to be held. . Stage IV Chronic Kidney Disease: Baseline creatinine 2.0. At baseline at the time of transfer from OSH. Cr on transfer back to [Hospital1 ] was 1.6. Zestril held and not re-initiated prior to transfer back to OSH. . Hypopituitarism: Per notes, post-traumatic, on hydrocortisone at home, on transfer on both hydrocortisone and fludricortisone. Will continue with plans to taper if remains at this facility. Continued hydrocortisone 15 mg PO daily, 10 mg at 3 PM. Continued fludrocortisone 0.1 mg PO BID. . Gastroesophageal Reflux Disease: continued PPI . Hyperlipidemia: continued statin and fibrate . Hypertension: Coreg re-initiated prior to transfer. Zestril held. . Benign Prostatic Hypertrophy: Floxmax held given foley . Type II Diabetes: Currently diet controlled but was on sliding scale at rehab. Insulin sliding scale was held. . Prophylaxis: Subutaneous heparin . Code: DNR not DNI (discussed with health care proxy) . Communication: Patient, son [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 64992], [First Name5 (NamePattern1) 553] [Last Name (NamePattern1) 64993] [Telephone/Fax (1) 64994] (cell) . Disposition: Transfer back to [Hospital ] Hospital ICU Medications on Admission: Medications from Rehab: Coreg 6.25 mg Po BID Prenisone 10 mg (taper) Flomax 0.5 mg PO daily Omeprazole 20 mg PO daily Multivitamin daily Vitamin D 800 IU daily Aspirin 81 mg PO daily Megestrol Acetate 800 mg PO BId Oxycodone 5 mg PO Q4h:PRN Tylenol PRN Insulin sliding sale Milk of Magnesia Dulcolax Fleets enemas . Medications on Transfer from [Hospital ] Hospital [2131-9-18]: Zosyn 3.375 IV Q6H Coreg 6.25 mg [Hospital1 ] Flomax 0.4 mg PO HS Prilosec 20 mg PO daily Hydrocortisone 15 mg PO daily, 10 mg at 3 PM Fludrocortisone 0.1 mg PO BID Zocor 40 mg PO daily Tricor 145 mg PO daily Zestril 5 mg PO daily Tylenol 650 mg PO Q6H:PRN Dilaudid 1 mg SC Q2H:PRN Vicodin 1 mg PO Q4H:PRN Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 3. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain, fever. 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100 or HR<60 . 9. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25 g Intravenous Q6H (every 6 hours). 10. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.5 mg Injection q4H: PRN as needed for pain. 11. Insulin Sliding Scale - Per Rehab sliding scale Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 ] Discharge Diagnosis: 1. Biliary sepsis . 2. Hypoxia . 3. CAD, Cardiomyopathy, CKD, Hypopituitarism Discharge Condition: Stable, to [Hospital ] Hospital ICU for further care. Discharge Instructions: You were transferred to [Hospital1 18] for endoscopic study of your biliary tract and pancreas (ERCP) and internalization of your biliary drain. You were intubated peri-procedure. The ERCP was technically uncomplicated and you had two plastic stents placed. During the procedure your blood pressure was labile and you required medicine to maintain an adequte blood pressure to perfuse your organs. You received fluids and there was minimal blood loss. You were extubated after the procedure and transfered to the intensive care unit for further monitoring of your blood pressure. Your blood pressures were stable but you did require increased oxygen to maintain oxygen saturation. This was attributed to atelectasis (collapsed lung, often seen after a procedure) and pain. Your pain was controlled with dilaudid and incentive spirometry was recommended. You were transferred back to [Hospital ] Hospital for further care. Followup Instructions: ERCP Recommendations: -Follow-up with Dr. [First Name (STitle) ] [Name (STitle) ] any problems- please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 1983]. -No aspirin, plavix, NSAIDS, coumadin for 72 hours. -Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ([Hospital1 ] [Telephone/Fax (1) 64995], pager [Numeric Identifier ]) -Repeat ERCP in 6 weeks for evaluation and stent pull. -Follow drainage from percutaneous drain and GB fossa. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] ICD9 Codes: 0389, 4254, 4280, 412, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6403 }	Medical Text: Admission Date: [2145-10-3] Discharge Date: [2145-12-24] Date of Birth: [2145-10-3] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname ] Twin II is the former 970-gram, 26 and [3-5] week twin II male admitted secondary to prematurity and respiratory distress. The infant was born to a 45-year-old gravida 2, para 0-2, white female. Prenatal screens revealed O negative, antibody negative, Rubella immune, rapid plasma reagin was nonreactive, hepatitis B surface antigen negative, hepatitis C negative, human immunodeficiency virus negative, and group B strep status unknown. MATERNAL HISTORY: History of hypothyroidism (on Synthroid), ureteral reflux (status post repair), fibroids (status post resection), herpes simplex virus with last lesion on [2145-9-1]. In [Last Name (un) 5153] fertilization pregnancy was donor egg (donor a 26-year-old). Pregnancy remarkable for the following: 1. Dichorionic-diamniotic twins with concordant growth. 2. Cervical shortening diagnosed at 21 weeks (treated with bed rest at home and then admitted on [9-14]); betamethasone complete on [9-17]. 3. Premature labor (treated with terbutaline and then with magnesium sulfate on [9-18]). 4. Question rupture of membranes on [9-18] of twin I. 5. Noted on the day of delivery to have advanced cervical dilatation with breech/breech presentation. ANTEPARTUM COURSE: Antibiotics given. Cesarean section under spinal anesthesia. This twin was a breech extraction with initial cry and activity. Given blow-by oxygen suction and developed marked contractions and was therefore intubated with a 2.5 endotracheal tube in the delivery room. Apgar scores were 7 at one minute of age and 8 at five minutes of age. The infant was transported to the Newborn Intensive Care Unit for further care. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed a premature male who was orally intubated. He was active. The infant's temperature was 97.8 degrees Fahrenheit, heart rate was 166, respiratory rate was 62, blood pressure was 45/24 with a mean of 32, and his oxygen saturation was 98% on 50% O2. Birth weight was 970 grams. Discharge weight was 3210 grams (75th percentile). Admission length was 37 cm (75th percentile). Discharge length was 49.5 (75th percentile). Admission head circumference was 24 cm (25th percentile). Discharge head circumference was 34 cm (75th percentile). On admission, anterior fontanel was soft and flat. Nondysmorphic. Intact palate. Fair aeration with crackles. No murmurs. The abdomen was soft. There was a 3-vessel cord. No hepatosplenomegaly. Pulses were 2+. Hypospadias. Testes in canal. Patent anus. No sacral dimple. No hip click. There was bruising on folds of feet. Normal tone and activity for age. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY ISSUES: As stated above, the infant was intubated in the Delivery Room. Ultimately received three doses of surfactant. Initially started on the conventional ventilator and was then transitioned to the high-frequency ventilator and then back to conventional ventilator over the first few days of life to establish adequate respiratory support. The infant did require three doses of hydrocortisone for lability. Ultimately transitioned to continuous positive airway pressure by day of life seven. There were several attempts over the next few weeks to transition off continuous positive airway pressure and finally achieved nasal cannula oxygen by day of life thirty-three. There were then several attempts to transition to room air and also achieved this goal by day of life fifty-eight. Currently, the infant is on room air with mild retractions intermittently. His baseline respiratory rate was 30s to 50s with no further respiratory issues. The infant was loaded with caffeine citrate on day of life four while weaning the ventilatory rate. The infant remained on caffeine citrate maintenance dose until day of life forty-five when it was discontinued. Since then, he has had no further major issues of apnea and bradycardia. The infant has had no apnea and bradycardia for greater than two weeks at the time of discharge. 2. CARDIOVASCULAR ISSUES: The infant initially had two normal saline boluses during transition and then received a dopamine drip up to 40 mcg/kg per minute. The infant responded to his hydrocortisone three doses and then was cardiovascularly stable. On day of life two, the infant was thought to have a presumed patent ductus arteriosus based on symptoms. The infant received one course of indomethacin with no further concerns for a patent ductus arteriosus. At the time of discharge, the infant was cardiovascularly stable with no murmurs. His baseline systolic blood pressures are in the 70s to 80s with diastolic blood pressures in the 30s to 40s and means in the 50s to 60s. 3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: Birth weight and discharge weight as stated above. Initially, the infant had an umbilical artery catheter and umbilical venous catheter. These remained in place until day of life six when a peripherally inserted central catheter line was placed for nutritional support. The infant initially was started on parenteral nutrition, and on day of life nine had enteral feedings started. The infant achieved full feeds by day of life sixteen and had caloric density increased to 30 calories with ProMod. He received some breast milk and some premature Enfamil formula up to 140 cc to 150 cc/kg per day. The infant is currently feeding breast milk 24, Enfamil 24, all by mouth. This is achieved by adding Enfamil powder 4 calories per ounce to breast milk or concentrating Enfamil to 24 calories per ounce. The infant is receiving supplemental ferrous sulfate 25 mg/cc, 0.25 cc by mouth once per day, which equals 2 mg/kg per day. The infant's last electrolytes on [11-3] revealed sodium was 137, potassium was 4.4, chloride was 104, bicarbonate was 28, blood urea nitrogen was 13, and his creatinine was 0.3. Calcium was 10.3. Alkaline phosphatase was 71. Phosphorous was 5.9. 4. GENITOURINARY ISSUES: Of note, on physical examination, the infant had a hypospadias. No circumcision has been done. The family will be referred to Urology at the [Hospital3 18242] for followup after discharge. 5. GASTROINTESTINAL ISSUES: The infant's peak bilirubin was 5.9/0.4. He responded nicely to double phototherapy. Rebound bilirubin on [10-19] was 3.6/0.3/3.3. 6. HEMATOLOGIC ISSUES: The infant received two blood transfusions during this admission; the last one being on [11-3] for a hematocrit of 24. The infant has not had a repeat hematocrit. 7. INFECTIOUS DISEASE ISSUES: The infant initially had a blood culture and complete blood count sent on admission because of prematurity which revealed a white blood cell count of 5.6 (with 28 polys and 0 bands). Platelets were 173,000. Hematocrit was 49.1. There were 46 nucleated red blood cells. The infant was started on ampicillin and gentamicin. Levels of gentamicin were 1.2 and 5.5. A repeat complete blood count on day of life two revealed a white blood cell count of 8.9 (with 70 polys, 0 bands). The platelet count was 153,000. Hematocrit was 40.5. On day of life four, another repeat complete blood count was done which revealed a white blood cell count of 10.1 (with 34 polys, 8 bands, 31 lymphocytes, and 15 monocytes). Platelet count was 164,000. At that time, a lumbar puncture was done to determine length of antibiotic treatment because of severity of illness. There was concern for infection. The infant had 1156 red blood cells in his lumbar puncture, 3 white blood cells, 10 polys, 25 lymphocytes, 53 monocytes, protein of 142, and a glucose of 42. The infant received a total of a 7-day course of antibiotics, and they were then discontinued. The infant has had no further issues with infection. 8. NEUROLOGIC ISSUES: The infant has had serial head ultrasounds that have been within normal limits with the last one being on [11-3]. At the time of this dictation, one more will be done on [12-24]. There has been no evidence of intraventricular hemorrhage and no paraventricular leukomalacia. The infant in neurologically appropriate for gestational age. 9. SENSORY ISSUES: Audiology screening has been performed with automated auditory brain stem responses with results passed. 10. OPHTHALMOLOGIC ISSUES: Serial eye examinations have been done with the last one being on [12-12]. This showed immature zone 3 with plans to follow up in three weeks (that would be week of [1-2]). Followup will be with Dr.[Name (NI) 50312] [Name (STitle) 50313] at [Location (un) ] Eye Associates (telephone number [Telephone/Fax (1) 50314]). 11. PSYCHOSOCIAL ISSUES: The parents have been involved. Mother had a lengthy hospitalization after delivery for infection. The mother has recovered nicely, and the parents visit daily. They look forward to transitioning home with their babies. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to home with parents. PRIMARY PEDIATRICIAN: Primary pediatrician is Dr. [First Name8 (NamePattern2) 50315] [Last Name (NamePattern1) 10132] (telephone number [Telephone/Fax (1) 50316]). CARE RECOMMENDATIONS: 1. Feeds: Continue ad lib feedings of breast milk or Enfamil 24 calories per ounce. 2. Medications: Continue ferrous sulfate (as stated above). 3. Car seat position screening not done at the time of this dictation. 4. State newborn screen status revealed serial screens have been sent; the last one being within range on [2145-11-19]. IMMUNIZATIONS RECEIVED: 1. Hepatitis B vaccine on [11-20] with follow-up vaccine on [12-24]. 2. DTaP on [12-3]. 3. Human immunodeficiency virus on [12-3]. 4. ITV on [12-2]. 5. Pneumococcal polyvalent conjugant vaccine on [12-2]. 6. Synagis on [12-24]. IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial virus prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks gestation. (2) Born between 32 and 35 weeks gestation with 2/3 of the following: Plans for day care during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities, or with school-aged siblings; or (3) With chronic lung disease. Influenza immunization should be considered annually in the Fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other care givers should be considered for immunization against influenza to protect the infant. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. Appointment with primary pediatric provider [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 50315] [Last Name (NamePattern1) 10132] (telephone number [Telephone/Fax (1) 50316]). 2. Early intervention [Hospital1 ] Area Early Intervention (telephone number [Telephone/Fax (1) 43005]). 3. Visiting nurse care group [Hospital6 407] (telephone number [Telephone/Fax (1) 37503]). 4. Dr. [Last Name (STitle) ] of Ophthalmology, [Location (un) ] Eye Associates (telephone number [Telephone/Fax (1) 50314]). DISCHARGE DIAGNOSES: 1. Former 26 and [3-5] week premature male (twin II). 2. Status post respiratory distress syndrome. 3. Status post presumed sepsis. 4. Hypospadias. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 35940], M.D. [MD Number(1) 35941] Dictated By:[Last Name (NamePattern1) 36251] MEDQUIST36 D: [2145-12-23] 18:34 T: [2145-12-23] 19:04 JOB#: [Job Number 50317] ICD9 Codes: 7742, 769, 4589, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6404 }	Medical Text: Admission Date: [2134-7-15] Discharge Date: [2134-7-31] Date of Birth: [2059-4-27] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1505] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: endotracheal intubation at outside hospital ER AVR(#19 CE perimount Magna) [7-22] History of Present Illness: 75 yo F hx DM II, presented to OSH ([Hospital1 46]) by EMS (7:30PM) for worsening dyspnea. Pt had been treated for pneumonia with resp sx's x2 weeks. On arrival, the patient was noted to have a LBBB. CE's significant for Trop T 1.91, CK 106. She was initially afebrile at 98.5, HR 100s, BP 90/, O2 sat 90% on RA. The patient was intubated for respiratory distress, ABG post 7.28/48/210, started on nitro drip, given IV lasix 40mg, lopressor, IV lovenox 90mg, ASA 324mg, plavix, and transferred to [Hospital1 18] for further care. On arrival, pt had low grade temp 100.2, HR 105, BP 94/64. Evaluated by cardiology fellow, felt that pt has LAFB with rate related QRS prolongation, cardiac enzymes flat. Given 80mg lasix IV, plavix 600mg, admitted to CCU for further care. Past Medical History: DM2 HTN PNA Giant Cell Arteritis Rt Hip replacement Rt knee replacement CCY Rt carpal tunnel release Social History: Lives alone. Denies tobacco and ETOH Family History: noncontributory Physical Exam: Admission VS: T 99.1 BP 113/74 HR 103 RR 18 O2 100% on PS 8/5, 50% FiO2 Gen: elderly female, intubated, sedated, well appearing, NAD HEENT: NCAT. Sclera anicteric. PERRL. Neck: thick neck, unable to see JVP. 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: Resp were unlabored, no accessory muscle use. bibasilar crackles with good air entry b/l, no wheezes. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. Pulses:Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2134-7-15] 08:23PM TYPE-ART PO2-113* PCO2-40 PH-7.44 TOTAL CO2-28 BASE XS-3 [2134-7-15] 08:19PM HGB-11.8* calcHCT-35 O2 SAT-70 [2134-7-15] 08:03PM PT-13.0 PTT-29.3 INR(PT)-1.1 [2134-7-15] 07:50PM GLUCOSE-209* UREA N-17 CREAT-0.7 SODIUM-139 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 [2134-7-15] 07:50PM CK(CPK)-1158* [2134-7-15] 07:50PM WBC-13.7* RBC-4.27 HGB-13.6 HCT-40.2 MCV-94 MCH-31.9 MCHC-33.9 RDW-13.2 [2134-7-15] 05:00AM GLUCOSE-214* UREA N-20 CREAT-0.9 SODIUM-137 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13 [2134-7-14] 11:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2134-7-14] 10:50PM ALT(SGPT)-31 AST(SGOT)-46* LD(LDH)-354* CK(CPK)-121 ALK PHOS-85 TOT BILI-0.6 [2134-7-14] 10:50PM ALBUMIN-3.9 CALCIUM-8.7 PHOSPHATE-5.6* MAGNESIUM-2.5 [2134-7-29] 07:20AM BLOOD WBC-11.7* RBC-3.63* Hgb-11.1* Hct-33.5* MCV-92 MCH-30.6 MCHC-33.1 RDW-14.3 Plt Ct-286 [2134-7-29] 07:20AM BLOOD Plt Ct-286 [2134-7-29] 07:20AM BLOOD Glucose-106* UreaN-16 Creat-0.7 Na-141 K-4.6 Cl-101 HCO3-33* AnGap-12 RADIOLOGY Final Report CHEST (PA & LAT) [2134-7-28] 8:37 AM CHEST (PA & LAT) Reason: evaluate effusion [Hospital 93] MEDICAL CONDITION: 75 year old woman s/p VR. REASON FOR THIS EXAMINATION: evaluate effusion STUDY: PA and lateral chest [2134-7-28]. HISTORY: 75-year-old woman status post MVR. Patient with pleural effusion. FINDINGS: The Swan-Ganz catheter has been removed. Median sternotomy wires are seen. There is again seen a left retrocardiac opacity and a left-sided pleural effusion. There is some atelectasis at the right base and a small right-sided pleural effusion. There are no signs for overt pulmonary edema. Overall, the findings are stable. Cardiology Report ECHO Study Date of [2134-7-22] PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for AVR, ?MVR Status: Inpatient Date/Time: [2134-7-22] at 13:28 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW4-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) ] R. [Doctor Last Name ] MEASUREMENTS: Left Atrium - Long Axis Dimension: 5.8 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.7 cm (nl <= 5.2 cm) Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 20% (nl >=55%) Aorta - Ascending: 2.8 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: 2.1 cm (nl <= 2.5 cm) Aortic Valve - Peak Gradient: 64 mm Hg Aortic Valve - LVOT Diam: 1.9 cm Aortic Valve - Valve Area: 0.4 cm2 (nl >= 3.0 cm2) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Severely depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Trace AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Moderate to severe (3+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Emergency study. Results were Conclusions: PRE CPB The pre-bypass study was limited by the fact that the patient became unstable and was quickly and urgently placed on bypass. The left atrium is moderately dilated. The left atrium is elongated. 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 severely, globally depressed. There maybe worse function of the septum. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The posterior leafllet of the mitral valve is moderately to severely thickened and moderately immobilized. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Post-CPB The patient is receiving norepinephrine, epinephrine, and milrinone by infusion. There is normal right ventricular systolic function. Left ventricular systolic function is markedly improved. The ejection fraction is in the range of 40%. Poor acoustic windows prevent the exclusion of a regional wall motion abnormality. There is a bioprosthesis in the aortic position. It appears well seated. The leaflets are only very poorly seen and their function can not be commented on. The effective orifice area (EOA) is about 1.2 cm2 and the maximum gradient is about 38 mm Hg with a cardiac output near 6 l/m. These numbers indicate an EOA slightly less than expected. There is very trace valvular AI. A perivalvular jet is not obvious but poor windows prevent complete exclusion. The thoracic aorta appears intacy. Electronically signed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD on [2134-7-22] 17:11. [Location (un) ] PHYSICIAN: ([Numeric Identifier 73141]) RADIOLOGY Final Report CAROTID SERIES COMPLETE [2134-7-19] 9:09 AM CAROTID SERIES COMPLETE Reason: Pre-op Eval for aortic valve repair [Hospital 93] MEDICAL CONDITION: 75 year old woman with Aortic Stenosis REASON FOR THIS EXAMINATION: Pre-op Eval for aortic valve repair Carotid duplex series in a 75-year-old woman with aortic stenosis. Preop evaluation of the carotids. FINDINGS: Duplex evaluation was performed on the bilateral carotid arteries. On the right, peak systolic velocities in cm/sec are as follows: 48/14 in the proximal ICA, 51/15 in the mid ICA and 66/22 in the distal ICA, 51/15 in the CCA and 57 in the ECA. The ICA/CCA ratio is 1.29 and this is consistent with a widely patent right ICA. On the left, the peak systolic velocities are as follows: 52/14 in the proximal ICA, 35/10 in the mid ICA and 48/12 in the distal ICA. There is a velocity of 66/18 in the CCA and 59 in the ECA. The ICA/CCA ratio is 0.78 and this is consistent with a widely patent left ICA. There is antegrade flow in both vertebral arteries. IMPRESSION: There is a widely patent right ICA and a widely patent left ICA with antegrade flow in both vertebral arteries. This is a normal carotid duplex exam. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: TUE [2134-7-20] 12:02 PM Brief Hospital Course: Mr [Known lastname ] is a 75yoW who presented to the ER at an outside hospital complaining of increasing dyspnea after having been tx for 2 weeks for pneumonia. In the ER she was intubated and found at that time to have EKG chaanges(new LBBB) andelevated TropT(1.91). She was then transferred to [Hospital1 18] for further evaluation and care. At [Hospital1 ] patient had cardiac cath that showed no sig CAD, sevAS [Initials (NamePattern4) ] [Last Name (NamePattern4) 109] 0.38cm2. A f/u echo showed sev AS and mod MR w/EF 20-25%. The patient extubated after studies completed. She was seen and accepted by CT surgery for AVR. On [7-22] she had an AVR(#19 CE perimount pericardial), please see OR note for full details. She tolerated the operation well and was transferred to the cardiac surgery ICU in stable condition on Milrinone Epinepherine and Propofol infusions. During that evening her epinephrine infusion was weaned to off. On POD 1 she was sucessfully extubated and her Milrinone infusion was weaned. On POD2 she experienced multipple episode of atrial fibrillation and was started on Beta blockade and Amiodarone and converted to sinus rhythm. On POD3 the Milrinone wean was completed and her PA catheter was removed. On POD5 she was transferred to the step down floor. Over the next several days she made slow progress in her activity and strenghth recovery and it was decided she would benefit from a short stay in a rehabilitation center. On post operative day seven she was discharged to [Location (un) 169] Rehab of [Location (un) 3320]. Medications on Admission: Glyburide 5mg [Hospital1 ] Prednisone-stopped at latest on [6-28] but PCP is unsure Percocet PRN for pain Actonel CaCarbonate neurontin 300mg [Hospital1 ] Keflex - 10 days . Allx Sulfa Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:14 Tablet(s) Refills:0 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg QD x 7days then 200mg QD. Disp:35 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Location (un) 169] of [Location (un) 3320] Discharge Diagnosis: s/p AVR(#19 CE perimount Magna)[7-22] PMH:DM2,HTN,PNA,Giant cell arteritis,Rt hip replacement,Rt knee replacement, CCY,Rt Carpal tunnel release Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medication as prescribed. Call for any fever, redness or drainage from wounds. Followup Instructions: [Hospital 409] clinic in 2 weeks Dr [Last Name (STitle) ] in 4 weeks PCP/Cardiologist in [3-28] weeks Completed by:[2134-7-29] ICD9 Codes: 486, 5180, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6405 }	Medical Text: Admission Date: [2108-6-7] Discharge Date: [2108-6-12] Date of Birth: [2047-11-25] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 922] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2108-6-7] 1. Aortic valve replacement with a 21-mm On-X mechanical prosthesis, serial number [Serial Number 104362], reference ONXACE. 2. Coronary artery bypass grafting times 1 with a reverse saphenous vein graft from the aorta to the posterior descending coronary artery. History of Present Illness: This is a 60 year old man with significant dyspnea on exertion and a recent diagnosis of severe aortic stenosis who is now preop for AVR/CABG [2108-6-6]. In the interim he underwent a catheterization which revealed an occluded right coronary artery. He continues to have dyspnea on exertion and occassionally experiences chest discomfort. He denies orthopnea, paroxysmal nocturnal dyspnea or syncope. He admits to being quite anxious iin coping with his upcoming surgery. Past Medical History: Aortic Stenosis Hypertension Hyperlipidemia Gastric dyspepsia Osteoarthritis ? Cervical radiculopathy Colon polyps s/p resection Resection of skin cancers Possible sleep apnea Glucose intolerance, controlled with diet Social History: Father died of cerebral aneurysm, Mother died from complications of DM Race: Caucasian Last Dental Exam: last week, dental clearance is in csurg office Lives with: Wife Occupation: works in a factory Tobacco:Former smoker quit 5-10 years ago, history of 1ppd since the age of 20 ETOH:denies Family History: Father died of cerebral aneurysm, Mother died from complications of DM Physical Exam: Pulse:72 Resp:20 O2 sat:20 B/P Right:135/75 Left: 126/61 Height:5'5" Weight:251 lbs General: WDWN in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] NlS1-S2, Murmur III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ PT [Name (NI) 167]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right: - Left: - Pertinent Results: [2108-6-7] Echo: Pre CPB: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The number of aortic valve leaflets cannot be determined due to large calcification. It is probably bicuspid. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate to severe (3+) aortic regurgitation is seen. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). Dr. [Last Name (STitle) 914] was notified in person of the results. This study includes epi-aortic imaging performed by the surgeon when selecting cross clamp and cannulation sites. Postbypass: Normal RV systolic function. LVEF 55%. Intact thoracic aorta. Metallic prosthesis seen well placed in the aortic position. It is functioning well with a residual mean gradient of 15mm of Hg. There is no periprosthetic leak. Mild MR. . [2108-6-12] WBC-12.6* [2108-6-11] WBC-11.9* RBC-3.70* Hgb-11.1* Hct-32.2* MCV-87 MCH-29.9 MCHC-34.4 RDW-13.6 Plt Ct-274 [2108-6-10] WBC-13.5* RBC-3.56* Hgb-10.5* Hct-31.8* MCV-89 MCH-29.5 MCHC-33.0 RDW-13.7 Plt Ct-227 [2108-6-9] WBC-17.7* RBC-3.83* Hgb-11.2* Hct-32.9* MCV-86 MCH-29.2 MCHC-34.1 RDW-13.6 Plt Ct-202 [2108-6-8] WBC-17.2* RBC-4.25* Hgb-12.1* Hct-37.5* MCV-88 MCH-28.4 MCHC-32.2 RDW-14.1 Plt Ct-291 . [2108-6-12] PT-24.1* INR(PT)-2.3* [2108-6-11] PT-19.6* PTT-27.3 INR(PT)-1.8* [2108-6-10] PT-16.0* PTT-30.4 INR(PT)-1.4* [2108-6-9] PT-15.9* PTT-24.0 INR(PT)-1.4* . [2108-6-12] Glucose-118* UreaN-20 Creat-0.8 Na-138 K-4.0 Cl-102 HCO3-29 [2108-6-11] Glucose-120* UreaN-23* Creat-0.6 Na-138 K-4.1 Cl-97 HCO3-33* [2108-6-10] Glucose-127* UreaN-24* Creat-0.7 Na-136 K-4.1 Cl-98 HCO3-34* [2108-6-9] Glucose-128* UreaN-24* Creat-0.7 Na-139 K-4.2 Cl-101 [2108-6-8] Glucose-144* UreaN-20 Creat-0.7 Na-139 K-4.6 Cl-105 HCO3-29 [2108-6-12] Calcium-9.0 Phos-4.1 Mg-2.2 Brief Hospital Course: Mr. [Known lastname 83237] was a same day admit on [2108-6-7] after undergoing pre-operative work-up as an outpatient. On this day he was brought to the operating room where he underwent an aortic valve replacement and coronary artery bypass grafting surgery. 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 without incident. On post-operative day one the patient was hemodynamically stable. His chest tubes were discontinued without complication. He was transferred to [Hospital Ward Name 121] 6 on post-op day two for further monitoring. He was started on coumadin therapy on day two for his mechanical aortic valve. INR was monitored daily and Warfarin was dosed for a goal INR between 2.5 - 3.0. On postoperative day three, epicardial pacing wires were removed without complication. He remained in a normal sinus rhythm. His renal function remained stable. Over several days, he continued to make clinical improvments with diuresis and was cleared for discharge to home on postoperative day five. Prior to discharge, arrangements were made and confirmed with Dr. [Last Name (STitle) 10740] who will monitor prothrombin time/INR as an outpatient. Medications on Admission: FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day MUPIROCIN CALCIUM [BACTROBAN NASAL] - 2 % Ointment - 0.5 (One half) tube each nare two times daily SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC CHLORHEXIDINE GLUCONATE - 2 % Liquid - wash from chin to toes daily daily for six days before surgery Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 7. warfarin 5 mg Tablet Sig: goal INR 2.5-3 Tablets PO once a day: dose to be adjusted based on INR - further dosing by Dr [Last Name (STitle) 10740] - first draw [6-13] . Disp:60 Tablet(s) Refills:2 8. warfarin 2 mg Tablet Sig: goal INR 2.5-3 Tablets PO once a day: dose to be adjusted based on INR - further dosing by Dr [Last Name (STitle) 10740] - first draw [6-13] . Disp:60 Tablet(s) Refills:2 9. coumadin/warfarin You are being discharged with two different doses of coumadin - 5 mg and 2 mg tablets so that your dose of coumadin can be adjusted based on INR results 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks: please take twice a day for 7 days then decrease to daily - to be reevaluate at wound check appointment . Disp:21 Tablet(s) Refills:0 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Tablet(s) 13. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours) for 2 weeks: take twice a day for 7 days with lasix and then decrease to once a day with lasix . Disp:21 Tablet Extended Release(s) Refills:0 14. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve replacement Coronary artery disease s/p Coronary artery bypass graft x 1 Diabetes mellitus type 2 Past medical history: Hypertension Hyperlipidemia Gastric dyspepsia Osteoarthritis Colon polyps s/p resection Resection of skin cancers Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with dilaudid and tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema +1 bilateral Lower extremity 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 monitor Blood glucose twice a day - you have been started on metformin for diabetes management as recommended by [Last Name (un) ] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication mechanical AVR Goal INR 2.5-3.0 First draw [6-13] Results to Dr [Last Name (STitle) 10740] phone [Telephone/Fax (1) 40144] fax [Telephone/Fax (1) 104363] Please do labs draws NO Fingerstick INR checks Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) 914] [Telephone/Fax (1) 170] Date/Time:[2108-7-3] 2:00 Cardiologist: Dr [Last Name (STitle) ] [Telephone/Fax (1) 62] Date/Time:[2108-8-10] 9:00 Wound check at cardiac surgery office [Telephone/Fax (1) 170] [6-20] at 10am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 10740] in [5-8] weeks [Telephone/Fax (1) 40144] Please contact [Name (NI) ] diabetes center for diabetes education classes Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication mechanical AVR Goal INR 2.5-3.0 First draw [6-13] Results to Dr [Last Name (STitle) 10740] phone [Telephone/Fax (1) 40144] fax [Telephone/Fax (1) 104363] Please do labs draws NO Fingerstick INR checks Completed by:[2108-6-12] ICD9 Codes: 4241, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6406 }	Medical Text: Admission Date: [2188-8-30] Discharge Date: [2188-9-4] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 2080] Chief Complaint: SOB, fatigue Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ]M with hx of polycythemia [Doctor First Name ], HTN, HL who p/w sob and fatigue. The pt states that he has been relatively healthy until ~1-2 months ago when he was admitted to NWH for weakness, malaise, for an unclear diagnosis. He states since then he has been placed on several different medications with varying diagnoses but doesn't feel like he's gotten accurate, consistent care. For the last few wks the pt has been increasingly sob, with increasing weakness over the past several days, anorexia for 3 days and nausea. Of note, the pt's son states that the pt takes his medications inconsistently. He puts them in his pocket and takes them throughout the day. Per the pt he has not taken his meds in several days, except for the levoxyl. Also of note, the pt's family says they've been concerned he's been depressed of late, not having the same exuberance or interest in taking care of himself as before. . Today he was brought into the hospital by family and found to be satting in the 80s on RA. He was in afib with a HR 129, 122/69 30 91%4L O2. He had a WBC 29.2, HCT 50, lactate 2.2, cr 1.7. He was given 3L NS. Bcx were sent. A cxr demonstrated multifocal pna and he was started on vanc, cefepime, levaquin. . On the floor the pt was 98.3 130 120/70 34 84%5L. He was comfortable, complained of being thirsty, and weak. He was continued on broad spectrum antibiotics, given PO fluids, and another 1L NS. The pt was also found to have LLE swelling for which he had LENIs that were negative. . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies 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: Polycythemia [Doctor First Name ] HTN HL ?AF ?CHF L knee injury 3y ago BPH on finasteride x6-7mo Social History: Never smoked, drank, illicits. Worked as a general practicioner and in rehab medicine until [2160] in NJ/NY. Moved to [Location (un) 86] bc wife had [Name2 (NI) ]. Cared for her for 10y until she passed a year ago. Stationary bike 1h/day. Exercise class 4x/wk. Family History: non-contributory Physical Exam: Physical Exam on Arrival to the MICU General: Thin elderly man, A&Ox3, tachypneic HEENT: conjunctiva red, dry mm Neck: supple, no LAD Lungs: RLL decreased breath sounds, +egophany CV: afib, tachycardic 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: Labs: [2188-8-30] 11:45AM BLOOD WBC-29.2* RBC-7.03* Hgb-14.8 Hct-50.1 MCV-71* MCH-21.1* MCHC-29.6* RDW-19.3* Plt Ct-879* [2188-8-30] 11:45AM BLOOD Neuts-92* Bands-0 Lymphs-2* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2188-8-30] 11:45AM BLOOD Glucose-111* UreaN-38* Creat-1.7* Na-134 K-5.0 Cl-99 HCO3-21* AnGap-19 [2188-8-30] 11:45AM BLOOD ALT-21 AST-34 CK(CPK)-75 AlkPhos-140* TotBili-1.5 [2188-8-30] 11:45AM BLOOD Lipase-36 [2188-8-30] 11:45AM BLOOD CK-MB-4 [2188-8-30] 11:45AM BLOOD cTropnT-0.08* [2188-8-31] 03:19AM BLOOD proBNP-[Numeric Identifier 8443]* [2188-8-30] 11:45AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1 [2188-8-30] 11:51AM BLOOD Lactate-2.2* Microbiology: - urine legionella [2188-8-30] negative - blood cultures x2 [2188-8-30] - PENDING TTE: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is mildly dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a very small pericardial effusion. CXR: [8-31] IMPRESSION: Bibasilar, right greater than left, pulmonary opacities could reflect aspiration or pneumonia in the appropriate clinical setting. Small bilateral effusions. LENIs: IMPRESSION: No DVT in both lower extremities. Brief Hospital Course: [Age over 90 ]M with hx of polycythemia [Doctor First Name ], HTN, HL who p/w sob and fatigue with imaging concerning for multifocal PNA. . # Multifocal pna: The pt presented with complaints of sob, fatigue, found to be hypoxic, with cxr c/w multifocal pna and wbc 29. Pt was started on vanc/cefepime/levaquin as concern for hcap given recent hospitalization. Given 3L ns in the ED for lactate 2.2. Given hypoxia, tachycardia, tachypnea in setting of polycythemia [Doctor First Name ], concern re: dvt, however lenis neg. He was started on vancomycin, cefepime, and levofloxacin. He was also given nebulizer. His respiratory status remained tenuous requiring high flow and NRB, but he requested to be on morphine and ativan for comfort in the MICU as well. Family meeting was held and there was plan to transition to CMO. He was transferred to floor, pain controlled and he expired on [2188-9-4]. . # [Last Name (un) ]: Pt presented with cr 1.7 unclear baseline. Initially thought to be pre-renal as he had very poor po intake x 3 days prior to presentation. However, even after 4L of IVF, creatinine remained stable. It is possible that this could have been his baseline. . # Afib with RVR: pt presented in afib with rvr 120s-140s. Pt states he may have had afib in the past, and he is on a high dose of beta blockade. RVR likely [12-26] not taking meds for several days compounded by hypovolemia and infection. However, despite multiple agents- lopressor, diltiazem, and digoxin- patient continued to be in RVR. Because of AF with RVR, he also had one episode of pulmonary flash which improved with additional beta blockade and diuresis. However, HR was unable to be optimally controlled. He was continued on ASA. CKMB was flat. Family meeting was held to discuss next plan as there was plan to transition to comfort only. . # Polycythemia [Doctor First Name ]: Patient with hx of pv treated with phlebotomy for HCT >45. HCT currently 50 on admission. Trended during admission . # HL: Held lovastatin while acutely ill . # BPH: continue finasteride . # Code: DNR/DNI # Disposition: ICU pending clinical improvement . Transitions of care: patient expired on [2188-9-4] in the context of being CMO. Medications on Admission: zolpidem 10mg daily lasix 20mg MWF Hydroxyurea 500mg [11-25] capsules as directed Metoprolol succinate 200mg daily Finasteride 5mg daily Levoxyl 100meq daily Lovastatin 20mg daily Amlodipine 5mg [Hospital1 ]-TID Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Discharge Condition: deceased Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2188-9-5] ICD9 Codes: 0389, 486, 5849, 4589, 4280, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6407 }	Medical Text: Admission Date: [2169-3-23] Discharge Date: [2169-3-27] Date of Birth: [2104-8-23] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Asymptomatic patient with abnormal EKG and positive ETT Major Surgical or Invasive Procedure: CABGx3, LIMA->LAD, SVG->Ramus, SVG->OM History of Present Illness: 65yo M with multiple cardiac risk factors with OA who was undergoing preoperative work up for a left hip replacement and was found to have an abnormal EKG and ETT. His subsequent cardiac cath showed 3 vessel disease. Past Medical History: HTN, hypercholesteremia, hypothyroidism, OA, BPH, nephrolithiasis Social History: Tobacco:40pack year history, quit [2165]. Retired firefighter. Occasional ETOH. Family History: Brother with CAD and CABG in his forties Physical Exam: in bed NAD Neuro AA&Ox3, nonfocal Chest CTAB resp unlab median sternotomy stable, c/d/i no d/c, RRR no m/r/g chest tubes and epicardial wires removed. Abd S/NT/ND/BS+ EXT warm with trace edema, LLE EVH c/d/i ecchymosis present Pertinent Results: [2169-3-27] 07:15AM BLOOD WBC-9.7 RBC-3.21* Hgb-10.3* Hct-29.5* MCV-92 MCH-31.9 MCHC-34.8 RDW-14.6 Plt Ct-314# [2169-3-27] 07:15AM BLOOD Plt Ct-314# [2169-3-27] 07:15AM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-139 K-4.0 Cl-103 HCO3-26 AnGap-14 [2169-3-27] 07:15AM BLOOD Calcium-8.3* Mg-2.1 RADIOLOGY Final Report CHEST (PA & LAT) [2169-3-25] 12:17 PM CHEST (PA & LAT) Reason: chest tubes removed [Hospital 93] MEDICAL CONDITION: 64 year old man with CAD s/p CABG. Please pager ordering PA with abnormalities. REASON FOR THIS EXAMINATION: chest tubes removed This was a chest 2 views (incorrectly stated as single view in dictation). the lateral film shows small bilateral pleural effusions. CHEST, SINGLE VIEW: HISTORY: Status post CABG post-chest tube removal. REFERENCE EXAMINATION: [3-23]. FINDINGS: There has been interval removal of the chest tubes and the mediastinal drains and the endotracheal tube. The right IJ line has been somewhat advanced and the tip is now in the right atrium. There is bibasilar subsegmental atelectasis with some dense retrocardiac opacity that could represent some consolidation as well as volume loss. There is no pneumothorax. DR. [First Name (STitle) ] [Doctor Last Name ] Approved: SUN [2169-3-26] 7:56 AM Cardiology Report ECHO Study Date of [2169-3-23] PATIENT/TEST INFORMATION: Indication: Eval LV function, eval murmur/AV Status: Inpatient Date/Time: [2169-3-23] at 09:48 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW589-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) ] R. [Doctor Last Name ] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) Aortic Valve - Peak Gradient: 21 mm Hg Aortic Valve - Mean Gradient: 11 mm Hg Aortic Valve - LVOT Diam: 2.4 cm Aortic Valve - Valve Area: 1.6 cm2 (nl >= 3.0 cm2) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal LV wall thickness. Overall normal LVEF (>55%). LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. Abnormal aortic valve. Mild AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Systolic motion of the mitral chordae (normal variant). No resting LVOT gradient. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. Conclusions: PRE BYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. The aortic valve is abnormal with fusion of the left and non-coronary cusp commissures. [Location (un) 109] by Continuity Equation is 1.6 to 1.7 cm2 and 1.8cm2 by planimetry. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). Chordal [Male First Name (un) ] is present. POST BYPASS Biventricular systolic function remains preserved. Study otherwise unchanged from pre-bypass. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD on [2169-3-23] 11:26. [Location (un) ] PHYSICIAN: Brief Hospital Course: Mr. [Known lastname 4643] was admitted to the [Hospital1 18] on [2169-3-23] for further management of his coronary artery disease. His catheterization at [Hospital1 18] revealed significant 3 vessel disease. Please see catheterization report for details. Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. He was worked-up in the usual preoperative manner. On [2169-3-23] he successfully underwent CABGx3 (LIMA->LAD, SVG->OM, SVG->Ramus). Afterward he was transferred to the Cardiac surgery recovery unit in stable condition and awakened neurologically intake. He was weaned from ventilator support, extubated, and pressors were weaned. On POD 2 he was then transferred to the Stepdown unit for further recovery. His chest tubes were removed without complication. He was gently diuresed to his preoperative weight, beta blockade and aspirin therapy were resumed, and physical therapy service was consulted to assist with his postoperative strength and mobility. Electrolytes were repleted as needed. On POD 3 his epicardial pacing wires were removed without complication, he continued to improve his ability to ambulate including climbing stairs without respiratory distress or chest pain. On POD 4 Mr. [Known lastname 4643] was 4kg above his preop weight with good exercise tolerance, no SOB, or Chest pain. His blood pressure was stable. His sternotomy and leg incision were clean, dry, and intact without evidence of infection. He was discharged home on POD 4 with services in good condition, cardiac diet, sternal precautions, and instructed to follow up with his PCP/cardiologist in [1-23] weeks. He will follow up with Dr. [Last Name (STitle) ] in four weeks. Medications on Admission: ASA Coreg Lipitor Levoxyl Zetia Folic Acid MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s)* Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:50 Tablet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:15 Tablet(s) Refills:2 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: CAD, HTN, hypothyroidism, OA, BPH, nephrolithiasis, hernia repair, T&A removal Discharge Condition: Good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in four weeks, [Telephone/Fax (1) 170] Follow up with Dr. [Last Name (STitle) ] in [1-23] weeks, [Telephone/Fax (1) 53156] Follow up with Dr. [Last Name (STitle) 2912] in [1-23] weeks, [Telephone/Fax (1) 25832] Completed by:[2169-3-27] ICD9 Codes: 2720, 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6408 }	Medical Text: Admission Date: [2180-2-17] Discharge Date: [2180-2-24] Date of Birth: [2113-12-9] Sex: M Service: CARDIOTHORACIC Allergies: Amoxicillin / Hydrochlorothiazide Attending:[First Name3 (LF) 922] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: [2180-2-18] Urgent CABG x4 (LIMA to LAD, SVG to DIAG, SVG to RAMUS, SVG to RCA) [2180-2-17] Left heart catheterization, Coronary angiogram History of Present Illness: This 66 year old male was referred for cardiac catheterization to evaluate exertional chest pain for the last 2-3 weeks and an abnormal stress test. Chest pain has ocurred with brisk walking and shoveling snow. At times the chest pain radiates to lower jaw and skips to left arm. He denies chest pain at rest. He was seen by primary care physician [Last Name (NamePattern4) ] [2180-2-9] and started on Imdur and Zocor with improvement. He underwent elective stress test today that showed ST elevation in inferior leads and V1-V2 accompanied by chest pain. The chest pain resolved with sl. Nitroglycerin. He was referred for catheterization direct from the lab. Past Medical History: Hypertension Glucose intolerance Hypertriglyceridemia Social History: Lives with:wife Occupation:[Name2 (NI) ] lab cordinator Tobacco:quit in [2139], history of smoking for 12 years ETOH:occasioanl Family History: mother died of an abdominal aneurysm at age 64, older brother had CABG in 50's, Brother with [Name (NI) 27349], younger brother with CABG Physical Exam: admission: Pulse:57 Resp:16 O2 sat: 100/RA B/P Right:134/91 Height:5'8" Weight:156 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]; split S2 sound Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] no Edema no varicosities 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: none Pertinent Results: [2180-2-18] Intraop TEE: Pre Bypass: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with mild (1+) mitral regurgitation. Post Bypass: Patient is AV paced, later A paced on phenylepherine infusion. Preserved biventricular function. MR [Name13 (STitle) 66098] mild. Aortic contours intact. Remaining exam unchanged. All findings discussed with surgeons at the time of the exam. . [2180-2-17] WBC-8.0 RBC-3.87* Hgb-11.6* Hct-31.9* Plt Ct-201 [2180-2-18] WBC-20.3* RBC-4.08# Hgb-12.3# Hct-33.2# Plt Ct-157 [2180-2-19] WBC-15.9 RBC-3.70* Hgb-11.0* Hct-30.9* Plt Ct-165 [2180-2-21] WBC-14.0* RBC-3.24* Hgb-9.9* Hct-27.4* Plt Ct-199 [2180-2-17] Glucose-112* UreaN-18 Creat-0.8 Na-139 K-4.1 Cl-103 HCO3-28 [2180-2-19] Glucose-77 UreaN-14 Creat-0.6 Na-137 K-4.0 Cl-107 HCO3-26 AnGap-8 [2180-2-21] Glucose-132* UreaN-28* Creat-0.7 Na-140 K-3.8 Cl-101 HCO3-31 [2180-2-24] UreaN-21* Creat-0.8 Na-140 K-4.2 Cl-99 [2180-2-17] %HbA1c-5.9 eAG-123 [2180-2-24] PT-13.4 INR(PT)-1.1 . [2180-2-20] Chest x-ray: Tiny left apical pneumothorax, which was barely visible on the previous study is unchanged. Bibasilar atelectasis is substantial, stable, and there is a small left pleural effusion unchanged. Cardiomediastinal silhouette has a normal postoperative appearance. Brief Hospital Course: Mr. [Known lastname 66099] was admitted [2180-2-17] after failing his stress test and was taken to the cardiac catheterization lab. This revealed severe severe three vessel coronary artery disease. He was started on intravenous heparin and nitroglycerin. The cardiac surgery service was consulted and he was worked-up in the usual preoperative manner. On [2180-2-18], Mr. [Known lastname 66099] was taken to the Operating Room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit in stable condition. Over the next several hours, he awoke neurologically intact and was extubated without incident. Beta blockade, aspirin and a statin were resumed. On postoperative day two, he was transferred to the step down unit for further recovery. He developed atrial fibrillation which converted back to sinus rhythm without intervention. On [2-22] he developed recurrent atrial fibrillation to 140 bpm with stable hemodynamics. Amiodarone as a 150mg bolus was given with conversion to back to a normal sinus rhythm. The Lopressor dose was increased and he was transitioned to oral Amiodarone. Due to recurrent atrial fibrillation, Warfarin anticoagulation was also initiated on [2-23]. At discharge, he was in a normal sinus rhythm. Target INR 2.0 to 2.5. Over several days, he continued to make clinical improvements and was eventually cleared for discharge to home on POD six. First INR draw will be the day after discharge. Dr. [Last Name (STitle) 30186] and [Hospital1 ] [Hospital3 ] will manage Warfarin as an outpatient. Prior to discharge, all arrangements were made for follow up and a wound check was scheduled for 10:00 on [2180-2-29] on [Hospital Ward Name 121] 6. Medications on Admission: Nadolol 40 mg daily calcium 500 mg daily Zocor 20 mg daily Imdur 30 mg daily Nitroglycerin 0.3 mg sl prn chest pain Aspirin 81mg Daily Discharge Medications: 1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:60 Tablet(s) Refills:0 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:6 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400 mg daily until [2180-3-6]. then take 200 mg daily starting [3-7]. Disp:120 Tablet(s) Refills:1 6. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day for 1 months. Disp:60 Tablet(s) Refills:0 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: Goal INR between 2.0 - 2.5. Disp:60 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Coronary artery disease, s/p coronary artery bypass graft x4 Postop Paroxysmal Atrial Fibrillation Hypertension Hypertriglyceridemia 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 Right,- healing well, no erythema or drainage. Edema none 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) ] ([Telephone/Fax (1) 170]) on [2180-3-16] at 1:30pm Cardiology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2920] [2180-3-14] @ 1150 AM ([Telephone/Fax (1) 2258]) Primary Care Dr. [Last Name (STitle) 30186] on [2180-3-1] @ 920 AM ([Telephone/Fax (1) 3530]) . Labs: PT/INR for Coumadin ?????? indication postop A Fib Goal INR 2.0 - 2.5 First draw day after discharge Results to phone fax Dr. [Last Name (STitle) 30186] @ [Telephone/Fax (1) 3528] . 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:[2180-2-24] ICD9 Codes: 4111, 9971, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6409 }	Medical Text: Admission Date: [2194-1-7] Discharge Date: [2194-2-2] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Altered Mental Status and hypotension Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ]F Russian-speaking h/o refractory nodular sclerosing Hodgkins Lymphoma was brought in by EMS and admitted after her home health care aide noted she was hypotensive to 88/40 and confused. In the ED, T 98.4 (rectal), HR 101, BP 102/53, RR 20, O2Sat 98% on 3L. Incontinant of guaiac-positive stool. Treated with 4 L NS, vanco 1g IV, ceftazadime 1g IV, and flagyl 500mg IV. Received 0.5 mg ativan and 2mg IV morphine for agitation. Pt was admitted to [Hospital Unit Name 153] where she completed a 10-day course of ceftazadime and vancomycin for urosepsis. A 7-day course of metronidazole was also completed for empiric treatment of C. Diff given loose stools in the setting of an elevated WBC count, although all C. Diff assays were negative. Pt was stabilized and was transferred to the floor for further care. At the time of transfer, active issues were poor nutritional status, thrombocytopenia and anemia. On the floor, however, pt experienced an episode of new Afib with RVR to 160s and hypotension to SBP 90-100s, as well as respiratory distress after she received fluid resuscitation. There was also a concern for tachy-brady syndrome because she had pauses up to 4 sec on telemetry; EP curbside, however, felt digoxin was not recommended. Pt was therefore readmitted to the MICU. While in the MICU, she was started on vancomycin and piperacillin-tazobactam as she had (1) sites of possible infection at the erosions under her breasts and on her right hip, as well as question of PNA, (2) rising WBC, reaching a high of nearly 17. MICU course was also marked by (1) hypotension, which responded to gentle NS boluses; (2) low UOP believed to be [2-22] both hypovolemia and a low baseline nitrogenous load/obligate urine output; and (3) recurrent Afib, for which she was transitioned to amiodarone 400mg PO daily, to run for 7 days before titrating downward. Past Medical History: # Nodular sclerosing Hodgkins Lymphoma ([3-/2188]) --Presentation: Inguinal lymphadenopathy, treated with local radiotherapy initially with good results. --CT [8-23]: Progression, treated with Cytoxan, Velban and Prednisone with a good response --Eroding mass at sacrum, treated with radiation therapy --[3-/2191]: Severe hypoxemia, somnolence, and generalized edema, with anasarca responsive to diuresis and oxygen supplements, and discharged on constant oxygen --[3-/2191]: CVVP trial, stopped in [10-28] because of low blood counts --Low-dose modified regimen: Chlorambucil 4mg daily for days [1-27], Procarbazine 50mg daily for days [1-27], Velban 10 mg IV on day 1 only, Neulasta 6mg on day 8. --[9-/2192]: Chemotherapy discontinued given poor response --[1-/2193]: L sided chest pain with lytic lesions in the thoracic vertebrae; received radiation therapy to T6-T8 including the right 7th rib --CT [8-/2193]: Interval decrease in vertebral lesions. # Lower extremity cellulitis # GERD # Arthritis # Chronic BLE edema # Hypothyroidism # Hypertension # Constipation Social History: Lives at home with health care aide. Son [Name (NI) ] very involved in her care. Three children. No tobacco, alcohol, and illicit drug use. Family History: Noncontributory Physical Exam: Initial Physical Exam GENERAL: Elderly female in no acute distress. Minimally reponsive to verbal stimuli but very responsive to tactile stimulation. VITALS: T 98.8 Rectal HR 79 BP 104/67 RR 15 SAT 97%4L NC HEENT: Sclera anicteric. Moist mucous membranes. NECK: 2+ carotid pulses. No LAD.No JVP elevation. CHEST: Lungs Clear Anteriorly and laterally. No axillary LAD. HEART: Regular. No murmurs. ABD: Soft, non distended, quiet bowel sounds, non tender to percussion. EXT: Pitting edema of feet bilaterally. Nonpalpable pulses. Feet cool. Reasonable capillary refill bilaterally. NEURO: Sleepy but arousable. Pupils 1-2mm bilaterally. Withdraws from painful stimuli. Good strength. Increased Tone. Mute reflexes bilaterally. Toes mute bilaterally. Physical Exam at Time of Transfer to Medical Floor VITALS: T 97.1 P 96 R 24 100/60 94% 2L NC GENERAL: Elderly female in no acute distress. Minimally reponsive to verbal stimuli but arousable with tactile stimulation. HEENT: Sclera anicteric. Dry mucous membranes. NECK: 2+ carotid pulses. No LAD. No JVP elevation. CHEST: Diminished breath sounds at bases bilaterally. No axillary LAD. HEART: Regular. No murmurs. ABD: Soft, distended, active bowel sounds, non tender to percussion. EXT: Pitting edema of all extremities bilaterally. Nonpalpable pulses. Feet cool. Reasonable capillary refill bilaterally. NEURO: Sleepy but arousable. Pupils 3-4mm bilaterally. Withdraws from painful stimuli. Diminished reflexes bilaterally throughout. Physical Exam upon transfer to MICU: VS: Temp: 98.1 BP: 87/35 HR: 102 RR: 31 O2sat 94% 2 LNC GEN: pleasant, comfortable, NAD, somewhat somnolent (falling asleep during the exam) HEENT: PERRL, EOMI, anicteric, tachy MM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd RESP: occ. crackle at bases, though difficult to assess b/c patient not cooperative during the exam CV: RR, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: warm, + anasarca with involvement of upper limbs SKIN: no rashes, no jaundice NEURO: somewhat somnolent. Cn II-XII grossly intact. Difficult to complete full neuro exam given somnolence Pertinent Results: [1-8] - CXR - IMPRESSION: Persistent right-sided effusion. No definite consolidation. Routine PA and lateral films are recommended for evaluation when feasible. [1-10]. Echo. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (probably 3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Based on [2193] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Compared with the report of the prior study (images unavailable for review) of [2190-12-22], there is no definite change. Brief Hospital Course: [Age over 90 ]F with Nodular Sclerosing Hodgkin's Lymphoma initially admitted for urosepsis, and who was transferred to the ICU with hypotension and AFib with RVR. # Goals of Care: The patient had a long hospital course with many family meetings reagarding goals of care. On [2194-1-21] the patient was made DNR/DNI but the family continued to want ICU transfers and pressors if needed, regardless of comfort to the patient. The patient was tranferred to the unit on [2194-1-30]. She was started on levophed for hypotension but eventually a decision was made that it was medically futile to escalate care. Care was not escalated and she expired at 14:26 on [2194-2-2]. The family declined autopsy. # Afib with RVR: Pt experienced transient episodes of Afib to 150's controlled with diltiazem and metoprolol, with spontaneous conversion but with multiple episodes of up to 4 second pauses and bradycardia to 40, likely junctional escape. Digoxin considered unfavorable in this patient. In the MICU, pt was started on amiodarone gtt, and converted to amiodarone PO. When the patient was readmitted to the ICU on [2194-1-30], she was having increased pauses up to 20 seconds. Her amiodarone was stopped. # Thrombocytopenia/Anemia: The patient was anemia and thrombocytopenic throughout the admission thought to be secondary to marrow infiltration of lymphoma. Was transfused total of 3 units PLT (1 unit each on [1-14] and [1-19]) with a transfusion threshold of 10. Will continue to trend platelets, transfuse for bleeding or platelet count < 10. Transfused 1 unit platelets with good bump on [1-25]. Also, the patient has been receiving pRBC transfusions for HCT <24 (total of four units since [2194-1-12]). # Hypotension: Early on in the admission, she was having hypotensive episodes after furosemide but was responsive to fluid blosues of 250 cc. ECHO demonstrated impaired LV relaxation and given elevated WBC, there was concern for distributive shock. Once no longer fluid responsive, she was started on phenylephrine gtt, which was weaned off. She was again hypotension later in her admission thought to be secondary to systemic vasodilation. She was started on levophed but a decision was then made to not escalate care. # Infection: WBC elevated with multiple possible infectious sources which could contribute to hypotension (ie, skin erosions under breasts, course breath sounds with ?PNA). Vanc and piptaz started on [1-22]; cultures of blood and urine pending; sputum not obtainable at this point. CDiff repeated with toxin B. C Diff neg, thus D/C flagyl [1-24]. Now with GNR from skin swab. # Hypernatremia: Noted to be periodically hypernatremic since admission (Na 148-150), due to free water defecit. She has been getting slow infusions of D5W as she has poor po intake and have not been able to keep up her free water intake. # Altered Mental Status: Increased lethargy compared to baseline on admission most likely [2-22] metabolic encephalopathy due to infection and acute renal failure, with slight improvement after resolution of urosepsis. Head CT negative for acute process. Thyroid studies show elevated TSH but this may be c/w sick euthyroid syndrome. # Respiratory Distress: Early in her admission, the patient developed labored breathing after receiving 1 L NS for hypotension c/w flash pulmonary edema. Diuresis with furosemide gtt lead to hypotension; albumin resuscitation lead to repeated respiratory distress. On [2194-1-30] she was on the floor and had a witnessed aspiration event and needed 100% Hi Flow mask. While in the ICU her O2 was weaned but again aspirated and had increasing O2 requirements. # Acute renal failure: Pt noted to have Cr up to 1.7 on admission from presumed baseline of 1.0, returned to baseline of 0.9. Likely was pre-renal due to dehydration and hypotension due to sepsis. Later in her hospital course, the patient was hypotensive and her creatinine again began to rise thought secondary to ATN. # Hypothyroidism: Initially treated with levothyroxine 12.5 mcg IV daily (half home dose). T3 low. TSH elevated. Resumed home dose 1/4. # Anasarca: Pt has diffuse edema and large bilateral pleural effusions likely third-spacing from malnutrition given low albumin (2.8 on admission, then 2.2) and poor po intake. Diuresis has been difficult due to hypotension as detailed above. Continue to monitor. # Urosepsis: Admitted with hypotension due to urosepsis requiring pressor support. Urine cultures from [1-9] were positive for E.coli, and pt completed treated with vancomycin and ceftazidime x10 days. Repeat UCx [2194-1-19] grew out yeast, which was not treated. Another repeat UCx [1-22] final again grew out yeast. # Right Hip pain: Pain due to destruction of the right acetabulum consistent with progressive lymphoma on CT scan. There is dramatic medial displacement of the right femoral head secondary to lack of remaining osseous support. Stable destruction of the right posterior sacroiliac joint and surrounding right sacral ala and iliac bone. The patient's pain is being controlled with fentanyl and lidocaine patches. # Bilateral pleural effusion: R>L, thought most likely due to agressive hydration in the setting of sepsis and hypoalbuminemia. Was difficult to effect a significant diurese in MICU due to development of hypotension in response to furosemide. Appears slightly improved on CXR from [2194-1-17], unchanged on [1-20] CXR. # Nodular Sclerosing Hodgkin's Lymphoma: Seen by oncology, no interventions at this time. Likely with bone marrow infiltration causing anemia and thrombocytopenia above, as pt with low retic count and no evidence of hemolysis. No further treatment per oncology. # Coagulopathy: Mild, likely due to nutritional deficiency. Encourage PO intake and trend LFTs, coags. Medications on Admission: Medications on Admission: 1. Levothyroxine 25 mcg daily 2. Docusate Sodium 100 mg [Hospital1 ] 3. Omeprazole 20 mg daily 4. Oxycodone-Acetaminophen 5-325 mg Q4H PRN 5. Ferrous Sulfate 325mg daily 6. Tylenol-Codeine #3 300-30 mg QID PRN 7. Ultram 50 mg every 4-6 hours 8. Lasix 20 mg daily 9. Senna 8.6 mg [Hospital1 ] prn 10. Aspirin 81 mg daily 11. Potassium Chloride 12. Multivitamin . Medications on Transfer 1. Acetaminophen 325-650 mg PO/PR Q6H:PRN 2. Miconazole Powder 2% 1 Appl TP TID apply to affected area 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 CAP PO DAILY 5. Ipratropium Bromide Neb 1 NEB IH Q6H 6. Bisacodyl 10 mg PO/PR DAILY:PRN 7. Senna 1 TAB PO BID constipation 8. Docusate Sodium 100 mg PO BID 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/cough 10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 11. Fentanyl Patch 25 mcg/hr TP Q72H 12. Lidocaine 5% Patch 1 PTCH TD QD apply to right hip. One per day, on for 12 hours then remove 13. Sarna Lotion 1 Appl TP TID:PRN 14. Levothyroxine Sodium 12.5 mcg IV DAILY 15. Pantoprazole 40 mg IV Q24H Discharge Medications: The patient expired at 14:26pm on [2194-2-2] Discharge Disposition: Extended Care Discharge Diagnosis: Urosepsis Aspiration Pneumonitis Atrial Fibrillation with RVR Lymphoma Discharge Condition: The patient expired at 14:26pm on [2194-2-2] Discharge Instructions: The patient expired at 14:26pm on [2194-2-2] Followup Instructions: The patient expired at 14:26pm on [2194-2-2] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 5845, 5070, 5119, 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6410 }	Medical Text: Admission Date: [2161-1-7] Discharge Date: [2161-1-9] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 13252] Chief Complaint: Seizure Activity Major Surgical or Invasive Procedure: * Intubation History of Present Illness: HPI: Patient is a [Age over 90 ] yo man with advance dementia and HTN who is only oriented to self at baseline here from [Doctor Last Name ] House nursing home after being found on the floor with shaking of arms and head concerning for seizure activity. Per [Doctor Last Name ] House staff, patient was found on the floor shaking per wife who [Name2 (NI) 546] in the same room. She awoke from a nap and found him on the floor then called for the nurses. By the time the nurses arrived, she had put a pillow under his head but he was still shaking his arms and legs. No evidence of urinary incontinence. Of note, patient was admitted from 7/23~24 with shaking episodes thought to be myoclonus and had EEG which only showed disorganized, slow rhythm c/w with encephalopathy but no seizure activity. Then he returned in [9-25] with shaking and again, no EEG captured events but given clinical suspicion for seizures, he was started on Lamictal then discharged back to [Doctor Last Name ] House on [9-29]. Per [Doctor Last Name ] House, he did not have any activities concerning for seizures since then. ROS completely negative as well including fever, cough, N/V/D or HA. He is only on Lamictal 100mg daily. At baseline, he is able to ambulate with walker and feed himself but needs assistance with other ADLs. He is only oriented to self and often belligerent. He was belligerent to the staff and EMS today as well. Upon arrival, patient was noted to have continued L arm shaking and some lip and eye twitching hence received 2mg IV Ativan then intubated for airway protection in the ED although patient is DNR/DNI per HCP, Mr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Past Medical History: - Clinically diagnosed seizure disorder - advanced Alzheimers dementia - HTN - Hypothyroidism - BPH . PSHx: - Thyroidectomy - Wisdom teeth removal Social History: - Lives in [Doctor Last Name ] House with his wife. - walks with a walker at baseline - able to feed himself, requires assistance with other ADLs . HABITS - Tobacco - remote: used to smoke for a few yrs ([4-20]) while in military but has not since [2095]. - ETOH - denies - Recreational Drugs: drink etoh or do drugs. He Family History: - positive for stroke (mother), heart failure (father) Physical Exam: ON ADMISSION: T 97.2 rectal BP 150/71 HR 49 RR 16 O2 sat 100% intubated Gen: Lying in bed, intubated and sedated. HEENT: Wearing [Location (un) 2848] J collar CV: RRR, no murmurs/gallops/rubs Lung: Clear Abd: +BS, soft, nontender Ext: No edema Neurologic examination: Mental status: Intubated and sedated - upon turning off the Propofol, gags intermittently and moves both toes spontaneously but does not open eyes or follow any commmands. Cranial Nerves: Pupils are small and minimally reactive. No blinking to visual threat - positive Doll's eyes. Corneal + on R only. +Gag. Face appears symmetric. Motor: Normal bulk and tone bilaterally. No observed myoclonus or tremor. Moves both feet spontaneously - extensor posturing with noxious stim of both UEs and withdrawal of both LEs. Sensation: Intact to noxious stim. Reflexes: 2s and symmetric for all except Achilles. Toes appear upgoing bilaterally. Pertinent Results: Admission Labs: WBC-14.6# RBC-4.50 HGB-13.9* HCT-43.1 MCV-96 PLT-268 GLUCOSE-125* UREA N-25* CREAT-1.1 SODIUM-137 POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-20* ANION GAP-24* ALT(SGPT)-12 AST(SGOT)-21 CK(CPK)-109 ALK PHOS-59 TOT BILI-0.4 CK-MB-5 cTropnT-<0.01 ALBUMIN-4.4 CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-2.4 LACTATE-10.5* PT-11.7 PTT-20.4* INR(PT)-1.0 Phenytoin: 16.6 (albumin 3.3) on [2161-1-9] . URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-<1 URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . Discharge Labs: . IMAGING: . CT C-Spine ([2161-1-7]): FINDINGS: There is no fracture or dislocation. There are multilevel degenerative changes through out the cervical spine, most pronounced at C6-7, with severe loss of intervertebral disc height. This appearance, however, is stable since [Month (only) 116]. There is grade 1 anterolisthesis of C4 on C5, also stable. At C3-4, there is severe right uncovertebral joint hypertrophy causing marked narrowing of the neural foramina, but this is also stable. There is no prevertebral soft tissue swelling. The visualized outline of the thecal sac appears grossly normal, although may be slightly indented at C6/7.The visualized lung apices appear clear. . IMPRESSION: No fracture or dislocation. Multilevel degenerative changes as described, stable. . Non-Contrast CT of Head ([2161-1-7]): IMPRESSION: No intracranial hemorrhage or edema. . EEG ([2161-1-8]): Abnormal portable EEG due to the left temporal delta slowing and the low voltage slow background. The first abnormality signifies a focal subcortical dysfunction in the left hemisphere. Vascular disease is one possible cause, but the tracing cannot specify the etiology. The background suggests a widespread encephalopathy. There were no epileptiform features. Brief Hospital Course: Mr. [Known lastname 19122] is a [Age over 90 ] year-old man with a past medical history including advanced Alzheimers Disease, clinical seizure disorder, and hypertension admitted [2161-1-7] to the Neuro-ICU following shaking of the limbs concerning seizure activity. He was transferred to the [Hospital1 18] neurology general floor service on [2161-1-8] and remained there until [2161-1-9]. . NEURO Following arrival, the patient was observed to have persistent facial twitching thought to be consistent with seizure activity. He was therefore given ativan 2 mg and a dilantin load. A post load dilantin level (corrected for albumin) was found to be therapeutic (19.2). The patient's outpatient lamictal regimen was also increased for improved seizure prophylaxis. No further clinical seizure activity was evident. A routine EEG was performed and demonstrated encephalopathy but no epileptiform activity. An underlying trigger could not be readily identified. Phenytoin level on day of discharge was 16.2. The patient's lamotrigine should be increased to 150 mg daily in 1 week after discharge, and continued at that dose thereafter. The phenytoin will be weaned. It should be given at 300mg PO daily for 2 weeks, then 200mg PO daily for 1 week, then 100mg PO daily for 1 week, then stop. He received his daily doses of lamotrigine and phenytoin on the day of discharge. . As the patient was found on the floor at [Doctor Last Name ] House, a CT of the cervical spine was performed; there was no evidence of fracture. A non-contrast CT of the head revealed no contributory intracranial pathology. He was seen by physical therapy and could walk with a walker (with assist). . RESP In the ED, the patient was intubated for airway protection. Soon after admission, he was extubated. . GI The patient was cleared to take a diet of ground solids and thin liquids on discharge, and was resumed on oral medications. Medications on Admission: MEDS: 1. Acetaminophen 325 mg PRN 2. Tamsulosin 0.4 mg bedtime 3. Donepezil 10mg bedtime 4. Levothyroxine 88 mcg daily 5. Lamictal 100 daily 6. Maalox PRN 7. Albuterol neb PRN 8. Docusate 100 daily . ALL: NKDA Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for T>100.4 or pain. 2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Lamotrigine 25 mg Tablet Extended Rel 24 hr Sig: See instructions Tablet Extended Rel 24 hr PO DAILY (Daily): 125mg PO daily for 1 week, then 150mg PO daily to continue. Disp:168 Tablet Extended Rel 24 hr(s) Refills:2 8. Phenytoin 50 mg Tablet, Chewable Sig: See instructions Tablet, Chewable PO once a day for 4 weeks: 300mg PO daily for 2 weeks, then 200mg PO daily for 1 week, then 100mg PO daily for 1 week, then stop. Disp:142 Tablet, Chewable(s) Refills:0 Discharge Disposition: Extended Care Facility: [Doctor Last Name ] House Discharge Diagnosis: Primary: Seizure Secondary: Alzheimer's disease Discharge Condition: Awake, oriented to self. Ambulatory with walker and assist. Discharge Instructions: You were admitted for a seizure. You received the medication Dilantin to help prevent further seizures. This medication will be decreased as an outpatient while the Lamictal is slowly increased. Please try to avoid activities that might place you at risk if you have a seizure while alone, such as tub bathing. Please take your medications as prescribed and attend follow-up appointments as detailed. If you have another event concerning for a seizure, please call your physician or return to the nearest emergency room. Followup Instructions: Neurology: DRS. [Name5 (PTitle) 540] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 44] Date/Time:[2161-2-18] 4:30 Please see your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 4320] [Last Name (NamePattern1) 4321], for post-hospitalization follow-up. Call ([Telephone/Fax (1) 8417] to arrange an appointment in the next 2 weeks. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 13255] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6411 }	Medical Text: Admission Date: [2190-2-5] Discharge Date: [2190-2-12] Date of Birth: [2145-10-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: EGD, colonoscopy History of Present Illness: 44F with recent discharge [1-31] for fall (with S4 sacral fracture), AIDS (CD4 74, VL >100,000 [1-13]; not on HAART), worsening pancytopenia, usually gets her care at [Hospital1 2177], presents after fall. She fell off of her bed, but cannot explain what happened. She had no LOC, no confusion, no dizziness, but she was weak and could not hold herself up. In the ED, CT Head negative, CT Cspine negative, XR T/L spine negative. CXR normal. Hct 20 which has been declining. Guaiac negative, was supposed to get 2URBC in ED, but never received it. Lives at home, cared for by her father who feels overwhelmed. She has had no fever, no chills, no dysuria, no cough. Past Medical History: # HIV/AIDS: CD4 74, VL >100K in [1-13]. Not on HAART secondary to concern for noncompliance. Was supposed to f/u with [Doctor First Name ] [Doctor First Name ] who will be her new ID doc on [2190-2-4] but ended up in ED instead after she fell # Hep C -no treatment # Hypothyroidism (diagnosed during prior hospitalization) # Vitamin B deficiency (diagnosed during prior hospitalization, felt to be causing her frequent falls) # Hx heroin addiction # ? Seizures: Had twitching during prior hospitalization, neuro started her on Keppra # Pancytopenia: Had extensive w/u during prior hospitalization, including LP, bone marrow bx, all of which were negative # Sacral fracture: felt [1-8] fall, subacute on imaging, ortho has seen and did not recommend operation # Bipolar d/o: on trileptal, paxil Social History: Patient is married. She lives with her father. She has one upstairs neighbor that helps her when she needs assistance. She smokes [4-12] cigarettes per day; she has been smoking for over 30 years. She denies alcohol use. She previously used drugs (heroin/cocaine) but tells us she has not used in 15 years. Family History: Sister died from "obesity." Mother died of [Last Name (un) 5487] cause. Father has "weak legs." Physical Exam: VS: 98.8 / 110/70 / 92 / 16 / 95% 2Lnc Gen: Pleasant, cachectic female in no acute distress. HEENT: 3 cm laceration on left posterior occiput. No conjunctival pallor. No icterus. MM somewhat dry. OP clear. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: RRR. nl S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: CTAB, no wheezes or crackles ABD: Soft, NT, ND. NL BS. No HSM EXT: Extremely thin. No edema. DP pulses 2+ bilaterally. SKIN: Scattered ecchymoses on knees/legs. NEURO: A&O X 3. CN II - XII intact. Strength 5/5 right LE; 4+/5 in left lower extremity. Pinprick intact bilateral lower extremities. No tenderness over spine. PSYCH: Listens and responds to questions appropriately, pleasant, somewhat vague on her medical history Pertinent Results: Studies: CT C-spine ([2190-2-5]): No evidence of fracture or malalignment. . CT Head ([2190-2-5]): No evidence of hemorrhage or mass effect. Mild age inappropriate generalized brain atrophy consistent with HIV encephalopathy. . L-spine x-ray ([2190-2-5]): No evidence of acute compression fracture or spondylolisthesis. . CXR AP ([2190-2-5]): No focal consolidations seen. . xray sacrum [2190-2-6]: There is an old healed fracture of the distal sacrum. No new fracture is present. . Pertinent labs: BCx x4 NGTD UCx negative . H.pylori serology pending . on admission: WBC-3.9* RBC-2.18* Hgb-7.1* Hct-20.9* MCV-96 MCH-32.8* MCHC-34.1 RDW-18.0* Plt Ct-74* On discharge: WBC-1.5* RBC-2.11* Hgb-7.0* Hct-20.5* MCV-97 MCH-33.2* MCHC-34.2 RDW-19.3* Plt Ct-81* Gran Ct-650* Glucose-80 UreaN-9 Creat-0.6 Na-142 K-3.8 Cl-116* HCO3-20* AnGap-10 . Other lab results: ALT-22 AST-45* LD(LDH)-349* CK(CPK)-145* AlkPhos-271* TotBili-0.4 Calcium-7.4* Phos-3.4 Mg-1.8 calTIBC-256* VitB12-1002* Folate-GREATER TH Ferritn-921* TRF-197* TSH-1.2 Free T4-0.97 Brief Hospital Course: Ms. [Known lastname 38777] is a 44 year old female with recent discharge [2190-1-31] for mechanical fall with resultant sacral fracture, AIDS (CD4 74, VL >100,000 [1-13], not on HAART), pancytopenia, presenting with another fall. During her first hospital day, she was triggered for somnulence and sent to the MICU for a brief stay for respiratory distress. This quickly resolved and she was transferred the next day back to the medicine floor for further care. Her hospital course is described below by problem. . #MICU course: On the medical floor, she was noted to be more somnolent. Her tox screen was positive for opiates, benzos, and methadone. Her primary team considered Narcan but did not give it as her mental status would intermittently improve. There was apparently also concern that her roommate gave her benzos (as her tox screen was positive for this but she's not ordered it.) There was also a question of her roommate seeing her taking oxycodone although she denies it. Also, she was getting a transfusion for Hct 20, and halfway through her 2nd unit of PRBCs, she developed a temp to 100.6 and the blood was stopped. Later tonight, she spiked a fever to 104.5. BP 103/70 (had been 104-114/50-85 all day), P 109 (80s all day), RR in 30s per team (although recorded as 20 by nurse), and O2 sat dropped to 88% on 0.5 L NC (improved to 94% on 12L venti mask). ABG was 7.45/33/70. CXR initially was thought to have a question of infiltrate, so she was started on vanco and zosyn, given a 500 cc NS bolus, and transferred to the MICU. She was stable throughout the day and then was transferred back to the floor on [2190-2-7]. Her cultures were all negative and antibiotics were stopped after 72hrs. Given no signs of infection, her altered mental status and brief episode of respiratory distress were thought to be related to medications. . # Falls: Was recently discharged [2-3] for fall. During that admission, Neurology was consulted during that admission and after extensive work up, her falls were thought to be multifactorial. She may have HIV myopathy/neuropathy, AIDS encephalitis, peripheral neuropathy from B12 deficiency, and narcotics, resultant pain from sacral fracture contributing. She was followed by physical therapy who felt she would benefit from rehab. . # Fever: Patient's fevers were extensively worked up during her last admission including an LP with no obvious source of infection. Her fevers are likely related to her HIV and possibly her medications. After her initial episode of 104, she remained afebrile. As described above, after 72 hrs of negative cultures and no source of infection, antibiotics were discontinued. . Her blood was sent for transfusion reaction work up as she had a temperature of 100.6 during a blood transfusion. There was no evidence of hemolytic reaction and the pathologist felt that given the much delayed time course of her 104 temp many hours afterwards, this was likely not related to the blood products. They did not recommend any premedications before transfusions. . # Failure to thrive: reports low PO intake and recent falls suggest very poor performance status. She has advanced HIV/AIDS and is quite malnurished (albumin 2.8) and deconditioned. Nutrition and physical therapy were following in house. She is on a regular diet with ensure plus supplements TID. She had calorie counts and was taking in about 1200 calories/day. . # Pancytopenia, unclear etiology: Was evaluated by Heme during last admission for fevers associated with immunosuppression and pancytopenia. BM biopsy from last admission showed hypercellular marrow with HIV associated dyspoiesis, evidence of cold agglutinins on blood smear. CMV viral load was negative. Her myelosuppression could be medication related (bactrim for instance). She needs this medication for OI ppx, but could possibly change this to another ppx medication. This will be discussed at her outpatient ID appointment next week. . # anemia: her anemia was severe HCT range 20-24 and her stools were guiac positive. She was taken for EGD and colonoscopy. The colon was clear, but she had severe gastritis and candidal esophagitis. She is being treated with twice daily PPI for the gastritis and an H. Pylori serology was pending at the time of discharge. Please call [Telephone/Fax (1) 71163] to follow up these results. She is also being given a 2 week course of fluconizole to treat the candidiasis. This medication can interact with her other medications to cause a prolonged QT interval. Her EKG shows a QT interval of ~470 at discharge. She should have daily EKGs while on the fluconizole to monitor this interval. . # HIV/AIDS: CD4 74, VL > 100,000 in [1-/2190]; not on HAART . She is on bactrim for ppx for opportunistic infections. She has a follow up appointment with [Hospital ] clinic on [2-22] to discuss possibly starting HAART. . ## Acute renal failure: On admission her Cr was 1.4 which was likely prerenal azotemia due to poor PO intake: Baseline creatinine 0.8. She returned to baseline with hydration. . # Hepatitis C infection: - no active issues . # Vitamin B 12 deficiency: continued vitamin b12. . # Hypothyroidism: continued levothyroxine . # History of bipolar disorder: continued trileptal, paroxetine . # History of heroin abuse: - Methadone 20 mg daily per outpatient regimen at Habit Management Institute . ## Social situation: - Separated from her husband and is cared for by her father who is overwhelmed by her needs and with whom she often fights. Social work was consulted and are in the process of setting up a program for HIV/drug abuse. . # History of lung nodule: - Small lung nodule seen incidentally on CT chest that may be followed up as outpatient . # FEN: Regular diet with supplementation of ensure plus TID # DVT Prophylaxis: pneumoboots # Code: Full Medications on Admission: -Methadone 20mg daily (followed at Habit Management Institute) -Oxcarbazepine 150mg [Hospital1 ] -Paroxetine HCl 20mg daily -Docusate Sodium 100mg [Hospital1 ] -Trimethoprim-Sulfamethoxazole 160-800 mg daily -Levetiracetam 1g [Hospital1 ] -Folic Acid 1 mg daily -Thiamine 100 mg daily -Levothyroxine 50 mcg dialy -Megace Oral 800mg daily -Fluticasone-Salmeterol 250-50 mcg/Dose [Hospital1 ] -Pantoprazole 40mg daily -Albuterol prn -Vitamin B-12 1000 mcg sc Qmonth -MS-Contin 15mg po daily -MSIR 15mg po Q8H Discharge Medications: 1. Oxcarbazepine 300 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Megestrol 40 mg/mL Suspension Sig: One (1) PO DAILY (Daily). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. 12. Methadone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 18. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. 20. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day for 13 days. 21. Outpatient Lab Work Please check CBC and electrolytes (WBC, HCT, Plt, sodium, potassium, bicarb, chloride, BUN, Cr, glucose) on [Hospital1 766] [2-15], [2189]. Replete as needed. 22. Heart Please do daily EKGs while on fluconizole for 2 weeks. Monitor QTc interval for prolongation (on discharge before fluconizole QTc was ~470). Discharge Disposition: Extended Care Facility: [Location (un) ] Manor Discharge Diagnosis: Primary Anemia Gastritits HIV/AIDS CD4 74, VL>100,000 Pancytopenia Esophageal candidiasis . Secondary Hepatitis C Hypothyroidism Vitamin B deficiency h/o seizures Bipolar disorder Discharge Condition: Good Discharge Instructions: You were admitted to the hospital after a fall and were also noted to have worsening anemia. For the anemia work up you underwent an endoscopy which showed gastrititis. You should now take your pantoprazole twice a day instead of once a day. . You were diagnosed with esophageal candidiasis which is an infection in your esophagus. You are being started on a new medication for two weeks to treat this (fluconizole). This medication can interact with some of your other medications. You should have an EKG checked every day to ensure your QTc interval does not become too long (this is a conduction change in your heart). Your EKG on discharge (before fluconizole) showed a QTc of ~470. . Your blood levels are quite low. You should have your laboratories checked on [Location (un) 766] [2190-2-15]. CBC including WBC, Hct and platelets. Electrolytes including sodium, potassium, chloride, bicarb, BUN, Cr, glucose. These labs should be repleted as needed. . Please continue to take all your medications and follow up with your appointments as below. . If you have any fevers >101, chills, chest pain, shortness of breath, lightheadedness, dizziness or falls please return to the emergency room or contact your physician. Followup Instructions: Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2-24] at 8:50 AM . Provider: [Name10 (NameIs) 2341] [Last Name (NamePattern4) 2342], M.D. Phone:[Telephone/Fax (1) 2343] Date/Time:[2190-2-17] 3:00 . Please follow up with infectious disease clinic Dr. [First Name (STitle) ] [Name (STitle) 766] [2-22] at 3:30pm. [Last Name (NamePattern1) ], [Hospital Unit Name ], Suite G. Across from emergency room. Please call ([Telephone/Fax (1) 4170] if you need to change this appointment. Completed by:[2190-2-13] ICD9 Codes: 5849, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6412 }	Medical Text: Admission Date: [2135-7-7] Discharge Date: [2135-7-13] Service: MEDICINE Allergies: Penicillins / Fosamax Attending:[First Name3 (LF) 425] Chief Complaint: Inferior wall MI Major Surgical or Invasive Procedure: Cardiac catheterization Esophagogastroduodenoscopy History of Present Illness: 82 year old male with history of DM2, HTN, hyperlipidemia, [Hospital 67277] transferred to [Hospital1 18] for cardiac catheterization in setting of acute inferior wall MI. The patient says that on the morning of admission, he woke up at midnight with shortness of breath which was worse on laying down and prevented him from sleeping. He additionally noted a dull chest pain, as well as pain in his cervical spine. The pain was [9-13] in severity and continuous throughout the night. There was no associated presyncope, palpitations, or diaphoresis. He presented to his primary care physician in the AM, and was directed to go to the ER after an EKG reportedly with atiral flutter. On arrival to OSH ED, his vitals were P 116, BP 118/76, R 16. An EKG at that time reportedly showed rapid AF. He was given multiple doses of IV lopressor without much change in HR. He was given SL nitro for his chest pain with decrease in BP to 83/59. Given the persistence of his chest pain he underwent CTA which was negative for dissection. 1st set of cardiac enzymes were negative. BNP was 71. A repeat EKG later in the afternoon demonstrated prominent ST elevation in the inferior leads. He was started on a heparin drip and given a plavix load and ASA, and transfer to [Hospital1 18] was arranged. . In the cath lab he was found to have a dominant LCx with an ulcerated 90% distal lesion prior to the bifurcation of the PLBR and PDA that was stented with a drug eluting cypher stent. Aortography did not demonstrate a dissection. His right and left sided filling pressures were both noted to be elevated, with a PCWP of 37, and PA 47/29. His CI was found to be 1.5, and he was started on dobutamine at the conclusion of the cath. His BP was consistently > 100 systolic throughout, with HR intermittently 110-120. He was brought to the CCU on a dobutamine drip at 0.5 mcg/kg/min. Past Medical History: 1) AAA status post repair about 15 years ago 2) DM2 3) Hypertriglyceridemia 4) Hypertension 5) Basal cell carcinoma of the ear 6) Squamous cell carcinoma, sublingual 7) BPH 8) COPD Social History: Smokes Heavy smoker for 60 years. Currently smokes 0.5-1 pack per day. Denies alcohol use or IVDU. Lives with his wife. Family History: Non-contributory. Physical Exam: 99.0, 109, 112/62, 18, 97% on 2L NC GENERAL: Overweight caucasian male appearing comfortable. HEENT: Asymmetric jaw line. NECK: No JVD, jugular venous pressure difficult to locate. COR: RR, normal rate, distant heart sounds but no murmurs/rubs/gallops. LUNGS: Rales at the left base. ABDOMEN: Normoactive bowel sounds, soft, non-tender. GROIN: Sheath in place in right groin. EXTR: DP palpable bilaterally. No edema Pertinent Results: [2135-7-7] 09:06PM WBC-9.3 RBC-3.50* HGB-10.3* HCT-28.9* MCV-83 MCH-29.5 MCHC-35.7* RDW-15.2 [2135-7-7] 09:06PM GLUCOSE-131* UREA N-24* CREAT-1.2 SODIUM-138 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-20* ANION GAP-19 . C. Cath. [2135-7-7] COMMENTS: 1. 2.Resting hemodyanmics revealed elavted right and left sided filling pressures with RVEDP of 25mmHg and pulmonary cappilary wedge pressure of 37mmHg. There was moderate pulmonary arterial systolic hypertension with PASP of 47 mmHg. The Cardiac index was reduced at 1.5 L/min/m2. 3.Successful primary PCI of the LCx with a 3.0 x 18 Cypher DES. Final angiography showed TIMI III flow, no dissection, no embolizationa and no peforation. 4. Asceding aortography revealed no evidenc of dissection. The descending aorta appeared moderately dilated. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Acute inferior myocardial infarction, managed by primary PCI of the LCx vessel. . Transthoracic Echocardiogram, [2135-7-9]: MEASUREMENTS: Left Ventricle - Ejection Fraction: <= 25% (nl >=55%) INTERPRETATION: Findings: This study was compared to the prior study of [2135-7-8]. LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Normal LV cavity size. Severe global LV hypokinesis. Severely depressed LVEF. RIGHT VENTRICLE: Dilated RV cavity. RV function depressed. AORTA: Normal aortic root diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: 1. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 2, The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 3. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. Compared with the prior study (images reviewed) of [2135-7-8], the LV is better visualized, and LV function is clearly reduced on this study. . EKG [2135-7-7] Irregular supraventricular tachycardia, possibly multifocal atrial tachycardia. Incomplete right bundle-branch block. Inferior ST segment elevations suggestive of an acute inferior wall myocardial infarction. Non-diagnostic T wave flattening in the precordial leads. No previous tracing available for comparison. . Transesophageal Echocardiogram [2135-7-11]: GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was monitored by a nurse in [Last Name (Titles) 9833] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). Local anesthesia was provided by of the echocardiographic results by e-mail. Conclusions: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There are complex (>4mm, mobile) atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The pulmonic valve leaflets are thickened. There is mild [1+] tricuspid regurgitation. IMPRESSION: No intraatrial thrombi identified. Moderate mitral regurgitation. . EGD [2135-7-11] Findings: Esophagus: Mucosa: Localized mild erythema of the mucosa was noted in the gastroesophageal junction. These findings are compatible with mild esophagitis. Stomach: Mucosa: Localized discontinuous erosions and erythema of the mucosa were noted in the antrum. These findings are compatible with gastritis with erosions. Duodenum: Normal duodenum. Other findings: Brunner's gland hypertrophy Impression: Mild erythema in the gastroesophageal junction compatible with mild esophagitis Erosions and erythema in the antrum compatible with gastritis with erosions Brunner's gland hypertrophy Otherwise normal EGD to second part of the duodenum Recommendations: Okay to use full anticoagulation. Give PPI [Hospital1 ], check H. pylori . [2135-7-11] H.Pylori testing: Negative . [2135-7-7] 09:06PM calTIBC-386 FERRITIN-56 TRF-297 [2135-7-7] 09:06PM TSH-0.052 [7-8] Free T4-1.1 Brief Hospital Course: 82 year old male with history of DM2, HTN, hyperlipidemia, [Hospital 67277] transferred to [Hospital1 18] for cardiac catheterization in setting of acute inferior wall MI. . 1) Inferior wall MI: Patient went to catheterization on arrival and was found to have a dominant LCX with a 90% stenosis that was stented with a drug eluting Cypher stent. He was hemodynamically stable throughout the procedure, however his cardiac index was found to be 1.5 during the procedure. He was therefore started on dobutamine after catheterization, which was titrated over over the course of the next 5 hours, with maintenance of CI >2.0, and was quickly discontinued. The patient was discharged on an increased dose of atorvastatin (20 mg) and an ACE inhibitor, lisinopril 2.5. Plans to either increase the ACE inhibitor or initiate a beta-blocker were left for outpatient management. He was also discharged on daily plavix and aspirin. . 2) Low cardiac index: The patient's low CI during cardiac cath could not be completely explained by his inferior MI, and a possible secondary component of cardiomyopathy was evaluated. Iron studies and free T4 levels were normal. Given the patient's atrial tachycardia on EKG and report of previous episodes of palpitations, tachycardia-induced-cardiomyopathy was the primary consideration. Echo was performed which demonstrated severe LV global hypokinesis. Follow-up echo in six weeks and further workup as an outpatient. Due to some increased lower extremity edema, the patient's outpatient dose of lasix was increased from 20 mg to 40 mg. . 3) Tachycardia: Patient presented with heart rate in 100-120s. EKG consistent with atrial tachycardia vs atrial flutter. Likely related to underlying lung disease from chronic smoking history. Heparin bridge to coumadin anticoagulation was started. TEE demonstrated no thrombus and patient was successfully electrically cardioverted and remained at a sinus rate <100, with irregular beats. Amiodarone was initiated prior to cardioversion and was continued post-discharge. Post discharge plan was to continue the patient on amiodarone at 200 mg TID for one month and subsequently to decrease to 200 mg QD. The patient's cardiologist was informed of this [Hospital1 4085] addition and could alter dosing at his discretion. The patient had a therapeutic INR at discharge after several days of 5mg coumadin and was sent home on 3 mg coumadin with a plan for INR check in 2 days post discharge. Coumadin could be continued at the discretion of the patient's PCP and cardiologist, dependent on bleeding risk. . 4) GI bleed: OSH reports hematocrit of 37, and following catheterization patient's hematocrit was 29. Patient subsequently had one guiac positive stool that was described as melanotic. GI was informed, and because of the plan to send the patient home on long-term coumadin for atrial arrhythmia, a GI workup was initiated. The patient had an EGD which demonstrated gastritis and mild esophagitis but no obvious bleeding source. He was discharged on oral PPI [Hospital1 ]. H. pylori testing was also performed. GI work up could be continued as an outpatient to identify source. Because no gastroduodenal ulcer was found and patient's hematocrit remained stable prior to discharge, he was deemed safe for discharge on warfarin. . 5) DM: Patient's blood sugar was well controlled with sliding scale insulin. He was discharged on his outpatient diabetes regimen. Medications on Admission: Humalog 75/25 36 units in AM, 25 QPM Metformin 500 mg [Hospital1 ] Pioglitazone 45 mg [Hospital1 ] Omeprazole 40 mg PO DAILY Gemfibrozil 600 mg PO BID Atorvastatin 10 mg PO DAILY Lasix 20 mg PO DAILY Ecotrin 325 mg PO DAILY Discharge Disposition: Home With Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: Primary diagnoses 1) Inferior Myocardial Infarction 2) Supraventricular Tachycardia 3) Gastritis 4) Benign prostatic hypertrophy Secondary diagnosis 1) COPD 2) Diabetes type II 3) hyperlipidemia Discharge Condition: Stable Ambulating without assistance Tolerating normal diet Discharge Instructions: When you came to the hospital, you had a blockage of one of your coronary arteries. The blockage was removed, and a drug eluting "Cypher" stent was placed in the artery to keep it open. This stent is at high risk for blockage again if you do not take Aspirin (or Ecotrin) and Plavix. Both of these medications must be taken every day. You have epsisodes of a fast heart rate, called a "tachycardia," which can occur even without symptoms. In the hospital, your fast heart rate was converted to a normal rate using a shock. In order to prevent this fast heart beat from returning, you have been started on a [Hospital 4085] called Amiodarone. You should take Amiodarone at a dose of one 200 mg tablet three times a day for the next month. After one month you should take one 200 mg tablet once a day. You should discuss this [Hospital 4085] with your cardiologist to decide how long you should take it for. Because of the potential for you to return to a fast heart rate, you are at risk for forming a blood clot in your heart, which can be a cause of stroke. You have been placed on a blood thinner [Hospital 4085] called "coumadin" to prevent a stroke from occurring. The appropriate level of coumadin, which is also called "warfarin," is determined with a test called an "INR" test. Your INR level should be between 2-2.5. If you take too much coumadin, you will be at increased risk for gastrointestinal bleeding. You should have your INR checked on Friday, [7-15] and again on Monday, [7-18]. If your INR level is too high, your physician will adjust your coumadin dose. You had a black stool while you were in the hospital, which is a sign of gastrointestinal bleeding. You should inform you primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 29478], about this, and you will need further evaluation for this problem. [Name (NI) ] have been placed on a double dose of omeprazole to prevent further bleeding. A colonoscopy may be required. If you have more black stools, or if you feel persistently lightheaded and dizzy, these may be signs that you have a gastrointestinal bleed and need to go to the emergency room immediately. Because you had a heart attack, your [Name (NI) 4085] regimen has been changed: 1) Your atorvastatin dose has been increased from 10 mg every day to 80 mg every day. 2) Your Lasix dose has been increased from 20 mg every day to 40 mg every day. 3) You have been started on Plavix 75 mg every day. As stated above, it is very important not to miss [First Name (Titles) ] [Last Name (Titles) 4085] on any day. 4) Continue taking your gemfibrozil, pioglitazone, metformin, and insulin doses at your usual doses. 5) Your dose of omeprazole has been increased from 40 mg once a day to 40 mg twice a day for the next 2 weeks. Afterwards you can go back to once a day. If you feel lightheaded on standing frequently or dehydrated, you may need to reduce your dose of lasix. You should make every attempt to stop smoking. This is the most important thing you can do to prevent a second heart attack. There are many different smoking cessation programs that are available to you. You should have an echocardiogram in [12-6] months to check your heart function. Your cardiologist will help you schedule this. Followup Instructions: You have an appointment to have your blood drawn to check your INR on Friday of this week. You should go to the lab at Dr. [Name (NI) 67278] office to have this done. While you are there, please schedule an appointment to see Dr. [Last Name (STitle) 29478] in the office within the next 2-3 weeks. PCP: [Name10 (NameIs) ],[Name11 (NameIs) 29557] [Name Initial (NameIs) ]. [Telephone/Fax (1) 3183]. You have an appointment with your cardiologist, Dr. [Last Name (STitle) ], on [7-26] at 11:15. We have updated him on your recent hospitalization. Please call Dr.[Name (NI) 33490] office at ([Telephone/Fax (1) 29561] to confirm the appointment. Completed by:[2135-7-14] ICD9 Codes: 4019, 2724, 4271, 5789, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6413 }	Medical Text: Admission Date: [2183-1-6] Discharge Date: [2183-1-15] Date of Birth: [2110-10-7] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: L sided neglect and confusion, R parietal hemorrhage seen on Head CT Major Surgical or Invasive Procedure: NONE History of Present Illness: The pt is a 72 year-old right-handed man with a PMH of advanced PD. Per his wife, he was more sleepy over the weekend and yesterday she noticed that he did not eat the L half of his plate. She had put muffins out for him and he only at the ones on the R, complaining of the fact that there were only crumbs on the plate, despite the fact that there was a half of a muffin on the L. Then over the course of the day he seemed to have a little difficulty navigating space and finding the stairs. He was however able to walk without greater trouble than his baseline. He was still not at baseline today so she brought him here. . In the ED he was given 1 gm of CTX, 1 gm of dilantin and 2mg of Zofran after having an episode of emesis. He remained hypertensive in the 200/99-> 170's/80's. . ROS: sleepy over the weekend per his wife; HA and nausea Past Medical History: - Advance Parkinson's disease, dx in [2179] vs [Last Name (un) 309] Body dementia with Parkinsonism - Orthostatic hypotension - Parotid benign tumor Social History: Dr. [Known lastname 1683] obtained a doctorate degree in physics from the [State 109986], Berkeley and worked as a physicist for ten years. Then he obtained a medical degree from [University/College ] [Location (un) ]. He worked as an internist for [Hospital1 18] for 21 years. He retired in [2181-1-8] Family History: Dr. [Known lastname 1683]?????? father died at age 75. His mother died at age 71 with probable Alzheimer??????s disease. A brother died at age 75. Dr. [Known lastname 1683] has one adopted daughter, aged 22, who attends Gibbs College. His wife is reportedly healthy and recently returned to work as a psychiatric social worker. Physical Exam: Vitals: T: 96.2 P: 71 R: 20 BP: 200/99-> 171/87 SaO2: 97% 2L General: Awake, but keeps eyes closed, NAD but initally tachypneic, cachectic HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: difficult to move neck in any direction, no carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: nl. S1S2 Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 1+ LE edema with erythema; Pain at R IV site but no erythema or edema; R wrist healing ecchymoses and abrasion . Neurologic: -Mental Status: awake, oriented to person, hospital and year. Unable to provide details about his history or symptoms. Inattentive, but with brief fluent speech (max 5 words); intact comprehension, does not repeat. Speech was not dysarthric. Pt does not attend to examiner on the L side of the bed. Masked face; Further testing deferred as pt states he is not feeling well . CN I: not tested II,III: does not cooperate with formal VF testing; does not blink to threat consistently bilaterally, pupils 2mm->1mm bilaterally, fundi normal w/ sharp discs III,IV,V: able to cross the midline on the L but does not fully abduct, no ptosis. No nystagmus V: + corneals and nasal tickle VII: masked face but no clear facial droop VIII: hears voice bilaterally IX,X: palate elevates symmetrically, uvula midline [Doctor First Name 81]: SCM/trapezeii [5-13] bilaterally XII: tongue protrudes midline, no dysarthria . Motor: limited exam as pt does not cooperate with formal testing; diffusely increased tone and rigidity w/ cogwheeling; intermittent R hand tremmor; antigravity throughout . Reflex: No clonus [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 2 1 Up R 2 2 2 2 1 Flexor . -Sensory: unreliable testing to light touch . -Coordination: deferred . -Gait: deferred Pertinent Results: Admission Labs: [2183-1-6] 08:35AM PT-12.3 PTT-29.0 INR(PT)-1.0 [2183-1-6] 08:35AM PLT COUNT-204 [2183-1-6] 08:35AM NEUTS-81.7* LYMPHS-11.9* MONOS-3.4 EOS-2.7 BASOS-0.2 [2183-1-6] 08:35AM WBC-7.5 RBC-4.44* HGB-13.7* HCT-38.5* MCV-87 MCH-30.8 MCHC-35.5* RDW-12.8 [2183-1-6] 08:35AM cTropnT-<0.01 [2183-1-6] 08:35AM CK(CPK)-72 [2183-1-6] 08:35AM GLUCOSE-117* UREA N-24* CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-32 ANION GAP-10 [2183-1-6] 08:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2183-1-6] 01:34PM PT-12.8 PTT-27.1 INR(PT)-1.1 [2183-1-6] 01:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2183-1-6] 01:34PM TSH-1.6 [2183-1-6] 01:34PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.0 [2183-1-6] 01:34PM ALT(SGPT)-9 AST(SGOT)-18 LD(LDH)-155 CK(CPK)-64 ALK PHOS-121* TOT BILI-0.3 . EEG: This is an abnormal portable EEG due to the slow background and additional bursts of generalized slowing. This abnormality suggests a moderate encephalopathy. Medications, metabolic disturbances, and infection are the most common causes. Of note is that focal abnormalities could be obscured by the diffuse generalized slowing. However, there were no focal findings in this recording and no epileptiform features . Head CT [1-6]: FINDINGS: There is 2.9 x 6.1 cm right parietotemporal hemorrhage, which dissects into the right lateral ventricle. Moderate surrounding vasogenic edema is noted. There is also another focus of intraparenchymal hemorrhage within the right temporal lobe measuring 13 mm. No hydrocephalus is visualized. There is subarachnoid hemorrhage within the right frontoparietal and temporal lobes. 5-mm left [Hospital1 ] subfalcine herniation is noted. No fracture is identified. The paranasal sinuses and mastoid air cells are clear. Calcification of the cavernosal internal carotid arteries is noted. . IMPRESSION: 1. Right temporoparietal hemorrhage associated with surrounding vasogenic edema and 5-mm subfalcine herniation. Considering the presence of small foci of hemorrhage on prior MR of the head of [2182-4-9], the most likely etiology is amyloid angiopathy. 2. Small focus of hemorrhage within the right temporal lobe may be the extension of the right temporal lobe bleeding in extraxial space or a new focus of hemorrhage. Another possibility is a small subarachnoid hemorrhage. 3. Right intraventricular hemorrhage with no hydrocephalus and right hemispheric subarachnoid hemorrhage. . Repeat Head CT [12-28]: 1. Essentially stable appearance of parenchymal and subarachnoid hemorrhage. 2. Decreased intraventricular hemorrhage. Stable ventricular size with partial effacement of the posterior right lateral ventricle. 3. Stable mild right subfalcine herniation Brief Hospital Course: Pt was admitted for his presenting symptoms. Pt was initially admitted to the ICU for monitoring. Pt completed a Head CT which showed Right parietal and temporal hemorrhage. Pt continued to show cognitive decline. Pt was transferred to the floor. Pallatative Care was consulted. A family meeting was conducted with neurology-stroke division, pallatative care team and the family including wife and daughter. The decision was made to make the patient CMO. CMO measures were taken. Medications were withdrawn. Case management and family decided on a hospice facility for 24hrs supervision and healthcare. Pt was trf to the hospice facility of the families choice, [Hospital1 3894]. Medications on Admission: - Exelon 9.5 mg/24 hour Transderm 24 hr Patch Apply one patch daily - Sertraline 50 mg Tab Oral 1 Tablet(s) , at bedtime - Carbidopa-Levodopa 25 mg-250 mg Tab, Rapid Dissolve Oral 2 Tablet, Rapid Dissolve(s) Three times daily - Fludrocortisone 0.1 mg Tab Oral 1 Tablet(s) Twice Daily - Omeprazole 20 mg Cap, Delayed Release Oral Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Ativan 0.5 mg Tablet Sig: 2-4 Tablets PO q4 PRN discomfort as needed. Disp:50 Tablet(s) Refills:0 3. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO q2 PRN pain as needed: Please give 5mg to 20mg q1-2 hrs SL PRN pain/dyspnea. Disp:20 ml Refills:0 4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal every seventy-two (72) hours as needed: Give as needed for congestion. Disp:5 patches Refills:0 5. Levsin/SL 0.125 mg Tablet, Sublingual Sig: [1-10] Sublingual q4 PRN congestion as needed: Give as need for congestion . Disp:30 tablets Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 3894] health hospice Discharge Diagnosis: Primary: Right Parietal and temporal hemorrhage secondary to amyloid angiopathy Secondary: Parkinson's Disease Discharge Condition: Stable. Increased symptoms of Parkinsonism symptoms including cogwheel rigidity, masked facies, Left facial paresis and unable to follow commands. Pt currently has audible yet comfortable respiratory rhythm. Discharge Instructions: You were admitted for evaluation of confusion and left sided neglect. You were found to have hemorrhages in the right parietal and temporal lobes and cognitive deficits due to progression of your Parkinson's Disease and dementia in the setting of this hemorrhage. Your family elected to focus your care on comfort based on your previously stated wishes, and we therefore stopped your Sinemet and Exelon, and consulted with the Palliative Care team about how best to make you comfortable. Followup Instructions: NONE [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 431
