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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6500
} | Medical Text: Admission Date: [**2112-8-9**] Discharge Date: [**2112-8-13**]
Date of Birth: [**2041-12-28**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: This is a 70 year old female
who was admitted on [**2112-8-9**], with history of arterial
venous dural fistula, which had been embolized in [**2112-6-17**]. She presented on [**2112-8-9**], for elective suboccipital
craniotomy with bilateral dural arteriovenous fistula
cranioplasty. The patient received two units of packed red
blood cells intraoperatively, but the Operating Room case was
otherwise uncomplicated.
Postoperatively, the patient was awake and alert; vital signs
were stable. The patient had full motor strength in both
upper and lower extremities. The patient was tolerating a
regular diet well. The incision was clean and dry, and the
patient was out of bed and ambulating postoperative day one.
The patient's sodium ppostoperatively was 136 and climbed to
144 postoperative day two. The patient also started putting
out large amounts of urine and an Endocrine consultation was
called to rule out diabetes insipidus.
The patient was ruled out for diabetes insipidus and
increased urine output and hypernatremia was considered to be
secondary to fluid overload in the setting of surgery.
The patient remained afebrile, neurologically unchanged
postoperatively. The patient was out of bed with Physical
Therapy, who recommended two to three times a week of
mobility and gait training.
The patient was discharged to rehabilitation on [**2112-8-10**] on
the following medications.
DISCHARGE MEDICATIONS:
1. Hydralazine 10 mg p.o. q. six hours.
2. Sliding scale insulin.
3. Hydromorphone 2 to 6 mg p.o. q. two hours p.r.n.
4. Famotidine 20 mg p.o. twice a day.
5. Decadron taper.
6. Docusate sodium 100 mg p.o. twice a day.
7. Acetaminophen 325 to 650 mg p.o. q. four to six hours
p.r.n.
DISCHARGE INSTRUCTIONS:
1. The patient was discharged with instructions to follow-up
with Dr. [**Last Name (STitle) 1132**] in one month in the office for a repeat
angiogram.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 27454**]
MEDQUIST36
D: [**2112-8-12**] 22:11
T: [**2112-8-12**] 23:50
JOB#: [**Job Number 51936**]
ICD9 Codes: 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6501
} | Medical Text: Admission Date: [**2134-6-12**] [**Month/Day/Year **] Date: [**2134-6-18**]
Date of Birth: [**2051-7-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2134-6-12**] Placement of pigtail chest catheter
History of Present Illness:
82 yo male s/p fall at home in garage on, no LOC able to recall
whole event. He reports that he tripped and thinks he fell and
hit his back, he did not hit his head. He went to see his PCP
on following day and he was taking tylenol for the pain. He
then presented to [**Hospital1 **] [**Location (un) 620**] two days following the fall because
he had difficulty sleeping and complaints of left flank/back
pain. He was evaluated there, found to have a negative head CT,
left rib [**9-30**]
fractures and hemothorax with INR 3.2 and was then transferred
to
[**Hospital1 18**] for further care.
Past Medical History:
Atrial fibrillation, s/p pacemaker placement, on coumadin
Hypertension
Prostate cancer status post XRT
Benign prostatic hypertrophy
Osteoarthritis
h/o rectal bleeding in [**2128**]
Mild dementia
Depression
Hypothyroidism
Retinitis pigmentosa.
Social History:
Lives with wife, is a retired computer salesman, denies tobacco,
alcohol, or IVDU. normal colonoscopy <10 y ago.
Family History:
Non-contributory.
Physical Exam:
Upon admission:
Temp (F): 95.9
Heart Rate: 71
Blood Pressure: 142/71
Resp Rate: 15
O2 Sat(%): 99%
Room Air/O2: 3L NC
Pertinent Results:
[**2134-6-12**] 10:39PM PT-18.0* INR(PT)-1.6*
[**2134-6-12**] 08:09PM HCT-29.1*
[**2134-6-12**] 08:09PM PT-20.9* PTT-31.8 INR(PT)-2.0*
[**2134-6-12**] 12:15PM GLUCOSE-95 UREA N-24* CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-29 ANION GAP-9
[**2134-6-12**] 12:15PM WBC-6.7 RBC-3.60* HGB-11.8* HCT-34.6* MCV-96
MCH-32.8* MCHC-34.2 RDW-14.2
[**2134-6-12**] 12:15PM NEUTS-69.2 LYMPHS-25.0 MONOS-4.0 EOS-1.6
BASOS-0.2
[**2134-6-12**] 12:15PM PLT COUNT-130*
Reason: reassess
Field of view: 36
Final Report (Revised)
CT CHEST [**2134-6-12**]
FINDINGS:
There is a pacemaker with leads in the right atrium and the
right ventricle.
The heart is enlarged. There is no pericardial effusion.
The aorta and pulmonary arteries are normal in caliber.
There are multiple small mediastinal lymph nodes that measure
less than 1 cm
in short axis and do not meet CT criteria for malignancy. The
tracheobronchial tree is patent.
There is a small left pleural effusion the measures up to 40 [**Doctor Last Name **]
in density and
is compatible with hemothorax. There is subsegmental atelectasis
in the left
lower lobe. Otherwise, the lungs are clear. The right pleural
effusion that
was seen in [**2130**] has resolved. There is no pneumothorax.
BONE WINDOWS:
The there is an acute nondisplaced fracture of the left 9th rib
at midaxillary
line. The rest of the fractures seen on an ouside CT are not
included on this
study. There are multilevel degenerative changes in the thoracic
spine. No
compression fracutres are identified.
Limited images through the abdomen demonstrate a 3 cm cyst in
the right
kidney.
IMPRESSION:
1. Small left hemothorax. No evidence of pneumothorax.
2. Non-displaced fracture of the left 9th rib.
CXR [**2134-6-17**]
FINDINGS: Portable upright chest radiograph is reviewed and
compared to
[**2134-6-17**] 8:23. Left pigtail catheter has been removed. There is
no
pneumothorax. There has been no significant interval change in
appearance of
the chest, with relatively low lung volumes, elevated
hemidiaphragms, and
slight apparent widening of the cardiac silhouette.
IMPRESSION: No pneumothorax status post pigtail catheter
removal.
Brief Hospital Course:
He was admitted to the Trauma service and transferred to the
Trauma SICU
for reversal of his INR, pain control and close monitoring.
Thoracic surgery was consulted for placement of chest pigtail
catheter because of the hemothorax. This remained in place for
several days and was eventually removed. Follow up chest film
showed no pneumothorax and persistent retrocardiac atelectasis
with small bilateral pleural effusions. He was encouraged to use
the incentive spirometer and to cough and deep breathe; he was
able to do this with lots of encouragement and reinforcement.
He was evaluated by Physical and Occupational therapy and they
have recommended rehab after acute hospital stay. The screening
process was initiated by case management and he was discharged
to a rehab facility on [**2134-6-18**].
Medications on Admission:
Detrol LA 4', Coumadin 4' (Wed 2), Amiodarone 200', Celexa 40',
Synthroid 88', Namenda 10", Toprol 37.5', Exelin 6"
[**Date Range **] Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Rivastigmine 3 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-25**]
hours as needed for pain.
11. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
[**Month/Day (3) **] Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
[**Location (un) **] Diagnosis:
s/p Fall
Rib fractures left [**9-30**]
Left hemothorax
[**Month/Year (2) **] Condition:
Good
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in Clinic in [**2-21**] weeks, call
[**Telephone/Fax (1) 600**] for an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
Completed by:[**2134-6-23**]
ICD9 Codes: 4019, 311, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6502
} | Medical Text: Admission Date: [**2186-8-7**] Discharge Date: [**2186-8-26**]
Date of Birth: [**2120-1-2**] Sex: M
Service: SURGERY
Allergies:
Pneumovax 23
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
c diff colitis
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
none
History of Present Illness:
HPI: The patient is a 66-year-old male who is known to have C.
difficile colitis and was admitted to the Gold surgery service
in
3/[**2186**]. He was referred to [**Hospital1 18**] for weakness, rigidity,
lethargy, decreased level of interaction, and anorexia. About a
week ago, he began having diarrhea. He has been on metronidazole
500mg po BID for several weeks.
In the ED, his initial vital signs were 97.3 129 146/93 18 99RA.
His heart rate stabilized to 80-90s after 2 liters of IVF. At
around 23:30, he became acutely hypotensive to SBP of 80s-90s,
maintaining his heart rate in the 90s. ICU bed was arranged for
close monitoring.
Past Medical History:
- Paroxysmal Atrial Fibrillation
- History of C diff colitis
- Bipolar Affective Disorder
- History of resolved hepatitis B
- History of rheumatic heart disease
- History of right MCA aneurysm clipped in [**2167**] at [**Hospital1 112**]
- History of pernicious anemia
- Gastroesophageal reflux disease
Social History:
He lives with his wife. Questionable history of alcohol abuse
(did abuse alcohol >20 years ago). He has not smoked for one
month but previously has a 40 pack year history. Previously on
2L O2 at home but not prior to this hospitalization.
Family History:
His father had lung cancer and his mother had congestive heart
failure.
Physical Exam:
PHYSICAL EXAM on admission:
97.3 129->90 146/93->80/50 18 99RA
Gen: thin male, NAD, no icterus, expressive aphasia, but A&0 x 3
HEENT: NC/AT, EOMI, PERRLA bilat., dry MM, without cervical LAD
on my exam
Cor: RRR without m/g/r, no JVD, no bruits
Lungs: CTA bilat.
[**Last Name (un) **]: +BS, soft, distended with tympany, NT, no masses, no
hernias
Ext: cold hands and feet, no edema, palpable pulses
PE: at discharge
Gen: grey, pale, mask faces, tremmer (pin wheel), expressive
aphasia, but AOx3
HEENT: PERRL, EMOI
COr: RRR
Lungs: CTA
Abd: +BS, still distended but improved, not "soft"
skin: calor and rubo s/p cellulitis from back spreading around
to front bilaterally, improved with antibiotics.
decubitus ulcer stage 3 maybe 4.
ext: cold, no edema
Pertinent Results:
[**2186-8-7**] 02:41PM WBC-14.6*# RBC-4.20*# HGB-13.6*# HCT-41.2#
MCV-98 MCH-32.4* MCHC-33.0 RDW-15.9*
[**2186-8-7**] 02:41PM NEUTS-66 BANDS-10* LYMPHS-14* MONOS-7 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-1*
[**2186-8-7**] 02:41PM LIPASE-21
[**2186-8-7**] 02:41PM ALT(SGPT)-9 AST(SGOT)-30 ALK PHOS-201* TOT
BILI-1.3
[**2186-8-7**] 02:41PM GLUCOSE-138* UREA N-22* CREAT-0.9 SODIUM-137
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-16
[**2186-8-7**] Abdominal CT:IMPRESSION: Wall thickening in the
descending and sigmoid colon, including
the rectum with mesenteric stranding consistent with colitis.
Interval
increase in large amount of free intra- abdominal and mesenteric
fluid.
[**2186-8-10**] Renal Ultrasound :
CONCLUSION: No evidence of renal abnormalities. Large volume of
ascites
noted.
[**2186-8-17**] Abdominal CT: IMPRESSION:
1. Increased size of bilateral simple pleural effusions with
increased
bibasilar dependent atelectatic changes.
2. Large volume abdominal pelvic ascites which appears grossly
stable.
3. Evaluation of bowel loops is limited by lack of IV and oral
contrast.
Given this limitation, there is no evidence for obstruction or
bowel
perforation.
4. Shrunken liver with nodular contour. Status post
cholecystectomy.
5. 4mm left pulmonary nodule. Per Fleichner society guidelines,
recommend
[**7-28**] month follow up chest CT if patient has risk factors for
pulmonary
malignancy.
[**2186-8-23**] Abdominal CT:
IMPRESSION:
1. Unchanged bilateral pleural effusions with associated
atelectasis.
2. Nodular, cirrhotic liver with no focal lesions on this
single-phase study.
There is again moderate ascites, with large gastric varices.
3. Normal appearance of intra-abdominal loops of small and large
bowel. No
evidence for colitis or enteritis.
4. Diffuse superficial soft tissue induration, consistent with
cellulitis.
There is no air in the soft tissues to suggest a more aggressive
process such
as necrotizing fasciitis, although this cannot be excluded by
imaging.
Brief Hospital Course:
Mr. [**Known lastname 2933**] was admitted to the intensive care unit and
underwent vigorous fluid resuscitation and maintained on IV
Flagyl and PO Vancomycin. He was seen by the infectious disease
service for further input in the treatment of his prolonged C
Diff colitis and they recommended continued treatment with
Flagyl and Vancomycin plus stopping any narcotics as he was at a
high risk of developing toxic megacolon.
His initial blood and urine cultures were negative and stool for
C Diff was positive.
His blood pressure improved with fluids and he did not require
any pressor support.
Vancomycin retention enemas were added for persistent diarrhea
and he underwent serial abdominal CT's to assess any colonic
changes. His abdominal exam over 3-4 days showed mild lower
abdominal tenderness and mild distention therefore continued
conservative non operative treatment with antibiotics was
planned.
Due to his prolonged period of poor nutrition/NPO,
hyperalimentation was started on [**2186-8-10**] and eventually he had a
PICC line placed in the left antecubital on [**2186-8-21**] for TPN and
antibiotics.
Of note, Mr. [**Known lastname 2948**] platelet count gradually decreased since
his admission from 130K to a low of 49K. His HIT was negative
and SRA is still pending. The hematology service was consulted
and felt that it was multifactorial including secondary to
cirrhosis, sepsis and anemia of chronic disease. Heparin was
not contraindicated and over the course of his hospitalization
his platelet count gradually increased to the 90K range.
Transfer to the [**Known lastname **] floor occured on [**2186-8-12**] and Lasix was
started to try to help with fluid mobilization. His PE showed
[**4-19**]+ peripheral edema as well as scrotal edema and some ascites.
He was treated with Lasix on a prn basis and his BUN/Cr
remained stable (22/0.5).
A superficial abdominal cellulitis was noted on [**2186-8-21**] beginning
on both flank areas and extending to the lower abdomen with no
connection to his sacral decubitus. He was started on broad
coverage antibiotics including Vancomycin and Zosyn without
improvement. He was subsequently changed to Daptomycin,
Ciprofloxicin and Flagyl with some improvement. Due to the
addition of broad spectrum antibiotics his oral Vancomycin was
increased to QID. He had no evidence of diarrhea and no change
in his abdominal exam. Recommendations from the infectious
disease service recommends cipro/flagyl/ dapto until [**8-31**] (10
days total).