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6414 }	Medical Text: Admission Date: [2191-7-15] Discharge Date: [2191-7-22] Date of Birth: [2136-8-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 54 y/o M with a PMHx of COPD, 60 pack year tob hx, and schizophrenia presented to [Hospital1 18] with progressive SOB and dyspnea. Pt states that his sx's initially began 2 weeks ago and have steadily worsened. He admits to a dry cough, with subjective fevers, but no documented elevated temperature. No prod cough or sputum production. No sick contacts. [Name (NI) ] denies any PND, orthopnea, or LE edema. His sx's worsened to the point where he was having difficulty breathing at rest and he called EMS. He was found to be breathing in the 40s and 90% on RA. He was given a Combivent neb en route and brought to [Hospital1 ]. . In the ED, he received Solumedrol 125mg IV x1, Levaquin 750mg IV x1, Albuterol nebs x2, Combivent nebs x1 and was initially placed on BiPaP but he did not tolerate this and was placed back on a NRB prior to arrival in the MICU. . MICU course significant for progressive weaning off BiPaP. Never intubated. CXRs did not demonstrate any consolidation but f/u CT demonstrated emphysematous lung with areas of ground glass opacity and focal nodularity. Past Medical History: (1) COPD; no hx of intubation or hospitalization (2) Schizophrenia (3) hx of Etoh abuse, quit 3 years ago (4) 60 pack year smopking hx, quit 3 weeks ago Social History: 60 pack year tob hx. Hx of etoh abuse, now sober. Denies any IVDU. On disability due to schizophrenia. Lives along at boarding house on Beacon St. Family History: no fam hx of lung disease, or CA Physical Exam: VS: Temp: 97.1 oral BP:174/94 HR:90 RR:22 O2sat: 96%RA GEN: Obese male, in mild resp distress, able to speak in short sentences without dyspnea HEENT: PERRLA, EOMI, anicteric, MMM, op without lesions NECK: Difficult to assess, but no apparent JVD RESP: Scattered rhonchi diffusely but no wheezes or rales appreciated with marginal inspiratory effort. No retractions, not using accessory muscles to inspire, no abd breathing. No dullness to percussion CV: Distant heart sounds, but appears regular without murmurs. ABD: Obese, nd, +b/s, soft, nt, no HSM appreciated EXT: no c/c/e NEURO: AAOx3. Moves all ext. Pertinent Results: [2191-7-15] . WBC-7.8 RBC-4.72 Hgb-15.5 Hct-40.7 MCV-86 MCH-32.8* MCHC-38.0* RDW-12.7 Plt Ct-180 . Glucose-135* UreaN-17 Creat-0.8 Na-121* K-4.0 Cl-88* HCO3-25 AnGap-12 . CK(CPK)-1748, MB Indx-1.1, cTropnT-<0.01 . Type-ART FiO2-98 pO2-169 pCO2-44 pH-7.35 calTCO2-25 Base XS--1 AADO2-483 REQ O2-82 Intubat-NOT INTUBA Comment-NEBULIZER . [2191-7-18] . WBC-23.4* RBC-4.09* Hgb-13.2* Hct-36.5* MCV-89 MCH-32.2* MCHC-36.1* RDW-13.1 Plt Ct-254 . [2191-7-22] . WBC-14.5* RBC-4.90 Hgb-15.7 Hct-44.4 MCV-91 MCH-32.0 MCHC-35.4* RDW-12.4 Plt Ct-357 . Glucose-89 UreaN-17 Creat-0.7 Na-126* K-3.7 Cl-89* HCO3-28 AnGap-13 . CK(CPK)-130 . TSH-0.33 EKG [7-15]: NSR 97. +LAD, nml intervals. No ST elevations/ depressions. No TWIs. Nml EKG - no previous to compare. . Imaging: . CTA Chest [7-18]: 1) No pulmonary embolism is identified. No pulmonary infarction is noted. 2) Multiple non-pathologically enlarged nodes are noted within the mediastinum. 3) Multiple illdefined areas of ground glass opacity are scattered in all lobes of both lungs. Additional scattered small nodular densities are present. Overall findings are nonspecific. Differential diagnoses include inflammatory/infectious process, COP (cryptogenic organizing pneumonia), eosinophilic pneumonias . Correlate clinically, with lab data and follow up . LE Venous Dopplers [7-18] FINDINGS: Grayscale and Doppler son[Name (NI) 1417] of bilateral common femoral, superficial femoral, popliteal, and calf veins were performed. There is normal compressibility, flow, and augmentation. . IMPRESSION: No evidence of DVT bilaterally. . Brief Hospital Course: 54 y/o M with a PMHx of COPD, schizophrenia presented to [Hospital1 18] with progressive SOB and dyspnea x 2 weeks, a/w subj. fevers/sweats/diarrhea. This is likely due a COPD exacerbation brought on by a mild infection. . 1. COPD exacerbation The patient's shortness of breath and dyspnea were felt to be due to a COPD exacerbation, given the history of subjective fevers/chills and diarrhea. In the MICU he was placed on steroids (solumedrol), antibiotics (azithro), nebulizers, and supplemental oxygen. He responded quite well and never required intubation, just BIPAP. Over the course of his MICU stay he was weaned off of BIPAP until stable to come to the floor, where he continued to improve on this regimen. He was continued on azithromycin throughout his stay, and we was switch to po prednisone with an oupatient taper planned. He benefitted from nebulizer treatments and as such he was provided with a nebulizer machine for his home, as well as instruction on its use and prescriptions for nebs. His oxygen saturation on RA ranged in the 92% range, which, given his extensive smoking history, was presumed to be near his baseline. His symptoms and pulmonary exam improved throughout his stay, and after passing PT evaluation for stair climbing (lives in a walk-up) he was cleared for discharge. . 2. Elevated CK Patient presented with elevated CK, unclear etiology, was likely mild rhabdo. Responded well to aggressive IVF, and trended down nicely over course of admission. On discharge it was in the 100s. He had an EKG and biomarkers which were negative for cardiac ischemia. . 3. Hyponatremia Was 121 on admission, resolved to 136 at best during hospitalization, but dropped just before discharge to 126. Euvolemic exam. Proposed etiologies include SIADH given his extensive lung disease and CT findings, hypothyroid (TSH was normal), HCTZ (held), and other medication related. Patient was discharged with instructions to repeat his sodium as an outpatient lab 2-3 days after discharge. This information was communicated to his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] to ensure proper follow-up, the patient has an appt with his PCP scheduled within 2 weeks of discharge. . 4. Schizophrenia We continued his Abilify and Paxil home regimen. Remained well controlled on meds. No A/V hallucinations during stay. . 5. Ground Glass Opacities on CT The differential diagnosis for these findings on CT is broad and includes inflammatory/infectious process, COP (cryptogenic organizing pneumonia), eosinophilic pneumonia (unlikely givne lack of eos). As the treatment for many of these conditions is steroids, he was kept on a slow steroid taper as per pulmonary guidance in the ICU and has a f/u appt with Dr. [Last Name (STitle) ] from pulm on [8-18] at 4PM . 6. Elevated Blood Glucose + Leukocytosis These effects were likely [2-25] steroids. He displayed no clinical signs of infection and had no history of diabetes. His WBC count was trending back towards near normal by discharge. His finsgersticks were managed with sliding scale insulin. . HTN - no prior diagnosis, but was hypertensive in the MICU. HCTZ was begun, but BP remained still elevated on floor. We d/c'ed his HCTZ given concerns about hyponatremia, and added amlodipine 5mg daily and lisinopril 10 mg daily with better BP control. . FEN: He ate a cardiac diet and did not require additional IVF on the floor. His electrolytes were repleted prn. For DVT prophylaxis, he was given Heparin sQ. He was maintained as full code. Medications on Admission: Abilify 10 qD Paxil 20 qD Combivent 1 inhalation [Hospital1 ] Discharge Medications: 1. Nebulizer machine 2. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. Disp:qs ML(s) Refills:0 5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:qs neb Refills:0 6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:0 7. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Take 3 tabs for 7 days, then 2 tabs for 5 days, then 1 tab for 3 days, then stop. Disp:34 Tablet(s) Refills:0 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Outpatient Lab Work Please have a sodium level checked on Monday, [7-25]. You should go to your PCP's office to have this done. Discharge Disposition: Home Discharge Diagnosis: Chronic Obstructive Pulmonary Disease exacerbation Discharge Condition: Good- ambulatory sats stable with walking and climbing stairs Discharge Instructions: You were hospitalized for a COPD exacerbation. You were treated with antibiotics, steroids, and nebulizers. You should continue to take the steroids as instructed, along with all of your other medications. Continue to keep yourself well hydrated. Maintain all of your follow-up appointments. You will need to go to your PCP's office on Monday to have your sodium level checked. You should call your doctor or return to the emergency room if you experience chest pain, shortness or breath, fevers or chills. Followup Instructions: You should keep your appointment with Dr. [Last Name (STitle) ] on [8-4]. You should go to Dr.[Name (NI) 110764] office on Monday with your prescription to have your sodium level checked. The following are your appointments to have your lungs evaluated: Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2191-8-18] 3:40 Provider: [Name10 (NameIs) 1570],[Name11 (NameIs) 2162] [Name12 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2191-8-18] 4:00 Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ]/DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2191-8-18] 4:00 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] ICD9 Codes: 2761, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6415 }	Medical Text: Admission Date: [2173-6-24] Discharge Date: [2173-6-25] Date of Birth: [2106-5-8] Sex: M Service: MEDICINE Allergies: Lipitor / Optiray 350 Attending:[First Name3 (LF) 443] Chief Complaint: Atrial Fibrillation Major Surgical or Invasive Procedure: D/C Cardioversion History of Present Illness: Mr. [Known lastname 27735] is a 67 year old male with past medical history significant for diabetes, HTN, GERD, and recent pancreatectomy for necrotizing pancreatitis who presents with nausea, diaphoresis and new onset atrial fibrillation. The patient was in his USOH on the morning of admission when he came to the [Hospital1 18] to have his percutaneous cholecystostomy tube removed. He returned to his rehabilitation facility ([Hospital 100] Rehab) without incident. Shortly after being seen by the physician [Name Initial (PRE) ] (Dr. [Last Name (STitle) ] he began to experience nausea and diaphoresis, which he experiences fairly frequently since his pancreatectomy. He then had a 5minute episode of epigastric pain. This was a [4-3] dull ache, that he had never felt before and that he distinguished as being lower down than the discomfort he experiences with reflux. The pain did not radiate and was not accompanied by subjective palpitations or light headedness. At this time the patient's physician had returned to the room and his heart rate was noted to be in the 162. Per the NH notes an EKG demonstrated new ST depressionsin V3-V5 with old TWF in III and AVF and LVH. Also noteworthy is that the physician at the nursing home documented the absence of CP, nausea, or diaphoresis. Patient was sent to the [Hospital1 18] via ambulance. Per the EMS record Vital signs were HR 160-180, BP 100/70, EKG showed SVT. Given 6mg IV adenosine and 15mg IV cardizem. In the ED the patient's vital signs were HR 160 BP 88/46 RR20 and Sa02 99% on RA. EKG showed Afib with RVR. He was given Dilt 20 IV and 120 PO, fentanyl 25 IV x2, Versed 1mg IV x2, amiodarone 150mg IV x1 and then 1mg/min gtt, and heparin gtt. DCCV 50 joules unsuccessful and then 200 joules with resolution to NSR. CXR performed and CTA deferred [2-26] contrast allergy. Past Medical History: chronic pancreatitis - complicated by pseudocyst. s/p multiple ERCP's with multiple sphyncterotomies. Now S/P pancreatectomy in [2173-2-24]. Diabetes - recent diagnosis. HTN Patient reports recent C.diff diagnosis - per daughter (a physician) he has been treated. [Last Name (un) 865] esophagus COPD h/o MRSA pneumonia Melanoma s/p removal 15 years ago Prostate CA - radical prostatectomy in [2165] Social History: significant for the absence of current tobacco use (quit 30 years aog. There is no history of alcohol abuse - drinks [1-26] beers/week. Family History: [Name (NI) ] father died of "Heart Disease" at age 51. [Name (NI) ] mother died unexpectedly in an automobile accident Physical Exam: VS: T:97.7 BP:97/51 HR:77 RR:25 O2:1005 on RA Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP flat CV: PMI located in 5th intercostal space, midclavicular line. Soft heart sounds. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles bilaterally at the bases with right worse than left. Abd: Soft, NTND. Patient has beefy red 6 inch midline surgical scar that drained clear fluid. He also has a RUQ dark purulent drainage tube lesion in the right upper quadrant presumed to be where the cholecystectomy drain was removed earlier today. No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: LABS ON ADMISSION: . [2173-6-24] 04:00PM WBC-10.5 RBC-3.32* HGB-8.9* HCT-27.2* MCV-82 MCH-26.8* MCHC-32.8 RDW-18.0* [2173-6-24] 04:00PM cTropnT-0.02* [2173-6-24] 04:00PM CK(CPK)-13* [2173-6-24] 04:00PM GLUCOSE-110* UREA N-10 CREAT-0.4* SODIUM-137 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11 [2173-6-24] 11:50PM PTT-150* [2173-6-24] 11:50PM TSH-2.3 [2173-6-24] 11:50PM CK-MB-NotDone cTropnT-0.07* [2173-6-24] 11:50PM CK(CPK)-16* . ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2173-2-15], left ventricular systolic function is now slightly less vigorous. . LABS ON DISCHARGE: [2173-6-25] 09:00AM BLOOD WBC-10.4 RBC-3.42* Hgb-9.1* Hct-28.4* MCV-83 MCH-26.6* MCHC-32.0 RDW-18.4* Plt Ct-685* [2173-6-25] 09:00AM BLOOD Glucose-121* UreaN-8 Creat-0.5 Na-138 K-3.8 Cl-108 HCO3-24 AnGap-10 [2173-6-25] 09:00AM BLOOD CK-MB-NotDone cTropnT-0.05* [2173-6-25] 09:00AM BLOOD Albumin-2.4* Calcium-8.6 Phos-3.4 Mg-1.8 Cholest-PND Brief Hospital Course: The patient was admitted to the CCU after d/c cardioversion converted him to Sinus Rhythym. Anticoagulation was begun with heparin IV. He will be discharged on a heparin drip and not started on warfarin given possible future surgical procedures. He remained in sinus rhythym with stable blood pressures. An echo revealed low-normal EF. Surgery saw the patient who agreed with a discahrge back to Rehab with surgery follow up. His primary outpatient cardiologist was called [2-26] a patient history of "fast heart rate" in the past. A message was left and the patient was encouraged to schedule a follow up appointment with this cardiologist on discharge. He has close follow up with surgery and care at [Hospital 100] Rehab. Medications on Admission: 1. Acetaminophen 325 mg PO Q4-6H:PRN fever 2. Docusate Sodium (Liquid) 100 mg PO BID 3. Ferrous Sulfate 325 mg PO DAILY 4. Heparin 5000 UNIT SC TID 5. Insulin SC (per Insulin Flowsheet) Sliding Scale 6. Lactase NF 3,000 unit Oral dialy 7. Lactulose 30 ml PO Q8H:PRN 8. Metoclopramide 10 mg PO QIDACHS 9. Metoprolol 25 mg PO BID 10. Morphine Sulfate 2 mg IV Q4H:PRN 11. Multivitamins 1 CAP PO DAILY 12. Sodium Chloride 2 gm PO DAILY 13. Zolpidem Tartrate 5 mg PO HS Discharge Medications: 1. Acetaminophen 325 mg Tablet [Hospital ]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever. 2. Metoclopramide 10 mg Tablet [Hospital ]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 3. Sodium Chloride 1 g Tablet [Hospital ]: Two (2) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet [Hospital ]: One (1) Cap PO DAILY (Daily). 5. Lactulose 10 g/15 mL Syrup [Hospital ]: Thirty (30) ML PO Q8H (every 8 hours) as needed. 6. Zolpidem 5 mg Tablet [Hospital ]: One (1) Tablet PO HS (at bedtime). 7. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) [Hospital ]: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Ferrous Sulfate 325 (65) mg Tablet [Hospital ]: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 50 mg/5 mL Liquid [Hospital ]: One (1) PO BID (2 times a day) as needed. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 12. Insulin Regular Human 100 unit/mL Solution [Last Name (STitle) ]: 2-10 UNITS Injection ASDIR (AS DIRECTED): per provided sliding scale. 13. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [Last Name (STitle) ]: 1000 (1000) UNITS Intravenous per hour: ADJUST INFUSION PER SLIDING SCALE. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Atrial Fibrillation with Rapid Ventricular Response . chronic pancreatitis - S/P pancreatectomy in [2173-2-24]. Diabetes - recent diagnosis. HTN Patient reports recent C.diff diagnosis - treated [Last Name (un) 865] esophagus COPD h/o MRSA pneumonia Melanoma s/p removal 15 years ago Prostate CA - radical prostatectomy in [2165] Discharge Condition: stable Discharge Instructions: Please take all medications as prescribed. Please attend all follow up appointments. You were admitted because of Atrial Fibrillation with a Rapid Ventricular Response. You were succesfully cardioverted. You will need to take blood thinning medications for some time. You will be taking Lovenox. You will not be started on warfarin as there may be more surgical interventions in the future. You will need to discuss with your surgeons when it will be ok to start coumadin. Followup Instructions: Provider: [First Name8 (NamePattern2) 251] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 476] Date/Time:[2173-7-5] 9:30 . It is recommended that you contact your Cardiologist Dr. [Last Name (STitle) 5655] in [Location (un) 8545] @ [Telephone/Fax (1) 27736] to set up a follow up appointment following the discharge from [Hospital 100] Rehab. . ICD9 Codes: 496, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6416 }	Medical Text: Admission Date: [2175-12-21] Discharge Date: [2175-12-28] Service: CT Surgery CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is an 80 year old man with a history of coronary artery disease, status post myocardial infarction in [2147] complicated by atrial fibrillation, who presented to an outside hospital with two days of increasing frequency of chest pain. The patient formerly had chronic stable angina for many years that resolved with rest. His symptoms at this time started to escalate on [2175-12-20] at about 3:00 a.m. and lasted several hours but went away with rest. The symptoms recurred several times during that day and became more severe on the morning of admission. Associated symptoms include sweats, nausea and palpitations, no shortness of breath. The patient went to the [Hospital ] [Hospital3 2063], where an electrocardiogram showed new inferior Q waves and ST depression with T wave inversions anterolaterally. The patient was given aspirin, nitroglycerin and morphine, heparin and Aggrastat were started, and his chest pain resolved. The patient was transferred to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] for an emergent cardiac catheterization. PAST MEDICAL HISTORY: 1. Myocardial infarction in [2147]. 2. Atrial fibrillation, last noted in [2151]. 3. Cerebrovascular accident in [2158]. 4. Osteoarthritis. 5. Benign prostatic hypertrophy. 6. Chronic stable angina. MEDICATIONS ON ADMISSION: (at home) Lopressor 25 mg p.o.b.i.d., digoxin 0.25 mg p.o.q.d., Tylenol 650 mg p.o.b.i.d., Relafen 500 mg p.o.b.i.d. and Xalatan 0.5% one drop o.u.q.d. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is a widower, former painting contractor. He does not use alcohol and has a remote history of tobacco. PHYSICAL EXAMINATION: On physical examination on admission, the patient was an irritable elderly man sitting at the edge of his bed in no acute distress. Neck: Supple, no jugular venous distention. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, distant S1 and S2, no murmur. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: No cyanosis, clubbing or edema, 1+ pulses bilaterally. Rectal: Heme negative. Neurologic examination: Alert and oriented times three. LABORATORY DATA: White blood cell count was 12.8, hematocrit 35.5, platelet count 264,000, prothrombin time 13.9, INR 1.3, partial thromboplastin time 122.5, CK 1,806, MB 79 and troponin greater than 50. Electrocardiogram revealed normal sinus rhythm at a rate of 85 beats per minute with a normal axis, inferior Q waves, [Street Address(2) 1766] depressions in V4 through V6, poor R wave progression noted. HOSPITAL COURSE: The patient was taken to the catheterization laboratory shortly after arrival at [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ]. Please see the catheterization report for full details. In summary, the catheterization reported showed left main and three vessel disease with a left ventricular ejection fraction of 20% to 25%. Cardiothoracic surgery was consulted and the patient was accepted for coronary artery bypass grafting. On the morning of [2175-12-22], the patient was brought to the Operating Room, at which time, he underwent coronary artery bypass grafting times four. Please see the Operating Room for full details. In summary, the patient had coronary artery bypass grafting times four with a left internal mammary artery to the left anterior descending artery, vein graft to the posterior descending artery and a vein graft to the obtuse marginal and diagonal sequentially. His bypass time was 99 minutes and crossclamp times was 83 minutes. The patient tolerated the procedure well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient's mean arterial pressure was 87 and central venous pressure 24. He was in a sinus rhythm of 100. He had propofol at 25 mcg/kg/minute, nitroglycerin at 0.5 mcg/kg/minute, Neo-Synephrine at 2.5 mcg/kg/minute and milrinone at 0.5 mcg/kg/minute. The patient was somewhat hypoxic in the immediate postoperative period. He was therefore kept sedated and ventilated throughout the course of his operative day. On the morning of postoperative day number one, the patient's sedation was discontinued, he was weaned from the ventilator and eventually extubated. He did well throughout the remainder of postoperative day number one until late in the afternoon, at which time he went into a rapid atrial fibrillation with a ventricular response rate of 80 to 140. He was begun at that time on an amiodarone drip. His rapid atrial rate was associated with some hypotension, which was controlled with his Neo-Synephrine drip. An initial attempt to wean the patient off his milrinone was unsuccessful and he was therefore returned to 0.5 mcg/kg/minute. On postoperative day number two, the patient was successfully weaned from his milrinone drip, however, he did remain on his Neo-Synephrine and amiodarone drips. Later in that day, the patient converted to a sinus rhythm and his amiodarone drip was converted to oral amiodarone. On postoperative day number four, the patient was off all vasoactive intravenous medications. He remained hemodynamically stable in sinus rhythm and he was transferred to [Hospital Ward Name 121] Six for continuing postoperative care and cardiac rehabilitation. Once on the floor, the patient continued to progress slowly. His activity level was increased with the assistance of the nursing staff and physical therapy. His diet was advanced to a regular diet. On postoperative day number six, he was deemed stable and ready for transfer to rehabilitation for continuing cardiac rehabilitation following his coronary artery bypass grafting. PHYSICAL EXAMINATION ON DISCHARGE: Vital signs: Temperature 97.3, heart rate 73 sinus rhythm, blood pressure 112/70, respiratory rate 20 and oxygen saturation 92% in room air. Weight preoperative was 62 kilograms, at discharge 68.3 kilograms. General: Alert and oriented times three, conversant, moves all extremities. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1 and S2 with a II/VI systolic ejection murmur. Chest: Sternum stable, incision with Steri-Strips, open to air, clean and dry. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: Warm with positive pulses bilaterally, 1+ pedal edema bilaterally, right lower extremity incision with Steri-Strips, open to air, clean and dry, large ecchymotic area on right thigh from kneecap to groin. LABORATORY DATA AT DISCHARGE: White blood cell count 10, hematocrit 31, platelet count 254,000, sodium 139, potassium 4.8, chloride 102, bicarbonate 28, BUN 30, creatinine 1.2, glucose 101. DISCHARGE MEDICATIONS: Amiodarone 400 mg p.o.b.i.d. times seven days then q.d. Lopressor 25 mg p.o.b.i.d. Lasix 20 mg p.o.b.i.d. times ten days. Potassium chloride 20 mEq p.o.b.i.d. times ten days. Colace 100 mg p.o.b.i.d. Ranitidine 150 mg p.o.b.i.d. Xalatan 0.5% one drop o.u.q.d. Aspirin 325 mg p.o.q.d. Relafen 500 mg p.o.b.i.d. Tylenol 650 mg p.o.q.4h.p.r.n. DISPOSITION: The patient is to be discharge to rehabilitation at the [First Name4 (NamePattern1) 1313] [Last Name (NamePattern1) ] in [Location 9583]. He is to have follow-up in the wound clinic in two weeks, follow-up with Dr. [Last Name (STitle) 1537] in one month and follow-up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], in three to four weeks. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2175-12-28] 10:45 T: [2175-12-28] 11:01 JOB#: [Job Number 38965] ICD9 Codes: 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6417 }	Medical Text: Admission Date: [2172-10-3] Discharge Date: [2172-10-7] Service: MEDICINE Allergies: Naproxen Attending:[First Name3 (LF) 2159] Chief Complaint: brbpr Major Surgical or Invasive Procedure: None History of Present Illness: HPI: [Age over 90 ] yo Russian speaking F with CAD, AFib, DM, HTN, CHF, CRI (Baseline Cr=1.4), anemia, who presents from [Hospital 100] rehab with 2 episodes of blood in her stool this am. She was found to have a supratherapeutic INR (5.9) at [Hospital 100] Rehab. She received one dose of Vit K 5 mg po and was transferred to [Hospital1 18] for evaluation. Per report patient denied lightheadedness, dizziness, CP, SOB, N/V, belly pain. Initial vitals revealed SBP in the mid 90's which increased to 110's without intervention, HR remained in the 60's. NG lavage negative. Hct noted to be 28.0. As per Nursing Home staff pt has been off coumadin for 5 days secondary to elevated INR. She was started on coumadin after her recent hip surgery. Her INR has been difficult to control. She has not been on any other new medications recently. . In the [Name (NI) ], pt received an additional 10 mg of SC Vitamin K and 2 units of FFP. She has two large bore IV's. She has not yet received a blood transfusion. . Past Medical History: PMH: 1. CAD 2. AF 3. CKD (Cr 1.5-1.7) 4. DM 5. h/o UTI 6. Osteoporosis 7. Glaucoma 8. Hyperlipidemia 9. HTN 10. Depression 11. Anemia Social History: Nursing Home resident, lives a [Hospital 100] Rehab. Contact is son [Name (NI) 4186] ([Telephone/Fax (1) 107323] and ([Telephone/Fax (1) 107324] (h) Family History: Non-contributory Physical Exam: Physical Exam: Tc 97.6 BP 107/66 HR 72 RR 16 Sat 97% RA Gen: well appearing elderly female, NAD HENNT: MMM, anicteric Neck: no LAD, JVD flat, no carotid bruits CV: RRR, nl S1S2, III/VI systolic murmur heard best at apex Lungs: soft bibasilar crackles Abd: soft, NT/ND, +BS, No HSM Ext: no edema, strong DP/PT pulses bilaterally, blood filled flacid blisters on bilateral heals w/o surrounding erythema Neuro: Moving all extremeties . Pertinent Results: [2172-10-3] 08:08PM ALT(SGPT)-20 AST(SGOT)-27 LD(LDH)-256* ALK PHOS-480* TOT BILI-0.7 [2172-10-3] 08:08PM HAPTOGLOB-121 [2172-10-3] 08:08PM HCT-19.6# [2172-10-3] 06:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2172-10-3] 06:00PM URINE RBC-[1-25] WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2172-10-3] 02:22PM GLUCOSE-134* UREA N-33* CREAT-1.3* SODIUM-140 POTASSIUM-5.4* CHLORIDE-113* TOTAL CO2-16* ANION GAP-16 [2172-10-3] 02:22PM WBC-11.9* RBC-2.98* HGB-9.3* HCT-28.0* MCV-94 MCH-31.2 MCHC-33.2 RDW-15.9* [2172-10-3] 02:22PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL [2172-10-3] 02:22PM PT-32.3* PTT-47.7* INR(PT)-7.9 Studies: CXR [2172-10-3]: hlar fullness, retrocardiac opacity with blunting of left costophrenic angle. . ECG: NSR, rate 64, nl intervals, nl axis, old Q's III, V1-V3, no new ST-T changes. . ECHO [2-25]: 1. The left atrium is mildly dilated. The interatrial septum is aneurysmal. 2. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis. Overall left ventricular systolic function is moderately depressed. 3. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. Brief Hospital Course: A/P: [Age over 90 ] yo Russian speaking F with CAD, AFib on coumadin, DM, HTN, CHF, CRI (Baseline Cr=1.4), anemia (baseline hct ~30), who presents from [Hospital 100] rehab with episodes of blood in her stool. . # GI bleed: The pt was admitted to the [Hospital Unit Name 153]. On admission the patient had a negative NG lavage in setting of INR of 7.9. Tthe etiology was felt to be a LGIB in the setting of a supratherapeutic INR. The DDX included diverticulosis, AVM, malignancy, hemorrhoids. On admission the pt received 15 mg of Vit K. She was given 2 units of FFP in addition to those given in the ED for a total of 4 Units and transfused 2 units of PRBC's. Initially she received q 6 hour hct checks and an IV PPI [Hospital1 ]. Her [Hospital1 ] and Coumdain were held. In the [Hospital Unit Name 153], the pt's hct stabilized. GI was consulted but did not want to do any intervention because they believed bleed was caused by supratherapeutic INR. The pt was transfered to the floor as she was hemodynamically stable, her hct is stable, and her INR dropped from 7.9 on admit to 0.9. While on the floor the pt initially reported feeling weak, but on the day of discharge reported feeling well after 2 days of po. . # Coagulopathy. The pt presented with an INR of 7.9. The pt had been off coumadin x5 days, but had been supratherapeutic and difficult to control on past admission. She had no new medications. Her coagulopathy was likely related to malnutrition and poor control on coumadin. She was given FFP and Vitamin K as above. Her coumadin was held. Her INR returned as above to 0.9. Per ortho, she was placed on lovenox 30 mg qd X 4 weeks for better-controlled anti-coagulation. . # CV: h/o CAD: The pt was placed on a BB and ACE-I, once her preussure could tolerate them. She wa splaced back on her home statin and [Hospital Unit Name ], once her hct was stable. pump: Pt has a known CHF (EF 30-35%). An ACE-I was added for afterload reduction. rhythm: h/o PAFIB. The remained in sinus with well controlled HR. She wa splaced on anti-coag as above. . # Recent Hip Fracture s/p reduction and fixation: The patient was kept non wt bearing throughout her admission with PT follow-up. She was placed on standing tylenol with prn oxycodone for pain control. Eventually she was weaned off the tylenol with the prns adequately controlling her pain. Ortho recommended lovenox out-pt as above. . # HTN. Her BP remained well-currently during admission. She was continued on her out-pt lopressor 25 mg po bid. Her out-pt amlodipine was d/c'd and lisinopril was added given her known poor pump fxn and DM. # DM. Not treated at [Hospital 100] Rehab. Her Blood sugars remained well controlled on this admission without treatment. . # FEN. The pt was initially made NPO. On discharge she was tolerating a regular heart healthy/DM diet. . # PPX. anti-coag discussed above, PPI [Hospital1 ] (switched to po once on the floor), bowel regimen . # Code: DNR/DNI as per NH records . # Communication: Son - [Name (NI) 4186] ([Telephone/Fax (1) 107323] /([Telephone/Fax (1) 107324] (h) . . Medications on Admission: Home Meds: 1. Amlodipine 10 mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Isosorbide Mononitrate 30 mg Sustained Release PO DAILY 4. trazadone 25 mg qhs prn insomnia 5. Mirtazapine 15 mg PO HS 6. Metoprolol Tartrate 100 mg PO BID 7. Lisinopril 5 mg PO DAILY 8. Oxycodone 5 mg PO Q4-6H as needed for pain. 9. Tylenol 975 mg q 6hrs 10. Senna 2 tabs qhs 11. simvastatin 20 mg qhs 12. coumadin d/c'ed 5 days ago . All: Naproxen Discharge Medications: 1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:15 Tablet(s) Refills:0 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. 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 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. 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 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 4 weeks. Disp:qs qs Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Primary Diagnoses: 1. GI Bleed 2. Supratherapeutic INR 3. Congestive Heart Failure Secondary Diagnoses: 1. CAD 2. PAfib 3. CKD 4. Diet controlled DM 5. s/p R hip ORIF 6. Hypertension 7. Osteoporosis 8. Hyperlipidemia Discharge Condition: stable, no further episodes of GI bleeding Discharge Instructions: Please contact your primary care doctor or 911 should you develop any abdominal pain, blood in your stools, abdominal pain, difficulty breathing, chest pain, or any other complaints. For DVT prophylaxis after her hip surgery, she should begin taking Lovenox, 30 mg sq qd x 4 weeks. She does not need coumadin. Mrs [Known lastname 107322] should have daily weights checked. If her weight increases more then 2 lbs, she should begin her outpatient Lasix dose. We have changed Ms. [Known lastname 107327] cardiac regimen as follows: 1. We have stopped her Isosorbide and Amlodipine. 2. We have increased her Lisinopril to 10 mg qd. 3. Her Metoprolol has been decreased to 50 mg [Hospital1 ]. 4. We strongly recommend titrating her Lisinopril and Metoprolol as tolerated for her congestive heart failure. If she is still hypertensive on max dose Lisinopril (ie, 40 mg), we would recommend adding back the amlodipine. 5. She is a diabetic and has CAD, therefore her Aspirin dose has been increased to full strength (ie, 325 mg). Followup Instructions: Please follow up with Dr. [Last Name (STitle) 2637] ICD9 Codes: 5789, 5859, 4280, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6418 }	Medical Text: Admission Date: [2102-9-20] Discharge Date: [2102-9-26] Date of Birth: [2040-10-16] Sex: M Service: SURGERY Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 6088] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2102-9-20]- emergent open repair of abdominal aortic aneurysm with bifurcated graft History of Present Illness: 61 year old man who presented to an OSH with abdominal pain and L flank pain beginning in the afternoon of [9-19]. He underwent abdominal CT which showed a 8.5 x 9.5 cm infrarenal AAA with a question of impending rupture. He was transferred to [Hospital1 18] for evaluation and management. Past Medical History: HTN, hyperlipidemia Social History: quit smoking 11 years ago denies EtOh Family History: non contributory Physical Exam: VS: 98.6 60 155/84 20 98%RA Gen: A&Ox3 NAD Neuro: CN 2-12 grossly intact CV: RRR, no m/r/g Pulm: CTAB GI: abd soft, NT, ND Ext: WWP, DP/PT palpable bilaterally Pertinent Results: CTA Abd/Pelvis [2102-9-20] IMPRESSION: 1. A 9.5 x 8.5 cm fusiform infrarenal aortic aneurysm with contrast dissecting through the intraluminal thrombus which is a CT sign concerning for impending rupture. No frank extravasation. 2. Stranding and fluid to the left of the aorta is of low density and exact etiology is uncertain. Given the low-density, it is unlikely that this is representative of prior leak or slow leak; however, this cannot be fully excluded. 3. Ectatic right common iliac artery to 2.4cm. Brief Hospital Course: Mr. [Known lastname 90850] was transferred to [Hospital1 18] on [2102-9-20]. He had a CTA of abdomen and pelvis demonstrating a 9.5x8.5cm fusiform infrarenal abdominal aortic aneurysm extending to the bifurcation. He was consented for an open repair and taken urgently to the operating room. He did well immediately post-operatively and was taken to the ICU intubated; however he was using all four extremities and responding to commands. On POD1 he was successfully extubated, remained cardiovascularly stable, with normal neuro exam. Pain was well controlled with epidural catheter. On POD2 he was transferred to the step-down VICU for further monitored care. He continued to be hemodynamically stable, with pain well controlled. The epidural was pulled on POD3 and he was transitioned to PO pain medication with good pain control. He began passing flatus and his diet was advanced to clear liquids. The foley catheter was removed on POD4 and he voided with no issues. He continued to tolerate PO, pain well controlled, neuro exam unchanged. On POD5 he is on a general diet, PO pain medication, ambulating without assistance. He is discharged home on POD6 in good condition and will follow up with Dr. [Last Name (STitle) ]. Medications on Admission: metoprolol, fenofibrate, simvastatin Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:20 Capsule(s) Refills:0 7. fenofibrate 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: abdominal aortic aneurysm HTN, hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [6-21] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [2-16] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal Followup Instructions: Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2102-10-5] 2:15 Please make an appoinment with your PCP upon DC for follow-up for your medications. Name: [Last Name (LF) 4343],[First Name3 (LF) ] A. Location: [Location (un) ] PRIMARY CARE Address: [Street Address(2) 26333] [Apartment Address(1) 26334], [Location (un) ],[Numeric Identifier 26335] Phone: [Telephone/Fax (1) 26330] Fax: [Telephone/Fax (1) 26331] Completed by:[2102-9-26] ICD9 Codes: 2859, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6419 }	Medical Text: Admission Date: [2120-6-5] Discharge Date: [2120-6-10] Date of Birth: [2050-3-25] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old female with a history of nonsmall cell lung cancer and mets to the brain. The patient is status post resection of right occipital region on [2120-5-3] with second resection in [2119-9-4]. On [2119-10-19] the patient received whole brain radiation. The patient was readmitted on [2120-4-25] for acute worsening. MRI at that time revealed an increased right occipital mass and edema. The patient was admitted on [6-5] for resection of that lesion. PAST MEDICAL HISTORY: History of lung cancer with metastasis to brain, status post two motor vehicle accidents. Hyperlipidemia, left renal artery thrombosis, gastroesophageal reflux disease, degenerative joint disease, status post TAH/BSO. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Decadron, Nystatin, Gemfibrozil and Prilosec. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: Unremarkable. PHYSICAL EXAMINATION ON ADMISSION: The patient was first seen by this physician [Name Initial (PRE) 26476]. At that time she was intubated and sedated, opening her eyes, nodding her head to commands. She had localizing pain, but no positional movements of her extremities. The patient's temperature was 98.6. Heart rate 100. Blood pressure 100/48, O2 sat 92% and breathing at 23 per minute on assist control. INITIAL LABORATORY: White blood cell count 6.8, hematocrit 31.5, platelets 120, PT 12.1, INR 1.0, PTT 22.1, sodium 137, potassium 3.7, chloride 104, bicarb 24, BUN 14, creatinine .7, glucose 194, calcium 7, magnesium 2, phosphate 2.5. HOSPITAL COURSE: The patient was admitted to the Neurosurgery Service. She received a Decadron taper beginning at 4 mg intravenous q 6 while in the recovery room. This was gradually tapered down and will continue to be tapered. On [2120-6-8] the patient became short of breath requiring oxygen via face mask. Her O2 sat at that time was 85%. Chest x-ray was obtained at that time and demonstrated infection versus lymphangitic carcinomatosis. The patient was treated with Ceftriaxone and Clindamycin. The patient on [6-8] also received a chest CT for purposes of staging her carcinoma. This demonstrated also multiple lymph nodes and potential lymphangitic carcinomatosis. The patient tolerated her craniotomy well and will be discharged to rehab on [2120-6-10]. DISCHARGE DIAGNOSES: 1. Nonsmall cell lung cancer with metastasis to brain. 2. Hyperlipidemia. 3. Gastroesophageal reflux disease. 4. Degenerative joint disease. 5. Status post TAH/BSO. MEDICATIONS ON DISCHARGE: Regular insulin sliding scale, NPH 18 units subQ q.a.m., 6 units subQ q.p.m., Percocet 5/325 one to two tabs po q 4 to 6 hours, Zantac 150 mg po b.i.d., Senna two tabs po b.i.d., Milk of Magnesia 30 milliliters po q 6 hours prn, Levaquin 500 mg po q day until [6-15]. Decadron taper 2 mg po b.i.d. on [6-11] and [6-12], 1 mg po b.i.d. on [6-13] and [6-14], 1 mg po q day on [6-15] and [6-16] and then Decadron will be discontinued. Gemfibrozil 600 mg po q day. FOLLOW UP: The patient will follow up with Dr. [First Name (STitle) ] in neurosurgery. She will also follow up in hematology/oncology clinic on [6-11]. DISCHARGE CONDITION: Stable. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 5476] MEDQUIST36 D: [2120-6-10] 08:21 T: [2120-6-10] 09:12 JOB#: [Job Number 26477] ICD9 Codes: 5119, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6420 }	Medical Text: Admission Date: [2151-9-23] Discharge Date: [2151-9-29] Date of Birth: [2072-8-9] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[Last Name (NamePattern4) 290] Chief Complaint: Cough, Nausea, Vomiting, Respiratory Failure Major Surgical or Invasive Procedure: Endotracheal Intbuation Central Line Arterial Line History of Present Illness: 79 yom with hx of SDH and dementia, CAD s/p CABG, who presents with fever to 104, cough and hypoxia. He had a prolonged hospital course [4-8] during which patient underwent craniotomy for subdural hematoma. Patient also developed Klebsiella PNA s/p trach and PEG. He has been in rehab since and now wheelchair bound wit poor functional status on/off tubefeeds. According to family, he received a feeding early Sunday morning and was found approx one hour later flat in bed with tubefeed material in his mouth. Since that time he had a cough and gargling breathing. He had overall fatigue and was essentially confined to bed, talking less and eating very little. On the evening prior to admission he spiked a fever to 103.8 and was noted to be hypoxic and in more respiratory distress. In the ED he received 2L IVFs, Vanco/CTX/Azithro as well as 5mg IV metoprolol for a SBP 220 and HR Afib in 130s. He desatted <90% on 6L and required NRB and was transferred to the ICU. Past Medical History: Diabetes Mellitus History of CAD History of Mitral regurgitation S/P CABG with LIMA graft in [2148], MV repair. Hypertension Hypercholesterolemia Chronic Kidney Disease 2 Sigmoid resection/polypectomies Social History: Retired engineer Denies tobacco [3-3] etoh/day Family History: non-contributory Physical Exam: At Admission: VS: HR 111 BP 141/75 RR 34 O2 95% on NRB Gen: Awake but drowsy, apparent respiratory distress w/ shallow breaths and abdominal breathing. Able to follow some commands, squeezes hand HEENT: MM dry Neck: Supple, no JVD, no LAD Heart: Irregular, tachycardic, no murmurs Lungs: Rhonchi throughout, poor air movement Abd: Slightly distended, soft, NT, normoactive BS Extrem: No edema Neuro: Pt is sleepy, answers questions appropriately Pertinent Results: At Admission [2151-9-22] 11:57PM BLOOD WBC-12.5* RBC-4.45# Hgb-14.5# Hct-41.9# MCV-94 MCH-32.5 MCHC-34.5 RDW-14.5 Plt Ct-167 [2151-9-22] 11:57PM BLOOD Neuts-93.6* Lymphs-3.6* Monos-2.4 Eos-0.2 Baso-0.2 [2151-9-22] 11:57PM BLOOD PT-11.3 PTT-22.9 INR(PT)-0.9 [2151-9-22] 11:57PM BLOOD Plt Ct-167 [2151-9-22] 11:57PM BLOOD Glucose-155* UreaN-17 Creat-1.0 Na-139 K-3.0* Cl-103 HCO3-25 AnGap-14 [2151-9-23] 07:44AM BLOOD Calcium-6.9* Phos-3.0 Mg-1.5* [2151-9-23] 04:13AM BLOOD Type-ART pO2-138* pCO2-48* pH-7.26* calTCO2-23 Base XS--5 [2151-9-22] 11:50PM BLOOD Lactate-3.2* [2151-9-23] 12:38PM BLOOD freeCa-1.14 At Discharge [2151-9-29] 02:20AM BLOOD WBC-7.7 RBC-2.92* Hgb-9.5* Hct-28.1* MCV-96 MCH-32.6* MCHC-34.0 RDW-14.8 Plt Ct-230 [2151-9-29] 02:20AM BLOOD PT-12.5 PTT-30.2 INR(PT)-1.1 [2151-9-29] 02:20AM BLOOD Plt Ct-230 [2151-9-29] 02:20AM BLOOD Glucose-200* UreaN-22* Creat-0.9 Na-145 K-3.5 Cl-110* HCO3-27 AnGap-12 [2151-9-29] 02:20AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.8 Brief Hospital Course: A/P: 79 year old man with CAD, DMII, past h/o SDH s/p craniotomy and Klebsiella VAP [4-7] who presents with cough, fever, altered mental status, vomiting, found to have a likely pneumonia on CXR. # Respiratory failure: Patient intially presented as hypoxic and hypercarbic, with tachypnea and shallow breaths. ABG at initial presentation was 7.26/48/138 on 100% NRB. He had a highly suspected aspiration event 4 days PTA with retrocardiac opacity on CXR that was otherwise clear making aspiration pneumonia most likely etiology of respiratory failure. Patient was thus intubated for hypoxic respiratory failure and was started on Vancomycin and Meropenum for broad spectrum coverage of underlying pnuemonia. Antibiotics were continued for a 7 day course. Patient initially had poor mental status, evaluated with head CT which was negative. His mental status gradually improved after sedation was turned off. Patient was gradually weaned off ventilator and extubated on [9-28]. # Septic shock: Patient was initially hypotensive after 5 liters of crystalloid in the setting of dropping urinary output and worsening mental status. Patient was also febrile to 104 with aspriation pneumonia as likely underlying source. Central venous access was obtained and leveophed was started to support MAP goals > 65. A-line was also placed for BP monitoring with a goal CVP > 10. Broad spectrum antibiotics were also started as discussed above. # Pneumonia: Patient was covered broadly with history strongly suggestive of aspiration but also known risks for hospital acquired pneumonia. He also had a known history of MRSA + swabs. A KUB was performed to rule out obstruction in the setting of possible aspiration from G-tube feeds which was negative. Legionella urine antigen was negative and BAL was possitive for moderate yeast growth and minimal growth of GNR. Patient was treated with 7 days of antibiotics and sputum was sent prior to discharge with a negative gram stain. # Oliguria: patient had a reduced urine output in the setting of sepsis concerning for poor forward flow vs. impending renal failure. He was initially given fluid boluses with some effect. The ICU team felt there was a large component of respiratory failure do to fluid overload and the patient was started on Lasix boluses to which he responded with excellent urine output. He was substantially diuresed with improved pulmonary function prior to extubation. # Diabetes mellitus: patient was started on a sliding scale with modest management of sugars in the setting of sepsis. He may require home dose of insulin at rehab. Medications on Admission: tylenol 650 prn vit D 1000U iron sulfate 325 [Hospital1 ] insulin 70/30 [Hospital1 ] RISS metoprolol tartrate 25 mg daily prilosec 20 daily senna visine opthalmic 1 drop [Hospital1 ] to left eye nasal saline 1 spray daily to both nostrils valsartan 320 once daily mag hydroxide prn constipation sorbitol prn constipation miconazole Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) syringe Injection TID (3 times a day). syringe 2. Chlorhexidine Gluconate 0.12 % Mouthwash [Hospital1 ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO BID (2 times a day): Please hold for BP < 110. 5. Furosemide 10 mg/mL Solution [Last Name (STitle) ]: 40 mg Injection DAILY (Daily). 6. Insulin Continue Humalog sliding scale - see attached 7. Colace 50 mg/5 mL Liquid [Last Name (STitle) ]: 100 mg PO twice a day. Additional medications from his home list may be started at the discretion of the rehab facility. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Pneumonia Discharge Condition: Good Discharge Instructions: You were admitted to the hospital for a pneumonia (lung infection). During the hospitalization, a machine helped you breath and you were given antibiotics. We also felt that part of your respiratory failure resulted from being fluid overloaded and we gave you some medicines which helped with this fluid balance. Please call your doctor or return to the emergeny department for any of the following - documented fevers, shaking chills - nausea with vomiting - chestpain, increasing shortness of breath - any other new symptoms which concern you Followup Instructions: Please follow up with your primary care doctor in [1-1] weeks for further evaluation and a physical exam. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 5070, 5185, 0389, 5849, 5180, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6421 }	Medical Text: Admission Date: [2124-1-13] Discharge Date: [2124-1-20] Date of Birth: [2050-3-27] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 14964] Chief Complaint: Progressive DOE x 6 months without angina. Major Surgical or Invasive Procedure: CABG x 2. History of Present Illness: This is a 73 yo female with known CAD, s/p PCI in [2113]. She reports a 6 month history progressive DOE. Out patient stress test showed mild ischemia of the basal inferior wall and basal septal wall with EF 67%. She was referred for elective cath [2123-1-12] revealing severe 2VD and prceeded to the OR [2123-1-13]. Past Medical History: CAD, s/p stent in [2113] Osteo arthritis gastro-esophageal reflux disease hypertension appendectomy lower right leg pain d/t pinched nerve Social History: Patient is widowed. She lives with her daughter in [Name (NI) 1474], MA. Family History: Patient denies. Physical Exam: On presentation: VS: 127/89 72 SR, 18, 96% on RA. HT 5'0" WT 198# CV: RRR Resp: CTA Abd: soft, NT, ND Extrem: warm, no edema, no varicosities. Pertinent Results: [2124-1-16] 04:55AM BLOOD WBC-12.6* RBC-2.83* Hgb-9.3* Hct-26.3* MCV-93 MCH-33.0* MCHC-35.5* RDW-14.7 Plt Ct-164 [2124-1-16] 04:55AM BLOOD Plt Ct-164 [2124-1-15] 02:54AM BLOOD PT-13.7* PTT-28.6 INR(PT)-1.2 [2124-1-18] 04:29AM BLOOD Glucose-86 UreaN-21* Creat-0.9 Na-140 K-4.0 Cl-99 HCO3-36* AnGap-9 Brief Hospital Course: Mrs. [Known lastname 20400] was admitted on [2123-1-12] for elective cath. Cath showed 95% LAD and 90% RCA occlusion with EF 65%. She was referred for cardiac surgery evaluation and on [2123-1-13] she proceeded to the OR and underwent CABG x 2 with LIMA to the LAD and SVG to the PDA. Total cardio-pulm bypass time 46 minutes and cross-clamp time was 22 minutes. She was transferred to the CSRU (initially)a-paced at 76 with MAP 61 and CVP 8 on neo. On the evening of the opertaive day she was successfully weened and extubated. On post-operative day one she was transferred to the inpatient floor. On post-operative day number two her chest tubes were removed without difficulty. On post-operative day three her cardiac pacing wires and foley catheter were discontinued. Her pain medication was changed form percocet and dilaudid to darvocet. She was evaluated by physical therapy. She continued in a NSR with frequesnt PVCs and occasional bursts of SVT without symptoms. On post-operative day four she continued with physical therapy. Her lopressor was increased to 50 mg [Hospital1 ] for HR control. On post-operative day five she was again evaluated by physical therapy who recommended rehabilitation screening. On post-operative day six she was discharged to rehabilitation in stable condition. Medications on Admission: prednisone 5 daily aciphex 20 daily lopressor 25 [Hospital1 ] zantac 300 daily diltiazem 30 tid zocor 20 daily aspirin 81 daily vitamin D Calcium xanax PRN darvacet [1-9] tabnlet q 8 hrs methotrexate 2.5 mg, 8 tabs on Sundays Leucovorin Calcium 5 mg, 4 tablets on Mondays Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 10 days. 10. Ferrous gluconate 300mg PO daily for one month 11. Ambien 5 mg q HS PRN x 2 weeks 12. Miconazole Powder to rash [Hospital1 ] PRN Discharge Disposition: Extended Care Facility: [Hospital 1474] Hospital TCU - [Hospital1 1474] Discharge Diagnosis: CAD, s/p CABG x 2. LIMA->LAD, SVG->PDA Atrial fibrillation. HTN,^chol,GERD,RA,Appy, Discharge Condition: Stable. Discharge Instructions: No heavy lifting, greater than 10 pounds. No bathing in tub/swimming pool. Shower daily and wash your incisions. -- Do not apply any creams/lotions/powders. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 70] in [4-12] weeks. Follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Follow-up with Dr. [Last Name (STitle) 6700] in [2-11] weeks. Completed by:[2124-1-20] ICD9 Codes: 4111, 9971, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6422 }	Medical Text: Admission Date: [2197-11-16] Discharge Date: [2197-11-22] Date of Birth: [2150-7-30] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 47 year old male without any significant cardiovascular history who, while exercising this morning on the exercise bike at the gym, slumped over and, according to eyewitnesses, was caught and lowered by his neighbor. [Name (NI) ] was given chest compression when found to be pulseless by a witness and was defibrillated times two by a portable defibrillator sensing probably ventricular fibrillation. Estimated time to defibrillation was five to 10 minutes. He was intubated and transported to [Hospital3 20284] Center. In the E.D. he was found to be agitated, dyspneic and unresponsive to commands. He was given Lopressor and nitroglycerin. His agitation and difficulty ventilating were improved with vecuronium and Ativan. He apparently had an exercise tolerance test earlier this year, exercising to stage 4 without any symptoms. It was unclear at the time of admission why this test was obtained. His cardiovascular risk factors included use of tobacco, hypertension and hypercholesterolemia. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. OUTPATIENT MEDICATIONS: BuSpar. ALLERGIES: Unknown. FAMILY HISTORY: Unknown. PHYSICAL EXAMINATION: On admission the patient was sedated and intubated. Vital signs were blood pressure of 102/57, pulse 90, afebrile, O2 sat 98% to 100% on assist control ventilation with FiO2 of 60%. LABORATORY DATA: On admission sodium was 139, potassium 4.4, chloride 101, bicarb 21, BUN 16, creatinine 1.5, glucose 196. White blood cell count was 15, hematocrit 48.6, platelets 380. HOSPITAL COURSE: The patient was emergently taken to the cath lab where coronary angiography was done which showed a right dominant system with two vessel coronary artery disease. The left main coronary artery was angiographically normal. The proximal LAD had discrete 99% stenosis with some haziness at the distal pole of the lesion suggesting thrombus. The remainder of the LAD had mild luminal irregularities as well as focal 50% stenosis in the mid-LAD. The first diagonal branch had 50% proximal stenosis. The left circumflex artery had mild luminal irregularities and produced a first obtuse marginal that was of moderate caliber and had 90% proximal stenosis. The RCA had mild luminal irregularities and 30% to 40% mid-RCA stenosis. The LAD was stented without dissection and without residual stenosis and TIMI 3 flow. Over the course of his stay in the hospital the patient remained hemodynamically stable and was successfully extubated. He was continued on aspirin and Plavix. Lopressor and captopril were added to his regimen as tolerated by his blood pressure. Repeat echocardiogram showed left ventricular cavity size to be normal. Overall left ventricular systolic function was mildly depressed with mild septal hypokinesis. No LV thrombus was seen. Aortic valve leaflets were mildly thickened and mitral valve leaflets were also mildly thickened with 1+ mitral regurgitation. In comparison with the previous study there was marked improvement in LV function. In light of questionable thrombus on the first echocardiogram, the patient was started on Coumadin with cross coverage with heparin. On day of discharge the patient's INR was therapeutic at 2.3 and heparin was discontinued. During the course of his stay the patient was also started on Lipitor 10 mg q.day. During his stay in the hospital the patient reported some short term memory loss and was scheduled to follow up with Dr. [First Name8 (NamePattern2) 17804] [Last Name (NamePattern1) ] in behavioral neurology clinic. The patient was discharged home with VNA to help with medication education and monitoring of INR levels for anticoagulation. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.day. 2. Lopressor 25 mg p.o. b.i.d. 3. BuSpar 5 mg p.o. t.i.d. 4. Lipitor 10 mg p.o. q.day. 5. Benadryl 25 mg p.o. q.six hours p.r.n. 6. Plavix 75 mg p.o. q.day for one month. 7. Sublingual nitroglycerin 0.4 mg p.r.n. for chest pain. 8. Zestril 2.5 mg p.o. q.day. 9. Coumadin 3 mg p.o. q.h.s. DISCHARGE DIAGNOSIS: Acute MI with v-fib arrest status post cath and stent to LAD. DISCHARGE STATUS: Discharged home. CONDITION ON DISCHARGE: Stable. [First Name8 (NamePattern2) 870] [Last Name (NamePattern1) ], M.D. [MD Number(1) 5219] Dictated By:[Name8 (MD) 5753] MEDQUIST36 D: [2197-11-28] 18:15 T: [2197-11-30] 08:38 JOB#: [Job Number 109626] ICD9 Codes: 4275, 3051, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6423 }	Medical Text: Admission Date: [2196-8-30] Discharge Date: [2196-9-4] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5129] Chief Complaint: tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: 88 yr/o female with Afib (on coumadin), severe dementia living at [Hospital3 ] who was sent in with concern for vaginal bleeding that per ED report started yesterday evening. Pt unable to give any history [1-19] to dementia. No family present at ED presentation. FS this am at nursing home 360, rec'd 8 units reg insulin . In the ED, initial vs were: 96.9 97 138/70 24 82%. Initially triggered for tachycardia and hypoxia. Hypoxia resolved with minimal O2 but tachycardia persisted. Speculum exam was difficult. Grossly bloody urine was noted with clots draining in foley. INR found to be 4.0. BP stayed stable. CAT scan of abdomen was done showing on wet read a marked distended bladder with enhancing wall and mild adjacent mesenteric fat stranding with bilateral hydroureter, likely due to to infection. No renal/ureteric stones seen. Also gallstones without evidence of cholecystitis. Patient was given ceftriaxone (for UTI), morphine, 1L IVF. Pt transfered to ICU over concerns for acute blood loss with tachycardia. Pt DNR/DNI. . VS prior to transfer were Afib 100-110 131/57 22 100% on 3L. . On the floor, initial vitals were T: 98.2 / BP 148/64 / HR 110-120s / RR 17-29 / Sats 100% on RA. . Review of systems: Unable to complete [1-19] dementia Past Medical History: 1. Dementia with Paranoid Features 2. Osteoporosis 3. Colon CA of ascending colon with micro-invasions diagnosed on colonoscopy [6-18] at NEBH s/p colectomy [7-19] at [Hospital1 112] w/clean margins, no nodes positive, no chemo given. 4. Iron deficiency Anemia (iron studies in [6-/2195]) 5. Hypertension 6. Atrial Fibrillation (pre-[2189]) 7. CVA: Occipital stroke 01/[2189] / 80-90%/75%-80% carotid stenosis 8. Type II Diabetes Mellitus (HbA1C 6.8% in [2189]) 9. Congestive Heart Failure, well-compensated 10. PUD s/p partial gastrectomy (in [2135]) seen on EGD [6-18] 11. Hyperlipidemia 12. Hypothyroidism and Left Thyroid lobe enlargement 13. Multiple hospitalizatons for altered mental status, some assoc with UTI, others ? etiology Social History: Lives in Nursing facility in [Location (un) ]. The patient has no immediate family members - husband and siblings died and patient has no children. [Name (NI) ] (nephew) is Health Care Proxy (from prior notes). No history of tobacco, alcohol, or drugs. At baseline walks with a walker. Family History: Born and raised in [State 1727]. Youngest child. Three brothers and three sisters, all deceased. No family. Husband died in [2130], 8 years after they were married and patient has no children. Physical Exam: ADMISSION: Vitals: T: 98.2 / BP 148/64 / HR 110-120s / RR 17-29 / Sats 100% on RA General: A&O x 0, lying in bed humming/moaning constantly, not answering question although alert, intermittently will respond to pain in certain areas, intermittently will say a inteligible word HEENT: Sclera anicteric, difficult to visualize post phaynx as pt will not open mouth Neck: supple, JVP not elevated, no cervical LAD Lungs: Clear to auscultation bilaterally in anterior fields, difficult to eval for wheezing as pt constatly humming, but no wheezes heard CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. exam again compromised by constant patient humming Abdomen: soft, around umbilicus, non-distended, bowel sounds present, no rebound tenderness or guarding, Tenderness around R flank although as pt lying back cannot assess for true CVA tenderness on that side GU: foley in place, bloody urine in bag but blood starting to clear from foley tubing Ext: leukwarm, 2+ pulses, no cyanosis or edema Guiac negative in ICU ICU Speculum exam with no blood in the external vault and no gross blood internally on exam. Cervix not well visualized. DISCHARGE: Pertinent Results: LABS: [2196-8-30] 07:30AM BLOOD WBC-9.5# RBC-3.68* Hgb-9.8* Hct-29.2* MCV-79* MCH-26.5* MCHC-33.5 RDW-15.8* Plt Ct-361 [2196-8-30] 07:30AM BLOOD PT-38.2* PTT-29.5 INR(PT)-4.0* [2196-8-30] 12:25PM BLOOD Glucose-189* UreaN-19 Creat-0.9 Na-137 K-4.3 Cl-104 HCO3-24 AnGap-13 [2196-8-30] 12:25PM BLOOD ALT-18 AST-24 AlkPhos-167* TotBili-0.5 MICRO: [8-30] UCx pending [8-30] Blood Cx pending x2 [8-30] MRSA Screen pending x2 IMAGING: [2196-8-30] CXR: No acute cardiopulmonary process. Stable cardiomegaly. [2196-8-30] Abd/Pelvis CT w/o Contrast 1. Markedly dilated bladder with mild bilateral hydroureter are likely related to infectious process. 2. Stable T10 vertebral body lesion. While this lesion may represent atypical hemangioma and size stability is reassuring, it is still concerning for metastatic disease in this patient with history of colon cancer. 3. Right hemicolectomy with enterocolic anastomosis in addition to stomach surgery changes (likely Billroth type procedure). No evidence of complication is seen though lack of oral contrast limits evaluation. 4. Cholelithiasis without evidence of cholecystitis. 5. Post-hysterectomy and bilateral oophorectomy changes are noted. 6. Left hemiarthroplasty with adjacent subcutaneous edema are likely due to recent surgery. Brief Hospital Course: 89 yo long-term care resident of [Hospital3 2558] w/ hx of AF on coumadin, dementia, colon cancer s/p colectomy presenting with reports of heavy vaginal bleeding overnight with clots. Upon presentation to hospital bleeding localized to urinary tract with INR supratherapeutic at 4.0. # Urinary tract infection: On admission, there was gross blood in the urine. At the time, etiologies considered included infectious, malignant and obstructive. A UA was indicative of likely infection with small leuks, 11-20WBC, and mod bacteria. An abdominal CT demonstrated signs of cystitis (stranding around bladder) without signs of malignancy. It was thought that the primary process was a cystitis, which precipitated mild bleeding in the setting of a supratherapeutic INR. Patient remained afebrile and hemodynamically stable with a stable WCC. Given past hx of E. coli UTI that was cipro resistant, patient was started on ceftriaxone 1g IV q24h, with plan for 10 day course for UTI. The urine culture grew out E.Coli resistant to quinolones and Bactrim but sensitive to Ceftriaxone, which was continued. A foley was left in place to allow for continuous irrigation of bladder until [2196-6-3] at which point the gross hematuria had resolved. After the CBI Foley was removed, however, she retained 699 ml of urine by bladder scan and Foley was reinserted on [6-4]. The urinary retention is probably due to the incompletely treated cystitis and the foley should be removed in 7 days for a voiding trial. Patient was stable and was transfered to the floor with the plan to continue antibiotics for a total of 10 days and arrange for outpatient cystoscopy with urology to evaluate for other possible etiologies of a bleed, including a transitional cell carcinoma. Supratherapeutic INR: On admission the patient was noted to have a supratherapeutic INR 4.0 after warfarin dose increase (4mg to 5mg) for subtherapeutic INR (1.62) 1 week prior. The patient's coumadin was held and she was given 2mg PO VitK. Her HCT remained stable at time of transfer out of the ICU. Her Coumadin was restarted on [9-4] at 2.5 mg/day with goal INR of 2.0. Last INR, on [9-3], was 1.4. DM II - with glargine 10 units at bedtime her FSBS ran in the 200-300 range with the addition of sliding scale lispro insulin around mealtimes. The dose of glargine was increased to 12 units on [9-4] and may need further increase if she remians hyperglycemis. She eats all of her meals fully. Medications on Admission: # Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). # Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). # Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). # Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). # Quetiapine 25 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as needed for agitation. # Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY # Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Senna 8.6 mg PO BID PRN constipation. # Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [12-19] Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. # Furosemide 20 mg Tablet Sig: One (1) Tablet PO MWF # Furosemide 40 mg Tablet Sig: One (1) Tablet PO [First Name8 (NamePattern2) ] [Last Name (un) ] SAT SUN # Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for L hip pain. # Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: Goal INR [1-20]. # Lantus 100 unit/mL Solution Sig: One (1) 20 units Subcutaneous at bedtime. # Metamucil Powder Sig: One (1) PO prn as needed for constipation. # Humulin R 100 unit/mL Solution Sig: One (1) Injection once a day as needed for hyperglycemia: sliding scale. Disp:30 Refills:0 Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) unit dose Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for agitation. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) unit dose Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 13. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Goal INR = 2.0. 17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 18. CeftriaXONE 1 gm IV Q24H Start: In am Start date [8-30] 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 20. Outpatient Lab Work Check INR daily until >2.0, then check with physician. 21. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units SQ Subcutaneous at bedtime: Hold if FSBS is less than 90 and [Name8 (MD) 138] MD. 22. Insulin Lispro 100 unit/mL Solution Sig: Two (2) UNITS SQ FOR EACH 50 MG/DL BLOOD GLUCOSE OVER 200 PER SLIDING SCALE FOR FSBS >200 Subcutaneous four times a day as needed for HYPERGLYCEMIA. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Urinary tract infection with resistant E.Coli Gross hematuria due to cystitis from UTI and over-anticoagulation with warfarin Transient hypoxemia due to atelectasis and/or mucous plugging - resolved Transient tachycardia due to hypovolemia - resolved Drmrntia Atrial fibrillation - on warfarin DM type II - uncontrolled with complications Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admited from the [Hospital3 2558] with urethral bleeding. we determined that the bleeding was most likely due to a urinary tract infection and overtreatment with the blood thinner warfarin. The bleeding has stopped and you have been restarted on a lower dose of warfarin. You are also on day 5 out of 10 of the antibiotic and ceftriaxone for the UTI. You received today's dose, and will need five more doses. A foley catheter had to be reinserted on [6-3] because you were retaining urine (most likely from the UTI as there was no blood). It should stay in place for 7-days and then removed so that you can try to void without it. You should have a follow up with a urologist in [2-18] weeks to ealuate other potential causes of urinary bleeding such as a tumor. Followup Instructions: Follow up per [Hospital3 ] attending physician ICD9 Codes: 5180, 4019, 2724, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6424 }	Medical Text: Admission Date: [2191-11-9] Discharge Date: [2191-12-25] Date of Birth: [2191-11-9] Sex: M Service: NB HISTORY: The patient is an ex-33 and 1/7 weeks baby boy, birth weight 1545 grams, born to a 36-year-old G1, now P2 mother, secondary to preterm labor. She was treated with tocolysis and betamethasone upon admission, fetal testing by report was within normal limits. Prenatal screens: Maternal blood type A positive, antibody negative, RPR nonreactive, hepatitis surface antigen negative, HIV negative, GBS unknown. The progression of labor and breech presentation of twin 2 prompted C-section. At delivery the infant emerged with decreased tone and respiration, required a few positive pressure ventilatory breaths, then was put on facial CPAP, heart rate was always greater than 100, Apgars were 6 and 7. HOSPITAL COURSE: RESPIRATORY: The infant initially was on facial CPAP in the delivery room and quickly transitioned to room air and has been on stable on room air since the end of [Month (only) 359]. He never required intubation or surfactant. CARDIOVASCULAR: He had some episodes of hypotension at birth that was treated with dopamine and it was discontinued by day of life 2. No murmur was ever appreciated on this infant and thus there was no need for treatment of a PDA. FLUIDS/ELECTROLYTES/NUTRITION: The infant started enteral feeds on day of life 3 by a PT tube and quickly worked up to full feeds and currently he is p.o. ad lib'ing and takes approximately 200 to 250 cc/kg/day of breast milk or Enfamil 20 kcal/ounce. GI: The infant had some elevated bilirubins on day of life 5 and was placed on phototherapy for approximately 2 days. He has never required another course of phototherapy. INFECTIOUS DISEASE: The infant underwent rule out sepsis workup, blood cultures were negative and ampicillin and gentamicin were discontinued after 48 hours. He has not required any additional courses of antibiotics during this acute course. NEUROLOGY: Given his gestational age greater than 33 weeks and stable hospital course he did not require a head ultrasound. SENSORY: Audiology hearing screening was performed which he passed. OPHTHALMOLOGY: Given gestational age of greater than 32 weeks he did not require an exam for retinopathy of prematurity. PHYSICAL EXAMINATION AT DISCHARGE: The infant's weight today [2191-12-23], is 3015 grams. The weight of 3015 grams is between the 25th to 50th percentile. His most recent length is 49 cm, which is between the 50th and 75th percentile. The head circumference is at 35 cm, which is between the 75th and 90th percentile. On exam, generally he is vigorous and active. HEAD AND NECK: Anterior fontanelle is open and flat, his palate is intact, he has bilateral positive red reflexes. PULMONARY: Lungs are clear to auscultation bilaterally. CARDIOVASCULAR: S1 and S2, regular rate and rhythm, no murmurs. ABDOMEN: Soft, nondistended, no hepatosplenomegaly. EXTREMITIES: He is warm and well- perfused with +2 femoral pulses. NEURO: He is appropriate for adjusted gestational age. GU: Normal male genitalia. CONDITION ON DISCHARGE: Stable. He is being discharged to home. The name of the primary pediatrician is [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 75763], MD, phone number [Telephone/Fax (1) ]. CARE AND RECOMMENDATIONS: Feeds at discharge: Infant is being discharged on p.o. ad lib of breast milk or Enfamil 20. Medications: He is on iron at 2 mg/kg/day of ferrous sulfate, in addition he is receiving gold line baby vitamins 1 mL p.o. every day. Iron and vitamin E supplementation: Iron supplementation is recommended for preterm and low-birth weight infants until 12 month corrected age. All infants, but predominantly breast milk should receive vitamin E supplementation at 200 International Units daily until 12 month corrected age. Car seat: Position screening was performed and the infant passed. State newborn screening: The most recent was done on [2191-11-23], and it was all within normal limits. Immunizations: The infant received hepatitis B vaccine on [2191-12-8], he did not receive Synagis as he does not qualify for he is greater than 32 weeks gestational age and does not meet the risk factors, however, Synagis immunization is recommended. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following four criteria: 1. born at less than 32 weeks, 2) born between 32 and 35 weeks with 2 of the following, day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, 3) chronic lung disease, 4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months age, before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home caregivers, this infant has not received Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. FOLLOWUP: Follow up appointments will be scheduled for the primary pediatrician and visiting nurse service will be visiting the home shortly after discharge. Of note, the twin brother, twin 2 was discharged one week ago and has been doing well at home. DISCHARGE DIAGNOSES: 1. Respiratory distress syndrome, rule out sepsis. 2. Transient hypovolemia - resolved. 3. Prematurity - 33 week gestation twin 1. 4. Hyperbilirubinemia - resolved. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55750] Dictated By:[Doctor Last Name 75644] MEDQUIST36 D: [2191-12-23] 11:34:18 T: [2191-12-23] 13:01:00 Job#: [Job Number 75764] ICD9 Codes: 769, 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6425 }	Medical Text: Admission Date: [2177-5-9] Discharge Date: [2177-5-15] Date of Birth: [2112-12-25] Sex: F Service: Thoracic Surgery CHIEF COMPLAINT: Lung cancer. HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old female who is status post right middle lobectomy in [2172-9-21] for a T1 N0 M0 lung cancer and who is status post a right upper lobe wedge resection of a mass found on subsequent followup. She was recently discharged on [2177-4-23] after that procedure. In the interim, the patient has done well and returns to [Hospital1 1444] for formal right upper lobectomy for the diagnosed undifferentiated large cell-type lung carcinoma. Of note, the wedge resection and lymph node biopsies were significant for no positive lymph nodes at the previous wedge resection. Previous workup for this mass had provided no evidence of metastasis. PAST MEDICAL HISTORY: Lung cancer in [2172]. PAST SURGICAL HISTORY: 1. Status post hemiarthroplasty for displaced right femoral neck fracture. 2. Status post right middle lobectomy in [2172]. 3. Status post sinus surgery. 4. Status post right upper lobe wedge resection in [2177-4-21]. MEDICATIONS ON ADMISSION: Medications on admission included Prempro 2.5 mg p.o. q.d. ALLERGIES: No known drug allergies. FAMILY HISTORY: Family history was noncontributory SOCIAL HISTORY: Social history significant for smoking greater than 30 years of one pack per day. Occasional ethanol use. She is married with two children. PHYSICAL EXAMINATION ON PRESENTATION: The patient had a temperature of 98, pulse of 78, blood pressure of 120/66, respiratory rate of 18, 98% on room air. She was awake, alert and oriented times three. She had no cervical lymphadenopathy. Her chest was clear bilaterally, and she had a regular rate and rhythm. Her abdomen was soft and nontender. Her incisions were clean, dry, and intact. She had no peripheral edema or clubbing. RADIOLOGY/IMAGING: Chest x-ray prior to surgery showed no evidence of pneumothorax or infiltrate. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories prior to admission included a white blood cell count of 5.6, hematocrit of 39.7, a platelet count of 228. Blood urea nitrogen of 12. ALT of 18 and AST of 21. HOSPITAL COURSE: On the day of admission the patient went to the operating room where she underwent right thoracotomy a right video-assisted thoracoscopy, and a multiple wedge resection of the right upper lobe. She also underwent mediastinoscopy with lymph node dissection. Findings in the operating room included multiple adhesions to the chest wall, and a thickened area on the previous line, and negative metastatic disease on frozen section. She tolerated this procedure well. She had 1400 cc in crystalloid, and a 250-cc blood loss, and made a urine output of 380 cc. She was extubated and sent to the Postanesthesia Care Unit in stable condition. Postoperatively, the patient has remained afebrile and hemodynamically stable. Her chest tube output has decreased appropriately and has produced serosanguineous drainage. A persistent air leak has remained throughout her admission. Her postoperative chest x-ray was significant for a residual pneumothorax which has remained stable throughout her postoperative recovery. The patient has been ambulating and tolerating a regular diet. The patient had epidural managed by the Acute Pain Service for the first four postoperative days and was changed to p.o. pain medication which was tolerating. Pathology was still pending. Of note, the patient had a positive urine culture which was greater than 100,000 gram-negative rods. The patient was to be sent home on a 5-day course of levofloxacin. DISCHARGE DISPOSITION: Due to the persistent air leak, a Heimlich valve was placed on the chest tube, and the patient was stable for discharge with chest tube and Heimlich valve in place. She was to go home with [Hospital6 407] nursing to help care for the wound. The patient was to follow up with Dr. [Last Name (STitle) 175] on [Last Name (LF) 766], [2177-5-19]. DISCHARGE DIAGNOSES: 1. Right lung adenocarcinoma, status post right upper lobectomy. 2. Urinary tract infection. MEDICATIONS ON DISCHARGE: (Medications on discharge included) 1. Vicodin 5/500 one to two tablets p.o. q.4h. p.r.n. 2. Colace 100 mg p.o. b.i.d. 3. Levofloxacin 500 mg p.o. q.d. times two more days (for a total of five days). CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [Last Name (STitle) 175] on [Last Name (LF) 766], [2177-5-19] for chest tube removal. [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 178], M.D. [MD Number(1) 179] Dictated By:[Last Name (NamePattern1) 3835] MEDQUIST36 D: [2177-5-15] 12:49 T: [2177-5-15] 16:08 JOB#: [Job Number ] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6426 }	Medical Text: Admission Date: [2128-4-30] Discharge Date: [2128-5-9] Date of Birth: [2081-9-22] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2186] Chief Complaint: dyspnea, calf pain Major Surgical or Invasive Procedure: None History of Present Illness: 46 yo M with morbid obesity and hypertension presented to an OSH with 5 day history of dyspnea on exertion and left calf cramping. Patient reports he first noticed difficulty breathing while mowing his lawn 5 days prior to admission and developed progressive DOE with dyspnea at rest the past 1-2 days. His left leg felt crampy 2 days ago but he did not notice increase in edema or redness. He denies chest pain but says his chest feels like he "just ran a marathon". No orthopnea, palpitations, cough, fever/chills/night sweats. He has baseline edema of his lower extremities, which he treats with elevation and compression stockings. He has not had recent travel or immobilization, no recent illnesses, no personal or family history of blood clots or PE. He initially presented to [Hospital1 ] [Location (un) 620] with vitals of: 97.9, HR 118, BP 169/105, RR 22, O2 86% on RA which improved to 95% on 2L NC. ECG there showed sinus tach at 104 with no ST-T changes. His CXR there was a poor study but did not indicate acute cardiopulmonary process. D-dimer was measured and elevated to 8.93 (upper normal 0.48) and troponin elevated to 0.065. Patient was transferred to [Hospital1 18] for further management. . In the emergency department initial vitals were: T 97, HR 100, BP 147/92, RR 18, O2Sat 98% 4L NC. He was empirically started on heparin drip with 1000 unit bolus and set at a rate of [2116] units per hour. Reason for transfer to the MICU is concern for impending clinical instability given hypoxemia. V/Q scan and CTA could not be performed given body habitus. . At the MICU, patient was slightly agitated and in mild respiratory distress. He was holding up his NRB mask and laying flat in bed, speaking in full sentences, but tachypneic and mildly diaphoretic. His vitals were BP 139/89, HR 116, O2 95% on NRB. He reported mild SOB, no chest pain with inspiration, no calf pain. Past Medical History: Hypertension Obesity Cellulitis in R leg L ankle infection Social History: Lives alone, works as a mechanic and software programmer. Fairly active at baseline. Never smoked, intermittent EtOH use ([6-2] beers some days, sometimes a week without drinking), last drink Wednesday (3-4 beers). No drug use. Mother passed away 5 weeks ago from pancreatic cancer. Family History: No family history of blood clots or PEs. Mother had pancreatic/liver cancer. Father died in [2116]. 3 siblings mostly healthy, sister with MS. Physical Exam: ADMISSION EXAM: GEN: obese man laying in bed in mild respiratory distress, diaphoretic, speaking in full sentences, AOx3 HEENT: EOMI, PERRLA NECK: obese, JVP could not be assessed, no cervical LAD PULM: CTA anteriorly, no rales or wheezes CARD: distant heart sounds, tachycardic, nl S1/S2, no m/r/g ABD: obese, soft, NT, BS+ EXT: 2+ pitting edema b/l to knee, chronic venous stasis changes, no open breaks in skin, faint distal pulses b/l NEURO: AOx3, declined remainder of exam PSYCH: anxious and slightly agitated DISCHARGE EXAM: Vitals: 96.9 136/63 55 20 96%RA General: very obese gentleman in NAD Lungs: Distant breath sounds but no wheezes, rales, ronchi CV: PMI nondisplaced (difficult to palpate), no RV heave, Regular rate, normal S1 + S2, no murmur Ext: warm, 2+ DP and radial pulses, no clubbing, (+) stasis dermatitis (brawny skin) from mid-shin downwards bilaterally; RLE with small 1cm nonhealed ulcer with no pus or erythema; palpable/tender area of induration posterior to left calf Pertinent Results: ADMISSION LABS [2128-4-30] 10:30PM BLOOD WBC-10.8 RBC-5.32 Hgb-15.7 Hct-44.9 MCV-84 MCH-29.4 MCHC-34.9 RDW-13.3 Plt Ct-359 [2128-4-30] 10:30PM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-139 K-3.7 Cl-100 HCO3-26 AnGap-17 [2128-5-1] 03:51AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1 [2128-4-30] 10:30PM BLOOD cTropnT-0.10* [2128-5-1] 03:51AM BLOOD CK-MB-9 cTropnT-0.15* [2128-4-30] 10:30PM BLOOD D-Dimer-7574* [2128-5-1] 02:25AM BLOOD Type-ART Temp-36.1 pO2-85 pCO2-37 pH-7.46* calTCO2-27 Base XS-2 Intubat-NOT INTUBA DISCHARGE LABS: [2128-5-6] 07:55AM BLOOD WBC-9.5 RBC-5.41 Hgb-15.4 Hct-45.9 MCV-85 MCH-28.5 MCHC-33.6 RDW-13.3 Plt Ct-320 [2128-5-9] 07:30AM BLOOD PT-20.6* PTT-150* INR(PT)-1.9* [2128-5-6] 07:55AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.2 CXR [2128-5-1] Limited study due to technique. Cardiomegaly without signs for acute cardiopulmonary process. EKG [2128-4-30] Artifact is present. Sinus rhythm. Normal tracing. No previous tracing available for comparison. EKG [2128-5-3] Atrial fibrillation with rapid ventricular response. Diffuse ST-T wave abnormalities are non-specific but clinical correlation is suggested. Since the previous tracing of [2128-5-1] atrial fibrillation has replaced sinus tachycardia and further ST-T wave changes are present. EKG [2128-5-4] Sinus rhythm. Diffuse ST-T wave changes are non-specific but clinical correlation is suggested. Since the previous tracing of [2128-5-3] sinus rhythm has replaced atrial fibrillation. Lower Extremity Ultrasound [2128-4-30]: IMPRESSION: Nonocclusive thrombus in the left popliteal vein. No definite thrombus in the right lower extremity. Brief Hospital Course: BRIEF HOSPITAL COURSE Mr. [Known lastname 10132] is a 46y/o gentleman who presented with SOB, hypoxia, and LLE DVT - though CTA was not feasible, the clinical picture was consistent with pulmonary embolus. He was started on a Heparin drip until he was therapeutic on Warfarin. He became stable from a respiratory standpoint and he was discharged home. . ACTIVE ISSUES . 1. Hypoxia, SOB: Pulmonary Embolus. Initial increased A-a gradient, O2 requirement, DVT, right heart strain on EKG all consistent with PE. Though unable to get CTA due to body habitus, clinical suspicion was very high. Not a Lovenox candidate due to body weight; he was started on Heparin gtt and bridged to Warfarin. He was weaned to to room air, and had no O2 requirement even with ambulation. He will likley require a 6 month course of treatment. He will follow up with his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] after discharge (he was given a lab slip for INR check), and will be followed at [Hospital1 ] [Location (un) 620] [Hospital 3052]. . 2. LLE DVT: popliteal DVT. Detected by tender palpable cord and confirmed by LENI. He was anticoagulated as described above. . 3. Paroxysmal Afib in the setting of PE: reslved. He had a few episodes of Afib/RVR with rate up to 140 which responded well to IV Diltiazem; the A fib resolved on [2128-5-3] (it had been <48 hours) and he remained in NSR for the remainder of his stay. Episodes were possibly due to PE; unknown if this has been a problem in the past. He was started on Metoprolol 25mg PO BID and will continue this after discharge. . 4. Hypertension: SBP up to 200's as an outpatient; up to 160 here. He had not taken Lisinopril for almost a year despite encouragement from his PCP. [Name10 (NameIs) ] was restarted on Lisinopril 10mg daily, which was uptitrated to 20mg daily. He will follow up with his PCP. . 5. Class III obesity: a risk factor for not only PE, but also CAD. He was continued on ASA (81mg in the setting of anticoagulation). He will have outpatient PCP f/u for healthcare maintenance and would benefit from a sleep study. . TRANSITIONAL ISSUES . Code Status: Full Code Emergency Contact: [Name (NI) ] [Name (NI) 44979] (friend) [Telephone/Fax (1) 89415] Labs/studies pending at discharge: none Medications on Admission: ASA 325mg daily Lisinopril 12.5mg daily 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. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. warfarin 5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:90 Tablet(s) Refills:2 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Outpatient Lab Work INR Check on [5-12] and [5-15] . Please fax results to Dr [First Name8 (NamePattern2) 30642] [Name (STitle) ] at [Telephone/Fax (1) 36518]. Discharge Disposition: Home Discharge Diagnosis: DVT with possible PE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 10132], You were admitted with calf pain and shortness of breath and were found to have a blood clot in one of your leg veins. It is also possible that you have a clot in your lungs, so we are treating this with a blood thinner called coumadin (warfarin) which you will need to take for 6 months. . We have made the following changes to your medications: - STARTED coumadin (warfarin)15 mg daily - STARTED metoprolol 25mg twice daily - INCREASED lisinopril to 20mg daily Followup Instructions: PRIMARY CARE Name: [Last Name (LF) ],[First Name3 (LF) ] M Location: INTERNISTS ASSOCIATED Address: [Street Address(2) 21374], [Location (un) ],[Numeric Identifier 3862] Phone: [Telephone/Fax (1) 6163] Date: Tuesday, [2128-5-11] at 11AM . [Hospital3 ] At your follow-up appointment, you will be set up at an [Hospital3 ] to monitor your INR and Warfarin dose. ICD9 Codes: 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6427 }	Medical Text: Admission Date: [2197-12-1] Discharge Date: [2197-12-13] Date of Birth: [2121-12-30] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2197-12-1] coronary artery bypass grafts x4,aortic valve replacement(25 [First Name8 (NamePattern2) ] [Male First Name (un) 923] tissue) History of Present Illness: 75 year old male with history of hyperlipidemia and aortic stenosis. He reports being able to walk about 30 minutes on flat ground without symptoms. He does reports shortness of breath after climbing stairs or walking up inclines relieved with rest. He also reports that symptoms have improved over the past several months, however, he has limited his activity. His most recent ECHO is from [2197-8-8] revealing a normal LV wall thickness, cavity size and regional/global systolic function with an LVEF of 55%, severely thickened and deformed aortic valve leaflets with critical aortic valve stenosis noting a valve area of <0.8 cm2, mild to moderate [1-29]+ aortic regurgitation as well as trivial mitral regurgitation. He was referred for right and left heart catheterization. He is now being referred to cardiac surgery for an aortic valve replacement and revascularization. Past Medical History: Critical aortic stenosis Mild to moderate aortic insufficiency Hyperlipidemia Hypertension [2191] Atrial tachycardia s/p ablation [2190] Colon cancer s/p chemo/XRT and surgery now with colostomy Glaucoma Past Cardiac Procedures: none PSH: LAR [7-31] Ileostomy takedown [12-1] Social History: Race:Caucasian Last Dental Exam:5 months ago, will call dentist and have dental clearance faxed to office Lives with:Wife Contact: [Name (NI) ] (wife) Phone #[Telephone/Fax (1) 55293]. Occupation:retired teacher Cigarettes: Smoked no [x] yes [] Other Tobacco use: ETOH: < 1 drink/week [x] [3-6] drinks/week [] >8 drinks/week [] Illicit drug use Family History: Family History:Premature coronary artery disease- Father died of MI at age 76 Physical Exam: Physical Exam Pulse:53 Resp:13 O2 sat:97/RA B/P Right:138/60 Left:140/62 Height:5'[97]" Weight:205 lbs General: Dry awake alert oriented Skin: [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] harsh 5/6 systolic ejection Murmur; with radiation to R carotid Abdomen: Soft [x] non-distended [x] non-tender [x] + bowel sounds Extremities: Warm [x], well-perfused [x] no Edema [] no Varicosities Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2 Left: 2 PT [Name (NI) 167]: 2 Left: 2 Radial Right: 2+ Left: 2+ Carotid Bruit Right: harsh murmur Left: + bruit Pertinent Results: Abd/Pelvis CT [2197-12-7] 1. Stable bilateral pleural effusions and atelectasis. 2. Small pericardial effusion. 3. Diminished volume of intraperitoneal free air likely related to recent surgery. 4. No bowel obstruction. [2197-12-1] PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [First Name (STitle) ] was notified in person of the results before surgical incision. POST-BYPASS: Normal RV systolic function. LVEF 55%. The aortic bioprosthesis is intact, functioning well with a residual mean gradient of 5 mm of Hg. Intact thoracic aorta. Minimal MR. [2197-12-11] 04:21AM BLOOD WBC-6.5 RBC-2.94* Hgb-9.1* Hct-27.6* MCV-94 MCH-30.8 MCHC-32.8 RDW-14.8 Plt Ct-239 [2197-12-10] 05:29AM BLOOD WBC-5.7 RBC-2.93* Hgb-9.2* Hct-27.5* MCV-94 MCH-31.3 MCHC-33.4 RDW-14.8 Plt Ct-213 [2197-12-12] 05:44AM BLOOD PT-15.6* INR(PT)-1.4* [2197-12-11] 04:21AM BLOOD Plt Ct-239 [2197-12-10] 05:29AM BLOOD PT-18.9* INR(PT)-1.7* [2197-12-12] 05:44AM BLOOD UreaN-16 Creat-0.9 Na-139 K-4.3 Cl-106 [2197-12-11] 04:21AM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-137 K-4.2 Cl-106 HCO3-24 AnGap-11 [2197-12-10] 05:29AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-140 K-3.9 Cl-107 HCO3-24 AnGap-13 Brief Hospital Course: The patient was brought to the operating room on [12-1] where the patient underwent Aortic valve replacement with size 25-mm St. [Male First Name (un) 923] Epic tissue valve and coronary artery bypass graft x4: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to distal left anterior descending artery, obtuse marginal and posterior descending arteries. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Pt did have minimal bowel sounds with nausea and vomiting with a history of a post operative ileus. A KUB revealed an ileus. Pt was made NPO. A Nasogastric tube was placed and general surgery was consulted when the patient had a prolonged ileus. An abdominal CT was performed and revealed no bowel obstruction. The patient's diet was slowly advanced with good tolerance and NG tube was removed. He regained his bowel sounds and his diet was advanced to regular. On discharge he was tolerating a regular oral diet well and his stoma was putting out stool. Pt also went into a rapid atrial fibrillation, he was given a bolus of amiodarone and given a drip for 24 hours and Lopressor was titrated up for better rate control. When the patients bowel sounds returned, he was started on PO amiodarone. He went into paroxysmal atrial fibrillation (rapid at times to 130's) but he was in rate controlled sinus rhythm at the time of discharge. Due to his repeated atrial fibrillation, he was started on Coumadin. INR goal 2.0-2.5 - Coumadin follow up was arranged with PCP. [Name10 (NameIs) ] patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #12 the patient was ambulating with assistance, the wound was healing well and pain was controlled with oral analgesics. He was discharged home with VNA and PT services. All appropriate follow up instructions and appointments were given. Medications on Admission: BRIMONIDINE 0.2 % Drops one drop right eye [Hospital1 ], DORZOLAMIDE 2 % Drops one drop right eye [Hospital1 ], METOPROLOL TARTRATE 25 mg [Hospital1 ], SIMVASTATIN 20 mg daily, TIMOLOL 0.5 % Drops one drop right eye [Hospital1 ], ASPIRIN 81 mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please tape, 200 [Hospital1 ] x 7 days, then 200 mg po qd untill f/u with PCP. [Name Initial (NameIs) ]:44 Tablet(s) Refills:2 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 7. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 8. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). [Hospital1 ]:30 Tablet, Chewable(s) Refills:2 10. Insulin Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Breakfast Glargine 25 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 2 Units 2 Units 2 Units 0 Units 160-199 mg/dL 4 Units 4 Units 4 Units 2 Units 200-239 mg/dL 6 Units 6 Units 6 Units 4 Units 240-280 mg/dL 8 Units 8 Units 8 Units 6 Units > 280 mg/dL Notify M.D. 11. Outpatient Lab Work Coumadin for AFib Goal INR 2-2.5 First draw [2197-12-14] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [Last Name (STitle) 3142] Results to phone [Telephone/Fax (1) 19980] (fax [Telephone/Fax (1) 19981]) 12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [Telephone/Fax (1) ]:90 Tablet(s) Refills:2 13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Telephone/Fax (1) ]:30 Tablet(s) Refills:2 14. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): [1-29] home dose while on amiodarone. [Month/Day (2) ]:30 Tablet(s) Refills:2 15. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily) for 7 days. [Month/Day (2) ]:14 Tablet Extended Release(s) Refills:0 16. warfarin 1 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily): dose based on INR for afib Goal 2.0-2.5. [Month/Day (2) ]:80 Tablet(s) Refills:2 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. [Month/Day (2) ]:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Critical aortic stenosis Mild to moderate aortic insufficiency Hyperlipidemia Hypertension Atrial tachycardia- s/p ablation, [2190] Colon cancer (s/p chemo/XRT and surgery now with colostomy) Glaucoma Discharge Condition: Alert and oriented x3 ,nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ to knees bilaterally 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. [First Name (STitle) ] ([Telephone/Fax (1) 170]on [2198-1-9] at 1:15pm in the [Hospital ] Medical Office Building [Last Name (NamePattern1) ] [Hospital Unit Name ]. Wound Check:WOUND CARE NURSE Phone:[Telephone/Fax (1) 170] Date/Time:[2197-12-20] 10:45 in the [Hospital ] Medical Office Building [Last Name (NamePattern1) ] [Hospital Unit Name ]. Cardiologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3142] ([Telephone/Fax (1) 19980]) on [2198-1-11] at 1:20pm Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR Coumadin for AFib Goal INR 2-2.5 First draw [2197-12-14] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [Last Name (STitle) 3142] Results to phone [Telephone/Fax (1) 19980] (fax [Telephone/Fax (1) 19981]) [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2197-12-13] ICD9 Codes: 4241, 9971, 2762, 5119, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6428 }	Medical Text: Admission Date: [2193-3-22] Discharge Date: [2193-3-28] Date of Birth: [2143-6-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: hypotension post-dialysis and abnormal CT scan Major Surgical or Invasive Procedure: aortic root pseudoaneurysm endostenting/ placement of ECMO [2193-3-27] History of Present Illness: 49 yo male with prior hospitalization for endocarditis from [2192-9-6] to [2193-2-7]. He underwent multiple aortic repairs, AVR, sternal debridement and flap closure, cholecystectomy, G-J tube placement, HD cath placement, and tracheostomy. After a prolonged ICU course, he became stable hemodynamically and was transferred to a rehab bed at [Hospital1 336]. At rehab on [3-21] , he became hypotensive to the 70's systolic after hemodialysis, and did not recover quickly. He had an urgent CT scan to evaluate his chest in the ED, and this revealed a large right PA pseudoaneurysm. Turned down for surgery at [Hospital1 336], and transferred back here for evaluation by Dr. [Last Name (STitle) 1290]. Past Medical History: endocarditis AVR/ multiple aortic replacements and repairs renal failure respiratory failure/tracheostomy asthma spontaneous PTX coccyx ulcer ( see DC summary dated [1-13] for full details) Social History: lives with wife and 2 sons has spent past 2 months in rehab unit no alcohol or tobacco use Family History: mother with CVA father with cardiomyopathy due to lymphoma Physical Exam: sedated, but awakens, nods head to questions, moves extrems weakly few coarse rhonchi bilat. RRR well-healed sternal chest wound, HD cath in place flat, soft abd; + BS with G-J tube in place extrems warm; increasing edema in right arm SBP 70's to 80's RA sats on 50% are 97% Pertinent Results: [2193-3-28] 04:44PM BLOOD WBC-9.2 RBC-3.30* Hgb-9.9* Hct-28.7* MCV-87 MCH-29.9 MCHC-34.4 RDW-18.6* Plt Ct-76* [2193-3-22] 11:25AM BLOOD WBC-18.8# RBC-2.99 Hgb-8.4* Hct-28.7* MCV-96 MCH-28.2 MCHC-29.3* RDW-23.7* Plt Ct-220 [2193-3-28] 04:44PM BLOOD Plt Smr-VERY LOW Plt Ct-76* [2193-3-22] 11:25AM BLOOD PT-16.8* PTT-63.3* INR(PT)-1.5* [2193-3-28] 04:44PM BLOOD Creat-2.9* Cl-108 HCO3-13* [2193-3-28] 03:48AM BLOOD Glucose-88 UreaN-63* Creat-3.0* Na-152* K-4.2 Cl-103 HCO3-22 AnGap-31* [2193-3-22] 11:25AM BLOOD Glucose-103 UreaN-44* Creat-2.7* Na-141 K-4.3 Cl-98 HCO3-25 AnGap-22* [2193-3-28] 04:44PM BLOOD ALT-860* AST-2261* LD(LDH)-2483* AlkPhos-168* Amylase-369* TotBili-4.1* [2193-3-22] 11:25AM BLOOD ALT-20 AST-25 LD(LDH)-342* AlkPhos-240* Amylase-35 TotBili-1.1 [2193-3-28] 04:44PM BLOOD Lipase-718* [2193-3-28] 04:44PM BLOOD Mg-2.7* [2193-3-22] 11:25AM BLOOD Albumin-4.2 Calcium-9.3 Phos-5.9# Mg-2.2 [2193-3-28] 07:11PM BLOOD Type-ART pO2-425 pCO2-30* pH-7.26* calHCO3-14* Base XS--12 [2193-3-28] 07:11PM BLOOD Lactate-16.3* K-4.3 Brief Hospital Course: Admitted [3-22] and underwent MRI of chest which confirmed pseudoaneurysm of aortic root. Followed by the renal and transplant teams for his renal failure and ? of abdominal hypoperfusion and ? of abdominal distention. ID also consulted once again on Mr. [Known lastname ], who had prior fungemia/[Female First Name (un) ]/MSSA and who was well-known to all of these services. Pressor support was instituted for hypotension and quadruple abx therapy continued. Cardiac cath was repeated on [3-26] with confirmation of anatomy. Lactate started to rise and there was concern for abdominal catastrophe and hypoperfusion to the gut. Dr. [First Name (STitle) ] from the transplant surgery team consulted with cardiac surgery again given his grave prognosis and increasing acidosis. On [3-27], he returned to the OR for endostent placement to help plug the aortic root pseudoaneurysm and ECMO placement/institution with Drs. [Last Name (STitle) 914] and [Name5 (PTitle) 1290]. He remained critically ill and the family was informed.He developed ST elevations likely due to the endostent's proximity to the left main coronary artery. Plans were made to wean the ECMO support, and cardiac tamponade developed due to leakage of the psuedoaneurysm. He continued to rapidly decline and the family made him DNR after discussions with Dr. [Last Name (STitle) 1290]. The patient became hypotensive in the evening with bradycardia. This was followed by asystole. He was pronounced expired at 7:45 PM on [2193-3-28] by Dr. [Last Name (STitle) 2637]. Dr. [Last Name (STitle) 1290] and the family were notified. Medications on Admission: tobramycin caspo cefepime vancomycin synthroid phoslo Discharge Disposition: Expired Discharge Diagnosis: endocarditis pseudoaneurysm of aortic root s/p endovascular stent placement in aortic root s/p ECMO Discharge Condition: expired Completed by:[2193-5-21] ICD9 Codes: 4275, 0389, 5856, 4271