Pt c diff colitis has responded well to PO vanco. Pt will
continue on 125 [**Hospital1 **] until [**8-31**] when [**Doctor Last Name 2949**] 125 TIDx7d, 125
BIDx7d, 125 qdx7d, 125 qodx7d, 125 q3dx14d.
The Neurology service was consulted during this admission for
evaluation of his bilateral hand tremors which seemed a bit
worse. Although Parkinson's disease could not be ruled out his
current situation precluded a definite assessment and they
recommended an out patient follow up with Dr.[**First Name (STitle) 951**]. His
Depakote continues at his home dose with a level of 53.
A speech and swallow evaluation was also done to assess the
ongoing question od possible aspiration. His baseline diet was
ground solids however over the last week he was tolerating
nectar thick liquids and pureed with no evidense of aspirating.
He remains on TPN while his diet is being slowly advanced.
Continue on nector thickness liquids and TPN until cleared to
advance, with one to one supervision.
Mr [**Name13 (STitle) 2950**] also impaired skin integrity on his R buttocks first
seen [**2186-8-22**]
[**Month/Day/Year 409**] Assessment by [**Month/Day/Year **] nurse [**2186-8-22**]: Sacral/coccygeal
unstageable pressure ulcer that is a DTI. Ulcer has evidence of
healing with necrotic area measuring 2 cm x 1 cm but affected
area measures 5 x 2 with ulcer on (R) buttock of 1 cm and more
linear ulcers on (L).Drainage is sero sang moderate amount. ALSO
there are superficial erosions on soft tissue of buttocks that
are caused by moisture and fungal rash.The area causes pain. ID
recommended Cipro/flagyl / Dapso treatment and standard [**Month/Day/Year **]
care.
Medications on Admission:
Zantac 150 mg po qd
Seroquel 25 mg po qhs
Heparin 5000u sc bid
Flagyl 500 mg po bid
Nystatin i po qid
Depakote 1000 mg po qhs
Albuterol neb inh q6h prn
MVI qd
digoxin 0.125mg po qd
flecainide 50mg po q12h
ASA 325mg po qd
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB/wheeze/cough.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB/wheeze/cough.
4. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for oral thrush.
10. Vancomycin 125 mg Capsule Sig: One (1) liquid PO QID (4
times a day) for 2 months: Pt should be on 125 QID until [**8-31**],
then taper to 125 qdx7d, 125 qodx7d, 125 q3dx14d.
Disp:*240 liquid* Refills:*0*
11. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q6H (every 6 hours).
12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours): Continue till [**8-31**].
13. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
Intravenous Q12H (every 12 hours): Continue till [**8-31**].
14. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): Continue until [**8-31**].
15. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR.
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
c diff colitis.
Please continue on antibiotics:
continute PO vanco 125 four times a day until [**8-31**] when [**Doctor Last Name 2949**]
125 three times a day x7days, 125 twice a day x7days, 125 per
day x7days, 125 every other day x7days, 125 every third day
x14days.
Cellulitis
ciprofloxacin / flagyl/ dapto until [**8-31**]
Nutrician, 1 to 1 feeding to prevent aspiration on nectar
thickened liquids. Please continue TPN until safe to advance
diet
Continue on nector thickness liquids and TPN until cleared to
advance
Discharge Condition:
improving
Discharge Instructions:
c diff colitis.
Please continue on antibiotics:
continute PO vanco 125 four times a day until [**8-31**] when [**Doctor Last Name 2949**]
125 three times a day x7days, 125 twice a day x7days, 125 per
day x7days, 125 every other day x7days, 125 every third day
x14days.
Cellulitis
ciprofloxacin / flagyl/ dapto until [**8-31**]
Nutrician, 1 to 1 feeding to prevent aspiration on nectar
thickened liquids. Please continue TPN until safe to advance
diet
Ulcer: Continue pressure relief measures per pressure
ulcer guidelines. Patient is on a 1st Step mattress
Continue with current [**Month/Year (2) **] care as per previous note.
Commercial [**Month/Year (2) **] cleanser cleanse all open wounds. Pat the
tissue dry. Apply moisture barrier antifungal ointment Apply a
piece of Aquacel AG to ulcer
Apply 1 pack of 4 x 4 gauze. Secure with 1 piece of pink hytape
across the center.
Do not cover the superficial areas on lower buttocks with gauze.
Treat with Miconazole powder and Criticaid clear anti fungal 3 x
a day.
Suspend heels off the bed with pillows under his calf.If these
do
not stay in place then order Waffle boots from distribution.
Notify MD [**First Name (Titles) **] [**Last Name (Titles) **] care nurse [**First Name (Titles) **] [**Last Name (Titles) **] or skin deteriorates.
You have had c diff colitis.
Please continue on antibiotics, cipro/flagyl/ dapto until [**8-31**]
continute PO vanco 125 [**Hospital1 **] until [**8-31**] when [**Doctor Last Name 2949**] 125 TIDx7d,
125 BIDx7d, 125 qdx7d, 125 qodx7d, 125 q3dx14d.
Continue on nector thickness liquids and TPN until cleared to
advance
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SPECIALTIES CC-3 (NHB)
Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2186-9-20**] 3:45
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2186-9-26**] 1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2187-2-7**] 2:40
ICD9 Codes: 0389, 5119, 5180, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6503
} | Medical Text: Admission Date: [**2178-2-22**] Discharge Date: [**2178-3-4**]
Date of Birth: [**2127-4-26**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Cystgastrostomy
History of Present Illness:
the patient is a 50 year old male presented to [**Hospital3 3765**]
with acute onset of left sided abdominal pain. He reports that
he had 3 "attacks" of sharp pain on Friday night [**2-20**] which
subsided and on Saturday morning had an attack which did not
resolve. There was no nausea or vomiting associated with the
pain. The pain is constant and radiates to his back and at
times to his left shoulder. He reports that it is similar to
previous attacks, although the pain in the past was more right
sided. He reports that he first had gallstone pancreatitis in
[**7-2**] and his gallbladder was removed. In [**2177-10-25**], he had
another attack of pancreatitis which he was hospitalized for. A
CT was done at this time, which showed a pancreatic pseudocyst.
He had similar pain in [**2177-12-26**] which resolved and did not
require hospitalization. On admission to [**Hospital1 **] on [**2-21**], his
amylase was 288 and lipase was 324, WBC was 11.9, Hct 39.3.
Repeat labs done at [**Hospital1 **] on [**2-22**] showed an amylase of 174 and
lipase of 136, WBC 9.0 and Hct 36.4. Denies any chest pain,
shortness of breath, fevers or chills. Last bowel movement was
yesterday, no melena or BRBPR. No emesis and some mild nausea
associated with dilaudid.
Past Medical History:
HTN
Recurrent pancreatitis
Social History:
Denies tobacco use or current EtOH use, past hx of social EtOH
use on business trips, which he stopped [**7-2**].
Family History:
Non-contributory
Physical Exam:
(On presentation)
Vitals: T 98.9 HR 83 BP 135/91 RR 18 94%RA
NAD, A+O x 3
PERRLA, EOMI, Anicteric
RRR, no m/r/g, No JVD
CTA B, no r/r/c
ABD +BS, soft, voluntary guarding, mild tenderness to palpation
RLQ and LUQ
EXT warm, well perfused, dp palp
Pertinent Results:
[**2178-2-24**] INTRAOP U/S: High-resolution linear array scans over
the pancreas region were obtained demonstrating a large complex
cystic collection measuring at least 5-6 cm in diameter and
containing two components which are joined by a wide 5-mm neck.
There was extensive echogenic material within the fluid
including some floating debris. After surveying several sites,
the best most proximate approach to the pseudocyst was through
the stomach with the cyst approximately 3-5 mm deep to the
stomach wall. After opening the anterior wall further, repeat
ultrasound through the posterior wall of the stomach was
performed, again to identify the closest site and this was
confirmed by placement of a needle under direct ultrasound
guidance into the cyst. Following visual confirmation of needle
placement into the cyst, the ultrasound scan was ended and
surgical cyst-gastrostomy was undertaken.
.
[**2178-2-23**] CTA ABD: IMPRESSION: 1. Necrotizing/hemorrhagic
pancreatitis with pseudocyst formation. The extent of
surrounding inflammatory change and size of the pseudocysts have
increased since [**2178-2-22**]. There is no evidence for
pdeudoaneurysm. The splenic vein is thrombosed. 2. Wall
thickening involving the stomach, first/second portion of the
duodenum
and splenic flexure likely related to adjacent inflammatory
change. 3. Rounded hypodense lesion within the interpolar region
of the right kidney
most consistent with cyst. 4. Multiple sub-cm hypodense lesions
within the liver, incompletely characterized.
.
[**2178-2-22**] 08:58PM HCT-36.7*
[**2178-2-22**] 02:29PM GLUCOSE-154* UREA N-9 CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11
[**2178-2-22**] 02:29PM estGFR-Using this
[**2178-2-22**] 02:29PM ALT(SGPT)-13 AST(SGOT)-13 ALK PHOS-64
AMYLASE-153* TOT BILI-1.3
[**2178-2-22**] 02:29PM LIPASE-106*
[**2178-2-22**] 02:29PM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-2.6*
MAGNESIUM-1.8 IRON-17*
[**2178-2-22**] 02:29PM calTIBC-298 FERRITIN-242 TRF-229
[**2178-2-22**] 02:29PM TRIGLYCER-77
[**2178-2-22**] 02:29PM WBC-10.0 RBC-4.23* HGB-12.6* HCT-36.6* MCV-86
MCH-29.9 MCHC-34.6 RDW-13.0
[**2178-2-22**] 02:29PM PLT COUNT-294
[**2178-2-22**] 02:29PM PT-14.6* PTT-25.4 INR(PT)-1.3*
Brief Hospital Course:
[**2178-2-22**] Patient evaluated in the [**Hospital1 18**] Emergency Department on
transfer from [**Hospital3 **] with primary complaint of
abdominal pain as detailed above. Patient was admitted to the
SICU for monitoring, serial HCT's, made NPO, and given IV
hydration and pain control. No acute events overnight.
.
[**2178-2-23**] Patient transferred from SICU to floor following stable
exams and HCT's. CTA Abdomen performed to rule out bleeding
into pseudocyst with results as detailed above. Pain control
adequate with PCA.
.
[**2178-2-24**] Patient underwent open cystgastrostomy with Dr. [**Last Name (STitle) **]
with intraop ultrasound as detailed above. There were no
complications during the procedure. The patient was extubated in
the OR and transferred to the PACU and ultimately [**Hospital Ward Name 121**] 9 for
recovery. No acute events overnight.
.
[**2178-2-25**] POD1 Patient sat up in bed for 6 hours. Pain well
controlled. NGT in place with PCA for pain control. No acute
events.
.
[**2178-2-26**] POD2 Patient with difficulty with pain control, PCA
dosing increased. Urine output stable. Patient OOB to chair.
Remains NPO with NGT per plan. No acute events.
.
[**2178-2-27**] POD3 Patient OOB to hallway without assistance. Pain
well controlled. NGT in place and good urine output overnight.
No acute events.
.
[**2178-2-28**] POD4 PCA discontinued. Patient with good pain control
with PO medication. NGT removed. Patient given sips and
tolerating it well. Ambulating in halls without assistance. No
acute events.
.
[**2178-3-1**] POD5 Patient given clear liquid diet and tolerating it
well. Given Dulcolax PR x 1 for constipation with good result.
All blood cultures from admission with NGTD. No acute events.
.
[**2178-3-2**] POD6 Patient given a regular diet. Excellent PO pain
control.
.
[**2178-3-4**] POD7 At the time of discharge patient was afebrile with
all vital signs within normal limits, tolerating a regular diet,
with good pain control with PO medication, and ambulating
without assistance. He was ruled out for C.diff after having
some loose stool.
He was discharged to home to follow up with Dr. [**Last Name (STitle) **] in 2
weeks.
Medications on Admission:
Amlodopine 5mg qd
Quinapril 40mg qd
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed: Do not consume alcohol, drive, or
operate machinery while taking this.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
1 months: Take this stool softener as long as you are taking
narcotics.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
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 resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**9-9**] lbs) for 6 weeks.
* Continue with drain care and flushing of the left sided drain.
* Monitor your incision for sign of infection (redness or
increased drainage).
* Keep incision clean and dry.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Please call
[**Telephone/Fax (1) 1231**] to schedule an appointment.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6504
} | Medical Text: Admission Date: [**2107-5-19**] Discharge Date: [**2107-5-25**]
Date of Birth: [**2027-6-12**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Zocor
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath and cough
Major Surgical or Invasive Procedure:
Cardiac catheterization with no intervention
History of Present Illness:
79-year-old with a history of CAD, with 2VD not candidate for
CABG s/p PCI with stent to ostial LAD [**1-/2107**] with residual known
proximal 80% Lcx in addition to a history of systolic CHF, COPD
and OSA who was transferred from the OSH after admission for
NSTEMI complicated by VT/VF which resolved with shock on the day
of transfer.
.
Mrs. [**Known lastname 40800**] presented to OSH yesterday ([**5-18**]) due to
worsening SOB, cough productive of whote phlegm and parasternal
chest pain which was related to cough and deep breathing but not
to exertion or rest without coughing. The cough had troubled her
for the preceeding two weeks. This was also associated with some
fatigue and chills but not with fever or night sweats. She
denied nasal congestion, sinus pain, ear pain, throat pain,
heartburn, diarrhea or urinary symptoms.
.
She reported orthopnea X 2 pillows, paroxysmal nocturnal
dyspnea, nocturia X [**1-5**]. These have been stable in recent days
prior to admission. She denied any lower extremity swelling.
.
On review of systems, she complained of chronic arthritic pains.
Otherwise, she denied any nausea or vomiting, diaphoresis,
fevers, prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
hemoptysis, bloody stools and fevers. All of the other review of
systems were negative.
.
Cardiac review of systems was notable for absence of ankle
edema, palpitations, syncope or presyncope.
.