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6429 }	Medical Text: Admission Date: [2129-11-13] Discharge Date: [2129-12-5] Date of Birth: [2077-11-24] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1481] Chief Complaint: S/P assault, intubated Major Surgical or Invasive Procedure: [2129-11-17] 1. Anterior cervical diskectomy, C3-C4, C4-C5, and C5-C6. 2. Open reduction of the fracture, C5 and C6. 3. Fusion C3 to C6. 4. Anterior instrumentation C3-6. 5. Anterior allograft spacers x 3. [2129-11-18] 1. Total laminectomy of C4, C5, C6 and C7. 2. Fusion C4-T1. 3. Instrumentation C4-T1. 4. Autograft. [2129-11-24] 1. Percutaneous tracheostomy and PEG tube History of Present Illness: Mr. [Known lastname 284] is a 52 year old male who was found slouched on the ground next to an apartment building. He was alert and oriented with abrasions on his head and neck. He ha some poor recall of the event but thought that he was choked. His voice became progressively hoarse. His GCS was 14 at the scene and he was moving all extremities. He was transferred to [Hospital1 18] Emergency Room where he was intubated on arrival for airway edema. Past Medical History: 1. seizure disorder Social History: + Tobacco + ETOH + Cocaine Living situation unclear. [Name2 (NI) ] has 5 children and many brothers and sisters Family History: non contributory Physical Exam: Temp 98 BP 161/96 HR 68 RR 28 HEENT Blood and minor abrasions on face, PERRLA Neck Cervicle collar in place, diffuse tenderness Chest coarse breath sounds throughout, no deformities COR RRR Abd soft, non tender, normal rectal tone Ext 0/5 motor for both upper extremities, hyporeflexic proximal extremity weakness of both lower extremities Pertinent Results: [2129-11-13] 08:55PM WBC-9.1 RBC-3.98* HGB-11.8* HCT-36.1* MCV-91 MCH-29.5 MCHC-32.6 RDW-13.2 [2129-11-13] 08:55PM PLT COUNT-339 [2129-11-13] 08:55PM PT-12.8 PTT-27.8 INR(PT)-1.1 [2129-11-13] 08:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2129-11-13] 09:14PM GLUCOSE-97 LACTATE-2.3* NA+-141 K+-4.4 CL--99* TCO2-27 [2129-11-13] 08:55PM UREA N-19 CREAT-1.5* [2129-11-13] 09:40PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]->=1.030 [2129-11-13] 09:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN->300 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5 LEUK-NEG [2129-11-13] Head CT : 1. No intracranial hemorrhage. 2. Probable chronic deformity of the nasal bones and left zygomatic arch. No definite acute fracture seen. 3. Punctate high densities in facial soft tissues noted - ? foreign body/surface debris; clinical correlation recommended. [2129-11-13] C Spine : 1. Linear lucencies seen along the inferior endplate of C5 and superior endplate of C6, as described above, with areas of sclerotic change, suggesting chronic fractures. No definite acute fracture or malalignment is seen. No definite focal soft tissue abnormalities noted. 2. Vascular calcifications along the carotid arteries remarkable for the patient's stated age. [2129-11-13] CTA Neck : Patent major arteries of the neck, without evidence of focal flow-limiting stenosis or occlusion. Opacification of the ethmoid air cells and the nasopharyngeal secretions related to intubation. [2129-11-13] CT Torso : 1. Acute right rib fractures as delineated above, without pneumothorax or pleural effusion. Patchy peripheral airspace opacities in the right lower lobe could represent aspiration or contusion. 2. No definite intra-abdominal injury seen. 3. Evidence of old trauma manifest as subacute right rib fractures, bullet fragment in the right paraspinal region in the chest, and heterotopic bone formation along the proximal left femur. [2129-11-15] Head CT : 1. No definite acute findings to account for the patient's symptoms. Relative hyperdense appearance to the origin of the left MCA seen on one image only. Findings could represent early vascular calcifications. However, thrombosis is not completely excluded. No loss of [Doctor Last Name 352]-white matter differentiation to suggest acute infarction, however, CT is not very sensitive for evaluation of such. 2. Opacification of paranasal sinuses and layering fluid in the nasopharynx are noted in this patient who is intubated. [2129-11-15] CT C Spine : 1. Age-indeterminate fracture lines as previously described, with areas of sclerotic appearance suggesting chronicity. 2. No definite focal soft tissue abnormality seen including hematoma or abscess. 3. Again there is normal opacification of major cervical vessels. 4. Intubated with OG tube in place, with fluid in the pharynx and paranasal sinus mucosal thickening [2129-11-15] CT T-L spine : 1. Questionable age indeterminate minor vertebral fractures at C5 and C6 with no evidence for cord compression. 2. Mild cervical and lumbar disc bulges causing no significant stenosis or cord compression. 3. Opacification involving the bibasilar lower lobes, likely representing aspiration pneumonia or atelectasis. 4. Bullet fragment within the right lower lobe (superior segment). Pneumothorax cannot be assessed as anterior nondependent portions of lungs not in FOV. [2129-11-17] CT C Spine : Anterior fusion hardware with screws traverse the levels at C3 through C6 with interbody grafts. A separate lateral radiograph demonstrates a probe at C5-6 level. Please refer to operative note for full details. [2129-11-18] CT C Spine : There is anterior spinal fusion of C3-C6 in image 1. Placement of posterior spinal fusion rods at C4, C5, C6, and T1 are seen in image 2 and 3. The patient is intubated and the tip is not visualized. [2129-11-28] Head CT : 1. No acute intracranial process. 2. Paranasal sinus disease. [2129-12-2] Left upper extremity ultrasound : Non-compressible left brachial vein consistent with venous thrombosis Brief Hospital Course: Mr. [Known lastname 284] was evaluated by the Trauma team in the Emergency Room, Intubated, scanned and finally transferred to the Trauma ICU for further evaluation and treatment. His pre admission Dilantin was continued and he had no seizure activity during his hospital stay. He was evaluated by the Ortho-Spine service and shortly after admission developed paralysis of both upper extremities and repeat CT showed cord compression. He subsequently underwent 2 fusion procedures ( see operative notes for details ). During his post op course he developed pneumonia with sputum culture positive for Beta strep and MRSA. He was treated with a 10 day course of antibiotics. His neuro exam gradually improved with cessation of Propofol as far as tracking, following commands and moving lower extremities by Post op day #4 however it took a little longer for his upper extremities to move. His pulmonary status was compromised by secretions and although he was maintained on low levels of CPAP/IPS his intubation was prolonged.. he was eventually extubated on [2129-11-22] however was unable to clear his secretions and he was electively intubated the same day. On [2129-11-24] he underwent a percutaneous tracheostomy as well as G Tube placement. Following a successful ventilator wean and stability on a trach [Last Name (un) ] he was transferred to the Trauma floor on [2129-11-26]. At this point, he was able to move both hands and fingers but was unable to lift his arms or shoulders. Unfortunately he fell out of bed on [2129-11-28] and underwent repeat CT of the head and C Spine. There was no evidence of a bleed and the hardware in the C spine was in alignment. From a nutritional standpoint he was tolerating feeding through his G tube but developed hyponatremia and hyperkalemia with a normal BUN and creatinine. His feeding were changed to a renal preparation and the Renal service was consulted. Upon evaluation of his hospital course and lab tests they determined that he had SIADH which caused his hyponatremia. Adrenal insufficiency was ruled out. His sodium was up to 139 and his potassium was stable at 4.9 prior to discharge. The cause of his SIADH was potentially from Pneumonia, pain, narcotics and possibly the use of Cipro which was given for his pneumonia. His activity level is improving. He is ambulating with assistance and his upper extremities have more purposeful movements. He had a video swallow and has severe aspiration so he continues to be NPO and will require a re evaluation later this week. He is able to cough up his secretions without difficulty and hopefully his tracheostomy tube can be down sized and he can be decannulated in the future. He is being discharged to rehab on [2129-12-5] for further intense physical therapy and occupational therapy. Medications on Admission: Dilantin ( not sure of dose) Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Phenytoin 125 mg/5 mL Suspension Sig: Four (4) ml PO TID (3 times a day). 3. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ml PO BID (2 times a day) as needed for Constipation: via G tube. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2 times a day): via G Tube. 7. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mls PO Q3H (every 3 hours) as needed for pain: via G tube. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. sodium chloride 2 GM Sig: Two (2) Gm three times a day: Give via G Tube. Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Primary diagnosis S/P Assault with 1. Cervical spondylosis 2. Spinal cord injury 3. Fracture at C5-C6; disruption of disk space, C3-C4. 4. Compromised airway 5. Pneumonia 6. SIADH 7. Left bascilic vein thrombosis 8. Severe dysphagia Secondary diagnosis 1. Seizure disorder Discharge Condition: Improving neurologically, able to move both arms, able to clear secretions and working with Physical Therapy Discharge Instructions: * Continue your tube feedings. No oral intake for the present time. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 600] for a follow up appointment in 2 weeks in the Trauma Clinic. Call the [Hospital 84470] Clinic at [Telephone/Fax (1) 3573] for a follow up appointment in 2 weeks with Dr. [Last Name (STitle) 363] Completed by:[2129-12-5] ICD9 Codes: 5070, 3051, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6430 }	Medical Text: Admission Date: [2123-6-30] Discharge Date: [2123-7-27] Date of Birth: [2056-9-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 4052] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Endoscopy with [Last Name (un) ] tube placement and failed TIPS [2123-7-1] TIPS [2123-7-7] Repeat TIPS with ultrasound guided biopsy [2123-7-12] History of Present Illness: 66 y/o white male resident of [Doctor Last Name ] House with a h/o Hep B and T2DM who presented to the ED approximately 2 hours after being discharged from [Hospital1 18] (recent admission [2123-6-24] to [2123-6-30] for UGIB) with dizziness and nausea. Patient states that soon after he arrived home he began to have some nausea and felt dizzy. He went to the bathroom and had a bowel movement which made him feel somewhat better. Afterwards, he still had nausea and dizziness that was not improving. He then presented to the [Hospital1 18] ED with the above complaints. He denied any LOC, CP, SOB, diaphoresis, vomiting, or hematemesis. . When he arrived to the ED his vitals were as follows: Initial BP was 90/50 at which point 1L bolus IVF NS was given. BP after first bolus was 126/88. BP then was 150/75 and then 135/70 after a total of 3L NS given in ED. . In the ED, patient stated that he felt better but some nausea remained. BP responded to fluids and initial HCT was 27.5 but re-calculated to be 31 and then 30 from a HCT of 32.6 from AM labs when he was discharged earlier today. T 97.2 HR 105 BP 122/69 RR 20 O2Sat 96% ROS: + for nausea and dizziness Negative for CP, SOB, vomiting, hematemesis, diaphoresis All other review of systems negative and consistent with patient's condition upon discharge earlier today. Past Medical History: 1) Hep B 2) Type 2 DM 3) EtOH/Drug abuse 4) Schizophrenia 5) Dementia 6) Hypercholesterolemia 7) CAD, unclear status Social History: History of EtOH abuse Physical Exam: Vitals upon presentation: See HPI General: Lying on side in bed. NAD. A/O x3. HEENT: NC/AT. PERRLA. EOMI. Neck supple. CV: Normal S1 and S2 with no m/r/g. Pulm: CTAB, no wheezes or crackles. Abd: Soft, NT, ND with normoactive BS. Ext: No cyanosis or edema. 2+ DP B/L. Exam otherwise unchanged since patient discharged earlier today. Pertinent Results: [2123-6-30] 08:06PM HGB-9.9* calcHCT-30 [2123-6-30] 04:58PM K+-4.1 [2123-6-30] 04:58PM HGB-10.2* calcHCT-31 [2123-6-30] 04:50PM GLUCOSE-151* UREA N-20 CREAT-1.1 SODIUM-137 POTASSIUM-6.1* CHLORIDE-107 TOTAL CO2-23 ANION GAP-13 [2123-6-30] 04:50PM ALT(SGPT)-28 AST(SGOT)-54* CK(CPK)-107 ALK PHOS-61 AMYLASE-13 TOT BILI-0.4 [2123-6-30] 04:50PM cTropnT-<0.01 [2123-6-30] 04:50PM CK-MB-2 [2123-6-30] 04:50PM ALBUMIN-2.8* CALCIUM-7.8* PHOSPHATE-4.2# MAGNESIUM-1.8 [2123-6-30] 04:50PM WBC-10.4 RBC-2.98* HGB-9.7* HCT-27.5* MCV-93 MCH-32.7* MCHC-35.4* RDW-14.6 [2123-6-30] 04:50PM NEUTS-84.3* BANDS-0 LYMPHS-9.8* MONOS-3.9 EOS-1.9 BASOS-0.1 [2123-6-30] 04:50PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL [2123-6-30] 04:50PM PLT SMR-LOW PLT COUNT-127* [2123-6-30] 04:50PM PT-14.9* PTT-28.9 INR(PT)-1.3* Brief Hospital Course: MICU COURSE: The patient is a 66 yo M recently admitted with an UGIB and was discharged home only to return 12 hours later to the ED with dizziness. In the ED, the patient was hypotensive and eceived 3L NS. His pressures increased from 90/50 to 135/70. His hct was stable from the time of discharge (32 -->31). He was admitted to the floor where he then became tacycardic and again hypotensive. He was thought to be re-bleeding and was transferred to the ICU for an EGD. Upon arrival in the ICU, he was again stable with BP's in the 120's and HR 70's. 4 hours later (prior to the EGD), the patient acutely dropped his pressures to the 60's and was tachycardic to the 150's. A hct showed a drop from 31 --> 24. He was transfused 5 units of PRBC and had approximately 4L of NS. He was intubated and an EGD was performed which showed his known gastric varice with evidence of recent bleeding. [Initials (NamePattern4) ] [Last Name (NamePattern4) 10045] tube was inflated and arrangements were made for an urgent TIPS procedure. He was taken to IR and a TIPS was attempted but unsuccessful. The [Last Name (un) 10045] tube was deflated after 12 hours. The patients hct again stabalized. A TIPS was then reattempted x 3 and was successful on third try On HD# 6, pt spiked a temp to 101. Sputum from ET tube grew out 4+GNR and 4+GPC. Given his recent hospitalization, he was broadly covered with vancomycin and zosyn. Also, pt was noted to be minimally responsive off sedation thought to be [1-28] slowed clearance of versed by his liver. Head CT was negative. His mental status was initially poor in the unit. On HD # Pt. was transferred out to the floor. He susequently developed respiratory distress and was readmitted to the MICU for aspiration pneumonia. He was treated with Levoquin and Flagyl in the unit and became afebrile. He continued to have ascites and paracentesis was performed in the unit. Pt's respiratory status improved after paracentesis. 600cc ascites fluid was negative for SBP, and patient was prophylaxed on Rifaxamin. He progressively regained mental status and respiratory status and after remaining afebrile he came back to the floor on HD# 19 with no antibiotic coverage. Once on the floor Pt's course continued as follows. # Respiratory Distress: Ddx included PE (pt has not been on SQ hep [1-28] coagulopathy from liver dz), aspiration (tube feeds), increasing abdominal distention leading to atelectasis and poor inspiration, fluid overload, hepatopulm syndrome. to NC with sats>95. CTA was not done as suspicion was low for PE due to adequeate oxygenation. Pts breathing was much more comfortable after paracentesis. Pt. initially suspicious for Pulm edema. He was diuresed with Lasix and Spirinolactone. His respiratory status and CXR improved with diuresis. Pt. O2 requirement progressed from non-rebreather to NC and by HD#26 he was saturating 95% on RA. # GIB: Patient with known cirrhosis and gastric varices. Recent melanotic episodes, EGD done [7-19] with fundic varices but no active bleed. Pt. continued to have + guaics on floor after GIB. By HD#21 Guaics were negative and nursing D/C guaic checks. No further episodes of GI bleeding were noted. - PPI [Hospital1 ] -Successful TIPS in the unit, Nadolol not necessary per Hepatology because of TIPS. . # Cirrhosis: -Pt was followed along by hepatology during hospitalization. His ascites was treated with Lasix and spirinolactone for diuresis which was successful. Pt. initially had some symptoms of encephalopathy on the floor. He was given Lactulose titrated to 4 BM's per day. His Mental Status progressively improved and he was conversant with no asterixis, A&O x 3 on HD#26. Rifaxamin for SBP prophylaxis. - liver lesions on ultrasound concerning for malignancy; aFP elevated; will need liver biopsy of lesions once stable if MRI proves that a mass is there - Pt. coags were stable on D/C -Pt requires MRI of Liver to determine if there is a mass suspicious for [Company 191]. U/S was suspicious for Liver mass, that requires further work-up. Pt. declined MRI x 2 Hepatology fine for MRI to be arranged as outpatient. Pt. likely to require Biopsy if MRI shows liver lesion suspicious for [Company 191]. . #[Name (NI) 3674] Pt. Hematocrit was stable on the floor. Because of history of anemia, Anemia work-up was undertaken which showed no evidence of hemolysis or Iron Deficiency. HCT on HD #26 was 28.6 # DM: RISS -sugars stable throughout floor stay . # Schizophrenia: psych following. started back on haldol 5mg [Hospital1 ] per psych recs; cont zydis -added 10 mg Celexa per psych. Celexa can advance to 20 mg if necessary. Standing Haldol and Cogentin and Perphenazine were added per psych recs. . # FEN: Speech and swallow eval showed Pt. unable to take any liquids and he was getting TF via Donhoff when Pt. arrived on the floor. TF were D/C when Pt. pulled out his Dobhoff tube and we were unable to replace it on HD#22. Pt. received TPN for 2 days and then on HD#26 S&S reeval showed Pt. able to take pureed solids and thickened liquids. Pt. returned to regular diet with aforementioned caveats and all PO meds. Pt is to take PO meds with thickened liquids. -Hypernatremia: Pt had a few episodes of hypernatremia in the MICU as well as on the floor. On HD#19 he was requiring free water boluses to trend down his sodium. On HD#26 Pt. sodium had been stable for 3 days. Pt. also required aggressive Potassium repletion throughout his hospital stay. On HD#26 patient passed Speech and swallow eval so will begin taking PO spirinolactone and hopefully spare potassium a little more. # ID: Paracentesis fluid negative for SBP on Gram stain and Cx. Blood Cx and catheter tip Cx Negative. Afebrile and no Abx at present save Rifaxamin for SBP prophylaxis. - Pt had one episode of Left sided erythema/thrombophlebitis from Left PICC on HD#23 . IV team was consulted and deemed that the line was not infected and that erythema was from mechanical thrombophlebitis. Pt never spiked a temp, and erythema resolved over the next day. . #CV: Had Sinus Tach with PAC's in the unit. One episode on HD# 21 of 10 beats of Vtach. Pt was asymptomatic with stable vital signs. EKG showed possible PAC's. No further episodes. . Wound Care: Pt. with Left LE pressure ulcer. Evaluated by wound care nursing and was D/C with instructions for duoderm dressing changes. . # Access: PICC (placed [7-16])-Pt. pulled out [7-22]; was replaced by IR [7-18], LIJ placed [7-19]-pulled out by patient [7-21]. PIV placed [7-22] . # Ppx: PPI, pneumoboots throughout hospital stay . #Dispo: Pt was dischargec to [Hospital1 ] in stable condition. He was scheduled for follow up in the liver clinic and with Dr. [Last Name (STitle) 1266] as listed on D/C instructions. Medications on Admission: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Olanzapine Oral 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 8. Perphenazine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 12. Disulfiram 250 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Naltrexone 50 mg Tablet Sig: One (1) Tablet PO QD (). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: Please take for 1 month and then re-access after repeat EGD in 1 month. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 17. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO twice a day for 2 weeks. Disp:56 Capsule(s) Refills:0 18. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 19. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Capsule PO once a day. 20. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Medications: 1. Insulin Regular Human 100 unit/mL Cartridge Sig: [2-5] units Injection per sliding scale as needed for hyperglycemia. 2. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous at breakfast and dinner. 3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB IH Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB IH Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-28] Sprays Nasal TID (3 times a day) as needed for nasal congestion. 12. Perphenazine 8 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift. 15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 16. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO Q6-8H (every 6 to 8 hours) as needed. 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Gastric Variceal Bleeding Aspiration Pneumonia Discharge Condition: Good Discharge Instructions: You have been admitted to the hospital following a gastrointestinal bleed from cirrhosis and a hospital course complicated by aspiration pneumonia. You should call your doctor or return to the emergency room should you experience any of the following: Fever > 101 Nausea and Vomiting Bloody Stools Severe Abdominal Pain Chest Pain Shortness of Breath Dizziness Loss of Vision Followup Instructions: Follow up in clinic with Dr. [Last Name (STitle) 1266] in Monday [2123-8-9] at 11:30 am. Please call ([Telephone/Fax (1) 8417] if you need to reschedule this appointment. Please follow up in Liver Clinic with Dr. [Last Name (STitle) 10285] on [2123-8-10] at 11:00am. Please call ([Telephone/Fax (1) 1582] if you need to reschedule this appointment [Known firstname ] [Last Name (NamePattern1) ] MD [MD Number(2) 4055] Completed by:[2123-7-27] ICD9 Codes: 2851, 5070, 0389, 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6431 }	Medical Text: Admission Date: [2158-1-2] Discharge Date: [2158-1-13] Date of Birth: [2106-7-5] Sex: F Service: CARDIOTHORACIC Allergies: Adhesive Attending:[First Name3 (LF) 165] Chief Complaint: chest pain Major Surgical or Invasive Procedure: pericardiocentisis [2158-1-6] Pericardial window for a large pericardial effusion History of Present Illness: Ms [Known lastname ] is a 51 year old female s/p AVR/MVR mechanical valve replacements on [2157-12-12] with recent hospitalization for LOC work-up presenting from clinic for management of new pericardial effusion. . Patient recently hospitalized from [12-22] -[12-26] after unwitnessed episode of loss of consciousness. Head CT negative. Seen by neurology. Questionable if symptoms consistent with seizure however started on Keppra and discharged back to rehab. Patient also treated with 3day course of ceftriaxone for UTI. . Day prior to planned cardiology appt reports localized right sided pleuritic chest pain as well as dyspnea on exertion. Regarding chest pain lasts minutes, no appreciable trigger, relieved with tylenol. Denies associated n/v, diaphoresis. Denies any syncopal of pre-syncopal episode. At cardiology clinic today found to be in atrial fibrillation; repeat post-surgical echo demonstrated mod-large pericardial effusion without signs of tamponade physiology. Transfer to cardiology for potentional pericardiocentesis and cardioversion. . On arrival to the floor, patient without complaint. . On review of systems, patient with prior history of stroke, reports pleuritic chest pain, occassional dizziness without syncope. Denies history of TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: Primary Pericardial Effusion Atrial Fibrillation . Secondary: Seizure Disorder Rheumatic Heart Disease, Paroxysmal atrial fibrillation, Mitral and Aortic Stenosis, Anemia, s/p right hemisphere stroke in [2157-2-4]: Her left side is still a little weak. Broken ankle Past Surgical History Mechanical AVR and mechanical MVR [2157-12-12] Social History: Divorced, 2 sons. Currently lives with one son; has two sons; Previously employed as a seamstress, cleaning woman -Tobacco history: denies -ETOH: denies -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; Mother with diabetes. Father with possible CVA. Physical Exam: VS: 97.3 120/80 86 18 100%RA GENERAL: Well appearing female, NAD, speaking in full sentences without problem, comfortable [Name (NI) 4459]: Bilateral peri-orbital ecchymosis; laceration over right eye with sutures in place, right conjunctival hemorrhage, PERRLA, EOMI, OP clear withou exudates, lessions NECK: Supple, JVD to level of mandible at 45degrees, no cervical or supraclavicular LAD CARDIAC: irreg, irreg with ii/VI systolic murmur and closing click, no audible rub, no peripheral edema, JVD to level of mandible CHEST: Healed mildline sternotomy scar, no tenderness LUNGS: 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. PULSES: 2+ peripheral pulses NEURO: II-XII intact, sensation intact, Strength 5/5 throughout with exception of LUE [3-7] (c/w baseline Pertinent Results: CXR: Compared to [2157-12-24], the large heart size is again noted which is likely unchanged considering differences in technique. It is uncertain how much of this is from cardiomegaly or pericardial effusion. The pulmonary vasculature is slightly plethoric, as before, likely reflecting pulmonary vascular congestion. There appears to be minimal atelectasis at the left lung base, otherwise, lungs are clear. Sternal wires with valve replacements are again noted. . TTE [1-4] Focused views: Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present. A bileaflet mitral valve prosthesis is present. The tricuspid valve leaflets are mildly thickened. There is a large circumferential pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2157-1-2], the circumferential pericardial effusion is similar in size . TTE [1-2] The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. A mechanical aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal disc motion and transvalvular gradients. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal disc motion and transvalvular gradients. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is a moderate sized pericardial effusion measuring 1.8cm inferior to the left ventricle, 2.5cm laterally, 0.6cm around the apex, and <0.5cm anterior to the right ventricle. There are no echocardiographic signs of tamponade. IMPRESSION: Moderate pericardial effusion with suggestion of loculation. No echocardiographic signs of tamponade. Well seated, normal functioning aortic and mitral valve mechanical prostheses. Low normal left ventricular systolic function [2158-1-13] 04:30AM BLOOD WBC-8.8 RBC-3.51* Hgb-9.9* Hct-29.1* MCV-83 MCH-28.1 MCHC-33.9 RDW-14.9 Plt Ct-262 [2158-1-12] 04:30AM BLOOD WBC-8.7 RBC-3.36* Hgb-9.4* Hct-27.9* MCV-83 MCH-27.9 MCHC-33.5 RDW-14.3 Plt Ct-211 [2158-1-13] 04:30AM BLOOD PT-35.2* PTT-86.0* INR(PT)-3.6* [2158-1-12] 04:30AM BLOOD PT-23.8* PTT-74.7* INR(PT)-2.3* [2158-1-11] 04:25AM BLOOD PT-20.4* PTT-101.3* INR(PT)-1.9* [2158-1-10] 12:00AM BLOOD PT-20.0* PTT-68.0* INR(PT)-1.8* [2158-1-9] 06:40AM BLOOD PT-18.6* PTT-31.3 INR(PT)-1.7* [2158-1-8] 04:25AM BLOOD PT-19.6* PTT-36.6* INR(PT)-1.8* [2158-1-7] 02:05AM BLOOD PT-17.2* PTT-26.5 INR(PT)-1.5* [2158-1-6] 08:15PM BLOOD PT-18.9* PTT-28.9 INR(PT)-1.7* [2158-1-12] Echo: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). A mechanical aortic valve prosthesis is present. A mechanical mitral valve prosthesis is present. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Low-normal global left ventricular systolic function. Trivial pericardial effusion without echocardiographic evidence of tamponade. Left pleural effusion. Compared with the report of the prior study (images reviewed) of [2158-1-9], the current study contains very limited views. Although previously reported as a very small pericardial effusion, on further review of the prior images the size appears consistent with the trivial pericardial effusion noted today. The left pleural effusion persists. Brief Hospital Course: Ms [Known lastname ] is a 51 year old female s/p AVR/MVR mechanical valve replacements on [2157-12-12] who presented with pleuritic pain and pericardial effusion now s/p pericardiocentisis on . . # Percardial Effusion. Etiology likely post-cardiac surgery on [12-13] with likely hemorrhagic in setting of supratherapeutic INR. Patient was without any preceding fevers, URI symptoms making infectious etiology less likely. WBC wnl, afebrile in house. Biomarkers negative x2. No significant metabolic derangements evident on labs. TSH wnl, rheumatod factor and [Doctor First Name ] negative. Patient remained hemodynamically stable. Monitored on telemetry. Pulsus monitored [Hospital1 ], thought hard to interpret in setting of atrial fibrillation. [1-2] TTE with moderate pericardial effusion with suggestion of loculation with no echocardiographic signs of tamponade. Due to size of effusion decision made to proceed with pericardiocentisis. INR was allowed to trend down in preparation for pericardiocentesis. The effusion was monitored on echo. The effusion increased considerably and the patient was referred for pericardial window with cardiac surgery. . # RHYTHM: Atrial Fibrillation. Patient with history of paroxysmal atrial fibrillation on coumadin. CHADS3. Patient was monitored on telemetry. Beta-blocker continued with rates well controlled. Regarding anticoagulation, INR supratherapeutic on admission, coumadin held and coags trended. On [1-4] INR 3.0 and due to history of CVA decision made to initiate heparin infusion. Rhythm monitor post-pericardiocentisis. possible cardioversion s/p pericardiocentisis . # Chest pain. Described as pleuritic and nature and associated with SOB. Patient without hypoxia, further INR supratherapeutic on admission making pulmonary embolism unlikely. Though EKG without signs of pericarditis likely effusion causing some degree of pericardial irritation resulting in pain. Biomarkers cycled and negative x2; EKG without signs of ischemia. CXR without acute process. Patient with intermittent complaints of pain in house - controlled with tylenol. # Seizure Disorder. Patient admitted [Date range (1) 17831] after an episode of LOC which was deemed secondary to seizure. Patient continued on Keppra. No seizure inactivity while hospitalized. . # Dsyuria. Patient recently treated with 3 day course of ceftriaxone for UTI. Repeat UA/Ucx . # s/p CVA [2-9] with residual left upper extremity weakness. Per patient at baseline Neuro exam monitored. At time of discharge function at baseline . # Hypertension. Normotensive throughout hospitalization. Control metoprolol and lisinopril. . # Depression. Continue Zoloft . Cardiac Surgery Course: The patient was brought emergently to the operating room on [2158-1-6] with Dr. [First Name (STitle) ]. Pericardial window was performed. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for observation and recovery. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tube was discontinued without complication. Initial CXR following removal of drain revealed a widened mediastinum. In the setting of hypotension and tachycardia, echo was performed which revealed a small inferolateral effusion, with nothing anterior. The patient remained hemodynamically stable. Heparin drip was started as a bridge to coumadin. Heparin was discontinued when INR became therapeutic. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 7, the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Bear [Doctor Last Name ] Nursing and Rehab in good condition with appropriate follow up instructions. Medications on Admission: 1. levetiracetam 500 mg [Doctor Last Name 8426] Sig: One (1) [Doctor Last Name 8426] PO BID (2 times a day): plan to increase to 750 mg [Hospital1 ] in 2 weeks. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. ranitidine HCl 150 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO DAILY (Daily). 4. aspirin 81 mg [Hospital1 8426], Delayed Release (E.C.) Sig: One (1) [Hospital1 8426], Delayed Release (E.C.) PO DAILY (Daily). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. bisacodyl 5 mg [Hospital1 8426], Delayed Release (E.C.) Sig: Two (2) [Hospital1 8426], Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. acetaminophen 325 mg [Hospital1 8426] Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/headache. 8. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: [12-4] PO Q8H (every 8 hours) as needed for itching. 9. metoprolol tartrate 50 mg [Month/Day (2) 8426] Sig: 1.5 Tablets PO TID (3 times a day). 10. warfarin 1 mg [Month/Day (2) 8426] Sig: One (1) [Month/Day (2) 8426] PO DAILY (Daily): goal INR 3-3.5 for mechanical Aortic and Mitral valves. 11. lisinopril 5mg QD 12. Vitamin D-3 400u 13. Zoloft 50mg tab QD Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg [Month/Day (2) 8426] Sig: One (1) [Month/Day (2) 8426] PO DAILY (Daily). 3. aspirin 81 mg [Month/Day (2) 8426], Delayed Release (E.C.) Sig: One (1) [Month/Day (2) 8426], Delayed Release (E.C.) PO DAILY (Daily). 4. acetaminophen 325 mg [Month/Day (2) 8426] Sig: Two (2) [Month/Day (2) 8426] PO Q4H (every 4 hours) as needed for pain, fever. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. sertraline 50 mg [Month/Day (2) 8426] Sig: One (1) [Month/Day (2) 8426] PO DAILY (Daily). 8. levetiracetam 500 mg [Month/Day (2) 8426] Sig: One (1) [Month/Day (2) 8426] PO BID (2 times a day). 9. lisinopril 5 mg [Month/Day (2) 8426] Sig: 0.5 [Month/Day (2) 8426] PO DAILY (Daily). 10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 11. metoprolol tartrate 50 mg [Month/Day (2) 8426] Sig: Two (2) [Month/Day (2) 8426] PO TID (3 times a day). 12. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H (every 6 hours) as needed for itching . 13. warfarin 1 mg [Month/Day (2) 8426] Sig: One (1) [Month/Day (2) 8426] PO DAILY (Daily): MD to dose daily for goal INR 2.5-3.5, dx: mechanical aortic and mitral valves. [Month/Day (2) 8426](s) 14. Outpatient Lab Work DAILY INR until stable, then M, W, F for goal 2.5-3.5 dx: mechanical aortic and mitral valves Discharge Disposition: Extended Care Facility: Bear [Doctor Last Name ] Nursing Center - [Location (un) 2199] Discharge Diagnosis: Primary Pericardial Effusion Atrial Fibrillation . Secondary: Seizure Disorder Rheumatic Heart Disease, Paroxysmal atrial fibrillation, Mitral and Aortic Stenosis, Anemia, s/p right hemisphere stroke in [2157-2-4]: Her left side is still a little weak. Broken ankle Past Surgical History Mechanical AVR and mechanical MVR [2157-12-12] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage No edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] [Telephone/Fax (1) 170] [2-6] at 1:15pm Cardiologist Dr. [First Name (STitle) 437] [Telephone/Fax (1) 62] [2-13] at 3:30pm Neurologist: [Name6 (MD) ] [Name8 (MD) ], M.D. Phone:[Telephone/Fax (1) 2574] Date/Time:[2158-4-11] 1:00 Please call to schedule the following: Primary Care Dr. [First Name (STitle) 17832] [Name (STitle) 16365] in [3-7] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR Coumadin for Mech AVR/MVR Goal INR 2.5-3.5 First draw day after discharge [2158-1-14], then daily until stable, Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by MD * Please arrange for INR/coumadin follow-up on discharge from rehab [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2158-1-13] ICD9 Codes: 2859, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6432 }	Medical Text: Admission Date: [2116-4-8] Discharge Date: [2116-4-14] Date of Birth: [2116-4-8] Sex: M Service: NB [Known lastname 55068] [Known lastname 5110] was born at 31-1/7 weeks gestation by cesarean section for preterm labor and previous cesarean section. The mother is a 32-year-old gravida 6, para 5 now 6 woman. Prenatal screens are blood type O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B antigen negative, and group B Strep unknown. This pregnancy was complicated by preterm labor beginning at 24 weeks treated with magnesium sulfate and betamethasone at that time. She presented on the night prior to delivery with progressive preterm labor. The infant emerged vigorous. Apgars were 8 at 1 minute and 9 at 5 minutes. The birth weight was 1520 grams, the birth length was 40 cm, and the birth head circumference was 29.5 cm. ADMISSION PHYSICAL EXAM: Pink, active, nondysmorphic infant, well perfused in room air. Skin without lesions. Heart was regular, rate, and rhythm, no murmur. Lungs clear, comfortable, no distress. Slightly tachypneic. Benign abdomen. Hips normal. Neurologic: Nonfocal and age appropriate. Patent anus. Left testicle undescended. Right in canal. HOSPITAL COURSE BY SYSTEMS: Respiratory status: The infant initially required continuous positive airway pressure after admission and then progressed to require an intubation at approximately 12 hours of age. He received one dose of Surfactant and he extubated to nasopharyngeal continuous positive airway pressure on day of life number one. He then was briefly in room and then required nasal cannula oxygen until day of life number 27 when he weaned successfully to room air. He has had no apnea or bradycardia. On exam, his respirations are comfortable. Lung sounds are clear and equal. Cardiovascular status: The infant has remained normotensive throughout his NICU stay. On day of life number one, he received a course of indomethacin for a patent ductus arteriosus confirmed by cardiac echocardiogram. He had resolution of the murmur at the completion of the medication course. On exam, he has a heart with regular, rate, and rhythm, no murmur. He is pink and well perfused. Fluid, electrolytes, and nutrition status: Enteral feeds were begun on day of life number three and advanced without difficulty to full volume feeding on day of life number eight. At the time of discharge, he is being fed 26 calories/ounce breast milk made 4 calories/ounce with Enfamil powder and 2 calories/ounce with corn oil. Gastrointestinal status: [Known lastname 55068] was treated with phototherapy for hyperbilirubinemia at prematurity on day of life number one until day of number five. His peak bilirubin on day of life number three was total 6.7, direct 0.4. Genitourinary: A circumcision is planned for the day of discharge. Hematology: The infant has received no blood product transfusions during his NICU stay. His hematocrit on [5-4] was 27.5 with a reticulocyte count of 3.4. He is receiving supplemental iron of 2 mg/kg/day. Infectious disease status: [Known lastname 55068] was started on ampicillin and gentamicin at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours, and the infant was clinically well and the blood cultures negative. There are no further ID issues. Neurology: Head ultrasounds were done on [2116-4-15] and [2116-5-8] both within normal limits. Sensory: Audiology: Hearing screening was performed with automated auditory brain stem responses and the infant passed in both ears. Ophthalmology: The last ophthalmology exam on [2116-5-11] revealed mature retinal vessels bilaterally. A follow-up exam is recommended in eight months. Psychosocial: Parents have been followed by [Hospital1 ] social worker, [Name (NI) 553] [Name (NI) ]. Mother has been very involved in the infant's care throughout his NICU stay. The infant is discharged home in good condition. Infant is discharged home with his parents. Primary pediatric care will be provided by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 55069] [Hospital2 48409] [Hospital3 37830], address 695 [Last Name (un) ] Parkway/[Apartment Address(1) 36475], [Street Address(1) ], [Numeric Identifier 51593], telephone number [Telephone/Fax (1) 55070]. RECOMMENDATIONS AFTER DISCHARGE: 1. Feeding: 26 calories/ounce breast milk made with 4 calories/ounce of Enfamil powder and 2 calories/ounce of corn oil. The mother will begin with breast feeding two times a day and advance as the infant tolerates and continues to gain weight. 1. Medications: Infant is discharged receiving iron sulfate (25 mg/mL) 0.2 cc p.o. daily to provide 2 mg/kg/day of elemental iron. 1. The infant has passed the car seat position screening test. 1. Last state newborn screen was sent on [2116-4-23] and was within normal limits. 1. The infant received his first hepatitis B vaccine on [2116-5-3]. Recommended immunizations: 1. Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the three criteria: 1. Born at less than 32 weeks, 2. Born between 32 and 35 weeks with two of three of the following: daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3. With chronic lung disease. 1. 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. DISCHARGE DIAGNOSES: 1. Prematurity at 31 and 1/7 weeks gestation. 2. Status post respiratory distress syndrome. 3. Sepsis ruled out. 4. Status post patent ductus arteriosus. 5. Status post hyperbilirubinemia. 6. Anemia of prematurity. 7. Status post circumcision. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2116-5-14] 02:23:57 T: [2116-5-14] 05:41:47 Job#: [Job Number 55071] ICD9 Codes: 769, 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6433 }	Medical Text: Admission Date: [2112-12-24] Discharge Date: [2112-12-30] Date of Birth: [2057-10-26] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 65 year old gentleman with a history of positive Type 1 diabetes, metastatic colon carcinoma, coronary artery disease, hypertension, gastroesophageal reflux disease, anemia, and laminectomy who presents with hematemesis, nausea, vomiting and subsequently was found to be in diabetic ketoacidosis. He was well until 10 and 12 days prior to admission at which point his daughter noted him to be sick, he got nausea, vomiting, chills, myalgias, nonproductive cough. He denies shortness of breath, however, he does note temperatures to 101. He notes he did not get a flu shot this year. His nausea persisted all week prior to admission. He awoke on the morning of admission and had nausea, vomiting and hematemesis, two cupfuls of "coffee ground." He had five episodes since with a total of approximately one cup of blood. He has had several of these before after getting chemotherapy. His last chemotherapy was [12-17], last esophagogastroduodenoscopy was three years ago. The patient received nasogastric lavage in the Emergency Room. He denies chest pain, shortness of breath, or diaphoresis. He does note lightheadedness. He has not been checking his glucoses frequently over the last four days. Yesterday his fingerstick was 539. He continues with his Humalog. No fingersticks were done on the day of admission. He came to the Emergency Room with tachycardia, fingersticks in 800s, bicarbonate was 9 and anion gap 20. He was given intravenous insulin and started on an insulin drip, declined nasogastric lavage. PAST MEDICAL HISTORY: 1. Colon cancer diagnosed [2112-6-28], low-grade mildly differentiated status post tumor resection, liver mass on magnetic resonance imaging scan, 3 out of 14 nodes positive, he is on TPT 11, 5-FU, Leucovorin, now just on TPT-11 complicated by nausea, vomiting and hematemesis. 2. Type 1 diabetes, followed by [Last Name (un) ], Dr. [Last Name (STitle) 24130] and complicated by gastroparesis. 3. Coronary artery disease, had myocardial infarction in [2112-6-28]. Catheterization and left circumflex on percutaneous transluminal coronary angioplasty but no stent. 4. Chronic renal failure with baseline 2.5. 5. Hypertension. 6. Gastroesophageal reflux disease. 7. Esophageal ulcers. 8. Anemia. 9. Peptic ulcer disease. 10. Status post laminectomy. 11. Chronic right foot ulcer followed by Dr. [Last Name (STitle) ] in Podiatry. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: He takes Protonix, Imdur, Labetalol 400 t.i.d., Hydralazine 10 q.i.d., Ativan 1 prn nausea, Loperamide, Humulin sliding scale, Glargine 36 units q. AM. FAMILY HISTORY: Father died of colon cancer. SOCIAL HISTORY: Two packs per day times 20 years, quit 30 years ago. Rare alcohol. No drug use. Retired telephone company worker, married with one daughter. PHYSICAL EXAMINATION: Afebrile at 96, pulse 121, blood pressure 129/65, respiratory rate 18, 99% on room air. Examination significant for normal S1 and S2, lungs clear to auscultation without crackles. Abdomen was soft, nontender. No abdominal tenderness. Extremities were without edema and right foot ulcer. Skin, dry and intact. The patient refused rectal examination. LABORATORY DATA: Laboratory data on the day of admission revealed white count 6.2, hematocrit 35.1, platelets 153, coags are normal. Chem-7 with sodium 127, potassium 6, chloride 88, bicarbonate 9, BUN 86, creatinine 6.9, glucose 707, phosphorus 8.0, liver function tests normal. Electrocardiogram, sinus tachycardia at 118, normal axis, ST depression of .5 mm in lead 3, V4, V5, minimal ST elevation. No significant change from [11-11]. HOSPITAL COURSE: 1. Diabetes - The patient was initiated on insulin drip for diabetic ketoacidosis which was subsequently weaned off over the next 36 hours. On [12-27], he had difficulty with hypoglycemia from overlapping Glargine doses, however, he subsequently maintained euglycemia. The patient was taking minimal p.o.. At the time of discharge from the Intensive Care Unit his Glargine dose was only 22 units. 2. Renal - His creatinine remained elevated throughout his intensive care unit course. Renal Consult Team saw the patient and felt his course to be consistent with acute tubular necrosis and expected his renal function to continue. At the time of discharge his creatinine was 5.5 and he had good urine output. His electrolytes were normal and acid-based status had improved. 3. Access - The patient was without intravenous access for the day of [2112-12-29]. PICC line was placed by Interventional Radiology. 4. Infectious disease - Patient with fevers, mild, and cough without sputum which suggested influenza. Viral swabs were negative and cultures were negative for six days on discharge to the floor. DISCHARGE DIAGNOSIS: 1. Likely influenza 2. Diabetic ketoacidosis 3. Acute and chronic renal failure 4. Coronary artery disease 5. Metastatic colon cancer MEDICATIONS ON DISCHARGE: 1. Ascorbic mononitrate 2. Aspirin 325 3. Hydralazine 20 q.i.d. 4. Lantis 22 5. Humulin insulin sliding scale 6. Protonix prn 7. Reglan 8. Tylenol [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Last Name (NamePattern1) 2396] MEDQUIST36 D: [2112-12-31] 00:05 T: [2112-12-31] 20:24 JOB#: [Job Number 24131] ICD9 Codes: 5845, 2765
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6434 }	Medical Text: Admission Date: [2156-6-17] Discharge Date: [2156-6-24] Date of Birth: [2104-4-22] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Patient is 52-year-old gentleman with slurred speech in the morning of admission in the shower, then fell, and had a seizure witnessed by his wife. Taken to an outside hospital. He is unresponsive, decerebrate posturing, and intubated at the outside hospital. Transferred to [Hospital1 69] for further management. Head CT scan shows large right frontal intracranial hemorrhage. PAST MEDICAL HISTORY: Hypertension. PAST SURGICAL HISTORY: Unknown. ALLERGIES: Patient has no known allergies. MEDICATIONS: Aspirin. PHYSICAL EXAMINATION: On physical exam, the patient was intubated, unresponsive. Right pupil was fixed and dilated. Left pupil was 3 mm and nonreactive. Patient's chest was clear to auscultation. Cardiac: S1, S2, no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities: Cool, positive pedal pulses. Neurologic examination: No eye opening, pupils right was fixed and nonreactive, 3 nonreactive, no corneals. Bilateral decerebrate posturing in the upper with minimal withdraw on the lowers. Patient was taken immediately to the OR, where he underwent a right frontal craniotomy for excision of hematoma, then underwent a diagnostic arteriogram which showed a right MCA aneurysm which was not treated. Postoperative, his pupils were 3.5 mm bilaterally and nonreactive. He was intubated with no sedation. He had weak corneal on right and left side and there was flexure posturing in the upper extremities bilaterally. Continued on Dilantin. Had a repeat head CT scan, which showed hydrocephalus and a vent drain was placed on [2156-6-18]. He remained in the Intensive Care Unit with no change in his mental status, decerebrate posturing. The family was notified of his poor prognosis and poor outcome. Patient was made comfort measures only and expired on [2156-6-24]. Patient was referred to the Organ Bank for organ donation, however, the patient did not progress to asystole within the two hour period specified by the hospital policy, and therefore organ donation was not carried out. Patient expired on [2156-6-24]. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2156-9-6] 11:12 T: [2156-9-16] 11:39 JOB#: [Job Number 48141] ICD9 Codes: 431
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6435 }	Medical Text: Admission Date: [2175-4-7] Discharge Date: [2175-4-17] Date of Birth: [2102-9-10] Sex: M Service: MEDICINE Allergies: Isordil / Dilaudid Attending:[First Name3 (LF) 3531] Chief Complaint: Back pain, fever. Major Surgical or Invasive Procedure: Elective endotracheal intubation for MRI. History of Present Illness: 72M with MDS, recently discharged from 12R for diffuse body pain without improvement or diagnosis, initially planned for direct admit back to 12R. However, given slowed mental status, refusing speaking per family, evaluated in ED. Initially in ED VS 104.3 114 141/59 18 99. Pt refusing conversation but followed commands. Labs significant for new renal failure Cr 2.7, with K 5.7, AP 377, Na 131, WBC 3.5 with 61%N and 9% bands, HCT 29.2, Plt 128, lactate 1.6. UA pending. Infectious workup showed CXR, CT head negative. Covered empirically for meningitis Vanc, CTX, ampicillin. . Family reported severe lower back pain and numbness in lower extremities, fever - concern for epidural abscess. Plan for MRI without contrast given renal failure, which was initiated but pt unable to tolerate due to agitation. Able to get C spine and part of T spine, ? epidimoma, intrathecal mass c1-2. Anesthesia intubated with 7.5 on propofol gtt. CXR confirmed placement of ETT and OG tube. Insufficient staffing to get MRI in ED. . Renal failure - baseline 1.5-1.6. No change in PO intake. Unclear cause. Given kayexalate 30, no EKG changes. No stools. Gotten 2L IVF. . VS on transfer: Temp 99.6. HR 125 since intubation, previously 90s, BP 135/69, AC 100, TV 450, 5PEEP, 12 PS, rate 20s. MV 10L. . Of note, during recent admission, pt presented with diffuse pain and source not identified. DDx included neutrogen related, MDS bony pain, lytic bony lesions (SPEP pending at discharge, now neg). Planned for outpt bone marrow biopsy . . Review of systems: Pt not answering questions. Past Medical History: 1. Myelodysplastic Syndrome 2. Obesity 3. Peripheral Vascular Disease s/p bilateral angioplasty 4. Atrial Flutter 5. Angina 6. Glaucoma 7. Hyperlipidemia 8. Coronary Artery Disease s/p CABG 9. BPH 10. Gout 11. s/p CCY 12. h/o Pancreatitis Social History: Home: lives with supportive wife Occupation: recently started a new job as a mechanical design engineer EtOH: Rare Drugs: Denies Tobacco: quit approximately 20 years ago; ~20-30 PPY history Family History: Mother - Alcoholism, Diabetes [Name (NI) ] Maternal Grandmother - Diabetes [Name2 (NI) ] Paternal Grandmother - Diabetes [Name2 (NI) ] Physical Exam: General: Intubated/sedated HEENT: Sclera anicteric, PERRLA Neck: supple, no LAD Lungs: bilateral BS, transmitted upper airway sounds CV: Tachycardic, no murmurs Abdomen: soft, obese, 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: sedated, unresponsive Pertinent Results: Admission Labs [2175-4-7]: CBC: WBC-3.5* RBC-2.96* HGB-9.5* HCT-29.2* MCV-99* MCH-32.2* MCHC-32.6 RDW-20.0* Diff: NEUTS-61 BANDS-9* LYMPHS-17* MONOS-13* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 Smear: HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL Other: [2175-4-7] 04:30PM ALBUMIN-3.8 [2175-4-7] 04:30PM LIPASE-53 [2175-4-7] 04:30PM ALT(SGPT)-13 AST(SGOT)-36 ALK PHOS-377* TOT BILI-1.5 [2175-4-7] 04:42PM LACTATE-1.6 Tox screen: [2175-4-7] 11:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG U/A: COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.018 BLOOD-NEG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-1 WBC-1 BACTERIA-MOD YEAST-NONE EPI-1 GRANULAR-[1-27]* . MICRO: Blood cultures 5/14, [4-8], [4-10], [4-15] - negative Urine Culture [4-8], [4-14] - negative Sputum Culture [4-8] x 2 - negative . CT HEAD: There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarction. Mild prominence of the ventricles and sulci is compatible with mild diffuse atrophy which is age-appropriate. There is no acute fracture. Included views of the mastoid air cells and paranasal sinuses are clear. There is moderate calcification of the cavernous segments of both internal carotid arteries, left greater than right. IMPRESSION: No acute intracranial process. . MRI: 1. 22 x 7 mm intramedullary mass within the cervical spinal cord from C2 to C3 which is hyperintense on T2-weighted imaging, with areas of lower signal intensity within the mid superior aspect. There may be an associated syrinx. This finding could represent a neoplastic process such as an astrocytoma. 2. There are multiple nodules within the lungs. Therefore, an intramedullary spinal metastasis is not excluded. Chest CT is recommended. 3. 11 x 8 mm right parotid lesion, T2 hyperintense may represent a cystic mass or node, and less likely a pleomorphic adenoma. 4. Multilevel degenerative changes throughout the cervical and thoracic spine, with partial ankylosis of C3 to C5 with bulky anterior osteophytes. 5. Rounded T1 hyperintense, T2 hypointense lesion within T6 and T2 hypointense lesions within the right T7 (with posterior extension), may represent metastases. These areas can be re-evaluated at the time of CT. 6. Elevated creatinine levels precluded the use of gadolinium. 7. No evidence of epidural abscess. 8. Trace secretions within the trachea. FINDINGS: I concur with Dr.[Name (NI) 85131] very comprehensive analysis. Additionally, there are multiple sternotomy sutures. There is no paravertebral soft tissue swelling to suggest an ongoing inflammatory process. CONCLUSION: Intramedullary mass within the upper cervical cord. See above report for differential diagnosis. Degenerative changes of the cervical spine. Please see above report for numerous additional observations. COMMENT: Please note that the present study contained imaging only as far distally as T9, as the patient was unable to continue the procedure at this time. . MRI HEAD: Non-enhanced study with: 1. No evidence of intracranial mass or cerebral edema. 2. Moderate global atrophy. 3. Diffusely and uniformly T1-hypointense regional bone marrow signal, as on the recent MR examinations of the spine; this likely relates to the apparently known underlying myelodysplastic syndrome . MRI Lumbar: Findings of concern for metastatic neoplastic disease involving the visualized lower thoracic and lumbar spine, with additional findings as noted above. Bone Scan [2175-4-13]: IMPRESSION: Widespread foci of abnormal tracer activity throughout the axial and appendicular skeleton as described above. Pattern most compatible with widespread osseous metastasis from an unknown primary. CXR [2175-4-14]: All these support lines and tubes have now been removed. Cardiac size is at the upper limits of normal. No failure is present. There is some loss of the right heart border suggesting infiltrate in right middle lobe. IMPRESSION: Probable right middle lobe pneumonia. CXR [2175-4-16]: FINDINGS: As compared to the previous radiograph, the mid lobe opacity is unchanged. In addition, a small left suprabasal opacity has occurred that could correspond to local atelectasis. Otherwise, there is no relevant change. Unchanged size of the cardiac silhouette. Unchanged absence of pulmonary edema. Unchanged absence of pleural effusions. Old right-sided clavicular fracture. The study and the report were reviewed by the staff radiologist. PATHOLOGY PENDING AT TIME OF DISCHARGE Brief Hospital Course: 72 yo M with MDS, chronic back pain of unknown source with recent neg eval, returns with back pain, fever, AMS. . # Fever: Patient admitted with fever and concurrent rise in WBC from 2s to 3.6 and diff changed from 3 30-40% neutrophils and no bands, to 61%N and 9%bands. Given the back pain there was concern for epidural abcess. Patient was started on Vanc/CTX 2g/Ampi for meningitis. MRI r/o abcess (no contrast given creatinine of 2.7), but showed metastatic disease to the spine. Patient initially did not spike on antibiotics, so thought was that it was covering whatever infectious process was going on. Ampicillin was stopped on [4-8] and CTX was decreased to 1g. Then, patient spiked again. So far cultures have been negative including blood and urine. CXR has been unchanged. VS have been stable not suggesting SIRS. Posibility includes malignancy-related fevers. Antibiotics were discontinued on [4-10] as no obvious source of fever was present. Patient again spiked a fever to 101 after his bronchosopy, and was noted to be confused an mildly hypoxic to 91 on RA. A CXR showed evidence of RLL infiltrate, so he was treated with 7 days of PO levofloxacin. . # Lung nodules: Multiple very small lung nodules. CT scan images from OSH were obtained and reviewed and nodules only seem to be amenable to open lung biopsy or CT-guided biopsy. Repeat CT torso showed interval increase in the size of his lung nodules as well as interval increase in the size of a mediastinal lymph node. Interventional pulmonary was consulted and performed bronchosopy on [2175-4-14] with biopsy of an endoluminal lesion, pathology was pending on discharge. . #. Spinal masses: MRI with multiple masses throughout his spine suggestive of metastatic disease. MRI of the head without any metastasis. Oncology was consulted and suggested biopsy of the lowest risk spinal lesions. Interventional neuro radiology felt that the spinal lesions were not necessarily metastasis and may be related to his MDS. A CT torso was performed, which was less suggestive of spinal metastasis. A bone scan was performed which suggested widespread bony metastatic disease. . # Acute on chronic renal failure: Cr baseline 1.5, stage 3 admitted with Cr of 2.7 UA with SG 1.018, pos for protein and bacteria, no WBCs/leuks/epis. He received IVF and had good UOP. Creatinine trended down to his baseline. . # Hyperkalemia: 5.7 on admission. He received kayexalate but no BM. No EKG changes. he was normal throughout the rest of the admission. . # Intubation: Pt electively intubated for MRI given concern for epidural abcess. He was kept intubated given concern for metastatic disease and further work up needed (MRI of head). He was succesfuly extuabted on [4-9]. . # Myelodysplastic Syndrome: On aranesp and neupogen. Some concern that this pain is related to his neupogen, although his pain has not improved despite decreased dose of neupogen. Given his worsening anemia and bony pain, there has been consideration of repeating a bone marrow biopsy. alk phos at baseline (300s-400s last week). SPEP last week with polyclonal IgM increase. UPEP showed was within normal limits. He received neupogen twice with subsequent increases in his WBC count from 1.5 to 7.8. Patient received PRBC to maintain a HCt of over 25. He was treated with neupogen twice during his hospitalization. . # Angina/CAD s/p CABG - Aspirin was held given possible procedure. Lisinopril and metoprolol were initially held. . # Aflutter: currently sinus. Holding metoprolol . # Hyperlipidemia - continued Zetia . # Enlarged prostate - patient was continued on Tamsulosin. On exam, prostate was enlarged, asymmetric, firm with irregular surface. PSA on admission was 14. Per [Location (un) 2274] records, PSA was 3 in [3-4], and 9 in [3-4]. # Gout: Patient noted R metatarsal-phalangeal joint pain and swelling, consistent with prior joint flare. He was treated with colchicine with modest improvement of his symptoms. . # Type 2 Diabetes [Date Range ] - Held glipizide and metformin given NPO and renal failure. Pt was put on ISS. Glipizide and metformin were restarted on discharge. . Medications on Admission: 1. Acetaminophen 1000mg [Hospital1 ] 2. Omeprazole 20mg [Hospital1 ] 3. Aspirin 325 mg Daily 4. Ranolazine 500 mg daily 5. Lisinopril 20mg Daily 6. Finasteride 5mg Daily 7. Metoprolol Succinate 100 mg daily 8. Ezetimibe 10mg Daily 9. Tamsulosin 0.4 mg qhs 10. Nitropatch 0.2mg/hour daily 11. Glipizide-Metformin 5-500 mg daily 12. Oxycodone 5-10mg q4 13. Neupogen Injection twice weekly 14. Aranesp (Polysorbate) 100 mcg/mL Solution Injection weekly Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO daily (). 6. Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours): On for 12 hours, then off for 12 hours. 7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 12H (Every 12 Hours). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. Disp:2 Tablet(s) Refills:0 13. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 days: start on [4-18]. Disp:1 Tablet(s) Refills:0 14. Oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every twelve (12) hours: Do not drive or operate heavy machinery as this can cause sedation. Disp:60 Tablet Sustained Release 12 hr(s) Refills:0 15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: do not operate heavy machinery or drive with this medication as it can cause sleepiness. Disp:60 Tablet(s) Refills:0 16. Glipizide-Metformin 5-500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Malignancy with metastases, unknown primary Fever Back Pain Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for back pain and fever. An MRI of your back did not show any signs of infection. Further imaging with CT and bone scan showed lung nodules, and lesions in your bones suspicious for cancer. A bronchoscopy was performed to take a biopsy of a lymph noed in your mediastinum (chest). After the procedure you developed fevers, confusion and shortness of breath. A CXR was suspicious for pneumonia, so you were treated with antibiotics. Also, your pain was controlled with long acting and short acting narcotics. Please note the following changes in your medications: 1. Please start Oxycontin 30 mg by mouth every 12 hours for your pain. This is your basal, long acting pain medication. 2. Please start Oxycodone 5-10 mg by mouth every 4-6 hours for BREAKTHROUGH pain. This is your short acting pain medication. * YOU SHOULD NOT DRIVE OR OPERATE HEAVY MACHINERY WITH THIS MEDICATION AS IT CAN CAUSE SLEEPINESS * 3. Please continue levofloxacin 750 mg by mouth for 2 more days (last day [4-19]). This is the antibiotic for your pneumonia. Take this in the morning after you have eaten. 4. Please continue to take colchicine 0.6 mg by mouth for 1 more day. Take this in the morning of [4-19] for your gout. Please keep all your medical appointments. Your lung lymph node biopsy is pending and your oncologist (cancer doctor) should follow up the results of this with you. Followup Instructions: Please follow up with your oncologist Dr. [Last Name (STitle) 28049]. Appointment: Wednesday, [4-19], 9:30am You have an appointment on [2175-4-21] at [Location (un) 2274]-[Location (un) ] at 2:30 pm. Primary Care Doctor Appointment With: [Last Name (LF) ],[First Name3 (LF) ] A Location: [Location (un) 2274]-[University/College ] Address: [Hospital1 3470], [University/College ],[Numeric Identifier 85132] Phone: [Telephone/Fax (1) 17476] ICD9 Codes: 5849, 486, 496, 2767, 4439, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6436 }	Medical Text: Admission Date: [2144-7-28] Discharge Date: [2144-8-5] Date of Birth: [2069-5-8] Sex: F Service: MEDICINE Allergies: Naproxen / Nsaids / Narcotic Analgesic & Non-Salicylate Comb Attending:[Last Name (NamePattern4) 290] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: right shoulder joint tap History of Present Illness: The patient is a 75 y.o. F resident of [Hospital3 ] with h/o cardiomyopathy, CAD, HTN, dementia, CRI, incontinence who presents with lethargy and rigoring x 3 days. At baseline she is demented but conversational, uses walker to go outside etc. The staff reports that patient has had decreased po intake since Sunday. NP saw patient today and she was seen to be rigoring and not as interactive as usual. She was going to be sent to [Doctor Last Name 1263] lethargy. At [Last Name (un) ] she had her clothes on backwards and was drooling. She completed a course of amoxicillin from [Date range (1) 11010]. In the ED she was given zosyn. Blood culture box not checked off prior to administration of abx. She was placed on a sitter in the ED. 1 LNS hung in the ED. <br> ROS could not be obtained from patient thus spoke with [Date range (1) 802]. Patient was moved to ALF in [Month (only) 404] in [2141] when she lost a lot weight- down to 85 lbs, confusing her medications, failure to thrive. She was first admitted to the hospital and then transferred to ALF. She appeared to be doing well to ALF. She c/o of knee pain which is chronic for her. No worse swelling noted. Otherwise no c/o. All other review of systems negative. <br> Spoke with [Year (4 digits) 802] who last saw her Sunday and she didn't really see anything wrong with her. She often confuses the dates of things eg when was the last time she saw her sons and she can't remember when she last saw people. Past Medical History: Taken from ED resident note as only paper work from ALF on admission was the med sheet. <br> Cardiomyopathy CAD HTN Hyperlipidemia Depression Anemia Anxiety Arthritis CRI Dementia Incontinence Social History: Resident at ALF at Gooddard house. Ambulates with walker at baseline. First contact: [Name2 (NI) 3548] [Location (un) 104486] - [Location (un) 802] 1 [Telephone/Fax (1) 104487]/cp [Telephone/Fax (1) 104488] Second contact: son- [Name (NI) 104489] [Initials (NamePattern4) ] [Name (NI) ] [Medical Record Number 104490]-[Telephone/Fax (1) 104491] Email: [E-mail address 104492] PCP: [Last Name (NamePattern4) ]. [Last Name (STitle) 104493] Elder Service plan/PACE/Geriatrics <br> At baseline alert. She is independent with dressing, feeding and toileting but wears depends in case she can't make it. She lives in ALF where someone comes to help her write her checks. She walks to the corner store. Her [Last Name (STitle) 802] buys her the "big stuff". Family History: She has one son in [Name (NI) 1559] and the rest out of the country. Her son in [Name (NI) 13025] has medical problems but the nieice couldn't say. No DM or HTN in the family. One sister with breast cancer and the other sister with lung CA. Her sister died of a heart attack. Physical Exam: per admitting physician: [Name10 (NameIs) ] Tm = 99.8 R, P = 82, BP = 149/53, RR = 14, 95%4L Current vitals on the floor 97.3, 83, RR = 22, 100% on 3L GENERAL: Elderly female laying in bed. NAD. Nourishment: Greatly at risk. Grooming: OK Mentation: Somnolent, barely arousable to sternal rub. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted L ear filled with cerumen. Ears/Nose/Mouth/Throat: dry MM, poorly fitting dentures Neck: supple, Prominent JVD [2-29] to thin habitus but not elevated. Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: tachycardic, nl. S1S2, no M/R/G noted Gastrointestinal: soft, scaphoid, normoactive bowel sounds, Rectal: External non-bleeding hemmrhoid. Soft stool in vault. Not impacted. Guaic negative brown stool Genitourinary: No supra-pubic tenderness. Skin: no rashes or lesions noted. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: ? L facial droop. Withdraws to pain. Could not perform neurologic exam due to somnolence. + foley catheter/ No sacral decubitus Psychiatric: Could not be assessed secondary to mental status. Pertinent Results: 136 106 72 --------------< 85 5.4 7 3.9 . WBC: 23 HCT: 26 PLT: 654 . PT: 17.9 PTT: 40.7 INR: 1.6 . [7-29]: Head CT: 1. No acute hemorrhage or mass effect. 2. Bifrontal lobe cerebral atrophy vs bifrontal higromas, follow-up is recommended. 3. Old lacunar infarction. . MRI abd: 1. Full width full thickness tears of the supraspinatus and infraspinatus tendons with tendon retraction and a high-riding humeral head. Associated marked muscular atrophy and fatty degeneration. 2. Complete tear of the long head of the biceps tendon. 3. Large joint effusion extending into the subachromial-subdeltoid bursa and biceps tendon sheath with evidence of synovitis. This could be inflammatory or infectious in etiology. 4. Post-surgical changes of the AC joint. 5. Extensive degenerative cyst formation about the humeral head. . [8-2] CT abd: 1. Severely limited evaluation due to lack of IV and p.o. contrast. No evidence of dilated loops of bowel. 2. Extensive calcification of the aorta and its branches. 3. Hypodense lesions in the liver which are too small to characterize. 4. Small amount of free fluid within the dependent portions of the abdomen and pelvis. . [8-3] echo: IMPRESSION: Severe hypokinesis of the distal [3-1] of the left ventricle. This could be consistent with stress cardiomyopathy (Takotsubo syndrome) or multi-vessel coronary artery disease. Diastolic dysfunction. Moderate mitral regurgitation. Moderate to severe tricuspid regurgitation and at least moderate pulmonary artery systolic hypertension. Brief Hospital Course: 75yo woman w hx ? cardiomyopathy, CAD, HTN CRI here metabolic acidosis, ? infection who ultimately died during hospital stay. Brief hospital course: . Patient presented with metabolic acidosis thought [2-29] ARF vs underlying infection. She received fluid resuscitation in the ICU with HCO3 and her metabolic acidosis improved. She was seen by renal and ID to assist with management. Patient was treated broadly for infectious sources and even had right shoulder tap. Not clearly c/w septic joint however she remained on broad abx. Patient had improvement in mental status and hemodynamics. However, had several episodes of acute pulm edema on the floor and echo c/w Takotsubo's syndrome. Her SOB improved with lasix but given the increased frequency of these episodes she was transferred back to the ICU. . In the ICU, patient very clearly stated her interest in DNR DNI. We also confirmed this with her son, [Name (NI) 47897] (HCP). We initially tried to manage her acute systolic CHF with lasix and nitro gtt but this was complicated by worsening renal dysfunction and hypotension. We were unable to give her IVF given her pulmonary edema. The patient became somewhat delirious at this time. We discussed her very poor clinical picture with her HCP and he asked that we focus on comfort care. The patient was started on morphine and titrated to comfort. At [2144-8-5] at 10:02am the patient was declared dead. Causes of death include: acute systolic CHF, ARF, and metabolic acidosis. Family was at the bedside and declined autopsy. . Comm: with two brothers and [Name2 (NI) 802] 1. [Name (NI) 47897] [Name (NI) ] (son/HCP) [Medical Record Number 104490]-[Telephone/Fax (1) 104494]. or [Telephone/Fax (1) 104495] 2. [Name (NI) 3548] [Location (un) 104486] ([Location (un) 802]) [Telephone/Fax (1) 104496], [Telephone/Fax (1) 104497], [Telephone/Fax (1) 104498]. 3. [Name (NI) 1158] (son) [Telephone/Fax (1) 104499] Medications on Admission: Amoxicillin 500 mg tid 5-21-5-30 Lasix 10 mg qd Glucosamine/Chondroitin ES Lidoderm patch 5% qd Lipitor 20 mg qd Lisinopril 5 mg qd MVT qd Nifedipine 30 ER qd oxycodone 5 mg qam oxycodone 2.5 mg [Hospital1 ] Salsalate 500 mg tid Sertraline 125 mg qd Tylenol 1300 mg tid Zyprexa 2.5 mg q 8 pm Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Causes of death: Acute systolic CHF - hours ARF - days Metabolic Acidosis - days Discharge Condition: expired Discharge Instructions: Patient came in with profound metabolic acidosis and found to have acute renal failure and elevated WBC. Infection suspected so patient was covered broadly. Etiology of infection not entirely clear. Patient then developed acute systolic CHF and worsening renal failure. Patient requested DNR DNI status. Given worsening status, patient's HCP requested focus on comfort. patient expired on [2144-8-5] at 10:02am. Followup Instructions: none [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 5849, 2762, 5990, 2930, 4280, 5859, 4240, 4168, 2724, 496, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6437 }	Medical Text: Admission Date: [2106-3-28] Discharge Date: [2106-4-6] Date of Birth: [2032-12-4] Sex: F Service: NEUROLOGY Allergies: Aspirin Attending:[First Name3 (LF) 618] Chief Complaint: right hip pain Major Surgical or Invasive Procedure: open reduction with internal fixation right hip History of Present Illness: 73yo RH F who is POD#1 from R hip repair after a mechanical fall caused a fracture. Perioperatively, she has been treated with a beta blocker and now postoperatively she has been started on lovenox for DVT prophylaxis. She was completely normal per her daughter today around 4-5pm, apart from pain, which was controlled with oxycodone (last dose 3pm and no further narcotics). At 8:30pm, however, the ortho PA was paged by the patient's nurse after she was found to have a new left facial droop and was thought to be disoriented and "confused", with slurred speech. We are consulted for concern of an acute infarction. The patient has had no nausea/vomiting and denies headache (in fact, she denies any difficulty or impairment). She denies dysarthria, though her son-in-law attests that her speech is markedly different from baseline. Past Medical History: PMH: No prior history of MI/CAD or stroke No h/o HTN Osteoporosis COPD MV prolapse s/p TAH Seen by neurology in [2102] by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 951] for RLS (neuro exam with mild peripheral neuropathy only) Social History: non smoker, social alcohol Family History: NC Pertinent Results: Admission labs: Chol 89 Triglyc 491 HDL 47 CHol/HDL 1.9 LD32 GLUCOSE-121* UREA N-19 CREAT-1.0 SODIUM-141 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14 WBC-6.5 RBC-4.11* HGB-12.4 HCT-36.4 MCV-88 MCH-30.2 MCHC-34.1 RDW-14.1 NEUTS-69.6 LYMPHS-24.0 MONOS-3.7 EOS-1.3 BASOS-1.4 PLT COUNT-195 PT-12.0 PTT-26.9 INR(PT)-1.0 [2106-4-5]: WCC7.3 Hgb 10.3 Hct 29 Plt360 INR 2.4 Na 136 K 3.8 Cl 100 Co2 28 BUN 16 Cr0.6 CT/CTA: 1. No obvious infarcts are noted on the non-contrast CT. However, MRI with diffusion-weighted imaging is more sensitive for the detection of acute infarcts. 2. Short segment focal stenosis in the pericallosal artery and right middle cerebral artery M2 segment which could be stenoocclusive or thromboembolic. 3. Mild atherosclerotic calcification in bilateral cervical internal carotid arteries, close to their origins, with no flow-limiting stenosis. 4. Multilevel degenerative disease of the cervical spine, not adequately evaluated on the present study. 5. Biapical pleural scarring. MRI/MRA: Limited study due to motion artifact. There are multiple acute infarcts in the distal right MCA territory, possibly embolic in etiology. TTE: 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. A small secundum atrial septal defect is present withbidirectional shunting (small amount). Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. CT chest and abdomen 1. No central or segmental pulmonary embolism. 2. Small bilateral pleural effusions with associated atelectasis. Some small opacities in the right lower lobe are nonspecific, and could be regions of focal atelectasis. 5-mm pulmonary nodule in the right upper lobe. In the absence of known malignancy, followup in one year is recommended. Postoperative appearance to the right hip and surrounding soft tissues and muscles consistent with recent surgery. CXR [2106-4-1] Small bilateral pleural effusions with left basilar atelectasis. Brief Hospital Course: Mrs.[Known lastname 95459] presented to the Emergency Department complaining of right hip pain after a fall. She was evaluated by the Orthopaedics department and found to have a right intertrochanteric hip fracture. She was admitted, consented, and medically cleared for surgery. On [2106-3-29], she was prepped and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. Post-operatively, she was extubated and transferred to the PACU for further stabilization and monitoring. She was then transferred to the floor for further recovery. On the floor, she remained hemodynamically stable with her pain controlled. On [3-30], she had acute onset dysarthria, left facial droop and left arm/leg weakness. On exam, she also had left-sided neglect and anosognosia and was inattentive, falling asleep frequently. CT and MRI showed right MCA infarction and the patient was transferred to the ICU for further monitoring. Metoprolol was discontinued and blood pressure allowed to autoregulate. She was started on aspirin 325mg daily, as her previously documented "allergy" consisted only of GI upset. She was also started on zocor for secondary stroke prevention. FLP was normal and HbA1c 5.7. She had an uneventful ICU course and by the next morning, her dysarthria and neglect had improved, leaving her with UMN pattern of weakness, affecting her face/arm/leg. Transferred to the floor. TTE from [3-30] was unremarkable for source of cardioembolism. TEE showed small secundum ASD with bidirectional flow, no source of thrombi and no significant aortic arch atheroma. Cardioembolic event thought most likely etiology of stroke in presence INR 2.0, so new goal INR 2.5-3.5. CTA of the neck showed "Short segment focal stenosis in the pericallosal artery and right middle cerebral artery M2 segment" thought to be stenoocclusive or thromboembolic. She was covered with lovenox 60mg [Hospital1 ] and started on coumadin 5mg qhs on [3-31], with the plan on continuing for 3-6 months and then transition to aspirin. LENIs were negative for DVT. Lovenox ceased on [2106-4-2] as INR therapeutic. INR supraptherapeutic to maximum 6.1 on [2106-4-3]. Coumadin held. Today ([2106-4-5]) INR 2.4 and restarting coumadin at 2mg daily. Please continue to monitor INR. There was an episode of hypotension overnight [2106-3-31] responsive to fluid treatment.Repeat head CT was unchanged. Abdominal CT was negative for retroperitoneal bleed. Stools negative for blood. Hct dropped to 22.0 and transfused 2 units rbc. Conincident with hypotensive episode, increased oxygen requirement occurred with concern for PE in context of perioperative stroke. CTA chest negative for PE. CT did show R upper lobe lung nodule which requires follow up scan at 1 year. Hematocrit now stable. Urinary tract infection was diagnosed on [2106-4-4] and treatment commenced with ciprofloxacin. Switched from tablets to suspension following episode of vomiting. To complete 3 days course (day 2 today). Repeat CT chest in 1 year for right upper lobe lung nodule. Neurology and orthopedic follow up arranged. Medications on Admission: Actenol Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Please restart actonel weekly (?dose 30mg qw) Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Right hip fracture Multiple infarcts in R MCA territory likely cardioembolic (AF) Post operative anaemia-transfused rbc Discharge Condition: Improved: No neurologic deficit. R hip wound healing. Discharge Instructions: Keep the incision clean and dry. You may apply a dry sterile dressing as needed for drainage or comfort. If you have any redness, increased swelling, pain, drainage, shortness of breath, or a temperature greater than 100.5, please call your doctor or go to the emergency room for evaluation. You may bear weight on your right leg. Resume all the medication you took prior to admission and take all medication as prescribed by your doctor. Feel free to call the orhtopedic office with any questions or concerns regarding the fracture or the neurology service regarding the stroke. Followup Instructions: 1. NEUROLOGY: Neurology Dr [Last Name (STitle) ] Tuesday [2110-5-4].30 am [Hospital Ward Name 23] 8 [Numeric Identifier 108659] Please bring referral from PCP. 2. ORTHOPEDICS: Please call Dr.[Name (NI) 4016] office @ [Telephone/Fax (1) 1228] for a follow up appointment in 4weeks after hospital discharge. 3. PCP: [Name10 (NameIs) 357] follow up with Dr. [Last Name (STitle) 2204] one week after discharge from Rehab. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 496, 5990, 2851, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6438 }	Medical Text: Admission Date: [2171-11-12] Discharge Date: [2171-11-19] Service: TRAUMA SURGERY HISTORY OF PRESENT ILLNESS: The patient is a [Age over 90 ]-year-old female who was recently discharged from [Hospital6 649] on [2171-7-5], after she underwent a right hip replacement. She was brought to [Hospital6 649] via ambulance after she was hit by a door and fell on her left hip. There was no reported loss of consciousness. She was unable to ambulate on her own. She was transferred with stable vital signs. She had a GSC of 15. PAST MEDICAL HISTORY: Hypertension. Diabetes type 2. History of lower GI bleed secondary to colonic polyp. Degenerative joint disease. Hypothyroidism. Arthritis. Glaucoma. Goiter. Bronchitis. PAST SURGICAL HISTORY: Right hip replacement in [2171-6-22]. Aortic valve replacement with porcine valve in [2156]. MEDICATIONS: Glucotrol 10 mg p.o. b.i.d., Univasc 50 mg p.o. q.d., Lasix 20 mg p.o. q.d., Levoxyl 75 mcg p.o. q.d., Potassium Chloride 10 mEq p.o. q.d., [Doctor First Name ] 60 mg p.o. b.i.d., Vitamin E, Multivitamin, Aspirin 81 mg p.o. q.d., Lumigan eyedrops 1 drop each eye q.h.s., Timoptic 0.5% eyedrops 1 drop each eye each morning, Protonix 20 mg p.o. q.d., Celebrex 200 mg p.o. b.i.d., Oxycodone 2.5 mg p.o. q.4 hours p.r.n. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient lives alone and is independent with all activities of daily living. She had been in rehabilitation after hip replacement and had been at home when the fall occurred. FAMILY HISTORY: Brother with diabetes. Mother with gastric carcinoma. Sister with lung carcinoma. Father with coronary artery disease. Note: There were will be an addendum to this discharge summary. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 18153], M.D. [MD Number(1) 18154] Dictated By:[Last Name (NamePattern1) 3835] MEDQUIST36 D: [2171-11-19] 13:46 T: [2171-11-19] 11:58 JOB#: [Job Number ] ICD9 Codes: 2765, 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6439 }	Medical Text: Admission Date: [2191-1-14] Discharge Date: [2191-1-22] Date of Birth: [2137-3-20] Sex: F Service: CT SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old female with cardiac risk factors of hypertension and prior smoking. PAST MEDICAL HISTORY: Significant for lung cancer status post right upper lobectomy in [2185]. In [2190-7-28], the patient began having significant chest pressure and shortness of breath occurring after walking for only several minutes. A dobutamine echocardiogram completed in [2190-7-28] was noted to have basal inferior posterolateral wall hypokinesis. In [2190-7-28], she had a catheterization which revealed the left anterior descending without obstructive disease, circumflex with 80% stenosis, and dominant right coronary artery with 90% stenosis. Ejection fraction of 54% was noted at that time. She had successful percutaneous transluminal coronary angioplasty and stenting. The patient again returned in [Month (only) 359] with similar symptoms. Angiogram revealed in-stent re-stenosis, which was successfully angioplastied. By [Month (only) 1096], symptoms began to recur. In [2190-11-27] she had an exercise tolerance test where she had [Street Address(2) 4793] depressions in the inferior leads in V4 to V6. PAST MEDICAL HISTORY: Hypertension, lung cancer, cataracts, retinal detachment. PAST SURGICAL HISTORY: Total abdominal hysterectomy, surgery for right retinal detachment, right upper lobectomy. ALLERGIES: No known drug allergies. MEDICATIONS: Aspirin 325 mg once daily, Lopressor 75 mg every morning and 50 mg every evening, Lipitor 10 mg once daily, Fosamax 10 mg once daily, Univasc 15 mg once daily, Premarin .9 mg once daily, Zoloft 25 mg once daily, Pred Forte 1% eyedrops to right eye. The patient had a repeat cardiac catheterization, which revealed left circumflex 90% included with in-stent stenosis, 80% re-stenosis of obtuse marginal, 80% re-stenosis of right coronary artery, mild progression of disease, normal ejection fraction. PHYSICAL EXAMINATION: Afebrile, vital signs stable. Head, eyes, ears, nose and throat: No bruits, no jugular venous distention. Lungs: Clear to auscultation. Cor: Regular rate and rhythm. Abdomen: Soft, nontender, nondistended. Extremities: No varicosities. HOSPITAL COURSE: The patient was brought to the operating room on [2191-1-15], where she had a coronary artery bypass graft x 2 and an atrial valve replacement which was initially unplanned for but done due to intraoperative findings. The patient had a #21 Carbomedics valve placed. Postoperatively, she was transferred to the Intensive Care Unit, where she was rapidly extubated. The patient was requiring a Neo-Synephrine drip for hypotension. On postoperative day one, her chest tubes were removed. On postoperative day two, Coumadin was started, and the Neo-Synephrine was appropriately weaned. On postoperative day three, the patient was transferred to the floor in stable condition. By postoperative day four, INR was in the therapeutic range. By postoperative day five, the patient was ambulating well, and tolerating a regular diet well. The patient continued to work with Physical Therapy and, by postoperative day seven, was in stable condition. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: Lopressor 50 mg twice a day, lasix 20 mg once daily for seven days, potassium chloride 20 mg once daily for seven days, Captopril 12.5 mg three times a day, Lipitor 10 mg once daily, Fosamax 10 mg once daily, Zoloft 25 mg once daily, aspirin 325 mg once daily, Coumadin 3 mg once daily, iron sulfate 325 mg three times a day, dilaudid 2 to 4 mg by mouth every four to six hours as needed for pain, Colace 100 mg by mouth twice a day. DI[Last Name (STitle) 408]E STATUS: The patient will go home. She will follow up with her primary care provider on [Name9 (PRE) 766], [1-24], for an INR check. Dr. [Last Name (STitle) 31759] covering for Dr. [Last Name (STitle) 410], was spoken to and this was assured. The patient will follow up with her cardiologist in three weeks. The patient will follow up with Dr. [Last Name (Prefixes) ] in four weeks. DISCHARGE DIAGNOSIS: 1. Status post atrial valve replacement and coronary artery bypass graft x 2 2. History of lung cancer 3. Cataracts LABORATORY DATA: On discharge, white blood cell count 12.4, hematocrit 23.3, platelets 295. INR 3.4. Sodium 141, potassium 4.2, chloride 105, bicarbonate 28, BUN 17, creatinine 0.5, glucose 114. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 1308] MEDQUIST36 D: [2191-1-21] 18:17 T: [2191-1-22] 00:49 JOB#: [Job Number 35288] ICD9 Codes: 4111, 4241, 9971, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6440 }	Medical Text: Admission Date: [2164-9-20] Discharge Date: [2164-10-9] Date of Birth: [2089-2-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1711] Chief Complaint: recurrent V-tach Major Surgical or Invasive Procedure: VT ablation including cold tip cardiac catherization Pericardial window with placement of intrapericardial catheter Intubation History of Present Illness: 75 yo man with h/o 2V CAD (occluded RCA and LCx), CHF (EF 20%) and an ICD placed in [2157] for inducible VT, HTn, high cholesterol, COPD who presented with recurrent V-tach. Pt was admitted to [Hospital 1514] Hospital on [2164-9-10] for an episiode of ICD firing and subsequently transfered to CMC on [2164-9-12] where his ICD was upgraded to a biventricular device and PT underwent a VT ablation. Unfortunately VT ablation was unsuccesful. Furthermore Pt's LV required revision on [2164-9-17] secondary to central line placement. Pt continued to have runs of slow V-tach and multiple ICD firings after unsuccessful ATP. Pt experienced all of this even while on lidocaine, amiodarone and quinidine. Pt transfered to [Hospital1 18] CCU after failed VT ablation for closer monitoring. Upon presentation Pt with some shortness of breath contributable to mild CHF, otherwise hemodynamically stable. Past Medical History: CAD (occluded RCA and LCx) CHF (EF 20%) s/p ICD AS HTn Hypercholesterolemia GERD COPD Anxiety Macular degeneration Social History: Former tobacco smoker (quit [2150]) and rare alcohol. Lives with his wife. Retired technical writer and editor. Family History: NC Physical Exam: VS: Afebrile, paced at 80, BP 122/55, rr 14 98% RA PE: Awake, alert, NAD Anicteric, blind, MMM, OP wnl supple, JVP 8-10 cm RRR, nl S1/S2, [1-6] SM heard best at apex CTAB abd soft, NT, ND, NABS, no HSM ext without edema, 2+ DPs bilat, thrombophlebitis right hand, femoral arteriol/venous sheath in place without hematoma A&O Pertinent Results: [2164-9-20] 07:00PM BLOOD WBC-11.9* RBC-3.15* Hgb-10.8* Hct-31.2* MCV-99* MCH-34.3* MCHC-34.6 RDW-13.5 Plt Ct-174 [2164-9-23] 05:50AM BLOOD WBC-11.9* RBC-3.18* Hgb-10.8* Hct-32.0* MCV-101* MCH-34.0* MCHC-33.8 RDW-14.0 Plt Ct-169 [2164-9-27] 05:58AM BLOOD WBC-11.6* RBC-3.02* Hgb-10.6* Hct-30.0* MCV-99* MCH-35.2* MCHC-35.4* RDW-13.8 Plt Ct-191 [2164-10-1] 05:03PM BLOOD WBC-9.1 RBC-3.17* Hgb-10.7* Hct-32.0* MCV-101* MCH-33.8* MCHC-33.5 RDW-13.8 Plt Ct-258 [2164-10-4] 05:56AM BLOOD WBC-9.0 RBC-2.95* Hgb-9.6* Hct-29.1* MCV-99* MCH-32.5* MCHC-33.0 RDW-14.5 Plt Ct-245 [2164-10-7] 06:55AM BLOOD WBC-9.5 RBC-3.03* Hgb-10.0* Hct-30.0* MCV-99* MCH-33.1* MCHC-33.5 RDW-14.8 Plt Ct-237 [2164-9-20] 07:00PM BLOOD PT-15.5* PTT-108.8* INR(PT)-1.5 [2164-9-20] 07:00PM BLOOD Plt Ct-174 [2164-9-28] 04:36AM BLOOD PT-14.1* PTT-31.1 INR(PT)-1.3 [2164-9-30] 01:02AM BLOOD Plt Ct-242 [2164-10-2] 04:53AM BLOOD Plt Ct-252 [2164-10-7] 06:55AM BLOOD Plt Ct-237 [2164-9-20] 07:00PM BLOOD Glucose-133* UreaN-26* Creat-1.1 Na-143 K-3.5 Cl-105 HCO3-28 AnGap-14 [2164-9-22] 05:22AM BLOOD Glucose-101 UreaN-26* Creat-1.2 Na-144 K-4.3 Cl-106 HCO3-29 AnGap-13 [2164-9-24] 06:01AM BLOOD Glucose-114* UreaN-25* Creat-1.2 Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 [2164-9-28] 04:36AM BLOOD Glucose-122* UreaN-29* Creat-1.0 Na-142 K-3.9 Cl-106 HCO3-30* AnGap-10 [2164-10-7] 06:55AM BLOOD Glucose-123* UreaN-25* Creat-1.1 Na-138 K-4.0 Cl-104 HCO3-25 AnGap-13 [2164-9-20] 07:00PM BLOOD CK(CPK)-218* [2164-9-21] 04:44AM BLOOD ALT-84* AST-113* LD(LDH)-309* CK(CPK)-203* AlkPhos-97 TotBili-0.5 [2164-9-20] 07:00PM BLOOD CK-MB-13* MB Indx-6.0 cTropnT-2.65* [2164-9-21] 04:44AM BLOOD CK-MB-20* MB Indx-9.9* cTropnT-3.66* [2164-10-1] 05:03PM BLOOD CK-MB-NotDone cTropnT-0.10* [2164-9-23] 05:50AM BLOOD ALT-104* AST-88* LD(LDH)-339* AlkPhos-109 TotBili-0.6 [2164-9-25] 05:30AM BLOOD ALT-104* AST-112* LD(LDH)-288* AlkPhos-100 TotBili-0.5 [2164-9-25] 02:43PM BLOOD ALT-126* AST-129* LD(LDH)-334* AlkPhos-105 TotBili-0.7 [2164-9-30] 01:02AM BLOOD ALT-147* AST-98* AlkPhos-124* TotBili-0.7 [2164-9-30] 08:45AM BLOOD ALT-145* AST-95* AlkPhos-123* TotBili-0.8 [2164-9-28] 11:19PM BLOOD Mg-2.0 [2164-9-29] 06:17AM BLOOD Calcium-8.2* Mg-1.9 [2164-10-6] 06:40AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.1 [2164-10-7] 06:55AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.9 [2164-9-23] 05:50AM BLOOD VitB12-438 Folate-10.3 [2164-9-25] 02:43PM BLOOD TSH-1.7 [2164-9-25] 02:43PM BLOOD Free T4-1.8* [2164-10-4] 09:03AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-460 PEEP-5 O2-40 pO2-127* pCO2-42 pH-7.41 calHCO3-28 Base XS-2 Intubat-INTUBATED Vent-SPONTANEOU [2164-10-1] 05:01PM BLOOD Lactate-4.2* [9-22] SUPINE AP PORTABLE CHEST: The tip of the right internal jugular line ends just below the level of the right clavicular head. A 3-lead pacemaker is present. The heart is enlarged, and the aorta is tortuous. There is increased pulmonary vascularity with indistinctness of the vascular margins and peribronchial cuffing, compatible with congestive heart failure. No pleural effusion is detected. The lateral portions of the right lung, including the right lateral costophrenic angle, are excluded from examination. IMPRESSION: Congestive heart failure. [9-24] Echo Conclusions: 1. The left atrium is dilated. 2. The left ventricular cavity is dilated. Overall left ventricular systolic function is severely depressed. 3. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. There is no pericardial effusion. There are no echocardiographic signs of tamponade. Cath: 1. Selective coronary angiography demonstrated a right dominant circulation with two vessel coronary artery disease. LMCA had no angiographically apparent CAD. LAD had mild diffuse irregularites. LCX was totally occluded after small OM1. Large OM2 filled via left to left collaterals. RCA was known to be occluded and therefore not selectly engaged. Distal RCA filled via left to right collateralls. 2. Limited resting hemodynamics showed normal blood pressure. FINAL DIAGNOSIS: 1. Severe two vessel coronary artery disease. Brief Hospital Course: 75 yo male w/ 2VD (occluded RCA, LCx), severely depressed EF, s/p ICD placement for VT in 98' admitted to an OSH for frequent ICD firing for VT and transferred after failed VT ablation. 1) V-Tach: Pt with a complicated history with an ICD placed in [2157] for inducible V-tach who originally presented to OSH for ICD firing; course there significant for upgrading his ICD to a [Hospital1 ]-ventricular device, an unsuccessful VT ablation and courses of lidoncaine, amiodarone and quinidine. Pt transferred to [Hospital1 18] for further EP evaluation. Initial study significant for probable scar in posterobaslal region of LV, initiation of VT after spontaneous VPDs and after failed attempt of pace termination the VT degenerated into VF requiring DCCV, lastly an ablation was undertook through the posterobasal scar. Pt with continued runs of V-tach after ablation. Pt maintained on lidocaine drip for antiarrthymic therapy. Pt continued to suffer from persistent runs of VT (many of the slow variety) of different morphology with ATP mostly ineffective; a few of which resulting in ICD firing. Mexelitine increased and lidocaine weaned to off and plan for epicardial ablation. Unfortunately, Pt with increased slow VT and a episode of sustained monomorphic VT with ICD firing requiring lidocaine gtt to be restarted and mexilitine held. Pt underwent epicardial ablation without difficulty, yet once again was unsuccessful as Pt continued to suffer from episodes of ventricular ectopy most likely secondary to an intramural VT. Pacer parameters were changed to DDI 90 with AV delay of 250 with hopes that the increased rate would suppress VT. Lidocaine was continued and mexilitine held. Yet again Pt with continued episodes of VTach. Hospital course then complicated by acute agitation and confusion secondary to lidocaine gtt (see details below). Lidocaine thus weaned to off and mexilitine and amiodarone restarted. Pt again to EP lab for NIPS, interrogation and attempted overpacing. As before Pt with recurrent episodes Vtach after reprogramming. Given unsuccesfull history after multiple ablations and pacer re-programming decision made to proceed to cold tip ablation and cardiac catherization to r/o ischemia as nidus for VT. Procedure without complication and tolerated well by Pt who returned to DDI 90 with BiV pacing. [Name (NI) 57398] Pt without further episodes of VTach or ICD firing. Pt transferred from CCU to floor and maintained on amiodarone 400mg daily and mexiletine 150mg q6hr. Pt to be discharged home on both of these medications at stated doses. Pt should follow up with Dr [Last Name (STitle) 23246] closely upon discharge. 2) CAD: Pt with known 2V CAD (RCA and LCx)and negative MIBI ([5-4]) who is medically managed. On presentation, Pt with positive cardiac enzymes without ECG changes most likely representating damage from recurrent VT and ICD firing however NSTEMI still a possibility. Pt clinically stable during hospital stay without obvious evidence of acute ishcemia. Pt maintained on ASA, Lipitor and Coreg, with Lisinopril being started. Given Pt's refractory VT after several ablations and medical management, it was felt appropriate to undergo a cardiac catherization to rule out reversible ischemia as a contributing factor to his ventricular ectopy. Results of which showed severe 2V CAD without evidence of reversible lesions. Pt to be managed with BB, ASA, statin, aldactone, ACEi. AS Pt stabilizes as an outpatient, up titration of the beta-blocker and ACEi might be necessary. 