At the OSH, her admission vitals were as follows: BP 116/60 HR
79 RR 29 SaO2 89% on 2L. She exhibited signs of florid heart
failure (CXR findings and a BNP 1300) and had positive cardiac
enzymes (Trop 4.96). Impression was a NSTEMI. She got 2 units of
blood as her Hct was 26. She was also diuresed overnight with
Lasix 80mg [**Hospital1 **]. As there was suspicion of a GI bleed (Blood on
per-rectal examination, guaiac positive), all anticoagulants and
antiplatelets were stopped and she was admitted to the ICU.
Today ([**5-19**]) In the early PM, after eating lunch she was found
to be unresponsive and in VTach/VFib. She was given CPR and then
defibrillated x1 into normal sinus rhythm. The downtime was <1
minute. She was then put on a 50% venti mask and she remained
hemodynamically stable. An amiodarone gtt was started. She was
transferred to [**Hospital1 18**] for consideration of catheterisation.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Coronary Artery Disease with previous NSTEMI
- Mitral valve prolapse with trace mitral regurgitation
- Congestive Heart Failure
- CABG: Evaluated for surgery but not a suitable candidate.
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**2107-1-1**]: 2VD in ostial LAD and proximal circ s/p ostial LAD
stent with DES. No intervention to proximal circ. Procedure
complicated by femoral AV fistula that resolved.
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Peripheral Vascular Disease
- Carotid Disease s/p bilateral carotid endarterectomy (f/u Dr
[**Last Name (STitle) 26438**]
- Chronic Obstructive Pulmonary Disease on home oxygen therapy
(2L/min) and chronic respiratory failure: Last PFT's Moderate
restrictive ventilatory defect with a marked gas exchange
defect. The DLCO is reduced out of proportion to the reduction
in TLC which suggests an interstitial process. per pulmonary
note: has severe COPD with superimposed restriction, severe
emphysema by CT scan, obesity, probably OSA.
- Chronic Kidney Disease (Stage III) with atrophic right kidney
and episodes of acute renal insufficiency
- Gastroesophageal Reflux Disease
- Fatty liver and ?liver cirrhosis
- Gout
- Rheumatoid Arthritis
- Thrombocytopenia ?ITP
- Anemia of chronic disease
- Rhabdomyolysis
- Diverticulosis of urinary bladder
- Bladder polyp s/p removal
- Morbid obesity
- Obstructive Sleep Apnea (Clinically Suspected)
- History of Bone marrow suppression to methotrexate
- History of shingles
- Small left adrenal nodule
Social History:
- Family: Lives alone. Widowed as husband recently died from
leukemia. Has a supportive family.
- Occupation: Used to work in a variety of jobs but now retired
on disability.
- ADLs: Could walk a block before she got breathless. Can dress
herself but with much difficulty.
- Tobacco history: Ex-smoker, quit 20 years ago.
- ETOH: Denied.
- Illicit drugs: Denied.
Family History:
- She has 3 sibilings who died of MIs. A brother passed away at
59 suddenly due to MI. Another brother has had multiple MIs s/p
CABG but passed away after the surgery. Her sister had double
bypass CABG but also passed away after the surgery.
- Otherwise, no family history of arrhythmia, cardiomyopathies,
or sudden cardiac death.
Physical Exam:
On Admission:
GENERAL: NAD.
HEENT: Normocephalic. No trauma to head. Sclera anicteric.
PERRL. No change in oropharynx.
NECK: Supple, no JVD. Thyroid gland not enlarged.
CARDIAC: Normal S1, S2. No S3 or S4. No carotid bruits.
LUNGS: Symmetric. [**Hospital1 **]-basilar crackles. Few expiratory wheezes.
ABDOMEN: Soft, mild tenderness in left lower quadrant but no
rebound tenderness, no palpable masses. No bruits.
EXTREMITIES: 1+ pitting pre-tibial edema. No cyanosis /
clubbing.
SKIN: No rash or eruptions.
PULSES: Diminished pulses over posterior tibial and dorsal pedal
arteries bilaterally.
NEURO: No focal deficits.
.
On Discharge
GENERAL: NAD.
HEENT: Normocephalic. No trauma to head. Sclera anicteric.
PERRL. No change in oropharynx.
NECK: Supple, no JVD. Thyroid gland not enlarged.
CARDIAC: Normal S1, S2. No S3 or S4. No carotid bruits.
LUNGS: Symmetric. CTA with scant bibasilar crackles.
ABDOMEN: Soft, nontender, nondistended no palpable masses. No
bruits.
EXTREMITIES: 1+ pitting pre-tibial edema. No cyanosis /
clubbing.
SKIN: No rash or eruptions.
PULSES: Diminished pulses over posterior tibial and dorsal pedal
arteries bilaterally.
NEURO: No focal deficits.
Pertinent Results:
CBC Trend:
[**2107-5-19**] 06:20PM BLOOD WBC-12.5* RBC-3.11*# Hgb-10.4*#
Hct-31.4*# MCV-101* MCH-33.6* MCHC-33.3 RDW-19.5* Plt Ct-219#
[**2107-5-20**] 06:33AM BLOOD WBC-11.0 RBC-3.06* Hgb-10.0* Hct-31.4*
MCV-103* MCH-32.8* MCHC-32.0 RDW-19.2* Plt Ct-199
[**2107-5-21**] 03:27AM BLOOD WBC-9.7 RBC-2.93* Hgb-10.1* Hct-29.8*
MCV-102* MCH-34.4* MCHC-33.7 RDW-18.7* Plt Ct-194
[**2107-5-22**] 08:50AM BLOOD WBC-10.3 RBC-3.13* Hgb-10.3* Hct-32.9*
MCV-105* MCH-32.8* MCHC-31.2 RDW-18.3* Plt Ct-177
[**2107-5-23**] 07:45AM BLOOD WBC-9.7 RBC-3.16* Hgb-10.4* Hct-33.1*
MCV-105* MCH-32.8* MCHC-31.2 RDW-17.8* Plt Ct-195
[**2107-5-24**] 07:15AM BLOOD WBC-11.6* RBC-3.09* Hgb-10.2* Hct-31.8*
MCV-103* MCH-33.1* MCHC-32.1 RDW-17.5* Plt Ct-167
[**2107-5-25**] 05:45AM BLOOD WBC-8.7 RBC 2.90* Hgb-9.5* Hct-29.6* MCV
102* MCH 32.7* MCHC 32.1 RDW-17.4* Plt Ct-193
.
Chemistry Trend:
[**2107-5-19**] 06:20PM BLOOD Glucose-112* UreaN-51* Creat-2.0* Na-142
K-4.0 Cl-101 HCO3-30 AnGap-15
[**2107-5-20**] 12:01AM BLOOD Glucose-119* UreaN-54* Creat-2.2* Na-141
K-3.7 Cl-100 HCO3-29 AnGap-16
[**2107-5-20**] 06:33AM BLOOD Glucose-125* UreaN-59* Creat-2.3* Na-140
K-4.1 Cl-99 HCO3-31 AnGap-14
[**2107-5-21**] 03:27AM BLOOD Glucose-195* UreaN-63* Creat-2.1* Na-140
K-4.0 Cl-102 HCO3-28 AnGap-14
[**2107-5-22**] 04:25AM BLOOD Glucose-154* UreaN-61* Creat-1.7* Na-141
K-4.4 Cl-103 HCO3-26 AnGap-16
[**2107-5-23**] 07:45AM BLOOD Glucose-127* UreaN-73* Creat-2.5* Na-139
K-4.7 Cl-101 HCO3-30 AnGap-13
[**2107-5-24**] 07:15AM BLOOD Glucose-117* UreaN-81* Creat-2.6* Na-137
K-4.5 Cl-99 HCO3-28 AnGap-15
[**2107-5-25**] 05:45AM BLOOD Glucose-135* UreaN-81* Creat-2.2* Na-135
K-4.2 Cl-98 HCO3-28 AnGap-13
.
Coags:
[**2107-5-19**] 06:20PM BLOOD PT-14.8* PTT-22.4 INR(PT)-1.3*
[**2107-5-22**] 08:50AM BLOOD PT-13.8* INR(PT)-1.2*
.
LFTs
[**2107-5-19**] 06:20PM BLOOD ALT-23 AST-47* LD(LDH)-337* CK(CPK)-94
AlkPhos-64 TotBili-0.7
[**2107-5-24**] 07:15AM BLOOD CK(CPK)-347*
.
Biomarkers Trend:
[**2107-5-19**] 06:20PM BLOOD CK-MB-10 MB Indx-10.6* cTropnT-0.88*
proBNP-[**Numeric Identifier 40801**]*
[**2107-5-20**] 12:01AM BLOOD CK-MB-6 cTropnT-0.89*
[**2107-5-20**] 06:33AM BLOOD CK-MB-6 cTropnT-0.93*
[**2107-5-21**] 03:27AM BLOOD cTropnT-1.41*
[**2107-5-22**] 04:25AM BLOOD CK-MB-4 cTropnT-1.50*
[**2107-5-23**] 07:45AM BLOOD CK-MB-7 cTropnT-1.41*
[**2107-5-24**] 07:15AM BLOOD CK-MB-5
.
HgA1c:
[**2107-5-19**] 06:20PM BLOOD %HbA1c-5.2 eAG-103
.
Cholesterol Panel
[**2107-5-19**] 06:20PM BLOOD Triglyc-74 HDL-57 CHOL/HD-2.0 LDLcalc-44
.
TSH
[**2107-5-19**] 06:20PM BLOOD TSH-2.4
.
ECG ([**2107-5-19**] 5:37:24 PM)
Sinus rhythm with atrial premature beats. ST-T wave
abnormalities. Since the previous tracing of [**2107-1-16**] atrial
premature beats are new. ST-T wave abnormalities are more
marked. Clinical correlation is suggested.
TRACING #1
.
ECG ([**2107-5-20**] 8:23:28 AM)
Sinus rhythm. ST-T wave abnormalities. Since the previous
tracing atrial premature beats are no longer seen. Rate is
decreased. ST-T wave abnormalities persist.
TRACING #2
.
ECG ([**2107-5-22**] 3:24:00 AM)
Sinus rhythm. Prolonged Q-T interval. Anteroapical T wave
inversions suggestive of myocardial ischemia. Clinical
correlation is suggested. Compared to the previous tracing of
[**2107-5-20**] precordial T wave inversions are less pronounced.
.
ECG ([**2107-5-23**] 9:07:36 AM)
Sinus rhythm with an atrial premature beat. Low lateral
precordial T wave amplitudes and minor ST-T wave abnormalities
in the lateral limb leads. Since the previous tracing of [**2107-5-22**]
ST-T wave abnormalities are now less prominent in the lateral
precordial leads and more prominent in the lateral limb leads at
a faster rate. The atrial premature beat is new.
.
IMAGING:
CHEST (PORTABLE AP) ([**2107-5-19**] 6:11 PM)
FINDINGS: In comparison with study of [**1-16**], there is enlargement
of the
cardiac silhouette with pulmonary vascular congestion.
Retrocardiac
opacification most likely represents atelectasis with small
effusion, though the possibility of supervening pneumonia would
have to be considered in the appropriate clinical setting.
.
CHEST (PORTABLE AP) ([**2107-5-23**] 8:37 AM)
The cardiac silhouette remains enlarged, similar from prior
study. There is pulmonary vascular congestion and bilateral
diffuse opacifications, which likely represents a combination of
pulmonary edema and pleural effusion, but infectious process
cannot be excluded in the appropriate clinical setting. No
pneumothorax is noted. The mediastinal and hilar silhouettes are
stable.
IMPRESSION:
1. Unchanged pulmonary vascular congestion and pulmonary edema,
but pneumonia cannot be excluded in the appropriate clinical
setting.
2. Bilateral pleural effusion is unchanged from prior study.
.
Portable TTE (Complete) ([**2107-5-21**] 10:21:55 AM)
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is low normal (LVEF
50%) secondary to mild hypokinesis of the inferior, posterior,
and lateral walls (the anterior septum and anterior free wall
are hyeprdynamic). Right ventricular chamber size and free wall
motion are normal. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. Compared with the findings of the prior
report (images unavailable for review) of [**2107-1-7**], mild
posterior and lateral hypokinesis is now present.
.
Cardiac Cath ([**2107-5-20**])
Coronary angiography showed right dominant system.
LMCA- Short, normal
LAD- Stent widely patent, no significant disease
LCX- Mild proximal disease, no significant other disease on
limited
views.
RCA- Mild diffuse disease only.
FINAL DIAGNOSIS:
1. Widely patent LAD stent
2. Mild non-significant CAD/ no culprit for NSTEMI.
Brief Hospital Course:
Ms [**Known lastname 40800**], a 79-year-old with a history of CAD, with 2VD not
candidate for CABG, s/p PCI with stent to ostial LAD ([**1-/2107**])
with residual known proximal 80% Lcx in addition to a history of
systolic CHF, COPD and OSA who was transferred from an OSH after
admission for NSTEMI + CHF exacerbation complicated by VT/VF
which resolved with shock on the day of transfer.
.
# NSTEMI.
Patient has a history of CAD with 2VD per cath in [**2107-1-1**];
patient is not a candidate for CABG due to high surgical risk in
the setting of severe COPD. Patient underwent an elective PCI at
that time with stent to ostial LAD [**1-/2107**] with residual known
proximal 80% Lcx. Patient presented to OSH [**5-18**] with lateral and
inferior EKG changes and raised troponins suggestive of a new
NSTEMI compatible with LCx distribution. She was transferred to
[**Hospital1 18**] for cardiac catheterization. She was continued on an IV
Heparin gtt and started ASA 325 mg PO, clopidogrel 75 mg PO
daily, atorvastatin 80mg daily. Patient underwent cardiac cath
on [**5-23**] which demonstrated widely patent LAD stent, mild
non-significant CAD and no culprit for NSTEMI. TTE demonstrated
normal left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is low normal (LVEF 50%) secondary to mild
hypokinesis of the inferior, posterior, and lateral walls (the
anterior septum and anterior free wall are hyperdynamic).
Patient remained chest pain free throughout remainder of her
stay.
.
# Acute decompensated sytolic CHF (NYHA Class III): On
presentation to OSH CXR showed florid pulmonary congestion.
Patient was diuresed in OSH with IV lasix. BNP = 1300. Likely
decompensated due to ischemia. On arrival patient with above
baseline O2 requirement (nasal canula at 5L; 2L at home).