3) CHF: Pt with ischemic cardiomyopathy and EF ~20% who on presentation was volume overloaded with evidence of slight CHF requiring additional lasix for diuresis. Pt improved clinically and was maintained on BB, ACEi, Aldactone, Lasix. Volume status was assesed daily and at times requiring lasix and other days euvolemic. During hospital course, Pt pacer was changed so that LV pacing was stopped. This along with volume overload the night before Pt experienced episode of flash pulmonary edema. Pt given Lasix 80 IV times two with good diuresis however Pt with continued difficulty breathing. Given his increased work and signs of tiring, respiratory therapy summoned to bedside and Pt began on non-invasive continous positive pressure ventilation. Pt did quite well and after several hours was slowly weaned from requiring pressure support to face mask and to nasal canula by the morning. Echo obtained during course showed worsening LV function and MR. For the remaining hospital stay Pt stable without signs of CHF exacerbation. Discharge home on LAsix 40 PO qd, lisinopril 2.5, aldactone 50. 4) MS change: While on Lidocaine gtt, Pt became increasingly confused and agitated to the point where psychiatry was called and Pt place in restraints for his own safety. Pt was given Haldol with good result. Lidocaine gtt discontinued and Pt slowly improved over the next few days. Pt given Haldol on a PRN basis only with avoidance of ativan. By discharge Pt at or near baseline, being alert and oriented with agitation. 5) Resp: Pt intubated for cold tip ablation and cardiac catherization. Pt weaned the following morning and extubated without difficulty. 6) Dysphagia: At the end of admission, Pt complaining of dysphagia to solids. Pt underwent a speech and swallow evaluation; through which Pt gave a prolonged history of early satiety, weight loss and the feeling of food getting stuck. Neurologically Pt was intact without lesion. Pt is in need of GI workup for dysphagia which should be partaken soon after discharged from rehab. Pt was instructed to make an appointment with a gastroenterologist in his area per his PCP's recommendation. Medications on Admission: Amiodarone 400 qAM and 200 qPM Lanoxin 0.125 mg daily Lasix 40 mg PO daily Potassium 20 mEq daily Hytrin 5 mg qHS Mg 400mg daily Coreg 25 mg [Hospital1 ] Lipitor 20mg qd Nitro patche 0.4 mg qPM Celexa 20 mg daily Actonel 5 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (). 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Mexiletine HCl 150 mg Capsule Sig: One (1) Capsule PO Q6HR (). 11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 19504] of [Location (un) 1514] - [Location (un) 1514], NH Discharge Diagnosis: ventrial tachycardia s/p ablation CHF CAD ventrial tachycardia s/p ablation CHF CAD Discharge Condition: good Discharge Instructions: please take all medications as prescribed. please call PCP or return to ED if suffering from severe chest pain, firing of ICD, syncope, shortness of breath, persistent nausea or vomitting, inability to tolerate food or liquid, significant weight loss or gain. Followup Instructions: please call and make a follow up appointment with cardiologist Dr [First Name4 (NamePattern1) 8797] [Last Name (NamePattern1) 23246] [Numeric Identifier 57618]) one to two weeks after discharge from rehab. please call and make a follow up appointment with your PCP Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4223] one to two weeks after discharge. you will need to follow up with a gastroenterologist of your PCP's choosing in the next few weeks to evaluate your recent weight loss, early satiety and dysphagia. ICD9 Codes: 4271, 496, 4019, 2724, 4168, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6441 }	Medical Text: Admission Date: [2190-9-4] Discharge Date: [2190-9-25] Date of Birth: [2114-9-3] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 76 year old male with a history of chronic obstructive pulmonary disease, atrial fibrillation, admitted on [2190-9-4]. The patient was a transfer in from an outside hospital. He was at an outside hospital and was noticed to have an upper GI bleed and was undergoing a CT scan of the abdomen when the patient developed pulseless electrical activity. He was resuscitated at the outside hospital with fluid, epinephrine, atropine and Amiodarone. The patient was intubated secondary to his hypertension and required several days of pressors to maintain his blood pressure. The patient was transferred to [Hospital1 188] for definitive care. He was transferred to the Medical Intensive Care Unit on [2190-9-4]. While at the [Hospital1 188] it was noticed that the patient had a hematocrit drop down to 27.5 and was transfused. He also had a chest CT scan which revealed bilateral subsegmental pulmonary embolisms. dictation stopped. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4122], M.D. Dictated By:[Last Name (NamePattern1) 5747] MEDQUIST36 D: [2190-9-23] 16:24 T: [2190-9-23] 16:56 JOB#: [Job Number 27062] ICD9 Codes: 5789, 4280, 5070, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6442 }	Medical Text: Admission Date: [2138-6-9] Discharge Date: [2138-7-5] Date of Birth: [2077-3-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Transfered from OSH in ARF s/p TIPS Major Surgical or Invasive Procedure: none History of Present Illness: 61 yo M with HCV cirrhosis complicated by variceal bleeding, refractory acites and edema who was admitted to OSH on [2138-6-5] for TIPS procedure which was complicated by intraperitoneal bleeding after hepatic puncture requiring transfusion of 3 units PRBC. During the procedure systolic BP reached a low of 90 and pt recieved iodinated contrast. Subsequent to the placement of the TIPS pt's creatinine bumped from a basline of 1.4 to 1.8->2.1->2.7, and the pt was transfered to [Hospital1 18] for management of acute renal failure. Past Medical History: 1. End stage Liver Disease [12-27] HCV Cirrhosis on liver transplant list. 2. DM Type 2 3. Hypertension Social History: Retired Construction worker, Currently Runs a small landscaping company. Tobacco: Quit 15 years ago, ETOH: Last drink 1 year Prior (drank heavily in past), no drugs Family History: Father=Alcoholic Physical Exam: VS: T:94.7 (oral) BP:165/81 P:67 R:20 O2:98% General: Middle aged man sitting cmfortably in NAD HEENT: NCAT PERRL EOMI OP clear Neck: no thyromegally/bruit/LAD CV: nml s1 s2 RRR, no m/r/g Chest: Bilateral rales at bases, no wheeze ABD: soft, +bs, nt, distended, peritoneal fluid draining into ostomy bag taped to R side of abdomen Rectal: Light brown stool in vault, guaiac negative Ext: 3+ pitting edema of bil LE to mid thigh, and mid bil UE to mid arm Neuo: A+Ox3, nonfocal, no asterisix Pertinent Results: Labs from OSH [2138-6-8]: 10 13.6/39.3 129 131/105/76\ 208 5.5/17/3.9/ AsT 115, ALT 83, AP 70, bili 2.3, total protein 4.3, albumin 1.8, INR 1.4 Ca 7.8 Mg 1.8 Phos 5.9 Brief Hospital Course: Mr [Known lastname 70384] had a prolonged, complicated hospital stay, with several transfers to the ICU for decompensated hepatic failure due to HCV (MELD=40), spontaneous bacterial peritonitis, and multifactorial renal failure (hepato-renal syndrome). As I only took care of him during his final ICU stay, I will attempt to briefly summarize the events that happened earlier in his course. He was transferred to [Hospital1 18] after TIPS for variceal bleeding at an outside hospital. His HCV cirrhosis was associated with coagulopathy, mild ascites, thrombocytopenia, and encephalopathy. He also had renal failure, likely a combination of contrast-induced nephropathy and ATN, and a retroperitoneal hematoma that occured as a complication of TIPS. He suffered from respiratory distress from volume overload, which responded to non invasive ventilation. He was additionally noted to have candiduria. He initially improved somewhat with supportive management of HCV cirrhosis, hemodialysis as needed, and expectant management of the hematoma. He received fluconazole for candiduria. On [6-25], he developed fever, respiratory distress and decreased sensorium, for which he was transferred to the ICU. He was treated for SBP with broad spectrum antibiotics and his respiratory distress again improved with noninvasive ventilation and ultrafiltration for volume management. His mental status improved somewhat, although not back to baseline, and he was transferred to the transplant service [Hospital1 ], where his overall status remained tenuous, with marginal blood pressures, leukocytosis despite antibiotics for SBP, and waxing and [Doctor Last Name 688] delirium. On [7-3], he became hypotensive and obtunded. He was transferred to the ICU again. Antibiotics were broadened for presumed sepsis, possibly from aspiration pneumonia or recurrence of SBP. Noninvasive ventilation was inadequate to maintain oxygenation and patient's encephalopathy was so severe that he could not protect his airway; he was therefore intubated for ventilatory support. Invasive hemodynamic monitoring, ie, pulmonary catheter placement was discussed with the family, but since he was septic from an unclear source, liver transplantation would not be an option and his family decided to withdraw invasive measures and focus on comfort measures. He subsequently expired. Medications on Admission: Nadolol 60 mg PO QD Omeprazole 20 mg PO QD Insulin: AM: NPH 30 Reg 10/PM:NPH 10 Reg 5 Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: hepatitis C virus infection with cirrhosis, ascites, spontaneous bacterial peritonitis Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 5845, 5715, 4280, 2767, 5070, 7907, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6443 }	Medical Text: Admission Date: [2181-9-23] Discharge Date: [2181-10-12] Date of Birth: [2120-10-31] Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Latex / Ampicillin / Lactose / Soy, Lentals, Beans Attending:[First Name3 (LF) 5037] Chief Complaint: need for BI-PAP/dyspnea Major Surgical or Invasive Procedure: cardiac catheterization with stent place in LAD central line placement History of Present Illness: This is a 60-year old Indian female with a complicated past medical history significant for type 1 IDDM (s/p revision renal and pancraes transplants, [2160] and [2174]), diastolic CHF (Echo 35-40%, [7-/2181]), sleep-disordered breathing (on 2L home oxygen at night) who presented with dyspnea from [Hospital 1319] Rehab. Per discussion with the nursing supervisor, the patient developed increased work of breathing over 1-2 hours. The patient also complained of feeling warm, but did not localized any particular infectious symptoms. She was given 20 of IV lasix, and did not have a good response. She was then transfer to [Hospital1 18] for further evaluation and treatment. In the ED, initial VS were T-101 (rectal), HR 100, 20, 100% fi 02 PS 8, 125/73. She was initially started on BI-PAP, but the patient ripped off the mask due to her altered mental status. She was given 5 of Haldol and started on non-rebreather. An ABG reveal 7.35/48/309 on the non-rebreather. She was had labored breathing and was using accessory muscle and was re-started Bi-PAP. She was given lasix 20 IV with good urine output (300cc in first hour). Blood and Urine cultures were sent, and a CXR was obtained. The patient was then started on empiric coverage of abx and heparin gtt here in the MICU. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. diastolic CHF (preserved EF 35-40%, moderate regional systolic dysfunction, [7-/2181]) 2. s/p renal transplant ([2157], complicated by chronic rejection, second transplant [2160]) 3. s/p pancreas transplant (with allograft pancreatectomy [5-/2174], redo transplant [6-/2175], acute rejection [7-/2180] which resolved with increased immunosuppresion) 4. diabetes mellitus type I (complicated by neuropathy, retinopathy, dysautonomia, no longer requires regular insulin after pancreas transplant) 5. autonomic neuropathy 6. sleep-disordered breathing (on 2L NC nighttime, unable to tolerate CPAP) 7. osteoporosis 8. hypothyroidism 9. pernicious anemia 10. cataracts 11. glaucoma 12. anemia from chronic kidney disease (on Aranesp previously) 13. Right foot fracture, complicated by RLE DVT 14. chronic LLE edema 15. Reucrrent MDR E.coli pyelonephritis 16. s/p anal polypectomy ([5-/2176]) 17. s/p bilateral trigger finger surgery ([8-/2178]) 18. s/p left [Year (4 digits) 6024] ([8-/2179]) Social History: Child psychiatrist, on disability. Lives alone in [Hospital1 8], MA. Has a PCA 8 hours/day. Ambulatory with a prosthesis for left leg. Was at [Hospital3 ] prior to this admission. Denies tobacco use or alcohol use; no recreational substance use. Family History: Father with MI at 57 year old; denies family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Vitals: T:97.7 BP:105/59 P:98 R: 18 O2: 98% on FIO2 .50 on humidified facemask General: somnolent, but oriented x3, clearly using accessory muscle to breath HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: crackles at base bilaterally, using abdomin and accessory muscles to breath Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place [Hospital3 ]: warm, well perfused, 2+ pulses, +1 edema on R leg, [Hospital3 6024] on left. Discharge PE: Tc 98.3 Tm 98.7 156/69 (101-156/51-74) 66 60-94 18 100 on RA GENERAL: Thin, woman in NAD, comfortable, appropriate. HEENT: sclerae anicteric, MMM. NECK: Supple CHEST: R sided HD line; dressing, clean, dry intact, no tenderness to palpation, no erythema appreciated HEART: RRR, S1, S2. LUNGS: clear to ausculation b/l ABDOMEN: soft, nondistended, no tenderness over L lower abdomen over transplanted kidney EXTREMITIES: WWP; No edema. left [Hospital3 6024]. NEURO: Awake, A&Ox3 Pertinent Results: [2181-9-23] 01:40AM BLOOD WBC-3.4# RBC-3.45 Hgb-10.3* Hct-31.7* MCV-92 MCH-29.8 MCHC-32.4 RDW-15.5 Plt Ct-125* [2181-9-23] 06:40AM BLOOD WBC-3.4* RBC-3.22* Hgb-9.5* Hct-28.6* MCV-89 MCH-29.4 MCHC-33.2 RDW-15.6* Plt Ct-145* [2181-9-23] 01:38PM BLOOD WBC-3.7* RBC-2.98* Hgb-9.0* Hct-27.3* MCV-92 MCH-30.3 MCHC-33.1 RDW-15.8* Plt Ct-102* [2181-9-24] 05:36AM BLOOD WBC-3.3* RBC-2.78* Hgb-8.3* Hct-25.6* MCV-92 MCH-29.9 MCHC-32.5 RDW-15.9* Plt Ct-101* [2181-9-24] 12:55PM BLOOD WBC-3.7* RBC-3.05* Hgb-8.8* Hct-29.0* MCV-95 MCH-28.8 MCHC-30.4* RDW-15.4 Plt Ct-123* [2181-9-23] 01:40AM BLOOD PT-13.1 PTT-31.7 INR(PT)-1.1 [2181-9-23] 06:40AM BLOOD PT-13.4 PTT-30.7 INR(PT)-1.1 [2181-9-23] 01:38PM BLOOD PT-14.3* PTT-63.1* INR(PT)-1.2* [2181-9-23] 07:42PM BLOOD PT-14.9* PTT-83.0* INR(PT)-1.3* [2181-9-24] 05:36AM BLOOD PT-15.0* PTT-98.8* INR(PT)-1.3* [2181-9-23] 01:40AM BLOOD Glucose-101* UreaN-125* Creat-2.2* Na-143 K-5.6* Cl-106 HCO3-25 AnGap-18 [2181-9-23] 06:40AM BLOOD Glucose-79 UreaN-124* Creat-2.1* Na-142 K-5.2* Cl-107 HCO3-24 AnGap-16 [2181-9-23] 01:38PM BLOOD Glucose-100 UreaN-120* Creat-2.2* Na-142 K-5.1 Cl-108 HCO3-21* AnGap-18 [2181-9-24] 05:36AM BLOOD Glucose-149* UreaN-116* Creat-2.4* Na-144 K-4.7 Cl-107 HCO3-24 AnGap-18 [2181-9-24] 05:51PM BLOOD Glucose-118* UreaN-109* Creat-2.5* Na-142 K-5.6* Cl-105 HCO3-26 AnGap-17 [2181-9-23] 01:40AM BLOOD CK-MB-4 proBNP-[Numeric Identifier 17772]* [2181-9-23] 01:40AM BLOOD cTropnT-0.06* [2181-9-23] 06:40AM BLOOD CK-MB-15* MB Indx-11.8* cTropnT-0.33* [2181-9-23] 01:38PM BLOOD CK-MB-15* MB Indx-8.8* cTropnT-0.73* [2181-9-24] 05:36AM BLOOD CK-MB-7 cTropnT-0.76* [2181-9-23] 06:40AM BLOOD Calcium-8.7 Phos-4.5# Mg-2.0 [2181-9-23] 01:38PM BLOOD Calcium-9.6 Phos-4.2 Mg-2.2 [2181-9-24] 05:36AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1 [2181-9-24] 05:51PM BLOOD Calcium-8.6 Phos-4.9* Mg-2.2 [2181-9-25] 04:00AM BLOOD Calcium-8.5 Phos-5.0* Mg-2.1 [2181-10-5] 04:13AM BLOOD calTIBC-215* Ferritn-174* TRF-165* [2181-9-26] 02:32AM BLOOD TSH-2.9 [2181-10-5] 04:13AM BLOOD PTH-64 [2181-10-3] 02:41PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2181-9-24] 05:36AM BLOOD tacroFK-4.8* rapmycn-4.7* [2181-9-25] 04:00AM BLOOD tacroFK-4.2* rapmycn-4.7* [2181-9-23] 02:17AM BLOOD Type-ART FiO2-100 pO2-309* pCO2-48* pH-7.35 calTCO2-28 Base XS-0 AADO2-353 REQ O2-64 [2181-9-23] 05:28AM BLOOD Type-ART Temp-37.0 Rates-/20 FiO2-60 O2 Flow-15 pO2-69* pCO2-46* pH-7.36 calTCO2-27 Base XS-0 Intubat-NOT INTUBA [2181-9-23] 05:50PM BLOOD Type-ART Temp-37.0 Rates-/16 FiO2-50 O2 Flow-10 pO2-86 pCO2-44 pH-7.40 calTCO2-28 Base XS-1 Intubat-NOT INTUBA Vent-SPONTANEOU [2181-9-25] 01:53AM BLOOD Type-ART Temp-36.4 O2 Flow-4 pO2-83* pCO2-46* pH-7.33* calTCO2-25 Base XS--1 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2181-9-26] 09:35AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-500 PEEP-5 FiO2-100 pO2-467* pCO2-33* pH-7.45 calTCO2-24 Base XS-0 AADO2-215 REQ O2-44 -ASSIST/CON Intubat-INTUBATED . Discharge labs: [2181-10-10] 07:58AM BLOOD WBC-2.4* RBC-2.58* Hgb-7.5* Hct-24.3* MCV-94 MCH-29.0 MCHC-30.9* RDW-14.8 Plt Ct-264 [2181-10-11] 05:15AM BLOOD WBC-2.4* RBC-2.77* Hgb-7.8* Hct-25.0* MCV-90 MCH-28.3 MCHC-31.3 RDW-15.2 Plt Ct-236 [2181-10-12] 05:10AM BLOOD WBC-2.5* RBC-2.75* Hgb-7.8* Hct-26.2* MCV-95 MCH-28.5 MCHC-30.0* RDW-15.2 Plt Ct-285 [2181-10-10] 07:58AM BLOOD PT-11.6 INR(PT)-1.0 [2181-10-11] 05:15AM BLOOD PT-11.6 INR(PT)-1.0 [2181-10-11] 05:15AM BLOOD Glucose-76 UreaN-18 Creat-2.0# Na-142 K-4.3 Cl-105 HCO3-30 AnGap-11 [2181-10-12] 02:07AM BLOOD Glucose-85 UreaN-28 Creat-2.7* Na-139 K-5.1 Cl-105 HCO3-29 AnGap-10 [2181-10-12] 05:10AM BLOOD Glucose-108* UreaN-29* Creat-2.7* Na-141 K-4.6 Cl-105 HCO3-29 AnGap-12 [2181-9-30] 09:56PM BLOOD CK-MB-14* MB Indx-1.4 cTropnT-1.71* [2181-10-1] 03:54AM BLOOD CK-MB-12* MB Indx-1.4 cTropnT-1.69* [2181-10-1] 02:50PM BLOOD CK-MB-6 cTropnT-1.86* [2181-10-2] 05:29AM BLOOD CK-MB-3 cTropnT-2.67* [2181-10-2] 02:59PM BLOOD CK-MB-2 cTropnT-2.17* [2181-10-12] 02:07AM BLOOD CK-MB-2 cTropnT-2.6* [2181-10-11] 05:15AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.0 [2181-10-12] 02:07AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1 [2181-10-12] 05:10AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2 [2181-10-9] 05:25AM BLOOD tacroFK-5.7 rapmycn-4.9* [2181-10-10] 07:58AM BLOOD tacroFK-5.3 rapmycn-4.9* [2181-10-12] 05:10AM BLOOD tacroFK-12.5 rapmycn-4.0* TEE ([2181-10-11]) 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. A patent foramen ovale is present with left-to-right shunt across the interatrial septum at rest. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic archand the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. No masses or vegetations are seen on the pulmonic valve. No mass or vegetation is seen on the catheter in the right atrium. There is no pericardial effusion. IMPRESSION: No valvular or catheter related vegetations seen. Patent foramen ovale. Moderately reduced left ventricular systolic function. Moderate mitral regurgiation. Mild aortic regurgitation. TTE ([2181-10-9]) The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the septum and anterior walls, distal inferior and distal lateral walls, and apex. The remaining segments contract normally (LVEF = 35 %). The estimated cardiac index is normal (>=2.5L/[Month/Day/Year ]/m2). 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Borderline left ventricular cavity enlargement with regional systolic dysfunction suggestive of multivessel CAD or other diffuse process. Moderate to severe mitral regurgitation. Pulmonary artery hypertension. VENOUS DUP UPPER [Month/Day/Year ] BILATERAL; ART DUP [Month/Day/Year ] UP BILAT COMPIMPRESSION: ([2181-10-11]) 1. Patent bilateral subclavian veins with normal phasic waveform. 2. Patent right cephalic and right and left cephalic vein in the arm, patent left basilic vein. 3. Thrombosed right basilic vein and left cephalic vein in the forearm. CT neck ([2181-10-11]) IMPRESSION: 1. No evidence of large focal mass compressing on the vocal cords or along the course of the laryngeal nerves; assessment is limited due to lack of IV contrast images. 2. Bilateral pleural effusions, right greater than left. 3. 6.4-mm nodule in the left upper lung. Recommend dedicated Chest CT to further evaluate. 4. Extensive vascular calcifications consistent with the patient's history of diabetes. 5. Degenerative disk disease, most prominent at C5-C6 and C6-7. Fluid with some debris is noted in the esophagus which is mildly dilated- correlate clinically. Renal ultrasound ([2181-10-4]) IMPRESSION: 1. No hydronephrosis. An echogenic pattern seen within the transplant kidney suggests that air may be present in the collecting system. If the Foley catheter has been manipulated, then this could represent reflux air. In the setting of pain, however, air could indicate an infection. 2. Patent renal transplant vasculature with mildly elevated resistive indices. Brief Hospital Course: This is a 60-year old Indian female with a complicated past medical history significant for type 1 IDDM (s/p revision renal and pancraes transplants, [2160] and [2174]), diastolic CHF (Echo 35-40%, [7-/2181]), sleep-disordered breathing (on 2L home oxygen at night) who presented with dyspnea. . #.Respiratory distress, hypercarbic - The patient presented with fever and increasing work of breathing with dyspnea that developed over 1-2 hours. She was started on empiric HCAP abx coverage of meropenem, cipro, and vanco. On [9-24] she had increasing respiratory rate and she was intubated on [9-26]. A bronchoscopy on [9-29] showed large amount of blood clots and thick mucus with no evidence of source of bleed or pna. On [9-30], she passed regular spontaneous breathing trial and she was extubated on [10-2]. . #. CAD - Cardiac enzymes initially rose upon arrival to the MICU. She had an ECHO which showed "LV hypertrophy and systolic dysfunction c/w CAD; severe mitral regurgitation and moderate tricuspid regurgiation; compared with the prior study the estimated PA systolic pressure is now higher." Cardiology was consulted and she had a cardiac catheterization on [9-27] - rotoblater used with DES to LAD. She tolerated the procedure well. On [9-30], she had ST elevation with a trop elevated to 1.71. Cardiology was consulted and they did not want to stent her. She was started on lisinopril 2.5mg PO qday. . #.Volume status ([Last Name (un) ] on CKD, CHF) - Difficult to manage given patient's renal failure and concominant severe mitral regurgitation. She was initially hypotensive and responded well to 2 U pRBCs and fluid boluses. An A-line was placed on [9-26]. She was started on Lasix gtt at 15mg/hr for a goal of -1 to -2 L. On [9-26], she received a tunnelled HD line for initiation of CVVH. She became hypotensive and did not respond to IVF, was startd on levophed on [9-27]. On [10-1], her SBP was very labile and it was difficult to strike a balance of IVF and pressors. Her levophed was weaned off on [10-2]. Since coming to the floors, the patient's blood pressures were also labile and she was continued on HD M,W,F to assist with volume control. She will be discharged to rehab with outpatient dialysis three times weekly for further volume control. . #. Fever- She was started on vancomycin and meopenem initially for presumptive HAP. Out of concern for possible varicella pneumonitis, her acyclovir dose was changed to a prophylactic dose. On [10-1] she spiked another fever to 38.2 and she was cultured. A urine culture resulted yeast in her urine and she was started on fluconazole. A blood culture resulted on [10-2] and showed GPC's in [3-26] bottles. Her IJ line was removed and the tip was cultured. Her A-line was also removed at this time. . #. CHF- the pt has known systolic CHF (LVEF-34-40%), was given lasix 20 IV at rehab and 20 IV in ED. Pt has reasonable responce (300cc within 1st hour). This pt should not be aggressively diureses right now as she's in an early septic phase and will likely be pre-load dependent. The patient's volume status was managed with HD/ultrafiltration. Patient's BPs have been very labile and so beta blockers were not initiated during this admission. . #. S/p renal/pancreatic transplant - She was continued on renal dosing of sirolimus and tacrolimus. Renal consultants were closely following her throughout her stay in the MICU. On [10-4], she began to develop LLQ pain. A renal US showed air in the transplanted kidney which is likely from her foley. She improved with no interventions necessary. On transfer to the floor, the patient did not have any abdominal pain and the issue resolved. The patient's tacrolimus and sirolimus levels were followed every morning; she was initially continued on tacrolimus 2.5 mg [Hospital1 ], sirolimus 1.5 mg daily, and prednisone 5 mg daily. However, her tacrolimus was eventually increased to 3 mg [Hospital1 ]. She will have to get her tacrolimus and sirolimus levels checked one time weekly as an outpatient. . #.A-fib with RVR - on [9-26], she developed afib with RVR and was started on IV metoprolol with PRN diltiazem. When she converted to sinus rhythm, she was started on amiodarone which was later stopped when she became bradycardic. She again went into afib with RVR on [9-28] after CVVHD. As a result, her CVVHD was backed off. The patient's Afib had resolved by the time she was transferred to the floor. . #Rash - disseminated rash developed 5 days prior to admission to MICU. ID was consulted and they recommended continuing acyclovir for concern of disseminated zoster. A sputum VZV was sent along with gram stain/culture. Dermatology was consulted and a biopsy was done which was consistent with an old varicella infection. She was taken off precautions. As per ID recommendation, the patient will need prophylaxis with acyclovir at 200mg q12h. . # acute kidney injury: The patient initiated dialysis during this hospital admission; likely secondary to acute tubular necrosis from decreased forward flow while she was pressor dependent in the MICU. The patient's creat peaked at 3.6 and at discharge, her creat was 2.7. The patient never had a post ATN diuresis that would be expected if her acute kidney injury secondary to ATN was resolving. She was still making some urine on the medicine floor, however, only in small amounts (~50 cc over the course of 24 hours). The patient will be discharged to rehab with outpatient dialysis follow-up. The patient had a tunnelled line placed on R chest; it was not pulled when she developed her coag negative Staph bacteremia, but was treated with Vancomycin. The patient's lisinopril was also discontinued given her acute kidney injury as well as her borderline low blood pressures. . # coag negative Staph bacteremia: The patient was found to have coag negative staph bacteremia growing out of [3-26] bottles. All of her lines were pulled, EXCEPT her tunnelled HD catheter line and it was decided to treat through the line. The patient will be on Vancomycin, HD dosing, for a total of two weeks (started on [2181-10-3]) and will continue the vancomycin with dialysis until [10-17]. A TTE was done could not rule out valvular vegetations, and a TEE was done showing that the patient did not have any vegetations. Please note, when getting the vanco trough, please make sure that trough is drawn AFTER the dialysis machine has been running for 10-20 minutes, as the patient's HD line is vanc blocked and we do not want that to be causing a falsely elevated trough. . # yeast UTI: The patient was also found to have yeast growing out of her urine. She was started on fluconazole 100 mg daily and will complete a two week course. Antifungal sensitivities were sent to [State ]. . # vocal cord paralysis: The patient was found to have vocal cord paralysis by ENT which can account for her weakened voice s/p intubation and her inability to drink thin liquids because would frequently aspirate. ENT wanted a CT neck/chest to rule out any masses that were pressing on the laryngeal nerve that could be causing larygneal nerve dysfunction, especially given her immunocompromised status. CT was negative for any masses. The patient will follow up with ENT as an outpatient. Speech and swallow was following the patient while inpatient and she will be discharged on dysphagia/avoid thin liquid diet. . # Hypothyroidism -continued on home levothyroxine. . #. type 1 DM s/p pancreatic transplant, complicated by neuropathy, retinopathy, dysautonomia, but no longer requiring insulin. The patient's sugars were under control during this admission. . # Glaucoma - pt continued on methazolamide . # teriparatide: Endo was consulted about whether patient should continue her teriparatide now given that she was initiated on HD. Was instructed to hold teriparatide for now. . Transitional Issues: . #: vanco trough: When getting the vanco trough, please make sure that trough is drawn AFTER the dialysis machine has been running for 10-20 minutes, as the patient's HD line is vanc blocked and we do not want that to be causing a falsely elevated trough. . # outpatient blood work: Please check tacrolimus and sirolimus levels weekly as an outpatient. . # RUE DVT: The patient was diagnosed with RUE DVT on previous admission. While she was in-patient the patient was not on any anticoagulation. She was instructed to hold a/c at discharge; please follow this up as an outpatient. Medications on Admission: 1. fosfomycin tromethamine 3 gram Packet Sig: One (1) packet PO once a week. 2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK ([Doctor First Name ],TU,TH). 3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK (MO,WE,FR,SA). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 10. ipratropium bromide 0.02 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 11. teriparatide 20 mcg/dose - 600 mcg/2.4 mL Pen Injector Sig: One (1) injection Subcutaneous once a day. 12. sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): at 6am. 13. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 16. cyclosporine 0.05 % Dropperette Sig: One (1) drop Ophthalmic [Hospital1 ] (2 times a day). 17. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 18. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 19. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day: with meals. 20. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 21. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 22. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) injection Injection once a month: most recent dose [2181-9-7]. 23. pentamidine 300 mg Recon Soln Sig: One (1) inhalation Inhalation once a month. 24. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 25. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 26. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 27. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO Q SUN/TUE/ THURS (). 2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO Q MO, WED, FR, SA (). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 5. acyclovir 400 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours). 6. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): please stop on [2181-10-16]. 7. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous HD PROTOCOL (HD Protochol): please stop [2181-10-17]. 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. doxepin 10 mg Capsule Sig: One (1) Capsule PO at bedtime. 12. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for glaucoma. 13. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation QID (4 times a day) as needed for sob/wheezing. 14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for sob/wheezing. 15. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. sirolimus 1 mg Tablet Sig: 1.5 Tablets PO once a day: 1.5 mg daily. 17. cyclosporine 0.05 % Dropperette Sig: One (1) Ophthalmic twice a day. 18. brimonidine 0.15 % Drops Sig: One (1) Ophthalmic three times a day. 19. latanoprost 0.005 % Drops Sig: One (1) Ophthalmic at bedtime. 20. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day: with meals. 21. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Ophthalmic twice a day. 22. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 23. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) Injection once a month. 24. pentamidine 300 mg Recon Soln Sig: One (1) Inhalation once a month. 25. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime. 26. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 27. Tylenol 325 mg Tablet Sig: One (1) Tablet PO q6h: PRN as needed for fever or pain. 28. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 29. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: primary diagnosis: hypercarbic respiratory failure coagulase negative staph bacteremia diabetes mellitus, type 1 status post renal and pancreas transplant Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). uses a prosthesis Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear Ms. [Known lastname 17759], It was a pleasure taking care of you while you were hospitalized at [Hospital1 18]. You were initially admitted to the hospital because you were having shortness of breath at rehab; you had respiratory failure and you were admitted to the intensive care unit and connected to a machine to help breath for you. While in the intensive care unit, you were also found to have acute heart dysfunction and you underwent a heart procedure where a stent was placed in your coronary artery. . Your blood pressures were very low and you needed medications to help support your pressures. During this time, we think that your kidneys were not getting enough fluid, and you developed kidney dysfunction. It was decided that you should start dialysis because of your poor kidney function, as well as to help stabilize your volume status. . As you were leaving the intensive care unit, you were found to have bacteria in your blood. You were started on antibiotics through your veins for this. Because bacteria in your blood can sometimes latch onto your heart valves, we did imaging of your heart; we did NOT find any bacteria latching onto your heart valves. . You also were found to have a urinary tract infection with yeast; we started you on an antifungal medication for this. You need to take another four more days of this medication (STOP on [2181-10-16]). . You were also seen by the ears/nose/throat (ENT) doctors [Name5 (PTitle) 1028] [Name5 (PTitle) 17773] were here because you were having some problems drinking thin liquids (instead of going into your esophagus, the liquid was entering your lungs). They found that you had a problem with your vocal cords, and they want you to follow up with them as an outpatient. . We made the following changes to your medications: START Vancomycin with your dialysis until [2181-10-17] START Fluconazole 100 mg daily until [2181-10-16] STOP lisinopril STOP carvedilol STOP Teriparatide CHANGE aspirin 81 to 325 mg daily DECREASE acyclovir from 400 to 100 mg daily STOP doxazosin START Plavix 75 mg daily INCREASE tacrolimus to 3 mg daily INCREASE sirolimus 1.5 mg daily STOP Coumadin until you see your PCP STOP fosfomycin tromethamine START Sevelamer 800 mg TID with meals /Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: [Hospital3 249] When: FRIDAY [2181-10-19] at 3:15 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: OTOLARYNGOLOGY-AUDIOLOGY When: TUESDAY [2181-10-23] at 10:00 AM With: [Name6 (MD) 15040] [Last Name (NamePattern4) 15041], MD [Telephone/Fax (1) 41] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 895] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: TRANSPLANT CENTER When: MONDAY [2181-10-29] at 12:30 PM With: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [Name6 (MD) 2105] [Name8 (MD) 2106] MD [MD Number(2) 5038] Completed by:[2181-10-12] ICD9 Codes: 5845, 486, 5856, 7907, 2930, 2449, 4240, 412, 4280, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6444 }	Medical Text: Admission Date: [2103-11-12] Discharge Date: [2103-11-25] Date of Birth: [2059-4-15] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1377] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Sigmoidoscopy History of Present Illness: Ms. [Known lastname 65453] is a 44 y/o female with a hx of UGIB [1-10] duodenal ulcers and EtOH liver disease who was transferred from [Hospital1 1562] hosptial due to altered mental status. . As per her sister, she was recently admitted to [Name (NI) 1562] hospital for an upper Gi bleed. She was discharged to [Location (un) 3244] detox facility for a couple of days. When she came home from detox, she was mildly confused. over the next few [Last Name (un) 32460] she become progressively more confused and had significant decrease in her functional status. Also having frequent diarrhea. Her sister took her to her PCP who promptly sent her to the ED. In the ED at [Hospital1 1562] (per report) it was thought her mental status may be related to her liver disease and she was transferred to [Hospital1 18]. . In the ED, initial VS: 98.0 90 113/50 18 98%. She had a head CT which was negative for an acute process. There was no ascitic fluid that was visulized therefore could not perform a diagnostic tap. She was given lactulose and ceftriaxone. ? given narcan with improvement of mental status. . Overnight, Cr was found to be 5.1 with BUN of 15. WBC 22. U/A suggestive of UTI. She was given 100g albumin for HRS and ceftriaxone for UTI, ? SBP. This morning on rounds, she was thought to be acutely confused, and transfer to the MICU transfer was requested for altered mental status and possible endoscopy. On evaluation this morning, she was confused and unable to give a history. She denied having any discomfort. She oriented to self but not to place and time. . REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Alcohol abuse Social History: Lives with his eldest of 2 sons. [Name (NI) ] lots of family support (mother, sisters, [Name2 (NI) 12232]) - requires 24 hour care at home. Not currently employed, on SSI. - Smoking: quit > 16 yrs ago, 25 pack year history - EtOH: history of abuse, last drink > 22 yrs ago - Drugs: history of polysubstance abuse including cocaine, crack, barbiturates, amphetamines, and marijuana. None for 20 years. Family History: No pertinent family history, including PSC, liver disease, or other gastrointestinal disease. (Has identical twin brother without above conditions). Grandfather with diabetes. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.1 132/74 96 20 99/ra GENERAL - NAD, drowsy, confused HEENT - scleral icterus NECK - supple, no thyromegaly, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, mild expiratory wheezing, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, distended but soft/NT, no masses or HSM, no rebound/guarding EXTREMITIES - several punctures in volar arms with surround erythmea, ? injection drug sites vs. prior IVs. bilateral LE 3+ edema NEURO - AAOx1, mild left facial droop, speech fluent, no pronator drift . Discharge Exam: Afebrile, HD stable, on RA GENERAL: Well appearing 51yo M. Comfortable, appropriate and in good humor. Mildly Jaundiced. HEENT: Sclera icteric though improved. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: RRR, III/VI systolic murmur with best heard at LUSB. LUNGS: Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Normoactive BS. Distended but Soft, non-tender to palpation, Tympanic to percussion, No HSM or tenderness. EXTREMITIES: WWP, trace LLE (reduced from baseline). NEURO: A and O x 3; approrpiately mentating; motor and sensory grossly intact Pertinent Results: ADMISSION LABS: [2103-11-12] 05:40PM BLOOD WBC-22.4* RBC-3.18* Hgb-10.4* Hct-33.0* MCV-104* MCH-32.9* MCHC-31.7 RDW-19.2* Plt Ct-387 [2103-11-12] 05:40PM BLOOD Neuts-74* Bands-0 Lymphs-16* Monos-5 Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-1* [2103-11-12] 05:40PM BLOOD PT-19.3* PTT-44.8* INR(PT)-1.8* [2103-11-12] 05:40PM BLOOD Glucose-81 UreaN-15 Creat-5.2* Na-131* K-3.2* Cl-97 HCO3-16* AnGap-21* [2103-11-12] 05:40PM BLOOD ALT-52* AST-150* AlkPhos-265* TotBili-4.8* DirBili-4.0* IndBili-0.8 [2103-11-12] 05:40PM BLOOD Lipase-23 [2103-11-12] 05:40PM BLOOD Albumin-2.3* Calcium-8.5 Phos-3.6 Mg-2.2 [2103-11-14] 02:37PM BLOOD Ammonia-147* [2103-11-13] 06:20AM BLOOD Osmolal-288 [2103-11-13] 06:20AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE [2103-11-12] 05:40PM BLOOD HCG-<5 [2103-11-12] 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2103-11-13] 06:20AM BLOOD HCV Ab-NEGATIVE [2103-11-13] 03:06AM BLOOD Type-ART pO2-90 pCO2-26* pH-7.42 calTCO2-17* Base XS--5 Intubat-NOT INTUBA [2103-11-12] 05:51PM BLOOD Glucose-77 Lactate-1.7 Na-132* K-3.2[2103-11-13] 03:06AM BLOOD Hgb-10.2 calcHCT-31 O2 Sat-96 COHgb-1 MetHgb-0 [2103-11-13] 03:06AM BLOOD freeCa-1.14 . Discharge Labs: [2103-11-24] 07:15AM BLOOD WBC-26.7* RBC-2.46* Hgb-7.8* Hct-25.5* MCV-104* MCH-31.6 MCHC-30.6* RDW-18.4* Plt Ct-490* [2103-11-24] 07:15AM BLOOD PT-22.1* INR(PT)-2.1* [2103-11-24] 07:15AM BLOOD Glucose-92 UreaN-36* Creat-1.3* Na-136 K-4.3 Cl-105 HCO3-17* AnGap-18 [2103-11-24] 07:15AM BLOOD ALT-25 AST-88* AlkPhos-151* TotBili-3.5* [2103-11-24] 07:15AM BLOOD Albumin-2.7* Calcium-8.1* Phos-5.5* Mg-1.7 . MICRO: BCx negative x4 UCx negative x2 C.DIFF NEGATIVE . IMAGING: [11-12] CT HEAD TECHNIQUE: Axial MDCT images were acquired of the head without contrast and reformatted into coronal and sagittal planes. FINDINGS: The exam is somewhat limited by patient motion, although repeat scans were performed. There is no intracranial hemorrhage, extra-axial collection, or mass effect. The ventricles and sulci are normal in size and configuration. [Doctor Last Name ] matter/white matter differentiation is preserved. The orbits are normal appearing. The soft tissues are unremarkable. There is an air-fluid level within the left maxillary sinus, and mucosal thickening of ethmoid air cells. The frontal sinuses are clear. An air-fluid level is seen in the sphenoid sinus with aerosolized debris. The mastoid air cells and middle ear cavities are clear. There is no osseous abnormality. IMPRESSION: 1. No acute intracranial process. 2. Air-fluid levels in multiple paranasal sinuses. . [11-12] LIVER ULTRASOUND: FINDINGS: The liver is diffusely coarse and echogenic consistent with history of liver disease. No focal lesions are seen. The gallbladder appears normal. The common bile duct is mildly dilated measuring up to 8 mm. No definite stone is seen within the common bile duct. To and fro flow is seen within the main portal vein. There is no ascites. The right kidney measures 13.9 cm in the long axis and is normal in appearance without hydronephrosis or stones. IMPRESSION: 1. Diffusely echogenic liver consistent with history of alcoholic hepatitis. 2. To and fro flow within the main portal vein without portal vein thrombosis. 3. Common bile duct measures up to 8 mm and is thus dilated. MRCP/ERCP could better evaluate for an obstructing cause. . [11-13] RENAL ULTRASOUND: The right kidney measures 12.1 cm. The left kidney measures 12.5 cm. There is no hydronephrosis, stones or masses. The bladder is only minimally distended and cannot be assessed. Small portion of a urinary catheter is seen. IMPRESSION: Normal renal son[Name (NI) ] . [11-16] HIDA SCAN: RADIOPHARMACEUTICAL DATA: 4.2 mCi Tc-[Age over 90 ]m DISIDA ([2103-11-16]); HISTORY: Common duct dilation, leukocytosis, and right upper quadrant pain. Evaluate for biliary pathology. METHODS: Following the intravenous injection of tracer, serial one-minute images of tracer uptake into the hepatobiliary system were obtained for 75 minutes. A delayed static image was obtained at 5.5 hours. Images of the injection site were also acquired. INTERPRETATION: Serial images over the abdomen show poor uptake of tracer into the hepatic parenchyma in a homogeneous pattern. At 15 minutes, the small bowel is visualized, although no tracer uptake is seen within the gallbladder throughout the first 75 minutes. The patient returned to the nuclear medicine suite after 5.5 hours for additional imaging, which revealed tracer activity within the gallbladder. IMPRESSION: 1. Diffusely poor tracer uptake throughout the liver is consistent with poor hepatocellular function. 2. Tracer activity within the gallbladder on delayed images excludes the diagnosis of acute cholecystitis. 2. Excretion of tracer into the small bowel excludes the diagnosis of complete biliary obstruction. . [11-17] CXR HISTORY: Alcoholic hepatitis. Aspiration event. IMPRESSION: AP chest compared to [11-13]: Consolidation in the perihilar left lung and in the right upper lung extending to the apex is readily explained by massive aspiration. A smaller region of consolidation may be present in the right lung projecting behind the lower pole of the right hilus. Mild cardiomegaly and mediastinal vascular engorgement have increased suggesting cardiac decompensation. Dr. [Last Name (STitle) ] was paged. . CXR [2103-11-18] Bilateral upper lobe consolidation is slightly more pronounced today than yesterday. Whether this is due to progression of pneumonia or deposition of early edema in a region of pre-existing pneumonia is difficult to say since the mediastinal veins are dilated in the supine position. Heart size is top normal, and there may be mild pulmonary vascular engorgement, but no clear edema elsewhere. There is no appreciable pleural effusion. Nasogastric tube passes into the stomach and out of view . Sigmoidoscopy [2103-11-23] - Polyp at 8cm in the rectum - Polyps at the ranging distance from 18 cm to 28 cm in the distal sigmoid colon - Grade 2 internal hemorrhoids - Otherwise normal sigmoidoscopy to splenic flexure - Recommendations: Patient will need colonoscopy for removal of polyps when her alcoholic hepatitis improves and her INR is less than 1.5. Brief Hospital Course: Ms. [Known lastname 65453] is a 44 year old female with a history of upper GI bleed (UGIB) secondary to duodenal ulcers and alcoholic liver disease who was transferred from [Hospital 1562] hospital due to altered mental status. . ACTIVE PROBLEMS BY ISSUES: . # Alcoholic Hepatitis: Hepatic encephalopathy, jaundice, LFTs with alcoholic picture, viral studies were negative. She has signficant synthetic dysfunction as well with a discriminant function of 51 on admission. Steroids were deferred initially for possible acute hepatitis since her LFTs and bilirubin were improving in the MICU with fluids. Hepatitis B and C virus serologies negative. On floor tube feeds were started to augment nutrition and improve hepatitis. NGT was accidentally self removed. Nutrition reconsulted and felt she could take adequate caloric intake to treat alcoholic hepatitis and so NGT was not replaced. Discriminant function 36 on discharge but patient clinically much improved, walking around floor, jaundice improving, POing well with downtrending T.Bili <4 on discharge. Patient discharged in improved condition agreement with plan to abstain from alcohol completely. She was discharged home with outpatient alcohol rehabilitation. . # Encephalopathy: The patient was transferred to the MICU for altered mental status (AMS); likely due to hepatic encephalopathy. A lumbar puncture was attempted, but unsuccessful. She received Narcan in the ED to which there was a questionable improvement in her mental status. She was given lactulose and rifaxamin, aiming for 4 bowel movements/day and was also started on empiric antibiotic coverage since she had a leukocytosis with the AMS including acyclovir, vancomycin, ampillicin, and ceftriaxone. The patient then had a right upper quadrant ultrasound that showed dilated common bile duct, so she underwent a HIDA scan which ruled out cholangitis as a cause of her AMS and leukocytosis. At that point, ampicillin was discontinued and the patient was continued on vanc/acyclovir, flagyl/ceftriaxone was added for intra abdominal pathology. Antibiotics were changed to Vanc/Zosyn after she developed PNA. The patient also has a drinking history and was started on thiamine. As the patient's mental status slowly improved, the acyclovir was stopped, as the concern for encephalitis lessened. On arrival to the floor her mental status continued to improve with lactulose and Rifaximin. He encephalopathy was attributed to alcoholic hepatitis and continued to improve throughot duration of stay. . # Acute Renal Failure: The patient was found to be in ARF (baseline creatinine is around 0.9) and presented with creat 5.2. FeNa of 0.22 consistent with prerenal etiology and muddy brown casts were found in the urine sediment suggesting acute tubular necrosis (ATN). With significant liver dysfunction hepatorenal syndrome (HRS) was of concern. Renal consulted but thought that the etiology was pure ATN. She underwent a renal ultrasound which was normal and an albumin challenge which ruled out hepatorenal syndrome. Creatinine continued to improve after albumin was given and with improvement in hepatitis. . # Aspiration pneumonia: She developed aspiration pneumonia on [11-17] with a rising leukocytosis. She was fed with a [Last Name (un) ]-gastric tube and continued on vanc/zosyn. She completed an HCAP course with Vanc/Zosyn and she remained on RA throughout duration of floor stay. . # Leukoctosis: Patient with profound leukocytosis which uptrended initially and remained elevated. Initial concern was for HCAP which was adequately treated. C.Diff returned negative multiple times. Leukocytosis remained elevated despite HCAP treatment and so WBCs thought most likely related to alcoholic hepatitis rather than infectious etiology. Cultures negative otherwise in work up. . # Upper GI bleed (UGIB): Presented with bright red blood per rectum (BRBPR), and a Hematocrit trending down 33 -> 30. Upon further questioning, she reported that she was having her menses. Her hematocrit remained stable and she did not recieve any blood transfusions. This was initially stable until 2 days prior to discharged when on the floor she began having GIB. Patient again felt this was menses though rectal exam with internal hemorrhoids. Flex Sig was completed given concern for rectal bleed which showed grade 2 hemorrhoids and multiple recto-sigmoid polyps. Polyps were not removed because of elevated INR and tenuous Alc Hep. Repeat colonoscopy deferred to outpatient after improvement in hepatitis and coagulopathy. . # Anion Gap Acidosis: She is noted to have a gap of 18 upon admission labs. Her lactate was within normal limits, no osmolar gap. Given BUN unlikely to be uremia, but possible contribution of acute renal failure. Also possible alcoholic/starvation ketosis. Gap closed and remained stable after transfer to floor from MICU. . # Sodium imbalance: She likely had hypervolemic hyponatremia due to liver dysfunction. She was maintained on a fluid restricted diet. She later developed hypernatremia while she was on tube feeds only for aspiration. This was treated with free water flushes through the NG tube. After hepatitis and HCAP improved/resolved her Na remained stable requiring no further intervention. . # Macrocytic Anemia: With significant alcohol use she is likely either folate or B12 deficient. . # Peptic ulcer disease (PUD): she has a history of duodenal ulcers and was continued on pantoprazole. . TRANSITIONAL ISSUES: - Colonoscopy needs to be completed as an outpatient with removal of colonic polyps after INR improves - Patient counseled extensively on the importance of alcohol abstainence and she is agreeable with plan. Should continue reinforcing abstinence - Consider Baclofen for alcohol abuse prophylaxis Medications on Admission: Oxycodone 5mg Vitamin B12 Ondansetron 4mg Pantoprazole 40mg daily Discharge Medications: 1. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as needed) as needed for rectal irritation. Disp:1 tube Refills:0 6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a day. Disp:1800 ML(s) Refills:1 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every twelve (12) hours as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: hepatic encephalopathy acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 65453], . You were admitted to the hospital because you were more confused than your baseline and there was concern that you had bleeding from your intestines. We did not find that there was any significant bleeding in your intestines and the levels of your blood stayed steady. You do have a hemorrhoid which bleeds a little bit when you have bowel movements. Flex Sigmoidoscopy performed showed polyps in your sigmoid colon which should be followed up after you are discharged. . For your confusion, we think that it relates to your liver disease. When your liver disease progresses, a condition called cirrhosis, your body builds up toxic substances. You were treated with lactulose to make you have bowel movements which will remove these toxic substances. . Finally, you developed a pneumonia because when you swallow the food sometimes goes into your lungs. This is called aspiration. You have to eat very slowly to help the food go into your stomach not your lungs. . The following changes were made to your medications: - START Folic Acid 1mg Daily - START Thiamine 100 mg DAILY - START Vitamin D 400 UNIT DAILY - START Hydrocortisone cream: apply rectally as needed for irritation - CONTINUE Pantoprazole - START Lactulose 30 mL Twice daily - START Rifaximin 550 mg twice daily . It is also very important that you keep all of the follow-up appointments listed below. . It is also very important that you have a colonoscopy to evaluate polyps in your colon. . It was a pleasure taking care of you in the hospital! Followup Instructions: Name: [Last Name (LF) 679], [Name8 (MD) 1158] MD Address: [Doctor First Name ],STE 8A, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 682] Appointment: Wednesday [2103-12-5] 10:45am [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] ICD9 Codes: 5845, 5070, 2762, 2760, 2761, 2768, 2859, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6445 }	Medical Text: Admission Date: [2181-8-10] Discharge Date: [2181-8-13] Date of Birth: [2119-10-10] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 61-year-old male (with a history of hypertension and hypercholesterolemia) presents with epigastric pain of one-half hour duration. The patient was in his usual state of health (able to walk four miles without symptoms) until [2181-8-8] when he noticed "pain in my belly". It was associated with diaphoresis and dyspnea on exertion and relieved by rest. He went to his primary medical doctor where he was found to be hypertensive. An EKG was taken, (which, by the patient's report, was found to be normal). He returned to work and over the next few days had stuttering episodes of epigastric/chest discomfort, each lasting approximately 30 minutes. On [2181-8-10], he presented to the [Hospital3 ] Emergency Room with 7/10 epigastric/chest pain. An EKG found ST elevations in leads V2 through V4 with a CK of 503 and a troponin T of 0.34. A bedside echocardiogram showed anteroseptal apical hypokinesis. The patient was rendered pain-free with heparin, Integrelin, labetalol, nitroglycerin IV, and aspirin. Of note, his systolic blood pressure was in the 180s. He was transferred to the [Hospital6 1760] for PTCA. Catheterization findings: Hemodynamics: (1) Mild elevation PCWP with preserved cardiac index. Left ventriculography, no MR, huge territory risk, anterolateral hypokinesis with anteroapical and apical inferior dyskinesis, hyperdynamic bases, quantitative EF 30%. Coronary angiography: Left dominant LMCA normal, LAD very proximal total occlusion of the LAD just after the first septal, post stent long wrap around LAD reperfused with TIMI-III flow, left circumflex dominant and normal, RCA large nondominant right. Intervention: Primary PCI and 3.0 by 23 mm Hepacoat stent to the LAD. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Hypertension. 3. Right hernia repair. ADMISSION MEDICATIONS: 1. Garlic. 2. Multivitamins. 3. Vitamin E. 4. Diovan/HCTZ 160/12.5. 5. Vitamin C. 6. Vitamin B12. 7. Zinc. 8. Coenzyme Q. 9. Folic acid. 10. Pravachol 40 mg q.d. (according to his [Location (un) 535], the patient had not refilled this medication since [2180]). ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient works for the [Company 2318] on the Green Line. He does not smoke or drink. No history of cocaine. FAMILY HISTORY: The patient is unaware of his family history as he is adopted. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.4, blood pressure 155/88, heart rate 79, respiratory rate 13, oxygenating 100% on 2 liters. General: Diaphoretic, pleasant gentleman lying on his back status post catheterization. HEENT: Moist mucous membranes. Pupils equal and reactive to light and accommodation. Extraocular movements intact. Visual fields intact. No oropharyngeal lesions. Cardiovascular: Regular rate. S1 greater than the S2 at the apex. No murmurs, rubs, clicks, or gallops. Nondisplaced PMI. No JVD. Pulmonary: Clear to auscultation bilaterally anteriorly. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. No hepatosplenomegaly. Extremities: 2+ dorsalis pedis and posterior tibialis, radial. No clubbing, cyanosis or edema. Neurologic: Nonfocal. Skin: The catheterization site was clean, dry, and intact with no hematoma, no bruit. LABORATORY DATA/STUDIES: Catheterization results: See HPI. ECG at 10:05 revealed a normal sinus rhythm, [Street Address(2) 2051] elevations in V2 through V4. At 10:44, normal sinus rhythm, [Street Address(2) 1766] elevations in V2 through V4 and T wave inversions in leads I and aVL with anterior Q waves. Chem-7: 140, 3.7, 101, 28, 17, 1.1, glucose 150. CBC: White count 8.9, hematocrit 45.1, platelet count of 160,000. INR 1.0. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit for observation, was placed on carvedilol 6.25 b.i.d, Pravastatin 40 q.d., Plavix 75 q.d., Integrelin drip at 2 per kilogram per minute, aspirin 325 q.d., Coumadin 5 mg and heparin drip was started after the Integrelin was shut off. The Coumadin was started due to the dyskinesis of the apex. The patient was closely observed and monitored via telemetry and hemodynamic monitoring. His CKs dropped nicely from an initial CK of 2,880 to 2,786, to 1,971. On [2181-8-11], the patient remained hemodynamically stable and was now breathing at 95% on room air. He was diuresing well. It was decided that the patient did not need an echocardiogram given the fact that he had an LV gram intracatheterization. The patient was transferred to the floor to a telemetry bed. On [2181-8-12], over the prior night, the patient had one episode of hypotension when he was sitting up in his chair. His systolic blood pressure dropped to the 50s. It returned to a systolic blood pressure of 110 after 500 cc normal saline bolus. The patient was asymptomatic during this episode aside from some mild diaphoresis. The telemetry showed no alarms. The patient's CK continued to drop nicely from 1,380 to 8.72. The patient's hematocrit and creatinine were stable. He was started on Captopril 6.25 t.i.d. and changed to Lovenox and the heparin was discontinued. A Physical Therapy consult was obtained which showed the patient meeting the physical therapy goals. On [2181-8-12], the patient's Captopril was increased to 12.5 t.i.d. The Coumadin was still at 5 mg. Carvedilol was at 6.25 b.i.d. The patient's INR was at 1.1. A chest x-ray showed a normal heart size with normal pulmonary vascularity with no effusions, no signs of failure. On [2181-8-13], the patient remained asymptomatic and hemodynamically stable, breathing at 97% on room air with a blood pressure in the 110s/60. The patient was instructed in how to administer Enoxaparin which would be overlapped with the Coumadin for two days. The patient was then discharged in good condition. At the time of discharge, the patient had near complete resolution of EKG changes with minimal (0.[Street Address(2) 1755] elevations in leads V2 and V3). At the time of discharge, the patient was asymptomatic. DISCHARGE DIAGNOSIS: Anterior myocardial infarction. DISCHARGE MEDICATIONS: 1. Aspirin 325 p.o. q.d. 2. Plavix 75 p.o. q.d. 3. Nitroglycerin 0.3 mg tablets sublingual, one tablet sublingual p.r.n. every five minutes up to a total of three doses. 4. Pantoprazole 40 mg tablets p.o. q.d. 5. Pravastatin sodium 20 mg tablet, two tablets p.o. q.d. 6. Carvedilol 3.125 mg tablet, two tablets p.o. b.i.d. 7. Coumadin 5 mg tablets one p.o. q.d. 8. Enoxaparin injection, one injection subcutaneously q. 12 hours times four injections. 9. Captopril 12.5 mg tablets, one tablet oral t.i.d. FOLLOW-UP PLANS: The patient was advised to return to the nearest Emergency Room with any new symptoms such as chest discomfort, shortness of breath, or palpitations. RECOMMENDED FOLLOW-UP: 1. Appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at the [Hospital6 1760] [Hospital Ward Name 516], [Hospital Ward Name 23] Building, [Location (un) ], South Suite, on [2181-8-15] at 10:30 a.m. Phone number [Telephone/Fax (1) 250]. 2. Appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Hospital Ward Name 23] Building, [Location (un) 1772], South Suite, on [2181-8-21] at 1:30 p.m., [Telephone/Fax (1) 250]. 3. Echocardiography, signal-averaged ECG, Holter monitor, T wave alternans testing on Tuesday, [2181-8-28] at 1:00 p.m. [Hospital1 ] [Last Name (Titles) 517], [Hospital Unit Name 723], 301. 4. Appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on Wednesday, [2181-9-5] at 12:30 p.m. at the [Hospital1 ] [Last Name (Titles) 8559], [Hospital Ward Name 23] Building, [Location (un) 436], Cardiac Services. 5. The patient's INR will be followed by Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) ] until such time that the patient could be seen in the [Hospital 191] [Hospital 197] Clinic. The patient's primary care doctor, Dr. [Last Name (STitle) 45630] [Name (STitle) ], was contact[Name (NI) ] regarding the patient's discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 1811] MEDQUIST36 D: [2181-8-15] 09:50 T: [2181-8-19] 15:34 JOB#: [Job Number 102118] cc:[Telephone/Fax (1) 102119] ICD9 Codes: 4019, 2720, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6446 }	Medical Text: Admission Date: [2179-12-18] Discharge Date: [2179-12-21] Date of Birth: [2144-9-28] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[Last Name (NamePattern4) 290] Chief Complaint: EtOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: 35M w/ hx of polysubstance abuse, OCD, anxiety, Hep C and multiple admissions for EtOH withdrawl. Presented to ED today with etoh intoxication, last drink being at 5pm prior to admission to [Hospital Unit Name 153] ([2-11] of vodka). Pt states that he feels more shaky today because he did not have enough money to drink his typical amount of alcohol which is [3-14] vodka. He also reports bilateral hand pain because he has fallen ~2x per day over the past several months, all falls associated with etoh intoxication. He also reports 18 months of abdominal pain. . The patient was tx to the [Hospital Unit Name 153] for further care given that he was requiring 10mg IV valium every 45-60 minutes. Past Medical History: Polysubstance abuse: EtOh, heroin IVDU, klonopin Hepatitis C from IVDU compartment syndrome RLE, [2171] OCD and anxiety since childhood depression, psychiatrist Dr. [Last Name (STitle) 60521] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. H/O SI with reportably tylenol overdose. Multiple admissions for alcohol withdrawl with history of DTs Social History: Homeless for past 16 years; lives in [Location ] common. Was incarcerated for 9 months due to possession charges. Hx of polysubstance abuse including ETOH, cocaine, heroin, benzos. Current drug of choice is ETOH; drinks 3 pints vodka a day. does not recall last use of heroin and cocaine. Denies current tobacco. Family History: mother died of complications of DM in '[62]. Father with depression and alcoholism Physical Exam: Exam: temp AF, HR 98-101 BP 148/92 RR 12 02 100% on NRB Gen: appears anxious, tremulous HEENT: pupils dilated, reactive to light; MMM CV: tachy but regular, no g/m/r Chest: clear bilaterally Abd: +BS, soft, mildly tender to light palpation throughout, no rebound Ext: no edema, 2+ DP neuro: AO x 3 Pertinent Results: [2179-12-17] 10:20PM ASA-NEG ETHANOL-335* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG . Abd CT: Normal appendix. Stable appearance of the abdomen and pelvis compared to the three previous CTs performed within the last year. . Brief Hospital Course: A/P: 35M with hx of etoh abuse and multiple prior admissions for detox who presents with etoh intoxication and withdrawal symptoms. . # Etoh withdrawal: The patient's presentation was typical of typical of prior withdrawals. He has a history of delirium tremens, withdrawal seizures, and consumes approximately [2-8] gallon of vodka per day. He was started on both standing Valium as well as PRN Valium per CIWA scale. He was monitored for seizures and other withdrawal symptoms. His tremulousness on his second hospital day improved, and his valium was decreased and then tapered off. He was given a banana bag with MVI, thiamine, folate. The patient was well-known to social work who saw him during this hospitalization. The patient expressed interest in attending alcohol rehabilitation however has a history of refusing to attend these programs [3-11] anxiety during prior hospital discharges. The alcohol rehab did not have available beds when the patient was medically ready for discharge, and he did not attend alcohol rehabilitation. Of note, the patient has had multiple prior admissions for detox at the [Hospital1 ], [Hospital1 2025] and [Hospital1 2177]. . # New O2 Requirement: Patient required O2, 3-4 L NC, during the 2nd day of his admission to maintain O2 sat above 94%. A chest xray was checked which showed no acute cardiopulmonary process and clear lungs. He was subsequently weaned off oxygen to room air without any desats. . # Bilateral hand swelling and pain: The patient has a long history of bilateral hand swelling. A uric acid was checked during last admission to evaluate for gout and was found to be on the low side (3.6). Additionally wrist x-rays were negative during his last admission. He was given motrin prn for pain with good effect. . # Elevated LFTs: LFTs chronically elevated and thought to be [3-11] EtOH. . # FEN: regular diet, pt now awake and alert . # Code: full code . Medications on Admission: Patient not taking any meds on admission Discharge Medications: 1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed: for joint pain. 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: . Primary: Alcohol withdrawal. . Secondary: Anxiety Discharge Condition: Good Discharge Instructions: . 1- Please take all medications as prescribed. Please call your doctor [First Name (Titles) ] [Last Name (Titles) ]/vomiting or fevers. . 2- Please call your psychiatrist Dr. [Last Name (STitle) 60521] at [Telephone/Fax (1) 61590] for an appointment to restart your antidepressant and anxiety medications. . Followup Instructions: . Please call your psychiatrist Dr. [Last Name (STitle) 60521] at [Telephone/Fax (1) 61590] for an appointment to restart your antidepressant and anxiety medications. . [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2179-12-31] ICD9 Codes: 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6447 }	Medical Text: Admission Date: [2167-12-19] Discharge Date: [2168-3-26] Date of Birth: [2097-12-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 4377] Chief Complaint: Transfer from [Hospital6 33] for cord compression Major Surgical or Invasive Procedure: XRT to spine History of Present Illness: 69 year old man with past medical history significant for htn, who was transferred from [Hospital3 ] Hosp on [2167-12-19] with concern for thoracic cord compression. The pt originally presented to his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] on [2167-12-15] with a complaint of low back pain and difficulty ambulating. He was sent for CT scan on [12-15] and CT scan showed a large bulky soft tissue mass 13x12 cm encasing the left kidney with extension into the pelvis, partially encasing left common iliac artery. The pt returned home on [12-15] with a prescription for Vicodin, but on [12-16] the pain in the pt's back became too severe and on [12-17] he presented to the [Hospital3 ] ED. The pt reported that since [Month (only) 1096] he had been experiencing anorexia, weight loss of 12 lbs, increasing abdominal bloating and drenching night sweats. . At [Hospital6 33] the pt's VS were 97.8, P103, RR 18, BP 143/99, POx 94%on RA. On labs drawn in the ED the pt had a WBC of 16.7, hct of 37.4, plts of 322, INR of 1.2, LDH of 3670, AST of 126, Cr of 2.6, calcium of 13.5 and uric acid of 16. The pt was admitted for management of acute renal failure, abdominal mass concerning for lymphoma and hypercalcemia. . During his OSH hospitalization the pt was found to have low back pain with difficulty ambulating and was evaluated by neurology which recommended MRI of the lumbar spine. MRI of lumbar spine showed marrow enhancement with evidence of cord compression from L1 to T11. The pt was then transferred on [2167-12-19] for further management of cord compression. . Past Medical History: Hypertension Social History: The pt is an electrician. He lives with his wife and has 4 adult children. He quit tobacco use 25 years ago. Family History: No family history of cancers, parents lived into 90's and died of "old age." Physical Exam: GENERAL: Middle-aged man in NAD, laying in bed, falling asleep occasionally during the interview. HEENT: Oropharyngx clear, poor dentition, EOMI, PERRLA, no cervical or clavicular LAD. CARDIAC: RRR no m/g/r S1, S2 nl LUNG: CTA anteriorly, no wheeze, rales or rhonchi ABDOMEN: soft, NT/ND, no hepatosplenomegaly, bowel sounds present EXT: warm, no clubbing, cyanosis or edema NEURO: A+O x3, CN II-XII intact Motor: Symmetric strength in upper extremities, absent pronator drift bilaterally, Diminished strength in bilateral lower extremities, legs in frog-leg position, unable to lift legs off bed, able to wiggle toes [Last Name (un) ]: Symmetric sensation bilateral upper and lower extremities. DERM: Left forehead lesion with hypopigmentation and two nevi Pertinent Results: Bone Marrow Biopsy [2167-12-19]: BONE MARROW EXTENSIVELY INVOLVED BY A HIGH-GRADE B CELL LYMPHOMA Immunophenotypic findings consistent with involvement by: a Lambda restricted B cell lymphoma that co-expresses CD10. Cytospin preparation of the FNA demonstrates a lymphoid population that consists of large atypical cells with high N:C ratio and some with cytoplasmic vacuoles. . MRI L spine [2167-12-30]: IMPRESSION: 1. Previously identified posterior, epidural lesion in the region of approximately T11 through L1 is not well evaluated on the current study. Repeat imaging at the T10 through L1 levels, with T1 and T2 pre- and post-gadolinium images is recommended. 2. Diffuse abnormal, heterogeneous signal seen throughout the vertebral bodies, most consistent with diffuse infiltration with lymphoma. 3. Low signal lesions consistent with previously seen lytic metastases identified within the iliac bones. . PE [2167-1-13] CT abdomen with contrast: IMPRESSION 1. Acute-appearing right lower lobe lobar and segmental pulmonary embolism. Please note, this examination was not tailored to evaluate the remainder of the pulmonary arterial vasculature. 2. Distended gallbladder containing multiple gallstones and mild pericholecystic fluid. These findings are suspicious for acute cholecystitis. If clinical concern remains for acute cholecystitis, a HIDA scan may be of diagnostic benefit. 3. Left retroperitoneal mass encasing the left kidney and ureter diagnosed by recent biopsy as B-cell lymphoma. Probably no interval change in extent or appearance compared to CT of [2167-12-29]. 4. Delayed left renal nephrogram concerning for poor renal function. Marked hydroureteronephrosis suggesting an obstructive component to the surrounding mass, likely near the UVJ. Areas of ureteral wall irregularity raise concern for local invasion as described. 5. Diverticulosis without evidence of diverticulitis. 6. Possible bone lesion right iliac bone. Brief Hospital Course: Mr. [Known lastname 14966] is a 70 year old man with past medical history significant for hypertension, who was transferred from [Hospital ] Hospitak on [2167-12-19] with concern for thoracic cord compression who was found to have mantle cell lymphoma, blastic variant. He ultimately died in the ICU secondary to a GI bleed. . During this hospitalization the following issues were addressed: . #. GI bleed: The patient was transferred to the ICU three times in the last week of his life. The last two transfers were for hematochezia/melena. During the first of GI bleeds, the decision was made for conservative management with platelets and RBC transfusions per the wishes of the family. Surgery and GI were consulted during the first bleed and the family was aware that EGD/colonoscopy were an option and the that IR would be an option if he began to bleed briskly. The family's goals at this time were to stabilize the patient so that he could be well enough to be discharged home to die. He was transferred back to the floor and the following evening had a large bloody bowel movement which prompted transfer back to the ICU. He had a brisk bleed and was transfused multiple units of RBCs, platelets, and FFP. He was then taken to IR for possible embolization. A family meeting took place and a decision was made for the patient to become DNR/DNI and CMO. He died later that morning of respiratory arrest with his family at his bedside. . # Mantle Cell Lymphoma, blastic variant: The pt had biopsy of his retroperitoneal mass on admission, and the biopsy revealed a high-grade lymphoma. Further pathology revealed likely Mantle Cell Lymphoma, blastic variant. On [2167-12-19] the pt was started on the [Last Name (un) ] protocol, and on [12-20] the pt started radiation to the spine. Radiation to the spine concluded on [2168-1-12], pt. was summarily started on [Hospital1 ] treatment for DLBCL. Developed febrile neutropenia, CT torso demonstrated no areas of abscess, pt. was started on neupogen, cefepime, vanc, and fluconazole. Counts steadily increased and the patient underwent the following regimen: ICE: Tolerated without significant issue Intrathecal Ara-C: After first round of intrathecal chemotherapy patient experienced altered mental status which did improve after one week. . # Tumor lysis syndrome: The pt was initially in acute renal failure likely secondary to tumor lysis syndrome. The pt received aggressive hydration and rasburicase. Over the first few days of admission the pt's electrolytes and uric acid returned to [Location 213] and the pt's renal function returned to baseline. . # Pulmonary Embolus: Pt. was complaining of pleuritic chest pain on [2167-1-13], localized to the right upper quadrant. Sent for Abdominal CT and incidentally found RLL embolus, started on heparin prior to cholecystecomy. Heparin stopped and then restarted post cholecystectomy and IVC filter on [2168-1-16]. Previous port site with hematoma on [2168-1-18], heparin stopped. Pt. developed hypoxia to 84% on RA and paO2 of 85 on NRB mask, pt. was to be sent to [Hospital Unit Name 153] but refused. Hypoxia and hypotension resolved, unclear as to etiology. . # Cholecystitis: Pt. was complaining of constant RUQ pain around the same time as his complaints of pleuritic chest pain. Surgery consulted, mass was felt on physical exam on RUQ. Cholecystecomy done on [2168-1-16] and a necrotic gallbladder was removed. Pt. was draining normally with no bilious liquid in JP drain, drain was removed and staples removed. Had an episode of bleeding from site while on heparin, but no other problems since heparin stopped. . Period reflecting [Date range (1) 81476]: Before the below chemotherapy regimen the patient was doing well on the floor. His mental status cleared completely and his left leg weakness did improve allowing him to walk several steps with assistive devices. Due to his speedy recovery, the decision was made to continue chemotherapy. Staging MRI of the spine was acquired prior to intrathecal therapy and did demonstrate an improvement. . Intrathecal Depocyt([3-13])/ICE([3-15]) # 2: Overnight [3-17] the patient developed fever, altered mental status, vomiting and poor cough. He was transfered to the ICU for intubation and supportive care. Cultures drawn 2 days prior during a febrile episode turned positive for yeast, later found to the [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 29361]. . AMS: The patient was admitted to the ICU in mid [Month (only) 547] for altered mental status and his work up revealed encephalitis likely secondary to chemo effects. He had an EEG consistent with encephalopathy, an MRI showing two small CVAs, and a negative LP. The patient returned to the BMT floor on [3-23] with mental status below baseline but improving and sufficient to protect his airway. Overnight, approximately 6 hours after his return he passed a large bloody bowel movement and was again transferred to the ICU. . # Cord Compression: Got XRT to spine for cord compr from L retroperitoneal mass on [12-20], 22, 23. [12-25] Rituxan (3 day course) started. Got Rituxan 1/23,[1-2] and [2168-1-17]. Mass decreased, seen by urology who decided against stent placement. L. hydronephrosis has been stable since the conclusion of radiation. . # Delirium: Spiked on [12-30], pansensi Pseudomonas and E Coli in UC, BC, on Cefepime. [12-31] PICC pulled, if spiking follow [Hospital1 18] F+N protocol. Pt. was switched to Zosyn post-cholecystectomy. Medications on Admission: Atenolol 50 daily Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased Completed by:[2168-4-5] ICD9 Codes: 5845, 2761, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6448 }	Medical Text: Admission Date: [2188-12-17] Discharge Date: [2188-12-23] Date of Birth: [2108-9-8] Sex: M Service: MEDICINE Allergies: Percocet Attending:[First Name3 (LF) 5123] Chief Complaint: somnolence, hypercarbic respiratory failure Major Surgical or Invasive Procedure: intubation and mechanical ventilation placement of left radial arterial line History of Present Illness: Mr. [Known lastname 35028] is an 80 year old man with a history of CAD s/p MI in [2181] and CABG in [2182], CHF with EF of 55% in [11-10], A. fib on warfarin, and 2 recent admissions for a right retroperitoneal abscess and right empyema which grew Pantoea spp (an Enterobacter-like bacteria) which was resistent to cefazolin and ampicillin, but sensitive to fluoroquinolones. He was treated with levofloxacin from [11-2] to [2188-11-8] for a 7 day course. Pigtail drains were placed in the retroperitoneal abscess and VATS was performed to debride the empyema. Warfarin was held to prevent bleeding. He was discharged to rehab on [2188-11-17] but readmitted on [2188-11-21] for subsegmental PE. Cultures from the residual pleural effusion and retroperitoneal mass were negative at that time. He was anticoagulated once again with Lovenox as a bridge to warfarin. That hospitalization was complicated by delirium and foley trauma. He was discharged to rehab and then home with VNA. . Today VNA found the Found to have spO2 69-80% on RA. He complained of SOB, PND, and DOE. EMS was called and he was brought to [Hospital 1562] Hospital. There, spO2 was 99% on 3L. A CXR showed the known RLL effusion as well as a possible new infiltrate in lingula. BNP was 1100, TnT was 0.17, and INR 2.5. Given the possible PNA, he was treated with azithromycin 500mg plus ceftriaxone 1g IV for CAP and transfered to [Hospital1 18] for further evaluation by Thoracic Surgery here. . On arrival to ED the patient was somnolent but easily arousable with verbal or physical stimuli. He denied and SOB or CP. Given his ongoing somnolence, an ABG was done which showed significant hypercarbia (pH 7.29 pCO2 94 pO2 81 O2Sat 95%). He was placed on BiPAP but his mental status worsened and he became unresponsive. He was intubated for hypercarbic respiratory failure. . Given his history of PE, a CTA was done which showed no PE and stable to improved RLL infiltrates. A CT of the head showed no bleed or process to explain his respiratory failure. No cultures were taken but the patient was treated empirically for HAP with vancomycin 1g IV x 1 on top of the ceftriaxone plus azithromycin received at [Hospital 1562] Hospital. Past Medical History: PMH: - Coronary artery disease s/p myocardial infarction ([4-/2181])with CABG in [2182] - Atrial fibrillation - Moderate aortic insufficiency - Moderate mitral regurgitation - Ischemic cardiomyopathy with EF 45% nuclear study [2186] - Hypertension - Hyperlipidemia - GERD - Prostate cancer [Doctor Last Name ] score 6 - Hypothyroidism - Bilateral ankle edema - Kidney stones - Right retroperitoneal abscess and right empyema, which grew Pantoea spp (a beta lactamase producing, Gram negative, Enterobacter-like bacteria) which was resistent to cefazolin and ampicillin, but sensitive to fluoroquinolones. - Segmental pulmonary embolism within the right lower lobe . Past Surgical History: - CABG [2182] - Permanent pacemaker placement [2183] - Left thoracotomy with total lung decortication ([Hospital1 18] [2183-12-5]) - Left thoracoscopy with pleural biopsy and drainage of pleural fluid ([Hospital1 18] [2183-11-10]) - Bilateral inguinal hernia repairs - Bilateral total knee replacements - Laparoscopic cholecystectomy Social History: The patient is a retired tool and dye maker; he worked around chemicals but no asbestos. He has never smoked, and occasionally drinks alcohol. He lives on [Location (un) ] with his wife for the past 20 years. Family History: Both parents died of coronary artery disease. One brother died at 72 of heart disease. Physical Exam: On Admission: GEN: Intubated and sedated. Elderly gentleman. HEENT: MMM, no obvious OP lesions. No cervical LAD. CV: Irregular rate, NL S1S2 no S3S4, II/VI SEM, JVD to the angle of the jaw PULM: Absent breath sounds in the R base, otherwise CTAB ABD: BS+, somewhat firm abdomen, nondistended, no obvious masses or HSM LIMBS: No clubbing, missing several fingers, koilinycchia SKIN: No skin break down, scattered ecchymoses NEURO: Intubated and sedated At discharge: Pertinent Results: Admission labs: 12.6 3.8--------139 40.4 . PMN 75.8 . 148 105 41 ----------------111 5.4 35 1.0 . Ca 9.4 Ph 4.1 Mg 2.2 . PT 24.4, PTT 34.2, INR 2.3 . Lactate 0.9 . TSH 35, Free T4 - . 1st CE: tropT 0.11 CK 38 2nd CE: tropT 0.15 Ck 23 . Vit B12 - Folate - Ferritin - TRF - Iron - Albumin - 3.9 . Micro:Sputum cxr - Commensal Respiratory Flora. Blood cultures - MRSA nasal screen - positive . Imaging: [12-17] CTA Chest - 1. No pulmonary embolus or acute aortic abnormality. 2. Right pleural fluid collection unchanged or slightly improved compared to the prior study. 3. No superimposed consolidation or pneumonia. . [12-17] CT Head - No hemorrhage or edema . [12-17] CXR - Cardiomegaly, right basilar effusion and consolidation . EKG: Atrial fibrillation with intermittent ventricular paced beats. ST-T wave abnormalities and intrinsic beats are non-specific. Since the previous tracing of [2188-11-8] intermittent intrinsic beats are now seen but there is probably no significant change. Brief Hospital Course: This is an 80 year-old man with s/p recent VATS and drainagae of an empyema and retroperitoneal abscess infected with Pantoea spp (an Enterobacter-like bacteria) and PE on warfarin as well as CAD s/p CABG, CHF, and Afib, admitted with hypercarbic respiratory failure. . # Hypercarbic respiratory failure: The etiology of the patient's respiratory failure is thought to be multifactorial, with likely aspiration pneumonitis in the setting of the patient's underlying lung abnormalities (right pleural effusion, PE, retroperitoneal abscess) and hypothyroidism (TSH 35) all contributing. Although the patient's respiratory failure was initially though to be infectious in origin, and he was treated with Vancomycin Flagyl and Levofloxacin for aspiration pneumonia (given his history of aspiration--see speech and swallow notes--as well as his recent history of hospitalization, rehab and empyema + retroperitoneal abscess growing Pantoea spp), antibiotics were discontinued after 2 days when the patient failed to spike a fever, become hypoxic or develop any significant leukocytosis or infiltrate on chest xray. He was intubated and mechanically ventilated for one day, and was extubated without difficulty. Although the OSH was concerned about CHF, the patient did not become hypoxic at any point and had no crackles on exam or evidence of CHF on xray. Based on the patient's ABGs, he seems to be somewhat of a chronic retainer (possibly due to pulmonary physiology s/p effusions and empyema and abscess and surgeries) and his pCO2 settled out at approximately 54. After transfer to the floor he never required supplemental oxygen, worked easily with physical therapy and had a rather uncomplicated hospital course. . # Aspiration - The patient was evaluated by video swallow, which showed aspiration with straw sips of thin liquids; penetration with cup sips of thin liquids. Speech and swallow therapy recommended: 1. PO diet: regular solids, nectar thick liquids during meals; 2. Between meals, pt may have single sips of water, coffee, and ensure shakes 3. TID oral care; 4. Assist with meals as needed to maintain aspiration precautions, including: a) sit fully upright for all PO b) swallow twice per bite/twice per sip c) no guzzling - single sips only 5. Repeat videoswallow study in [1-4] weeks either as an outpatient. . # Pulmonary embolus: The patient was diagnosed [2188-11-22] with Segmental pulmonary embolism within the anterior basal segment of the right lower lobe pulmonary artery. Warfarin as an outpatient. Admission CTA showed no further PE. Although initially held, the patient was started back on Warfarin while hospitalized. He should continue this for the previously prescribed duration at home. -He must bridge to an INR of 2.0 -lovenox 80mg sc bid until then . # CAD: S/p CABG in [2182], chronically in Afib. Ventricularly paced. The patient was continued on his home medications--aspirin, pravastatin, and metorprolol. His cardiac enzymes were cycled without elevations, and he was monitored on telemetry without events. On the floor he did not require tele. . # Hypothyroidism: The patient's TSH was found to be 35. His Free T4 was 0.95. His Levothyroxine was increased from 75mcg daily to 100mcg daily. His TSH will need to be re-checked in 1 month. It should be noted that this may simply reflect increased recent compliance (as TSH lags behind free T4) or sick euthyroid, and should be followed closely as an outpatient. . Medications on Admission: Home Medications: (per most recent DC summary) - Acetaminophen 325 -650 mg PO Q6H PRN:pain - Aspirin 325 mg PO DAILY - Carvedilol 3.125 mg PO BID - Enoxaparin 80 mg SQ Q12H - Furosemide 40 mg PO DAILY - Levothyroxine 75 mcg PO DAILY - Lisinopril 10 mg PO DAILY - Metoprolol Tartrate 50 mg PO BID - Omeprazole 20 mg PO DAILY - Pravastatin 80 mg PO DAILY . [Hospital 1562] Hospital Medications: - Aspirin 325mg PO dailg - Colace 100mg PO BID - Levothyroxine 75mcg PO daily - Pravastatin 80 mg PO daily - ASA 325mg PO daily - Metoprolol Tartrate 50mg PO daily - Remeron 15mg PO HS - Warfarin 5mg PO QPM - ProAir HFA albuterol IH PRN - Acetaminophen 650mg PO PRN - Miralax 17g PO PRN - Azithromycin 500mg PO x 1 - Ceftriaxone 1g IV x 1 Discharge Medications: 1. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours): until INR>2.0. Disp:8 Syringes Refills:4 2. Hospital Bed Indication: Aspiration Pneumonia/Pneumonitis 3. [3-2] Commode per PT/OT recs 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 100 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 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 10. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. 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 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Primary: 1. respiratory failure 2. hypothyroidism 3. aspiration Secondary: 1. pulmonary embolism 2. atrial fibrillation 3. coronary artery disease Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital for respiratory failure. Although you were intubated for a little while in the ICU, you were extubated without complication. We think you likely aspirated (breathed down GI contents) prior to your admission. These problems quickly resolved while you were in the ICU and your antibiotics were stopped. While you were in the ICU you were on antibiotics and your Coumadin was lowered to 2mg, we restarted your home dose of 5, however your INR was low at 1.6. You need to have this followed up on Thursday in coumadin clinic. The following changes were made to your home medications: You were started on Lovenox 80mg subcutaneous injection twice oer day as you were taught in the hospital You were re-started on your home lasix for your leg swelling. This is only until your INR is greater than 2 as checked by your VNA. You were started on pantoprazole 40mg daily for your GI upset Your synthroid was changed to 100ug daily. Followup Instructions: Thursday in your home coumadin clinic. Monday with your PCP [1-30] with your home Urologist Completed by:[2189-1-12] ICD9 Codes: 5070, 4271, 2760, 4280, 2449, 412, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6449 }	Medical Text: Admission Date: [2149-8-29] Discharge Date: [2149-9-9] Date of Birth: [2079-1-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3283] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 70yo man with diabetes mellitus type 2, CAD, 140 pack year smoking history, who was transferred at the request of his PCP from the [Hospital6 33] ICU to the [Hospital1 18] MICU Friday [2149-8-29] for continued treatment of respiratory distress requiring supplemental O2, labile blood sugars, and a new lung mass found on CT. One week prior to admission to [Hospital3 ] he developped a non-productive cough, fevers, and increased fatigue. He had a 10 pound unintentional weight loss over the past 1-2 months. On Monday [2149-8-25] he was found unresponsive at home with a FSBG of 21. He was working in his yard when he felt dyspneic and fatigued and sat down. He lost consciousness and awoke on the ground. He called a friend and EMS arrived shortly. . In the [Hospital6 33] ED he received glucagon and his glucose increased to 70. CXR revealed eosinophilic v. atypical PNA v. inflammation from COPD exacerbation, so he was started on Levaquin and Solumedrol and admitted. His BNP was elevated to 9248 and he was diuresed with Lasix 40 mg IV BID. On [2149-8-27] a chest CT demonstrated a 4 cm spiculated mass in the LLL and hilar and mediastinal lymphadenopathy. While on steroids, he became hyperglycemic and he was transferred to the MICU for insulin gtt. In the MICU he became hypoxic and was placed on a NRB. CXR demonstrated bilateral airspace disease, pulmonary edema, and possible atypical PNA. On transfer to the [Hospital1 18] MICU on [8-29], his SOB was slightly improved, but he felt fatigued. Past Medical History: -CAD, s/p CABG in [2131], (LIMA to LAD, SVG to RCA, SVG to OM1, SVG to D1) -PCI in [2142] with stenting of SVG to RCA and PDA -Diabetes requiring insulin, complicated by peripheral neuropathy, retinopathy -Hypertension -Hyperlipidemia -Peripheral vascular disease -Insomnia -GI bleed secondary to peptic ulcer disease -Chronic gastritis -Depression -Status post AAA repair in [2131] -Status post aorto-popliteal bypass Social History: Married for 20 years. Worked as a machinist for [Company 2318], served in the NAVY. Now retired. Reports exposure to asbestosis working for [Company 2318] on a daily basis for 10 years. Never used mask or ventilator. Tobacco: 140 pack year history, smoked 3.5 ppd, quit 14 years ago. History of alcohol abuse, sober for 37 years. Family History: Father died of asbestosis (worked in shipyards). Mother died of COPD. CAD strong in family. Physical Exam: V/S: HR: BP: RR:18 02sat: 95% on 2 L/min)2 General: Awake and alert, lying in bed, pleasant, in no acute distress HEENT: Normocephalic and atraumtic, sclera anicteric, oral and nasal mucosa pink and without exudates Neck: full range of motion, no lymphadenopathy, no JVP seen with head of bed elevated to 30 degrees, no thyromegaly or thyroid nodules Lungs: Diffuse rales bilaterally to halfway up lung fields, no expiratory wheezes, no rhonchi, no friction rubs, no squeaks CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Midline scar, non-distended, normoactive bowel sounds, soft, non-tender, no guarding, no organomegaly GU: not examined Ext: No edema, warm, well perfused, radial and dorsalis pedis arteries have 2+ pulses bilaterally, + clubbing of fingernails, no edema of lower extremities Neuro: CN 2-12 intact, decreased sensation to light touch below knees, ... Pertinent Results: [2149-8-29] 05:02PM BLOOD WBC-18.8# RBC-3.66 Hgb-9.7* Hct-30.2* MCV-83 MCH-26.5* MCHC-32.1 RDW-15.7* Plt Ct-390 [2149-9-1] 01:10PM BLOOD WBC-16.3* RBC-3.81* Hgb-10.3* Hct-32.2* MCV-84 MCH-27.1 MCHC-32.1 RDW-14.7 Plt Ct-374 [2149-9-5] 02:44PM BLOOD WBC-20.6* RBC-3.79* Hgb-9.8* Hct-31.0* MCV-82 MCH-25.9* MCHC-31.6 RDW-15.6* Plt Ct-530* [2149-9-7] 07:20AM BLOOD WBC-27.5* RBC-3.38* Hgb-8.7* Hct-27.8* MCV-82 MCH-25.7* MCHC-31.3 RDW-15.0 Plt Ct-550* [2149-9-8] 03:41AM BLOOD WBC-23.7* RBC-3.23* Hgb-8.4* Hct-26.5* MCV-82 MCH-26.2* MCHC-31.9 RDW-16.2* Plt Ct-492* [2149-9-9] 06:40AM BLOOD WBC-30.6* RBC-2.97* Hgb-7.6* Hct-25.1* MCV-85 MCH-25.6* MCHC-30.3* RDW-15.3 Plt Ct-429 [2149-9-5] 07:35AM BLOOD PT-12.1 PTT-31.2 INR(PT)-1.0 [2149-9-5] 02:44PM BLOOD PT-13.3 PTT-150* INR(PT)-1.1 [2149-8-29] 05:02PM BLOOD Glucose-172* UreaN-39* Creat-1.2 Na-138 K-3.8 Cl-104 HCO3-23 AnGap-15 [2149-9-9] 12:40PM BLOOD UreaN-57* Creat-1.5* K-5.2* [2149-9-5] 02:44PM BLOOD CK(CPK)-397* [2149-9-9] 06:40AM BLOOD CK(CPK)-4146* [2149-9-9] 12:40PM BLOOD CK(CPK)-3956* [2149-9-9] 06:40AM BLOOD Calcium-7.6* Phos-5.9# Mg-2.1 [2149-9-2] 04:49PM BLOOD [Doctor First Name ]-NEGATIVE [2149-9-2] 04:49PM BLOOD ANCA-NEGATIVE B [2149-9-5] 03:21PM BLOOD Type-ART pO2-55 pCO2-40 pH-7.44 calTCO2-28 Base XS-2 Intubat-NOT INTUBA [2149-9-5] 03:21PM BLOOD Glucose-159* Lactate-2.2* Na-133* K-4.1 Cl-96* CT Chest [2149-9-2]: IMPRESSION Pulmonary fibrosis associated with emphysema. Left lower lobe lung mass, malignant until proven otherwise. Cytology Sputum (expectorated) [2149-9-3]: POSITIVE, CONSISTENT WITH SQUAMOUS CELL CARCINOMA. LENI [2149-9-4]: CONCLUSION: 1. No ultrasound evidence of above-knee deep venous thrombosis in relation to either lower limb. 2. There is significant thrombus identified within the right popliteal artery, which is almost completely occluded. There is, however, some peripheral flow identified. The popliteal artery is non-aneurysmal on the right. 3. There is a small [Hospital Ward Name 4675] cyst seen on the right. ART Ext [2149-9-5]: IMPRESSION: Severe right lower extremity ischemia with absent ankle signals and flat PVRs. Mild/moderate left lower extremity occlusive disease with evidence of aortoiliac and tibial occlusive disease. There is a significant deterioration on the right compared to 4/[2149]. CT Abd/Pelvis CT Angiogram [2149-9-5]: IMPRESSION: 1. Aortobifemoral graft remains patent. 2. Occlusion of right fem-[Doctor Last Name ] bypass close to its proximal origin. No previous imaging is available to determine the chronicity of occlusion. 3. Patent bypass from the left common femoral artery to left anterior tibial artery. 4. Diffuse interstitial lung disease and left lower lobe mass as identified on prior CT. 5. Marked distention of the urinary bladder. CT Head w/ & w/out contrast [2149-9-5]: IMPRESSION: Mild brain atrophy and old lacunar infarct in the right thalamus, unchanged. No contrast CT evidence of metastatic disease to the brain. CXR [2149-9-7]: FINDINGS: In comparison with the study of [9-6], there is little overall change. Again there are diffuse reticular markings more prominent on the right. Cardiac size remains within overall normal limits. The radiographic findings are again consistent with severe pulmonary fibrosis, possibly complicated by asymmetric pulmonary edema. Brief Hospital Course: 70 yo M with h/o CAD s/p CABG, IDDM, and recently identified emphysema, pulmonary fibrosis, & LLL lung mass, who presents with respiratory distress and hypoglycemia. . #. Respiratory Distress: On admission, the patient was admitted to the MICU where his presenting symptoms of dyspnea, cough, & hypoxia (<90%) had improved with inhaled bronchodilators, steroids, O2, and Levaquin. On [8-31], he was transferred to the general medicine floor with a decrease in his supplemental O2 needs from 6L to 4L NC and a good response to IV Lasix. He completed his course of Levaquin and an aggressive taper of Prednisone while continuing to receive Lasix, Albuterol, and Ipratroprium nebs. His O2 nasal cannula was weaned to 3L of O2 at ~92%. The pulmonary team was consulted and request a CT to further evaluate his pulmonary disease. The CT demonstrated paracentral and centrilobular emphysema in the upper lobes with extensive ground glass opacities and peripheral interstitial lung abnormalities in the right lung and the left lower lobe. It also showed a 6mm anterior right upper paratracheal lymph node and a 1.9 by 1.2mm right lower paraesophageal lymph node. Finally, a 4cm mass was seen in the left lower lobe of the lung, consistent with malignancy. The etiology of his interstitial lung disease was unknown and he was scheduled to receive a bronchoscopy for further evaluation, but this was cancelled after the patient continued to trigger for hypoxic episodes with O2 sats to the high 60's-low 70's on 3L's. These episodes of hypoxia were complicated by poor surveillance due to PVD. As a result of his hypoxia in conjunction with other medical concerns (right popliteal thrombosis), his bronchoscopy was cancelled. He continued to require 3L's of O2 and was discharged to home on 3L of oxygen and inhaled bronchodilators. . # Right popliteal artery thrombosis: On [9-4], Mr. [Known lastname 19122] had an episode of [10-25] sudden onset right calf pain following a physical exam earlier in the day that was positive for dorsalis pedis pulses bilaterally. At the time of pain onset, the patient's right leg was cooler than the left with a thready pulse. LENI's were obtained and he was found to have a nearly occlusive right popliteal artery. He was started on a heparin gtt and Vascular surgery was consulted. They were unable to obtain dopplerable pulses in the right foot and despite the heparin gtt the patient's foot worsened. Given his poor pulmonary status and new diagnosis of malignancy, vascular declined intervention. The patient additionally refused amputation. As a result of the arterial thrombosis, his CK levels became elevated (4000's) and his Cr began to rise. After a discussion with the team about the progression of the disease, the patient made himself DNR/DNI. After <24 hours in the MICU for nursing needs, Palliative care was consulted and both the patient and his wife requested that he be allowed to return home on hospice. He was discharged to home on hospice with IVF's to minimize the kidney damage caused by impending rhabdomyolosis, SC Heparin 4 times daily to minimize the pain from his leg, and pain medications. . # DM2: The patient has IDDM, for which he uses an insulin pump at home. He has had frequent admissions to [Hospital6 ] over the past few months for hypoglycemia, and he was briefly in the MICU at OSH for hyperglycemia [2-17] steroids. On admission to the [Hospital1 18], he continued to have episodes of hypo and hyperglycemia requiring an insulin gtt in the MICU. He improved on this regimen and was transferred to the floor on his home NPH 38u [Hospital1 ] and Humalog sliding scale. On [8-31] after transfer to the floor, his FSG was 34 in the AM. [Last Name (un) ] was consulted and recommended changing his regimen to Lantus with a Humalog sliding scale. This scale was refined in keeping with his decreasing steroid regimen. As a result, his blood sugars ranged from 150-300's, but he had no further episodes of hypoglycemia or extreme hyperglycemia. Mr. [Known lastname 19122] was discharged on 18u of Lantus qHS and a Humalog sliding scale. . # Pulmonary Nodule: The patient was found to have a 4 cm pulmonary nodule in his LLL on CT at an OSH. This was concerning for cancer, given his extensive smoking history, asbestos exposure, and clinical history of weight loss and fatigue. A repeat CT was performed at the [Hospital1 18] per Pulmonology work-up and confirmed this 4 cm mass in the left lower lobe. An expectorated sputum culture was also sent that was positive for squamous cell carcinoma on [9-4]. The patient and his family was told of the diagnosis on [9-5], but given his other medical concerns, specifically his arterial thrombosis of the right leg, there was no further work-up of the cancer as an inpatient. The patient was discharged to home on hospice for his leg complications, so outpatient oncology follow-up was not scheduled. . # CAD: The patient has a history of CAD, s/p CABG in [2131]. He is currently followed by Dr. [First Name (STitle) 437] in cardiology. He denies chest pain and had MI work up at OSH, and recent TTE showed EF 55%. As an inpatient, his [Last Name (LF) ], [First Name3 (LF) ], and Carvedilol were continued and he was discharged on these medications. . # Depression: The patient has a history of depression, for which he takes Cymbalta and Sertraline at home. Cymbalta was recently discontinued, as OSH was concerned for eosinophilic pneumonia, but was restarted as an inpatient based on his clinical presentation and progression. He was discharged to home on this medication. . Mr. [Known lastname 19122] was admitted as FULL CODE, but became DNR/DNI during this inpatient hospitalization and he was discharged to home with hospice. Medications on Admission: Medications at home: [Known lastname ] 80 mg daily Coreg 12.5 mg [Hospital1 ] Cymbalta 30 mg daily Lisinopril 5 mg daily, Neurontin 600 mg three times daily Zoloft 75 mg daily Aspirin 81 daily. . Medications on transfer from OSH: Dextrose 50% 25 mL prn Glucagon 1 mg prn Zolpidem 5 mg qhs prn Albuterol 2.5 mg nebulization q6h Aspiring 81 mg daily Atorvastatin 80 mg daily Carvedilol 25 mg [Hospital1 ] Enoxaparin 40 mg daily (prophylactic dose) Furosemide 40 mg IV BID Gavapentin 600 mg TID Lispro Insulin SS Ipratropium nebulization q6h Levofloxacin 500 mg IV daily Methylprednisolone IV 60 mg q8h Pantoprazole 40 mg daily Sertraline 75 mg daily Discharge Medications: 1. Home Oxygen Continuous pulsed oxygen at 3 liters a minute 2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. Disp:1 inhaler Refills:2 11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) disk Inhalation twice a day. Disp:1 inhaler Refills:2 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:30 Tablet(s) Refills:2 13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. Disp:1 month supply Refills:2 14. Humalog Pen 100 unit/mL Insulin Pen Sig: One (1) sliding scale dose Subcutaneous qACHS: Please refer to your sliding scale for dosing of insulin. Disp:1 month supply Refills:2 15. Insulin Needles (Disposable) Needle Sig: One (1) needle Miscellaneous qACHS. Disp:1 month supply Refills:2 16. [Hospital 485] Hospital Bed Dx: Respiratory Failure 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 3750 (3750) units Injection every six (6) hours. Disp:2 week supply Refills:10 Discharge Disposition: Home With Service Facility: Hospice of the [Hospital3 ] Discharge Diagnosis: Primary: Chronic obstructive pulmonary disease, Diabetes Mellitus Type II, Squamous cell carcinoma of the lung, Right popliteal artery occlusion Rhabdomyolysis Coronary artery disease, Dyslipidemia, Depression, Hypertension, Peripheral vascular disease Discharge Condition: Improved. Oxygen saturation 95% on 3L. Right leg cool. Discharge Instructions: You were admitted to the hospital due to an episode of respiratory distress and low blood sugars. While you were in the hospital, you were placed on oxygen and several inhaled medications to improve your breathing. You were also given a short course of oral steroids to reduce the inflammation in your lungs in order to ease your shortness of breath. Out of concern for infection, you were placed on a regimen of antibiotics that you completed in the hospital. Pulmonologists were consulted to assess your respiratory distress and requested a CT scan of your chest. It revealed evidence of emphysema as well as some fibrosis of the lungs. They recommended that you be discharged to home on oxygen and some inhaled medications to support your breathing. The CT of the scan also revealed a mass in the left lobe of the lung concerning for malignancy. A sputum culture obtained during this admission, confirmed a diagnosis of squamous cell cancer of the lung. There were no interventions made on the cancer while you were here. While you were in the hospital, your blood glucose levels continued to fluctuate. The diabetes specialists from [Last Name (un) ] Diabetes Center evaluated you and recommended that you switch your home NPH insulin to a once nightly dose of a different kind of insulin called Lantus and that you replace your insulin pump with individual injections of insulin before meals. You were given teaching about how to use this insulin at home, so please continue to follow this new insulin regimen. A home visiting nurse will be able to monitor your blood glucose levels once you were at home. . Also, while you were in the hospital, you had pain your right leg that was determined to be a block in an artery in your leg. You were put on a medication to thin the blood and help prevent additional clots. Vascular surgery examined you and did not believe that surgery would be able to restore the blood supply to the lower leg. The physicians spoke with you and determined that you were not interested in an amputation of the lower leg. As a result, you were continued on blood thinners and intravenous fluids to help flush enzymes from the damaged leg out of your body so that they would minimize harm to your kidneys. You are being sent home with a plan to continue to receive fluids at home. At home, you will not be able to walk on your leg, so you will have assistance at home to aid with moving from place to place. . Medications: The following changes were made to your medication regimen, 1. Oxygen: In the hospital, you were placed on oxygen to aid your breathing and maintain an adequate oxygen level in your blood. Please continue to use this oxygen at home when you are active or if you feel short of breath. 2. Albuterol, 1-2 puffs every 4 hours as needed: This medication is used to help with shortness of breath. If you have shortness of breath, you should use this medication and can take it up to every 4 hours as needed. If you are not short of breath, you do not need to take this medication. 3. Advair 1 puff twice a day: This medication is also to help with your breathing. Please take this twice a day as directed. Please continue to take this medication each day even if you are not feeling short of breath as its effect is long-term. 4. Spiriva 1 puff once a day: This medication was also prescribed to help your shortness of breath. Please continue to take this medication once a day even if you are not feeling short of breath. 5. Lasix, 20mg twice daily: In the hospital, you were placed on a medication called Lasix to help remove excess fluid from your body. Please continue to take this medication as directed until you follow-up with your primary care physician. 6. Lantus, 20 units each night: This medication is an insulin to replace your previous dose of NPH. Please give yourself 20 units of Lantus once a night. . If you have any new shortness of breath or difficulty breathing, chest pain or pressure, lightheadedness, dizziness, or feelings like you might lose consciousness, please call your hospice or your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Followup Instructions: You may follow-up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], on [9-18] at 11:40am, if needed. ICD9 Codes: 486, 3572, 4019, 2724, 311, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6450 }	Medical Text: Admission Date: [2167-2-27] Discharge Date: [2167-3-4] Date of Birth: [2139-8-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac cath History of Present Illness: MR. [Known lastname 10113] is a 27 yo M with ADHD who presented with sscp while doing judo. He describes being in his usual state of health until today at 7PM at which time he had acute substernal chest pain. He felt as though he'd been punched in the chest with the pain a 12 out of 10 in severity. The pain was not improved with resting and associated with nausea and dizziness. When the pain persisted until 1 AM, he called his mother and then went to the ER. He does not recall having previous episodes of pain such as this and has had no exertional symptoms ever. . Upon arrival the patient had vitals of 96.9 164/81 71 16 100 % RA. He had an ECG which showed a STEmi. aspirin 324 mg was given as well as plavix 600 mg x 1, heparin bolus (6000), integrillin bolus and nitro gtt. . While in the lab the patient was found to have a nonocclusive thrombus in the LAD which was intervened upon with thrombectomy and IC reapro, nicardipine. The angiojet thrombectomy was complicated by a vagal episode that resolved spontaneously. . 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. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for ?dyspnea on exertion but the absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: ADHD intermittent hematuria [3-9] ureterocoeles s/p excision Obstructive sleep apnea Social History: Patient lives with 2 roommates in [Hospital1 ]. He is unemployed and recently graduated Americorps. He had never smoked, drank or used IVdrugs Family History: No family history of early MI, or scdotherwise non-contributory Physical Exam: Date and time of exam: [2167-2-27] 6:00 General appearance: Alert and oriented x 3 Height: 70 Inch, 178 cm BP right arm: 127 / 88 mmHg T current: 97.6 C HR: 74 bpm RR: 15 insp/min O2 sat: 98 % Eyes: (Conjunctiva and lids: WNL) Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and palette: WNL) Neck: (Right carotid artery: No bruit), (Left carotid artery: No bruit), (Jugular veins: Not visible), (Thyroid: WNL) Respiratory: (Effort: WNL), (Auscultation: WNL) Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1: WNL, S2: physiologically split, S3: Absent, S4: Absent) Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No), (Pulsatile mass: No), (Hepatosplenomegaly: No) Genitourinary: (WNL) Femoral Artery: (Right femoral artery: mild tenderness medially with small area of blood on gauze, No bruit), (Left femoral artery: No bruit) Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery: Right: 2+, Left: 2+), (Posterior tibial artery: Right: 2+, Left: 2+), (Edema: Right: 0, Left: 0) Skin: ( WNL) Pertinent Results: LABS ON ADMISSION: . [2167-2-27] 01:50AM WBC-8.9# RBC-5.24 HGB-15.2 HCT-44.0 MCV-84 MCH-29.0 MCHC-34.5 RDW-14.0 [2167-2-27] 01:50AM NEUTS-82.6* LYMPHS-13.3* MONOS-3.1 EOS-0.6 BASOS-0.3 [2167-2-27] 01:50AM GLUCOSE-98 UREA N-13 CREAT-1.2 SODIUM-138 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 . Cardiac enzymes: [2167-2-27] 01:50AM BLOOD cTropnT-0.04* CK(CPK)-398* [2167-2-27] 05:38AM BLOOD cTropnT-0.27* CK(CPK)-751* CK-MB-38* MB Indx-5.1 [2167-2-27] 11:13AM BLOOD CK(CPK)-1257* CK-MB-86* MB Indx-6.8* [2167-2-27] 09:15PM BLOOD CK(CPK)-1210* [2167-2-28] 06:25AM BLOOD cTropnT-1.12* CK(CPK)-889* CK-MB-41* MB Indx-4.6 [2167-3-1] 05:41AM BLOOD cTropnT-1.03* CK(CPK)-440* CK-MB-8 . HYPERCOAGULABILITY WORKUP: [2167-2-27] 03:49PM BLOOD Anticardiolipin IgG-2.5 Anticardiolipin IgM-9.5 (normal) [2167-2-27] 09:49AM BLOOD Protein C - 98, Protein S - 82 (normal) [2167-2-27] 05:38AM BLOOD FACTOR V LEIDEN - NEGATIVE [2167-2-27] 05:38AM BLOOD [Doctor First Name ]-NEGATIVE dsDNA-NEGATIVE [2167-3-2] 12:40PM BLOOD PROTHROMBIN MUTATION ANALYSIS- PENDING . TOX: [2167-2-27] 05:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2167-2-28] 08:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2167-2-28] 08:55AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG . URINE BENZOYLECGONINE (Cocaine metabolite) - PENDING . LABS ON DISCHARGE: [2167-3-3] 06:40AM BLOOD WBC-5.8 RBC-4.83 Hgb-13.6* Hct-40.9 MCV-85 MCH-28.3 MCHC-33.4 RDW-14.3 Plt Ct-494* [2167-3-4] 06:20AM BLOOD PT-14.6* PTT-33.0 INR(PT)-1.3* [2167-3-3] 06:40AM BLOOD Glucose-85 UreaN-13 Creat-1.2 Na-138 K-4.8 Cl-102 HCO3-30 AnGap-11 . [2167-2-27] EKG: Sinus rhythm. Inferior Q waves with ST segment elevation and lateral precordial ST segment elevation. Consider inferolateral infarction. No previous tracing available for comparison. Clinical correlation is suggested. . [2167-2-27] Echo: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with mild apical hypokinesis. The remaining segments contract normally (LVEF = 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) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. No intracardiac thrombus seen. . . . CARDIAC: . Cath ([2-27]) COMMENTS: 1. Coronary angiography of this left dominant system revealed single vessel thrombus without visualized coronary artery stenoses. The LMCA appeared normal. The LAD had a significant amount of nonocclusive thrombus in the first third of the vessel with slow flow throughout the vessel. The LCx had no significant disease. The RCA was a small, nondominant vessel without significant disease. 2. Limited resting hemodynamics revealed normal systemic arterial blood pressure (SBP 123 mm Hg). 3. Left ventriculography was deferred. 4. Successful thrombectomy with both the export catheter and the Angiojet device. Final angiography revealed some residual thrombus which was improved and improved distal flow. 5. Right femoral arteriotomy was closed with a 6 French Angioseal device. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal ventricular function. 3. Successful thrombectomy of the LAD thrombus. . . CAT ([3-2]) COMMENTS: 1- Selective angiography of the left coronary artery reevaled short but patent LMCA. The thrombotus in the proximal LAD hasd largely resolved with mild non-obstructive residual mural thrombus. The LAD is a large vessel that wraps around teh apex and supplies the inferior wall. Contrary to the completion angiogram (performed [2167-2-27]), the apical LAD is now patent with TIMI III flow but significant residual thrombus burden seen. The LCX was a dominant vessel without angiographic lesions. The RCA was not injected (known to be small non-dominant vessel). 2- Limited hemodynamic assessment revealed normal systemic aretrial pressure (105/72 mmHg). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Patent LAD throughout with very mild mural thrombus proximally (was near occluded on the initial angiogram) and significant non-occlusive thrombus at the apical LAD with TIMI III flow down taht segment (had no flow on the previous angiogram). Brief Hospital Course: Mr [Known lastname 10113] is a 27 yo M with ADHD (on methylphenidate before), admitted w acute coronary thrombosis causing STEMI now s/p thrombectomy. . # STEMI: Patient presented with chest pain and was found to have an ST-elevation myocardial infarction. He went to the cath lab where he was found to have an LAD thrombus that was thrombectomized. He had no other sign of atherosclerotic coronary disease. Medical therapy was undertaken including integrilin and heparin drips, aspirin, plavix, atorvastatin, and beta blocker titrated to heart rate of 60. Repeat cath showed a distal LAD thrombus, separate from the previous one. Hence pt was started on coumadin (w lovenox as a bridge). Goal is to keep coumadin for [4-10] mos. . Regarding the cause of the event, his only risk factor was obesity and obstructive sleep apnea. Tox screen was negative, though urine benzoylecgonine (cocaine metabolite) is pending on discharge. Methylphenidate use was also considered as a potential cause, given case reports of its association with MI. Lipid panel was normal (LDL 116). Hypercoagulable and autoimmune workup were negative, though Prothrombin mutation analysis is pending on discharge. . # PUMP: Patient was euvolemic on exam. Echo demonstrated LV ejection fraction of 55% with mild regional left ventricular systolic dysfunction and mild apical hypokinesis. . # RHYTHM: Rhythm was sinus. . # ADHD: Methylphenidate was discontinued out of concern for causing myocardial infarction. He was no treatment for now, can follow up with psych as outpatient, no outpatient psych at this time. . # Obstructive sleep apnea: untreated at this point per patient . Medications on Admission: methylphenidate 54 mg Qday Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 6 months. Disp:60 Tablet(s) Refills:0 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 6 months. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day. Disp:30 Tablet(s) Refills:0 6. Metoprolol Succinate 100 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:0 7. Outpatient Lab Work Please check INR. Please fax results to [Company 191] [Hospital 3052]: [Telephone/Fax (1) 2173] 8. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:14 syringe Refills:0 9. Outpatient Lab Work Please have your INR checked on Friday, [3-6], and fax the results to [Company 191] Anticoagulation Management Services @ ([Telephone/Fax (1) 10845]. Discharge Disposition: Home Discharge Diagnosis: primary: ST-elevation myocardial infarction secondary: attention deficit hyperactivity disorder, obstructive sleep apnea Discharge Condition: stable, free of chest pain Discharge Instructions: You came to the hospital because you had chest pain, and you were found to have had a heart attack. You were given medications to help open up the arteries to your heart. Several medications were started that you will need to continue at home for your heart. Your methylphenidate was stopped because it may have contributed to the heart attack. You should talk with your doctor about whether this medication can be restarted or whether there might be another option for your ADHD. . Because you will need to be taking a blood thinner (warfarin) for 3-6 months, you will need to have your blood tested periodically. Please go to the [Hospital1 2025] outpatient lab with the attached prescription on Thursday, [3-5]. The [Company 191] anticoagulation nurses will then call you to tell you if you need to adjust your warfarin dose. . Please return to the emergency room if you have recurrent chest pain, shortness of breath, high fevers and chills, or other symptoms that are concerning to you. Followup Instructions: Please follow up with your primary care physician: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2167-4-1] 10:30 . You also have an appointment to follow up with a cardiologist: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2167-3-18] 1:00 Completed by:[2167-3-4] ICD9 Codes: 4271