Patient intermittently diuresised with Furosemide 20 mg IV. On
HD3 patient creatinine elevated and decision made to hold to
diuresis. Patient was started on ACEi and continued on beta
blocker.
.
# RHYTHM. She developed an episode of VTach/VFib possibly as a
complication of her recent NSTEMI. The downtime was <1 minute.
This required CPR and defibrillation x1 which subsequently
converted her to normal sinus rhythm. She was monitored on
telemetry without further event.
.
# COPD: Chronic Obstructive Pulmonary Disease on home oxygen
therapy (2L/min) and chronic respiratory failure. Last PFT's
Moderate restrictive ventilatory defect with a marked gas
exchange defect. FEV1/FVC actual = predicted = 0.65. Per
pulmonary note: has severe COPD with superimposed restriction,
severe emphysema by CT scan, obesity, probably OSA. Now
presenting with worsening cough of 14 days productive of sputum.
No fever. Has leukocytosis to 12.5. Dif is pending. No clear
infiltrates on CXR except possible small infiltrate at left
heart border. Given her prolonged cough with increased sputum in
the setting of risk factors including chronic prednison, severe
underlyting lung disease, diabetes, CHF and her age would tend
to cover her with Abx for CAP organisms. She was started on PO
Levofloxacin for likely 5day treatment course. She was continued
on home Advair (500/50), ipratropium nebs as well as standing,
chronic prednisone 5mg
.
# Anemia: Has baseline macrocytic anemia, with Hct ~ 30-31. In
OSH noted to have PR bleeding per-rectal examination and was
guiaic positive. Hct was 26 and she received PRBC X2, now Hct
31. B12, Folate were normal in [**Month (only) 404**]. Patient continued on
Pantoprazole 40 mg PO Q24H in the setting of Plavix + Asprin.
HCT stable in house.
.
# Chronic Kidney Disease (Stage III). Creatinine in [**2107-1-1**]
was 2.1. Creatinine did uptrend in setting of diuresis as well
as contrast load during catheterization. Patient continued to
make urine thoughout hospitalization. Creatinine at time of
discharge was 2.2.
.
# Question of cirrhosis. Patient has history of fatty liver with
recent CT demonstrating nodular liver. Has chronic macrocytosis,
low albumin, borderline elevated INR and mild chronic
thrombocytopenia. All suggesting chronic liver disease. Of note
current elevated AST is likely of cardiac origin.
- Out-patient hepatlogy f/u.
.
# HTN: Converted to Metoprolol succinate from tartrate and
started on Lisinopril for her CHF instead of felodipine. Her
blood pressure was well controlled during her hospital stay.
Lisinopril should be uptitrated as creatinine allows.
.
# HLD. Patient was started on Atorvastatin 80mg daily for
treatment of CAD. Her lipid panel was normal.
.
OUTPATIENT ISSUES:
- Continue Atorvastatin 80mg daily
.
# DM. Her HbA1c was 5.2%. Her glypizide was held and she as put
on an insulin sliding scale and a low carbohydrate diet.
.
OUTPATIENT ISSUES:
- Restart glypizide
.
# Gout: She has some minor joint pain that was treated with
Tramadol prn, No evidence of acute flare.
- Continue Febuxostat 40 mg PO DAILY
.
# Rheumatoid Arthritis. Hydroxychloroquine was held in the
context of recent arrythmias as well as ABx treatment with
levofloxacin to avoid excess QT prolongation. This should be
restarted as an outpt.
.
#Urinary Tract Infection. A UA was positive on [**5-25**], but she was
asymptomatic. She was treated with PO levofloxacin for 5 days
for her pneumonia, course was finished at the time of the
postivie U/A. Urine cultures were sent. Rehab will be called if
the results are positive.
.
OUTPATIENT ISSUES:
- Urine culture results will need to be followed-up as an
outpatient
Medications on Admission:
HOME MEDICATIONS:
- Advair Diskus 500/50 mcg one inhalation [**Hospital1 **]
- Uloric one pill qd
- Aspirin 162mg qd
- Iron sulfate 325mg qd
- Folic acid 1mg qd
- Lasix 20mg qd
- Felodipine 5mg daily
- Glipizide 5mg qd
- Glucosamine and chondriotin [**Hospital1 **]
- Lopressor 50mg po bid
- Lovaza 2g [**Hospital1 **]
- Plavix 75mg qd
- Pravastatin 10mg po at bedtime
- ReQuip 1mg po at bedtime
- Prednisone 5mg qd
- Plaquenil 200mg po qd
- Spiriva 18mcg inhalation qd
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. febuxostat 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
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:*0*
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lovaza 1 gram Capsule Sig: Two (2) Capsule PO twice a day.
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation: hold for diarrhea.
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
18. ferrous sulfate 324 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
19. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsulr Inhalation once a day.
20. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Non ST elevation myocardial infarction
Acute on Chronic Systolic congestive heart failure
Ventricular tachycardia
Acute on chronic kidney disease
Community aquired pneumonia
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 Mrs [**Known lastname 40800**],
.
you were transferred to our hospital after suffering a
myocardial infarction ("heart attack") which was complicated by
heart failure and heart rythm disturbances. You underwent
coronary catheterization which did not show any lesions that
require intervention. Your kidneys worsened temporarily because
of the catheterization dye, they are improving today.
.
The following changes were made to your medications:
.
- Felodipine was stopped
- Plaquenil was stopped
- Pravastatin was stopped
- Lopressor 50mg tablet was changed to a long acting formulation
at 100 mg daily
- Omeprazole was changed to pantoprazole to protect your stomach
from the medicines.
Please do not resume these medications without consulting your
doctor.
.
- Aspirin tablet was increased to Aspirin 325mg tablet: please
take one tablet once daily.
.
- Lisinopril 2.5mg tablet was started for blood pressure. Please
take one tablet once daily.
.
- metoprolol succinate 100 mg Tablet Extended Release 24 hr
was started to help your heart beat more efficiently. Please
take one tablet once daily.
.
- Atorvastatin 80mg was started. Please take one tablet once
daily.
.
- Laxtulose was started as needed for constipation
.
- STart Tramadol to treat the pain in your knee and chest wall
area.
.
Daily weights every morning, please notify Dr. [**Last Name (STitle) 5017**] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY
Address: [**Street Address(2) **], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 39854**]
Phone: [**Telephone/Fax (1) 5424**]
Appointment: Monday [**2107-6-6**] 2:15pm
Completed by:[**2107-5-26**]
ICD9 Codes: 5849, 486, 4280, 496, 5715, 5990, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6505
} | Medical Text: Admission Date: [**2174-5-7**] Discharge Date: [**2174-5-11**]
Date of Birth: [**2121-5-9**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2174-5-7**] Thoracentesis
History of Present Illness:
53 yo female who six weeks ago was a pedestrian struck by a
truck on the
left side resulting in multiple fractures including clavicle and
13 ribs. She was left with a pleural effusion on the left which
was documented during an emergency room visit on [**4-25**] at [**Hospital1 **]. She has been using an incentive spirometer at
home reportedly faithfully. Over the past 2-3 days she has
noticed dramatically increased orthopnea such that she is now
sleeping sitting up but no
significant increase in dyspnea on exertion, fever, sputum
production.