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6451 }	Medical Text: Admission Date: [2101-4-15] Discharge Date: [2101-4-19] Date of Birth: [2024-10-9] Sex: F Service: ORTHOPAEDICS Allergies: Cortisone / Niacin / Percocet / Hydrocodone Attending:[First Name3 (LF) 8587] Chief Complaint: left knee pain, nonunion Major Surgical or Invasive Procedure: [4-15]: Revision Left total knee arthroplasty with distal femoral replacement and hardware removal History of Present Illness: Ms. [Known lastname 19704] is a very pleasant 76-year-old female with a history of coronary artery disease, hypertension, gout, hypothyroidism and bilateral knee osteoarthritis treated with total knee replacement in [2087]. She sustained a left distal femoral periprosthetic fracture in [2099-10-29]. This was treated with open reduction and internal fixation with [Initials (NamePattern4) ] [Last Name (NamePattern4) 101] plate by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Despite anatomic reduction, a nonunion developed at the distal femoral fracture site. She was experiencing ongoing distal femoral pain while ambulating. CT was consistent with a nonunion. Preoperative knee aspiration confirms no evidence of infection and ESR and CRP were normal. The decision was made to proceed with a revision total knee replacement with resection of the fractured distal femur and reconstruction with a distal femoral replacement. Past Medical History: CAD S/P Stent([2097-11-28]) L TKR([2087]) elivated cholesterol HTN Gout Hypothyroid Social History: Lives with husband Family History: n/a Physical Exam: Upon Discharge: AVSS NAD NCAT RRR, S1S2 CTAB Soft, NTND LLE - incision is c/d/i. +DP pulse. NVI in distribution of [Last Name (un) 938]/Gastroc/TA. SILT. There is normal post-operative swelling. Minimal erythema. Hinged knee brace in place. Pertinent Results: [2101-4-15] 09:18PM BLOOD WBC-10.9# RBC-3.21* Hgb-9.5* Hct-26.4* MCV-82 MCH-29.5 MCHC-35.9* RDW-13.8 Plt Ct-153 [2101-4-16] 02:13AM BLOOD WBC-8.6 RBC-3.52* Hgb-9.8* Hct-28.0* MCV-79* MCH-27.8 MCHC-35.0 RDW-15.8* Plt Ct-128* [2101-4-16] 12:12PM BLOOD Hct-24.3* [2101-4-16] 03:48PM BLOOD Hct-26.2* [2101-4-17] 09:40AM BLOOD WBC-9.0 RBC-3.09* Hgb-9.0* Hct-25.5* MCV-83 MCH-29.1 MCHC-35.2* RDW-16.0* Plt Ct-93* [2101-4-18] 06:25AM BLOOD WBC-7.3 RBC-2.94* Hgb-8.7* Hct-24.3* MCV-83 MCH-29.7 MCHC-35.9* RDW-15.5 Plt Ct-100* [2101-4-19] 07:00AM BLOOD WBC-6.1 RBC-3.74# Hgb-10.9# Hct-30.9# MCV-83 MCH-29.1 MCHC-35.1 RDW-15.2 Plt Ct-134* [2101-4-15] 06:40PM BLOOD PT-14.5* PTT-32.2 INR(PT)-1.3* [2101-4-15] 09:20PM BLOOD PT-14.9* PTT-31.9 INR(PT)-1.3* [2101-4-15] 09:18PM BLOOD Glucose-112* UreaN-19 Creat-0.9 Na-143 K-3.9 Cl-112* HCO3-24 AnGap-11 [2101-4-16] 02:13AM BLOOD Glucose-133* UreaN-19 Creat-0.8 Na-141 K-3.9 Cl-111* HCO3-24 AnGap-10 [2101-4-17] 09:54AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-141 K-3.4 Cl-106 HCO3-28 AnGap-10 [2101-4-16] 02:13AM BLOOD Calcium-8.3* Phos-4.0 Mg-1.8 [2101-4-17] 09:54AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.9 Left knee xrays [4-18]: FINDINGS: There has been total revision of the total knee arthroplasty. Further information can be gathered from the operative report. No loosening appears to be present about the femoral component. Brief Hospital Course: Mrs. [Known lastname 19704] arrived at [Hospital1 18] for her elective surgery. She was taken to the OR and she tolerated the procedure well. She received 2 units of blood intraoperatively. She was transferred to the SICU on POD 0 and remained intubated overnight. She was transfused another unit of prbcs for a HCT of 26. in the AM of POD 1, she was extubated and transferred to the floor. Her pain was well controlled with IV and then PO pain meds. She began tolerating a regular diet without problems. [Name (NI) ] [Name2 (NI) 19705] drain was removed. Her dressing was removed on POD 2 and her wound was clean, dry, and intact. Her foley catheter was removed on POD 2 at midnight. She was tranfused another 3 units of blood on the floor between POD 2 and 3. She was fitted for hinged knee brace and worked with physical therapy. Throughout her stay she remained stable with normal vital signs. She is being discharged to a rehab facility today in good condition with staples in place. Medications on Admission: Allopurinol, atenolol, clopidogrel, furosemide, isosorbide mononitrate, levothyroxine, Naprosyn, nitroglycerin, Crestor, Colace, Metamucil, and aspirin. Discharge Medications: 1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) inj Subcutaneous Q12H (every 12 hours) for 4 weeks. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed for pain. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 13. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q 8H (Every 8 Hours). 18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Painful nonunion of periprosthetic left distal femoral fracture Discharge Condition: Stable Discharge Instructions: experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by a visiting nurse at 2 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 4 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg twice daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by VNA in 2 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. 12. ACTIVITY: 50% Partial weight bearing with unlocked knee brace on the operative leg. No strenuous exercise or heavy lifting until follow up appointment. Continue to use your CPM machine as directed. Physical Therapy: Please help with ambulation and gait training 50% partial weight bearing in unlocked [Doctor Last Name 6587] Full ROM CPM advancing as tolerated to 0-100. Treatments Frequency: CPM advancing as tolerated to 0-100. Lovenox injections. Wound checks. VNA to remove staples at 2 weeks. Followup Instructions: Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2101-4-27] 12:25 Provider: [First Name4 (NamePattern1) 6100] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2101-4-27] 12:45 Completed by:[2101-4-19] ICD9 Codes: 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6452 }	Medical Text: Admission Date: [2144-6-29] Discharge Date: [2144-7-7] Date of Birth: [2068-7-10] Sex: M Service: MEDICINE Allergies: Codeine / Iodine; Iodine Containing Attending:[First Name3 (LF) 2880] Chief Complaint: MSSA bacteremia, pacemaker associated endocarditis and osteomyelitis Major Surgical or Invasive Procedure: s/p sternotomy and epicardial lead placement [2144-7-1] History of Present Illness: 75 yo male with CAD, h/o CHB who was in his USOH (= volunteering, drove, mild forgetfulness) was sent home for work with fever/flu-like sympt, chills, disorientation, and diarrhea. Pt was admitted for pneumonia, tx with abx, and sent home in a couple days. He however got much worse, could no longer stand up, not eating/drinking/high fevers, and very disoriented. Early [Month (only) 958] pt was readmitted, changed abx, and sent to nursing home rehab. When he left he was nearly at baseline, watching TV, conversing well. Then abruptly he began having back pain, vomitting, diarrhea, and dysphagia. Pt admitted 3rd time and EGD done. CXR/CT, no TEE done at that point, and sent to rehab on IV abx x6wks for PT/OT. Pt had a stroke at rehab, stayed with sister for a while, and then at an ID appointment suspected endocarditis. Also at that time infection was found at the spine. Pt was readmitted a couple days ago, and found to be s/p PPM with recurrent MSSA sepsis, prior CVA (likely septic emboli), L spine osteo. The pt had his pacing system explanted at OSH (leads positive for MSSA) on [2144-6-15] and now presents with temp wire in place for planned epicardial pacing system. Currently being treated with IV oxacillin. . 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. * 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: prostate CA bladder CA recurrent MSSA bacteremia CAD s/p stenting PUD depression chronic LBP HTN hyperlipidemia CRI, baseline Cr ~1.9 dementia Alzheimer's disease CHF anemia requiring transfusion FTT CVA, likely from septic emboli Social History: Retired telephone worker. Quit smoking 15 years ago. Drank 6pack/day of beer, and 30pack/yr hx (stopped 20y ago) Family History: nc Physical Exam: VS - 97.5, 96/68, 80, 18, 98%2L Gen: NAD. Oriented x3. Pt hearing impaired. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple no JVP 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: Crackles heard throughout. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2144-7-7*] 06:11AM BLOOD WBC-7.7 RBC-3.26 Hgb-10.3* Hct-29.8* MCV-92 MCH-31.7 MCHC-34.6 RDW-16.8* Plt Ct-342 [2144-7-1] 01:08PM BLOOD WBC-14.1* RBC-2.76* Hgb-8.5* Hct-25.7* MCV-93 MCH-30.9 MCHC-33.2 RDW-16.7* Plt Ct-460* [2144-7-1] 11:45AM BLOOD WBC-10.6# RBC-2.83* Hgb-8.8* Hct-26.5* MCV-93 MCH-31.1 MCHC-33.3 RDW-16.2* Plt Ct-433# [2144-7-1] 04:30AM BLOOD WBC-5.3 RBC-2.78* Hgb-8.7* Hct-25.9* MCV-93 MCH-31.4 MCHC-33.6 RDW-15.9* Plt Ct-233 [2144-7-5] 05:25AM BLOOD PT-18.9* PTT-36.2* INR(PT)-1.7* [2144-7-1] 01:08PM BLOOD Plt Ct-460* [2144-6-30] 11:27AM BLOOD PT-14.1* PTT-31.4 INR(PT)-1.2* [2144-7-1] 11:45AM BLOOD Fibrino-481* [2144-7-7] 06:11AM BLOOD ESR-71* [2144-7-7] 06:11AM BLOOD Glucose-82 UreaN-36* Creat-1.6* Na-140 K-3.4 Cl-105 HCO3-24 AnGap-14 [2144-7-2] 04:57PM BLOOD Glucose-132* UreaN-38* Creat-2.2* Na-133 K-3.9 Cl-99 HCO3-23 AnGap-15 [2144-6-30] 05:00AM BLOOD Glucose-88 UreaN-31* Creat-1.4* Na-132* K-3.9 Cl-97 HCO3-27 AnGap-12 [2144-7-5] 05:25AM BLOOD ALT-8 AST-9 LD(LDH)-185 AlkPhos-86 TotBili-1.3 [2144-6-30] 11:27AM BLOOD ALT-12 AST-18 AlkPhos-140* TotBili-0.6 [2144-7-7] 06:11AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1 [2144-7-5] 05:25AM BLOOD CRP-166.1* [2144-7-4] 02:03AM BLOOD CRP-195.1* Brief Hospital Course: The pt had his pacing system explanted at OSH (leads positive for MSSA) on [2144-6-15]. . Pt had operation on [2144-7-1] for apicardial lead placement via sternotomy. He was transferred to the CVICU for hemodynamic monitoring. He was weaned from sedation, awoke without any neurologucal changes, and was extubated without complications. During the ICU course pt had ARF and Cr increased to 2.2, with his baseline near 1.5. Pt was thought to have nephrotoxic vs. ischemic ATN. His renal function continued to improved and by discharge his Cr was 1.6 near his baseline. He continued to improve and was transferred back to the floor postop day 2. . Once back on the floor pt, pt continued to remain afebrile, and WBC normalized. Pt's blood culture remained negative. Pt was thought to be no longer infected through his pacer. . * (very important) Pt did continue to have spine osteomyelitis. ID was consulted. Pt's pain improved over hospitalization. Pt revcieved IV Nafcillin, and needs to continue to get it for 6wks as outpt. Pt also needs weekly labs faxed to [Hospital ] clinic. Pt has an outpt CT with contrast of the spine scheduled to f/u with the infection. Pt has a f/u appointment with ID outpt scheduled. . Due to the [Doctor First Name 48] pt needs mucomyst the day before and after the CT scan (prescribed- as noted in d/c paperwork). . Pt needs INR checked. Pt did not have significant elevation of liver enzymes, but continued to have incr. INR. Pt does not need to be anticoagulated - does not have Afib, from our knowledge. . Pt also had UTI growing proteus. Pt recieved cipro for which he recieved the full course, and when recultured after foley was removed. Pt no longer grew anything from urine culture. Cipro was also d/c. . Concering his dysphagia the etiology needs to be investigated as outpt. Plummer-[Doctor Last Name ] syndrome (esophageal webs, iron-deficiency anemia, koilonychia (however no koilonychia seen)) was a thought. Please continue to follow swallow eval recs. - PO intake of nectar thick liquids and puree. - Pills crushed with puree. - 1:1 supervision for all pos when patient is awake and alert. - Alternate between bites and sips. Slow rate if intake. - If patient is noted with difficulty on this diet, decreased mental status/alertness, continued pain please make him NPO. . Iron-def anemia - continue iron . GERD stable on protonix . Mild cog impairment - continue aricept . Medications on Admission: Oxacillin 2 g IV until [2144-7-30] Metoprolol 50 mg [Hospital1 ] Aricept 10 mg QHS Trazodone 175 mg QHS Paxil 60 mg daily Fe sulfate 325 mg [Hospital1 ] Lasix 10 mg daily KCl 10 mEq daily Protonix 40 mg daily ASA 325 mg daily Lidoderm, 12 hours on/12 hours off Colace 100 mg [Hospital1 *] Hep subq Dilaudid PRN Guaifenesin 600 mg q12 PRN Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:15 Tablet(s)* Refills:0 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) Intravenous Q4H (every 4 hours) for 6 weeks. 9. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain for 5 days: 12 hours on, 12 hours off. Disp:5 Adhesive Patch, Medicated(s) Refills:0 11. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every twelve (12) hours as needed for cough. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 15. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital ] Health Care Discharge Diagnosis: primary dx: - MSSA pacer infection - acute renal failure - ATN - urinary tract infection secondary dx: - thoracic vertebrae osteomyelitis - dysphagia - incr INR Discharge Condition: fair Discharge Instructions: You had a bacterial line infection and your pacer was removed because it was seeded by the bacteria. You had surgery for a new epicardial pacer, and in the ICU your course was complicated by acute renal failure. Your creatinine has improved and is close to your baseline. After coming back to the floor your blood cultures did not show any signs of infection from your vitals either. 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 No creams, lotions, powders, or ointments to incisions No lifting more than 10 pounds for 10 weeks No driving for 4 weeks after sternal incision Followup Instructions: Dr [Last Name (STitle) 914] in 4 weeks [Telephone/Fax (1) 170] (please call to schedule appointment) Pt needs CBC, LFTs, Chem7 (lytes) checked weekly. Fax the results to [Telephone/Fax (1) 432] To [Hospital ] Clinic CT spine [7-13] at 1:45, at [Hospital Ward Name 452] 3 at [Hospital Ward Name ]. Please do not eat 3 hours prior. Please also take mucomyst 600mg [Hospital1 ] x 4 doses. Take 2 doses day before procedure, take second two doses after procedure. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2144-7-8] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 456], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2144-7-27] 10:00 [First Name11 (Name Pattern1) 900] [Last Name (NamePattern1) 2882] MD, [MD Number(3) 2883] Completed by:[2144-7-8] ICD9 Codes: 5849, 5990, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6453 }	Medical Text: Admission Date: [2179-3-10] Discharge Date: [2179-3-14] Date of Birth: [2120-6-4] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 58 year old male with a very complicated previous medical history who was transferred to the [Hospital1 69] on [2179-3-10], from [Hospital ] Rehabilitation for increasing lethargy, low grade temperatures and hypoxia. He had been in prior to admission. He was noted to have increasing lethargy over the few days and then on the day of admission his oxygen saturation decreased to the low 80% on his baseline four liters of oxygen. He had a low grade temperature. Notably he had had a PICC line placed recently. Arterial blood gases at [Hospital1 ] showed pH 7.05, pCO2 76 and FIO2 95. The FIO2 is unknown on the sample. He was transferred to the [Hospital3 ] only of feeling weak and of feeling very tired. He was disoriented. PAST MEDICAL HISTORY: 1. AIDS diagnosed in [2169]. Only opportunistic infection is apparently Candidal esophagitis. He also has severe cardiomyopathy secondary to HIV. His ejection fractions have been variously recorded at 30 to 40% and then 70% on a most recent echocardiogram. He has severe right ventricular dilation and hypokinesis. 2. End stage renal disease on hemodialysis. 3. Chronic obstructive pulmonary disease on four liters home oxygen. 4. Pulmonary embolus and deep vein thrombosis in [2168]. 5. Hepatitis B. 6. Hepatitis C. 7. Sustained ventricular tachycardia, status post ablation in [2178-11-24]. 8. Pneumonia, some with Methicillin resistant Staphylococcus aureus, one requiring intubation 9. Pancreatitis. 10. PPD positive. 11. VRE positive. 12. Methicillin resistant Staphylococcus aureus positive. 13. History of intravenous drug use, on Methadone. 14. Question of history of obstructive sleep apnea. MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg q.d. 2. Vitamin C 500 mg b.i.d. 3. Folate 1 mg q.d. 4. Epivir 25 mg q.d. 5. Prevacid 30 mg p.o. q.d. 6. Megace 400 mg q.d. 7. Multivitamin one q.d. 8. Senokot two at night. 9. Zoloft 50 mg q.d. 10. Bactrim double strength one p.o. q.Tuesday, Thursday and Saturday. 11. Zerit 20 mg q.d. 12. Coumadin 2.5 mg q.d. with a goal INR 2.0 to 3.0. 13. Zinc Sulfate 220 mg q.d. 14. Albuterol and Atrovent nebulizers. 15. Methadone 50 mg q.a.m. 16. Valium 5 mg a day. 17. Lactulose q.p.m. 18. Colace 100 mg b.i.d. 19. Percocet one p.o. q4hours prn 20. Vancomycin one gram and 80 mg Gentamicin on [2179-3-9]. ALLERGIES: Thorazine causes anaphylaxis, H2 blockers cause thrombocytopenia. Haldol, Clindamycin, Codeine and Stelazine all cause rashes. PHYSICAL EXAMINATION: At the time of admission to the Medicine Intensive Care Unit, the patient is comfortable, sleeping, but arousible, cachectic man. Temperature was 97.4, blood pressure 112/48, pulse 99, respiratory rate 12, oxygen saturation 96% on 50% face mask. The pupils were 4.0 millimeters bilaterally and reactive. There is no jugular venous distention. He had crackles at his lung bases. His heart was regular. He had a II/VI systolic ejection murmur at the left upper sternal border. His abdomen was soft, nontender, nondistended, normoactive bowel sounds. Liver edge was one to two centimeters below the costal margin. There was no cyanosis, clubbing or edema. He did not cooperate with neurologic examination but moved all four extremities. LABORATORY DATA: At the time of admission, laboratories were notable for a white count 4.4 without a left shift, hematocrit 43.9 and platelets 87,000. His Chem7 was 135, potassium 7.8, chloride 102, bicarbonate 15, blood urea nitrogen 64, creatinine 7.2 with a glucose of 95. Arterial blood gases on two liters showed pH 7.09, pCO2 57 and pO2 60. Electrocardiogram had slightly peaked T waves in the lateral leads which was unchanged from baseline. Chest x-ray showed mild pulmonary edema but no infiltrates. HOSPITAL COURSE: The impression at the time of arrival to the Emergency Department was that this was a 58 year old man with complicated medical history presenting with acidosis, hyperkalemia, and lethargy. He was treated with insulin, glucose, Kayexalate and taken to emergent hemodialysis. At that time, he complained only of dyspnea and fatigue with a question of increase in his sputum production. He was then admitted to the Medical Intensive Care Unit and was also placed on bilevel positive airway pressure and he should receive Vancomycin, Gentamicin and Levofloxacin, but these were discontinued after only one dose. Cultures are negative to date. He improved rapidly with dialysis and BiPAP and his antibiotics were discontinued. The pulmonary critical care team's overall impression was fluid overload versus bronchitis and felt that a possible left lower lobe process noted on chest x-ray was not pneumonia. His temperature maximum during this hospitalization was 99.9. On [2179-3-13], he was felt ready for transfer back to [Hospital1 ], however, a bed was not available and he was transferred to the floor. He complained only of feeling very weak (diffusely) but said that his breathing was improved about 50 to 60% of the way back to baseline. A repeat chest x-ray showed improvement in the pulmonary edema. It showed no infiltrate. At this time, his date of discharge is not clear. An induced sputum for pneumocystis will be sent prior to discharge. However, it is felt clinically low probability that pneumocystis is involved in this presentation. DISCHARGE DIAGNOSES: 1. Profound metabolic acidosis, etiology unclear. 2. Concurrent respiratory acidosis. 3. Hyperkalemia secondary to acidosis. 4. Mental status changes secondary to multiple metabolic abnormalities, improved. 5. Severe chronic obstructive pulmonary disease. 6. End stage renal disease, on hemodialysis. 7. HIV/AIDS. 8. Cardiomyopathy. MEDICATIONS ON DISCHARGE: 1. Amiodarone 200 mg p.o. q.d. 2. Vitamin C 500 mg p.o. b.i.d. 3. Epivir 25 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Megace 400 mg p.o. q.d. 6. Multivitamin one tablet p.o. q.d. 7. Senokot two tablets p.o. q.h.s. 8. Zoloft 50 mg p.o. q.d. 9. Zerit 20 mg p.o. q.d. 10. Coumadin 2.5 mg p.o. q.d. with a goal INR of 2.0 to 3.0. 11. Zinc Sulfate 220 mg p.o. q.d. 12. Albuterol and Atrovent nebulizers q.i.d. and q2hours p.r.n. 13. Methadone 50 mg p.o. q.a.m. 14. Lactulose 30 ccs p.o. b.i.d. 15. Colace 100 mg p.o. b.i.d. 16. Percocet one tablet p.o. q6hours p.r.n. 17. Bactrim double strength one tablet p.o. q.Tuesday, Thursday, and Saturday. He will continue to be followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. [First Name11 (Name Pattern1) 4283] [Last Name (NamePattern4) 4284], M.D. [MD Number(1) 7551] Dictated By:[Last Name (NamePattern1) 108133] MEDQUIST36 D: [2179-3-14] 15:51 T: [2179-3-14] 16:07 JOB#: [Job Number 108134] ICD9 Codes: 2762, 2767, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6454 }	Medical Text: Admission Date: [2196-4-5] Discharge Date: [2196-4-12] Date of Birth: [2140-5-7] Sex: F Service: Hepatobiliary Surgical HISTORY OF PRESENT ILLNESS: [Known firstname ] [Known lastname 1007] is a 55 year old female who presented with persistent nausea, vomiting and recurrent left upper quadrant abdominal pain. Upper gastrointestinal series was obtained on [2196-2-26] which revealed multiple dilated loops of proximal small bowel consistent with partial small bowel obstruction. After extensive discussion with the patient the decision was made for an operative intervention to mechanically decompress this problem. PHYSICAL EXAMINATION: The patient is an obese, 55 year old female in no apparent distress. Head, eyes, ears, nose and throat, mucous membranes moist, no evidence of oral ulcers. Sclera anicteric. Cranial nerves 2 through 12 intact and no evidence of cervical lymphadenopathy. Chest is clear to auscultation bilaterally. Cardiac regular rhythm and rate, no murmurs. Abdomen soft, obese, nondistended and mildly tender to palpation as appropriate with the postoperative course. There was no evidence of erythema along the surgical incision site and staples were intact. Extremities, no evidence of edema and no rash noted. LABORATORY DATA: Pertinent laboratory data reveals [2196-4-11], chemistry with sodium 139, potassium 3.2, chloride 105, BUN 3, creatinine .4, magnesium 1.6, phosphorus 2.9, calcium 7.9. HOSPITAL COURSE: The patient is a 55 year old female who underwent an uncomplicated lysis of adhesions, gastrostomy tube placement, transverse colectomy with primary anastomosis, open biopsy peritoneal carcinomatosis on [2196-4-5]. The patient's postoperative course was unremarkable with return of bowel function and appropriate advancement of diet. By [2196-3-12], the patient was tolerating regular diet without difficulty with gastrostomy tube clamped, in position. The patient's pain was well controlled with oral Percocet and the decision was made to discharge the patient in good condition. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Lysis of adhesions. Gastrostomy tube placement. Transverse colectomy with primary anastomosis. Open biopsy of peritoneal carcinomatosis. MEDICATIONS ON DISCHARGE: Metoprolol 50 mg p.o. b.i.d. Protonix 40 mg p.o. q.d. Dilaudid 2 mg 1 to 2 tablets p.o. q. 4-6 hours prn pain Colace 100 mg p.o. b.i.d. FOLLOW UP PLANS: The patient was instructed to follow up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 468] in one to two weeks. [First Name8 (NamePattern2) 251] [Name8 (MD) ], M.D. [MD Number(1) 4984] Dictated By:[Name8 (MD) 11079] MEDQUIST36 D: [2196-5-5] 11:39 T: [2196-5-5] 12:02 JOB#: [Job Number ] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6455 }	Medical Text: Admission Date: [2124-7-23] Discharge Date: [2124-8-23] Date of Birth: [2079-10-1] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: hypotension Major Surgical or Invasive Procedure: tracheostomy tube placement PEG tube placement History of Present Illness: 44 yo woman with hx motor neuron disease recently admitted for falls, brought to the ED on this occassion for respiratory distress. Per report, pt had a respiratory code at her nursing facility, at which time she was intubated and brought to an outside hospital. Large amounts of secretions were present in the posterior pharynx, and narcan was given without improvement in sxs. At the OSH ED, she was given ceftriaxone and azithromycin for UTI and PNA. She was then transported to [Hospital1 18] and became hypotensive with sats in the 80s, this improved with manual bagging. . On arrival to the ED, CXR was performed which showed a hazy R lung field, therefore she was given levofloxacin, vancomycin and flagyl. Pressures dropped and she was started on phenylepherine. 3 attempts at an IJ were unsuccessful, therefore a femoral line was placed. She was given 7 L of luid. Pressures on transfer were 99.3 104 92/67, 98% on vent. . On arrival on the floor, pt is intubated and sedated. Family is at bedside and states that the pt was in her normal state of health when they were out last night at a casino. At that time she complained of some mild general fatigue, however no SOB, cough, CP or other discomfort. Per her sister, she had recently had some difficulty with choking when eating. She does have some difficulty moving her L leg at baseline, but is mobile in a wheelchair and has full function of upper extremities. . Review of systems (per family): (+) Per HPI (-) No recent fever, chills, night sweats, recent weight loss or gain. No headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. No chest pain, chest pressure, palpitations, or weakness. No nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. No dysuria, frequency, or urgency. No rashes or skin changes. Past Medical History: -suspected motor neuron disease, likely ALS, who is followed in the [Hospital 7817] Clinic here with Dr. [Last Name (STitle) ] and likely -presumptive Dx Fronto-Temporal Dementia -cervical myelopathy -anxiety disorder Social History: Does not work at present. Lives with her mother (who is in her 70s and still working), and sister. She denies tobbaco or alcohol use. Denies illicit drug use. Family History: ? Motor neuron disease in her aunt who died in her 60s Sister with emotional problems Physical Exam: ADMISSION: Vitals: T:101.2 BP:105/68 P:97 R: 10 O2: 97% on vent General: Intubated, sedated HEENT: ET tube in place, PERRL, sclera anicteric Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, interosseous line in left tibia DISCHARGE: General: Cachectic, comfortable, on trach collar HEENT: PERRL, Normocephalic Cardiovascular: RRR, nl S1/S2, no mrg Lung: poor inspiratory effort, no usage of accessory muscles of respiration, mild crackles throughout stable from prior exam Abdominal: Soft, Non-tender, naBS, G-tube site, c/d/i Extremities: No lower extremity edema; Skin: Warm Neurologic: Attentive, follows simple commands Pertinent Results: Laboratory Values: [2124-7-23] 01:00PM BLOOD WBC-16.5* RBC-4.25 Hgb-13.0 Hct-40.3 MCV-95 MCH-30.5 MCHC-32.2 RDW-13.1 Plt Ct-287 [2124-8-2] 03:07AM BLOOD WBC-28.5* RBC-3.92# Hgb-12.0# Hct-36.8# MCV-94 MCH-30.6 MCHC-32.6 RDW-13.1 Plt Ct-725 [2124-8-10] 04:13AM BLOOD WBC-8.1 RBC-2.61* Hgb-7.8* Hct-24.1* MCV-92 MCH-29.9 MCHC-32.5 RDW-14.3 Plt Ct-448* [2124-7-23] 11:50PM BLOOD Neuts-86.1* Lymphs-9.6* Monos-4.0 Eos-0.1 Baso-0.1 [2124-8-5] 03:32AM BLOOD Neuts-75* Bands-10* Lymphs-7* Monos-4 Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-0 [2124-8-8] 03:52AM BLOOD Neuts-79.8* Lymphs-13.3* Monos-4.2 Eos-2.4 Baso-0.2 [2124-7-23] 01:04PM BLOOD PT-12.4 PTT-22.6 INR(PT)-1.0 [2124-8-8] 03:52AM BLOOD PT-15.5* PTT-26.5 INR(PT)-1.4* [2124-7-23] 01:04PM BLOOD Fibrino-640* [2124-7-23] 11:50PM BLOOD Glucose-152* UreaN-15 Creat-0.4 Na-147* K-3.6 Cl-117* HCO3-23 AnGap-11 [2124-8-1] 04:57PM BLOOD Glucose-94 UreaN-10 Creat-0.3* Na-128* K-4.1 Cl-86* HCO3-37* AnGap-9 [2124-8-2] 04:20PM BLOOD Glucose-82 UreaN-5* Creat-0.3* Na-146* K-3.9 Cl-110* HCO3-34* AnGap-6* [2124-8-5] 06:15PM BLOOD Glucose-122* UreaN-7 Creat-0.3* Na-114* K-3.8 Cl-82* HCO3-29 AnGap-7* [2124-8-10] 04:13AM BLOOD Glucose-95 UreaN-5* Creat-0.3* Na-137 K-3.7 Cl-100 HCO3-28 AnGap-13 [2124-8-2] 03:07AM BLOOD ALT-155* AST-54* LD(LDH)-394* AlkPhos-84 Amylase-224* TotBili-0.5 [2124-7-23] 01:00PM BLOOD Lipase-46 [2124-8-9] 02:40AM BLOOD CK-MB-3 cTropnT-0.04* [2124-8-9] 03:46PM BLOOD CK-MB-5 cTropnT-0.05* [2124-8-9] 11:54PM BLOOD CK-MB-3 cTropnT-0.06* [2124-8-10] 04:13AM BLOOD CK-MB-3 cTropnT-0.05* [2124-7-26] 03:42AM BLOOD Albumin-2.5* Calcium-7.6* Phos-2.0* Mg-1.8 [2124-7-27] 06:00PM BLOOD Osmolal-299 [2124-8-5] 07:16PM BLOOD Osmolal-245* [2124-8-7] 08:37PM BLOOD Osmolal-278 [2124-8-2] 09:57AM BLOOD TSH-3.6 [2124-8-2] 09:57AM BLOOD Free T4-1.7 [2124-8-2] 09:57AM BLOOD Cortsol-14.1 [2124-7-23] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2124-7-24] 12:35AM BLOOD Type-ART Temp-37.5 Tidal V-400 PEEP-5 FiO2-40 pO2-59* pCO2-47* pH-7.30* calTCO2-24 Base XS--3 Intubat-INTUBATED [2124-7-23] 01:00PM BLOOD Glucose-117* Lactate-2.8* Na-147 K-4.8 Cl-94* calHCO3-34* [2124-8-10] 05:15AM BLOOD Lactate-0.7 [2124-7-23] 01:00PM BLOOD freeCa-1.16 [2124-7-31] 08:48AM BLOOD freeCa-1.01* Imaging: CT HEAD W/O CONTRAST Study Date of [2124-8-6] 9:39 AM IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. 2. No definite CT evidence of osmotic demyelination. Note that MRI, if not contra-indicated, would be more sensitive to characterize this abnormality if clinical concern persists. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [2124-8-3] 10:03 AM IMPRESSION: 1. Immense wall thickening of the entire colon and rectum consistent with pseudomembranous colitis. Dr. [Last Name (STitle) ] was informed of this finding. 2. Large bilateral pleural effusions with bibasilar compression atelectasis. 3. Moderate ascites and anasarca. 4. There is a small patchy density in the right upper lobe that may be infectious or inflammatory in etiology. Could also represent a focus of atelectasis. Would recommend reexamining this area on any future studies. RENAL U.S. PORT Study Date of [2124-7-26] 1:30 PM IMPRESSION: 1. No hydronephrosis, or perinephric fluid collection. 2. Ascites. 3. Small left pleural effusion. 4. Subcentimeter nonobstructive renal stone in the lower pole, and few punctate small nonobstructive renal stones in the left kidney Reports: TTE (Complete) Done [2124-8-10] at 2:23:44 PM FINAL Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Aortic valve not well seen. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal mitral valve supporting structures. No MS. Normal LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal tricuspid valve supporting structures. No TS. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 70%). 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 is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. EEG Study Date of [2124-8-8] IMPRESSION: This is a mildly abnormal VEEG telemetry due to the presence of a slow alpha frequency background rhythm seen throughout the recording consistent with a diffuse mild encephalopathy. Normal sleep architecture was preserved. There were no focal abnormalities or epileptiform features observed. [2124-8-22] Chest X-Ray IMPRESSION: Right PICC in low SVC in standard location. Brief Hospital Course: 44 yo female with hx of ALS, now presenting after respiratory code with hypotension, new R-sided infiltrate concerning for sepsis. . # Fever/PNA: She initially presented with an enterococcus UTI and HAP with a R sided pleural effusion. She was treated with broad specturm antibiotics (Vanc, Flagyl and Cefepime), and early goal directed therapy was initiated. She became febrile, and her IJ was removed since it was thought to be source of infection. She continued to spike fevers necessitating continuned antimicrobial therapy. An infectious source was not found, and blood cultures remained negative. Subsequently she developed hypotension in the setting of large quanities of stool and she was given empiric PO vanco therapy for C. Diff. Eventually, she had yeast grow out of her urine and she was placed on fluconazole for ten days. She also had Staph Aureus grow out of her sputum culture that was sensitive to vancomycin. She was placed on empiric vancomycin for treatment of a second HAP, with the plan to complete 14 days of antibiotic coverage (day 1 = [8-16], day 14 = [8-30]). Throughout her hospital course she continued to spike fevers without a known source. Blood cultures remained negative, although she did have one positive blood culture that grew out coag negative staph. It was thought to be a contaminant and repeat blood cultures did not speciate any bacteria. RUQ ultrasounds did not show acute cholecystitis. Her chest X-ray did not show any acute infiltrate or cardiopulmonary process. Her C.diff PO vanco therapy will end 10 days after her last dose of IV vanco ([9-9]). . # Motor Neuron Disease, Fronto-Temporal Dementia: Patient with chronic motor neuron and fronto-temporal processes of uncertain etiology. No change in current function. At baseline she is cachectic with minimal ability to move lower extremities. She currently has a trach in place for chronic respiratory failure (negative inspiratory force = 24). She was maintained on olanzapine, and diazepam for anxiety. her primary nuerologist was contact[Name (NI) ] during her admission. . #Respiratory Failure/Tracheostomy: Patient admitted with respiratory failure in setting of chronic motor neuron disease (as discussed above) and new HAP, requiring intubation. After several failed extubations, thought to be secondary to respiratory failure and patient's anxiety (as disccused below), tracheostomy was placed. Since then patient has been weaned from ventilatory support, so that she is rested on vent at night and on trach collar / passy-muir valve during the day as tolerated (with periodic resting). . # Central Diabetes Insipidus: Ms. [Name13 (STitle) 22016] required vasoactive support with vasopressin for several episodes of hypotension that were believed to be secondary to sepsis and hypovolemia. After discontinuing the vasopressin, Ms. [Name13 (STitle) 22016] would make large quanities of dilute urine (Nadir U OSM - 127), and her serum sodium would rise. Endocrine was consulted for potential central diabetes insipidous, and requested a water deprivation test. We were unable to preform the test since initially her blood pressure remained labile. She had one episode of acute hyponatremia where her serum sodium nadired at 114 and climbed to the 140's in the span of a day. Renal was consulted to determine how to replete her free water, and she was subsequently placed on ddvap 100 mcg [Hospital1 ]. Her serum sodium remained stable when her free water and tube feeds remained constant. Her serum sodium is now stable in the 130's and she has been switched to intranasal DDAVP. . # Hypotension: When she presented to the ICU she initially was strated on goal-directed therapy with concern for sepsis. She and required vasoactive support with levophed and vasopressin. She had several additional episodes of hypotension, and which required volume resuscitation. The first episode was secondary to sepsis in the setting of her C. diff infection, the second episode was secondary to discontinuation of her vasopressin and production of large quanities of urine. Her blood pressure has remained stable since she was placed on ddvap. She has required additional volume resuscitation with .5-1L boluses on several occasions. Her blood pressure remained stable at SBP 110's and decreases to the 90's while she sleeps. # L-sided infiltrate/R pleural effusion: Upon admission, there was concern for new HAP vs aspiration PNA in the setting of acute respiratory failure. She intially started on broad specturm antiobiotics, Vancomycine, Cefepime, and flagyl, and was intubated. She initially required vasoactive support with levophed and norepi, and eventually was left on vasopressin for several days. After becoming volume overloaded for aggressive fluid resuscitation after episodes of hypotension, she was diuresised with resolution of her L side infiltrate and R sided pleural effusion. . # Eosinophilia: After several weeks in the [Hospital Unit Name 153], she developed an eosinophilia of unknown etiology. It was thought to be secondary to a drug reaction. She did not have any rashes. Her eosinophils are now trending down. . # UTI: She grew enterococcus in her urine. She was treated with vancomyocin. . # Anxiety: The patient was initially extubated and re-intubated for stridor. She was thought to have laryngeal edema and started on decadron. Per the anesthesiologist performing the second intubation, her vocal chords did not appear to be edematous and a larger ET tube was placed that the initial tube. Anxiety may have played a role in her re-intubation, and it was thought that paradoxical ?laryngeal spasm. She was re-intubated for a third time after acutely becoming short of breath. Again, anxiety was thought to contribute to her dyspena. Diazepam was given PRN for the anxiety. After her tracheostomy, she required intermitent doses of diazepam. Medications on Admission: 1. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Diazepam 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 4. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Medications: 1. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. 6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): to be completed on [9-9]. 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 9. Vancomycin 1250 mg IV Q 12H 10. Desmopressin 10 mcg/spray Aerosol, Spray Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-25] Drops Ophthalmic PRN (as needed) as needed for dry eye. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 14. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-25] Sprays Nasal TID (3 times a day) as needed for nasal congestion. 15. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: NE [Hospital1 ] Discharge Diagnosis: Primary Diagnosis: Respiratory Failure Secondary Diagnosis: Hospital Acquired Pneumonia Urinary Tract Infection Central Diabetes Insipidus C. dificile Colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Non-ambulatory. Out of Bed with assistance to chair. Discharge Instructions: Ms. [Known lastname 22013], it was a pleasure taking part in your care at [Hospital1 1535]. You were diagnosed with respiratory failure, central diabetes insipidus (an inability to concentrate your urine), and several infections of your lungs, urine, and colon. You are currently on antibiotics (oral vancomycin and IV vancomycin) to treat these infections. Your IV vancomycin treatment course will end on [8-30]. Your oral vancomycin treatment course will end on [9-9]. During your stay you were unable to breathe adequately on your own, so a trachesotomy tube was placed. You also received a tube in your stomach to provide nutrition. Since a tracheostomy was placed to help you breathe, you will require regular maintenance care of your airway. Your medications were updated as follows: Mirtazapine 30 mg Tablet One Tablet PO (at bedtime). Heparin 5,000 unit/mL Solution One Injection TID Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ] Insulin Sliding Scale AS DIRECTED Diazepam 5 mg Tablet One (1) Tablet PO Q8H as needed for agitation. Olanzapine 2.5 mg Tablet One Tablet PO DAILY Vancomycin 125 mg Capsule One Capsule PO Q6H (to be completed on [9-9]) Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated One (1) Adhesive Patch, Daily Vancomycin 1250 mg IV Q 12H Desmopressin 10 mcg/spray Aerosol, Spray One (1) Spray Nasal [Hospital1 ] Senna 8.6 mg Tablet One (1) Tablet PO BID as needed for constipation. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette 1-2 Drops Ophthalmic as needed for dry eye Ipratropium Bromide 0.02 % Solution One Inhalation Q6H as needed for shortness of breath or wheezing Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-25] Sprays Nasal TID as needed for nasal congestion. Tizanidine 2 mg One (1) Tablet PO TID Followup Instructions: Patient should have follow-up with PCP [First Name4 (NamePattern1) 8513] [Last Name (NamePattern1) ] [Telephone/Fax (1) 22017] If further questions regarding neurologic prognosis, patient may follow-up with outpatient neurologists, but currently poor prognosis has been communicated to patient and there are no known interventions available to her: Neuromuscular - Dr. [First Name (STitle) ] [Name (STitle) 3524] - ([Telephone/Fax (1) 13172] Cognitive Neurology - Dr [First Name (STitle) ] [Name (STitle) 8012] - ([Telephone/Fax (1) 1703] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 0389, 5070, 5119, 5990, 2761, 2762, 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6456 }	Medical Text: Admission Date: [2198-4-13] Discharge Date: [2198-4-21] Date of Birth: [2124-9-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3507] Chief Complaint: Gallstone Pancreatitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: 73M cad, s/p CABG [01] yrs ago, HTN, hyperlipd, afib on amiodarone presented to ED on [4-13] with sudden onset generalized abd pain/nausea/vomiting. S/P CCY 4yrs ago (was necrotic per report). Denied fevers, chills, dysuria, lighheadedness, chest pain, SOB. In ED, CT abd showed extensive intra- and extra-hepatic biliary ductal dilatation with a 2.6 cm oblong stone likely impacted in the ampulla. There was associated edema in the pancreas head with surrounding inflammatory change consistent with biliary stone pancreatitis. ERCP was preformed on [2198-4-13], found impacted stone in the major papilla--was started on levo and amp. However, the endoscopists were unable to remove the stone. Instead, they peformed a sphincterotomy and placed a pigtail biliary stent. Upon admission to the floor, the patient's LFTs had trended down and his elevated amylase/lipase have resolved. The patient was maintained on zosyn and remained afebrile. . His floor course was complicated by afib + RVR and newly discovered pericardial rub. The patient was able to maintain his pressures. Bedside echo was done to rule out cardiac tamponade and was negative for pericardial effusion. The patient had continued to have abdominal pain with a significant leucocytosis, so the surgical team was consulted to evaluate his abdomen with the concern that there was may have been a perforation during the procedure. Repeat abdominal CT, however, did not demonstrate an acute surgical issue. Past Medical History: CAD s/p Cabg [01] yrs ago CHF with EF 40% ([2-11]) CCY in [2193] HTN Afib on amiodarone--not anti-coagulated, pt refused coumadin, didn't like the frequent f/u, cardioverted in [2-11] Rectal CA s/p local excision BPH Hypercholesterolemia Social History: h/o tobacco use: 30pack years. now occasional etoh, used to drink heavily. denies IVDU . Family History: died at [Age over 90 ]yo CHF--mother; Father: Liver disease Physical Exam: 96.3 136/78 96 18 99%3L (micu exam) GENL: elderly male, in bed HEENT: elev JVP to jaw, OP clear, EOMI CV: Irregularly irregular, +systolic murmur Lungs: crackles 1/2 up Abd: soft, NT, ND, +BS Ext: no edema, 2+ pedal pulses Pertinent Results: [2198-4-13] 08:11AM BLOOD Lactate-4.2* [2198-4-16] 10:35PM BLOOD Lactate-1.3 [2198-4-16] 06:30AM BLOOD TSH-0.34 [2198-4-13] 06:15AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2198-4-13] 07:40PM BLOOD CK-MB-4 cTropnT-0.02* [2198-4-18] 04:00AM BLOOD CK-MB-3 cTropnT-0.02* [2198-4-13] 06:15AM BLOOD Lipase-8835* [2198-4-14] 06:10AM BLOOD Lipase-688* [2198-4-18] 04:00AM BLOOD Lipase-28 [2198-4-13] 06:15AM BLOOD ALT-406* AST-582* CK(CPK)-77 AlkPhos-242* Amylase-[2111]* TotBili-2.7* [2198-4-16] 06:30AM BLOOD ALT-177* AST-55* LD(LDH)-509* CK(CPK)-63 AlkPhos-139* Amylase-70 TotBili-1.6* [2198-4-21] 06:10AM BLOOD ALT-46* AST-19 AlkPhos-94 TotBili-1.0 [2198-4-13] 06:15AM BLOOD Glucose-204* UreaN-20 Creat-1.4* Na-144 K-3.6 Cl-102 HCO3-28 AnGap-18 [2198-4-21] 06:10AM BLOOD Glucose-86 UreaN-19 Creat-1.3* Na-144 K-3.1* Cl-100 HCO3-34* AnGap-13 [2198-4-13] 06:15AM BLOOD Neuts-84* Bands-2 Lymphs-11* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2198-4-13] 06:15AM BLOOD WBC-19.2# RBC-4.52 Hgb-14.8 Hct-43.3 MCV-96 MCH-32.7* MCHC-34.1 RDW-14.3 Plt Ct-269 [2198-4-16] 06:30AM BLOOD WBC-25.9* RBC-4.55* Hgb-14.7 Hct-44.1 MCV-97 MCH-32.2* MCHC-33.2 RDW-13.9 Plt Ct-170 [2198-4-21] 06:10AM BLOOD WBC-15.7* RBC-4.19* Hgb-13.5* Hct-40.6 MCV-97 MCH-32.2* MCHC-33.2 RDW-14.0 Plt Ct-272 . CT Torso: CT CHEST WITHOUT AND WITH IV CONTRAST: The aortic root is mildly dilated measuring 4.2 x 4.1 cm in transverse and AP dimensions respectively. There is no evidence of aortic dissection. The heart size is enlarged. There are extensive coronary artery calcifications. There is moderate mediastinal lipomatosis. The patient is status post CABG and median sternotomy. No filling defects are identified within the pulmonary vasculature to suggest pulmonary embolus. The lungs demonstrate dependent atelectatic changes. There is no parenchymal consolidation to suggest underlying pneumonia. There is a moderate hiatal hernia. Airways are patent to the subsegmental bronchi bilaterally. There is no pericardial or pleural effusion. No pathologically enlarged mediastinal or hilar lymph nodes are identified. A filling defect in the right common carotid artery may reflect mixing artifact, although underlying thrombosis is not entirely excluded. The thyroid is enlarged and contains numerous low-density nodules. . CT ABDOMEN WITH IV CONTRAST: There is severe intrahepatic biliary ductal dilatation with the right common hepatic duct measuring up to 2 cm. The patient is status post cholecystectomy. The liver parenchyma is uniformly dense, possibly secondary to amiodarone therapy. Subcentimeter rounded hypodensities are seen throughout the liver, too small to characterize, likely cysts. The common bile duct is dilated to 1.6 cm. There is thickening of the distal common bile duct adjacent to an oblong 2.6-cm hyperdensity consistent with a stone that appears to protrude into the lumen of the duodenum. There is extensive inflammatory change in the adjacent mesenteric fat with edema and architectural distortion in the head of the pancreas consistent with acute pancreatitis. There are multiple periportal, aortocaval and peripancreatic enlarged lymph nodes measuring up to 1.4 cm in short axis. . The stomach and unopacified loops of large and small bowel are grossly unremarkable. There is no free intraperitoneal air. The spleen and adrenal glands appear normal. The kidneys demonstrate cortical thinning but enhance symmetrically and excrete contrast normally. Several subcentimeter rounded hypodensities within both kidneys are too small to characterize, likely cysts. There are extensive calcifications throughout the abdominal aorta and its branches. A normal air- filled appendix is seen in the right lower quadrant. . CT PELVIS WITH IV CONTRAST: The ureters, urinary bladder, rectum and sigmoid colon are normal. The prostate is mildly enlarged measuring 5.6 x 4.1 cm. Small bilateral fat-containing inguinal hernias. There is no free pelvic fluid and no inguinal or pelvic lymphadenopathy. . IMPRESSION: 1. No evidence of aortic dissection or pulmonary embolus. Mild dilatation of the ascending aortic root measuring 4.2 x 4.1 cm. 2. Extensive intra- and extra-hepatic biliary ductal dilatation with a 2.6 cm oblong stone likely impacted in the ampulla. There is associated edema in the pancreas head with surrounding inflammatory change consistent with biliary stone pancreatitis. Further characterization with ERCP is recommended. 3. Multiple low-attenuation nodules in an enlarged thyroid gland. Correlate clinically and with thyroid ultrasound if warranted. 4. Subcentimeter rounded hypodensities throughout the liver which are too small to characterize, likely cysts. Diffuse attenuation of the liver parenchyma may reflect response to amiodarone treatment. 5. Atrophic kidneys containing tiny cysts which are too small to fully characterize. No hydronephrosis or calculi are identified. 6. Moderate degenerative change in the lumbar spine with grade 2 anterolisthesis of L5 on S1. 7. Low attenuation within the right internal jugular vein likely secondary to mixing, although underlying thrombus is not excluded. Correlate clinically and with vascular ultrasound if warranted. . Echo: EF 20% The left atrium is moderately dilated. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated with severe global left ventricular hypokinesis and inferior and apical akinesis. No focal aneurysm or masses/thrombi are seen. Right ventricular chamber size is normal. There is moderate global right ventricular free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([2-6]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild symmetric left ventricular hypertrophy with cavity dilation and global/regional left ventricular systolic dysfunction c/w diffuse process (multivessel CAD, toxin, metabolic, etc.). Right ventricular free wall hypokinesis. Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. Dilated ascending aorta. . CXR [4-20] PA AND LATERAL CHEST: Cardiomediastinal silhouette is unchanged from a few days prior with cardiomegaly and calcification of the aortic arch again noted. Left-sided pleural effusion has decreased in size and retrocardiac density representing atelectasis versus consolidation persists. Right lung appears clear and there is no overt evidence of edema. A minor amount of fluid is seen within the left major fissure. Midline sternotomy wires are unchanged. . IMPRESSION: Some decrease in size of left-sided pleural effusion. No new acute cardiopulmonary process. . Brief Hospital Course: #Gallstone Pancreatitis s/p ERCP: as noted the patient underwent ERCP with unsuccessful removal of a large gallstone. However, a stent was placed with relief of biliary obstruction and normalization of LFTs/[Doctor First Name ]/lipase. Repeat RUQ U/S with resolved CBD dilation and no definite stone seen, ?had passed. Nevertheless, will f/u for repeat ERCP in 4 weeks for repeat ERCP, stent removal and repeat cholangiogram. ASA held for 10 days post-ERCP. Coumadin not started as pt with recent sphincterotomy. As mentioned, despite a significant leucocytosis, repeat Abd CT after procedure without perforation or complication from ERCP. Was kept on 7 days of Zosyn in house. No evidence of cholangitis. . #Cardiovascular Issues Ischemia: serial CE negative; ECG without acute changes. Pump: given concern for ?rub, an Echo was obtained. It showed [Last Name (LF) ], [First Name3 (LF) ] EF of 20%, and [2-6]+MR. ?if Rub heard was MR with an S3. Nevertheless, pt should have very close f/u with his PCP/Cardiology, given the fact he had an Echo at the VA in [2-11] with an EF of 40%. Continued on ACE-I. Hospital course complicated by mild CHF that resolved with IV lasix. D/C'd on home dose. ?if decreased EF was d/t contributing tachycardia-induced CM. Rhythm: the patient had rapid A fib during his hospitalization, with rates initially in the 120s. Lopressor increased to 150XL [Hospital1 ], and Diltiazem 240 daily added. On this regimine, HR was ~90s. [Month (only) 116] need to start Dig as an outpatient. Of note, the patient asked to be cardioverted numerous times during his stay. This would be impractical as the patient could not be coumadinized because of his recent sphincterotomy and need for repeat ERCP. In addition, given the fact that he is already on Amio, and has failed to maintain NSR in the past, repeat cardioversion highly unlikely to restore NSR. Pt would likely benefit for EP referral for both A fib ablation and ICD given ischemic CM. Prevention: statin held given transaminits. Can be restarted as an outpatient. ASA held as above. . #Thyroid Nodules: needs outpatient f/u. . #?RIJ clot: as noted on CT. U/S normal. Likely mixing artifact. Medications on Admission: Fosinopril 20, Toprol XL 75, Simvastatin 80, ASA 325, Coumadin (had been stopped recently), Lasix 40, Amio 400 daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO twice a day. Disp:90 Tablet Sustained Release 24 hr(s) Refills:2 5. Fosinopril 20 mg Tablet Sig: One (1) Tablet PO qd (). 6. DILT-CD 240 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT START until [4-23]. 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:60 Tab Sust.Rel. Particle/Crystal(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. Gallstone Pancreatitis s/p ERCP 2. Congestive Heart Failure 3. Atrial Fibrillation 4. Hyperlipidemia 5. Thyroid Nodules Secondary Diagnoses: h/o Rectal CA s/p local excision BPH s/p CCY CAD s/p CABG Discharge Condition: stable Discharge Instructions: Please call Dr. [Last Name (STitle) 48975] should you develop any fevers, chills, sweats, abdominal pain, nausea, vomiting, chest pain, shortness of breath, or any other complaints. It is very important to call the Visiting Nurses when you get home. Followup Instructions: It is EXTREMELY IMPORTANT to call Dr.[Name (NI) 100920] office Monday morning for followup. ICD9 Codes: 4280, 5849, 0389, 4254, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6457 }	Medical Text: Admission Date: [2114-8-10] Discharge Date: [2114-8-18] Service: MEDICINE Allergies: Vicodin Attending:[First Name3 (LF) 896] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Intubation History of Present Illness: The patient is an 89-year-old woman with a recent history of myelodysplastic syndrome requiring transfusions, presenting after experiencing abdominal pain at home. and not feeling well over the previous two days. The patient is a transfer from [Hospital1 ]. She was being worked up in their Emergency Room for a likely pancreatitis ("foggy" pancreas on CT with distended gallbladder). When she returned from the CT, she developed respiratory distress and tachypnea. She was treated with Benadryl duonebs. The patient was then intubated and sedated, after which she was transferred to [Hospital1 18] for additional care. She had received at least one dose of Zosyn at [Location (un) 620]. Upon originally arriving in the Emergency Department, she was not opening her eyes but she was following simple commands. The initial blood gas was 7.38/32/200/20, based on which the Emergency Department was willing to lower the FiO2 to 40%. The patient was also provided fentanyl for pain; propofol as her sedating [Doctor Last Name 360]. Surgery was consulted, but the patient was not felt to be a candidiate for cholecystectomy. The patient received 4 liters of fluid during her stay in the Emergency Department. She had a fever to 101.3 in the ED, for which she received Tylenol. The patient's vitals upon leaving the Emergency Department were HR 92 BP 111/53 RR 18 97% saturation on vent Fi O2 40 PEEP 5 Tv 500 with peak flow 20. . On arrival to ICU, patient was intubated and sedated but appeared comfortable. Her blood pressure dropped to 80s/50s, so she was bolused 1L of NS to which BP responded to 100s systolic. Daughter and granddaughter at bedside. Past Medical History: PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT, HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR): -no current outpatient treaters, previously followed by Dr. [Last Name (STitle) 46087] [Name (STitle) 105194] hx of MDD -previous trials of imipramine, lithium, and outpatient ECT -previous trial of celexa in [2112] per OMR -1 previous inpatient hospitalization she reports she did not find helpful -denies hx of SA PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES, OR OTHER NEUROLOGIC ILLNESS): hx of hyperthyroidnow now w/hypothyroidism treated w/ synthroid hx of breast CA s/p lumpectomy hx of paroxysmal a fib hx of MI hx of HTN hx of emboilism to right eye after arteriogram for MI hx of diverticular perforation, status post bowel resection Social History: She is widowed. She lives at [Location ] on the [Doctor Last Name ] in independent living. She has rare alcohol. No smoking. Lives independently. Gets help with housework. Does not walk with a walker. Family History: FAMILY PSYCHIATRIC HISTORY: Denies family hx of mental illness inlcuding depression, bipolar, schizophrenia -denies family hx of suicide attempts Physical Exam: On Admission: Vitals: BP: 103/43 P: 67 R: 17 18 O2: FiO2 40% General: Intubated, sedated, responds to voice, does not follow commands HEENT: Sclera anicteric, intubated Neck: Supple, no LAD Lungs: Diffuse rhonchi and expirtaory wheeze CV: S1, S2, systolic ejection murmur Abdomen: soft, distended, bowel sounds very quiet, no apparent rigidity GU: Foley in place Ext: warm, well perfused, 2+ radial pulses, edema of lower extremities Pertinent Results: On Admission: [2114-8-10] 03:45AM BLOOD WBC-5.4 RBC-2.17# Hgb-6.5# Hct-19.6# MCV-90# MCH-30.0 MCHC-33.3 RDW-20.5 Plt Ct-15# [2114-8-10] 03:45AM BLOOD PT-13.0 PTT-22.6 INR(PT)-1.1 [2114-8-10] 03:45AM BLOOD Glucose-122 UreaN-19 Creat-1.0 Na-138 K-3.6 Cl-111* HCO3-17* AnGap-14 [2114-8-10] 03:45AM BLOOD ALT-28 AST-31 LD(LDH)-407* AlkPhos-49 TotBili-1.1 [2114-8-10] 03:45AM BLOOD Lipase-1579* Studies: CXR [8-13]-Confluent lower lobe opacities with a left effusion, small, likely represent atelectasis. Echo [8-10]-Mild regional left ventricular systolic dysfunction, c/w CAD. Calcific aortic valve disease with minimal stenosis/mild regurgitation. Mild to moderate mitral regurgitation. Moderate pulmonary hypertension. RUQ US-IMPRESSION: Distended gallbladder with gallbladder wall edema, pericholecystic fluid with a small amount of sludge and tiny stones visualized in the gallbladder. There is however no evidence of intra- or extra-hepatic biliary ductal dilatation. Although cholecystitis cannot be fully excluded, although these findings are likely related to inflammatory changes from adjacent pancreatitis. Brief Hospital Course: Ms. [Known lastname ] was an 89 year old female who suffered from transfusion dependent myelodysplastic syndrome that was transferred from [Hospital1 18] [Location (un) 620] to [Hospital1 18] on [8-10]. She had initially presented to [Hospital1 18] [Location (un) ] with abdominal pain where she was found to have pancreatitis. In their emergency department, she developed respiratory distress and was intubated necessitating transfer to [Hospital1 18]. Ms. [Known lastname ] arrived at [Hospital1 18] intubated and sedated. She was able to follow simple commands and appeared comfortable. She was followed by the ERCP team who believed the pancreatitis was due to a passed gallstone and that no intervention was necessary. Ms. [Known lastname ] outpatient hematologist confirmed that the patient had likely moved from MDS to AML and that the family was declining chemotherapy. At [Hospital1 18] she had 20% blasts on peripheral smear and required intermittent platelet and PRBC transfusions. Following one platelet transfusion, the patient became difficult to ventilate and had a drop in her BP. CXR showed new opacities bilaterally and effusions. The primary team consulted with the blood bank/pathology and a diagnosis of TRALI was suspected. On [8-14] the patient was on pressure support ventilation and was no longer sdedated. A family meeting was held during which it was decided that when the patient was extubated, she would not be reintubated. She was extubated on the 27th. Following extubation the patient immediatly began to show signs of increased work of breathing. Attempts were made to improve the patient's respiratory status including diuresis and supplemental oxygenation. However, by the afternoon of the 27th it became clear that the patient was not going to be able to maintain her oxygenation. Family was called to bedside. Palliative care was called and were also at bedside. After discussion, family consensus was to move forward on comfort measures only On [8-17] the patient was transferred to a private room on a medical floor. She was placed on a morphine drip and a scopalamine patch. With family at bedside, she expired on [8-18]; time of death 15:52. Medications on Admission: ATORVASTATIN - (Not Taking as Prescribed: pt stopped) - 10 mg Tablet - 1 Tablet(s) by mouth daily CLONAZEPAM - (Prescribed by Other Provider: [Name Initial (NameIs) 3532]) - 0.5 mg Tablet - 1 Tablet(s) by mouth three times a day DANAZOL - 200 mg Capsule - three times a day - No Substitution LEVOTHYROXINE - 100 mcg Tablet - 1 Tablet(s) by mouth daily LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day PHYSICAL THERAPY - - gait training and general reconditioning -- eval& treat SERTRALINE - 25 mg Tablet - 1 Tablet(s) by mouth daily CALCIUM CARBONATE - (Prescribed by Other Provider) - 500 mg Tablet, Chewable - 1 Tablet(s) by mouth twice a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 2,000 unit Capsule - 1 Capsule(s) by mouth once a day Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable ICD9 Codes: 5845, 5990, 4019, 2449, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6458 }	Medical Text: Admission Date: [2160-4-3] Discharge Date: [2160-4-18] Date of Birth: [2094-5-1] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: mitral regurgitation, coronary artery disease Major Surgical or Invasive Procedure: mitral valve annuloplasty(28mm CE Ring), coronary artery bypass grafts(SVG-OM) [2160-4-8] History of Present Illness: This 65 year old male with chronic diastolic heart failure and myxomatous mitral degeneration was found to be in rapid AF when presenting for an ETT. Admits to a few months of worsening dyspnea. He developed flash pulmonary edema the night prior and was treated with Lasix and nitroglycerin. He was found to have significant mitral regurgitation on TEE and single vessel coronary disease at cath today.He is transferred for operation. Past Medical History: hypertension dylipidemia noninsulin dependent diabete mellitus asthma hypothyroidism Social History: Race:Hispanic Last Dental Exam: Lives with:wife and son Contact: Phone # Occupation: Cigarettes: Smoked no [] yes [x] last cigarette 3 days ago_ Hx: Other Tobacco use:1/2-1ppdx50 years ETOH: < 1 drink/week [] [3-11] drinks/week-beer8 drinks/week [] Illicit drug use-denies Family History: Family History:Premature coronary artery disease Father MI < 55 [] Mother < 65 [x] Physical Exam: Pulse:80 SR initially then 90s-130s rapid afib Resp:16 O2 sat:98% on 3L B/P Right: Left:129/68 Height: Weight: Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [x] intact [x] HEENT: PERRL [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [x] grade _4/6_____ 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 without hematoma Left:2+ DP Right:[2-4]+ Left:[2-4]+ PT [Name (NI) 167]:[2-4]+ Left:[2-4]+ Radial Right: 2+ Left:2+ Carotid Bruit Right: none Left:none Pertinent Results: [2160-4-16] 05:45AM BLOOD WBC-11.0 RBC-4.44* Hgb-12.2* Hct-37.1* MCV-84 MCH-27.5 MCHC-32.9 RDW-14.9 Plt Ct-442* [2160-4-18] 06:40AM BLOOD PT-29.1* INR(PT)-2.8* [2160-4-17] 05:50AM BLOOD PT-25.7* INR(PT)-2.5* [2160-4-16] 05:45AM BLOOD PT-25.8* INR(PT)-2.5* [2160-4-15] 04:45AM BLOOD PT-21.7* INR(PT)-2.1* [2160-4-14] 03:37AM BLOOD PT-18.3* INR(PT)-1.7* [2160-4-18] 06:40AM BLOOD Glucose-99 UreaN-16 Creat-0.9 Na-137 K-4.1 Cl-101 [2160-4-3] 09:55PM BLOOD Glucose-120* UreaN-23* Creat-1.0 Na-141 K-3.5 Cl-107 HCO3-23 AnGap-15 [2160-4-3] 09:55PM BLOOD %HbA1c-6.5* eAG-140* Findings LEFT ATRIUM: Marked LA enlargement. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV cavity size. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV chamber size. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. Calcified tips of papillary muscles. No MS. [First Name (Titles) ] vena contracta is >=0.7cm Severe (4+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB: 1. The left atrium is markedly dilated. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 4. The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. 5. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve leaflets are moderately thickened. The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. There is a central jet with bilateral leaflet retraction. The annular size is enlarged at 3.7 cm. Dr. [Last Name (STitle) ] was notified in person of the results. POST-CPB: On infusion of Phenylephrine, epi, milrinone. Well-seated annuloplasty ring in the mitral position with 1-2+ residual Mitral regurgitation. The LVEF is 40% on inotropic support, but may represent an overestimation due to mr. [First Name (Titles) ] [Last Name (Titles) ] remains 1+. The aortic contour is normal post decannulation. Brief Hospital Course: He underwent the usual preoperative work up and on [4-8] went to the Operating Room for mitral repair and single vessel graft. He weaned from bypass on Milrinone, Epinephrine and NeoSynephrine infusions. He transferred to the CVICU intubated and sedated. Over the next few days he weaned from vasoactive drugs and was extubated. He required reinstitution of milrinone for support and again weaned off, this time with Lisinopril for afterload reduction. He had heart block post operatively and EP saw him, there was no indicastion then for a pacemaker. rapid atrial; fibrillation recurred and Amiodarone was given. Coreg was then added due to his underlying heart failure. He continued to have a ventricular rate in the 110-130 range and he was digitalized with good rate control into the 80s. As he was on three nodal agents EP was reconsulted and they recommended to continue the current regimen and wean Amiodarone as usual. Coumadin was resumed and arrangements were made for the Greater [Hospital 487] Health Care Center to follow this as before. Follow up apppointments were made and instructions discussed with the patient and his wife. Medications on Admission: lasix 40 IV daily cardizem 240mg PO daily niacin 500 mg daily sotalol 80 po bid lisinopril 40mg twice daily lovastatin 40mg daily gemfibrozil 600mg daily levothyroxine 50mcg every morning celexa 40mg daily klonopin 1mg three times daiy as needed-anxiety magnesium oxide 400mg daily campral 333mg po three times daily albuterol mdi 2 puffs every 4 hours as needed for wheezing insulin sliding scale Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:50 Tablet(s) Refills:0 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 9. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg(two tablets twice daily) for two weeks, then 200mg (one tablet) twice daily for two weeks, then on tablet daily until instructed to discontinue. Disp:100 Tablet(s) Refills:2 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 13. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 14. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 15. Outpatient [Name (NI) ] Work PT/INR [4-21] and prn. Results to Greater [Hospital 487] Health Care Center [Hospital 197] Clinic 16. Coumadin 1 mg Tablet Sig: as directed Tablet PO once a day: 1mg 3/16,17,18. Dose 3/19 and after as directed by Healt Care Center clinic. Disp:100 Tablet(s) Refills:2 17. digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other day. Disp:50 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: mitral regurgitation cornary artery disease s/p mitral valve repair s/p coronary artery bypass graft paroxysmal atrial fibrillation hypothyroidism depression anxiety hypertension hyperlipidemia noninsulin dependent diabetes mellitus asthma 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: Surgeon:Dr.[Last Name (STitle) ]([Telephone/Fax (1) 170]) on [2160-5-21] at 1pm Cardiologist: Dr.[Last Name (STitle) ] will call with appointments Please call to schedule appointments with: Primary Care: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],NP ([Telephone/Fax (1) 63099]) in [5-8] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR2-2.5 First draw [2160-4-21] Results to fax [Telephone/Fax (1) 92595] (Greater [Hospital 487] Health Care Center) Completed by:[2160-4-18] ICD9 Codes: 2724, 3051, 4240, 2859, 4280, 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6459 }	Medical Text: Admission Date: [2113-3-2] Discharge Date: Date of Birth: [2113-3-2] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: The patient is the 1285, twin A product of an IVF Di/Di twin gestation born at 29-1/7 weeks to a 30-year-old primiparous mother. This pregnancy was complicated by vaginal bleeding due to placenta previa. The mother was transferred from [Name (NI) ] Hospital to [Hospital1 ]. She was treated with betamethasone prior to her transfer and subsequently at [Hospital1 ] Hospital. A UTI was treated with Macrobid. Prenatal screens showed maternal B+ blood type, antibody screen negative, RPR nonreactive, rubella immune, hepatitis B negative, and GBS unknown status. The patient was born by C-section after an episode of vaginal bleeding. The baby emerged vertex and had [Name (NI) ] scores of 8 and 8. She was given CPAP via neopuff in the Delivery Room. She was transferred to the NICU after visiting with the parents. FAMILY HISTORY: Notable for a mother who works as a pharmacist and father who works for the cable company. DISCHARGE PHYSICAL EXAMINATION: Pink, active, nondysmorphic infant with a weight of 1260 gm. HEENT exam: Unremarkable. Skin showed no lesions. Cardiac exam showed a normal S1/S2 without murmurs. Pulses were 2+ and equal bilaterally without delay. Lungs were clear. Abdomen was benign. There was no hepatosplenomegaly. Genitalia were those of a normal premature female. Neuro exam was nonfocal and age appropriate. Hip exam was unremarkable. Spine was intact. Anus was patent. There was full range of motion of all extremities. HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: The patient was admitted to the NICU. She was initially maintained on CPAP with low inspired oxygen concentration. On the second day of life, she was heard to have a murmur consistent with a patent ductus arteriosus and was treated with a course of indomethacin. The murmur has resolved following treatment. No echocardiogram has been done. The patient was weaned from CPAP on the [Hospital 76823] hospital day. She has subsequently been in room air with a comfortable respiratory status. She has intermittent apnea of prematurity. She is currently being treated with caffeine therapy. The patient never had a UA or UA line. 2. Fluid/electrolytes/nutrition: The patient was initially maintained NPO on IV fluids with parenteral nutrition. The patient was begun on enteral feeds on the fourth hospital day. She has progressed without difficulty through her current feedings of breast milk 20 at 140 mL per kg. Her PICC line is to be discontinued. 3. GI: The patient's maximum bilirubin was 7.1 on [3-11]. She was treated with phototherapy and a repeat on [3-13] is 3.1. phototherapy is to be discontinued and a rebound bilirubin is suggested at [Hospital ] Hospital. 4. Hematologic: The patient's initial hematocrit was 39.7. A repeat on the fourth day of life was 35. The patient has received no transfusions. 5. ID: Because of the initial respiratory distress and prematurity, the patient was begun on a 48 hour rule-out with ampicillin and gentamycin. Initial white count was 6.5 with 30 polys and 0 bands. Blood culture remained negative and the patient has remained clinically stable after the discontinuation of antibiotics. 6. Neurologic. The patient had a head ultrasound on [3-7] which showed no evidence of IVH and was otherwise normal. 7. Routine health care maintenance: The patient has not received any immunizations as of today. A specimen has been sent to the [Location (un) 511] Regional Newborn Screening Program. No abnormal results have been reported. 8. Discharge disposition: Transfer to level 2 facility at [Hospital ] Hospital under the care of Dr. [First Name (STitle) ]. The primary pediatrician is Dr. [Last Name (STitle) 49780] in [Location (un) 1456]. 9. Feedings at the time of discharge are breast milk 20 at 140 mL per kg. 10.Medications: Caffeine 9 mg per day. 11.Iron and vitamin B supplementation: a. Iron supplementation is recommended for premature and low birth weight infants until 12 months corrected age. b. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units (may be provided as a multivitamin preparation) daily until 12 months of corrected age. c. Car seat position testing has not yet been done. 12. a. Immunizations recommended [Dictate verbatim]: b. ??????Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following four criteria: 1) born at <32 wks; 2) born between 32 and 35 0/7 wks with 2 of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings; 3) chronic lung disease; or 4) hemodynamically significant CHD.?????? c. ??????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.?????? d. ??????This infant has not received rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age.?????? DISCHARGE DIAGNOSES: 1. Respiratory distress syndrome. 2. A 29-1/7 weeks premature infant. 3. Hyperbilirubinemia. 4. Patent ductus arteriosus. 5. Rule out sepsis. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], MD [MD Number(1) 36143] Dictated By:[Last Name (NamePattern1) 56160] MEDQUIST36 D: [2113-3-13] 12:40:06 T: [2113-3-13] 13:36:38 Job#: [Job Number 76824] ICD9 Codes: 769, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6460 }	Medical Text: Admission Date: [2114-10-9] Discharge Date: [2114-11-24] Date of Birth: [2044-6-15] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3918] Chief Complaint: cough and fevers x 1 month Major Surgical or Invasive Procedure: endotracheal intubation bone marrow biopsy History of Present Illness: 70 yo female with complicated hx of lung disease, thought likely to be Rheumatoid lung, previously evaluated/treated at [Hospital1 ] in MN, now presents with symptoms similar to previous presentations with cough and fevers x 4-5 weeks. . Pt notes that her sx previously began approx [7-9], with onset of rhinorrhea with post-nasal drip, development of a cough, and subsequent persistent fevers. During the initial episode, she was treated with levofloxacin and her symptoms appeared to improve for a few months. Her symptoms later recurred. She was evaluated at [Hospital3 14659] in MN, where her nephew is a pulmonary-critical physician. [Name10 (NameIs) ] the diagnosis is not entirely clear, she is presumed to have rheumatoid lung disease without evidence of articular involvement. She had a repeat CT chest at [Hospital1 ] approx 6 weeks ago; pt not aware of results. Pt states that she has had extensive testing, but is unclear about details. She notes that she has a hx of hematologic involvement with her prior episodes, and has required blood transfusion previously. Her HCT has dropped from 30 to 24. . More recently, she was provided a course of Levofloxacin, which she completed [9-30], which did not provide benefit. . For futher details of prior admission at [Hospital1 ], see PMH below. . . ROS: +: as per HPI, plus: night sweats - last 1 month ago, decreased appetite, LE edema, cough, hematochezia. Hemorrhoids. Fatigue. . Denies: weight changes, chills/rigors, photophobia, loss of vision, sore throat, chest pain, palpitations, LE edema, orthopnea/PND, DOE, SOB, hemoptysis, nausea, vomiting, abdominal pain, abdominal swelling, diarrhea, constipation, hematemesis, melena, easy bleeding/bruising, LAD, dysuria, rashes, myalgias, arthralgias, headache, confusion, dizziness, vertigo, paresthesias, weakness, depression, orthostasis. Past Medical History: 1. Significant for a diagnosis of rheumatoid lung disease. She was hospitalized after complaints of cough and fever at the [Hospital3 85404] in 08/[2112]. She was found to have interstitial pulmonary infiltrates, had a hematologic involvement, elevated CCP, and mild splenomegaly. Her lung disease was consistent with organizing pneumonitis and small airways inflammatory process. She had a lung biopsy, which was not diagnostic, but consistent with potential rheumatoid lung disease. Has been treated with prednisone and azathioprine as well as hydroxychloroquine. There was some question of whether there was a component of hypersensitivity pneumonitis as well given that she lived in a house in [State 760] with significant mold. She has subsequently moved from that house. She has no joint manifestations of rheumatoid arthritis. The patient spent much of the winter of [2112], hospitalized in the [Hospital3 14659]. She had a prolonged hospitalization in [7-/2113], and then again was readmitted in 12/[2112]. See below. Was subsequently in a rehabilitation facility until [2114-3-15], and recently moved to [Location (un) 86]. 2. Proximal lower extremity myopathy. 3. Distal fibular fracture in [1-/2114], after a fall, underwent nonoperative treatment. 4. Deep venous thrombophlebitis, diagnosed also in [10/2113], had a repeat ultrasound revealing some residual clot after three months; therefore, I had an extension of her course to a six-month total period of treatment, finished this at the end of 06/[2113]. 5. Urge incontinence. 6. Osteoporosis. 7. Osteoarthritis. She is soon to undergo a right total hip replacement at the [Hospital3 14659]. 8. C. diff colitis x2. 9. Recurrent urinary tract infections. Had an admission for urosepsis at the [Hospital3 14659] from [2113-11-2], to [2113-11-22]. 10. Anemia of chronic disease. 11. GERD. 12. Thyroid nodule with a negative biopsy and evaluation in the past. 13. Fibrocystic changes in breast. 14. Cardiovascular. The patient had an extensive lower extremity edema during her hospitalization, had a normal echocardiogram in [3-/2114], revealing an ejection fraction of 60% with no valvular heart disease. 15. Diverticulosis. Had a colonoscopy in [12/2113], that was otherwise unrevealing. 16. History of hypertension, taken off medications during [Hospital1 ] hospitalization. PAST SURGICAL HISTORY: Status post appendectomy, status post tonsillectomy, and thumb surgery on the left eight years ago. Social History: (Per record review. Was confirmed with patient.) The patient was born in [State 760]. She has never married and has never had any children. Lives with a cat at home and as above has recently moved to [Location (un) 86] to be closer to her family. Her brother and [Name2 (NI) 802] live in [Name (NI) 1439]. Drinks occasional alcohol. No history of tobacco. No history of IVDU. Did have a blood transfusion when she was hospitalized at the [Hospital1 ]. She is able to drive and is fairly independent at this point, limited mostly by the pain in her right knee. Denies any falls at home. No history of abuse. Has two brothers. Family History: (Per record review. Was confirmed with patient.) Mother died secondary to complications from what sounds like colon cancer, also had a history of diabetes. Father was a longtime smoker, had COPD. Both brothers have a history of CAD and valvular heart disease, but no early CAD in the family. No breast or ovarian cancer. Physical Exam: VS: 99.2 106/50 91 20 93RA GEN: AAOx3. Pleasant, non-toxic. HEENT: eomi, perrl, MMM. Neck: No LAD. JVP WNL. RESP: CTA B. No WRR. CV: RRR. No mrg. ABD: +BS. Soft, NT/ND. Obese. Ext: 2+ LE edema B to knee. No clubbing. Neuro: CN 2-12 grossly intact. Pertinent Results: [2114-10-9] 10:36AM BLOOD WBC-3.7* RBC-2.70* Hgb-7.9* Hct-24.7* MCV-91 MCH-29.1 MCHC-31.9 RDW-20.5* Plt Ct-155 [2114-10-9] 10:36AM BLOOD Neuts-81* Bands-0 Lymphs-12* Monos-4 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [2114-10-11] 07:05AM BLOOD WBC-3.7* RBC-2.46* Hgb-7.3* Hct-23.1* MCV-94 MCH-29.6 MCHC-31.5 RDW-21.0* Plt Ct-150 [2114-10-9] 10:36AM BLOOD Glucose-108* UreaN-18 Creat-0.7 Na-139 K-3.9 Cl-108 HCO3-23 AnGap-12 [2114-10-9] 10:36AM BLOOD ALT-13 AST-32 LD(LDH)-1134* AlkPhos-61 TotBili-0.8 [2114-10-11] 07:05AM BLOOD LD(LDH)-1273* [2114-10-9] 10:36AM BLOOD proBNP-652* [2114-10-9] 10:36AM BLOOD TotProt-6.3* Mg-2.1 Iron-45 [2114-10-9] 10:36AM BLOOD calTIBC-209* VitB12-353 Hapto-88 Ferritn-790* TRF-161* [2114-10-11] 07:05AM BLOOD RheuFac-3 [2114-10-10] 07:00AM BLOOD B-GLUCAN- Negative [2114-10-15] 01:15PM BLOOD HIV Ab-NEGATIVE [2114-10-14] 08:45AM BLOOD PEP-ABNORMAL B IgG-1745* IgA-250 IgM-473* IFE-MONOCLONAL [2114-10-20] 09:26AM BLOOD [Doctor First Name ]-POSITIVE * Titer-1:40 [Last Name (un) ] [2114-10-20] 09:26AM BLOOD ANCA-NEGATIVE B [2114-10-18] 07:00AM BLOOD Cortsol-12.8 [2114-10-14] 08:45AM BLOOD CRP-39.8* Anti-CCP: >250 (Strong Positive: >59) Aspergillus and B-glucan: negative BCR/ABL [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 85405] BCR-ABL T(9;22) FUSION 0.000 VITAMIN D, 1,25 (OH)2, TOTAL 26 Induced sputums: negative for PCP QUANTIFERON-TB GOLD Results Pending BRUCELLA ANTIBODY, AGGLUTINATION Results Pending CMV IgM: negative Lyme Serology: negative Toxoplasma: IgG positive, IgM negative Blood and urine cultures negative. CT CHEST W/O CONTRAST IMPRESSION: 1. No evidence of PCP infection or rheumatoid lung interstitial disease. 2. Mixed solid/ground-glass 1.8 cm LUL nodule concerning for neoplasm such as bronchoalveolar cell carcinoma; 3-month followup CT is recommended to evaluate for resolution. 3. A left lower lobe crescentic soft tissue irregulartiy, smaller lingular ground glass opacity and 3 mm LLL nodule should all be reevaluated at that time. 4. Splenomegaly; given rheumatoid arthritis and decreased WBC, this suggests Felty syndrome. 5. Right thyroid nodules, for which ultrasound would be more appropriate for evaluation. 6. Severe tracheomalacia; severe bronchomalacia of right mainstem bronchus/bronchus intermedius. CT ABD/PELVIS IMPRESSION: 1. Splenomegaly with spleen measuring 18 cm in the axial dimension and 16 cm in the craniocaudal dimension and multiple splenules. No CT evidence of portalhypertension. Splenomegaly is nonspecific, and lymphomatous/leukemic etiologies are differential considerations. No other adenopathy in the abdomen or pelvis. 2. Compression fracture of the T12 vertebral body with mild retrolisthesis of T12 on L1. 3. The left adrenal is mildly thickened which may represent adrenal hyperplasia. Peripheral blood FLOW CYTOMETRY IMMUNOPHENOTYPING INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by non-Hodgkin lymphoma are not seen in specimen. Correlation with clinical findings is recommended. Flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. SPECIMEN: BONE MARROW ASPIRATE ONLY. DIAGNOSIS: CELLULAR MARROW WITH MARKED ERYTHROID HYPERPLASIA AND NUMEROUS HEMOPHAGOCYTIC HISTIOCYTES. THERE IS NO EVIDENCE OF MYELODYSPLASIA. SEE NOTE. Note: There is no morphologic evidence of lymphoma or a classic chronic myeloproliferative syndrome. The presence of numerous hemophagocytic histiocytes raises the possibility of a macrophage activation syndrome which may be related to her previously diagnosed rheumatoid disease. Although her diagnosis of rheumatic lung disease has been put in doubt by recent imaging of the lungs, her inflammatory markers remain elevated and may be due to an ongoing rheumatological or other autoimmune disorder. CHROMOSOME ANALYSIS-BONE MARROW KARYOTYPE: 46,XX[14] INTERPRETATION: No clonal cytogenetic aberrations were identified in metaphases analyzed from this unstimulated specimen. This normal result does not exclude a neoplastic proliferation. Mosaicism and small chromosome anomalies may not be detectable using the standard methods employed. Cardiac Echo: IMPRESSION: Normal biventricular systolic function. Normal estimated left ventricular filling pressure. Moderate estimated pulmonary artery systolic hypertension. PET IMPRESSION: 1. Splenomegaly without associated increased FDG-avidity to suggest lymphomatous involvement. No FDG-avid adenopathy. 2. Mild diffusely increased FDG-avidity involving the bone marrow that is non-specific and could be related to drug reaction, though leukemic involvement cannot be excluded, for which clinical correlation and interval follow-up can be obtained as indicated. 3. Lower lobe predominant subpleural reticulation demonstrating increased FDG-avidity most compatible with a component of rheumatoid lung involvement and associated active inflammation. 4. Grossly stable ground-glass nodule in the left upper lobe; though does not demonstrate FDG-avidity, BAC is not excluded, and continued follow-up is recommended. 5. Stable heterogeneously enlarged right thyroid lobe with multiple non-FDG avid nodules that can be correlated with ultrasound. Brief Hospital Course: Ms. [Known lastname ] was a 70 year old female with a PMH significant for possible RA (on prednisone, azathioprine, and hydroxychloroquine), possible RA associated ILD, and DVT (not currently anticoagulated) admitted on [2114-10-9] for 4 months of productive cough and several weeks of fever to 102. She was transferred to the [Hospital Unit Name 153] for hypoxic respiratory distress. During her prolonged hospital stay, she has been evaluated by rheum, ID, hematology-oncology and pulmonary for her fever, CTD, pancytopenia, splenomegaly, and possible ILD. She underwent bone marrow biopsy demonstrating hemophagocytic histiocytes, therefore the diagnosis of HLH was strongly considered. She was restarted on cyclosporine, dexamethasone, and infliximab. As patient was mentating/performing well on SBP's >80, that was set as the limit for pressor use. After starting treatment for HLH with cyclosporine, dexamethasone, IVIg, and infliximab, the patient was eventually weaned off pressors with BP's staying in the 80-90 /40-50 range. In addition, she has a LUL ~2 cm nodule concerning for BAC. . Her hospital course has been complicated by episodes of transient hypoxia and intermittent hypotension. She was never intubated or required non-invasive ventilation and she was eventually weaned to RA. In terms of her hypotension, she was started on pressors on admission to MICU. Infectious, endocrine & cardiac work up were unrevealing and she was eventually started on midodrine for pressure support. She was started on epogen for anemia. Lastly she had evidence of a missed STEMI and was started on aspirin. . On the floor she continued to deteriorate clinically and her code status was changed to comfort measures only. Medications on Admission: ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth q week AZATHIOPRINE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - one teaspoon by mouth [Hospital1 ] prn cough may cause sedation HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day OXYBUTYNIN CHLORIDE - 5 mg Tablet - 0.5 (One half) Tablet(s) by mouth three times a day Medications - OTC ASCORBIC ACID - 1,000 mg Tablet - 2 Tablet(s) by mouth once a day ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day CALCIUM [CALCIO [Doctor First Name 15] [Month (only) 16]] - 500 mg Tablet - 1 Tablet(s) by mouth (1250) [Hospital1 ] CHOLECALCIFEROL (VITAMIN D3) - 2,000 unit Tablet - 1 Tablet(s) by mouth once a day DOCUSATE SODIUM - 100 mg Capsule - 2 Capsule(s) by mouth once a day FOLIC ACID - 0.4 mg Tablet - 1 Tablet(s) by mouth once a day GLUCOSAMINE HCL-MSM - 750 mg-750 mg Tablet - 2 Tablet(s) by mouth once a day MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day OMEGA-3 FATTY ACIDS [FISH OIL] - 1,000 mg Capsule - 1 Capsule(s) by mouth twice a day Discharge Medications: EXPIRED Discharge Disposition: Expired Discharge Diagnosis: EXPIRED Discharge Condition: EXPIRED Discharge Instructions: EXPIRED Followup Instructions: EXPIRED [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 3922] Completed by:[2115-1-13] ICD9 Codes: 2761, 7907, 5990, 2875, 4019, 4168, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6461 }	Medical Text: Admission Date: [2158-6-22] Discharge Date: [2158-7-5] Service: TSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: SOB, here for pleuroscopy Major Surgical or Invasive Procedure: [2158-6-24]: Pleuroscopy History of Present Illness: 81 yo man with h/o A fib (on coumadin), HTN, DM, hyperthyroidism, and recurrent pleural effusion x 6 weeks who is being admitted for pleuroscopy tomorrow. Patient had effusion drained at [Hospital 46] Hosp 6 weeks ago. Over the past 6 weeks, the fluid has reaccumulated and the patient's pulmonologist referred the patient to [Hospital1 18] intervential pulmonology for pleuroscopy. Patient was to have procedure done today, but had high coags. Patient admitted today to receive FFP in preparation of pleuroscopy tomorrow. Past Medical History: HTN A fib Hyperthyroidism DM recurrent pleural effusion (drained 6 weeks ago at [Hospital 46] Hosp) s/p appy at age 8 Social History: unknown Family History: unknown Physical Exam: VS: T=100.6 BP=134/74 HR=139 RR=18 O2=96% GEN: elderly man, lying in bed, not speaking in full sentences, SOB HEENT: PERRL OU, EOMI bilaterally, OP clear, MMM CV: No elevated JVD, Non-displaced PMI, tachy at about 150, Normal S1S2, No M/R/G RESP: + accessory muscle use, dullness to percussion on left side, decreased BS on left, no w/r/r ABD: Normo active BS, obese, non-tender, no rebound, non-distended, no masses, no organomegaly appreciated; appy scar RLQ EXT: no cyanosis, edema, or clubbing PULSES: 1+ dp/pt pulses bilaterally NEURO: A&Ox3; CN II-XII intact bilat; sensation and motor exams intact bilaterally Pertinent Results: [2158-6-23] 06:30AM BLOOD WBC-12.4* RBC-4.54* Hgb-11.8* Hct-37.7* MCV-83 MCH-26.0* MCHC-31.3 RDW-12.4 Plt Ct-441* [2158-6-24] 04:30AM BLOOD WBC-11.8* RBC-3.80* Hgb-10.3* Hct-31.5* MCV-83 MCH-27.2 MCHC-32.7 RDW-12.4 Plt Ct-320 [2158-6-22] 12:30PM BLOOD PT-18.5* INR(PT)-2.3 [2158-6-24] 08:23AM BLOOD PT-16.5* PTT-38.6* INR(PT)-1.8 [2158-6-23] 06:30AM BLOOD Glucose-114* UreaN-22* Creat-0.7 Na-137 K-4.1 Cl-98 HCO3-27 AnGap-16 [2158-6-24] 04:30AM BLOOD Glucose-186* UreaN-23* Creat-0.7 Na-140 K-3.7 Cl-100 HCO3-27 AnGap-17 [2158-6-24] 11:10AM BLOOD Calcium-9.0 Phos-4.6* Mg-1.9 [2158-6-24] 11:53AM BLOOD Type-ART Temp-37.7 PEEP-5 O2-50 pO2-134* pCO2-56* pH-7.33* calHCO3-31* Base XS-2 Intubat-INTUBATED Vent-SPONTANEOU [2158-6-25] 12:12AM BLOOD pO2-76* pCO2-39 pH-7.39 calHCO3-24 Base XS-0 [2158-7-3] 04:59AM BLOOD WBC-7.8 RBC-3.62* Hgb-9.5* Hct-29.9* MCV-83 MCH-26.3* MCHC-31.7 RDW-14.0 Plt Ct-405 [2158-6-28] 09:50PM URINE Hours-RANDOM Creat-154 Na-LESS THAN K-42 Brief Hospital Course: Mr. [Known lastname 10680] was admitted to the floor to receive FFP in order to bring his INR below 1.5 so that he could have pleuroscopy the following day. During the first night of his admission, he was in a fib on telemetry and his heart rate was initially in the 150's. He had not taken his evening dose of atenolol yet. He was given that dose, as well as a dose of IV lopressor. His heart rate then came down to the 110's. Later that evening, he required another dose of IV lopressor as well as PO metoprolol. * Mr. [Known lastname 58571] INR was originally 2.3. He was initially given 2 units of FFP which brought his INR down to 1.9. An additional 2 units were given; however, his INR was still too high at 1.8. The procedure was postponed until the following day so that the patient could receive more FFP in an attempt to lower his INR < 1.5. He was given an additional 2 units of FFP overnight, and a recheck of his INR was 1.8. He was given 2 more units of FFP, but his INR remained at 1.8. He was brought to the operating room to have a VATS by thoracic surgery despite having an INR=1.8. He required the OR because it was a weekend day, and there were no [Name8 (MD) 58572] RN's to do the procedure in the pulmonary procedure suite. After the procedure, the patient had a prolonged stay in the PACU because he was in rapid a fib and had new onset mild CHF (likely rate related). He was diuresed and rate controlled (with diltiazem drip and PO metoprolol). He was maintained on dilt drip and metoprolol on transfer to the floor. Thoracic surgery recommended that they perform a decortication later in the week to free the patient's trapped lung. * For the following week, the patient was continued on rate control with diltiazem drip and metoprolol. His metoprolol was slowly titrated up while trying to keep SBP>90. He was bolused gently on [1-3] occasions for low BP (with 250 cc NS). Overall, the patient did well in the pre-op period; however, his rate was difficult to control while maintaining adequate BP. His rate remained in the range of 90-110 (occasionally up to 120), with BP in range of 90-110/50-80. His INR continued to rise despite receiving FFP and holding coumadin. After reaching 3.2, vitamin K 5mg po was given x 1 dose to reverse pt so he would be able to go for decortication. After vitamin K, the patient's INR fell to 1.9.* Cardiology was consulted the day prior to surgery for recommendations of better rate control. They recommended digoxin 0.125 mg PO qd and lisinopril 75mg PO TID for rate control. The patient was rate controlled prior to left thorocatomy and decortication on [6-28]. Post-operatively the patient did well and was transferred to the ICU intubated. The patient's TSH was evaluated and deemed to be low POD #1 with this may have been adding to difficult with rate control of his afib. His anti- hyperthroid med methimazole 10 mg PO BOD was restarted POD 5.The patient was diuresed with lasix while in the unit and responded well and his creatinine remained stable. He was treated with aggressive pulmonary toilet and his chest tubes remained to suction. POD 3 the patient had a PA and Lateral CxR to evaluate the left lung and the fluid in the intrapleural space. The patient's CXR appeared stable and much improved to previous films that had showed a large pleural effusion on the left side.The patient's pain was managed with PO morphine PRN and toradol 15mg PO PRN. The was put on aspiration precaustions and his INR was stable at 2.5. The patient began to work with PT on POD 3 in order to improve his mobility. The patient had a weak cough and difficulty moving around in bed.The patient remained stable in the unit POD [3-6]. He was transfered to the floor on POD 6 where he was restarted on all his home meds. Particularly he was switched from lopressor to atenolol and restarted on his glyburide 1.5 mg PO BID and coumadin 2 mg PO qd. The patient continued to work with PT and made improvement in his strength and previously limited mobility. The patient will follow up with Dr. [Last Name (STitle) ] in addtion to a prior schedule pulmonology appointment. THe patient is going to rehab on all his prior meds and on the same doses of those medications. He is doing well and will require once a day dressing changes along with physical therapy in order to increase his strength and mobility. The patient will also require aggressive pulmonary toilet and encourage for taking food. Medications on Admission: Methimazole 10 mg PO BID lisinopril/HCTZ 20/12.5mg po QD Atenolol 50 qam, 25 qpm Glyburide 1.25 mg po BID Coumadin 2 mg po qhs Tylenol 2 tabs [Hospital1 ] Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Methimazole 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO QD (once a day). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 6. Methimazole 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO QD (once a day). 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Glyburide Micronized 3 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for type II DM. Discharge Disposition: Extended Care Facility: [Hospital3 30191] - [Location (un) 22287] Discharge Diagnosis: Recurrent pleural effusion PMH: Diabetes mellitus type II, hypertension, repeated history of pleural effusions, atrial fibrillation, hyperthroidism Discharge Condition: Stable Discharge Instructions: Please come to the emergency room if you have worsening shortness of breath, chest pain, severe cough, or fever. Take all medications as prescribed. Followup Instructions: Please follow up with pulmonology as scheduled. Please follow with Dr. [Last Name (STitle) ] [Last Name (STitle) ] as scheduled. If appointment not already schedule or change in patient's condition occurs, patient should call Dr.[Doctor Last Name 4738] office inorder to schedule appointment. ICD9 Codes: 4280, 5119, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6462 }	Medical Text: Admission Date: [2159-2-15] Discharge Date: [2159-2-20] Date of Birth: [2144-1-28] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 358] Chief Complaint: Elevated blood sugar Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname ] is a 15 yo female with DM1 who presented earlier today to [Hospital6 5016] with a complaint of not feeling well x 3 days. She states that she ran away from her group home on Monday and had not taken any insulin since then. She reports that on Tuesday, she begain experiencing myaligias, polydypsia, polyuria, and increased fatigue. She called her group home today and reported feeling lightheaded and nauseous. She was met by EMS and brought to [Hospital3 ]. She denies any fevers, chills, cough, dysuria, diarrhea. She denies any sick contacts. LMP was [1-16]. On arrival at OSH, finterstick was 351, T 97.8, BP 110/57, hR 104, RR18 , SpO2 100% on RA. UA was positive for 4+ ketones. Serum and urine tox screens and urine B-HCG were negative. Review of her lab values revealed WBC 22.5 and anion gap of 21. She received 2 L NS, 10 units IV regular insulin and 54 units of Humalog 75/25 and was transferred to [Hospital1 18]. On arrival at [Hospital1 18] ED, T 98.3, HR 117, BP 120/68, SpO2 98% on RA. She received 2L D51/2NS, 20 meq KCL and insulin drip at 5 units/hour. Past Medical History: IDDM, diagnosed 5 years ago, last HbA1c 11.1% [2159-2-1], followed by Dr. [First Name (STitle) 14840] at [Hospital ] Clinic Migraine headaches Depressive disorder Social History: Born in the DR [Last Name (STitle) ] moved to the US at age 8. She is currently in the 8th grade at The [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 21883] School. She is a resident of the Key Program. She is currently under the custody of DSS and is legally separated from her mother due to allegations of physical abuse. She has a history of alcohol abuse, but states that she quite 4-5 months ago. She previously smoked an occasional cigarette "when she could get it" but also quit [3-10] months ago. She previously used marijuana. She denies any recent drug use. She is sexually active with multiple partners and has a history of promiscuity. She has a history of running away and drinking and smoking while on the run. Family History: Non-contributory Physical Exam: AF, VSS GEn -- overweight young female, NAD HEENT -- nodulocystic acne on face, op clear Heart -- regular, no mrg Lungs -- clear Abd -- soft, benign Ext -- no edema neuro -- grossly intact Pertinent Results: Admission Labs: [2159-2-15] 06:50PM GLUCOSE-108 UREA N-26* CREAT-1.2* SODIUM-137 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-11* ANION GAP-29* [2159-2-15] 06:54PM GLUCOSE-103 NA+-139 K+-4.3 CL--106 TCO2-10* [2159-2-15] 09:53PM GLUCOSE-131* NA+-132* K+-9.8* CL--105 TCO2-15* [2159-2-15] 10:20PM GLUCOSE-136* NA+-132* K+-4.5 CL--106 TCO2-14* [2159-2-15] 06:50PM WBC-26.4* RBC-4.87 HGB-14.5 HCT-42.7 MCV-88 MCH-29.7 MCHC-33.9 RDW-12.7 [2159-2-15] 06:50PM NEUTS-90.1* BANDS-0 LYMPHS-6.2* MONOS-3.2 EOS-0.2 BASOS-0.2 [2159-2-15] 06:50PM PLT SMR-NORMAL PLT COUNT-338 [2159-2-15] 06:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CXR: [2-16] - No evidence of acute cardiopulmonary abnormalities. [2159-2-19] 07:30AM BLOOD WBC-8.1 RBC-4.34 Hgb-12.6 Hct-37.7 MCV-87 MCH-29.0 MCHC-33.3 RDW-13.0 Plt Ct-272 [2159-2-19] 07:30AM BLOOD Glucose-158* UreaN-10 Creat-0.7 Na-140 K-4.4 Cl-102 HCO3-30 AnGap-12 [2159-2-19] 07:30AM BLOOD Calcium-9.2 Phos-4.5# Mg-1.7 [2159-2-15] 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2159-2-16] 07:30AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2159-2-16] 07:30AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-TR Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2159-2-16] 07:30AM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE Epi-3 Urine and Bld cx negative. Brief Hospital Course: Ms. [Known lastname ] is a 15 yo female with DM1 who presented with diabetic ketoacidosis following four days of medication non-compliance, after running away from her group home. Anion gap of 25 at time of presentation, 12 on arrival to [Hospital Unit Name 153]. Likely triggered by medication non-compliance; however, infectious work-up pursued given leukocytosis with left-shift, and negative. Insulin drip initiated, titrated to fingersticks 150-200, then switched to home regimen of lantus and humalog. Blood sugars well controlled at time of transfer to floor. She remained well controlled on home regimen with instructions to see her primary [Last Name (un) ] physician within three weeks of discharge. Seen by psych per request of DSS, no acute intervention felt to be required for her depression. Psych does recommend the patient be connected with a pediatric psychiatrist for longterm care, which was discussed with her social worker with DSS and will be arranged. Medications on Admission: Humalog 75/25 56 units qAM Lantus 18 units qAM Humalog sliding scale Naproxyn 375 mg PRN headache Zomig Cromolyn 4% eyedrops 4x/day Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous once a day. 2. insulin 75/25 resume previous schedule of 56 units in the morning and 28 units at night. Discharge Disposition: Home Discharge Diagnosis: diabetic ketoacidosis Discharge Condition: none Discharge Instructions: You were hospitalized with diabetic ketoacidosis. Followup Instructions: Please see Dr. [First Name (STitle) 14840] at the [Hospital ] Clinic on [3-5] at 3:15pm. The psychiatrists here recommend you see a child psychiatrist regularly for your depression, please make an appointment after discharge. ICD9 Codes: 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6463 }	Medical Text: Admission Date: [2146-12-19] Discharge Date: [2146-12-29] Date of Birth: [2093-6-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2745] Chief Complaint: transfer from OSH for respiratory failure Major Surgical or Invasive Procedure: Intubated by EMS History of Present Illness: Mr. [Known lastname 5395] is a 53 yo man with obesity, glucose intolerance and borderline hypertension who was initially taken to an OSH after being found at home by his son nearly unresponsive with vomitus on his shirt. . He was intubated in the field and taken to [Hospital3 ]. On admission, he was febrile to 103, tachycardic to the 140s, tachypneic to the high 30s and sating in the 80s on high FiO2 initially. He underwent LP, CT head and CXR, which revealed bilateral patchy pulmonary infiltrates and evidence of mastoiditis. His initial WBC count was 4.7 and initial BUN/Cr was 28/3.8. A d-dimer was positive, but given the renal failure, he only underwent LENIs that did not demonstrate evidence of thrombosis. He was initially broadly covered with antibx for PNA, both CAP and aspiration, and bacterial meningitis and HSV encephalitis with acyclovir, ceftriaxone, ampicillin, azithromycin, vancomycin, clindamycin. The LP was not suggestive of meningitis or encephalitis. Sputum gram stain demonstrated 4+ GPCs in pairs, chains and clusters, and sputum and blood cultures are pending. His inital CK was ~2400 and rose to ~20,000. Urine was apparently positive for Strep pneumoniae antigen. . On further history from the pt's wife, he had been in his usual state of health until the night prior to admission to [Hospital1 5979]. At that time, he was c/o ear fullness, but he did not mention fever or cough. The next day, the pt's son tried to awaken him in the middle of the day, but he was apprently taking a nap and did not want to be disturbed. Later that evening, the pt's son returned home, and the pt could not be awakened, so EMS was called. . ROS was otherwise unobtainable. . Past Medical History: Obesity ? DM2 ? HTN Social History: No tobacco, social EtOH, no illicits Family History: NC Physical Exam: Vitals: T: 98.8 BP: 153/103 P: 101 R: 35 SaO2: 99% General: opens eyes to voice, squeezes hands to command, wiggles toes to command, intubated HEENT: PERRL, anicteric, no conjunctival injection, bull neck, no LAD Pulmonary: Lungs with bilateral ronchi anteriorly, no wheeze or rales Cardiac: RR, distant S1 S2, no murmurs, rubs or gallops appreciated Abdomen: obese, soft, NT, ND, normoactive bowel sounds Extremities: No edema, 2+ radial, DP pulses b/l Neurologic: Opens eyes to voice, squeezes hands on command, wiggles toes on command Pertinent Results: [2146-12-19] 10:21PM WBC-17.2* RBC-4.21 HGB-11.8* HCT-34.2* MCV-81* MCH-27.9 MCHC-34.4 RDW-13.7 [2146-12-19] 10:21PM NEUTS-82* BANDS-10* LYMPHS-7* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2146-12-19] 10:21PM PLT COUNT-216 [2146-12-19] 10:21PM PT-13.4 PTT-28.1 INR(PT)-1.2* [2146-12-19] 09:53PM GLUCOSE-144* UREA N-36* CREAT-1.5* SODIUM-142 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-30 ANION GAP-11 [2146-12-19] 09:53PM CK(CPK)-[Numeric Identifier 77019]* [2146-12-19] 09:53PM CALCIUM-8.1* PHOSPHATE-2.0* MAGNESIUM-2.3 . [2146-12-20] Chest CT: 1) Bilateral, multifocal consolidation; CT appearance in correlation with laboratory/clinical history suggestive of multifocal pneumonia, however improvement on subsequent chest radiograph is somewhat atypical. Findings and distribution not typical for aspiration or noncardiogenic pulmonary edema. 2) Fatty liver. . [2146-12-20] Head Ct: 1. Hypodense globus pallidi which may represent carbon monoxide or other toxin exposure. Consider MRI for further evaluation. 2. Fluid-filled mastoid air cells and middle ear cavities. 3. Periodontal disease and/or current or old infection around the roots of multiple teeth. 4. No acute hemorrhage, masses, or mass effect. . [2146-12-21] MRI/MRA Head - T2 hyperintensities and slow diffusion involving the globus pallidi as well as small foci of slow diffusion involving the deep watershed distribution bilaterally and the right anterior watershed distribution. These findings may represent carbon monoxide poisoning or other toxin exposure versus global hypoxia/anoxia. . [2146-12-23] MRI Head - 1) T2 hyperintensities and slow diffusion involving the globus pallidi as well as the subcortical white matter are unchanged since [2146-12-21] and may represent global hypoxia/hypoperfusion event or carbon monoxide poisoning. 2) Bilateral mastoiditis. Brief Hospital Course: A/P: 53 yo man intially found lying on his couch unresponsive covered in vomitus transferred from OSH with multilobar pneumonia, ARDS, acute renal failure and bilateral globus pallidus hypodensity on head CT, doing well since extubated yesterday, some right deltoid weakness on exam. . # PNA/ARDS: possibly [1-21] Strep pneumo (suspected given urine positive for S.pneumo antigen at OSH) complicated by aspiration and ARDS. Also possibly aspiration pneumonia [1-21] vomiting and decreased mental status from unknown precipitant. He was intubated in the field by EMS and transferred to [Hospital1 ]. Nasopharyngeal aspirate at OSH with Strep pneumo and Hemophilus influenza. He was transferred here on [12-20] due to incrasing ventillatory requirements and ARDS. He was maintained on low pressure mechanical ventillation. In addition, antibiotic coverage was broadened to vancomycin, zosyn and ciprofloxacin per ID recommendations to cover for ventillator associated pneumonia given his persistant fevers up to 103. He continued to improve daily and was extubated [2146-12-25] without difficulty. Ciprofloxacin was weaned off on day 7. Vancomycin and Zosyn were continued to complete a 14 day course. . #Bilateral Globus Pallidus Infarct/Unresponsive on Admission - very concerning for anoxic brain insult vs toxic metabolic process. Also classically seen in CO poisoning, although no evidence of other family members affected so less likely. MRI confirmed this finding also with decreased signal in watershed areas of the brain also seen with anoxic insult. Repeat MRI did not show progression. CSF at [Hospital3 ] without growth on culture. Patient had right deltoid weakness which per neurology was likely to right brachial plexus injury from his time down on his right side. This clinically improved during his admission. Otherwise no focal neuro deficits. Patient scheduled to f/u with behavioral neurology. . #Diarrhea - Patient with profuse diarrhea on admission and throughout most of ICU stay. Stool studies negative for C.diff x5. He was treated with brief course of oral flagyl, however this was stopped early as the diarrhea resolved and stool studies were negative. . #Bilateral opacification of middle ear and mastoid air cells- seen on head ct at OSH, pt also had been reporting ear fullness. Currently denies ear pain but state that ears don't feel normal. Seen by ENT, felt that radiographic and clinical signs not c/w mastoiditis. -if necessary pt can f/u with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 77020] . #ARF: Likely combination of volume depletion and mild degree of rhabdomyolysis [1-21] being down vs possible seizure. Resolved. . # Rhabdomyolysis: He had elevated CPK up to 20,000 at OSH possibly due to seizure, but no evidence of seizure activity on EEG at OSH, also possibly from being down for prolonged time. CK's trended down with IVF. . # Prophylaxis: Heparin SC 5000 tid . #Access - PICC . # Code status: FULL CODE Medications on Admission: Home medications: Methylphenidate . Medications on transfer: Ceftriaxone 2 grams q12hrs Esomeprazole Heparin SC tid Methylprednisolone 20 daily Vancomycin 1 g [Hospital1 ] Discharge Medications: 1. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) bag Intravenous Q8H (every 8 hours): Give Until [2147-1-2]. 2. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) bag Intravenous Q 8H (Every 8 Hours): Give until [2147-1-2]. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 4. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for diarrhea/yeast. 5. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: PICC Flush. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO q6 prn as needed for fever or pain. 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 ] Discharge Diagnosis: Multilobar Pneumonia Bilateral Globus Pallidus Infarct Rhabdomyolysis Discharge Condition: Vital Signs Stable Discharge Instructions: Return if having fever, chills, shortness of breath, coughing up blood, severe chest pain. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD, PHD Behavioral Neurology Phone:[Telephone/Fax (1) 8645] Date/Time:[2147-2-20] 2:00 [Location (un) ]. [Location (un) ], [Numeric Identifier 4774] (neuropsych testing will be arranged at that time). ICD9 Codes: 5185, 5849, 5070, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6464 }	Medical Text: Admission Date: [2148-7-7] Discharge Date: [2148-7-10] Date of Birth: [2106-4-27] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2145] Chief Complaint: s/p motor vehicle accident Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 15300] is a 42 yo woman with h/o type I diabetes who presents with diabetic ketoacidosis after motor vehicle accident on [7-6]. She was in the rear seat of the vehicle when her car was hit from behind; she was wearing a seat belt. After the accident she felt intense neck and lower back pain, describing them as spasms with severity of [10-17] (with 10 being the worst). She initially had difficulty moving her extremities, reportedly from left shoulder pain, upper extremity tingling and numbness as well as right knee pain. She did not lose conciousness during the accident and states remembering the events well. She did not notice any bruising, bleeding or lacerations and did not feel lightheaded. She has also recently had symptoms of sore throat, rhinorrhea, nausea/vomiting and abdominal pain. She believes her son has had similar symptoms. She denied fever or chills. In the ED, her vitals were T 98.2 153/70 HR 89 RR 18 98% on RA; glucose was >500. She was evaluated by the ED staff and the trauma team; she had no fractures or hemorrhages on extensive radiologic imaging. A plan was made for discharge to home, but while she was awaiting discharge in the ED, she developed symptoms of lightheadededness, dizziness and generalized weakness when she got up to go to the bathroom. Blood glucose was very elevated at 649. On further history, she noted that she had missed her AM insulin dose of 32 units of Lantus and 10 units of Humalog which she takes during meals. Her usual home FSG ranges in the 250-300s. She was given 22 units regular insulin IV in the ED and her glucose dropped to 235. Of note, ketones were 150, and anion gap was elevated at 20. Head CT was negative for CVA or hemorrhage. She was admitted to the MICU for treatment of diabetic ketoacidosis. Overall her nausea has improved with some residual abdominal pain. She continues to complain of lower back, neck and left shoulder pain and headache. Review of sytems: (+) Per HPI (-) Otherwise negative. Denies fever, chills, night sweats. Denies sinus tenderness. Denies cough, shortness of breath. Denied chest pain or tightness, palpitations, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: Type 1 diabetes mellitus Depression Social History: Lives in [Location (un) 538] with three children. Denies tobacco, alchohol, illicit drug use. Family History: Diabetes in maternal grandmother. Physical Exam: Exam on transfer from MICU to floor: T 99 110/60 HR 88 RR 16 100%RA FSG 163 GEN: lying in bed supine in NAD, alert, pleasant HEENT: NC/AT, PERRL, EOMI, MMM, OP clear NECK: intact range of motion but moderate TTP left trapezius, no LAD, normal JVP CV: RRR, normal S1, S2, no M/R/G CHEST: clear bilaterally ABD: soft, nondistended, normal bowel sounds, mild epigastric tenderness, no hepatosplenomegaly EXTR: no cyanosis or edema, left shoulder movement intact but reported pain with abduction; lower thoracic and lumbar region with moderate TTP paraspinal area; cervical region (C2-C6) left sided TTP overlying trapezius as well; right patella tender to palpation without knee effusions; 2+ DP/rad pulses bilaterally NEURO: AOx3, CNII-XII intact, strength normal bilaterally in UE, LE, including hand grip, elbow flexion/extension, shoulder abduction, knee extension/flexion, hip flexion, plantar flexion. 2+ DTR in [Name2 (NI) ]/LE. Psych: pleasant, alert, euthymic mood, response appropriate. Thought process linear, logical, coherent. Pertinent Results: [2148-7-10] 07:15AM BLOOD WBC-9.1 RBC-3.97* Hgb-12.0 Hct-36.0 MCV-91 MCH-30.2 MCHC-33.2 RDW-13.7 Plt Ct-377 [2148-7-9] 07:20AM BLOOD WBC-10.3 RBC-3.93* Hgb-11.5* Hct-35.2* MCV-90 MCH-29.4 MCHC-32.8 RDW-13.3 Plt Ct-375 [2148-7-8] 02:10AM BLOOD WBC-11.6* RBC-4.13* Hgb-12.8 Hct-37.3 MCV-90 MCH-31.1 MCHC-34.4 RDW-13.7 Plt Ct-387 [2148-7-6] 07:30PM BLOOD WBC-9.4# RBC-4.39 Hgb-13.2 Hct-41.0 MCV-94 MCH-30.1 MCHC-32.2 RDW-13.3 Plt Ct-390 [2148-7-10] 07:15AM BLOOD Glucose-231* UreaN-16 Creat-0.5 Na-136 K-4.7 Cl-103 HCO3-26 AnGap-12 [2148-7-9] 07:20AM BLOOD Glucose-97 UreaN-17 Creat-0.5 Na-137 K-4.1 Cl-107 HCO3-24 AnGap-10 [2148-7-8] 06:20PM BLOOD Glucose-258* UreaN-16 Creat-0.6 Na-132* K-3.9 Cl-105 HCO3-17* AnGap-14 [2148-7-8] 06:00AM BLOOD Glucose-52* UreaN-17 Creat-0.7 Na-140 K-3.9 Cl-114* HCO3-17* AnGap-13 [2148-7-8] 02:10AM BLOOD Glucose-212* UreaN-15 Creat-0.8 Na-137 K-4.0 Cl-112* HCO3-15* AnGap-14 [2148-7-7] 10:00PM BLOOD Glucose-285* UreaN-12 Creat-0.7 Na-137 K-4.3 Cl-108 HCO3-11* AnGap-22* [2148-7-7] 01:00PM BLOOD Glucose-236* UreaN-12 Creat-0.7 Na-137 K-4.9 Cl-106 HCO3-11* AnGap-25* [2148-7-7] 04:15AM BLOOD Glucose-292* UreaN-12 Creat-0.5 Na-137 K-4.1 Cl-106 HCO3-19* AnGap-16 [2148-7-6] 09:59PM BLOOD UreaN-18 Creat-0.6 Na-134 K-4.3 Cl-102 HCO3-21* AnGap-15 [2148-7-6] 07:30PM BLOOD Glucose-649* UreaN-21* Creat-0.8 Na-128* K-5.8* Cl-94* HCO3-22 AnGap-18 [2148-7-7] 04:15AM BLOOD ALT-8 AST-9 LD(LDH)-116 CK(CPK)-29 AlkPhos-72 TotBili-0.9 [2148-7-10] 07:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.7 [2148-7-9] 07:20AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0 [2148-7-7] 11:17AM BLOOD %HbA1c-12.0* [2148-7-6] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2148-7-8] 04:44AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.021 [2148-7-8] 04:44AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-250 Ketone-15 Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR [2148-7-8] 04:44AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [2148-7-7] 02:49PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.023 [2148-7-7] 02:49PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2148-7-6] 07:20PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-[4-11] ================== MICROBIOLOGY: [2148-7-8] 4:44 am URINE Source: Catheter. FINAL REPORT [2148-7-9] URINE CULTURE (Final [2148-7-9]): GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. (normal genital flora) ================== IMAGING: 1)AP AND LATERAL CHEST XRAY: The heart size is normal. Mediastinal and hilar contours are normal. The pulmonary vascularity is normal. The lungs are clear and there is no pleural effusion or pneumothorax. IMPRESSION: No acute process. 2)CT HEAD W/O CONTRAST: There is no intracranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarct. The calvarium is intact. Trace layering fluid is present in the maxillary sinuses, with minimal mucosal thickening, bilaterally. The mastoid air cells are well aerated, bilaterally. IMPRESSION: No intracranial hemorrhage or fracture. 3) CT ABD/PELVIS W/ CONTRAST: Minimal hypoventilatory changes are noted at the lung bases. There is no pleural or pericardial effusion. The liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys appear normal. There is no hydronephrosis or hydroureter. Intra-abdominal loops of large and small bowel are of normal caliber and there is no free air or free fluid. The appendix is normal. CT PELVIS WITH CONTRAST: The rectum and sigmoid colon are filled with stool. The uterus is mildly enlarged, but otherwise unremarkable. The adnexa and bladder are unremarkable. Bone windows reveal no worrisome lytic or sclerotic lesions. IMPRESSION: No acute abdominopelvic process identified. Mildly enlarged uterus, perhaps leiomyomatous, without focal large fibroid detected. 4) TRAUMA C-SPINE/L-SPINE: AP, lateral, swimmer's, and odontoid views of the cervical spine reveal no evidence for fracture or acute subluxation. Vertebral body heights and vertebral alignments are maintained. The C1 through C6 vertebral bodies are seen on the lateral view, with C7 and T1 visualized on the swimmer's view. On the odontoid view, evaluation of the atlanto-odontoid articulation is limited by rotation. There are no suspicious lytic or sclerotic osseous lesions in the cervical spine. Visualized lung apices are unremarkable. LUMBAR SPINE: There are five non-rib-bearing lumbar-type vertebral bodies visualized. There is no evidence for fracture or malalignment. Vertebral body heights are maintained. Intervertebral disc heights are maintained. There are no suspicious lytic or sclerotic osseous lesions. There are no abnormal soft tissue calcifications. The SI joints appear unremarkable. IMPRESSION: No evidence for fracture or malalignment in the cervical or lumbar spines. 5) THREE VIEWS OF THE LEFT SHOULDER: There is no evidence for fracture or dislocation involving the glenohumeral or acromioclavicular joints. Osseous alignments are normal. Joint spaces are preserved. There are no suspicious lytic or sclerotic osseous lesions, no abnormal soft tissue calcification. Visualized portion of lung apices are unremarkable. There are no displaced rib fractures identified. IMPRESSION: No fracture or dislocation. 6) RIGHT KNEE (3 VIEWS): FINDINGS: There is no fracture or malalignment. Joint spaces are preserved. There is minimal degenerative change, with minimal osteophyte formation in the superior aspect of the patella. There is no joint effusion. There are no abnormal soft tissue calcifications. There are no suspicious lytic or sclerotic osseous lesions. IMPRESSION: No acute fracture. No joint effusion. Brief Hospital Course: 42 yo woman with hx Type I diabetes mellitus Typr I who presents with diabetic ketoacidosis after motor vehicle accident. # Diabetic Ketoacidosis: Pt was initially seen in the ED with blood sugars in the 600s with an anion gap indicating diabetic ketoacidosis. Pt was treated in the ICU overnight with insulin drip and frequent blood sugar checks. After her sugars were noted to be well controlled and her anion gap normalized, she was transitioned to subcutaneous lantus with a humalog sliding scale. Exact etiology of DKA is not clear but may have been a combination of not taking her regular lantus (therefore no basal insulin in her system) as well as possible viral syndrome. Prior to discharge the pt's blood sugars were well controlled and she was discharged on Lantus with sliding humalog scale, with instructions to follow up closely with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ]. # Nausea/Vomiting: On admission pt was noted to have some nausea and vomiting which was attributed to several factors including gastroparesis, viral gastroenteritis, DKA. Pt was given anti-emetics PRN and prior to discharge was able to tolerate normal po intake without further nausea or emesis. # s/p MVA: Pt presented to the ED after a rear-ended accident and was assessed by the trauma team in the ED. In the [Name (NI) ], pt underwent many imaging studies which included a 3 view knee x-ray (which showed no acute fracture or joint effusion), L-spine and C-spine plain film (which showed no evidence for fracture or malalignment in the cervical or lumbar spines), shoulder x-ray which showed no fracture or dislocation. CT scans were obtained of the head which showed no intracranial hemorrhage or fracture; CT abdomen/pelvis which showed no acute abdominopelvic process, but did identify an incidental finding of a mildly enlarged uterus, perhaps leiomyomatous, without focal large fibroid detected. (Her PCP was sent [Name Initial (PRE) ] letter with a summary of these findings). On the floor she continued to report some neck, left knee pain, and back pain and did have some tenderness to palpation in these areas. She likely has continued muscle spasm and soft tissue strain from her MVA. Her neurologic function was intact. She was treated with tylenol, ibuprofen, and lidocaine patch. Pt was discharged on a regimen of prn acetaminophen, flexeril and ibuprofen for pain control. (note that the initial emergency room paperwork had a plan for discharge with valium and percocet prn, but ultimately these were not prescribed when she was discharged from the hospital) # Depression: Pt was continued on her home regimen of paroxetine and amitriptyline. Medications on Admission: Paroxetine 50 mg PO QD Amitriptyline 50 mg po qhs Lantus 32 units daily Humalog 10 units with meals Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 2. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:20 Tablet(s) Refills:0 3. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32) units Subcutaneous once a day. 4. Insulin Lispro 100 unit/mL Solution Sig: Ten (10) units Subcutaneous three times a day: Take as your sliding scale at home. 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for pain for 5 days. Disp:30 Tablet(s) Refills:0 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 3 days. Disp:12 Tablet(s) Refills:0 7. Flexeril 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for pain: [Month (only) 116] cause drowsiness. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic Ketoacidosis, Type 2 diabetes Secondary: s/p motor vehicle accident Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted to the hospital after presenting with complications from your diabetes called diabetic ketoacidosis. Whilst in the hospital you were admitted to the intensive care unit until your blood sugars remained normal. We recommend that you continue to take your insulin as directed and not miss a dose. We added several medications to your regimen. 1) Please take 20mg of Omperazole once a day 2) Please take 1,000mg of Acetminophen three times a day as needed for pain over the next 5 days 3) Please take 600mg of Ibuprofen as needed for pain over the next 3 days 4) Please take Flexeril 5mg at bedtime as needed for pain, please do not use this medication if you are not in pain. This medication can cause severe drowsiness, do not operate any heavy machinery or drive a vehicle whilst on this medication. We made no other changes to your medications If you experience any further episodes of weakness, dizziness, fevers, chills please call your doctor or return to the ED. Followup Instructions: Please make an appointment to see your doctor within the next week. Please call Dr.[Name (NI) 15301] office at [Telephone/Fax (1) 15302] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158] ICD9 Codes: 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6465 }	Medical Text: Admission Date: [2201-10-14] Discharge Date: [2201-10-21] Date of Birth: [2164-5-10] Sex: M Service: SURGERY Allergies: Shellfish / Topamax / Augmentin Attending:[First Name3 (LF) 2836] Chief Complaint: Nausea and vomiting Major [First Name3 (LF) 2947] or Invasive Procedure: PICC History of Present Illness: 37 yo M with recent admission for acute on chronic pancreatitis caused by prior alcohol binge. He had a complicated course, which included ARDS, emergent tracheostomy, E. coli bacteremia, and MRSA pneumonia. He was discharge to [Hospital3 ] on [10-8]. He was doing reasonably well there, where he was [Month/Day (2) 19284] a PMV during the day, tube feeds were weaned off, and was he advanced to a regular diet. He returns today after complaining of nausea and repeated vomiting, with an estimated volume of 2300cc throughout the day. He also had a temperature of 100.7. His WBC was down to 11K. He was on Meropenem at the time of discharge, which was stopped on [10-8] to complete a 2 week course for treatment of his GN bacteremia. [Location (un) ] through his progress notes from Rehab, it appears he has had a significant amount of reflux, despite being on Prilosec. A CT scan was obtained at the OSH, which raised concern of a peripancreatic fluid collection with some compression of the stomach and duodenum. He has a known pseudocyst, as noted on a CT done here on [10-3], measuring 9.4 (TRV) x 7.8 (AP) x 12.1 (CC)cm, as well as a separate small fluid collection anterior to the stomach. The images from the CT done at the OSH were not sent with him. He has been nauseated all day. He has had some abdominal pain, mostly in the epigastrum, which is slightly more than baseline. He has felt feverish and has had some chills. He continues to complain of heart burn. His trach has been continually causing him discomfort. He has a productive cough. He has been moving his bowels regularly. Past Medical History: PMH/PSH: - Tracheostomy [2201-9-14] (emergent) - Multiple episodes of alcoholic pancreatitis; history of ARDS requiring intubation in the setting of severe pancreatitis in [2194], recent admission as above - Splenic hematoma s/p splenectomy. Tail of pancreas was densely adherent to spleen hilum, had distal pancreatectomy - GERD - HTN - Sleep apnea tried on CPAP, biPAP but hasn't tolerated - Hypercholesterolemia - Chronic pain (L abdomen & shoulder) on methadone - Alcoholism/Alcohol withdrawal; several admissions for DTs and intubations - Right upper quadrant abscess, status post percutaneous catheter drainage in [2192-5-5]. - Fatty liver and hepatomegaly on US [2191] - Hypertriglyceridemia - Migraine HA/cluster HAs - Asthma - Depression - multiple suicide attempts - False positive RPR Social History: SocHx: Tobacco: quit smoking over a year ago, used to smoke 1 ppd EtOH: started drinking 7th grade, drank 30 beers a night plus few shots of alcohol in his 20's, abstinent since [2194], attended AA but found it boring. Drugs: remote hx MJ, cocaine. Denies IVDA. Denies recent drug use. Living: Previously lived with mother. Currently at rehab. On disability for chronic pain. Family History: Father CAD (1st MI in 40's), EtOH. Mother type 2 DM, 3 sisters: 1 with seizure d/o, 1 with migraines, + family hx alcoholism (father, 2 sisters) Physical Exam: PE: 100.0 114 150/100 20 96%4L NAD. Awake and alert. Slightly diaphoretic. Anicteric. Tacky mucosal membranes. Trach in place, c/d/i. Regular and tachycardic. Coarse BS bilaterally. Protuberant, possibly midly distended. +BS. Tender to palpation in the epigastrum. No guarding or rebound. Pertinent Results: [2201-10-15] 03:18AM BLOOD WBC-18.7* RBC-2.63* Hgb-7.7* Hct-24.2* MCV-92 MCH-29.3 MCHC-31.9 RDW-14.1 Plt Ct-986* [2201-10-19] 06:45AM BLOOD WBC-13.5* RBC-2.75* Hgb-8.0* Hct-25.1* MCV-91 MCH-29.0 MCHC-31.8 RDW-14.2 Plt Ct-831* [2201-10-19] 06:45AM BLOOD Glucose-148* UreaN-10 Creat-0.6 Na-138 K-4.3 Cl-101 HCO3-31 AnGap-10 [2201-10-15] 03:18AM BLOOD ALT-161* AST-38 AlkPhos-930* Amylase-79 TotBili-0.5 [2201-10-14] 03:49AM BLOOD ALT-275* AST-95* AlkPhos-1419* Amylase-78 TotBili-0.8 [2201-10-19] 06:45AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9 [2201-10-19] 09:16AM BLOOD Triglyc-142 . Radiology Report CT PELVIS W/CONTRAST Study Date of [2201-10-14] 6:59 AM IMPRESSION: 1. Large fluid-filled pancreatic pseudocyst which is unchanged in appearance compared to previous examination. 2. Slight interval increase in left anterior abdominal wall fluid collections compared to prior examination. 3. Patient is status post distal pancreatectomy and splenectomy. 4. No sign for bowel obstruction. . Radiology Report CHEST (PORTABLE AP) Study Date of [2201-10-17] 8:45 PM Final Report REASON FOR EXAMINATION: Evaluation of NG tube placement in a patient with ethanol pancreatitis. Portable AP chest radiograph was compared to the prior study. The NG tube was inserted in the meantime interval with its tip coiling in the proximal stomach. The cardiomediastinal silhouette is stable. No change in bibasilar linear opacities consistent with atelectasis is present. The tracheostomy is at the midline, with the tip approximately 4.3 cm above the carina. The upper lungs are unremarkable and the cardiomediastinal silhouette is stable. Brief Hospital Course: This is a 37 yo M well known to General Surgery and Dr. [First Name (STitle) ] following recent admission for acute on chronic pancreatitis caused by EtOH binge complicated by respiratory failure, ARDS, need for emergent trach, E. Coli bacteremia, and MRSA pneumonia. Now presenting with nausea and vomiting for the last 24 hours, suspicious for enlarging pseudocyst with outlet obstruction. Lipase is normal, so recurrent pancreatitis seems unlikely. Low grade fevers and leukocytosis suspicious for infectious process. He may have early sepsis. He was Pan Cx: [10-14] BCx: GPC clusters; staph coag neg (1 set only) [10-14] UA: [6-16] WBC, few bact, small Leuk, trace Protein He was started on Vanc/Meropenem given recent MRSA PNA & E.coli bacteremia He was NPO/IVF's with LR 150cc/hr. He had a NGT/Foley. A CT ABD was performed and unchanged pancreatic pseudocyts and fluid collections. He likely had duodenal obstruction [2-7] pseudocyst. . A PICC was placed and he was started on TPN. He required bowel rest due to the pseudocyst and nausea. His abdomen was soft and nontender with no peritoneal signs. The NGT was removed on HD5. His TPN was ramped up and he was discharged to rehab with TPN and ordered for sips of fluid. He reported +flatus and +BM prior to discharge. His antibiotics were stopped once the culture data came back negative. He will have a repeat CT on [11-2] and plan for OR pseduocystgastrostomy on [11-3]. Resp: He was stable with trach in place. He was suctioned as needed. Medications on Admission: Meds at Rehab: Zofran 4mg IV q4h prn, Methadone 60mg q8h, Lopressor 25'', Tizanidine 4'', Colace 100'', Omeprazole 40', Mucomyst nebs q6h prn, Pancrease 4500u qid, Senokot 8.6mg [Hospital1 ] prn, Reglan 20mg w/ meals, Clonidine 0.3mg TD qweek, Buproprion 100''', Tizanidine 12mg [Hospital1 ], Quetiapine 100mg [Last Name (LF) ], [First Name3 (LF) ] 81', Desenex 2% powder prn, SQH 5000''', Regular ISS, Loperamide 2mg qid prn, Albuterol q6h prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Tizanidine 2 mg Tablet Sig: Six (6) Tablet PO [First Name3 (LF) ] (once a day (at bedtime)). 7. Methadone 40 mg Tablet, Soluble Sig: 1.5 Tablet, Solubles PO TID (3 times a day). 8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs Miscellaneous Q6H (every 6 hours) as needed. 9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). 10. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 11. Bupropion 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO [First Name3 (LF) ] (once a day (at bedtime)). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 18. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). 19. PICC PICC care per protocol. TPN Daily Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: Nausea and vomiting Pancreatic Pseudocyst Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please take all new meds as ordered. * No heavy lifting (>10lbs) for 6 weeks. * Continue to increase activity daily * Continue with TPN Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2201-11-2] 10:15. Please call Dr. [First Name (STitle) ] at ([Telephone/Fax (1) 6347] with questions or concerns. You are tentatively scheduled to be admitted on [2201-11-2] with possible OR on [2201-11-3]. Dr.[Name (NI) 5067] office will help arrange this. Completed by:[2201-10-21] ICD9 Codes: 4019, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6466 }	Medical Text: Admission Date: [2125-1-12] Discharge Date: [2125-1-20] Date of Birth: [2068-2-19] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: s/p CABGx3 LIMA-->LAD, SVG-->Diag [1-16] History of Present Illness: 56 y/o man with PMH significant for "heart problems" admitted through the ED for CAD and cardiac cath on [2124-1-16]. Pt reports that he has had problems with his heart for the past five years. He is unable to given any specifics. He reports that he saw a physician at the urging of his wife when he first developed chest "squeezing" five years ago and was prescribed SL NTG. He has not seen a physician again for his cardiac issues until establishing care at [Hospital3 ] approximately four weeks ago. In the interum, he continue to have occasional chest pressure and took SL NTG for this that relatives obtained for him from [Name (NI) 651]. He reports that during this time he had intermittent chest pain but is unable to describe exactly how often. It sounds like it occurred approximately one time per month and was always relieved with SL NTG. . At this time, the pt reports that he has had increasing episodes of CP over the past two months. He reports that he has CP up to three times per day but then will go for two to three days without any pain. He describes the sensation as a pressure or squeezing sensation over his substernal chest area and occasionally radiates to his left arm. It is not associated with any symptoms including SOB, diaphoresis, n/v, or syncope. He reports that it is always relieved with one SL NTG. Pt reports that it can occur both with exertion and at rest. It seems to occur fairly frequently at night when he gets up to urinate. The pt's most recent episode of CP occurred this morning when he was walking to his physician's office. It was relieved with one SL NTG. The physician then sent him to [Hospital1 18] for further care. In pertinent recent history, the pt had a exercise MIBI at [Hospital1 18] on [1-9] that showed a moderate reversible perfusion defects of the inferior wall and septum. . In further discussion, the pt denies SOB. No PND or orthopnea. He has one to five episodes of nocturia per night. He denies any LE swelling. . In the ED, the pt's VS were 72 155/77 16 100% RA. Pt will be admitted to [Hospital Unit Name ] for further care. Past Medical History: Pt is unable to give any PMH. A member of the [Hospital Unit Name ] team spoke with the pt's PCP but he was unable to give any PMH for the pt as he only started seeing him about one month ago. The pt denies any knowledge of having HTN or DM. Social History: The pt moved to the [Location (un) 86] area with his wife in [2114]. [Name2 (NI) ] works as a chef. He has smoked one pack per day since he was a teenager-- approximately 40 years. He reports that he used to drink ETOH but has only drank on rare occasions since moving to [Location (un) 86]. Family History: Pt denies any history of CAD, MIs, HTN, or DM in his family. Physical Exam: PE: 98.0 72 155/77 16 100% RA Gen- Well appearing man resting in bed. Alert and oriented. NAD. HEENT- NC AT. PERRL. EOMI. Anicteric sclera. MMM. No lesions in the oropharynx. Adentulous. Cardiac- RRR. S1 S2. No m,r,g. No carotid bruits. Pulm- CTAB. No wheezes, rales, or rhonchi. Abdomen- Soft. NT. ND. Positive bowel sounds. Extremities- No c/c/e. 2+ DP pulses. Equal bilateral femoral and radial pulses. Pertinent Results: [2125-1-12] 02:45PM WBC-9.2 RBC-4.84 HGB-15.7 HCT-44.3 MCV-92 MCH-32.5* MCHC-35.5* RDW-13.2 [2125-1-12] 02:45PM NEUTS-38.5* LYMPHS-47.4* MONOS-6.2 EOS-6.9* BASOS-0.9 [2125-1-12] 02:45PM PLT COUNT-251 [2125-1-12] 02:45PM PT-11.6 PTT-22.3 INR(PT)-0.9 [2125-1-12] 02:45PM GLUCOSE-92 UREA N-14 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [2125-1-12] 02:45PM ALT(SGPT)-92* AST(SGOT)-45* [2125-1-12] 02:45PM CK-155 CK-MB-3 [2125-1-12] 02:45PM cTropnT-<0.01 . ECG: NSR at 81 beats per minute. Normal axis. Normal intervals. 0.[Street Address(2) 1755] elevation V1-V4. No tracing available for comparison. . CXR: normal . Exercise MIBI ([2125-1-9]): Exercised for 7 min on [Initials (NamePattern4) ] [Last Name (NamePattern4) ] protocol and stopped for fatigue. Developed mid-sternal chest "tightness"with exercise that resolved with three minutes of recovery. 0.5 mm ST segment depression in the anterolateral leads that resolved by three minutes into recovery. MIBI images showed a moderate reversible perfusion defects in the inferior wall and septum suggestive of multi-vessel CAD. There was also inferior wall hypokinesis with a calculated EF of 40%. Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2125-1-12] for further management of his chest pain. He was taken to the catheterization lab where he was found to have a diffusely stenosed left main coronary artery, mid total occlusion of the left anterior descending with retrograde filling via a diagonal collateral, and a totally occluded right coronary artery after the acute marginal, left ventricular ejection fraction of 45-50%. Given the severity of her disease, the cardiac surgical service was consulted for surgical revascularization. She was worked-up in the usual preoperative manner. On [2125-1-16] he successfully underwent CABGx4 (LIMA->LAD, SVG->Diag, SVG->OM). Afterward he was transferred to the Cardiac surgery recovery unit in stable condition and awakened neurologically intake. On POD 2 He was weaned from ventilator support, and extubated. His pressors were weaned and chest tubes removed. He was then transferred to the Stepdown unit for further recovery. He was gently diuresed to his preoperative weight, beta blockade and aspirin therapy were resumed, and physical therapy service was consulted to assist with her postoperative strength and mobility. On POD 3 his epicardial pacing wires were removed without complication, he continued to improve his ability to ambulate including climbing stairs without respiratory distress or chest pain. On POD 4 Mr. [Known lastname ] was 3kg above his preop weight with good exercise tolerance, no SOB, or Chest pain. His blood pressure was stable. His sternotomy and leg incision were clean, dry, and intact without evidence of infection. He was discharged home on POD 4 with services in good condition, cardiac diet, sternal precautions, lasix 20mg po QD for 14 days, and instructed to follow up with his PCP and cardiologist in [1-8] weeks. He will follow up with Dr. [Last Name (STitle) ] in four weeks. Medications on Admission: Unknown. Pt reports that he takes three pills but does not know what they are or what they are for. Per Pharmacy ([Doctor First Name ] [Doctor Last Name ], [Last Name (NamePattern1) ].) patient only written for nitro, last filled in [2121]. Called PCP office and spoke to coverage who will email med list. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:56 Capsule, Sustained Release(s) Refills:2 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:28 Tablet(s) Refills:2 8. Metoprolol Tartrate 50 mg Tablet Sig: 1 [1-8] Tablet PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: CAD Discharge Condition: Good. Discharge Instructions: Shower, wash incision with soap and water and pat dry. No lotions, creams or powders to incisions. No driving or lifting more than 10 pounds. Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Followup Instructions: Dr. [Last Name (STitle) ] 3-4 weeks Dr. [Last Name (STitle) ] 2 weeks Completed by:[2125-1-20] ICD9 Codes: 4280, 4111, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6467 }	Medical Text: Admission Date: [2135-11-22] Discharge Date: Date of Birth: [2135-11-22] Sex: F Service: NB HISTORY: Baby Girl [Known lastname ] [Name2 (NI) ] is a 28 [4-13] week gestational age female born via cesarean section to a 31 year old gravida I, para 0 mother with unremarkable prior medical history. Prenatal laboratories as follows: Blood type O negative. Antibody negative. Hepatitis B surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. ANTENATAL HISTORY: Significant for estimated date of delivery of [2136-2-10]. In [Last Name (un) 5153] fertilization, diamniotic, dichorionic twin gestation with concordant fetal growth. Spontaneous preterm rupture of membranes occurred on the morning of delivery, [2135-11-22] with labor progressing to cesarean section secondary to breech presentation following a spontaneous vaginal delivery of infant twin I. Betamethasone administered nine hours prior to delivery. Antibiotic started at that time as well. Infant was deliver via cesarean section, vigorous on delivery, given blow-by oxygen times seven minutes with resolution of cyanosis. Patient exhibited mild respiratory distress and was transferred to the Neonatal Intensive Care Unit for further management. PHYSICAL EXAMINATION ON PRESENTATION: Birth weight 1145, head circumference 26.5. Vital signs heart rate 150, respiratory rate 70 to 80s, temperature 98.3, blood pressure 48/29, SAO2 94 percent in room air. Head, eyes, ears, nose and throat: Anterior fontanelle open and soft, nondysphoric. Palate intact. Red reflex present bilaterally. Neck supple, no carotid effects sign. Respiratory: Clear to auscultation bilaterally. Good air entry. No retraction. Cardiac: Regular rate and rhythm, S1, S2 normal, no murmur. Soft, distended, no hepatosplenomegaly, normal active bowel sounds. Anus patent. Genitourinary: Normal female genitalia. Extremities: Well perfused, no cyanosis or edema. Femoral pulses 2 plus bilaterally. Spine intact. No dimpling. Ortolani Barlow sign not present. Neurologic: Spontaneous MAEW, appropriate tone on examination. Moro, suck, plantar, palmar grasp intact. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Secondary to mild respiratory distress patient was placed on CPAP plus six at room air for the first day of life. On day of life number two patient remained on CPAP with increased incidences of apnea and bradycardia. Secondary to these events a chest x-ray was obtained which revealed a moderately sized left lateral pneumothorax, approximately 30 percent of the left thorax volume. Due to the volume of the pneumothorax as well as the patient's symptomatology a chest tube was placed in the left thorax with no complications and remained in the patient through hospital number three. On hospital day number four the chest tube was discontinued with resolution of pneumothorax on chest x-ray. Patient remained asymptomatic in terms of apnea and bradycardia following removal of chest tube. Patient remained on CPAP until hospital day number seven at which point she was transitioned to room air and remained on room air until hospital day number 16. On [2135-11-9] patient was placed on nasal cannula of 100 percent O2 at 20 cc of flow for mild intermittent desaturations. In addition, patient exhibited apnea of prematurity in the first week of life and was started on caffeine citrate. At the time of interim summary patient remains on caffeine citrate for control of apnea of prematurity. CARDIOVASCULAR: PATIENT remained cardiovascularly stable throughout her hospital course. FLUIDS, ELECTROLYTES AND NUTRITION: Patient was started on intravenous of D10W at 80 cc per kilo on day of life number one secondary to her respiratory issues and pneumothorax. Patient remained NPO on parenteral nutrition until day of life eight at which point she was started on enteral feeds. Enteral feeds were quickly advanced to full feeds on day of life 14. At the time of interim summary on [2135-12-12] patient is on breast milk of 26 kilocalories per ounce at 150 cc per kilo per day. Patient has no signs of feeding intolerance. HEMATOLOGY: Patient's CBC at birth revealed a white count of 3.9, hematocrit of 44. Patient was placed on antibiotics of Ampicillin and Gentamicin and remained on these antibiotics for 48 hours until sepsis was ruled out via blood cultures. White count on day of life number 2 was 6.6. Patient's peak bilirubin was 3.6 on day of life number six. She remained on phototherapy through day life 14 at which point it was discontinued with appropriate follow up bilirubin levels. NEUROLOGIC: Patient received a head ultrasound on day of live seven which was normal. DISCHARGE DIAGNOSES: Prematurity at 28 4/7 weeks twin gestation. Respiratory distress, resolved. Pneumothorax, resolved. Apnea of prematurity. Feeding immaturity. Hyperbilirubinemia, resolved. Pending issues: will need repeat HUS, follow-up of newborn screen, hearing screen pre-discharge, synagis and Hepatitis B. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 56662] Dictated By:[Last Name (NamePattern1) 56760] MEDQUIST36 D: [2135-12-12] 15:38:22 T: [2135-12-12] 16:50:20 Job#: [Job Number 59808] ICD9 Codes: 769, 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6468 }	Medical Text: Admission Date: [2165-4-11] Discharge Date: [2165-4-16] Date of Birth: [2103-8-11] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1406] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2165-4-12] Coronary artery bypass grafting x5 (left internal mammary artery to left anterior descending artery,reverse saphenous vein graft to posterior descending artery, second diagonal artery and sequential reverse saphenous vein graft to the first obtuse marginal artery and distal left circumflex artery). History of Present Illness: This 61 year old male has a two week history of shortness of breath when walking his dog. Prior to presenting to an outside hospital he had chest pain after climbing a flight of stairs with palor and he denies diaphoresis. He went to his doctor's office for evaluation the next day and was sent to ED where he ruled in for a NSTEMI with a Troponin of 0.24 Past Medical History: hypercholesterolemia Knee Arthritis Diverticulosis s/p inguinal hernia repair obstructive sleep apnea Social History: Lives with: spouse Occupation: owns resturant Tobacco: denies ETOH: occassional glass of wine Family History: father - MI age 70 Physical Exam: Admission: General: no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no lymphadenopathy Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [x] Murmur no Abdomen: Soft [x]non-distended [x] bowel sounds + [x] no palpable masses - tender left lower quadrant with palpitation - mild - occurs with diverticulosis flare up Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: alert and oriented x3 non focal Pulses: Femoral Right: +2 Left: +2 - right groin s/p mynx closure DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: [2165-4-14] 05:55AM BLOOD WBC-8.9 RBC-3.32* Hgb-10.5* Hct-29.8* MCV-90 MCH-31.7 MCHC-35.3* RDW-12.9 Plt Ct-138* [2165-4-11] 03:10PM BLOOD WBC-7.5 RBC-4.50* Hgb-13.2* Hct-39.9* MCV-89 MCH-29.3 MCHC-33.0 RDW-12.9 Plt Ct-208 [2165-4-14] 05:55AM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-139 K-4.0 Cl-105 HCO3-27 AnGap-11 [2165-4-11] 03:10PM BLOOD Glucose-107* UreaN-10 Creat-0.8 Na-141 K-4.0 Cl-106 HCO3-28 AnGap-11 [2165-4-11] 03:10PM BLOOD CK-MB-2 cTropnT-0.14* Intra-op echo: PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. 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. There is no pericardial effusion. POST CPB: 1. Preserved [Hospital1 ]-ventiruclar systolic function 2. No change in valve structure and function. 3. Intact aorta [2165-4-14] 05:55AM BLOOD WBC-8.9 RBC-3.32* Hgb-10.5* Hct-29.8* MCV-90 MCH-31.7 MCHC-35.3* RDW-12.9 Plt Ct-138* [2165-4-13] 03:14AM BLOOD PT-13.5* PTT-30.6 INR(PT)-1.2* [2165-4-14] 05:55AM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-139 K-4.0 Cl-105 HCO3-27 AnGap-11 Brief Hospital Course: He was transferred from an outside hospital for surgical evaluation after cardiac catheterization revealed triple vessel disease. Due to stated episodes of apnea, the Sleep Service was consulted for suspected sleep apnea and he was started on auto set CPAP with continuous oxygen saturation with desaturations to 84% during sleep. He was brought to the Operating Room on [4-12] and underwent coronary artery bypass graft surgery. See operative report for further details. He recieved Vancomycin for perioperative antibiotics. He was transferred to the intensive care unit for post operative management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. His auto CPAP was resumed post extubation and he continued to use it throughout his hospitalization. Physical Therapy worked with him on strength and mobility. CTs and temporary pacing wires were removed according to protocol. He continued to do well and was ready for discharge to to home with services on post operative day four. Wounds were clean and healing well. Arrangements were made for outpatient follow up, medications and restrictions were also discussed with him. The Sleep Service will see him as scheduled and a CPAP device was arranged for home use. Medications on Admission: Glucosamine Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 4 weeks. Disp:50 Tablet(s) Refills:0 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 6. 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) 1110] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass grafts obstructive sleep apnea Non ST elevation myocardial infarction hypercholesterolemia Knee Arthritis Diverticulosis s/p inguinal hernia repair Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr. [Last Name (STitle) ] for Dr. [Last Name (STitle) ] at [Hospital1 ] Heart Center - Thursday, [5-2] at 9am ([Telephone/Fax (1) 6256]) Dr. [Last Name (STitle) 1295] at [Hospital1 ] Heart Center on Friday, [4-26] at 3pm ([Telephone/Fax (1) 6256]) Sleep F/[Initials (NamePattern4) ] [Last Name (NamePattern4) 3688] [Last Name (NamePattern4) 10476], MD Phone:[Telephone/Fax (1) 8645] Date/Time:[2165-4-25] 9:00 - [Hospital1 18] [Location (un) ] [Location (un) ] Please call to schedule appointment with PCP [Name Initial (PRE) ] 1-2 weeks Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 5835] Completed by:[2165-4-16] ICD9 Codes: 2859, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6469 }	Medical Text: Admission Date: [2100-7-14] Discharge Date: [2100-7-18] Date of Birth: [2055-7-18] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5606] Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: Central line placement ERCP History of Present Illness: 44yo F w/ PMHx significant for EtOH abuse, pancreatitis, known cholethiasis presented to the ED with 3 days of RUQ pain. This RUQ pain was not relieved with tylenol and motrin. The pain starts in the RUQ and radiates to the midaxillary line or to her back. The pain has been so severe that she has not had an appetite and has not been able to sleep well. When she does eat, she has noticed that there are times when her abdominal pain is worse. She reports nausea and vomitting. She also reports weakness and chills, but denies fevers. She reports diarrhea over the past couple of days as well as dark stools but not melena. She denies hematochezia. She reports defuse itching that started today. . In the ED, initial VS were: T 97.0 P 98 BP 94/58 R 15 O2 sat 100% RA. The patient was started on Unasyn 3mg IV times 1 and given morphine 2mg IV x3, and zofran 4mg IV. Surgery also saw the patient while she was in the ED recommended that the patient have urgent ERCP to relieve CBD obstruction and to have a cholecystectomy once her cholangitis resolves during this hospitalization. Because of persisently low BPs, the patient was bolused for a total of 5L of NS. Despite volume resuscitation, the patient's SBP remained in the 80s. A LIJ was placed in the ED and placement confirmed with CXR. The patient was subsequently started on Levophed at 0.03mcg/kg/min. Of note, vancomycin was also started in the ED and prior to transfer she recieved 1mg IV Dilaudid. . When the patient arrived to the unit, VS were: T 96.5 HR 119 BP 99/65 RR 19 O2 Sat 97% RA. The patient is conversant and able to provide her history. Levophed was set at 0.3mcg/kg/hr. . 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 constipation, . Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Past Medical History: -asthma -h/o seizures Past Surgical History: -Cesarian sectionx2 -s/p tonsillectomy Social History: - Tobacco: 4 Cigarettes/day - Alcohol: Denies use for 2-3 years - Illicits: Denies. Family History: No family history of biliary disease. Mother with HTN, asthma, and arthritis. Physical Exam: ADMITTING PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera icteric. MMM. Oropharynx without erythema or exudate. Neck: Supple. JVP not elevated. no LAD. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardia +. Normal S1 + S2. No murmurs, rubs, gallops. Abdomen: Normal, active BS+. Soft, non-distended. No tenderness to palpation over RUQ. No rebound tenderness or guarding. No organomegaly. No [Last Name (un) 108289] sign. GU: Foley in place. Skin: Jaundiced appearance. Ext: WWP. 2+ DPs. No clubbing, cyanosis or pitting edema. Pertinent Results: ADMISSION LABS: [2100-7-13] 11:05PM PT-15.6* PTT-27.5 INR(PT)-1.4* [2100-7-13] 11:05PM PLT COUNT-309 [2100-7-13] 11:05PM NEUTS-89.5* LYMPHS-8.4* MONOS-1.3* EOS-0.5 BASOS-0.3 [2100-7-13] 11:05PM WBC-10.6 RBC-3.23* HGB-9.8* HCT-27.9* MCV-86 MCH-30.3 MCHC-35.1* RDW-19.3* [2100-7-13] 11:05PM ASA-NEG ACETMNPHN-12 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2100-7-13] 11:05PM ALBUMIN-3.9 [2100-7-13] 11:05PM LIPASE-153* [2100-7-13] 11:05PM ALT(SGPT)-462* AST(SGOT)-1703* ALK PHOS-1489* TOT BILI-3.6* [2100-7-13] 11:05PM estGFR-Using this [2100-7-13] 11:05PM GLUCOSE-151* UREA N-23* CREAT-1.5* SODIUM-134 POTASSIUM-2.5* CHLORIDE-97 TOTAL CO2-18* ANION GAP-22* [2100-7-13] 11:12PM LACTATE-2.1* [2100-7-14] 01:54AM URINE MUCOUS-RARE [2100-7-14] 01:54AM URINE GRANULAR-1* HYALINE-5* CELL-0 [2100-7-14] 01:54AM URINE RBC-0 WBC-23* BACTERIA-FEW YEAST-NONE EPI-1 [2100-7-14] 01:54AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [2100-7-14] 01:54AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.011 Urine cultures negative x 2. [2100-7-14] CTA Abd W and W/o contrast: IMPRESSION: Decompressed biliary tree following placement of plastic stent. Persistent pancreatic duct dilatation. Ill-defined hypoenhancing area in the pancreatic head is nonspecific and may relate to an area of focal pancreatitis; however, a focal mass lesion cannot be excluded. There are a number of peripancreatic lymph nodes which are enlarged as described above. Normal appearance of the kidneys and adrenal glands. Correlation with outside imaging would be of benefit to evaluate for interval change. A low-attenuation predominantly cystic lesion in the pancreatic tail likely represents a small pseudocyst. The lesion appears to indent the stomach. [2100-7-16]: US ABD: IMPRESSION: 1. Heterogeneous liver parenchyma in keeping with fatty infiltration. 2. Patent hepatic vasculature. 3. Satisfactory position of the CBD stent with air in the CBD and left-sided biliary duct system. 4. There is persitent irregular eccentric gall bladder wall thickening measuring 1.4 cm maximally. 5. Pancreatic duct dilatation as described. [7-16] CXR: mild lower lobe atelectasis. ERCP Impression: A stricture was seen at the distal common bile duct. A sphincterotomy was performed. Balloon sweep was peformed without extraction of stones or sludge. A 7cm by 10FR Plastic stent biliary stent was placed successfully. A single 2 cm stricture was seen in the distal pancreatic duct CBD and PD stricture most likely secondary to pancreatic mass vs. chronic pancreatitis. Brief Hospital Course: MICU COURSE:44yo F w/ PMHx significant for EtOH abuse, pancreatitis, known cholethiasis presented to the ED with 3 days of RUQ pain and hypotension. #Hypotension: Pressures unresponsive to saline boluses in ED. She had a central line placed in the ED and was started on Levophed in the ED with normotensive pressures in the unit. The patient's hypotension was thought to be multifactorial in etiology in part due to sepsis with her biliary tree being a likely source of infection and poor oral intake in the days prior to admission. On admission, patient had a lactate of 2. She was weaned from pressors as tolerated, with a goal of keeping MAPs >65 and bolusing with NS PRN to maintain CVPs between 8 and 12. Antibiotics were started in the ED and continued through the patient's in the [Hospital Unit Name 153]. Since being off pressors, the patient's BPs were maintained without fluid boluses. . #RUQ Pain: RUQ U/S showing dilated pancreatic duct and a heterogeneous pancreas as well as cholelithasis and elevated LFTs were suggestive of an obstructing process. The differential for the patient's RUQ pain upon admission included Pancreatits versus cholecystitis versus ascending cholangitis. She was seen by surgery in the ED who recommended ERCP and cholecystectomy later during the hospitalization. ERCP was performed and showed pancreatic/CBD strictures c/w malignancy vs chronic pancreatitis. The patient also had a biliary stent placed. Given the concern for malignancy, the patient had an abdominal CT done, which showed 2.4x2.0 cm (3a:38) cystic structure arising from the panc tail could reflect pancreatic pseudocyst (given h/o EtOH pancreatitis) vs. cystic pancreatic neoplasm. No definite pancreatic head mass though artifact from CBD stent limits assessment. Panc duct is dilated as on recent ERCP. Irregularity also seen in pancreatic tail (3a:46) of uncertain significance. Fatty liver. Heterogeneous perfusion in the liver is noted with multiple, non mass like sites of early arterial enhancement. Enlarged celiac and portocaval nodes. Gastrosplenic varicies noted. General surgery and pancreaticobiliary surgery service were aware of the patient wanted the patient to be kept NPO and antibiotics continued. They suspected the CBD stricture might be due to chronic pancreatitis, which is more probable due to past and possibly current EtOH intake and pancreatic cyst on CTA. The patient will need repeat ERCP in 6 weeks for stent exchange. . #Transaminitis: AST:ALT ratio >2:1, suggestive of alcholism. Elevated ALP suggests a biliary blockage which is consistent with findings on RUQ U/S. LFTs were trended through her stay in the [Hospital Unit Name 153]. ALP and total bilirubin improved after ERCP, but the patient's AST and ALT continued to rise. There was concern that the acutely elevated AST and ALT represented some other hepatic insult beyond those caused by the biliary tree obstruction. Hepatitis serologies and HIV were sent. The results of these studies are pending upon discharge from [Hospital Unit Name 153]. . #[Last Name (un) ]: On admission, patient's sCr 1.5, baseline unknown. [Last Name (un) ] thought to be most likely prerenal, secondary to sepsis and poor po intake given patient's 3-day h/o abdominal pain. With IVFs the patient's sCr improved to <1.0. . #Anion-gap Metabolic acidosis: Patient initially presented with an anion gap of 19, with elevated lactate 2.1. Patient's hypotension may have led to organ ischemia is suggestive by elevated sCr. Elevated lactate may be due in part to patient's underlying h/o EtOH abuse [1-27] impaired hepatic gluconeogensis. Anion gap was followed and resolved. Lactate normalized in the [Hospital Unit Name 153]. . #UTI: On admission, there was concern for UTI given the results of UA. Urine culture was drawn and was pending when patient left the [Hospital Unit Name 153]. Patient was on Unasyn, s/p 1 dose vancomycin in ED. . #Anemia: Microcytic w/ MCV 86, suggestive of fe deficiency anemia versus anemia of chronic disease. . #Asthma: Home albuterol and fluticasone were continued through her admission in the [Hospital Unit Name 153]. . #Alcohol history: Patient with a known history of EtOH abuse. No level drawn in ED and there were no signs of intoxication when the patient was admitted during her stay in the [Hospital Unit Name 153]. Patient was monitored for signs of withdrawal. She did not need to be placed on CIWA scale while in the [Hospital Unit Name 153]. Floor course: The patient was trasnferred to the floor on [7-16]. Her abdominal pain improved and her transaminitis improved. IV narcotics were discontinued and her pain was treated with oxycodone. Her diet was advanced. A liver consult was obtained for her transaminitis. They recommended checking [First Name8 (NamePattern2) ] [Doctor First Name ], [Last Name (un) 15412] antibody ceruloplasmin and immunoglobulins for other causes of acute heptatitis which are pending. Hepatitis serologies for Hep A, B, and C were negative. HIV was also negative. Repeat US showed satisfactory position of the CBD stent as well as patent hepatic vasculature. She was counseled extensively by me as well as gastroenterology about the need to follow up for repeat imaging for further eval of a pancreatic mass vs chronic pancreatitis. She understands that she should also follow up in the liver clinic. She will follow up with her PCP and will also need further evaluation of cholecystectomy as an outpatient. (Dr. [First Name (STitle) ] from surgery saw her during her hospital course.) She was transitioned from Unasyn to Augmentin at discharge to complete a week of antibiotic coverage. Blood and urine cultures all showed no growth. She was discharged in stable condition with follow up. Medications on Admission: Albuterol inhaler Flovent 2 puffs inh [Hospital1 ] Discharge Medications: 1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 2. oxycodone 5 mg Capsule Sig: [12-27] Capsules PO every four (4) hours as needed for pain. Disp:30 Capsule(s) Refills:0 3. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:5 Tablet(s) Refills:0 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [12-27] Inhalation every four (4) hours as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: cholangitis Discharge Condition: stable, tolerating regular diet, normal mental status, ambulating Discharge Instructions: You were treated for cholangitis. You underwent ERCP. We are concerned that you may have a pancreatic mass vs chronic pancreatitis causing strictures. You must follow up with Dr. [Last Name (STitle) ] for stent replacement and for further imaging. You should also follow up in the liver clinic as you had evidence of significant liver injury. You should also follow up with your PCP this week as well. You should also take the antibiotics as prescribed. Followup Instructions: You should call your PCP to schedule an appointment this week. You should also call the liver clinic tomorrow morning (MONDAY, [7-19]) to schedule an appointment. Their phone number is [Telephone/Fax (1) 2422]. The following appointments were already scheduled for you. Department: GASTROENTEROLOGY When: WEDNESDAY [2100-8-4] at 10:00 AM With: [Name6 (MD) 1948] [Last Name (NamePattern4) 1949], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: THURSDAY [2100-9-2] at 9:00 AM Department: DIGESTIVE DISEASE CENTER When: THURSDAY [2100-9-2] at 9:00 AM With: [Name6 (MD) 1948] [Last Name (NamePattern4) 1949], MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 1951] Campus: EAST Best Parking: Main Garage ICD9 Codes: 0389, 5849, 2762, 2768, 5990, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6470 }	Medical Text: Admission Date: [2159-5-4] Discharge Date: [2159-5-30] Date of Birth: [2105-7-5] Sex: M Service: PURPLE SURGERY ADMITTING DIAGNOSIS: Morbid obesity. HISTORY OF PRESENTING ILLNESS: This patient is a 53-year-old male, with Class 3 morbid obesity. He has a weight of 318.6 pounds, height of 5'[65]", and a body mass index of 46. He has attempted numerous weight loss programs, as well as medications in the past without significant long-term success. He also has several co-morbidities associated with his morbid obesity including dyslipidemia and hypoandrogenemia. He now presents for surgical management of his morbid obesity. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Dyslipidemia. 3. Hypoandrogenemia. 4. History of UTIs. 5. Status post arthroscopic knee surgery on the left. 6. Status post open appendectomy. MEDICATIONS: 1. Lipitor 10 mg qd. 2. AndroGel topical qd. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION - VITAL SIGNS: Blood pressure 132/84, heart rate 82. GENERAL: No acute distress. HEAD AND NECK: Anicteric, no lymphadenopathy. CHEST: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm. GI: Obese, soft, nondistended, and nontender. EXTREMITIES: No edema. HOSPITAL COURSE: This patient was admitted on [2159-5-4], and underwent a laparoscopic gastric bypass procedure. The patient tolerated the procedure well, and there were no immediate postoperative complications. Please see operative note for further details. Following the operation, the patient received a methylene blue test, and this did not reveal any leakage. On postoperative day #2, the patient underwent an upper GI series which did not demonstrate any leakage or obstruction. The patient's pain was well-controlled with a morphine PCA. By postoperative day #3, the patient began developing abdominal cramping along with severe nausea, vomiting and diarrhea. His temperature climbed to as high as 105??????. An Addison-like syndrome was suspected, and an endocrine consult was obtained. The endocrinologist had a low suspicion for Addison-like syndrome, but they recommended that the patient be started on stress steroids. Due to the rapid deterioration in the patient, the patient was taken to the operating room for a laparoscopic exploration. This was largely unremarkable. Following the operation, the patient remained unstable. The patient developed a septic-like picture, with the decreased blood pressure and urine output. A Swan-Ganz catheter was placed, and the patient remained intubated. He was started on Levophed and vasopressin, as well as broad-spectrum antibiotics including ampicillin, levofloxacin, Flagyl and fluconazole. He was given aggressive fluid resuscitation. On [5-8], an infectious disease consult was obtained, and they suspected a toxic mediated process due to the rapid sequence of events. A hematology consult was also obtained for a left shift in the patient's white count differential. They attributed this mostly due to stress response and had low suspicion for any oncologic process. On [5-8], TPN was started. On [2159-5-9], the patient's antibiotics were changed to vancomycin, linezolid, levofloxacin and Flagyl. He was given APC for his sepsis-like syndrome, and IVIG to neutralize any toxin. The patient was negative for heparin-induced thrombocytopenia. On [2159-5-10], the patient remained critically ill. The patient was taken back to the OR for an exploratory laparotomy. On gross examination in the operating room, the bowels appeared largely unremarkable. Upon the request of Dr. [Last Name (STitle) ], Dr. [Last Name (STitle) 1888] performed a colonoscopy intraoperatively. This revealed enterohemorrhagic colitis. The patient received, over the course of 2 days, over 12 units of packed red blood cells. The abdomen was left open, and the mesh removed due to high intra-abdominal pressures and severe fluid overload. The patient began to improve following the colectomy and remained stable in the ICU. By [5-12], cultures had returned for Methicillin resistant Staphylococcus aureus from the rectum. This made a Staph aureus toxic shock syndrome highly suspicious. The patient was started on aggressive diuresis, and on [2159-5-13], the patient went back to the OR for further washout and partial closure. The patient remained stable for the most part, and was given a transfusion of platelets for slightly low platelets. By [5-16], the patient's Swan-Ganz catheter was discontinued. On [5-17], the patient's vancomycin and levofloxacin were discontinued, and the patient continued on linezolid and Flagyl for possible C. diff infection and MRSA. The patient's hydrocortisone was also discontinued. On [5-19], the patient underwent a complete fascial closure. His tube feeds were started on the following day, and a physical therapy and occupational therapy consult were obtained. On [5-21], the C. diff returned negative, and the Flagyl was discontinued. The patient continued to have persistent low-grade temps, and a chest x-ray was performed. This revealed left lower lobe consolidation. Sputum cultures also returned as Pseudomonas. The patient was then started on ceftazidime. By [5-23], the wound was again further closed, and a VAC was placed on the areas that remained open. By [5-26], the patient was extubated and off sedation. He appeared to make significant progress during the ICU stay. His linezolid was also discontinued upon recommendation by the infectious disease consult. He was started on a stage 2 diet by [5-27], and advanced to stage 3 on [5-28]. He appeared to tolerate his diet well. The patient was transferred to the floor successfully on [2159-5-29]. He remains stable while on the floor, and tolerating a stage 3 diet. He was continued on TPN, and a PICC line was placed for further IV antibiotics, and for continued TPN following discharge. His total caloric intake was decreased, but his protein intake was maximized. It was felt that the patient was ready for discharge to rehab by [2159-5-30]. DISCHARGE STATUS: Rehabilitation. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Morbid obesity, status post laparoscopic gastric bypass procedure. 2. Staphylococcus aureus toxic shock syndrome. 3. Enterohemorrhagic colitis secondary to toxic shock syndrome, status post total colectomy with ileostomy. 4. Pseudomonas pneumonia, treated with ceftazidime. 5. Sepsis. FOLLOW-UP INSTRUCTIONS: The patient is to follow-up with Dr. [Last Name (STitle) ] within 2-3 weeks following discharge. The patient is to continue on daily TPN with a caloric intake of 1,000 calories, 150 of amino acids, and 200 of dextrose. The patient should receive a total of 2 weeks of ceftazidime through his PICC line. DISCHARGE MEDICATIONS: 1. Ceftazidime 2 gm IV q 8 x 2 weeks. 2. Lopressor 125 mg po tid. 3. Roxicet elixir 5-10 cc po q 4-6 h prn pain. 4. Testosterone 2.5 mg patch, 1 patch transdermal q 24 h. 5. Insulin sliding scale. 6. Heparin flush 100 U/cc, 1 cc IV qd prn. Instructions: Ten cc normal saline followed by 1 cc of 100 U/cc heparin in PICC line. 7. Loperamide 2 mg po qid for diarrhea. 8. Protonix 40 mg po bid. 9. Albuterol inhaler prn. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3799], M.D. [MD Number(1) 3800] Dictated By:[Name8 (MD) 3430] MEDQUIST36 D: [2159-5-30] 12:35 T: [2159-5-30] 12:37 JOB#: [Job Number 53762] ICD9 Codes: 5849, 5185
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6471 }	Medical Text: Admission Date: [2144-7-16] Discharge Date: [2144-7-25] Date of Birth: [2067-6-25] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This is a 76 year old female patient, who was transferred to [Hospital1 188] after having undergone a cardiac catheterization at [Hospital6 2910] for a planned right coronary artery intervention. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Polymyalgia rheumatica. Status post cerebrovascular accident in [2-26]. She had an abnormal stress test which was followed up with the aforementioned catheterization. This revealed two vessel coronary artery disease and she was transferred to [Hospital1 69] for right coronary artery intervention. MEDICATIONS: 1. Plavix 75 mg p.o. q. Day. 2. Prednisone 25 mg p.o. q. Day. 3. Hydrochlorothiazide 25 mg p.o. q. Day. 4. Norvasc 5 mg p.o. q. Day. 5. Calcium. 6. Aspirin 81 mg p.o. q. Day. 7. Potassium chloride 10 mEq p.o. q. Day. SOCIAL HISTORY: The patient is a former smoker. She smoked one pack a day for many years and quit in [2144-2-23]. PHYSICAL EXAMINATION: On admission to the hospital, the patient was alert and oriented, however, forgetful. Lungs were clear to auscultation. Regular rate and rhythm cardiac examination. Her abdomen was soft, obese and nontender. Her extremities had trace edema bilaterally. LABORATORY DATA: Unremarkable. HOSPITAL COURSE: The patient was taken to the catheterization laboratory here, for attempted angioplasty and stent of the right coronary artery. However, this resulted in acute occlusion of the stent, necessitating emergency coronary artery bypass graft. The patient was taken to the operating room on [2144-7-16], where she underwent an emergent coronary artery bypass graft times two with a left internal mammary artery to the left anterior descending, saphenous vein graft to the distal right coronary artery. Postoperatively, she was on Dobutamine, Propofol and insulin drips and was transported from the operating room to the cardiac surgical recovery unit in good condition. The patient went with an intra-aortic balloon pump, which was placed in the cardiac catheterization laboratory. Initially, in the first 24 hours, the patient had some problems with hypoxia and restlessness and she was maintained on Propofol drip until her pulmonary status stabilized. She remained on Dobutamine, Nitroglycerin intravenous drips, as well as Neo-Synephrine. She was begun with diuresis on postoperative day number two, received a unit of packed red blood cells and had her intra-aortic balloon pump discontinued on postoperative day number one. The patient, on postoperative day number two, continued with hypoxia and chest x-ray was obtained. This showed a small right pneumothorax but the patient continued to worsen from an oxygenation standpoint throughout the course of the day. A repeat chest x-ray showed an increasing size of the right pneumothorax and right chest tube was inserted at that time. Initially, a small air leak was obtained and a repeat chest x-ray showed near complete resolution of the pneumothorax. By postoperative day number three, the patient's respiratory status had significantly improved and she was weaned from mechanical ventilation and subsequently extubated successfully. She began to become hypertensive; therefore, Lopressor was increased and she was continuing to be diuresed. On postoperative day number four, the patient remained on intravenous nitroglycerin for hypertension as well as Metoprolol, Aspirin, Plavix and Lasix. She was awake and alert; however, she was confused and disoriented with periods of intermittent agitation. On postoperative day number five, she was weaned off vasoactive intravenous drips. She remained hemodynamically stable on five liter nasal cannula with an oxygen saturation of 96 percent. Her Captopril was increased. Her chest x-ray revealed no signs of pneumothorax and her chest tube was subsequently discontinued. On postoperative day number four, the patient had some atrial fibrillation but this was non sustained. She appeared to have had it for less than an hour and has not had subsequent dysrhythmia. When she did have the atrial fibrillation/flutter, her potassium was noted to be 3.0 at that time. Since her potassium had been repleted, she had not had further atrial dysrhythmia. On postoperative day number six, neurology consultation had been obtained due to the family's request, because of the patient's continued episodes of agitation and disorientation. Head CT scan was obtained. This showed no acute infarction. The patient subsequently had a urinalysis sent which was negative and she has been incontinent of urine intermittently. On postoperative day number seven, the patient remained having intermittent bouts of agitation, mostly overnight and was treated with low dose Haldol. She was hemodynamically stable and beginning to progress from an ambulation standpoint, although she was only able to walk a short distance in her room with assistance. On postoperative day number eight, [7-24], the patient remained stable from a hemodynamic standpoint and felt that she would be best served by being discharged from the hospital to progress with physical therapy at a rehabilitation facility. LABORATORY DATA: Most recent laboratory values are from today, [7-24], which include a white blood cell count of 13,900 which is down from the previously recorded 15.8. Her hematocrit is 31.5. Platelet count is 224,000. Sodium of 136; potassium of 3.2; chloride 102; C02 23; BUN 15; creatinine 0.8; glucose 137. The patient also has a recent Clostridium difficile which was sent due to some diarrhea and this was negative. Most recent chest x-rays from today, [7-24], shows no evidence of pneumothorax and left lower lobe collapse with a small left pleural effusion. PHYSICAL EXAMINATION: Temperature is 99.3; pulse 92 and normal sinus rhythm; blood pressure 157/70; respiratory rate 24. Oxygen saturation on room air is 94 to 96 percent. The patient has been incontinent of urine and her input and output have not been clearly recorded as a result of this. Her weight today is 86.3 kg, which is below her preoperative weight of 89 kg. The patient also, as previously stated, had a urinalysis on [7-23], which was negative. Neurologically, the patient is awake and responsive; however, disoriented to time and place, reorients easily. Pulmonary examination: She has few scattered, upper airway rhonchi; otherwise, her lungs are clear to auscultation. Coronary examination is regular rate and rhythm. Abdomen is obese, soft, nontender. Extremities have 1 plus edema bilaterally. Her sternal and leg incisions are healing well with a few areas of ecchymosis throughout. She has no erythema or drainage from any of her incisions. She does, however, have what looks to be a yeast rash in her groin area, for which she was started on Nystatin powder today. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. twice a day. This should be re-evaluated in about five to seven days, to assess for continued need for diuresis after that point. 2. Aspirin 325 mg p.o. q. Day. 3. Tylenol 650 mg p.o. q. Four hours prn for pain. 4. Plavix 75 mg p.o. q. Day for three months or until discontinued by her cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2912]. 5. Captopril 25 mg p.o. three times a day. 6. Prednisone 20 mg p.o. q. Day. This should also be re- evaluated by the patient's primary endocrinologist. She is on the Prednisone for polymyalgia rheumatica and, upon discharge from rehabilitation, she should follow-up with her endocrinologist at that time. His name is Dr. [Last Name (STitle) 55838]. 7. Lopressor 75 mg p.o. twice a day. 8. Potassium chloride 40 mEq. p.o. twice a day. 9. Miconazole powder to perineal area three times a day prn. 10. Protonix 40 mg p.o. q. Day. DISCHARGE DIAGNOSES: Coronary artery disease. Status post coronary artery bypass graft. Hypertension. Hypercholesterolemia. Polymyalgia rheumatica. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern1) 5664] MEDQUIST36 D: [2144-7-24] 16:35:58 T: [2144-7-24] 17:36:45 Job#: [Job Number 55839] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6472 }	Medical Text: Admission Date: [2189-3-16] Discharge Date: [2189-3-24] Date of Birth: [2142-5-12] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 46 -year-old female with severe symptomatic mitral regurgitation presenting for mitral valve repair. PAST MEDICAL HISTORY: Includes arthritis of the hands. PAST SURGICAL HISTORY: She had a left knee surgery approximately six months prior to admission. ADMITTING MEDICATIONS: Include Vasotec 5.0 mg a day, Lasix 20 mg q day, Naprosyn 500 mg [Hospital1 ]. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On admission, in general, the patient was an obese female in no acute distress. Head and neck examination were within normal limits. Heart examination: normal S1, S2, with a II/VI systolic murmur. Lungs were clear bilaterally. Abdomen was obese, but soft, nontender, nondistended. Extremities were warm and well profused with 2+ dorsalis pedis and posterior tibial pulses bilaterally. HOSPITAL COURSE: The patient underwent cardiac catheterization which showed normal coronary arteries, severe mitral regurgitation with a left ventricular ejection fraction of 25% to 30%. The patient was taken to the Operating Room on [2189-3-17] where she underwent an uncomplicated mitral valve replacement with a [Street Address(2) 7163]. [Male First Name (un) 1525] mechanical valve. She tolerated the procedure well and was transferred to the Cardiothoracic Intensive Care Unit postoperatively for hemodynamic monitoring. She was extubated on postoperative day zero without incident. She remained in the Intensive Care Unit until postoperative day two, at which time she was transferred to the floor. On the floor, chest tube, central line, Foley catheter, and pacing wires were removed without any difficulty. The patient remained hemodynamically stable and afebrile on the floor. She worked with Physical Therapy, was able to achieve only level 3 ambulation. It was felt that she would benefit from short term rehabilitation stay prior to discharge home. DISPOSITION: She was discharged on [2189-3-24] to a rehabilitation facility. DISCHARGE MEDICATIONS: Lopressor 25 mg po bid, Lasix 20 mg po q day, K-Dur 20 mEq po q day, Colace 100 mg po bid, Zantac 150 mg po bid, Percocet one to two tablets po q four to six hours prn, Coumadin 2.0 mg po q day, Captopril 25 mg po q eight hours, amiodarone 200 mg po q day, Tylenol 650 mg po q four hours, and Prempro 2.5 mg po q day. The patient's INR was therapeutic above 2.0 prior to discharge. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSIS: Severe mitral regurgitation, status post mitral valve replacement. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 33441] MEDQUIST36 D: [2189-3-24] 13:11 T: [2189-3-24] 13:09 JOB#: [Job Number 106909] ICD9 Codes: 4240, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6473 }	Medical Text: Admission Date: [2102-11-9] Discharge Date: [2102-11-22] Date of Birth: [2021-9-15] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 20506] Chief Complaint: Eyelid droop and weakness Major Surgical or Invasive Procedure: IVIG infusion. History of Present Illness: HPI: Patient is a 81 yo RHM with hx of HTN, DM, hyperlipidemia and chronic LBP here with question of myasthenia [Last Name (un) 2902]. Patient reports that 1 month ago, he suddenly awoke with L sided hearing loss. He also reported numbness of the L ear to touch and occasional clicking noise in the L side in addition to complete hearing loss that occurred overnight. He was seen per Dr. [Last Name (STitle) 3878] (ENT) who evaluated him with MRI of brain that did was not revealing (no mass) and treated him with 1 week of oral steroids with no improvement. Then about 2 weeks ago, patient was noticed to have L ptosis per son and developed vertical diplopia (items afar seem to be on top of each other). This diplopia is not present when he awakes but it starts within minutes after waking up. He was also noticed to be more fatigued and easily tired although still able to continue most of his daily activities including laundry, walking up/down the stairs and etc. Around 3 days ago, patient noticed that he was having trouble swallowing food/water in large gulps. If he drank or ate more than teaspoon at a time, things would come out his nose. He also felt that food was getting stuck in his throat and he had trouble expectorating. He also started to need to cut up his pills because he had trouble swallowing them whole. He went to see his PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] for his monthly B12 shots and upon hearing his symptoms, referred the patient to Dr. [Last Name (STitle) ] for myasthenia [Last Name (un) 2902] evaluation and treatment. Patient reports that he has not taken any meds today. ROS otherwise negative including recent fever/chills, N/V/D, falls, HA or sick contact. At baseline, patient occasionally uses a cane for additional support but completely independent in all his ADLs including IADLs. Of note, patient underwent open cholecystectomy for failed ERCP in [7-11] with no post-operative complications including awaking from the anesthesia. Past Medical History: h/o facial basal cell carcinoma chronic lower back pain Aortic stenosis Hypertension Hyperlipidemia Diabetes Mellitus [2102-6-27] Left biliary duct stent placement for left duct stricture (jaundiced) [2102-7-4] open cholecystectomy Social History: Patient was in the navy and worked on boats his entire life. He is married and lives with his "bride". He denies tobacco, alcohol or drug use. He has a history of asbestos exposure. Family History: No family history of malignancy. Physical Exam: T 97.7 BP 117/64 HR 77 RR 16 O2Sat 100% RA - able to count to 20 in one breath. NIF -14 with mask and VC 900. Gen: Lying in bed, NAD Neck: No carotid or vertebral bruit CV: RRR, 2/6 SEM best heard LUSB Lung: Clear anteriorly Abd: +BS, soft, nontender Ext: No edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive - able to do DOW backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. [Location (un) ] intact. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV & VI: Extraocular movements intact bilaterally, no nystagmus. Develops transient vertical ptosis in 20 seconds. V: Sensation intact to LT and PP. VII: L ptosis. VIII: Hearing intact to finger rub only on R. X: Palate elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline, movements intact Motor: Normal bulk and tone bilaterally. No observed myoclonus or tremor. No asterixis or pronator drift - fatigable R delt -> weakens to 4- from 5-. Weak neck flexor but intact extensor. [Doctor First Name ] Tri [Hospital1 ] WE FE FF IP H Q DF PF R 5- 5- 5 5 5- 5 5- 5 5 5 5 L 5 5- 5 5 5- 5 5- 5 5 5 5 Sensation: Intact to light touch, pinprick, and cold but decreased vibratory sensation in both big toes and decreased proprioception, worse on R than L. Reflexes: 2s for UE and patellar but none for Achilles. Toes upgoing on L only. Coordination: FTN, FTF and HTSs normal. Gait: Deferred. Pertinent Results: [2102-11-8] 02:50PM WBC-4.4 RBC-4.82# HGB-14.1 HCT-42.9# MCV-89# MCH-29.2# MCHC-32.8 RDW-13.9 [2102-11-8] 02:50PM PLT COUNT-145* [2102-11-8] 02:50PM TSH-1.3 [2102-11-8] 02:50PM TOT PROT-7.4 ALBUMIN-4.1 GLOBULIN-3.3 CALCIUM-9.1 MAGNESIUM-2.1 [2102-11-8] 02:50PM ALT(SGPT)-23 AST(SGOT)-29 ALK PHOS-50 TOT BILI-0.8 [2102-11-8] 02:50PM estGFR-Using this [2102-11-8] 02:50PM UREA N-18 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-31 ANION GAP-14 [2102-11-8] 02:50PM GLUCOSE-218* [2102-11-9] 10:45AM PLT COUNT-129* [2102-11-9] 10:45AM NEUTS-69.0 LYMPHS-22.5 MONOS-6.3 EOS-0.8 BASOS-1.4 [2102-11-9] 10:45AM WBC-4.7 RBC-4.75 HGB-13.9* HCT-41.8 MCV-88 MCH-29.3 MCHC-33.2 RDW-14.5 [2102-11-9] 10:45AM GLUCOSE-175* UREA N-19 CREAT-0.9 SODIUM-141 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-31 ANION GAP-11 [2102-11-9] 04:10PM PT-13.0 PTT-29.5 INR(PT)-1.1 Brief Hospital Course: The patient was admitted and the initial goal had been to start plasmapheresis, however given the significant aortic stenosis, this was deferred in favor of an initial attempt to treat with IVIG. He was also started on pyridostigmine. His baseline NIF and VC were low at -40 and 800, however he did not appear to be able to fully cooperate with testing and thus these numbers were thought to be partially artifically decreased. He had some minor improvement in his strength after 5 days of IVIG. Prior to initiation of steroid therapy, he was checked for a urine infection and incidentally found to have a urinary tract infection, and thus he was treated with antibiotics for a 5-day course initially with ceftriaxone, transitioned to ampicillin once sensitivities returned. He failed a speech and swallow evaluation, but initially refused to have an NG tube placed, thus he fed himself purees over the weekend [Date range (1) 21226]. He did not have any overt aspiration, however on [11-15] there continued to be extreme concern for aspiration, thus he did agree to an NG tube being placed and on [11-15] he began NG feeds. On [11-16] he developed acute onset of oxygen requirement and lethargy accompanied by a fall in his NIF and vital capacity to -20 and 400 cc. Given concern for acute respiratory failure, he was transferred to the medical intensive care unit. An ABG immediately prior to transfer was notable for a carbon dioxide level of 58, lower than was expected based upon the clinical picture. In the MICU, he was treated with BiPAP for one day with substantial improvement, and no alternative etiology was identified for his acute change in mental status. A pheresis catheter was placed due to the potential need to initiate plasmapheresis despite his aortic stenosis if he were not to regain his strength and require further respiratory support. However, he made a substantial improvement over the course of 24 hours, and was transferred back to the floor on [11-18] on 2L nasal cannula, again able to ambulate with a normal mental status. He was also found to have an elevated PTT due entirely to subcutaneous heparin (based on hepzyme test), thus he was no longer given subcutaneous heparin instead ambulation and pneumoboots for prophylaxis. He was started on prednisone 10 mg daily on [11-14] which was briefly held for his urinary tract infection and reinitiated on [11-16]. By day of discharge, this increased to prednisone 40 mg daily. He continued to have stable NIF and VC. His feeds were advanced to an oral diet after evaluation with video swallow study. He received physical therapy. He was discharged home with plan to receive physical therapy as an outpatient as well. Medications on Admission: 1. Pantoprazole 40mg [Hospital1 ] 2. Propranolol 80 mg daily 3. Enalapril Maleate 5 mg DAILY 4. Hydralazine 50 mg [Hospital1 ] 5. Niaspan 1000mg daily 6. Aspirin 325 mg daily 7. Vitamin D 8. Centrum Silver 9. Alendronate 70 - every Wednesday 10. B12 shots - monthly Discharge Medications: 1. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for T>100.4 or pain. 3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:2 8. Niacin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Myasthenia [Last Name (un) ]. Discharge Condition: Stable, normal neurologic exam. Discharge Instructions: Your were admitted for eyelid droopiness and diagnosed with myasthenia [Last Name (un) 2902], treated with IVIG. The myasthenia causes it to be difficult ot swallow, and you required an NG tube to feed and take medications. Before discharge, your feeds were advanced to an oral diet. You briefly had difficulty breathing and so were transferred to the MICU for observation and treated with BiPAP support. Your breathing improved and were transferred back to the general floor. You received physical therapy. You were treated with prednisone which you will continue after discharge. 1. Take all medications as directed. 2. If you experience new or worsening symptoms, please contact your physician or if urgent, please proceed directly to the nearest emergency room. Followup Instructions: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8157], M.D. Phone:[Telephone/Fax (1) 1971] Date/Time:[2102-12-12] 9:00 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2102-12-15] 4:30 Completed by:[2102-12-17] ICD9 Codes: 5990, 2762, 2859, 4241, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6474 }	Medical Text: Admission Date: [2203-3-8] Discharge Date: [2203-3-8] Date of Birth: [2120-1-1] Sex: M Service: NEUROLOGY Allergies: Phenytoin Attending:[First Name3 (LF) 5018] Chief Complaint: Evalaute for large IPH Major Surgical or Invasive Procedure: None History of Present Illness: 83yo man with PMH significant for L temporal hemorrhage followed by Dr. [Last Name (STitle) ] in neurology was transfered from OSH for evaluation of large IPH. he was last seen in his usal state of health at 2 pm. he did not respond to phone calls from his friend who called his daughter. She called 911, he was found unconscious and unresponsive , was intubated , taken to OSH where CT scan showed large IPH in R frontal lobe. He was transfered to [Hospital1 18] for further care. Past Medical History: left temporal hemorrhage thought to be due to amyloid angiopathy possibly left corneal transplant PMR diabetes hyperlipidemia anemia memory loss low back pain chronic left head pain as above Social History: lives alone, independent in ADLs Family History: no h/o stroke or ICH Physical Exam: PE: VS: T 97.3, HR 84, BP 100/60, intubated Gen- Intubated on ventilator CV: RRR, nl S1, S2, no m/r/g Chest: CTA bilaterally Abdomen: soft, NTND, BS+ EXt- warm perfused, no c/c/e Neurologic examination: Unsconsciuos, unrepsonsive, intubated not on sedatives pupils [6-14] BL, has corneal opacity on left side, pupils fixed and non reactive. No corneal reflex, no dolls eye movement, mild gag Motor: withdraws to painful stimuli in all limbs, no spontaneus movements Reflexes: 1+ and symmetric throughout, BL plantars upgoing Pertinent Results: [2203-3-8] 12:30AM BLOOD WBC-6.7 RBC-2.84* Hgb-8.9* Hct-27.1* MCV-95 MCH-31.5 MCHC-33.0 RDW-15.5 Plt Ct-224 [2203-3-8] 12:30AM BLOOD Plt Ct-224 [2203-3-8] 12:30AM BLOOD PT-15.1* PTT-28.1 INR(PT)-1.3* [2203-3-8] 12:30AM BLOOD Glucose-203* UreaN-31* Creat-2.5* Na-140 K-3.7 Cl-107 HCO3-17* AnGap-20 CT head [3-8] NON-CONTRAST HEAD CT: There is a large right frontal intraparenchymal hemorrhage which, allowing for differences in technique, is not definitely larger compared to the outside hospital study performed three hours prior. This large focus measures 4.7 x 6.9 cm. There is diffuse cerebral edema, which is worst in the right frontal lobe, with associated large amount of mass effect including effacement of the right lateral ventricle, 2 cm leftward shift of normally midline structures, leftward subfalcine herniation of the right frontal lobe, and downward transtentorial herniation. There is dilatation of the posterior [Doctor Last Name 534] of the left lateral ventricle which is filled with blood, otherwise the frontal [Doctor Last Name 534] of the left lateral ventricle, third ventricle, and fourth ventricle are effaced. There are other foci of intraparenchymal hemorrhage, such as in the right occipital lobe, as well as diffuse foci of subarachnoid hemorrhage, particularly along the right cerebral hemisphere. Blood is also seen in what appears to be the third ventricle (2:15). The soft tissues appear grossly unremarkable. The patient has had prior left lens replacement. Secretions are noted layering posteriorly within the nasopharynx. No skull fracture is demonstrated. There is mucosal thickening noted within the anterior ethmoid air cells bilaterally as well as mildly within the left maxillary sinus. The mastoid air cells are aerated. Vascular calcifications are noted along the cavernous carotid arteries as well as the right vertebral artery. IMPRESSIONS: 1. Large right frontal intraparenchymal hemorrhage. Diffuse cerebral edema with particular hypodensity in the right frontal lobe, probably related to the hemorrhage, but also could be due to right frontal infarction due to right frontal subfalcine herniation towards the left. 2. Diffuse effacement of the ventricular system except for slightly dilated posterior [Doctor Last Name 534] of the left ventricle. 3. Other smaller foci of intraparenchymal hemorrhage as well as diffuse subarachnoid hemorrhage. 4. Downward transtentorial herniation. Brief Hospital Course: Mr. [Known lastname ] was admitted to neuro ICU for management of IPH. He was transfered from OSH for evaluation of large right frontal bleed. He was intubated when he arrived in ED and his exam showed dilated fixed pupils, no corneals, no dolls eyes, very mild/absent gag with GCS of 3 and BL upgoing toes. He was seen by neurosurgery who felt intervention was not beneficial given huge bleed and signs of brainstem death with herniation. The prognosis was discussed in detail with family including HCP. Prognosis was poor due to large bleed and unfavourable neuro exam. He was made comfort measures and extubated in ICU. He was given morphine and ativan for comfort measures. He expired on [2203-3-8] at 5.15 am. Medical examiner was called as death occured in less than 24 hrs after arrival who waived the case. Medications on Admission: gabapentin Citalopram Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Right frontal bleed Discharge Condition: dead Discharge Instructions: none Followup Instructions: none [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] ICD9 Codes: 431, 2724, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6475 }	Medical Text: Admission Date: [2131-7-27] Discharge Date: [2131-8-16] Date of Birth: [2083-10-5] Sex: F Service: SURGERY Allergies: Penicillins / Iodine; Iodine Containing / Peanut Attending:[First Name3 (LF) 695] Chief Complaint: N/V/D Major Surgical or Invasive Procedure: Therapeutic Paracentesis Orthotopic Liver [First Name3 (LF) ] [2131-8-5] History of Present Illness: 47 year old female with HepC/Cirrhosis on liver [Month/Day/Year ] list, referred for abnormal labs, WBC of 77K on [7-25]. She complains of RUQ pain (chronic) as well as 2 days of nausea, vomiting, and diarrhea. No Melena or BRBPR. Recently admitted with SBP in [6-/2131], and more recent admission for therapeutic paracentesis. Felt very fatigued and dehydrated. Admits to poor po intake b/c of N/V, and decreased urine output. Also admits to feeling of heart racing. Denies CP, SOB. Has minimal cough. No dysuria. . In the ED, vs=T97.2, BP 120/64, HR 112, RR 18, 99%ra. Labs notable for normal WBC, and diagnostic paracentesis was negative for SBP. Sodium noted to be 123 (discharged with Na 128), and Cr 1.2 (baseline 0.6). LFTs, Tbili, INR all at baseline values. CXR negative for pneumonia. Past Medical History: - HCV cirrhosis - Hepatoma, s/p RFA of 1 lesion in [2130-9-27] - h/o HSV infection - cold sores in the past - HPV - h/o cervical dysplasia - ? Hepatorenal syndrome type 2 - Ventral hernia s/p repair - Osteopenia Social History: Lives with Husband and 3 children. Has 4 children. Husband and all 4 children have tested negative for HCV. Quit smoking 27 years ago. Did clerical work in the past. Occasional ETOH in the past. Denies street drugs. Family History: Mother has HTN. Father had HTN and passed away with brain tumor. Physical Exam: vs: T97.8, BP 102/60, HR 79, RR 18, 100%ra gen: jaundiced but appears well otherwise heent: icteric sclerae. EOMI. dry mm lungs: bibasilar crackles, but otherwise CTA b/l heart: RRR, nl S1S2, no M/R/G abd: Tympanic. Distended. Non-tender. ext: 1+ b/l edema, L slightly greater than R neuro: AAOx3. No asterixis. Pertinent Results: On Admission: [2131-7-26] WBC-10.3# RBC-3.65* Hgb-12.3 Hct-36.7 MCV-101* MCH-33.6* MCHC-33.4 RDW-17.4* Plt Ct-93* PT-23.7* PTT-44.5* INR(PT)-2.3* Fibrino-111* Glucose-114* UreaN-37* Creat-1.2* Na-123* K-3.5 Cl-86* HCO3-25 AnGap-16 ALT-66* AST-149* AlkPhos-211* TotBili-30.2* Lipase 60 TotProt-7.2 Albumin-3.8 Globuln-3.4 Calcium-9.3 Phos-4.2 Mg-2.9* On Discharge: [2131-8-16] WBC-9.5# RBC-3.77* Hgb-11.4* Hct-33.1* MCV-88 MCH-30.3 MCHC-34.5 RDW-16.5* Plt Ct-155 PT-14.7* INR(PT)-1.3* 87 UreaN-32* Creat-2.0* Na-137 K-4.8 Cl-98 HCO3-30 AnGap-14 ALT-22 AST-18 AlkPhos-72 TotBili-2.5* Lipase-20 Calcium-8.7 Phos-3.5 Mg-1.8 Brief Hospital Course: 47 y.o. female with ESLD on [Month/Day/Year ] list, referred for leukocytosis but this was lab error, admitted with N/V/D and hyponatremia. She was treated with fluid resuscitation and had a diagnostic paracentesis that was negative for SBP, ultrasound neg for portal vein thrombosis. During the admission she developed increased coagulopathy and was starting to have increased confusion, Head CT was negative for mass effect or hemorrhage. Blood cultures were nagative. She continued to be managed medically and on [2131-8-5] she was offered a liver. She underwent Orthotopic deceased donor liver [Date Range ] (piggyback), portal vein to portal vein anastomosis, common bile duct to common bile duct (no T tube), celiac patch (donor) to junction of common hepatic and splenic artery (recipient) with Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. She had 9 liters of ascites deeply stained due to her hyperbilirubinemia. She had severe portal hypertension with marked collaterals and a small cirrhotic shrunken liver. She had somewhat abnormal anatomy in that her gastroduodenal artery came off somewhat anterior just proximal to the bifurcation of the right and left hepatic arteries. She received 1000 cc normal saline, 2500 cc of Plasma-Lyte, 10 units of fresh frozen plasma, 9 units of packed red cells, 4 units of platelets and made 540 cc of urine. Estimated blood loss was 5000 cc. She was transferred in stable condition to the SICU. POst op ultrasound revealed Patent hepatic vasculature with absent diastolic flow in hepatic arteries. There was no biliary dilatation or hepatic collections identified. She was extubated on POD 2. Liver ultrasound on POD 5 showed patent vasculature with good diastolic upstrokes. She followed the post op pathway and made excellent progress daily. The Lateral drain was left in place at discharge as volumes were still elevated, however the medial drain was d/c'd prior to discharge. Her main complaint was pain at the hernia site in her left abdomen. This responded well to an abdominal binder. She did have complaints of nausea which were reported better once the hernia was under better control. Of special note, the donor liver was from a woman that expired following exposure to someone who had eaten nuts and suffered an anaphylactic reaction and died. Patient was thoroughly instructed as well as the family on avoidance of nuts and nut products. She was sent home with epi pens. In addition, RAST testing was initiated and shouls be followed in the post op period for development of a transmitted peanut allergy. At the time of discharge she was ambulating, tolerating diet and had regained bowel function. She was well versed in her meds. She was not sent home on insulin as readings were acceptable in the post op period with minimal need for insulin coverage. Medications on Admission: Folic Acid 1 mg PO DAILY Cyanocobalamin 100 mcg PO DAILY Ciprofloxacin 250 mg PO Q24H Ascorbic Acid 500 mg PO DAILY Oxycodone 5 mg, 1 Tablet PO Q6H PRN Omeprazole 40 mg PO DAILY Acetaminophen 325 mg 1 tab PO Q6H prn Furosemide 20 mg po daily Spironolactone 25 mg PO BID Lactulose prn Nadolol 40mg po daily Mag oxide 400mg po daily Caltrate +D 600 po BID Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day. 2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other 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. 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: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: HCV Cirrhosis now s/p orthotopic liver [Hospital ] Nausea Dehydration Hernia Discharge Condition: Stable Discharge Instructions: Please call the [Hospital ] clinic at [Telephone/Fax (1) 673] for fever > 101, chills, nausea, vomiting, inability to take or keep down medications, increased abdominal pain, yellowing of eyes Monitor the incision for redness, drainage or bleeding Empty and record drain output twice a day and more often as needed. Call the office if the drain output increases, changes in color or develops a foul odor. You may wear the binder to help control the hernia Take your medications exactly as prescribed. Lab tests every Monday and Thursday, results faxed to [Telephone/Fax (1) 697] AVOID ALL PEANUTS, NUT PRODUCTS, and oils as reviewed with you by [Doctor First Name 1370], your dietitian No driving if taking narcotic pain medication No lifting of anything heavier than a gallon of milk Followup Instructions: [Last Name (LF) ],[First Name3 (LF) 156] [First Name3 (LF) ] SOCIAL WORK Date/Time:[2131-8-22] 10:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2131-8-22] 11:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2131-8-29] 11:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2131-8-17] ICD9 Codes: 5715, 5849, 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6476 }	Medical Text: Admission Date: [2187-8-26] Discharge Date: [2187-8-28] Date of Birth: [2160-2-7] Sex: F Service: [Year (4 digits) ] Allergies: Flagyl Attending:[First Name3 (LF) 11304] Chief Complaint: infected obstructive nephrolithiasis presents to ED with L flank pain Major Surgical or Invasive Procedure: cystoscopy and placement of 6 x 24 French double-J ureteral stent, LEFT sided, [2187-8-26] History of Present Illness: 27F [Location 7972] F w/ Hx of kidney stoes and intermittent L back pain radiating around to abdomen x 1 week, acutely worse this AM awaking her from sleep. H/o kidney stones approx 8mos PTA and states it feels like her previous stones. Denies fevers, diarrhea, hematuria, dysuria, endorses N/V. On ED presentation Tachy to 120s initially with pain, got toradol and morphine and HR returned to [Location 213]. UA looked infected and started on CTX. Renal U/S showed moderate to severe L hydro with obstructing stone. Confirmed on KUB. [Location 159] consult obtained, planning for stone removal Patient also received a loading dose of gentamicin. . She was taken to the OR and had a stent placed. She will likely need ESWL in the near future. . On arrival in the ICU, she was anxious, complaining of [7-11] colicky left flank pain with itnermittent extermely painful spasms. She was also nauseous and vomited. She was tachycardic, in Atrial Fibrillation, with a max HR in the 180s. She received 5mg IV metoprolol and her HR came down to 100s. . 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: - Kidney Stones - Depression/Anxiety - Tobacco Abuse - Recurrent BV Social History: - Tobacco: Mild use - Alcohol: Mild use - Illicits: Denies use SH: Lives with parents who she describes as strict, but supportive. Recently lefft job in billing/desk work 2 weeks ago. Smokes [3-6] cigarettes/day. Drinks 3 times a week, 4 drinks at a time. Marijuana use, denies cocaine or other illicit use. . Family History: - DM in grandparents FH: Negative for arrythmia, heart disease, or thyroid abnormality. . Physical Exam: General: Alert, oriented, NAD, AVSS HEENT: Sclera anicteric, MMM, oropharynx clear 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 No peripheral edema at calves/pain to deep palpation Pertinent Results: [2187-8-26] 3:14 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2187-8-29] MRSA SCREEN (Final [2187-8-29]): No MRSA isolated. = = = = = = = = = = ================================================================ [2187-8-26] 1:38 pm URINE Site: CYSTOSCOPY LEFT RENAL PELVIC. FINAL REPORT [2187-8-29] URINE CULTURE (Final [2187-8-29]): ESCHERICHIA COLI. 200 CFU/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------------ 2 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S = = = = = = = = = = = ================================================================ Time Taken Not Noted Log-In Date/Time: [2187-8-26] 11:14 am URINE Site: NOT SPECIFIED FINAL REPORT [2187-8-28] URINE CULTURE (Final [2187-8-28]): 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 = = = = = = = = = = = ================================================================ [2187-8-26] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2187-8-26] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] = = = = = = = = = = = ================================================================ ECCHO RESULTS: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. 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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve 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. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2187-8-27] 16:09 = = = = = = = = = = = ================================================================ [2187-8-28] 08:00AM BLOOD WBC-9.5 RBC-4.04* Hgb-12.4 Hct-36.7 MCV-91 MCH-30.8 MCHC-33.9 RDW-13.8 Plt Ct-257 [2187-8-27] 03:54AM BLOOD WBC-13.9* RBC-3.59* Hgb-11.2* Hct-32.1* MCV-90 MCH-31.1 MCHC-34.7 RDW-13.4 Plt Ct-216 [2187-8-26] 07:00AM BLOOD WBC-15.2* RBC-4.31 Hgb-13.7 Hct-39.0 MCV-91 MCH-31.9 MCHC-35.2* RDW-13.9 Plt Ct-255 [2187-8-28] 08:00AM BLOOD PT-12.6 INR(PT)-1.1 [2187-8-28] 08:00AM BLOOD Glucose-89 UreaN-4* Creat-0.7 Na-138 K-3.8 Cl-107 HCO3-21* AnGap-14 [2187-8-27] 03:00AM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-139 K-3.6 Cl-112* HCO3-20* AnGap-11 [2187-8-28] 08:00AM BLOOD Calcium-8.9 Mg-1.8 [2187-8-27] 03:00AM BLOOD Calcium-7.7* Phos-1.5* Mg-2.5 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION 27 yr/o F presenting with symptoms classic for kidney stones and kidney stone with hydronephrosis on Renal USS. ACTIVE PROBLEMS # Renal stones: Presented with classic symtpoms and with 8mm obstructive stone on L ureteropelvic junction with mod-Severe L hydronephrosis. Multiple nonobstructing calculi also noted in L kidney. Patient received ceftriaxone and gentamicin while in the ED, and [Month/Day/Year ] placed JJ ureteral stent... Pain was controlled with... . # UTI:Patient with leukocytosis on admission and UA showed evidence of UTI. Cx grew GNR. Was started on CTX and given dose of Gent prior to JJ stent. Patient was continued on ceftriaxone post procedure... . # Atrial Fibrillation with RVR. New, likely secondary to pain. However, given concern for structural heart disease or metabolic pathology TTE and TSH were measured. TSH was normal and TTE was wnl. Rate was controlled with IV metoprolol as required to control HR <110.... The above notes were for her [Hospital Unit Name 153] admission. Ms. [Known lastname 3586] was admitted to Dr. [Last Name (STitle) ] [Last Name (STitle) 159] service. This is a 27-year-old female with a history of nephrolithiasis, as well as urosepsis secondary to obstructive calculus back in [2183], who now presents with similar symptoms as well as a florid UTIs by urinalysis, and white count with a leukocytosis of 15. She is tachycardic in the emergency department and brought to the operating room urgently for decompression of the left upper collecting system. The patient was transferred to the [Hospital Unit Name 153] from the PACU in stable condition and transferred to the general surgical floor on POD1 where she remained. On POD1, pain was well with IV and PO medications and she was hydrated for urine output >30cc/hour, and provided with pneumoboots and incentive spirometry for prophylaxis. On POD1, the patient ambulated, restarted on home medications, basic metabolic panel and complete blood count were checked. On POD1 the urethral Foley catheter was removed without difficulty and diet was advanced as tolerated. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. The patient was given explicit instructions to follow-up in clinic for definitive stone management. Medications on Admission: Medications: - Ibuprofen PRN - Clindamycin Cream . Allergies: - Metronidazole Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: .5 Tablet Extended Release 24 hr PO once a day: (take one half of 25mg tablet). 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. Disp:28 Tablet(s) Refills:0 9. multivitamin Oral Discharge Disposition: Home Discharge Diagnosis: 1) PREPROCEDURE DIAGNOSIS: Left obstructing ureteral calculus with urinary tract infection and tachycardia. 2) POSTOPERATIVE DIAGNOSIS: Left obstructing ureteral calculus with urinary tract infection and tachycardia. 3) Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: --No vigorous physical activity for 2 weeks. -Expect to see occasional blood in your urine and to experience urgency and frequency over the next month. -Your kidney stones may still be in the process of passing. You may experience some pain associated with spasm of your ureter especially while there is an INDWELLING URETERAL STENT. This is normal. Take IBUPROFEN as directed and take the narcotic pain medication as prescribed if additional pain relief is needed. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Make sure you drink plenty of fluids to help keep yourself hydrated and facilitate passage of stone fragments. -You may shower and bathe normally. -Do not drive or drink alcohol while taking narcotics or operate dangerous machinery -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative -Resume all of your pre-admission/home medications, unless otherwise noted. -You will be discharged home with medications to control your infection and help control your heart rate. Please review the pharmacy prescribed and given instructions. -Call your urologist??????s office for follow-up AND if you have any questions. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: Please call to arrange/confirm your follow-up appointments AND if you have any questions. Your upcoming appointments are listed below. You have an indwelling ureteral stent that MUST be removed and/or exchanged in the next few weeks time. Please follow-up as advised. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2187-8-30] 1:45 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 11307], MD Phone:[Telephone/Fax (1) 164] Date/Time:[2188-2-14] 1:15 You should see the following physician to establish primary care: This doctor will discuss with you how to manage your Metoprolol (Toprol) and tell you when you can stop it. This doctor will also check your blood pressure. Thursday [8-30] at 1:45, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 732] [Location (un) ] [Hospital Ward Name 23] Building, North Suite, [Hospital1 827] Completed by:[2187-8-29] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6477 }	Medical Text: Admission Date: [2167-5-27] Discharge Date: [2167-7-20] Date of Birth: [2099-6-25] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: acute myocardial infarction Major Surgical or Invasive Procedure: [2167-5-28] left heart catheterization, coronary angiogram,attempted angioplasty of right coronary artery, placement of intraaortic balloon [2167-5-28] emergency right ventricular assist device [2167-5-28] exploration for mediastinal bleeding [2167-6-2] exploration of mediastinum, attempted wean of assist device [2167-6-3] mediastinal exploration,washout [2167-6-8] removal ventricular assist device/mediastinal washout/closure of chest [2167-6-22] Exploratory laparotomy, small bowel resection. [2167-6-23] Exploratory laparotomy,enteroenterostomy, cholecystectomy and gastrostomy tube placement. [2167-6-30] Exploratory laparotomy with lysis of adhesions. History of Present Illness: As per the patient,the night prior to admisssion she felt acutely diaphoretic, cold, with left leg weakness and had an episode of diarrhea. She denies any pain with this episode, however, it was associated with nausea. She tried to get out of bed but could not support herself on the left leg. Today she awoke with 6/10 anginal chest pain and tried to get out of bed, but felt lightheaded and fell down. She felt weaker in the left leg and is not sure whether she was weaker on the arm. She fell down on the left side. Her husband called 911 and she went to an outside hospital where she was found to have an evolving infarction and was transferred here. Past Medical History: Dyslipidemia hypertension migraines s/p hysterectomy h/o amaurosis fugax s/p cervical disc surgery [76] yrs ago osteoarthritis Social History: -Tobacco history: 45 pack year history (current) -ETOH: occ -Illicit drugs: denies Family History: Sister died of pancreatic cancer a few months ago. No stroke , CAD Physical Exam: Admission PE: VS: 98.1, 70-90, 100-119/60-77, 14-23, 97-100 RA GENERAL: NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva pink, No xanthalesma. NECK: Supple with no JVD noted. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. slightly inattentive Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. No right-left confusion. No evidence of apraxia or neglect. memory [1-21] immediate and 0/3 at 5 mins, calculations slightly impaired. [Location (un) 1131] writing intact. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Extraocular movements intact bilaterally. BL end gaze nystagmus 6-7 beats. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal bulk and tone bilaterally. No pronator drift. [Doctor First Name ] Tri [Hospital1 ] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 4- 4- 5 4- 5 4- Sensation: Intact to light touch, pinprick. No extinction to DSS., impared vibration in toes, left greater than right. Position normal. Reflexes: 1 + except 2 plus on left kness. Toes downgoing bilaterally. Coordination: FNF and [Doctor First Name ] normal. Gait/ Rhomberg - defd Pertinent Results: [2167-7-7] 03:25AM BLOOD WBC-7.2 RBC-3.28* Hgb-9.3* Hct-29.1* MCV-89 MCH-28.3 MCHC-31.8 RDW-16.4* Plt Ct-578* [2167-5-27] 02:30PM BLOOD WBC-6.5 RBC-4.24 Hgb-12.1 Hct-36.3 MCV-86 MCH-28.5 MCHC-33.2 RDW-14.2 Plt Ct-341 [2167-7-1] 04:20AM BLOOD PT-16.0* PTT-32.8 INR(PT)-1.4* [2167-5-27] 02:30PM BLOOD PT-12.3 PTT-117.7* INR(PT)-1.0 [2167-7-7] 03:25AM BLOOD Glucose-114* UreaN-20 Creat-0.5 Na-138 K-3.9 Cl-104 HCO3-29 AnGap-9 [2167-5-27] 02:30PM BLOOD Glucose-116* UreaN-18 Creat-0.9 Na-144 K-4.2 Cl-111* HCO3-21* AnGap-16 [2167-7-2] 03:57AM BLOOD ALT-36 AST-23 LD(LDH)-220 AlkPhos-96 Amylase-101* TotBili-1.2 [2167-5-28] 12:35PM BLOOD ALT-25 AST-84* LD(LDH)-369* AlkPhos-24* Amylase-41 TotBili-0.6 [2167-7-1] 04:20AM BLOOD Lipase-36 [2167-5-28] 12:35PM BLOOD Lipase-85* [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 2801] [Hospital1 18] [Numeric Identifier 39152]Portable TTE (Complete) Done [2167-6-30] at 1:45:56 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] Division of Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2099-6-25] Age (years): 68 F Hgt (in): 61 BP (mm Hg): 108/60 Wgt (lb): 140 HR (bpm): 107 BSA (m2): 1.62 m2 Indication: Left ventricular function. Right ventricular function. Shortness of breath. ICD-9 Codes: 785.0, 786.05, 416.9 Test Information Date/Time: [2167-6-30] at 13:45 Interpret MD: [First Name8 (NamePattern2) 35980] [Name8 (MD) 35981], MD Test Type: Portable TTE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2010AW000-0:00 Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Left Ventricle - Stroke Volume: 50 ml/beat Left Ventricle - Cardiac Output: 5.38 L/min Left Ventricle - Cardiac Index: 3.32 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.17 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 5 < 15 Aorta - Sinus Level: 2.0 cm <= 3.6 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm Aortic Valve - LVOT VTI: 16 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 148 ms 140-250 ms Findings Patient on phenylephrine 1 mcg/kg/min LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Markedly dilated RV cavity. Moderate global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Severe [4+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: The patient appears to be in sinus rhythm. Resting tachycardia (HR>100bpm). Left pleural effusion. Conclusions The left atrium is normal in size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Severe [4+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Preserved left ventricular systolic function. Markedly dilated right ventriular size. Moderate right ventricular systolic dysfunction. Severe (4+) tricuspid regurgitation. Electronically signed by [First Name8 (NamePattern2) 35980] [Name8 (MD) 35981], MD, Interpreting physician [Last Name (NamePattern4) ] [2167-6-30] 14:13 Brief Hospital Course: After arrival Mrs. [Known lastname ] was taken to the cath lab, where catheterization showed an occluded RCA. Attempts to open the RCA were unsuccessful and she was returned to the CCU for monitoring and became hemodynamically unstable with hypotension. She returned to the cath lab in cardiogenic shock and an IABP was placed. Cardiac Surgery was consulted and she was taken emergently to the Operating Room for ventricular assist device placement. Please refer to Dr[Doctor First Name ] operative report for further details. The right heart was essentially akinetic and the Abiomed assist device was implanted, the IABP left in place and multiple pressors infusing. She transferred to the CVICU in critical condition on phenylephrine, Milrinone and insulin drips. Later that day she returned to the Operating Room for mediastinal washout for bleeding. Clot evacuation was performed and the chest was left open. Over the next several days the patient required increasing pressor support. Bedside washout was done again on [5-29] and she went back to Operating Room for washout and possible device weaning on [6-2]. On [6-3] another mediastinal washout was done and the patient did not tolerate device weaning. She was kept sedated and paralyzed during this time and total parenteral nutrition was begun. On [6-6] and 18 Dopamine was weaned off, Levophed and Neo Synephrine were weaned significantly, the balloon pump was weaned to 1:2, and the device to 3 liters a minute. She was aggressively diuresed during this time and maintained on Vancomycin/Zosyn and Diflucan (for yeast in sputum) perioperatively. She was appropriately Heparinized during this time as well. On [6-8] she returned to the Operating Room and the device was explanted and the chest closed. Milrinone was increased empirically and Levophed added. The right ventricular function appeared significantly improved. On [6-9], IABP was removed. All pressor support was weaned off. She continued to have fevers to 102, without a source, despite multiple cultures being obtained. She was extubated on [6-15] and continued to have an ileus. She was very confused, with auditory hallucinations, although there was a non focal exam and she recognized family. This persisted and gradually improved. A CT of the torso was repeated for continued fevers and a small bowel obstruction was noted. An exploratory laparotomy found necrotic small bowel which was resected. The abdomen was left open and a reexploration the following day resulted in a cholecystectomy and the abdomen was closed. [6-30] she was taken back to the operating room for significant adhesions of the omentum to the small and large bowel, as well as interloop adhesions of the small bowel that were lysed. Antibiotic regimen followed according to Infectious Diseases recommendations. She was ultimately weaned from the ventilator and extubated. TPN was continued for nutritional support. Trophic tube feeding was begun when approved by the surgical team. She continued to slowly clear her mental status and improve her strength. The Physical Therapy service worked with her during the ICU stay. She continued to progress and was transferred to the step down unit for further monitoring on POD# 40 from her original procedure. She continued on triple abx therapy. Mrs. [Known lastname ] had intermittant recurrent abdominal pain on [7-12]. Tube feeds were held and the exam improved. Tube feeds were resumed at 3/4 strength through her jejunal feeding tube with no abd pain. The G-j tube was noted to be leaking from a crack. It was replaced on [2167-7-15] with a simple G-tube for continued feeding. TPN was stopped on [2167-7-19] when her full strength elemental tube feeds were at goal. She suffered from copious amount of loose stool which was c-diff negative. A flexiseal device was used to protect her skin and collect stool. Her tube feeds were changed to full strength vivonex and banana flakes were added. Her diarrhea improved and stool cultures from [2167-7-16] were negative for c-diff. the flexiseal was removed. She passed her swallowing study and began to take po's slowly but in sufficicent quantity to stop tube feeds at the time of discharge. Prior to discharge Nutrition and speech and swallow final recommendations were made. She continues to have persistant sinus tacycardia on diltiazem and carvedilol. She requires tacycardia due to her poor RV function. We have attempted to keep her systolic blood pressure greater than 110 for gastric perfusion. Her mental status has cleared considerably but remains intermittantly confused and she suffers from overwhelming anxiety at times. Her anxiety responds well to low dose ativan and reassurance. On POD# 53 from her original surgery, she was cleared by Dr.[First Name (STitle) ] for discharge to [Hospital3 105] [Hospital 39153] in [Location (un) 701]. All follow up appointments were advised. Medications on Admission: MEDICATIONS: (OPT) Amitriptyline 25 mg POQHS Simvastatin 40 mg POQHS Topiramate 200 mg PO daily Verapamil 40 mg POQD Buspirone 5 mg POBID prn depression/anxiety ( prior to OR): Acetaminophen Amitriptyline Aspirin EC Atropine Sulfate BusPIRone Clopidogrel DOPamine Eptifibatide Heparin Metoprolol Tartrate Ondansetron Ranitidine Topiramate Warfarin Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for HA. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for to groin. 7. Ibuprofen 100 mg/5 mL Suspension Sig: Two (2) PO Q8H (every 8 hours) as needed for pain. 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stool. 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for anxiety. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO HS (at bedtime) as needed for insomnia. 13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: coronary artery disease s/p attempted angioplasty cardiogenic shock with right heart failure s/p right ventricular assist (Abiomed) placement s/p explant of Abiomed device s/p mediastinal exploration,chest washout x 3 acute inferior myocardial infarction hypertension dyslipidemia migraines degenerative joint disease postoperative small bowel obstruction s/p exploratory laparotomy,small bowel resection,lysis of adhesions s/p re-eploration of abdomen,cholecystectomy and abdominal closure s/p hysterectomy s/p lumpectomy Discharge Condition: Alert and oriented x 2, nonfocal Ambulating with assistance Incisional pain managed with oral analgesics Incisions: Sternal - healed no erythema or drainage abdomen: healing, no erythema or drainage, steristrips intact Edema [12-24]+ LE edema to the hips 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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. [First Name (STitle) ] ([Telephone/Fax (1) 170]) Monday [8-17] @ 1:00 pm [Hospital Ward Name ] 2A Cardiologist Dr. [Last Name (STitle) ] Tuesday [8-25] @ 9:00 AM Please call to schedule appointments with: General Surgery: Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] #[Telephone/Fax (1) 673] please call for appoinment follow up in 2 weeks Primary Care: Dr.[First Name (STitle) ] L.[Doctor Last Name ] in [11-22] weeks after discharge from rehab ([Telephone/Fax (1) 8129]) Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2167-7-20] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6478 }	Medical Text: Admission Date: [2156-9-29] Discharge Date: [2156-10-3] Date of Birth: [2097-10-11] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3227] Chief Complaint: Lower back pain Major Surgical or Invasive Procedure: None History of Present Illness: Per the patient, she is a 58 y.o woman named [Name (NI) 55388] [Name (NI) 79724]. She states she was riding on a boat near [Initials (NamePattern4) ] [Last Name (NamePattern4) 19700] [2156-9-29] when the boat struck a wave and slammed down causing a strong axial load to her back. She was in a seated position. There was no fall, but she reports immediate lower back pain that is sharp, and non-radiating. It was a [10-8]. She was taken to [Initials (NamePattern4) ] [Last Name (NamePattern4) 19700] hospital secured on a backboard. She was reported and documented to have a resultant L2 burst fracture. She had not micturated or defecated since the accident. There was no LOC or seizure activity at the scene. Past Medical History: osteoporosis Hypothyroidism Bilateral breast implants Social History: Hx: lives at home with husband. Does gardening as a hobby. occasional ETOH use, no tobacco or illicit drugs. Family History: non-contributory Physical Exam: T: 98.5 BP:128/78 HR:68 RR:16 O2Sats:97% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA EOMs full as tested Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Back: There is mild TTP over the spinous processes of L1-L3 Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [Last Name (un) 938] G R 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. There is no saddle anesthesia. Reflexes: B T Br Pa Ac Right 2+ 2+ Left 2+ 2+ Propioception intact Toes downgoing bilaterally Rectal exam: + rectal tone. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2156-10-2] 07:40AM 9.3 4.19* 13.0 38.5 92 31.0 33.7 12.9 282 BASIC COAGULATION PLT [2156-10-2] 07:40AM 282 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2156-10-2] 07:40 93 8 0.6 140 4.0 104 27 13 Calcium Phos Mg 8.6 2.6* 1.8 TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp Barbit Tcl [2156-9-28] 08:25PM NEG NEG1 NEG NEG NEG NEG CT L-spine: IMPRESSION: Burst fracture of L2, with significant retropulsion of the fracture fragments and narrowing of the canal. MR of the lumbar spine is recommended to evaluate for cauda equina compression. MR [Name13 (STitle) ]: 1. L2 compression fracture with retropulsion of fracture fragments causing moderate-to-severe canal stenosis. This is below the level of the conus; however, it does cause complete effacement of the thecal sac surrounding the cauda equina. Clinical correlation is recommended to determine degree of nerve root compression. 2. Small, likely epidural, hematoma anterior to the cord superior to the region of canal stenosis. 3. Apparent discontinuity of the anterior longitudinal ligament at the L2 level. The posterior longitudinal ligament, supraspinous ligaments, and interspinous ligaments appear intact. Brief Hospital Course: The patient was transferred to the [Hospital1 18] from [Initials (NamePattern4) ] [Last Name (NamePattern4) 19700] Hospital. She arrived in the ED and a Neurosurgery Consult was obtained. Repeat CT of her T and L-spines were obtained confirming her diagnosis of an L2 burst fracture with retropulsion. An MRI was obtained for assessment of cord compression and/or ligamentous injury. After reviewing this case with several spine surgeons, a spectrum of management options were discussed. Ultimately, it was felt that the patient can try a short course of lumbar bracing -- reserving anterior stabilization should she fail bracing challenge. She was fitted and recieved a TLSO brace which should be worn at all times when up and out of bed. While she had suffer some pain during initial attempts at sitting, this pain improved significantly in subsequent days. She was able to tolerate sitting, standing, and walking with the help of PT. Given her significant improvement, the patient was discharged on [2156-10-4]. Medications on Admission: Actonel, Synthroid Discharge Medications: 1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-31] Drops Ophthalmic PRN (as needed). 4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 Injection TID (3 times a day). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. 12. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: [Doctor First Name ] medical center Discharge Diagnosis: Lumbar 2 vertebral body burst fracture with retropulsion Discharge Condition: Stable Discharge Instructions: Spine Diagnosis Based Education: 1. You should not over-exert yourself for the first few weeks home. Make sure you walk every day whatever distance is comfortable. If your back or legs start to hurt, you have gone too far. There is no stair climbing restriction but make sure to use available hand rails. 2. AVOID vigorous activities such as heavy house or yard work. This also includes raking, shoveling and mowing the lawn. 3. Do not lift greater than 10 lbs which is about one gallon of milk. 4. Do not sit upright in a straight chair for longer than 2 hours at a time. You may be more comfortable on a recliner, couch or bed. You must wear your brace when upright either sitting or standing. Do not wear the brace in bed as it could cause blistering or sores. 5. Your travel will be limited. You cannot sit or stand longer than two hours at a time. 6. Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. Call your surgeon or go to the nearest ER if you have: Leg pain that is continually increasing or not relieved by pain medications. Call for any new weakness, numbness, tingling in your extremities. Any signs of infection at the wound site: redness, swelling, tenderness,drainage or if you develop a fever greater than or equal to 101?????? F. Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] next week [Telephone/Fax (1) 1669] to update your progress. Completed by:[2156-10-3] ICD9 Codes: 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6479 }	Medical Text: Admission Date: [2159-1-17] Discharge Date: [2159-2-3] Date of Birth: [2159-1-17] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname ] is a 2205-gram male born at 33 and [3-26] gestation to a 34-year-old gravida 3/para 1 (now 2) mother with prenatal screens blood type A positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, and group B strep status unknown. The pregnancy was complicated by cervical shortening with preterm labor since [79] weeks gestation. The mother also had a history remarkable for a 24- week delivery of a female infant who died at 22 days of age in the [Hospital1 ] NICU. During this pregnancy, the mother was treated with bed rest and magnesium sulfate. She was made betamethasone complete at 26 weeks. She also experienced chronic abruption. Baby boy [Known lastname ] was delivered by cesarean section secondary to fetal stress and abruption on the day of delivery. Rupture of membranes was at the time of delivery. Resuscitation at delivery was uncomplicated with just poor color with Apgar scores 7 at 1 minute and 8 at minutes of life. He was transferred to the NICU for further management of his prematurity and some respiratory distress. PHYSICAL EXAMINATION ON ADMISSION: Birth weight was 2205 grams (75th percentile), length was 45 cm (60th percentile), and head circumference was 33.5 cm (90th percentile). HEENT examination revealed an anterior fontanel that was soft and flat. Facial features were nondysmorphic. Red reflex was appreciated bilaterally. His palate was intact. Chest examination revealed fair aeration with mild retractions and some tachypnea. The heart was regular in rate and rhythm without a murmur. Femoral pulses were 2 plus. The abdomen was soft with a 3-vessel cord, and no hepatosplenomegaly. Genitourinary examination revealed normal male genitalia with testes descended bilaterally and a patent anus. There were no hip clicks. There were no sacral dimples. Skin examination revealed a small excoriation in the mid lumbar region. Neurologic examination was notable for an active infant moving all extremities with normal tone. SUMMARY OF HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY: Baby boy [Known lastname ] had initial mild respiratory distress, for which he was started on CPAP of 6 cm. He required 25 to 30 percent oxygen over the first 24 hours to 36 hours of life. A chest x-ray was streaky bilaterally. Over the first 72 hours of life, he was successfully weaned from CPAP and by day of life five ([1-22]) baby boy [Name (NI) ] had transitioned to room air. He has remained on room air with good saturations since that time. He was initially begun on caffeine for mild apnea of prematurity, but this was discontinued on day of life five, and he has had no apnea or bradycardia episodes since that time. 2. CARDIOVASCULAR: Baby boy [Known lastname ] initially required a single normal saline bolus for delayed capillary refill on admission. He has otherwise had normal blood pressures and perfusion throughout his stay. He has no murmur. 3. FLUIDS, ELECTROLYTES AND NUTRITION: Baby boy [Known lastname ] was initially held nothing by mouth and begun on intravenous fluids at 80 cc/kg per day. Feedings were initiated on day of life three and advanced to full enteral feeds of 140 cc/kg per day by day of life six. Thereafter, calories were advanced. Patient was initially fed via gavage tube, with oral feedings introduced and advanced as tolerated. At the time of discharge, he was feeding breast milk or Similac 26 calories per ounce (4 cals by powder or concentration and 2 cals by corn oil). He has voided and stooled appropriately throughout his stay. Electrolytes were normal during his hospitalization. 4. HEMATOLOGIC: Baby boy [Known lastname 59292] initial hematocrit was 54 percent. This has not been rechecked since the day of his admission, but he remained pink and well perfused. He did experience some hyperbilirubinemia with a peak bilirubin of 11.7 on day of life three. He was briefly treated with phototherapy, and his most recent bilirubin was a total bilirubin of 2.2 with a direct bilirubin of 0.4 on day of life eight. 5. NEUROLOGIC: Baby boy [Known lastname ] has had a normal neurologic examination throughout his stay and does not qualify by gestational age for screening head ultrasounds. 6. SENSORY: A hearing screen was performed with automated auditory brain stem responses, which was passed on [2-2]. 7. INFECTIOUS DISEASE: Baby boy [Known lastname ] was initially evaluated for sepsis with a blood count which was reassuring and blood cultures. He was treated with ampicillin and gentamicin, and when those blood cultures were negative at 48 hours the antibiotics were discontinued. He has had no other Infectious Disease issues during this hospitalization. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home with parents in a car seat. PRIMARY PEDIATRICIAN: [Hospital3 ] Health [Hospital3 38797] CARE RECOMMENDATIONS: 1. Feedings at discharge are breast milk or Similac 26 calories per ounce with 4 of those extra calories coming from Similac powder and 2 calories coming from corn oil. 2. Baby boy [Known lastname ] is not on any medications. 3. Car seat position screening was passed. 4. State newborn screens have been sent on [2159-1-20] and [2159-2-2]. 5. Baby boy [Known lastname ] has received his first hepatitis B immunization on [2159-1-30] IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: (1) born at less than 32 weeks gestation; (2) born between 32 and 35 weeks gestation with two of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or (3) with chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach six months of age. Before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out of home caregivers. DISCHARGE FOLLOWUP: Followup will be with [Hospital3 ] Health [Hospital3 38797] two to three days after discharge. DISCHARGE DIAGNOSES: 1. Respiratory distress syndrome - resolved. 2. Feeding immaturity - resolved. 3. Hyperbilirubinemia - resolved. 4. Rule out sepsis - resolved. 5. Apnea of prematurity - resolved. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) ] Dictated By:[Doctor Last Name 56593] MEDQUIST36 D: [2159-2-2] 09:36:59 T: [2159-2-2] 10:16:15 Job#: [Job Number 59293] ICD9 Codes: 769, 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6480 }	Medical Text: Admission Date: [2185-9-7] Discharge Date: [2185-9-8] Date of Birth: [2109-8-12] Sex: F Service: EMERGENCY Allergies: Sulfa (Sulfonamides) / Ampicillin / Codeine Attending:[First Name3 (LF) 2565] Chief Complaint: cerebral hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 76F with PMH notable for hypertension, dm2, who was found by daughter with whom she lives at 7 am. Pt was per report gurgling with vomit in her mouth and on her pillow. She was unresponsive to her daughter's calls and was breathing heavily. SHe had previously been seen at at 9pm the night before "totally fine" at her baseline mental status. EMS was called and pt was intubated in the field due to lack of gag reflex and poor mental status. She was not sedated for the intubation. . In the ED, the pt was noted to be unresponsive. Initial vitals were hr 70, bp 170/78, rr 12, 02sat 99% on the vent. Pt was not sedzated and had GCS of 3. CT head revealed large hemorrhagic CVA with midline shift and transtentorial and tonsillar herniation. Neurosurgery consult confirmed grim prognosis and likely irreversible neurologic injury. Extensive discussion between the patient's supportive family and the ED staff resulted in a decision to focus on pt comfort. Pt was made DNR/DNI (although she would remain intubated). She was transferred to the ICU for further care. Past Medical History: Hypertension Diabetes Mellitus Dementia Glaucoma. Legally blind Subarachnoid hemorrhage status post fall in [2182-5-9]. Social History: The patient lives with her daughter. [Name (NI) ] alcohol or tobacco use. She has another daughter in the area and two grandsons, who helps care for her. Family Hx: mother with [Name (NI) 11964], daughter died of gastric ca . Family History: NC Physical Exam: Gen: Elderly, cachectic female, intubated and unresponsive HEENT: Small right pupil, opacified left. Dry mm, intubated. Anicteric sclerae Neck: Supple, no LAD Heart: RR, no m/g/t Lungs: Coarse bs b/l Abd: Soft, scaffoid, NABS Ext: Warm, thin, nonpalpable pulses Neuro: Unresponsive, right pupil minimally reactive, left eye opacified. Unable to assess cranial nerves, muscles nl bulk but flaccid tone. Cannot assess sensation, areflexic patellae and babinski b/l . Pertinent Results: [2185-9-7] 09:00AM WBC-14.6* RBC-4.51 HGB-14.5 HCT-41.5 MCV-92 MCH-32.2* MCHC-35.1* RDW-13.5 [2185-9-7] 09:00AM [Month/Day/Year ]-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2185-9-7] 09:03AM GLUCOSE-226* LACTATE-4.7* NA+-147 K+-3.4* CL--106 TCO2-29 [2185-9-7] 09:00AM UREA N-15 CREAT-0.5 . CT Head: There is a massive area of hemorrhage in the right frontal- pariatrial region that that has caused shift of midline of 2.3 cm. This massive hemorrhage is associated with surrounding edema and also extends to the right lateral ventricle. There is also enlargement of temporal horns of lateral ventricles suggesting non-communicating hydrocephalus. There is blood in the fourth ventricle and there is complete obliteration of the cisterns. There is also nonvisualization of any CSF space at foramen magnum suggesting inferior vermian herniation. There is also no space around the mid brain suggesting transtentorial herniation. The bone windows do not show any signs of fracture. There are no extra-axial hemorrhages. IMPRESSION: Massive right fronto-parietal hemorrhage with associated shift of midline and severe mass effect and non-communicating hydrocephalus and transtentorial and inferior tonsillar herniation. Brief Hospital Course: Patient is a 76yo female history notable for HTN and SAH p/w massive intracranial hemorrage with likely irreversible neurologic injury. Family wishes pt be comfortable. Asking her to remain intubated since several family members are coming to see her. . 1) Subarrachnoid hemmorhage and herniation: Based on physical exam and respiratory status, pt met criteria for brain death. The ET tube was removed and the patient subsequently expired at 15:02. . Medications on Admission: Metformin 500 [Hospital1 ], Lipitor 10 QD, Lisinopril 25 [Last Name (LF) 244], [First Name3 (LF) ] 81 mg Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired ICD9 Codes: 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6481 }	Medical Text: Admission Date: [2194-8-19] Discharge Date: [2194-8-26] Date of Birth: [2148-6-7] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: Type I DM admitted for pancreatic transplant Major Surgical or Invasive Procedure: pancreas transplant [2194-8-19] History of Present Illness: 46 yo man s/p LRKT [2191] and failed pancreatic transplant [2191] here for his second pancreatic transplant. Past Medical History: DMI s/p pancreas/kidney transplant; pancreas transplant failed [3-12] thrombus ESRD s/p LRKT CAD s/p CABG s/p PTCA [9-11] HTN orthostasis, autonomic dysfunction GERD PUD hypertensive gastropathy s/p fem-[Doctor Last Name ] polycythemia [Doctor First Name ] grade II esophagitis Social History: EtOH 1/week, + tobacco 1pack/3 weeks; on disability, lives at home alone; is out at the Yacht club Family History: mother w/ breast ca; o/w DM/HTN/CVA/hyperchol Physical Exam: Gen: well appearing man, NAD HEENT: PERRL, oropharynx without erythema/exudate, neck supple without masses CV: RRR, no murmurs/rubs/gallops Lungs: CTA bilaterally Abd: soft, NT/ND, +BS with well-healing incision c/d/i Ext: no edema, no palpable pulses bilateral dorsalis pedis, warm extremeties bilaterally Neuro: alert and oriented x 3 Brief Hospital Course: Patient was admitted and underwent an uncomplicated pancreatic transplant on [2194-8-19]. He was stable postop and was transferred to the floor. He was placed on a dilaudid PCA for pain, and also started on a 200U heparin drip. He continued to do well with blood sugars well controlled ranging in the low 100's. He did experience two episodes of low blood sugar in the early post operative period with blood sugars in the 60's. He did well over the next few days while receiving his standard immunosuppresion protocol of ATG and Solumedrol. His diet was advanced to sips on post op day #4 which he tolerated well. Blood sugars continued to be well controlled with no insulin requirement. On postop day #6, the patient had two blood sugars levels of 213 and 214 respectively and was sent down for a pancreatic ultrasound. The ultrasound revealed good a-v flow through the pancreas and no major fluid collections. On post op day #7 he received an abdominal CT which revealed normal appearing pancreas and kidney with a small amount of fluid around the transplanted kidney. His blood sugars returned to [Location 213] with no other elevated levels. He was tolerating regular diet, maintaining normal blood sugars and was dischared on post op day #8 in good condition. Medications on Admission: Bactrim, Atorvastatin 10mg qd, Cellcept [Pager number ] tid, Lantus 25U qhs, Reglan 10mg [Hospital1 ], Prednisone 1mg tid, Protonix 40mg [Hospital1 ], Midodrine 10mg [Hospital1 ], Tacrolimus 0.5mg qhs, 1mg qAM, Florinef 0.1mg qd, Humalog insulin SS, Vitamin C, Ferrous gluconate, ASA 81mg 3X/week Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Monday-Wednesday-Friday. 9. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Prednisone 1 mg Tablet Sig: One (1) Tablet PO three times a day. 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day: potassium level to be checked Thursday [8-28]. Disp:12 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Pancreas transplant [2194-8-19] DM Type I hypertension s/p cabg s/p kidney transplant [2-8] Discharge Condition: stable Discharge Instructions: Call if fevers, chills, nausea, vomiting, inability to take medications, redness/bleeding, blood sugars 200 or greater, tenderness over pancreas/kidney. Labs every Monday & Thursday for cbc, chem 7, calcium, phosphorus, ast, t.bili, amylase, lipase, albumin and trough prograf level. Check blood sugar at least every morning and evening. Call if glucose 200 or greater. keep record of blood sugars No heavy lifting Check sugars every 6 hours Followup Instructions: Provider: [Name10 (NameIs) 1344] [Last Name (NamePattern4) 3125], MD Where: LM [Hospital Unit Name 3126] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2194-9-1] 1:10 Provider: [Name10 (NameIs) 1344] [Last Name (NamePattern4) 3125], MD Where: LM [Hospital Unit Name 3126] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2194-9-8] 9:40 Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Where: LM [Hospital Unit Name 3126] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2194-9-15] 3:20 ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6482 }	Medical Text: Admission Date: [2198-5-7] Discharge Date: [2198-5-10] Date of Birth: [2157-11-3] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: bronchoscopy with stenting to L main bronchus History of Present Illness: 40 year old female with recent dx of metastatic esophageal cancer with R main bronchus stent and esophageal stent, transferred from OSH ED with resp failure since home O2 ran out this AM. Husband states that pt respiratory distress occured acutely and did not improve with new O2 tanks. He states that she did not complain of any chest pain but he states that she did have fevers and cough earlier that day. Intitially at OSH patient was T 103, BP 99/35, HR 130s-170s (sinus)95% NRB. Pt was intubated and given imimpenem, solumedrol. Her ABG at OSH was 7.25/75/75 before intubation. Transferred to [Hospital1 18] for further care. In the ED at [Hospital1 18] patient afebrile [Company 5249] 99 rectal and CXR showed stable RML/RLL collapse. Past Medical History: esophogeal cancer (poorly diff adenocarcinoma of distal esophogas), s/p esophageal stent with mets to adrenal, pancreas and T12 vertebrae anxiety disorder, HTN, Chronic obstructive pulmonary disease, ?Non small cell lung cancer with 80% stenosis of R main bronchus, s/p stent. Social History: Mr.and Mrs.[Last Name (STitle) 66599] have no children and are each other's support system. She is a homemaker and he is employed at [Company ]. Quit smoking in [Month (only) 404] Family History: NC Physical Exam: PE: T 97.9 BP 116/67 HR 95 RR 31 O2Sat 100% on CMV 450x16 PEEP 5 FiO2 0.6 Gen: Patient sedated but responsive to verbal stimuli Heent: PERRL, sclera anicteric, pt with ETT and OG tube Neck: no LAD Lungs: Diffuse ronchi with hyperresonance at RLL Cardiac: RRR S1/S2 no murmurs, difficult to hear given BS Abdomen: soft, NT, decreased BS Ext: no edema, warm, DP +2 Neuro: sedated but responsive to verbal stimuli Pertinent Results: [2198-5-7] 05:23PM PLT SMR-HIGH PLT COUNT-554# [2198-5-7] 05:23PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [2198-5-7] 05:23PM NEUTS-94.7 BANDS-0 LYMPHS-3.2* MONOS-1.6* EOS-0.2 BASOS-0.3 [2198-5-7] 05:23PM WBC-16.4* RBC-3.72* HGB-10.2* HCT-31.1* MCV-84 MCH-27.3 MCHC-32.7 RDW-16.6* [2198-5-7] 05:23PM ALBUMIN-3.1* [2198-5-7] 05:23PM ALT(SGPT)-16 AST(SGOT)-28 LD(LDH)-398* ALK PHOS-103 TOT BILI-0.4 [2198-5-7] 05:23PM GLUCOSE-140* UREA N-8 CREAT-0.8 SODIUM-137 POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-29 ANION GAP-19 [2198-5-7] 05:25PM LACTATE-2.2* [2198-5-7] 11:16PM LACTATE-1.9 [2198-5-7] 11:16PM TYPE-ART TEMP-36.6 PO2-283* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-4 . Chest CT [5-8]: IMPRESSION: 1) No pulmonary embolism. 2) Extensive tumor involving the mid and distal esophagus invading into the right hilum and intimately associated with the left atrium. This tumor narrows and encases the right-sided pulmonary arteries and occludes the right middle and right lower lobe bronchi. 3) Interval placement of an esophageal stent as well as an apparent right- sided bronchial stent which is now located within the fistulous tract connecting the residual esophageal lumen and the right lower lobe bronchi. It is possible that this stent has migrated from its intended location in the bronchus intermedius. 4) Persisting total collapse of the right middle lobe and right lower lobe. 5) Persisting fluid-filled cavitary lesion in the right middle lobe, which may be superinfected. 6) Persisting ground glass and tree-in-[Male First Name (un) 239] opacities in the right upper and left lower lobes, likely infectious. 7) Lytic lesion in the T12 vertebral body, likely metastasis. Brief Hospital Course: A/P: 40 y/o F with PMHx significant for metastatic esophageal CA, ? NSCLC s/p R bronchus and esophageal stents who presents from OSH with fever and respiratory distress. . 1. Respiratory Distress: The intial suspicion was that the patient had developed a pneumonia which led to a decompensation on the backgroudn of her poor baseline with R lung atelectasis from her tumor. She was treated empirically with Zosyn and vanco given recent hospitalization. However, a bronch was performed to evaluate her airways and the stent placement. This unfortunately showed very severe anatomical defects caused by the urdelying cancer. There was obstruction noted of both L and R mainstem bronchus. The esophageal stent was noted to be eroding through the esophageal wall into the R mainstem bronchus. The patient returned for another bronch by interventional pulmonary with a plan to make an aggressive attempt to treat the lesions as best as possible. However, removal of the esophageal stent which was eroding into the R bronchus was not possible. The L mainstem bronchus was stented. Discussions were held with the family and with the patient who remained awake, alert and fully aware of her surroundings and able to communicate (non-verbally given that she was intubated). It was explained to the patient and the family that she would never be able to be safely extubated given the severity of the disease and that her prognosis from the aggressive cancer was one of terminal progression likely over weeks to a few months. The patient ultimately elected for comfort measures only. She was extubated on [2198-5-10] in the company of her family. She soon passed away quietly and comfortably with her friends and family present Medications on Admission: Atenolol Paxil Wellbutrin Albuterol Norvasc Pulmacort Discharge Medications: not applicable Discharge Disposition: Expired Discharge Diagnosis: End stage metastatic CA respiratory failure post-obstructive pneumonia sepsis Discharge Condition: deceased Discharge Instructions: not applicable [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] ICD9 Codes: 496, 5180, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6483 }	Medical Text: Admission Date: [2187-12-7] Discharge Date: [2187-12-19] Date of Birth: [2136-1-20] Sex: F Service: CARDIOTHORACIC Allergies: Bactrim / Gentamicin Attending:[First Name3 (LF) 1406] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [2187-12-14] 1. Aortic valve replacement with a St. [Male First Name (un) 923] Epic tissue valve, reference #[Serial Number 91351]. 2. Mitral valve a repair with closure of anterior leaflet perforation and closure of partial anterior, mitral leaflet cleft with 28-mm [Company 1543] CG Future annuloplasty ring, model #63HR. History of Present Illness: 51 year old female seen in [Hospital ] clinic on [12-7] in follow up for Enterococcal endocarditis and referred to ED for further evaluation due to altered balance, vision changes, nausea, anterior chest discomfort, orthopnea, and DOE, worsening over the past week. She is 6 weeks into IV PCN/gent complicated by recent AKIN due to gentamycin. In ED she had non contrast head CT was negative for acute findings and Chest CT questioned spleenic infarcts however ultrasound ruled out acute splenic infarcts. She had TTE that showed new involvement for mitral valve, she was continued on IV PCN, but then discontinued by infectious disease then resumed next day, however TEE revealed moderate-sized vegetation on the aortic valve. Severe (4+) aortic regurgitation is seen with reversal of flow in the aortic arch. The mitral valve is abnormal. There is small vegetation abscess on the anterior leaflet of the mitral valve with perforation. Severe (4+) mitral regurgitation is seen. Now referred for surgical evaluation Cardiac Catheterization: none CT scan chest [2187-12-7] [Hospital1 18] 1. No evidence of pulmonary septic emboli. Evaluation for pulmonary embolism is not possible given lack of IV contrast. 2. 3-mm pulmonary nodule in the right upper lobe and a 2-mm pleural-based nodule in the left lower lobe are present. 3. Splenic hypodensity better seen on prior contrast enhanced abdominopelvic CT consistent with infarct. Cardiac Echocardiogram: TEE [2187-12-10] preliminary report [Hospital1 18] LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Moderate-sized vegetation on aortic valve. Severe (4+) AR. MITRAL VALVE: Abnormal mitral valve. Small vegetation on mitral valve. Abscess cavity adjacent to mitral valve. Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No vegetation/mass on pulmonic valve. PERICARDIUM: No pericardial effusion. Conclusions No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta to 42 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. There is a moderate-sized vegetation on the aortic valve. Severe (4+) aortic regurgitation is seen with reversal of flow in the aortic arch. The mitral valve is abnormal. There is small vegetationabscess on the anterior leaflet of the mitral valve with perforation. Severe (4+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion Past Medical History: Enterococcal endocarditis aortic valve dx [10/2187] fibromyalgia hepatitis c s/p 1 yr interferon ([12/2177]/[2178]) GERD ? Sciatica Past Surgical History s/p appendectomy s/p cholecystectomy s/p tubal ligation Social History: Race:Caucasian Last Dental Exam: edentulous Lives with: alone (boyfriend there off and on) Contact: [Name (NI) 717] [Last Name (NamePattern1) 91352] Phone # home [Telephone/Fax (1) 91353] cell [Telephone/Fax (1) 91354] Occupation: not currently working Cigarettes: Smoked no [] yes [x] last cigarette [12-5] Hx: 1-2 packs per day since age 15 - ~~50-72pack year history ETOH:drank heavily as teenager quit at age 21 Illicit drug use cocaine and YHC as teenager and young adult none recently Family History: Mother breast ca - deceased 62 Father lung and heart disease deceased 79 Physical Exam: Pulse: 100 Resp: 18 O2 sat: 96% RA B/P 138/64 General: Sitting in bed slightly winded with talking, breathing easy after resting Skin: Dry [x]red non raised rash under bilateral breast R>L Midline to right abdominal surgical scar healed HEENT: right eye with slight divergence, no variance left, pupils equal and reactive to light, decreased visual acuity right eye Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur diasytolic [4-8] and systolic [5-9] Abdomen: Soft [x] non-distended [x] tender left upper quadrant with light palpation bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema trace bilateral LE Varicosities: None [x] Neuro: Alert, oriented x3 forgetful in relation to medical treatment over last two months, R=L strength 5/5 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 Bruit vs murmur Pertinent Results: [2187-12-18] 05:44AM BLOOD Hct-28.0* [2187-12-17] 05:45AM BLOOD WBC-8.4 RBC-3.48* Hgb-9.8* Hct-29.4* MCV-84 MCH-28.2 MCHC-33.4 RDW-15.1 Plt Ct-153 [2187-12-18] 05:44AM BLOOD PT-13.3 INR(PT)-1.1 [2187-12-17] 05:45AM BLOOD Plt Ct-153 [2187-12-17] 05:45AM BLOOD PT-13.6* INR(PT)-1.2* [2187-12-14] 12:52PM BLOOD PT-14.0* PTT-37.2* INR(PT)-1.2* [2187-12-18] 05:44AM BLOOD UreaN-19 Creat-1.0 Na-136 K-4.3 Cl-100 [2187-12-17] 05:45AM BLOOD Glucose-141* UreaN-19 Creat-1.1 Na-135 K-4.3 Cl-98 HCO3-26 AnGap-15 [2187-12-16] 02:06AM BLOOD Glucose-120* UreaN-16 Creat-1.1 Na-137 K-3.9 Cl-101 HCO3-25 AnGap-15 Brief Hospital Course: 51 yo female with a history of hepC with a nearly 2 month history of enterococcal endocarditis who presented with worsening dyspnea and TTE showed abscess and perforation of anterior mitral valve leaflet. Patient also has 4+ MR [First Name (Titles) ] [Last Name (Titles) ]+ although she remained hemodynamically stable. She was considered to have failed therapy with penicillin and gentamicin and it was thought that she would need ampicillin/ceftriaxone for 4-6 weeks per the infectious disease service. On [2187-12-14] she underwent an aortic valve replacement with a St. [Male First Name (un) 923] Epic tissue valve and mitral valve a repair with closure of anterior leaflet perforation and closure of partial anterior, mitral leaflet cleft with 28-mm [Company 1543] CG Future annuloplasty ring. See operative note for full details. She was transferred to the CVICU in stable condition and weaned off all vasoactive medications on post operative night. She was extubated post operative night without incident and started on inhalers and Flovent for a significant tobacco history. She was transfused 2 units of blood on postoperative night for a low mixed venous and a hematocrit of 24.4. She had a good cardiac output the following day and her PA catheter was removed. Her chest tubes and pacing wires were removed per cardiac surgery protocol. On POD2 she went into a slow atrial flutter in the 50's. Coumadin was started when she remained in afib/flutter. Infectious disease service followed the patient pre and post operatively and recommended ceftriaxone IV until OR cultures finalized. She was transferred to the step down unit on POD2 in stable condition. Physical therapy worked with her for strength and mobility. She was gently diuresed toward preoperative weight and her beta blockers were adjusted for good heart rate and blood pressure control. Of note the patient does need repeat CT of chest in 12 months to follow-up pulmonary nodules seen on a preop Chest CT. She also needs ophthalmology follow up in 1 month (appointment already scheduled) for follow-up of left retinal irregularity seen on bedside exam (benign nevus vs optic melanoma) and psych follow-up to address patient's anxiety. On POD5 she was ambulating with assistance, her incisions were healing well and she was tolerating a full oral diet. Coumadin is to continue for INR goal of 2.0-3.0 for atrial fibrillation and follow up Coumadin dosing should be set with PCP upon discharge from rehab. Her OR valve tissue Cultures returned negative and per ID, no further antibiotics or ID follow up is needed. On POD5 she was transferred to [Location (un) ] rehab in Plimoth in stable condition. All follow up appointments were arranged. Medications on Admission: penicillin G sodium 5 million unit Solution for Injection 3 millions every four (4) hours lisinopril 2.5 mg Tab 1 Tablet(s) by mouth once a day amitriptyline 50 mg Tab 1 Tablet(s) by mouth HS (at bedtime) oxycodone-acetaminophen 2.5 mg-325 mg Tab 1 Tablet(s) by mouth every 4-6 hours as needed for pain Discharge Medications: 1. amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Dose based on INR Goal 2.0-2.5. 9. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:60 Tablet(s) Refills:0 10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 11. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [2-4] Puffs Inhalation Q6H (every 6 hours). 12. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 15. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO twice a day for 10 days. 16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. 17. Outpatient Lab Work check INR on [2187-12-20] then mon/wed/fri until stable Goal INR 2.0-2.5 for afib Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - [Location (un) 3320] Discharge Diagnosis: Endocarditis of aortic and mitral valve with severe aortic regurgitation and severe mitral regurgitation. Post-op afib Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with dilaudid Incisions: Sternal - healing well, no erythema or drainage Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [1-17] at 1:00pm Cardiologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 2 weeks Opthalmology: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4853], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2188-1-8] 2:30 Please call to schedule appointments with your Primary Care Dr. [First Name (STitle) ] in [5-8] weeks [Telephone/Fax (1) 91355] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation Goal INR 2.0-3.0 First draw [2187-12-20] Coumadin follow up to be arranged by rehab with PCP upon discharge Completed by:[2187-12-19] ICD9 Codes: 4280, 5849, 9971, 4240, 4241, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6484 }	Medical Text: Admission Date: [2185-4-8] Discharge Date: [2185-4-12] Date of Birth: [2185-4-8] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname ] is the 2.090 kg product of a 33 and [2-1] week twin gestation, born to a 29 year-old, Gravida II, [Name (NI) ] II mother. Prenatal screens A positive, antibody negative. Hepatitis surface antigen negative. RPR nonreactive. Rubella immune. GBS unknown. Rupture of membranes occurred less than 24 hours prior to delivery. Received Penicillin prior to delivery. Mother was treated for preterm labor at 25 weeks and again at 30 weeks. She subsequently went into preterm labor prior to Cesarean section that was performed for breech presentation of twin A. Delivery was uncomplicated and the infant received Apgars of 8 and 9. PHYSICAL EXAMINATION: On admission, weight was 2.09 kg, 75th percentile. Length 47 cm, 75th percentile. Head circumference 21 cm, 75th percentile. Well-appearing, in no acute distress. Anterior fontanel open and flat. Palate intact. No murmurs appreciated. Comfortable in room air. No flaring, tachypnea, grunting or retractions. Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds, no masses appreciated, warm, pink, well perfused, moving all extremities. Tone appropriate for gestational age. Normal female external genitalia. HOSPITAL COURSE BY SYSTEMS: Respiratory: Infant has been in stable in room air throughout hospital course without issue. Cardiovascular: No cardiovascular issues. Fluids, electrolytes and nutrition: Infant was initially started on 80 cc/kg/day of D-10-W. Enteral feedings were initiated on day of life #1. Infant is currently receiving 140 cc/kg/day of premature Enfamil or breast milk 20 calorie, tolerating well. Discharge weight is 2035g. Gastrointestinal: Bilirubin on day of life 3 was 9.2 over 0.3. She was on phototherapy and it decreased to 6.7/0.3 the folowing day, phototherapy was stopped. Hematology: Hematocrit on admission was 53.1. She has not required any blood transfusions. Infectious disease: CBC and blood culture were negative on admission with a white count of 14.5, 27 polys, 70 lymphs, 0 bands. Platelet count of 353. Infant received Ampicillin and Gentamycin for a total of 48 hours, at which time blood cultures remained negative and the antibiotics were discontinued. Neurologic: Infant has been appropriate for gestational age. Sensory: Hearing screen has not been performed but should be done prior to discharge home. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: [Hospital3 1280] Hospital. NAME OF PRIMARY PEDIATRIC GROUP: [Hospital6 67209] Group. CARE RECOMMENDATIONS: Continue 140 cc/kg/day of breast milk or premature Enfamil 20 calorie, advancing caloric density as appropriate. Medications: Not applicable. Car seat position screening has not yet been performed. State newborns screens have been obtained and are pending. Infant received hepatitis B vaccine on [2185-4-12]. DISCHARGE DIAGNOSES: 1. Premature infant born at 33 weeks gestation. 2. Mild hyperbilirubinemia. 3. Rule out sepsis with antibiotics. [First Name11 (Name Pattern1) 3692] [Initials (NamePattern4) ] [Last Name (NamePattern4) 27992], MD [MD Number(2) 65951] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2185-4-12] 00:37:06 T: [2185-4-12] 05:41:10 Job#: [Job Number 67210] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6485 }	Medical Text: Admission Date: [2102-6-24] Discharge Date: [2102-6-28] Date of Birth: [2029-12-9] Sex: M Service: [Hospital1 ] CHIEF COMPLAINT: Purulent dialysis catheter discharge. HISTORY OF THE PRESENT ILLNESS: This is a 72-year-old male with end-stage renal disease on hemodialysis with a history of CHF, diabetes type 2, atrial fibrillation, hypertension, status post AICD placement who was in his usual state of health until hemodialysis on the day of admission when he had chills and a temperature to 101. His line site appeared to be purulent and hemodialysis was stopped. Blood cultures were drawn. The patient was taken to the Emergency Department. In the Emergency Department, the patient was found to be hypotensive. He received vancomycin, gentamicin, and ceftriaxone. He continued to be hypotensive on the floor with a BP of 50/palpable and was transferred to the MICU. In the MICU, Surgery removed his right-sided tunneled dialysis catheter. The vancomycin was continued and the gentamycin level remained therapeutic. His blood pressure responded well with MAP of 60 with only a little bit of normal saline fluid bolus given. The patient continued to mentate well. The patient was then transferred to the [Hospital1 139] Service in stable condition. He had a low-normal blood pressure. He was mentating well without access for dialysis. PAST MEDICAL HISTORY: 1. End-stage renal disease secondary to diabetes mellitus type 2, hemodialysis every Tuesday, Thursday, and Saturday. The patient has a nonfunctioning left radial graft. 2. Diabetes mellitus type 2, last hemoglobin A1C was 6.1 in [5-24]. 3. Congestive heart failure. 4. Nonischemic cardiomyopathy secondary to ETOH with an ejection fraction of 20-25%. 5. Hypertension. 6. Atrial fibrillation, maintained on Coumadin. 7. Gout. 8. Fatty liver. 9. History of thrombocytopenia, HIT antibody negative. 10. AICD. 11. Status post left hip replacement. ADMISSION MEDICATIONS: 1. Allopurinol 100 once a day. 2. Digoxin 0.125 mg once a day. 3. Glipizide 2.5 once a day. 4. Lisinopril 5 once a day. 5. Nephrocaps 1 once a day. 6. PhosLo 667 three times a day. 7. Coumadin 2 mg on Monday, Wednesday, and Friday, 3 mg on Tuesday, Thursday, Saturday, and Sunday. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is separated and lives with his daughter. [Name (NI) ] smoked cigars for 55 years but quit in [2101-8-23]. He has a history of heavy alcohol use. PHYSICAL EXAMINATION ON TRANSFER FROM THE MICU TO THE [Hospital1 ] SERVICE: Vital signs: Temperature 98.4, heart rate 91, blood pressure 73-101/44-64, respiratory rate 16-25, oxygen saturation 93-98% on room air. General: The patient was in no acute distress, sitting in a chair, chatty. HEENT: mucous membranes moist. The oropharynx was clear. The pupils were equal, round, and reactive to light. Extraocular movements intact. The neck was supple without JVD. Cardiovascular: Irregularly/irregular heart sounds with a III/VI systolic ejection murmur. Pulmonary: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: Without clubbing, cyanosis or edema. Neurologic: Cranial nerves II through XII intact. There was 5/5 strength times four extremities. LABORATORY/RADIOLOGIC DATA: WBC 15.8, hematocrit 38.8, with 12 bands from [2102-6-24]. Sodium 136, potassium 4.7, BUN 72, creatinine 7.5, glucose 84, INR 1.6, calcium 8.6, phosphate 8.8. The patient had CKs of 252, 281, 253, 95. Digoxin level was 0.05. HOSPITAL COURSE: This is a 72-year-old male with end-stage renal disease on hemodialysis who was admitted to the MICU with a probable right IJ tunnel catheter line infection and hypotension. He was treated with vancomycin, gentamicin, and ceftriaxone and his BP stabilized. The patient was transferred to the floor. 1. HYPOTENSION: The patient has baseline low blood pressure in the 90s/50s which was likely exacerbated by bacteremia/sepsis. He did not require any pressors and minimal saline boluses. His pressure was maintained. After transfer to the floor, the patient continued to do well and his pressure remained in the 90s/60s. 2. INFECTIOUS DISEASE: The patient likely had a line infection in his tunneled out catheter. The catheter was removed by surgery on the second day of admission. Blood cultures grew out from the catheter tip coagulase-negative Staphylococcus which was sensitive to vancomycin which the patient was continued on. A new right-side tunneled catheter was placed by Interventional Radiology on [2102-6-27]. The patient underwent dialysis on [2102-6-28] without incident. 3. ATRIAL FIBRILLATION: The patient was rate controlled with digoxin during his stay. Anticoagulation was held secondary to his infection an anticipated replacement of line. The patient was instructed to restart his Coumadin on the day after discharge as an outpatient. 4. DIABETES MELLITUS TYPE 2: The patient was initially on Glipizide 5 twice a day because of misunderstanding about his Glipizide dose and he experienced low blood sugars on this dose. He was then switched to his outpatient dose of Glipizide 2.5 and his blood sugars improved. He was maintained on [First Name8 (NamePattern2) ] [Doctor First Name ] diet, fingersticks q.i.d. 5. END-STAGE RENAL DISEASE: The patient was without access for several days and he was constantly monitored for the need for dialysis. A line dialysis catheter was placed and the patient was hemodialyzed without incident on the morning of discharge. The patient was followed by the Renal Team while he was in-house. 6. PERIPHERAL ACCESS: The patient was maintained on pneumoboots and bowel regimen. 7. CARDIOVASCULAR: The patient had an echocardiogram during this admission for increased murmur which showed increased and also secondary to a small troponin leak on this admission and also secondary to the fact that the patient had been experiencing some chest pain intermittently during his dialysis sessions. The echocardiogram showed a markedly dilated left atrium and markedly dilated right atrium. There was moderate regional left ventricular systolic dysfunction with focal hypokinesis in several regions with moderate aortic stenosis and 1+ aortic regurgitation. There was mild to moderate mitral regurgitation as well as borderline coronary artery systolic hypertension. This showed an increase in the severity of the aortic stenosis. DISCHARGE DISPOSITION: To home. CONDITION ON DISCHARGE: Good. DISCHARGE INSTRUCTIONS: 1. Please contact primary doctor or return to the Emergency Department if any chest pain, shortness of breath, dizziness, palpitations, nausea or vomiting. 2. The patient should contact Dr. [Last Name (STitle) 8499] on [2102-6-29] to set up an appointment within one week. 3. Starting on [2102-6-29], the patient should take 3 mg of Coumadin every day for three days and then resume taking Coumadin as he was before which is 2 mg on Monday, Wednesday, and Friday and 3 mg on Tuesday, Thursday, Saturday, and Sunday. 4. The patient should discuss with his primary doctor whether to restart his blood pressure medications. 5. The patient should see cardiologist within four weeks as arranged by Dr.[Name (NI) 11509] office. DISCHARGE MEDICATIONS: 1. Digoxin 125 micrograms q.d. 2. Nephrocaps one capsule q.d. 3. Calcium acetate 667 mg, two tablets t.i.d. with meals. 4. Allopurinol 100 mg q.d. 5. Glipizide 2.5 mg q.d. 6. Aluminum hydroxide 30 mg orally q. eight hours. 7. Vancomycin 1 gram IV to be given with hemodialysis for a vancomycin trough less than 15. 8. Coumadin 3 mg for three days and then to resume taking Coumadin as before, 2 mg on Monday, Wednesday, and Friday, and 3 mg on Tuesday, Thursday, Saturday and Sunday. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 6280] Dictated By:[Last Name (NamePattern1) 6006] MEDQUIST36 D: [2102-6-29] 10:12 T: [2102-7-3] 19:05 JOB#: [Job Number 22580] ICD9 Codes: 7907, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6486 }	Medical Text: Admission Date: [2194-12-30] Discharge Date: [2195-1-16] Date of Birth: [2134-4-16] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Coronary artery disease Major Surgical or Invasive Procedure: 1. Coronary artery bypass graft x1, saphenous vein graft to obtuse marginal artery 2. Emergency resternotomy and ECMO insertion 3. Emergency coronary artery bypass graft x1, saphenous vein graft to posterior descending artery 4. Closure of sternotomy History of Present Illness: This is a 60-year-old patient with chronic chest pain which was investigated. The patient was found to have a positive stress test followed up by coronary angiogram which demonstrated single-vessel disease in the obtuse marginal artery, which could not be dealt with by PCI. Thus, he was scheduled for surgery and is now electively admitted for coronary artery bypass grafting. Past Medical History: Hypertension Hypercholesterolemia Obesity RA s/p knee & elbow arthroscopy s/p tonsillectomy Social History: Patient is a retired project manager who has a remote history of smoking and quit in [2158]. Patient denies recreational drugs, and consumes alcohol socially. Family History: Mother died of MI at 72 years of age. Brother died at 62 of MI. Physical Exam: HR 110 BP 135/92 (right arm) 167/84 (left arm) Wt 220lbs Gen: pleasant male appearing his stated age in NAD Skin: no rashes, good skin turgor HEENT: oropharynx benign, EOMI Neck: supple, no JVD Chest: CTA bilaterally Heart: RRR, normal S1 and S2 without murmur Abd: soft, NT/ND, NABS, no pulsatile mass or organomegaly Ext: warm, no edema Neuro: alert and oriented, CNII-XII grossly intact, [3-27] muscle strength Pertinent Results: [2194-12-30] 09:53AM BLOOD WBC-9.1 RBC-3.10* Hgb-9.6* Hct-26.7* MCV-86 MCH-30.9 MCHC-35.8* RDW-14.8 Plt Ct-118* [2195-1-16] 07:20AM BLOOD WBC-7.2 RBC-3.37* Hgb-10.2* Hct-30.0* MCV-89 MCH-30.2 MCHC-33.8 RDW-16.5* Plt Ct-261 [2194-12-30] 09:53AM BLOOD PT-14.0* PTT-23.9 INR(PT)-1.2* [2194-12-30] 09:53AM BLOOD Plt Ct-118* [2195-1-16] 07:20AM BLOOD PT-15.1* PTT-25.6 INR(PT)-1.4* [2195-1-16] 07:20AM BLOOD Plt Ct-261 Brief Hospital Course: The patient was admitted to the hospital on [2194-12-30] for an elective coronary artery bypass graft. The patient went to the operating room and underwent CABGx1 with saphenous vein graft to the OM. Please see operative note for complete details. Immediately post-operatively, as the patient was being to the CSRU, he suffered a VF arrest. ACLS protocol was initiated. The patient was unresponsive to external defibrillation, and the chest was emergently opened. Manual cardiac massage was initiated for approximately 20 minutes until the patient was placed on emergency ECMO and taken back to the operating room. A second bypass graft to the PDA as performed (please see separate operative note for complete details), and the patient was transferred to the cardiac catheterization lab in critical condition. A coronary artery catheterization revealed occlusive right main disease with backflow from the patent bypass graft. An IABP was placed, and the patient was taken to the CSRU, where he remained in critical condition. His chest was left open and required two exlorations overnight for bleeding. This was treated with massive volume and blood product recussitation. The patient was kept intubated and paralyzed overnight. On post-op day #1, an echocardiogram was obtained which, on comparison to a TEE obtained during re-exploration, showed improved RV systolic function, improved tricuspid and mitral regurgitation, improved LV systolic function with an overall EF of 35%. The patient required multiple pressors post-operatively, and these were gradually weaned. On postoperative day 3, the patient had improved to the point where a closure of the chest was attempted. The patient tolerated this procedure well. On postoperative day [1-21], a bronchoscopy was performed with BAL sent. This ultimately grew only oropharyngeal flora. ARDSnet protocol was initiated for ventillatory support and a HIT screen was sent for thrombocytopenia and came back negative. By postoperative day #[3-25], the patient was requiring only minimal pressor support, and his IABP was removed. An infectious diseases consult was obtained for low-grade fevers and for recommendations on appropriate antibiotic coverage. Based on these recommendations, vancomycin and meopenem were started. New bilateral chest tubes were placed for pleural effusions. On postoperative day [6-28], a post-pyloric Dobhoff feeding tube was placed, and tube feeding was initiated. Meropenem was stopped and IV vancomycin continued based on ID recommendations. On postoperative day [8-30], the patient was extubated. He was agressively diuresed. Agressive pulmonary toilet was continued, and the patient was able to get out of bed to a chair. His beta blockade was gradually increased for mild hypertension. On postoperatve day 13/11, the patient passed a swallow evaluation, and the Dobhoff feeding tube was removed. He was started on a clear liquid diet, which was gradually advanced. An ACE inhibitor was started. Two days later, the patient was transferred to the floor. The patient did well. He was seen daily by both physical therapists and occupational therapists. By discharge, he was able to walk, but had difficulty with ADLs secondary to residual weakness in his hands. He was discharged to rehab on postoperative day 17/15 in stable condition. Medications on Admission: Nifedipine XL 90mg PO QD Atenolol 50mg PO QD Aldactone 25mg PO BID Benicar 40/12.5mg PO QD Imdur 60mg PO QD Crestor 10mg PO QD ASA 81mg PO QD Methylprednisone 4mg PO QD Arava 20mg PO QD Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dosage Injection TID (3 times a day). 11. Leflunomide 10 mg Tablet Sig: One (1) Tablet PO QD () as needed for arthritis. 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Coronary artery disease s/p CABGx2 Hypertension Hypercholesterolemia Obesity RA s/p knee & elbow arthroscopy s/p tonsillectomy Discharge Condition: Stable Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 1290] in 4 weeks. Please follow up with your local PCP and cardiologist in [12-26] weeks. ICD9 Codes: 4275, 4111, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6487 }	Medical Text: Admission Date: [2152-1-13] Discharge Date: [2152-1-24] Date of Birth: [2073-5-12] Sex: F Service: CARDIOTHORACIC Allergies: Tetracycline Attending:[First Name3 (LF) 165] Chief Complaint: syncope Major Surgical or Invasive Procedure: [2152-1-17] dental extractions [2152-1-18] MV Repair/cabg x3 (26 mm CE [Doctor Last Name 405] ring/LIMA to LAD, SVG to OM, SVG to PDA) History of Present Illness: 78 yo female with known CAD with medical management. She had a syncope 1 week priot to admission. She ruled out for an MI at that time. St elevations with ischemia was noted, and the pt. refused initial rx and left AMA. She represented for further workup. Past Medical History: NIDDM HTN elev. chol. MI CAD Social History: retired no tobacco use no ETOH use lives alone Family History: not known Physical Exam: 98.8 RR 16 130/80 97% RA sat. 5'6" 170# NAD PERRL,anicteric,noninjected,normal oropharynx neck supple, no [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] bruit appreciated CTAB RRR, no m/r/g soft, NT, ND, +BS warm, well-perfused, no peripheral edema,mild varicosities below the knee nonfocal exam, alert and oriented x3 2+ bil. fems.radials 1+ bil. DP/PTs 1+ carotids Pertinent Results: [2152-1-23] 02:58PM BLOOD WBC-7.7 RBC-3.43* Hgb-10.1* Hct-30.4* MCV-89 MCH-29.4 MCHC-33.2 RDW-14.6 Plt Ct-202# [2152-1-23] 02:58PM BLOOD Plt Ct-202# [2152-1-23] 02:58PM BLOOD Glucose-277* UreaN-17 Creat-1.0 Na-137 K-3.9 Cl-103 HCO3-24 AnGap-14 [2152-1-13] 11:55PM BLOOD %HbA1c-7.3* Conclusions PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with hypokinesis of the inferoseptal, anteroseptal, anterior and anterolateral walls. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) 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: For the post-bypass study, the patient was receiving vasoactive infusions including Milrinone and Norepinephrine, Epinephrine and is being AV paced. 1. A mitral valve annuloplasty ring is well seated. No [Male First Name (un) ] is seen. Trace MR is seen. Mean gradient across the valve is 8mm of Hg with a CO of 5.5. 2. LV function is slightly improved. RV function is preserved. 3. Aorta is intact post decannulation. 4. Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 928] [Name8 (MD) 929], MD, MD, Interpreting physician [Last Name (NamePattern4) ] [2152-1-18] 15:56 RADIOLOGY Final Report CHEST (PA & LAT) [2152-1-23] 3:01 PM CHEST (PA & LAT) Reason: evaluation of effusion [Hospital 93] MEDICAL CONDITION: 78 year old woman with s/p mvr, cabg REASON FOR THIS EXAMINATION: evaluation of effusion CLINICAL INDICATION: Evaluate for effusion. FINDINGS: Two views of the chest were obtained and compared to the prior examination dated [2152-1-20]. There are persistent bilateral pleural effusions that have slightly decreased since the prior examination. There is a persistent left retrocardiac opacity likely secondary to underlying atelectasis, although a superimposed pneumonia cannot be entirely excluded. The patient is status post mitral valve replacement, CABG and median sternotomy. The cardiac silhouette is slightly less prominent as noted on the prior examination. IMPRESSION: Minimal interval decrease in size of bilateral moderate-sized pleural effusions. Otherwise, no significant interval change. DR. [First Name (STitle) 2353] [Doctor Last Name ] Approved: SUN [2152-1-23] 5:25 PM ?????? [2146] CareGroup IS. All rights reserved. Brief Hospital Course: Admitted [1-13] and cardiac workup completed over the next few days. Three day course of bactrim started for a UTI.Dental consult also done and chest CT done. Continued on IV heparin, then stopped for teeth extractions. IV NTG also started. Dental extractions done [1-17]. MVrepair /cabg x3 done [1-18] with Dr. [First Name (STitle) ]. Transferred to the CVICU in fair condition on epinephrine, milrinone, levophed, and insulin drips. Extubated early in the AM POD #1. Chest tubes removed on POD #2 and trasnferred to the floor to begin increasing her activity level. Pacing wires removed on POD #3. Beta blockade titrated and she was gently diuresed toward her preop weight. Cleared for discharge to rehab, but pt. refused discharge over the weekend. Bed available and discharged to rehab on POD #6. Pt. is being covered with SSI and is to make all rehab appts. as per discharge instructions. Medications on Admission: glyburide 6 mg daily lovastatin 80 mg daily enalapril 10 mg daily toprol XL 50 mg daily ECASA 81 mg daily protonix 40 mg daily regular insulin SS ( added at OSH: xanax 0.5 mg HS/prn) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Humalog insulin per sliding scale flowsheet Discharge Disposition: Extended Care Facility: Bayberry Commons Discharge Diagnosis: CAD/MR s/p MVrepair/cabg x3 NIDDM HTN MI elev. chol. Discharge Condition: stable Discharge Instructions: no lotions, creams, or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, or drainage SHOWER daily and pat incisions dry Followup Instructions: see Dr. [First Name (STitle) ] in [11-24] weeks see Dr. [Last Name (STitle) 64868] in [12-26] weeks see Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2152-1-24] ICD9 Codes: 5990, 4240, 412, 2720, 4019, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6488 }	Medical Text: Admission Date: [2198-11-20] Discharge Date: [2198-11-25] Service: NEUR MED CHIEF COMPLAINT: Falling down with left-sided weakness. HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old right-handed woman with history of atrial fibrillation, hypertension, high cholesterol, who was found unresponsive on the morning of admission by her son. She had been in her usual state of health the night before. He went to check on her in the morning around 8:00, and he found her in bed, not talking, with her eyes closed and moaning. He called the emergency medical service, who brought her to the emergency department. When first seen in the E.D., she continued to have her eyes closed with moaning, no response to verbal stimuli, would move all four extremities to noxious stimuli, but was thought to have a right eye deviation as well a left facial droop and a left hemiparesis. She was sent to the Neuro Intensive Care Unit overnight for blood pressure monitoring and was sent out to the neurology floor the next morning. She had a head CT on the day of admission because of her pacemaker, which showed evidence of atrophy and large ventricles with no evidence of an acute stroke. PAST MEDICAL HISTORY: Significant for coronary artery disease, abdominal aortic aneurysm repair, atrial fibrillation, hypertension, aortic valve replacement with porcine valve in [2188], CABG x3 in [2188], multiple stents to her coronary arteries, rheumatic fever, high cholesterol, dementia, status post pacemaker for sick sinus syndrome. There is no history of diabetes. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg p.o. b.i.d. 2. Captopril 25 mg p.o. t.i.d. 3. Zantac 150 mg p.o. b.i.d. 4. Aspirin 325 mg p.o. q.d. 5. Lipitor 20 mg p.o. q.d. 6. Stool softener. 7. Digoxin 0.125 mg p.o. q.d. The patient in the past had been on Coumadin, however it was discontinued 1-1/2 years ago after multiple falls and a subdural hemorrhage. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives on her own in an apartment above her son, who visits her several times a day. He reports that she still drives, she cooks for herself, and he just checks on her multiple times a day. FAMILY HISTORY: Unknown. OBJECTIVE: At the time of admission, her blood pressure was 220/90. Later it went up to almost 250/118, heart rate was 78. She was satting 91% on room air with a respiratory rate of 18. She was afebrile. Generally, she was awake, alert, talkative, in no acute distress by the time she was transferred to the floor, however on initial admission she was lying in bed, would open her eyes spontaneously, would moan. HEENT exam was normocephalic, atraumatic with mucous membranes that are moist. Cardiovascular: Rate was irregularly irregular. Respiratory: Clear to auscultation bilaterally. Abdomen soft, nontender, nondistended, with positive bowel sounds. Extremities: No edema. Warm feet bilaterally. Neurologically, the patient was uncooperative with motor exam, however she moved all four extremities. It was felt that the right upper extremity was weak. On her cranial nerve exam, pupils were reactive bilaterally with a right deviation of her eyes. Also she was noted to have a left facial droop. On motor exam she would withdraw her legs to noxious stimuli bilaterally. Her reflexes were 2+ and symmetric throughout with upgoing toes bilaterally. LABS ON ADMISSION: Her white count was 12, hematocrit 40, chem-7 was unremarkable. CK was 165 with an MB of 4, troponin of less than 0.3. Calcium 9.6, digoxin 1.0. UA was negative. EKG showed some T-wave inversions on anterolateral leads. HOSPITAL COURSE: 80-year-old woman found unresponsive with a possible right frontoparietal stroke with left face and arm weakness, as well as decreased alertness which had resolved by the morning after admission. She continued to be in atrial fibrillation throughout her hospital course. She had a repeat head CT which showed no evidence of subacute infarct. She was ruled out for myocardial infarction with consecutive cardiac enzymes. She continued to be very frontal after she woke up a bit. Her exam was notable for very colorful language, very emotional, she would be tearful at times and then laughing and joking, swearing. Quite often she was inattentive. Her speech would wander off the subject. She was not oriented to the hospital or the year at any time. She continually said it was [2182] or [2189]. She often thought she was at home, later she thought she was at a hotel. Her naming and repetition were intact. She could do days of the week backward with prompting. Her recall was 1 out of 3 immediately. She was very perseverative and unable to do 2-step commands. Also her left arm and face weakness had totally resolved by the time she arrived to the medical floor. Instead, there was noted to be a slight right facial droop. Her strength in her arms was full, as well as the strength in her legs, with no evidence of a drift. She had some agitation after receiving a dose of Ativan which made her sleepy and a little bit more confused for several days, however she was changed to Seroquel every night at 6:00 pm with significant improvement, decreased agitation during sleep as well as increased alertness during the day. She had an EEG which showed background rhythm which was slightly slow, as well as evidence of sleep, but no evidence of epileptiform activity. She did have some moderately high blood sugars, in the 160s and 170s, during admission, however the son denies that she has any history of diabetes. She will need to be followed up as an outpatient for evaluation of her glucose issues. Otherwise, the patient was observed in the hospital for several days with continued improvement in her mental status. The plan is to discharge her today. DISCHARGE DIAGNOSES: 1. Dementia. 2. TIA. 3. Atrial fibrillation. 4. Status post CABG. 5. Status post aortic valve replacement, porcine valve. 6. High cholesterol. 7. Hypertension. DISCHARGE MEDICATIONS: 1. Captopril 75 mg p.o. t.i.d. 2. Atenolol 100 mg p.o. b.i.d. 3. Lipitor 20 mg p.o. q.d. 4. Seroquel 25 mg p.o. q. 6:00 pm. 5. Digoxin 0.125 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. and 325 mg to 650 mg q.4-6h. p.r.n. 7. Colace 100 mg p.o. b.i.d. [Last Name (LF) ],[First Name3 (LF) ] 13.140 Dictated By:[Dictator Info ] MEDQUIST36 D: [2198-11-25] 11:49 T: [2198-11-25] 11:20 JOB#: [Job Number 106276] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6489 }	Medical Text: Admission Date: [2131-2-15] Discharge Date: [2131-2-20] Date of Birth: [2061-12-10] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) / Keflex / Ibuprofen Attending:[First Name3 (LF) 1835] Chief Complaint: Left Occipital Brain Mass recurrance Major Surgical or Invasive Procedure: [2-15]: Left Occipital Craniotomy for Mass Resection History of Present Illness: Patient is being electively admitted for recurrent occipital brain mass. Past Medical History: Hypertension, Hyperlipidemia, Osteopenia, GERD, Hypthyrodism s/p thyroidectomy, Diverticulosis, Glaucoma, s/p TAH, s/p craniotomy [2128] for Glioma Social History: Resides at home with daughter. Family History: Colon CA and Diabetes Physical Exam: On Discharge: Alert and oriented to name and hosptial. Pupils equal, round and reactive to light. Spontaneous eye opening. EOM grossly intact with two beat left gaze nystagmus. No pronator drift, however right sided dysmetria. Moves all extremities spontaneously and symmetrically with full strength. Sensation grossly intact. Pertinent Results: Labs on Admission: [2131-2-16] 03:37AM BLOOD WBC-20.3# RBC-3.27 Hgb-9.8* Hct-29.1* MCV-89 MCH-30.1 MCHC-33.8 RDW-19.0* Plt Ct-192 [2131-2-16] 03:37AM BLOOD PT-12.7 PTT-22.5 INR(PT)-1.1 [2131-2-16] 03:37AM BLOOD Glucose-137* UreaN-19 Creat-1.0 Na-140 K-4.5 Cl-106 HCO3-25 AnGap-14 [2131-2-16] 03:37AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.9 Labs on Discharge: [2131-2-19] 06:19AM BLOOD WBC-13.2* RBC-2.94* Hgb-9.1* Hct-26.5* MCV-90 MCH-31.0 MCHC-34.4 RDW-19.0* Plt Ct-271 [2131-2-19] 06:19AM BLOOD PT-12.0 PTT-28.0 INR(PT)-1.0 [2131-2-19] 06:19AM BLOOD Glucose-81 UreaN-17 Creat-0.9 Na-141 K-4.3 Cl-105 HCO3-25 AnGap-15 [2131-2-19] 06:19AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1 Imaging: MRI Wand [2-16]: TECHNIQUE: Limited imaging of the brain was performed, post-contrast, using spin-echo and MP-RAGE sequences. FINDINGS: There is a large heterogeneously enhancing lesion, in the left posterior temporal and the occipital lobes, extending to the splenium of the corpus callosum as well as into the periatrial region, not significantly changed, compared to the most recent CT scan allowing for the technical differences. A few areas of increased signal, in the adjacent bone, are again unchanged. There is minimal shift of the midline structures to the right side, not significantly changed. Continued mass effect, on the atrium and posterior part of the body of the left lateral ventricle and effacement of the occipital [Doctor Last Name 534] and sulci, unchanged. Pachymeningeal enhancement, of the tentorium, and the adjacent dura along the convexity is also unchanged. There is near total/total empty sella, with no definite pituitary gland visualized, unchanged. IMPRESSION: 1. Large heterogeneous lesion, in the left posterior temporal and the occipital lobes, extending into splenium, with mass effect on the left lateral ventricle, may relate to glioma/radiation necrosis, demonstrated for surgical planning, not significantly changed. MRI Head(post-op) [2-16]: Comparison is made with preoperative study from [2131-2-15]. There are postoperative changes in the left occipital lobe including a post op cavity. There is some hemorrhage within the operative bed. There is residual enhancement in the left occipital lobe and temporal lobe with enhancement extending into the splenium of the corpus callosum. There is a small amount of restricted diffusion along the margins of the ostoperative cavity and within the enhancing tumor mass in the temporal lobe. This could represent foci of acute ischemia. There is dural enhancement in the left hemisphere which is likely postoperative in nature. There is a small subgaleal fluid collection on the left. Intracranial flow voids are maintained. There is bilateral mastoid opacification. Pathology [2-15]: DIAGNOSIS: I. Foreign body: Gross examination only. II. Brain, left occipital, resection (A): Glioblastoma, WHO grade IV (See note). III. Brain, left occipital, resection (B-M): Glioblastoma, WHO grade IV (See note). IV. Brain, left occipital, resection (N-O): Glioblastoma, WHO grade IV (See note). Brief Hospital Course: Patient was electively admitted on [2-15] for excision of recurrent mass in the left occipital lobe. She was monitored post-operatively in the ICU overnight. After an uneventful stay, she was transferred to the neurosurgery floor. Prior to transfer, MRI was performed showing expected residual mass. Physical and occupational therapy were consulted and determined her to be an appropriate candidate for home with her family and outpatient services, and she was discharged on [2-20] with follow up arranged. Medications on Admission: Dexamethasone 4mg qam 2mg qpm, Keppra 1000mg [Hospital1 ], Levothyroxine 88 mcg daily, Metoprolol tartrate 25mg [Hospital1 ], Omeprazole 40mg [Hospital1 ], Percocet 5mg-325mg q4hr:prn, Simvastatin 40mg daily, Timolol 0.5% 1 drop each eye daily, Colace 100mg [Hospital1 ] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO bid (). Disp:60 Tablet(s) Refills:0 6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA of the [Location (un) 1121] Discharge Diagnosis: Left Occipital Brain Mass Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [6-29] days (from your date of surgery) for removal of your sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [Hospital 341] Clinic on [2131-3-12] at 11:30am. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 5074] of [Hospital1 18], in the [Hospital Ward Name 23] Building. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain, as this was done during your acute hospitalization. Completed by:[2131-2-20] ICD9 Codes: 2449, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6490 }	Medical Text: Admission Date: [2164-6-9] Discharge Date: [2164-6-14] Date of Birth: [2108-12-4] Sex: F Service: MEDICINE Allergies: Motrin / Compazine / Haldol / Nitrofurantoin / Iodine / Vancomycin Hcl Attending:[First Name3 (LF) 4232] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 55 yo female with history of HIV (last CD4 >1000 with VL undetectable), HCV, HBV, former IVDU, CHF, recurrent UTI with VRE/ESBL, and recurrent DVT on warfarin who presented with fever and low back pain. The patient was recently hospitalized from [Date range (1) 23527], again for fever and lower back pain. During this previous hospitalization, she was found to have an elevated INR to 13 of unknown etiology, and her INR decreased without intervention. She was treated for HCAP with a 7-day course of linezolid and cefepime given her history of VRE and diuresed for pulmonary edema given dCHF. She was continued on her home dose of methadone, dilaudid and gabapentin for her chronic pain disorder (including back, leg, neck, head). After discharge she says she was feeling okay at home but two days ago developed fevers, dysuria, increased urinary frequency, and nausea/vomiting with blood in her emesis. She denied any new weakness, no numbness or tingling, no radiation to legs or urinary retention. She stated that her back pain was of the same quality as usual but more intense. On arrival to the ED, VS were 101.7, 112, 151/112, 100% on O2. Labs were notable for UA with few bacteria/large leukocytes/51 WBCs, INR 11.1, normal WBC of 9.7 (80% PMNs). She was started on empiric IV cefepime and linezolid for infection and given 5 mg PO vitamin K for elevated INR. Blood cultures were sent. She was also given sumatriptan for headache and zofran for nausea. CXR showed mild pulmonary vascular congestion (unchanged from prior CXR) and bibasilar airspace opacities. She was noted to be guaiac positive. Several hours after arrival to the ED, the patient became more lethargic and was started on IVF. CT head was obtained given elevated INR and headache but did not reveal acute process. She received 2L of IV normal saline because pressures dropped to 83/40 and improved to 90s/50s with fluid. She was also was noted to have a cellulitic looking patch of skin on her RLE. Her tox screen is positive for methadone. She was transferred to the MICU for further management of her hypotension, where she did not require pressors and was continued on her home medications and started on meropenem. The patient covertly took some of her home methadone in the ICU, but she remained afebrile and stable for several hours and was transferred to medicine for further care. Her vital signs on transfer were T99 BP 140/83 HR 83 RR 13 94% 4L. Past Medical History: 1. HIV, sexually transmitted, diagnosed [2150] on HAART (last CD4 greater than 1000, viral count undetectable) 2. Hepatitis B and Hepatitis C virus (sexually transmitted, diagnosed [10/2151], s/p IFN x 6 months with failure to suppress VL) 3. Asthma 4. Ovarian cancer (diagnosed [2142], s/p oophorectomy and chemo) 5. Morbid obesity 6. s/p MVA with L4-L5 laminectomy in [2151], operation c/b infection, including VRE requiring re-exploration and drainage 7. Chronic back pain and Left leg pain 9. Cholecystectomy, [2142] 10. Osteoarthritis involving bilateral knees 11. Recurrent UTIs (including ESBL UTI, [4-/2163] and [8-/2163]) 12. Recurrent cystitis consistent with urethral syndrome or chronic cystitis 13. QT Prolongation induced by Abilify 14. s/p tibial fracture on [2160-11-5], medically managed 15. s/p ORIF right proximal tibia fracture with [Last Name (un) 101] plate ([2161-7-13]) 16. History of DVT s/p ORIF right proximal tibia fracture (on Coumadin) 17. OSA (failure to comply with home CPAP) 18. Diastolic CHF (preserved EF) 19. Osteomyelitis of leg 20. H/o alcohol dependence 21. H/o opioid dependence 22. Anxiety disorder 23. Depression 24. ?Bipolar disorder Social History: Lives alone in apartment in [Location (un) 86], limited contact with family. Mother recently died. Only has support with a few friends, especially her HCP; attests to tobacco use of 120 pack-year and currently smokes [11-28] PPD (previous 3-PPD); no current alcohol use; denies recreational substance use. Family History: Father is deceased and had HTN, CAD. Mother is deceased after long course with ESRD, HTN, multiple strokes and CHF. Aunt with neuroblastoma, otherwise no other cancers. Physical Exam: Physical Exam: General: Alert, oriented, no acute distress, appears drowsy 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: diffuse inspiratory and expiratory wheezes, poor air movement at bases bilatrally, no crackles Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no edema, 4 cm diameter round area of warmth and erythema on RLE with central scab Neuro: 5/5 strength upper/lower extremities, grossly normal sensation Discharge Exam: Vitals: T 98.3 BP 116/62 HR 68 RR 18 94% 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Faint heart sounds, but regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Poor air movement, otherwise CTAB Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no RUQ tenderness Ext: warm, well perfused, 2+ pulses, no edema, 4 cm diameter round area of erythema on RLE with central scab and warmth, not expanded. Neuro: 5/5 strength upper extremities, grossly normal sensation Skin: Erythema consistent with tinea cruris. Pertinent Results: ADMISSION LABS: [2164-6-9] 12:25PM BLOOD WBC-9.7 RBC-4.72 Hgb-14.7 Hct-47.3 MCV-100* MCH-31.2 MCHC-31.1 RDW-18.4* Plt Ct-163 [2164-6-9] 12:25PM BLOOD Neuts-80.1* Lymphs-12.0* Monos-4.6 Eos-2.0 Baso-1.3 [2164-6-9] 02:30PM BLOOD PT-108.2* PTT->150* INR(PT)-11.1* [2164-6-9] 12:25PM BLOOD Glucose-104* UreaN-7 Creat-0.6 Na-136 K-5.0 Cl-97 HCO3-28 AnGap-16 DISCHARGE LABS: [2164-6-14] 09:00AM BLOOD WBC-6.1 RBC-3.75* Hgb-12.0 Hct-38.2 MCV-102* MCH-31.8 MCHC-31.3 RDW-17.8* Plt Ct-160 [2164-6-14] 09:00AM BLOOD PT-14.3* PTT-39.0* INR(PT)-1.3* [2164-6-14] 09:00AM BLOOD Glucose-110* UreaN-14 Creat-0.4 Na-138 K-4.4 Cl-95* HCO3-39* AnGap-8 [2164-6-14] 09:00AM BLOOD ALT-72* AST-97* AlkPhos-242* TotBili-1.7* [2164-6-14] 09:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8 LFT TREND: [2164-6-11] 05:31AM BLOOD ALT-82* AST-127* AlkPhos-275* TotBili-2.7* [2164-6-12] 11:20AM BLOOD ALT-76* AST-112* AlkPhos-257* TotBili-3.1* [2164-6-14] 09:00AM BLOOD ALT-72* AST-97* AlkPhos-242* TotBili-1.7* MICROBIOLOGY: [2164-6-9] URINE CULTURE-FINAL FINAL REPORT [2164-6-13] URINE CULTURE (Final [2164-6-12]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. Cefepime sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- I CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- 2 S [2164-6-9] BLOOD CULTURE -NO GROWTH [2164-6-9] BLOOD CULTURE -NO GROWTH IMAGING: # CHEST (PORTABLE AP) Study Date of [2164-6-9] Semi-upright portable chest radiographs were obtained. The examination is limited due to poor penetration likely secondary to body habitus and portable technique without evidence of focal consolidation. Retrocardiac opacities are not well assessed on this single radiograph but appear improved compared to the radiograph from [5-16]. For better evaluation, consider PA and lateral views. Heart is moderately enlarged. Mild pulmonary vascular engorgement appears slightly improved. Right humeral fixation hardware is incompletely assessed. IMPRESSION: Improved retrocardiac opacities and pulmonary vascular congestion on this limited study. For better evaluation, two-view chest radiograph could be obtained. # CHEST (PA & LAT) Study Date of [2164-6-9] Low lung volumes are present. Moderate cardiomegaly is unchanged. The mediastinal contours are stable with calcification of the thoracic aorta which is mildly tortuous. There is mild pulmonary vascular congestion unchanged from the radiograph performed earlier in the day. Streaky opacities in lung bases are re- demonstrated. No pleural effusion or pneumothorax is identified. Evaluation the osseous structures is limited due to the patient's large body habitus. Partially imaged is orthopedic hardware within the right humeral head. IMPRESSION: Mild pulmonary vascular congestion unchanged compared to the radiograph from earlier in the day. Bibasilar airspace opacities could reflect areas of infection but are improved from [2164-5-16]. # CT HEAD W/O CONTRAST Study Date of [2164-6-9] FINDINGS: Study slightly suboptimal due to noisy images. There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarction. Exam is essentially unchanged from the recent comparison. Ventricles and sulci remain mildly prominent, compatible with age-related involutional changes. Right basal ganglia hypodensity could reflect a prominent VR space and is unchanged. There is no shift of normally midline structures. [Doctor Last Name ]-white matter differentiation is preserved. Imaged paranasal sinuses and mastoid air cells are well aerated. There is no fracture. IMPRESSION: No acute intracranial hemorrhage or mass effect. # LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [2164-6-12] FINDINGS: The liver is diffusely echogenic, consistent with fatty infiltration. No concerning liver lesion is identified. No biliary dilatation is seen and the common duct measures 0.8 cm. The portal vein is patent with hepatopetal flow. The patient is status post cholecystectomy. The pancreas and midline structures are obscured from view by overlying bowel gas. The spleen is at the upper limits of normal measuring 13.0 cm. IMPRESSION: Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. Brief Hospital Course: 55 yo female with history of HIV (last CD4 >1000 with VL undetectable), HCV, HBV, former IVDU, CHF, and recurrent DVT on warfarin presented with fever and low back pain, with evidence of UTI. She was transferred to the MICU for hypotension, where she was stabilized without use of pressors and transferred to medicine. ACTIVE ISSUES: # UTI: In the ED was tachycardic, hypotensive and febrile, requiring ICU admission. Her symptoms improved with aggressive fluid resuscitation and broad spectrum antibiotics. She was initially treated with meropenem given her history of ESBL and VRE in the past. Her urine culture grew ESBL E. coli, and she was narrowed to Bactrim once sensitivities returned. She remained stable and was discharged with plan to complete a 14 day course, last dose [2164-6-24]. #Elevated INR: Pt with INR elevated to 11 on admission. Etiology unclear but had recent INR of 13 and variable INR in the past above goal range of [12-30]. She reports compliance with medication, however she often misses INR monitoring. She had guaiac positive stools and occasional blood streaked vomitus and received vitamin K in the ED. She refused FFP. Her Coumadin was held and her INR dropped to subtherapeutic levels without evidence of bleed. She initially refused Coumadin in house, and then refused daily monitoring. Her Coumadin dose was decreased to 3 mg daily given risks of elevated INR associated with Bactrim use. She was set up with daily VNA for continued INR monitoring. # Lethargy: Patient was originally lethargic in the MICU, likely due to use of pain medications, UTI, and retention of carbon dioxide. A head CT did not show bleed. Her Dilaudid, Klonopin, gabapentin, sumatriptan, and Dilaudid were all held and she improved shortly after transfer to medicine. There was concern that she was taking her own dose of methadone while in house and these medications were placed in the safe for the remainder of her hospitalization. CHRONIC ISSUES: # Elevated LFTs: The patient has hepatitis B and hepatitis C and has had transiently elevated LFTs in the past. She did not appear jaundiced and her LFTs were trended during her hospital course when blood draws could be obtained. A RUQ ultrasound showed only fatty infiltration. # Depression: The patient was originally treated with linezolid for broad-spectrum coverage, and her home Escitalopram was held given risk of serotonin syndrome. She was restarted on Escitalopram shortly after linezolid was discontinued, and her depressive symptoms were well-controlled. # HIV: The patient's most recent CD4 count is >1000. During hospitalization, the patient was continued on her home HAART regimen. #Headaches: The patient complained of chronic headaches with a description suggestive of migraines. Imitrex 50mg PRN was continued to control her headaches. # Asthma: continued home meds with Advair in place of symbicort (non formulary med) and PRN nebs. Pt remained stable throughout hospitalization. # Chronic dCHF: Pt was continued home Lasix 40mg PO daily. # Intertrigonal [Female First Name (un) ]: Continued her home miconazole. # Chronic pain: Continue her home methadone 30mg TID, Dilaudid 2 mg PRN. The patient stated that she was on 10 mg Dilaudid q 4 hr at home but did not require this dosing in house. #Constipation: Patient was kept on home bowel regimen, but she did not have a bowel movement by the time that she was medically cleared for discharge. She was given an enema prior to discharge. TRANSITIONAL ISSUES: Pt has had very difficult to control INR. She was set up with daily INR monitoring through VNA. Her Coumadin dose will likely need to be increased once her Bactrim course is completed. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Miconazole Powder 2% 1 Appl TP TID 5. Clonazepam 1 mg PO TID fo not drive, operate machinery, or take other sedating medications while on this medication 6. Docusate Sodium 100 mg PO BID 7. Methadone 30 mg PO TID 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN breakthrough pain fo not drive, operate machinery, or take other sedating medications while on this medication 9. RiTONAvir 100 mg PO DAILY 10. Atazanavir 300 mg PO DAILY 11. Furosemide 40 mg PO DAILY 12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath 13. Symbicort NF (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION 2 PUFFS TWICE DAILY 14. Escitalopram Oxalate 5 mg PO DAILY 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Ranitidine 150 mg PO HS 17. Gabapentin 800 mg PO QID 18. Senna 1 TAB PO BID:PRN constipation 19. Sumatriptan Succinate 100 mg PO ONCE migraine Duration: 1 Doses 20. Acetaminophen 500 mg PO Q6H:PRN fever do not exceed 3 grams daily 21. Albuterol Inhaler 2 PUFF IH Q4H prn wheezing or SOB 22. Warfarin 10 mg PO DAILY16 Discharge Medications: 1. Acetaminophen [Telephone/Fax (1) 1999] mg PO Q6H:PRN fever Do NOT exceed 2 grams/day 2. Atazanavir 300 mg PO DAILY 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Clonazepam 1 mg PO BID hold for sedation or RR <10 5. Docusate Sodium 100 mg PO BID 6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 7. Escitalopram Oxalate 5 mg PO DAILY 8. Furosemide 40 mg PO DAILY 9. Gabapentin 800 mg PO Q8H 10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath 11. Methadone 30 mg PO TID do not drive, operate machinery, or take other sedating medications while on this medication 12. Miconazole Powder 2% 1 Appl TP TID 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. Ranitidine 150 mg PO HS 15. RiTONAvir 100 mg PO DAILY 16. Senna 1 TAB PO BID:PRN constipation 17. Sumatriptan Succinate 100 mg PO DAILY:PRN migraine 18. Sulfameth/Trimethoprim DS 1 TAB PO TID RX Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth three times a day Disp #26 Tablet Refills:0 19. Albuterol Inhaler 2 PUFF IH Q4H prn wheezing or SOB 20. Symbicort NF* (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION 2 PUFFS TWICE DAILY 21. Warfarin 3 mg PO DAILY16 RX Coumadin 3 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 22. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain do not drive, operate machinery, or take other sedating medications while on this medication 23. Outpatient Lab Work Please have INR checked daily. ICD 9: 453.8 Please fax results to [Last Name (LF) ],[First Name3 (LF) ] J. Phone: [Telephone/Fax (1) 798] Fax: [Telephone/Fax (1) 21392] Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: PRIMARY: UTI supratherapeutic INR SECONDARY: HIV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you at [Hospital1 827]. You were admitted with a urinary tract infection and very high INR (blood level of coumadin). We treated you with antibiotics and your symptoms improved. We also decreased your dose of coumadin because of possible interactions with the antibiotics. It is important that you have your INR checked as directed by VNA and [Hospital3 ]. Please make the following changes to your medications: # START bactrim DS one tablet three times a day, last dose 7/27 # DECREASE coumadin to 3mg daily while on the bactrim. This dose will be adjusted based on your INR by the coumadin clinic and your visiting nurse. # DECREASE gabapentin to 800 mg three times a day for your kidney function and oversedation # We recommend decreasing your clonazepam to 1mg twice a day, as you were very sleepy when you were admitted # We also recommend decreasing your dilaudid, again since you were very sleepy while here. You did not require any dilaudid in the hospital. Please continue all other medications as prescribed. Followup Instructions: The following appointments have been scheduled for you: [2164-6-20] at 3:00 pm with Dr. [Last Name (STitle) ] [2164-6-27] at 4:20 pm with Dr. [Last Name (STitle) ] [2164-7-23] at 3:50pm with Dr. [Last Name (STitle) 1140] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 4236] Completed by:[2164-6-19*] ICD9 Codes: 5990, 4589, 4280, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6491 }	Medical Text: Admission Date: [2117-6-9] Discharge Date: [2117-6-28] Date of Birth: [2093-8-26] Sex: F Service: OME This dictation covers the hospitalization between [2117-6-9] and [2117-6-28]. The remainder of the hospitalization course will be dictated in a separate discharge summary by the next intern taking care of this patient. CHIEF COMPLAINT: Recurrent Hodgkin's disease admitted for an auto bone marrow transplant. HISTORY OF PRESENT ILLNESS: This is a 23 year old female with recurrent Hodgkin's lymphoma who is admitted for an auto peripheral stem cell transplant. The patient was initially diagnosed in [2112-1-29] with early stage Hodgkin's disease status post ABVD times four cycles with local radiation chemotherapy and obtained complete remission. Follow up scans revealed no recurrent disease. Routine follow up in [2116-9-28] showed an increasing ESR and PET scan obtained revealed new left lower lobe nodules, FVG avid. The patient is status post thoracotomy for removal of the masses, consistent with recurrent Hodgkin's lymphoma and anterior mediastinal lymphadenopathy, positive for pathology but PET negative, which was consistent with nodular sclerosing Hodgkin's disease. The patient was recently admitted for high-dose Cytoxan therapy for stem cell collection that was complicated by diarrhea, lethargy and altered mental status with OxyContin and emesis. The workup was revealing. The patient was treated supportively with relief. Most recently she had a right earlobe cellulitis which was treated with intravenous Oxacillin and transitioned to Keflex times ten days with resolution, approximately one week prior to admission. REVIEW OF SYSTEMS: Since discharge, no complaints, no headache, visual changes, oral lesions, no fevers, chills or nightsweats. No chest pain, shortness of breath, palpitations, lightheadedness, dizziness, weakness, no abdominal pain, no nausea, vomiting, diarrhea or constipation. PAST MEDICAL HISTORY: Right earlobe cellulitis. Ovarian cyst. History of shingles in [2108-6-28]. Hodgkin's lymphoma as described above, diagnosed in [2112], status post ABVD times four cycles, status post high-dose Cytoxan and local radiation therapy. MEDICATIONS ON ADMISSION: Multivitamin one tablet p.o. q. day. ALLERGIES: Eggs cause wheeziness, flue shots cause wheezing. Intravenous contrast allergy, causes hives. Vancomycin ? pruritus and hives. SOCIAL HISTORY: Lives with her boyfriend in [Name (NI) 3844], rare alcohol use, denies tobacco history. Recently employed in the electronic industry. FAMILY HISTORY: Distant leukemia, distant breast cancer in mother's cousin. PHYSICAL EXAMINATION: General: Alopecia, young female, pleasant in no apparent distress. Temperature 97.3, blood pressure 98/68, heart rate 96, respiratory rate 18. Head, eyes, ears, nose and throat: Oropharynx clear. Mucous membranes moist. Mucous membranes moist. Pupils equal, round and reactive to light. Extraocular muscles intact. Right ear without erythema or drainage. Neck: No jugular venous distension, no lymphadenopathy, no masses. Chest: Clear to auscultation bilaterally. Left Port-A-Cath in place with dressing clean, dry and intact. No tenderness or erythema. Coronary, regular rate and rhythm, no murmurs, rubs or gallops. Abdomen, soft, nontender, nondistended. Positive bowel sounds, no hepatosplenomegaly and no masses. Extremities, warm and well perfused, no edema. Skin, no rashes. Neurological, alert and oriented times three. Cranial nerves II through XII intact. Five out of five bilaterally, upper and lower extremity strength. Light touch sensation intact. Finger-nose-finger within normal limits. Gait within normal limits. LABORATORY DATA: Beta ANC was 2,080, fibrinogen 341, white count 2.8 with 71 polys and 18 lymphs. Hematocrit 29.3, platelets 350, INR 1.1. Potassium 3.6, creatinine 0.6, uric acid 5.5, LDH is 161, total bilirubin 0.3. Pathology of bone marrow, mildly hypocellular marrow with maturing trilineage hematopoiesis, no morphological evidence of involvement by Hodgkin's lymphoma. Bone marrow smear, 86 percent polys, 0 percent bands, 7 percent monos, 3 percent lymphs, 4 percent eos. Bone marrow aspiration smear, less than 1 percent blasts. Bone marrow biopsy, no tumor or lymphoma, normal maturation. HOSPITAL COURSE: Oncology - The patient returns with recurrence of Hodgkin's disease. The patient is status post stem cell collection and is admitted for auto bone marrow transplant. The patient underwent a preparation with Cytoxan and Mesna, increased TNN and Etoposide which was unremarkable. Seven days prior to transplant, the patient was transplanted with her peripheral stem cells and had an uncomplicated course. She was maintained on Allopurinol for tumorlysis. She had no evidence of tumorlysis during this hospitalization stay. She was maintained on routine anti- emetic care, intravenous fluids per protocol and routine oral care. Heme - The patient presented with pancytopenia. She was transfused to maintain her hematocrit greater than 25 and platelets greater than 20 without bleeding. On [6-12], her ANC was greater than 1000, however, she was neutropenic on [6-17]. On [6-26], her ANC was greater than 1000. Infectious disease - The patient is status post cellulitis. She was maintained on Ciprofloxacin and Acyclovir as per protocol which was started on day -2. She had a low-grade fever to 100.5, however, she was not neutropenic at that time and no antibiotics were started. When she became neutropenic she had an episode of fever. She was started with Vancomycin for question of a line infection and Ciprofloxacin was discontinued and changed to Cefepime. Cultures grew out 2 out of 4 bottles positive for Apha Streptococcus sensitive for Vancomycin but intermediate sensitivity for Penicillin. The patient was maintained on Vancomycin. The remainder of her surveillance blood cultures were no growth to date. She had acute Redman's syndrome with Vancomycin and it was run over four hours with some premedication with Benadryl with improvement and resolution with the remainder of her Vancomycin treatment. She also had a chest x-ray which showed bilateral pleural effusions but no infiltrates. She further had spikes and she had a one day course of Ambazone for a spike to 101, and Fluconazole was discontinued. Stretch speciation was sensitive for Vancomycin and Cefepime was discontinued once her ANC was greater than 1000. She received a 110 dose of Ambazone which was discontinued, once her ANC was increased. Acute renal failure - The patient was on [6-28], had an acute episode of renal failure with increase in creatinine from 0.5 to 1.7. Workup is pending at this time. She has a urinalysis that is pending. Renal was consulted in the evaluation of this patient. Initial thoughts were that this was due to Ambazone the 110 dose versus Streptococcus bacteremia. The patient is waiting an echocardiogram for evaluation of vegetation. The patient has been afebrile since and has been just maintained on Vancomycin. Diarrhea - The patient had some episodes of diarrhea, all were Clostridium difficile negative times four. Hematemesis - The patient had a scant amount of vomitus approximately 20 cc with an episode of hematemesis which was likely related to esophagitis and mucositis. The patient was started on Protonix intravenously b.i.d. She also had some chest pains with some swallowing, likely all consistent with esophagitis. The patient had an electrocardiogram which was negative with the episode of chest pain. She was treated with morphine prn with resolution. The patient was initially started on Fluconazole but was discontinued to Ambazone once she spiked a fever and then the Ambazone was subsequently discontinued. Access - The patient has a Port-A-Cath in the left chest that was done prior to her admission. Surgery had come in and placed a right internal jugular and this was discontinued and placed to an interventional radiology-placed new triple lumen catheter. So, her chemotherapy was delayed one day given the fact that surgical placement was in the wrong position. However, when she spiked a fever she had some erythema around her site and the line was discontinued. Cultures were negative for infection. Emesis - The patient had some significant nausea before her stem cell transplant. She was subsequently maintained on _______ and Zofran, however, Decadron was added to improve her nausea control as well as Zyprexa and she had no further nausea during the remainder of her hospitalization stay. Earache - The patient had complained of some earache after she had some chest pain, likely associated with the esophagitis. This was all thought to be due to referred pain from her esophagitis given the fact that the nerve that innervates her esophagus does radiate up to her ear. She had a normal cranial nerve examination, this was likely thought to be referred pain from the esophagitis. The remainder of the hospitalization stay will be dictated in a separate discharge addendum summary by the next intern taking care of this patient as described above. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7779], M.D. Dictated By:[Last Name (NamePattern1) 12481] MEDQUIST36 D: [2117-6-28] 15:12:36 T: [2117-6-28] 20:14:01 Job#: [Job Number 35541] ICD9 Codes: 7907, 5845
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6492 }	Medical Text: Admission Date: [2100-9-15] Discharge Date: [2100-10-6] Date of Birth: [2050-2-13] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: Fall, shortness of breath Major Surgical or Invasive Procedure: Tracheostomy [9-25] Change of tracheostomy [9-30] IR-placement of R thoracic pigtail catheter [10-4] History of Present Illness: 50yo M suffering a fall from ~10ft, landing on his back. Initially brought to [Hospital3 59514] Hospital, imaging revealing multiple BL rib fxs, and transferred to [Hospital1 18] by ambulance for further eval and mgmt. Past Medical History: DM2 HTN psoriasis s/p repair of R hand injury Social History: married, lives in [State 4260]. Currently in MA working as window repairer. Family History: unavailable Physical Exam: O: T:100.3 BP: 180/93 HR:117 RR 36 O2Sats 100% NRB Gen: in distress; pain HEENT: Pupils:3.5-2.5 bilat, EOMs intact, small tongue lac, TMs clear Neck: Supple. Lungs: good effort, tender to palp over ribs bilaterally, limited auscultation but BL BS present, no crepitus. Cardiac: tachy. S1/S2. Abd: Soft, obese, NT, BS+ Ext: Warm and well perfused. R hip tenderness. Rectal: good tone, no gross blood Neuro: GCS 15 Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [Last Name (un) 938] G R 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch intact. Reflexes: B T Br Pa Ac Right 2+ Left 2+ Toes downgoing bilaterally Pertinent Results: [2100-10-3] 02:22AM BLOOD WBC-7.3 RBC-2.74* Hgb-8.1* Hct-25.2* MCV-92 MCH-29.6 MCHC-32.2 RDW-14.8 Plt Ct-272 [2100-10-2] 03:51AM BLOOD PT-15.6* PTT-25.4 INR(PT)-1.4* [2100-10-3] 02:22AM BLOOD Glucose-146* UreaN-36* Creat-1.0 Na-139 K-4.8 Cl-107 HCO3-26 AnGap-11 [2100-10-3] 02:22AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.5 [2100-9-30] 02:05AM BLOOD Type-ART pO2-87 pCO2-54* pH-7.42 calTCO2-36* Base XS-8 Brief Hospital Course: 50yo M transfer to [Hospital1 18] as a trauma basic. Evaluation in the trauma bay revealed a GCS of 15, HD stable, mildly labored breathing but maintaining saturation on supplemental oxygen. Imaging from OSH as well as here included CT Head (negative), CT C-Spine (no acute injury), and CT Torso (rib fx R [2-23] and rib fx L 1,[2-20]; R scapular fracture; possible R adrenal hemorrhage; and transverse process fx T9, L1 and L3). The patient was admitted to the TSICU under the Trauma Surgery service. Neurosurgical consult indicated no operative management for the transverse process fractures. Respiratory status declined over the first hospital day leading to endotracheal intubation on HD 2. This remained his major issue as ventilator status failed to improve. He developed a MSSA PNA (dx'd by BAL on HD 4), which was treated with a 7-day course of Nafcillin. His failure to wean led to an open tracheotomy performed on HD 11, with placement of a #8 Portex. The trach tube caused local irritation, presumably due to being too short in relation to his body habitus, and was therefore changed at the bedside on HD 16 to a #8 [Last Name (un) 295]. The vent wean continued but a few days later regressed. CXRs showed a R pleural effusion, which was drained by an IR-placed pigtail cathether (1500cc of serosanguinous fluid on the first day) on HD 20. Sedation during endotracheal intubation was weaned off shortly after tracheotomy. Analgesia and anxiolytics are currently morphine and ativan. Patient is interactive and appropriate with episodes of mild agitation. There were no cardiovascular issues throughout his stay; antihypertensives were eventually begun when he became hypertensive. Tube feeds were begun shortly after intubation via a nasogastric tube. PEG was not an option given his body habitus, and thus a Dobhoff was placed at the bedside. Renal function was stable. Gentle diuresis with a lasix drip was employed to facilitate the ventilator wean. Hyperkalemia at the time of admission was treated successfully with calcium, insulin, and bicarbonate; no further electrolyte abnormalities ensued. Glycemic control became problem[Name (NI) 115] after reaching goal tube feeding; the patient's home doses of oral antiglycemics were added to a progressively more-agressive insulin sliding scale. Besides the MSSA PNA, the patient's sputum also grew out Enterobacter on HD 12. Because the patient had no fever, no leukocytosis, and no sputum, and because the colony counts were <100,000, no antibiotics were given. No hematologic concerns arose; no transfusions were needed throughout. Prophylaxis included Heparin SQ and pneumoboots, as well as pepcid until tube feeds reached goal. Access included an arterial line and central venous catheter placed on HD 1. The right subclavian was changed on HD 11. At the time of discharge, patient is awake and alert, tolerating a tube feed diet via Dobhoff, on oral medications, ventilated via trach, afebrile, with stable vital signs. Medications on Admission: actos 30mg daily, cozaar 15mg daily, amlodipine/benzapril 10-20mg daily, glyburide 5mg daily Discharge Medications: 1. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [Hospital1 ] (2 times a day). Disp:qs qs Refills:2 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 3. Metoprolol Tartrate 50 mg Tablet Sig: 0.75 Tablet PO TID (3 times a day): hold for SBP < 100 or HR < 60. 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 5. Oxycodone 5 mg/5 mL Solution Sig: Ten (10) mL PO Q4H (every 4 hours) as needed for pain. 6. Glyburide 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 8. Metoclopramide 5 mg/mL Solution Sig: Two (2) mL Injection Q6H (every 6 hours). 9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) mL Mucous membrane twice a day. 10. Colace 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a day. 11. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) mL PO every four (4) hours as needed for pain. 12. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day: hold for SBP < 100. 13. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day. 14. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) puff Inhalation twice a day. 15. Combivent 18-103 mcg/Actuation Aerosol Sig: Six (6) puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. Senna 8.8 mg/5 mL Syrup Sig: Five (5) mL PO twice a day as needed for constipation. 17. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-16] gtt Ophthalmic every four (4) hours as needed. 18. Hydrocortisone 2.5 % Cream Sig: One (1) application Topical twice a day. 19. Morphine 2 mg/mL Syringe Sig: [12-16] mL Injection Q1H (every hour) as needed for Pain. 20. Lorazepam 2 mg/mL Syringe Sig: [12-16] mL Injection every four (4) hours as needed for agitation. Discharge Disposition: Extended Care Facility: [Hospital ] Rehab Discharge Diagnosis: L1, L3-8, R3-11 rib fx with right-sided flail Right scapula hair-line fracture Right transverse process fracture T9, L1, and L3 respiratory failure Right pleural effusion morbid obesity Diabetes mellitus, type 2 Hypertension psoriasis Discharge Condition: Stable Discharge Instructions: Please [Name8 (MD) 138] MD or come to ER for: fever or chills; nausea, vomiting, diarrhea, constipation, abdominal distension, abdominal pain, intolerance of tube feeds; shortness of breath, secretions from trach, dislodgment of trach, clogging of trach; redness, drainage, or swelling at trach site. Continue tube feeds via nasogastric Dobhoff tube. Continue foley to gravity. Wean vent as tolerated. Followup Instructions: Please follow-up with a trauma surgeon in [State 4260], near where you are being discharged to. You may call the office of Dr. [Last Name (STitle) ], Trauma Surgery at [Hospital1 18], at [Telephone/Fax (1) 6429] for any concerns or questions. ICD9 Codes: 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6493 }	Medical Text: Admission Date: [2117-9-13] Discharge Date: [2117-9-22] Date of Birth: [2067-11-26] Sex: M Service: [Last Name (un) ] ADMITTING DIAGNOSES: Post necrotic cirrhosis, awaiting liver transplant. HISTORY OF PRESENT ILLNESS: The patient is a 50 year old male with history of HPV and HCC who presents for liver transplantation. The patient underwent EXLAP [6-/2116] for his HCC and at that time was unresectable. He then underwent chemo-embolization/RFA, which significantly reduced the tumor. The patient is currently a good transplant candidate. Interpreter was present for both history on [2117-9-4] and on [2117-9-13]. All the history from [2117-9-4] has not changed. The patient currently has no fevers, chills, nausea, vomiting, and no abdominal pain. The last time the patient ate on [2117-9-13] was at 7:00 am. PAST MEDICAL HISTORY: HPV, HCC, post-traumatic stress disorder/depression, question alcohol abuse, quit five years ago. PAST SURGICAL HISTORY: EXLAP, [6-/2116] for liver biopsy of tumor. Left upper extremity war wound. Status post chemo- embolization/RFA in [2106]. ALLERGIES: Motrin, which gives him hives. MEDICATIONS ON ADMISSION: Wellbutrin 75 mg once a day Amitriptyline 75 mg q.day Epivir 150 mg q.day SOCIAL HISTORY: Married times 30 years. History of tobacco, quit 10 years ago. History of alcohol abuse, quit 5 years ago. No I.V. drug abuse. FAMILY HISTORY: Patient has six daughters, alive and healthy, seven siblings, healthy until killed in [Country 3992] War. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.4, blood pressure 146/90, heart rate 90, respirations 20, 90 percent on room air, weight 77.3. GENERAL: In no acute distress well-appearing male. HEENT: Atraumatic, normocephalic. Pupils are equal, round, react to light. EOMs are full. Mouth: Poor dentition. Tongue midline. No exudates. NECK: Supple. No palpable nodes. No thyromegaly. No carotid bruits. Lungs clear to auscultation and percussion bilaterally. CV: Regular rate and rhythm. Normal S1 and S2 without murmurs or rubs. ABDOMEN: Well-healed abdominal scar, slightly distended but soft. Positive bowel sounds, nontender. Slight left upper quadrant tenderness. No rebound. EXTREMITIES: No C/C/E. Left upper extremity deformity secondary to injury. NEURO: Awake, alert, oriented times three. Cranial nerves II - XII intact. Motor in upper extremity 5 out of 5 bilaterally, no drift. LABORATORY DATA: [2117-9-13]: WBC 5.8, hematocrit of 44.7, platelets 200, sodium 140, 4.2, 104, 27, BUN/creatinine 13 and 1.0. Platelets 108. ALT 40, AST 26, alk phos 64, serum bili 0.6, PT 12.9, PTT 22.7, INR 1.1. EKG: Normal sinus rhythm. No ST wave changes. Chest x-ray from [9-13]: Lungs clear, no infiltrate. The patient was typed and crossed for 10 units of FFP, packed red blood cells, cryo, and platelets. The patient was currently NPO, pre-meds ordered, consent on the chart. Reviewed information with Dr. [First Name8 (NamePattern2) 3825] [Last Name (NamePattern1) 3826]. Patient went to surgery on [9-13]/;[2116] with preoperative diagnosis of chronic Hep B and hepatoma, the suture, backtable bench of a deceased donor liver performed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Please see detailed note regarding surgery. Also the patient had a piggyback cadaveric liver transplant, portal vein to portal vein anastomosis, common hepatic artery to hepatic artery branch patch anastomosis, bile duct to bile duct, performed by Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 816]. Again, please see detailed surgery note for more information. Postoperatively, the patient went to the SICU. The patient received ganciclovir, Hep B immunoglobulin, lamivudine was started. Methylprednisone, Bactrim and Unasyn were started. Morphine sulfate was started for pain management. Duplex ultrasound of the liver was obtained on [2117-9-14], demonstrating normal son[Name (NI) 493] appearance of the liver and hepatic duct. Flow in hepatic veins is normal. Portal vein is hepatopetal with peak velocity approximately 20 cm/second. The main hepatic artery demonstrates brisk upstroke with a resistive index of 0.46; similar brisk upstroke is seen on the left and right hepatic arteries. On the postoperative day, the patient was intubated, sedated. The patient had two JPs, a T-tube. The patient was extubated on [2117-9-15], continued on Neomycin, Bactrim, lamivudine, Valcyte, ganciclovir. Right IJ was placed postoperatively and chest x- ray confirmed placement, demonstrating bilateral effusions, no pneumothorax. On [2117-9-16], cardiology was consulted for Afib, suggested rate control with Lopressor, aspirin as necessary, if surgically accepted. It was demonstrated that platelets were slightly low at 67. Blood tests were sent off, which were unremarkable. Patient was transferred from SICU to FAR-10 on [2117-9-17]. While in the ICU, one of the JPs were removed, [9-21] T-tube to drainage and another JP drain. PT and OT were consulted. Continued to be afebrile, vital signs stable. Continued on SK 0.2, MMF, Solu-Medrol, prednisone was started 20 mg q.day on [2117-9-19]. Foley was removed on [2117-9-19]. Cholangiogram was obtained on [2117-9-18], demonstrating no intra- or extrahepatic biliary dilatations, narrowing of the common duct, T-tube insertion. Pre-contrast to the extrahepatic duct into small bowel. Since surgery, all his LFTs have been dropping slowly except for the alk phos which slowly increased. On [2117-9-15], ALT was 697, AST 473, alk phos 56, total bili 0.5. On [2117-9-20], ALT was 298, AST 74, alk phos 206, total bili 1.2. Of note, when cardiology was consulted, troponins were obtained and on [2117-9-15], troponin was 0.025 and on [2117-9-16], troponin was 0.02, and on [2117-9-16] the troponin was less than 0.01, which would rule out patient having myocardial infarction. On [2117-9-20], T-tube was capped. The patient had stool cultures sent off for C-diff on [2117-9-19], [2117-9-21], because loose/borderline diarrhea, which demonstrated that both of those cultures were negative. On [2117-9-20], hepatology was consulted, had recommended DC-ing lamivudine, instead put patient on adefovir 10 mg q.day. On [2117-9-20], the patient did receive another dose of Hep-_____ and prior to receiving the dose, quantitative HPV of antigen and antibody was obtained. On [2117-9-20], quantitative hepatitis antigen was negative and quantitative hepatitis antibody was positive, greater than 150 miu/ml. The patient continues to do well with no complaints, ambulating a regular diet, awaiting medication teaching. Continues to be afebrile. Vital signs stable. Good I&Os. Labs on [2117-9-22] are the following: WBC 10.8, hematocrit of 36.3, platelets 62, sodium 135, 4.4, chloride 100, bicarb 22, BUN/creatinine of 31, 1.0, with glucose 154, ALT 220, AST 36, alk phos 199, total bili 0.9. FT level on Herpsera was 11.8. The patient is going to be going home tomorrow with services after patient has been taught how to administer insulin. The patient will be going home on the following medications. DISCHARGE MEDICATIONS: Tylenol 325 to 650 mg p.r.n. Dulcolax 10 mg q.h.s. p.r.n. Fluconazole 400 mg q.24 Hepsera 10 mg q.day Lopressor 75 mg b.i.d. MMS 500 q.i.d. Oxycodone 4 mg q.4-6 hours p.r.n. Prednisone 20 mg q.day. Bactrim SS one tab q.day Regular insulin, sliding scale, fingersticks q.i.d. Prevacid 30 mg q.day. Tacrolimus 4 mg b.i.d. Ganciclovir 900 mg q.day. The patient is to follow up with Dr. [Last Name (STitle) 497] on [2117-9-24] at 11:00 a.m. Telephone number is [Telephone/Fax (1) 2422]. Also please arrange an appointment with [Doctor First Name 2398], who is the coordinator, for followup appointment next week, [Telephone/Fax (1) 673], if [Doctor First Name 2398] has not made an appointment for patient. Please make sure that patient has an interpreter for followup appointment. Also please instruct the patient that he should call [Telephone/Fax (1) 30335] if any fevers, chills, nausea, vomiting, inability to take medications, abdominal pain, jaundice, lethargy, lower extremity edema or any problems drinking or taking any foods by mouth. The patient should have labs every Monday and Thursday for CBC, chem-10, AST, ALT, alk phos, total bili, albumin and a Prograf trough level. The results of those lab tests should be faxed to the [Hospital1 18] Transplant Office, at [Telephone/Fax (1) 21087]. The patient should not be driving while taking pain medications. The patient may shower, no heavy lifting. Discharge is to home with services. FINAL DIAGNOSES: Hepatitis B and hepatocellular carcinoma, status post liver transplant [2117-9-13]. DISCHARGE CONDITION: Stable. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 4841] Dictated By:[Last Name (NamePattern1) 4835] MEDQUIST36 D: [2117-9-22] 19:51:40 T: [2117-9-22] 23:06:13 Job#: [Job Number 53815] ICD9 Codes: 5715
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6494 }	Medical Text: Admission Date: [2119-1-19] Discharge Date: [2119-1-23] Service: MEDICINE Allergies: sulfa or amoxicillin Attending:[First Name3 (LF) 2291] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: This is an 87 year old male with PMH of ischemic cardiomyopathy with an EF of 45% s/p PPM/AICD placement in [2113] for AV block, HTN, recently diagnosed sarcoidosis after a [Year (4 digits) ] biopsy, and recent brief admission for bronchiectasis/UTI with discharge on [1-14] now returning with shortness of breath. He was discharged on a course of ciprofloxacin for UTI/bronchiectasis. He was doing well at home until a few day ago when he developed gradually worsening shortness of breath and [Month/Year (2) ] productive of clear sputum. His symptoms were exacerbated by activity. He reports no fevers or chills, no headache, change in vision or neck pain. He continues to have burning with urination since his recent diagnosis of UTI, difficulty starting urinary stream. Denies any abdominal pain, no focal numbness tingling or weakness, no rash. This episode of shortness ofbreath was more severe than his previous. On admission from [1-13] to [1-14], patient presented with acute onset shortness of breath with [Month/Year (2) ] productive of whitish sputum without fever or leukocytosis, felt to be consistent with bronchiectasis flare. Sxs resolved overnight so pt was discharged on ciprofloxacin to be completed on [1-23]. In the ED, initial VS were: 98.0, 86, 107/50, 22, 100% 4L Nasal Cannula. He then became hypoxic to the 80s and tachypneic to the 30s, but was never hypotensive. Exam was notable for diffuse rhonchi, no JVD, trace LE edema, and patient was placed on non-rebreather to maintain sats in the low 90s. He was then placed on BiPap and unable to be weaned. EKG was at baseline. Labs notable for a lactate of 2. CXR was unremarkable. He received Combivent, albuterol nebs x 2, 125mg of IV solumedrol, 40mg IV lasix, and 750mg IV levofloxacin. On arrival to the MICU, patient was breathing comfortably on bipap which was placed in the ED in the late afternoon. He reports improvement since arrival on bipap. He soon became tachypneic to 50s and uncomfortable. ABG was obtained at 1AM and showed 7.46/45/57/bicarb=33 with no previous comparison. He was transitioned to high flow oxygen shortly after arriving. He continues to have burning with urination despite treatment for his UTI with cipro. Past Medical History: bradycardia - with primary AV block s/p AICD and pacer placement Recurrent urethral strictures [12-29] childhood infection Mild systolic dysfunction - EF of 40-45% on Echo in [2110] Chronic [Year (4 digits) ], congestion and hoarseness with referral for possible sarcoidosis. Chronic sinusitis. Osteoarthritis. Right knee surgery. Defibrillator/pacemaker. Social History: Denies smoking, alcohol use, recreational drug use. Lives at home with wife. Family History: Father died of CVA; sister has [Name (NI) 4278]. Physical Exam: ON ADMISSION: Vitals: T: 98.5, BP: 110s-130s/60s-70s, P: 90s-100s, R: 35, O2: 96% on bipap General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, difficult to auscultate heart sounds over bipap Lungs: Clear to auscultation anteriorly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, trace LE edema bilaterally Neuro: motor strength and sensory grossly equal and intact bilaterally, gait deferred AT DISCHARGE: VS: Tmax/Tc 97.7/97.7; 110/80; 90; 18; 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, EOMI, PERRL Neck: supple, JVP not elevated CV: RRR, nl S1, S2, no MRG Lungs: CTAB, respirations unlabored Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, no edema Neuro: motor strength and sensory grossly equal and intact bilaterally, gait deferred Pertinent Results: Admission Labs: [2119-1-19] 03:55PM BLOOD WBC-7.4 RBC-3.82* Hgb-12.0* Hct-35.8* MCV-94 MCH-31.5 MCHC-33.6 RDW-14.3 Plt Ct-235 [2119-1-19] 03:55PM BLOOD Neuts-70.4* Lymphs-18.7 Monos-6.5 Eos-2.8 Baso-1.7 [2119-1-19] 03:55PM BLOOD Glucose-115* UreaN-11 Creat-1.1 Na-139 K-4.1 Cl-98 HCO3-32 AnGap-13 [2119-1-19] 06:59PM BLOOD Lactate-2.0 PT/PTT/INR [2119-1-20] 05:36PM BLOOD PT-13.6* PTT-150* INR(PT)-1.3* [2119-1-21] 02:22AM BLOOD PT-13.0* PTT-150* INR(PT)-1.2* [2119-1-22] 07:00AM BLOOD PT-12.4 PTT-56.3* INR(PT)-1.1 [2119-1-22] 07:15PM BLOOD PT-13.2* PTT-71.9* INR(PT)-1.2* [2119-1-23] 06:33AM BLOOD PT-13.2* PTT-69.8* INR(PT)-1.2* Discharge labs: [2119-1-23] 06:33AM BLOOD WBC-9.0 RBC-3.67* Hgb-11.6* Hct-33.8* MCV-92 MCH-31.5 MCHC-34.2 RDW-14.8 Plt Ct-190 [2119-1-23] 06:33AM BLOOD Glucose-99 UreaN-11 Creat-0.9 Na-140 K-3.9 Cl-103 HCO3-31 AnGap-10 [2119-1-21] 02:22AM BLOOD ALT-22 AST-47* LD(LDH)-246 AlkPhos-53 TotBili-0.4 [2119-1-19] 03:55PM BLOOD proBNP-379 [2119-1-23] 06:33AM BLOOD Calcium-9.3 Phos-2.1* Mg-2.3 [2119-1-23] 06:33AM BLOOD Vanco-36.7* IMAGING: ECHO [2119-1-23]: The left atrium is elongated. No right-to-left shunt is seen on intravenous saline injection at rest. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 35-40 %), but the apical half of the ventricle is not well seen. The estimated cardiac index is normal (>=2.5L/min/m2). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the [Month/Day/Year ] level. 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. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with regional systolic dysfunction c/w CAD. Mild mitral regurgitation. No right-to-left intracardiac shunt identified. Dilated ascending aorta. Compared with the prior report (images unavailable for review) of [2111-6-12], the severeity of mitral regurgitation may be somewhat reduced and global systolic function is slightly worse. CXR [2119-1-21] MPRESSION: Increased retrocardiac density consistent with left lower lobe collapse and/or consolidation, worse compared with [2119-1-19]. Bilateral LENIS [2119-1-19]: IMPRESSION: Nonocclusive thrombus within the distal left common femoral vein extending to the proximal superficial femoral vein. CT Chest [1-13]: Bilateral bronchiectasis with bronchial wall thickening consistent with a bronchial inflammatory process. Again noted is right middle lobe loss of volume with a peripheral consolidation which may represent atelectasis, but malignancy cannot be excluded. Dedicated chest CT is again recommended in 3 months. Stable lung nodules Microbiology: Blood cultures [2119-1-19]: pending URINE CULTURE ([2119-1-19]): <10,000 organisms/ml. Urine culture [2119-1-21]: no growth Speech and Swallow Eval [2119-1-23]: This swallowing pattern correlates to a Functional Oral Intake Scale (FOIS) rating of 5. RECOMMENDATIONS: 1. Ground consistency solids with thin liquids. 2. Meds whole with water. 3. TID oral care. 4. Recommended video swallow and barium swallow as outpatient for further evaluation of symptoms. To schedule, please call ([Telephone/Fax (1) 97885]. Brief Hospital Course: 87 year old male with PMH of ischemic cardiomyopathy s/p PPM/AICD placement, HTN, recently diagnosed sarcoidosis after a [Telephone/Fax (1) ] biopsy, and recent brief admission for bronchiectasis/UTI with discharge on [1-14], who presented with shortness of breath. # DVT/presumed PE: Pt presented with SOB, with LENIS positive for DVT of LLE. Pt is highly immobile at home, although no recent surgery or known history of malignancy. Last colonoscopy in [2114] with polypectomy, plan repeat in 5 years. Given sob/respiratory distress (see below), presumed to have PE. No evidence of RH strain. Started on hep gtt on [2119-1-19]. Respiratory status improved: initially required BiPAP in MICU but quickly transferred to the floor, where he remained stable, satting mid-high 90s on 3L NC, O2 sat high 90s on room air and mid 90s on ambulation at the time of discharge. Pt was started on warfarin 2.5 on [1-21].5 on [1-22], and 4mg on [1-23], DC [Last Name (un) ] on 4mg daily. Heparin drip DCed on [1-23], and started Lovenox 1.5mg/kg daily (110mg daily) to bridge. Likely will need 6 months anticoagulation for provoked DVT/PE. Contact[Name (NI) ] Dr. [Name (NI) 97886] office to follow Lovenox/Coumadin bridging and future INR. # Respiratory distress/hypoxia - Rapidly resolved after BIPAP in MICU. Suspicion for PE given DVT and new O2 requirement/hypoxia and pt was started on anticoagulation (see DVT/PE above). On admission, BNP was <400 pointing away from a cardiac etiology. ECHO on [1-23] showed slightly worse global dysfunction compared to [2110], now EF 35%. Out of concern for possible pneumonia (HCAP as pt was recently hospitalized)and pt was started on levoquin in the ED, transitioned to vanc/cefepime in the MICU. Pt was also given steroids in the ED on arrival. CXR initially did not suggest acute infection. CT scan from prior admission showed bronchiectasis, and it was felt some of his SOB/hypoxia could be related to superinfection or bronchiectasis flare. On [2119-1-21] WBC was elevated but pt afebrile and with improving respiratory status. Leukocytosis thought to be from steroids received in ED. However on [1-21] showed retrocardiac opacity which could represent consolidation, and pt was continued on antibiotics. Pt was administered respiratory therapy - chest PT treatments, acapella, pulmonary toilet. Patient switched back to Levaquin on [1-23] and planned for total 7-day course for CAP. Blood culture pending at time of discharge. # UTI/[Name (NI) 30294] pt sent home on cipro from last admission, had not yet finished his course. Cipro was DCd, pt placed on vanc/cefepime c/f CAP. Pt has history of recurrent UTIs likely [12-29] BPH. Continued home regimen of finasteride, terazosin, and tamsulosin. Urine culture on [1-19] grew <10,000 organisms. DC home on 7-day course of levaquin to cover CAP which also covers UTI. # Possible Sarcoid. Patient has chronic sinusitis, Chronic [Month/Year (2) ], congestion and hoarseness with a [Month/Year (2) ] bx in [2118-11-27] c/w sarcoidosis, however definitive diagnosis remains unclear. Continued home nasal saline. Steroids, after the 1 time dose in the ED, were not continued. # Ischemic cardiomyopathy. ECHO on [1-23] showed slightly worse global dysfunction compared to [2110], now EF 35%. BNP on admission <400. Pt did not appear fluid overloaded on exam. Furosemide initially held in the setting of presumed PE. Restarted on discharge. Continued home metoprolol, ASA, rosuvasatin. Patient has previously been on lisinopril, but was discontinued for unclear reason. Please address this on follow up. # Conjunctivitis. Continued outpatient ofloxacin. # Depression/anxiety - Patient was recently started on sertraline which was continued. # Aspiration risk- [Name (NI) ] wife expressed concern about patient choking on his food. Speech and swallow eval reveals a swallowing pattern correlates to a Functional Oral Intake Scale (FOIS) rating of 5. Recommended Ground consistency solids with thin liquids (which patient is already doing at home), meds whole with water. Also recommended video swallow and barium swallow as outpatient for further evaluation of symptoms. PT WAS MAINTAINED AS FULL CODE THROUGHOUT THE COURSE OF THIS HOSPITALIZATION. # Transitional issues: 1. Anticoagulation: Dr.[Name (NI) 2935] office was contact[Name (NI) ] regarding management of anticoagulation with Lovenox to coumadin bridge. VNA to help administer daily lovenox. VNA to draw PT/INR on [2119-1-26] and fax results to Dr.[Name (NI) 2935] office. 2. Follow up final blood culture results 3. Address restarting ACE-I/[Last Name (un) ] given repeat ECHO findings. 4. Outpatient video swallow Medications on Admission: Medications (confirmed w/ wife): -Finasteride 5 mg PO once a day. -Furosemide 40 mg PO daily. -Metoprolol tartrate 12.5 mg PO BID. -Rosuvastatin 40 mg once a day. -Potassium chloride 20 mEq Tablet PO every other day. -Sertraline 12.5 mg PO daily. -Tamsulosin 0.4 mg PO HS. -Aspirin 81 mg PO daily. -Multivitamin PO daily. -Calcium carbonate-vitamin D3 600 mg-400 unit PO twice a day. -Aleve 220 mg PO twice a day as needed for pain. -[Last Name (un) 14822] [Last Name (un) 97884] with steroid. -Terazosin 5 mg PO daily -Ofloxacin 0.3% One drop four times a day into both eyes. -Ciprofloxacin 500 mg PO Q12H until [1-23] -fluticasone nasal spray Discharge Medications: 1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO every other day. 6. sertraline 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 11. Aleve 220 mg Capsule Sig: One (1) Capsule PO twice a day as needed for pain. 12. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 13. sodium chloride 0.65 % Aerosol, Spray Sig: [11-28] Sprays Nasal QID (4 times a day) as needed for nasal congestion. Disp:1 unit Refills:0 14. ofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic QID (4 times a day). 15. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 16. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 6 days: last day [1-30]. Disp:6 Tablet(s) Refills:0 17. warfarin 4 mg Tablet Sig: One (1) Tablet PO q4pm: as instructed by Dr. [Last Name (STitle) 2204]. Disp:30 tablets Refills:0 18. Lovenox 120 mg/0.8 mL Syringe Sig: One Hundred-Ten (110) mg Subcutaneous once a day: unless otherwise instructed by Dr. [Last Name (STitle) 2204]. Disp:7 units Refills:0 19. Outpatient Lab Work Please have VNA check INR on [2119-1-26]. Please fax results to patient's PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2204] MD at [Telephone/Fax (1) 7922] 20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:qs qs Refills:0 21. guaifenesin 50 mg/5 mL Liquid Sig: Five (5) mL PO every six (6) hours as needed for [Telephone/Fax (1) ]. Disp:1 bottle Refills:1 22. nebulizer & compressor Device Sig: One (1) unit Miscellaneous every 4-6 hours as needed for shortness of breath or wheezing: dx: pneumonia. Disp:1 unit Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Primary: -Deep vein thrombosis -Suspected pulmonary embolism -Community acquired pneumonia Secondary: -Ischemic cardiomyopathy -Bronchiectasis PE 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: Mr. [Known lastname 97883], It was a pleasure taking care of you during your hospitalization. You were admitted because of difficulty breathing. We think this is caused by a clot in your left leg that travelled up to your lungs. We treated you with blood thinners, which you will continue and be monitored by Dr. [Last Name (STitle) 2204]. We are also treating you with, levofloxacin, an antibiotic for pneumonia (last day will be [1-30]). You were also evaluated by our speech and swallow specialists, who recommended that you continue a normal diet, but you should have an outpatient video swallow evaluation which you PCP can coordinate We made the following changes to your medications: STARTED Lovenox (injection blood thinner, will stop once your coumadin level is in good range) STARTED Coumadin (you should have your INR checked by your VNA on [1-26]) STARTED Levofloxacin (last day [1-30]) STARTED Albuterol nebulizers as needed for shortness of breath STARTED Guaifenesin 5-10mL every 6 hours as needed for [Month (only) ] Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: We are working on a follow up appointment with your primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2204] within 1 week of discharge. The office will contact you at home with an appointment. If you have not heard within 2 business days please call the office at [Telephone/Fax (1) 2205]. Department: [State ]When: WEDNESDAY [2119-2-8] at 2:00 PM With: [First Name11 (Name Pattern1) 2946] [Last Name (NamePattern4) 6564], MD [Telephone/Fax (1) 2205] Building: [State ] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: RHEUMATOLOGY When: THURSDAY [2119-3-16] at 2:00 PM With: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 2226] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 861] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: CARDIAC SERVICES When: FRIDAY [2119-6-23] at 11:30 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2119-1-23] ICD9 Codes: 486, 5990, 4019, 311, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6495 }	Medical Text: Admission Date: [2142-2-22] Discharge Date: [2142-3-1] Date of Birth: [2100-9-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1377] Chief Complaint: Transferred from MICU to floor after stay for unresponsiveness, fever Major Surgical or Invasive Procedure: Right central line placement History of Present Illness: 41 yo m w/ h/o HIV ([1-15] aCD4 234), HBV, admitted for failure to thrive. Partner at bedside significant particpant in history, states that prior to development of ascites pt weighed approx 125. Prior to paracentesis usually 150. Now down to 130s. Ascites better controlled on no salt diet. Also having sig diarrhea- [1-17] lactulose as titrated vs imminent confusion/encephalopathy. Denies f/c/n/v. Admitted for post-pyloric placement. Pt had a post pyloric tube placed on [2-22] and a theraptuic paracentesis on [2-23] with 3.5 L out. He recevied lactulose during this time. Transferred to the MICU on [2-24] for unresponsivness to painful stimuli, hyperkalemia, fever. ABG on admission was 7.51/17/105/14. Lytes were significant for K 7.5 with peaked TW on EKG. Temp 101.4 rectally. Cultures were drawn, hyperkalemia treated with D50/insulin/calcium/kayexalate. MICU team felt that the patient was in sepsis with an alkalosis on top of chonic metabolic acidosis. Central line placed for resuccitation, placed on CTX/vanco. for presumed SBP or hosp. acquired infxn. LP deferred given coagulopathy. Hyperkalemia resolved with kayexalate. For his liver failure, pt started on vitamin K x 3 days. Renal failure (Cr 3.2) while in MICU. Pt thought to be hypoperfusing with intravascular dryness. Renal team consulted and considered hepatorenal syndrome vs. pre-renal renal failure as etiology. Hyponatremia from diuretics. Anemia is noted to be a chronic problem from HIV and ESRD, transfused 1 units PRBCS. Other issues were stable. Pt was called out MS improved. Called out to the floor for further managment. Pt states he feels more alert, denies pain. He wants to eat. Past Medical History: HIV Hep B/End Stage Liver Dx CRI Anemia Neuropathy Tonsillectomy Paracentesis x 3(last [12-6]) Mod Pulm HTN Heart murmur Social History: Works in real estate2-3 cigs/day. 25 pk yr hx. No EtOH. No drugs. From [Country 4194]. Lives with his partner. Family History: Mom:DM No early MIs Physical Exam: Temp BP Pulse Resp O2 sat Gen - Alert, no acute distress, middle aged thin man HEENT - PERRL, extraocular motions intact, anicteric, dry MM with some dried blood near tongue Neck - no JVD, no cervical lymphadenopathy, triple lumen in right neck, no erythema or drainage from line site Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, 3/6 SEM murmur rad to axillae, no rubs, or gallops Abd - Soft, nontender, distended, with normoactive bowel sounds; left sided tap sit with small bruise Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis, 1+edema to mid shin edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [1-27] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact, no asterixis Skin - small red papular rash on lowr neck and chest wall Pertinent Results: Labs [2-25] CXR: The right IJ line has been pulled back and the tip is now in the superior vena cava. The film is again obscured by motion. No focal infiltrate is seen. The feeding tube tip is off the film, at least in the second portion of the duodenum. [2-24] Head CT: There is no intra or extra-axial hemorrhage, mass effect, shift of normally midline structures. Differentiation of [Doctor Last Name 352]/white matter is preserved. Sulci, ventricles, and basal cisterns are all within normal limits. The visualized paranasal sinuses, and mastoid air cells are well aerated. The surrounding osseous and soft tissue structures are within normal limits. IMPRESSION: No intracranial hemorrhage or mass effect. Brief Hospital Course: Impression: 41 yo M with h/o HIv, hep B cirrhosis, who was admitted for FTT s/p post pyloric feeding tube, tap [2-23], who was transferrred to the ICU for unresponsiveness. Pt currently awake, afebrile, HD stable, with improving renal failure who is being transferred to the floor awaiting further management of his liver disease. Plan: 1. Fever: On admission patient was afebrile. Unclear source as both initial peritoneal fluid and fluid from diagnostic tap in ICU were w/o evidence of SBP. Patient defervesced on CTX and vancomycin. On transfer back to floor was vancomycin and ceftriaxone were held as no known source had been established. Culture data remained negative and patient had been afebrile x48h prior to discharge. 2. Hypotension- hypotensive event likely [1-17] lg volume fluid shift following therapeutic paracentesis. Although only 3L removed (less than that usually recommended for albumin replacement), patient has underlying renal disease and thus could not appropriately buffer redistribution. Hyperkalemia was likely [1-17] to add'l renal hypoperfusion and rapidly resolved in ICU w/ administration of fluid. Rapidity of resolution not c/w hepatorenal syndrome. Following fluid administration patient did well w/o further episodes of hypotension. 3. Hep B cirrhosis: Awaiting transplant for liver and kidney. Coagulopathy related to cirrhosis. Lactulose was continued for mgmt of previously diagnosed encephalopathy, vit K x 3 days for coagulopathy. Patient remained w/ good mental status following hypotensive event. 4. Acute on CRF: Improving renal function. Pt started on midodrine, octreotide, albumin in ICU. Discontinued prior to d/c as renal function had rapidly improved. 5. Anemia: Transfused 2 unit PRBCs. No evidence of ongoing bleeding. 6. HIV: On HAART, restarted following transfer out of ICU. Continued on bactrim for ppx. 8. FEN: TF's, 9. PPx: pnuemboots, PPI 10. Code: Full while in house. HCP [Name (NI) 12395] [Name (NI) 12396]. Medications on Admission: Bactrim single-strength Mondays,Wednesdays, and Fridays; atenolol 25 q. day; lactulose 2 tablespoons twice a day lamivudine 150 mg every day; tenofovir 300 mg every-other-day; Lexiva 700 mg b.i.d. Neurontin 600 mg b.i.d. Aldactone 25 q. day; Mg ox 400 b.i.d. Reglan 10 t.i.d.; Procrit 20,000 units qwed; Mycelex 1 tablet five times per day Rescriptor 400 mg t.i.d. furosemide 20 mg q. day; MVI Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO QMON,WED,FRI (). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QOD, START SAT [2-25] (). 5. Fosamprenavir Calcium 700 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane 5X PER DAY (). 9. Delavirdine Mesylate 100 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 12. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [Hospital1 ] () as needed for hiv. 13. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Thirty (30) ML PO TID (3 times a day). Disp:2700 ML(s) Refills:2 14. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:20 Tablet(s) Refills:0 15. Procrit 20,000 unit/mL Solution Sig: One (1) ML Injection qWED (). 16. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day: Do not take with Delaviradine. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: 1) post-pyloric tube placement 2) transient hypotension post paracentesis 2) ESLD 3) HIV 4) HBV Discharge Condition: Good, afebrile, VSS, tolerating p.o. Discharge Instructions: 1) Please continue to take your medications as you were previously 2) Please attend your follow up appointments. 3) Return to medical care if you develop fever, nausea, vomiting, or abdominal pain. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: LM [Hospital Unit Name 5628] Phone:[Telephone/Fax (1) 673] Date/Time:[2142-3-7] 1:20 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] ICD9 Codes: 5715, 2762, 0389, 2875, 5849, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6496 }	Medical Text: Admission Date: [2127-11-25] Discharge Date: [2127-12-1] Date of Birth: [2127-11-25] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname ] [Known lastname 59670] is a term male infant with a birth weight of 4410 gm who was admitted to the Newborn Intensive Care Unit from the Newborn Nursery on day of life three for management of hyperbilirubinemia secondary to isoimmunization. Mother is a 32-year-old gravida three, para two, now three woman with an estimated date of delivery of [2127-12-7]. Prenatal screens included blood type B positive, anti C antibody positive, rubella immune, RPR nonreactive, hepatitis B surface antigen negative and group B strep unknown. This pregnancy was complicated by macrosomia. [Known lastname ] was delivered by repeat cesarean section. Apgar scores were nine and nine at one and five minutes, respectively. [Known lastname ] was initially admitted to the Newborn Nursery. His total bilirubin on day of birth was 3.4. On day of life three, his bilirubin increased to 14.9 prompting his admission to the Newborn Intensive Care Unit. He otherwise was healthy appearing and feeding well. PHYSICAL EXAMINATION: On admission, weight 4410 gm, head circumference 38.5 cm, length 21 cm. Very active and vigorous infant. Skin pink with mild jaundice noted in the diaper area. Anterior fontanel open and flat. Sclera icteric and palate intact. Red reflux present bilaterally. Mild tongue tied present. Neck supple. Lungs clear bilaterally. Regular rate and rhythm. No murmur. Femoral pulses two plus bilaterally. Abdomen soft with active bowel sounds. No masses or distention. Extremities warm and pink with brisk capillary refill. Genitourinary: Normal uncircumcised male, testes bilaterally descended, anus patent, hips stable, clavicles intact. Neurological: Normal tone and normal suck. HOSPITAL COURSE: Respiratory: Remained stable on room air during admission. Cardiovascular: Has remained hemodynamically stable during admission. Fluids, electrolytes and nutrition: Monitored for hypoglycemia secondary to large for gestational age. All glucose screens were within normal limits. [Known lastname ] has been breastfeeding ad lib demand well, voiding and stooling appropriately. Birth weight was 4410 gm. Discharge weight was 4335 gm. Gastrointestinal: The mother's blood type is B positive, anti C antibody positive. The baby is O positive, DAT positive. Initial bilirubin on day of birth was 3.4. On day of life two, the bilirubin increased to 12.2 and phototherapy was started. The bilirubin continued to rise under phototherapy on day of life two to 14.9. On day of life three, [2127-11-28], he was admitted to the Intensive Care Unit Nursery for management. On admission, his total bilirubin level was 14.6. The direct was 0.3. Due to isoimmunization with anti C antibody, he was given a dose of IVIG. He remained under phototherapy until day of life six ([2127-12-1]). His bilirubin on day of life six was 11.7 and phototherapy was discontinued and he was transferred to the newborn nursery. A bilirubin will be checked about 12 hours after phototherapy was discontinued which was 13.3/0.3 and then again 12 hours later on the morning of [2127-12-2] it had risen to 14.9/0.3. He was restarted on phototherapy. Hematology: The infant is O positive. Hematocrit on admission 37 percent with a reticulocyte count of 3.1 percent. Hematocrit on [2127-12-1] was 39 percent with a reticulocyte count of 2.9 percent. Infectious Disease: There have been no infectious disease issues during this hospitalization. Neurology: His examination is age appropriate. Sensory: He needs a hearing screen prior to discharge. CONDITION ON DISCHARGE: A stable six-day-old term infant. DISPOSITION: Transfer to Newborn Nursery. PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) 1169] [Last Name (NamePattern1) ], M.D. at Pediatrics West, telephone number [Telephone/Fax (1) 54661], fax number [Telephone/Fax (1) 59671]. CARE AND RECOMMENDATIONS: A) Ad lib demand breastfeeding. B) No medications. C) Car seat position screen not indicated. D) State screen was sent on [2127-11-27] and is pending. E) Hepatitis B immunization was given on [2127-11-28]. F) Follow-up appointments. The mother is scheduling a follow- up appointment with pediatrician on Wednesday, [2127-12-3], if he is discharged home on [2127-12-2]. DISCHARGE DIAGNOSES: 1. Term, large for gestational age, male infant. 2. Isoimmunization secondary to anti C antibody. 3. Hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2127-12-1] 15:57:45 T: [2127-12-1] 16:22:19 Job#: [Job Number 59672] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6497 }	Medical Text: Admission Date: [2142-2-14] Discharge Date: [2142-2-17] Date of Birth: [2117-8-7] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[First Name3 (LF) 5119] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [Date range (1) 13924] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [2134] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([2139]) and ESRD ([2135]) 2. CKD/ESRD: - Diagosed [2135] - Initiated dialysis [2137] but refused it as of [2140], has survived despite this - PD catheter placement [5-18] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [2140] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([2139]); related to a catheter - Negative lupus anticoagulant ([4-/2138], [8-/2138], [9-/2140]) - Negative anticardiolipin antibodies IgG and IgM x4 ([2137]-[2140]) - Negative Beta-2 glycoprotein antibody ([4-/2138], [8-/2140]) 6. HOCM: Last noted on echo [8-17] 7. Anemia 8. History of left eye enucleation [2139-4-20] for fungal infection 9. History of vaginal bleeding [2139] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [6-16] and [5-17] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [5-20], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [2140-4-10]. 4. PD catheter placement in [2141-5-11]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [2141-10-27] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [Last Name (un) ] in place Neuro: following commands, answers appropriately, [5-15] motor strength, sensation is intact. Pertinent Results: [2142-2-14] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [2142-2-14] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [2142-2-14] 07:40AM PLT COUNT-101* [2142-2-14] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [2142-2-14] 07:40AM CK-MB-6 [2142-2-14] 07:40AM cTropnT-0.09* [2142-2-14] 07:40AM LIPASE-80* [2142-2-14] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [2142-2-14] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [2142-2-14] 07:44AM LACTATE-1.3 [2142-2-14] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [2142-2-14] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [Hospital1 ] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [Hospital1 ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [Last Name (STitle) ] in [Month (only) 958] as scheduled. [First Name7 (NamePattern1) 1569] [Initial (NamePattern1) ] [Name8 (MD) ] MD [MD Number(2) 5122] Completed by:[2142-2-21] ICD9 Codes: 5856, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6498 }	Medical Text: Admission Date: [2168-10-15] Discharge Date: [2168-10-28] Service: CARDIAC SURGERY HISTORY OF THE PRESENT ILLNESS: This is an 81-year-old gentleman with known coronary artery disease, status post myocardial infarction in [2155], treated with Streptokinase, status post myocardial infarction in [2165], treated with a stent to the LAD in [2166]. The patient also has known aortic stenosis followed by serial echocardiograms with an ejection fraction in [2166-11-20] of 35% with an aortic valve area of 1 cm squared. The patient presented to an outside hospital complaining of ten days of what he describes as his anginal equivalent which is right arm squeezing not relieved by nitroglycerin. At the outside hospital, his workup was initially negative, discharged home and subsequently represented with the same symptoms and at that time did have a small troponin leak. He was transferred to [Hospital6 1129] on [2168-10-8] for further evaluation and transthoracic echocardiogram at that time showed an aortic valve area of 0.7 cm squared. Cardiac catheterization showed a patent proximal LAD at the site of the prior stent, a 90% first diagonal lesion and 70% focal third diagonal lesion, 70% proximal obstruction of the first obtuse marginal and minimal irregularities in the right coronary artery. The patient and his family elected to be transferred to [Hospital6 1760] for operative treatment of his coronary artery disease and his aortic stenosis. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus, noninsulin-dependent. 3. Hypercholesterolemia. 4. Gout. 5. Peripheral vascular disease. 6. Known right iliac artery aneurysm. 7. History of complete heart block, status post permanent pacer insertion. 8. Elevated PSA. 9. Status post AAA repair in [2157]. 10. Status post cholecystectomy. 11. Status post right inguinal hernia repair. 12. History of left elbow bursitis. 13. Status post right fem-[Doctor Last Name ]. SOCIAL HISTORY: The patient has a history of remote tobacco abuse. He lives with his sister in [Name (NI) 745]. He admits to a minimal amount of ETOH use. ALLERGIES: Streptokinase. ADMISSION MEDICATIONS: 1. Lopressor 50 mg p.o. t.i.d. 2. Vasotec 10 mg q.a.m., 5 mg q.p.m. 3. Norvasc 2.5 mg p.o. q.d. 4. Pravachol 40 mg p.o. q.d. 5. Digoxin 0.25 mg p.o. q.d. 6. Lasix 40 mg p.o. q.o.d. 7. Enteric coated aspirin 325 mg p.o. q.d. 8. Plavix 75 mg p.o. q.d. 9. Vitamin E. 10. Nitroglycerin p.r.n. 11. Glucophage 500 mg p.o. q.p.m. 12. Probenecid 125 mg p.o. b.i.d. HOSPITAL COURSE: The patient was admitted to the [Hospital6 1760] and underwent preoperative evaluation for cardiac surgery. He had electrophysiology consult to evaluate his pacemaker which was functioning properly. He underwent a dental evaluation which showed that he had no problems that would put him at risk for cardiac surgery or aortic valve replacement. The patient had an ultrasound of his carotid arteries which showed no significant stenosis. On[10-17], the patient was taken to the Operating Room with Dr. [Last Name (Prefixes) ]. The patient underwent an aortic valve replacement with a 23 mm [Last Name (un) 3843]-[Doctor Last Name ] pericardial valve as well as a CABG times one with SVG to OM. In the Operating Room, a transesophageal echocardiogram showed that the patient's ejection fraction was 20-25%. The patient was transferred to the Intensive Care Unit on low-dose epinephrine infusion and propofol. Total cardiopulmonary bypass time was 132 minutes, cross-clamp time 100 minutes. The patient was weaned and extubated from mechanical ventilation on his first postoperative evening. The patient's hemodynamics as well as his cardiac index remained good. The epinephrine was weaned to off on postoperative day number one with continued good hemodynamics. The patient was started on Captopril for afterload reduction. On postoperative day number one, the Electrophysiology Service interrogated the patient's internal pacemaker which showed that it continued to function appropriately after bypass surgery. On postoperative day number two, the patient was noted to have mild thrombocytopenia. Heparin dependent antibodies were sent to the laboratory which were subsequently negative. On postoperative day number two, the patient was transferred from the Intensive Care Unit to the regular part of the hospital. The patient began ambulating with physical therapy. The patient had complaints of right scapular and back pain which the patient had previously and this pain responded well to Percocet. The patient was started on Lasix for diuresis. On postoperative day number three, the patient was noted to have an elevated white blood cell count. All of his incisions looked fine without erythema or drainage. Blood, urine, and sputum cultures were sent. The patient was also noted to have a rising creatinine. The patient's baseline creatinine was thought to be 1.1 to 1.5. The patient's creatinine on postoperative day number three rose to 1.6. The patient's Captopril was discontinued as this was thought to be the likely source. Repeat laboratory studies later on postoperative day number three showed that the patient had a rising potassium up to 5.6. The patient was given one dose of Kayexalate and subsequently the patient's potassium returned to [Location 213]. Also, the laboratory studies on postoperative day number three, the patient's white blood cell count which had been 16 had risen to 19 with a left shift. The patient's urinalysis showed positive blood, positive protein, small leukocyte esterase, [12-8] red blood cells, and many bacteria. The patient was started on levofloxacin for a presumed urinary tract infection. On postoperative day number four, the patient's repeat liver function tests which on postoperative day number three had been only mildly elevated, had risen significantly with AST that had risen to 1,260 from 264, ALT 2,002 from 279. A GI consult was obtained and the patient's medications that were thought to be the most likely culprits were discontinued. The patient had his Probenecid, Pravastatin, his levofloxacin discontinued and because of the patient's multiple ongoing issues it was elected to transfer the patient back into the Intensive Care Unit for closer monitoring. As the day progressed on postoperative day number four, the patient began complaining of increasing nausea and right upper quadrant pain. A right upper quadrant ultrasound performed at the bedside showed normal flow within the portal and hepatic veins. The common bile duct was within normal limits without evidence of choledocholithiasis. The gallbladder was found to be absent. The Hepatology Service felt that the most likely cause of the transaminitis was medication. The patient had liver function tests followed daily after that and they continued to trend down thereafter. The patient's INR which had risen to 1.5 to 1.6 proceeded to decrease to 1.3. The patient also had a transthoracic echocardiogram performed which showed an ejection fraction of 15-20%, normal left ventricular wall thickness, mildly dilated left ventricular cavity, normal right ventricular wall thickness, normal right ventricular chamber size, 1+ mitral regurgitation, 2+ tricuspid regurgitation, a normally functioning aortic bioprosthetic. Overall, it was felt to be not significantly changed from preoperatively. The patient's urinary tract infection which had initially been treated with levofloxacin was subsequently treated with IV ceftriaxone as levofloxacin was potentially one of the medications that was contributing to the elevated transaminases. The patient's creatinine began to decrease and the patient's white blood cell count began to decrease as well on the antibiotics. By postoperative day number eight, the patient had stabilized. The acute transaminitis was resolving and the patient was transferred back from the Intensive Care Unit to the regular part of the hospital. On postoperative day number nine, the patient worked with physical therapy and was able to complete a level V which included walking 500 feet and climbing one flight of stairs without difficulty without requiring oxygen and remaining hemodynamically stable. The Hepatology Service on postoperative day number nine still did not have a clear etiology of the elevated liver function tests; however, they recommended that the patient follow-up with his primary care physician as an outpatient for monitoring of his liver function tests as well as checking [First Name8 (NamePattern2) ] [Doctor First Name ], AFP, a ferritin, a TIBC, and AMA. Over this period of time, the patient continued to complain of symptoms of reflux. The patient has a history of reflux disease and with his elevated liver function tests, his H2 blocker and proton pump inhibitor were discontinued. The patient was medicated with Maalox which had good effect. The patient was started on Carafate for stress ulcer prophylaxis. On postoperative day number ten, the patient's pacer wires were removed without difficulty. On postoperative day number 11, the patient was noted to have edematous bilateral lower extremities with his right leg greater than his left. His right leg was the site of his saphenous vein harvest; however, the patient complained of significant calf tenderness and cramping when he was walking. It was decided to perform a right lower extremity ultrasound to rule out DVT. This was negative for any clot and the patient was noted to have small bilateral pleural effusions on chest x-ray. The patient was given a dose of IV Lasix with prompt response for large amounts of urine output and decrease in the edema in his lower extremities. By[Last Name (STitle) 14810]perative day number 11, the patient was cleared for discharge to home; however, on his laboratory examination on postoperative day number 11, the patient was noted to have a slightly more elevated white blood cell count of 16.9. The patient's white blood cell count had been remaining in the mid teens range. This was elevated from the prior day at 13.8. This was discussed with Dr. [Last Name (Prefixes) ] and Dr. [Last Name (Prefixes) 411] examined the patient. The patient had been afebrile, felt well, and had wanted to go home. It was decided that the patient would be pan cultured and would be discharged to home with strict instructions to return to the hospital if he had any evidence of fever or felt unwell and the cultures would be followed for any evidence of infection. The patient's urinalysis showed occasional bacteria, no white blood cells, no leukocyte esterase, essentially negative for a urinary tract infection. The patient's blood cultures are pending at this point. The patient's chest x-ray showed continued small bilateral pleural effusions. Therefore, the patient is cleared for discharge to home. CONDITION ON DISCHARGE: T maximum 97.8, pulse 73, asensed V paced, blood pressure 134/80, respiratory rate 18, room air oxygen saturation 94%. White blood cell count 15.9, hematocrit 32.5, platelet count 253,000. Potassium 4.5, BUN 30, creatinine 1.1. AST 37, ALT 243, alkaline phosphatase 72, LDH 30, amylase 122, lipase 17. The patient was awake, alert, and oriented times three, neurologically nonfocal, ambulating without difficulty. The heart revealed a regular rate and rhythm without rub or murmur. The lungs revealed that breath sounds were clear bilaterally, decreased at the posterior bases. No wheezes, rhonchi, or rales noted. The patient does not have a productive cough. The abdomen revealed normoactive bowel sounds, soft, nontender to light or deep palpation, nondistended. The patient was tolerating a regular diet and having regular bowel movements. Sternal incision revealed that the Steri-Strips were intact. The incision was clean and dry. There was no erythema or drainage. The sternum was stable. The patient has bilateral trace to 1+ pitting edema of the right lower extremity vein harvest site. Steri-Strips were intact. The incision was clean and dry without erythema or drainage. DISPOSITION: The patient is to be discharged to home in stable condition. DISCHARGE DIAGNOSIS: 1. Coronary artery disease and aortic stenosis. 2. Status post aortic valve replacement and coronary artery bypass graft. 3. History of complete heart block with permanent pacer insertion. 4. Postoperative transaminitis, now resolving. 5. Postoperative urinary tract infection. 6. Persistent postoperative leukocytosis. 7. Chronic renal insufficiency. DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 325 mg p.o. q.d. 2. Digoxin 0.125 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. 4. Norvasc 2.5 mg p.o. q.d. 5. Oxycodone 5 mg p.o. q. four to six hours p.r.n. 6. Lopressor 100 mg p.o. b.i.d. 7. Lasix 20 mg p.o. b.i.d. times ten days. 8. Potassium chloride 10 mEq p.o. b.i.d. times ten days. 9. Carafate 1 gram p.o. q.i.d. 10. Colace 100 mg p.o. b.i.d. 11. Calcium carbonate 500 mg p.o. q.d. 12. Glucophage 500 mg p.o. q.d. The patient is to be discharged home in stable condition. FO[Last Name (STitle) ]P: The patient is to follow-up with his primary care physician, [Last Name (NamePattern4) ]. .................... in one week for repeat laboratory evaluation of his postoperative transaminitis. The patient is to follow-up with his cardiologist, Dr. [Last Name (STitle) 50500], in one to two weeks. The patient is to follow-up with Dr. [Last Name (Prefixes) ] in two weeks. The patient is to return to the floor in one week for a wound check. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 1541] MEDQUIST36 D: [2168-10-28] 05:14 T: [2168-10-28] 20:42 JOB#: [Job Number 50501] ICD9 Codes: 4241, 4254, 5990, 2875, 4111, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6499 }	Medical Text: Admission Date: [2175-11-20] Discharge Date: [2175-11-23] Date of Birth: [2102-4-4] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5018] Chief Complaint: Left sided weakness and left facial droop Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 73 year-old right-handed man with PMH significant for BPH who presents with acute onset left sided weakness. He was last known well around midnight, when he went to the bathroom and checked the thermostat. He then went to sleep. His wife heard him screaming on the floor of the bedroom around 3:30 AM. He tried getting out of bed, but fell; the left side of his face was noted to be drooping at that time and he was unable to move the left side of his body. He vomited at home. He was taken to [Hospital3 26615] Hospital, where it was noted he arrived shortly after 5 AM. He vomited at OSH and received Zofran. CT scan performed there reportedly showed hyperdense R MCA and he was transferred to [Hospital1 18] for further management. CODE STROKE called 7:49 AM. Of note, his wife says that he was doing well yesterday. Norecent infectious symptoms or evidence of any illness. He didreportedly drink several beers and a few shots yesterday. He has no history of vascular risk factors. He does not smoke. He does; however, have a strong family history of stroke; his father deceased from a stroke (believed to be in his 70s) and his paternal aunt had a stroke as well. Neuro ROS: He says he cannot feel his left arm and cannot move the left side of his body. No headaches, vertigo, lightheadedness, blurry or double vision. No dysphagia. No difficulty with speech production or comprehension. General ROS: Positive for nausea and vomiting earlier, nausea improved. No recent infectious symptoms, fevers or chills. No chest pain or tightness, palpitations, shortness of breath, cough or abdominal pain. Past Medical History: -BPH Social History: He lives with his wife. [Name (NI) ] does not smoke or use illicit drugs. He says he drinks 2 beers per day; his wife says he drinks occssionally but yesterday had mutliple shots and beers. Family History: Father deceased from stroke. Paternal aunt also had a stroke. Physical Exam: Initial Physical Exam: Vitals: T: 95.9 P: 79 R: 18 BP: 178/91 SaO2: 94% NIH Stroke Scale score was: 19 1a. Level of Consciousness: 1 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 1 3. Visual fields: 2 4. Facial palsy: 3 5a. Motor arm, left: 4 5b. Motor arm, right: 0 6a. Motor leg, left: 4 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 1 9. Language: 0 10. Dysarthria: 1 11. Extinction and Neglect: 2 General: drowsy but easily arousable HEENT: NC/AT, no conjuctival injection, dry mucus membranes, no lesions noted in oropharynx Neck: Supple Pulmonary: lcta b/l Cardiac: RRR, S1S2, II/VI systolic murmur Abdomen: soft, NT/ND, +BS Extremities: warm, well perfused Neurologic: Mental Status: drowsy but easily arousable, oriented to person, month and year. Able to follow simple commands. No right-left confusion. Left visual and sensory hemineglect- he could not identify his own hand; however he is aware that he has no feeling in his left arm. Language: speech is dysarthric. Intact naming, repetition and comprehension. Cranial Nerves: PERRL 2 to 1 mm and brisk. Left hemianopia. Right gaze preference in primary gaze, but able to look all the way to the left; EOMs full. Left upper and lower facial weakness. Motor: Normal bulk. Normal tone on right, left side flaccid. Strength full on right side. Left hemiplegia. Sensory: Absent light touch LUE. There was light touch sensation present in LLE, but this extinguished. Coordination: No intention tremor or dysmetria on F-N-F on left Gait: deferred given left lower extremity plegia. = = = ================================================================ Discharge Physical Exam: Essentially unchanged except for improvement in his left-sided neglect with ability to count people on his right and left side. Able to identify his own hand. His SBPs ranged 140s-160s. Pertinent Results: Admission Labs: [2175-11-20] 08:00AM GLUCOSE-146* NA+-140 K+-3.9 CL--104 TCO2-24 [2175-11-20] 07:57AM CREAT-1.0 [2175-11-20] 07:45AM UREA N-17 [2175-11-20] 07:45AM WBC-11.8* RBC-4.53* HGB-13.8* HCT-39.7* MCV-88 MCH-30.5 MCHC-34.8 RDW-12.8 [2175-11-20] 07:45AM NEUTS-87.9* LYMPHS-8.6* MONOS-3.1 EOS-0.3 BASOS-0 Other Pertinent Labs: [2175-11-20] 03:19PM cTropnT-<0.01 [2175-11-20] 07:45AM cTropnT-<0.01 [2175-11-20] 08:57AM %HbA1c-6.1* eAG-128* [2175-11-20] 07:45AM ALT(SGPT)-15 AST(SGOT)-21 ALK PHOS-51 TOT BILI-0.2 [2175-11-20] 07:45AM ALBUMIN-4.1 [2175-11-20] 07:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2175-11-20] 07:45AM PLT COUNT-364 [2175-11-20] 07:45AM PT-12.6 PTT-21.8* INR(PT)-1.1 [2175-11-20] 07:45AM FIBRINOGE-357 Pertinent Radiographic Studies: [2175-11-20] CT BRAIN PERFUSION/CTA NECK & HEAD FINDINGS: HEAD CT: There is a large hypodense area in the right MCA territory with loss of [Doctor Last Name 352]-white differentiation. The right M1 segment of the MCA is hyperdense and there are multiple hyperdense branches in the sylvian fissure. These findings are consistent with a large right MCA infarction with occlusion of the M1 and Sylvian branches. There is no evidence of hemorrhage, or mass. There is no shift of midline structures. The ventricles and sulci are prominent, consistent with age-related atrophy. No suspicious osseous lesions are identified. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. CT PERFUSION: There is a large area of increased transit time in the right MCA distribution, extending into the anterior cerebral and posterior cerebral distributions. There is decreased cerebral blood volume in the right MCA territory. Thus, there is a matched deficit in the MCA distribution, with penumbra in the adjacent right ACA and MCA distributions. HEAD AND NECK CTA: The right internal carotid artery is occluded from its bifurcation to the petrous portion of the internal carotid artery, where flow is reconstituted. The left internal carotid artery is patent throughout its course. The right vertebral artery is patent, and the left vertebral artery may be stenosed at its origin from the left subclavian artery. This finding may also be due to artifact. 3D reconstructions demonstrate occlusion of the right MCA in the distal M1 region. There is no evidence of aneurysm formation. There are atherosclerotic changes in the bilateral cavernous portions of the internal carotid arteries. There is a 14mm nodule in the left lobe of the thyroid (4:71), and a calcification in the right lobe. There is no cervical lymphadenopathy. There are multilevel degenerative changes of the cervical spine. IMPRESSION: 1. Large infarct involving most of the right MCA territory. There is evidence of poor flow in the right ACA and PCA territories. 2. Occlusion of the right internal carotid artery from the carotid bifurcation to proximal to the petrous portion. 3. No evidence of intracranial hemorrhage. 4. 14mm thyroid nodule. This finding can be better assessed on ultrasound. Brief Hospital Course: 73 year-old right-handed man with PMH significant for BPH who presents with acute onset left sided facial droop and left hemiplegia, NIHSS 19. Initial exam was notable for left neglect (visual and sensory), right gaze preference (but full EOMs), left facial weakness, left hemiplegia, and left sensory defecits greater in upper than lower extremity. On CT, there was a large hypodensity noted in the right MCA territory. CTA showed complete occlusion of the right internal carotid artery at the bifurcation with reconstitution distally as well as an occluded right middle cerebral artery. He did not receive tPA upon arrival as he was outside of the therapeutic time window. He was started on ASA 325mg and atorvastatin 80mg and admitted to the neuro ICU. His symptoms improved, with decreased neglect and slight finger flexion on left arm and [3-11] proximal and 4+/5 distal strength in the lower extremities. Given the stability of his neurologic deficits he was transferred to floor on [11-21]. On the floor, he continued to have headaches and c/o nausea requiring IV ondansetron. He was tolerating ground solid food, but severe nausea and depression precluded appropriate oral nutritional intake. His nausea was aggressively managed and he was encouraged to eat. Given the severity of his deficits, it was determined that he would benefit from rehabilitation. We assessed his treatable stroke risk factors: LDL 127, HbA1C 6.1%. He was continued on atorvastatin 80mg daily. He will require continued monitoring and treatment of his lipids and sugars in order to decrease future stroke risk. ========================================================== . Transitional issues: . 1. Stroke: he will be transfered to rehab for an undetermined amount of time. He follow up with neurology, Dr. [Last Name (STitle) ] in [4-12] weeks to further assess improvement and recovery. 2. Thyroid nodule: incidental finding that should be followed by his PCP. 3. HTN: his BP was first allowed to autoregulate over the first 48hrs, it was then kept between 140-160 systolic with lisinopril 5mg daily. His systolic BP goal should be 140-160 for one week (until [2175-11-27]), then decreased to <140 systolic likely with the aid of further BP medications. 4. BPH: he did not remember the medication he was taking for BPH, he might require initiation of BPH medication if he begins having symptoms of urinary retention. Medications on Admission: -med for BPH (he does not recall name) -Vitamin C Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Right MCA embolism with infarction Right ICA occlusion 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: Mr. [Known lastname ], It was a pleasure taking care of you during your hospital stay. You had a stroke which affected the right side of your brain. We have arranged for you to get rehabilitation during your convalescence. In order to decrease your future risk of stroke, we have started you on a daily aspirin and cholesterol-lowering drug. On imaging, you were found to have a 14mm nodule in your thyroid. You should have this followed by your primary care physician. Please note the following medications changes: START: - aspirin 325mg daily - atorvastatin 80mg daily Followup Instructions: You have an appointment with neurologist Dr. [Last Name (STitle) ] in the [Hospital 18] [Hospital 878] clinic on [1-2] at 4:00pm. The clinic is located on the [Hospital1 18] [Hospital Ward Name 516], [Hospital Ward Name 23] Bldg, [Location (un) ]. Phone:[Telephone/Fax (1) 657]. Also, please call [Telephone/Fax (1) 5685] to schedule an appointment with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. His office is located at the following address: BEACON FAMILY MEDICINE [Street Address(2) 76340], [Location (un) ],[Numeric Identifier 76341] [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] ICD9 Codes: 4019

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