Physical exam:
Looks relatively
Past Medical History:
Osteopenia
OCD
Anxiety
Social History:
Married
Works as a social worker
Family History:
Non contributory
Pertinent Results:
Upon admission:
[**2174-5-7**] 11:49PM GLUCOSE-166* UREA N-10 CREAT-0.6 SODIUM-135
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
[**2174-5-7**] 11:49PM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2174-5-7**] 11:49PM WBC-13.2*# RBC-3.64* HGB-10.2* HCT-31.1*
MCV-85 MCH-28.1 MCHC-32.9 RDW-13.8
[**2174-5-7**] 11:49PM PLT SMR-HIGH PLT COUNT-536*
[**2174-5-7**] 11:49PM PT-14.2* PTT-33.5 INR(PT)-1.2*
CHEST (PORTABLE AP) [**2174-5-7**] 8:57 PM
IMPRESSION: AP chest compared to [**5-7**], 6:57 p.m.:
There has been no increase in left pleural effusion but
consolidation in the left mid and lower lung has increased
substantially, an unusual pattern for first reexpansion
pulmonary edema suggesting instead pulmonary hemorrhage. There
is no pneumothorax. Right lung is clear and heart size is
normal. Minimally displaced fracture of the left seventh rib is
unchanged and may be a second fracture, of the left tenth rib
laterally, chronicity indeterminate.
Cytology Report PLEURAL FLUID Procedure Date of [**2174-5-7**]
REPORT APPROVED DATE: [**2174-5-10**]
SPECIMEN RECEIVED: [**2174-5-9**] [**-7/1936**] PLEURAL FLUID
SPECIMEN DESCRIPTION: Received 5ml bloody fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: Undiagnosed effusion.
PREVIOUS BIOPSIES:
[**2173-11-19**] [**-6/4622**] THIN LAYER PREP PAP SMEAR WITH IMAGING
[**2172-8-18**] [**-5/3366**] THIN LAYER PREP PAP SMEAR WITH IMAGING
[**2171-3-28**] 05-[**Numeric Identifier 10694**] THIN LAYER PREP PAP SMEAR
[**2162-11-26**] 96-[**Numeric Identifier 10695**] PAP
95-[**Numeric Identifier 10696**] PAP
DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS.
CHEST (PA & LAT) [**2174-5-10**] 10:36 AM
IMPRESSION: PA and lateral chest compared to [**2174-5-9**]:
Previously severe left lung consolidation has improved. A
smaller volume of consolidation remains in the right apex and
perihilar right mid lung. Small bilateral pleural effusions are
probably unchanged over the past several days. Heart size is
normal. There is no pneumothorax.
Brief Hospital Course:
She was admitted to the Trauma Service. She underwent chest xray
which revealed no increase in left pleural effusion but
consolidation in the left mid and lower lung which had increased
substantially since last chest radiograph in early [**Month (only) 116**] but no
pneumothorax. She was transferred to the ICU where she was
monitored closely; she was placed on supplemental oxygen. Serial
chest xrays were followed. Interventional Pulmonology was
consulted for Thoracentesis; 2.5 liters was drained from the
left chest. A bronchoscopy was done 2 days later which revealed
patent airways with minimal to no secretions. She was started on
Levaquin for presumed pneumonia.
She is being discharged to home with skilled nursing from
visiting nurses. She will follow up in Surgery clinic in 1 week;
an xray will be [**Month (only) 1988**] prior to this appointment.
Medications on Admission:
MS Contin 30bid, Klonopin 0.25"', Prozac 60'
Discharge Medications:
1. Morphine 15 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO every twelve (12) hours.
Disp:*120 Tablet Sustained Release(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
4. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical every twenty-four(24)
hours: Apply to affected area.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VISITING NURSE AND COMMUNITY HEALTH
Discharge Diagnosis:
Left pleural effusion
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills,
headache, dizziness, chest pain, shortness of breath, nausea,
vomiting, diarrhea and/or any other symptoms that are concerning
to you.
Continue with the antibiotics for another 10 days.
You may resume your usual home medications as prescribed.
Followup Instructions:
Follow up next week with Dr. [**Last Name (STitle) **] in Surgery Clinic, call
[**Telephone/Fax (1) 6429**] for an appointment. You will need to have an xray
prior to this appointment.
You also have an appointment with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2174-6-16**] 8:30 you will need to have
an xray prior to this appointment on Date/Time:[**2174-6-16**] 8:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2174-5-11**]
ICD9 Codes: 5119, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6506
} | Medical Text: Admission Date: [**2180-4-9**] Discharge Date: [**2180-4-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
diaphoresis, black bowel movement
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
87yoW with history of CAD s/p PCI to LAD [**2177**], CHF with EF 47%,
breast cancer, colitis NOS presenting with melana. Patient was
in her normal state of health until [**2180-4-8**] when she felt sweats
at night. She awoke on the morning of [**2180-4-9**] again diaphoretic
with palpitations and lightheadedness. She called for help and
went to the bathroom where she passed a large black bowel
movement. She noted mid-epigastric pain that has been ongoing
for several weeks. She denied any abdominal cramping, nausea,
or vomiting.
.
In the ED, initial Hct 26.5. She received one unit PRBC and was
admitted to MICU. EGD showed a single non-bleeding ulcer at the
GE junction, blood in the body and fundus of the stomach. She
received an additional three units PRBC overnight and was ruled
out for acute coronary syndrome by three negative sets of
cardiac enzymes. She denied chest pain or shortness of breath.
.
On ROS she denies fevers, chills, headache, cough, dysuria,
hematuria, new skin changes or rashes. She does note some RLE
muscle cramps for the past few days. All other systems per HPI.
Past Medical History:
1. 2-v Coronary artery disease s/p MI [**1-/2178**]; Cath with PCI to
LCx, LAD; reversible defect IL pMIBI [**1-/2180**], EF 47%
2. Breast cancer s/p B mastectomy
3. Colitis NOS
4. Secundum ASD (L -> R), 2+AR, [**11-21**]+MR
5. Squamous cell cancer
6. Hypothyroid
7. Hypercholesterolemia
8. Depression
9. s/p Appendectomy
10. s/p TAH
Social History:
lives alone with [**Hospital 2241**] home health aides present
at baseline, she dresses herself, walks without assistance, and
prepares meals
widowed two months ago
previously worked in development office at [**Hospital **] Hosp for
47yrs
denies tob, EtOH
.
Contact: daughters
[**Name (NI) **] [**Telephone/Fax (1) 94693**] (HCP)
[**Name (NI) **] [**Telephone/Fax (1) 94694**]
Family History:
non-contributory
Physical Exam:
On admission:
98.0 94 104/41 14 98%RA
Gen: elderly woman, comfortable, NAD
HEENT: PERRL, anicteric, conjunctiva pale, OP clear with
modestly dry MM
HEENT: supple, no LAD, no JVD
CV: RRR, III/VI pansystolic murmur, no s3s4, 2+radial and DP
pulses
Resp: CTAB
Chest: mastectomy scars, sternal wound 1.5cm diameter, dressed
with cream and dry gauze
Back: winged scapula, nontender
Abd: +BS, soft, ttp mid-epigastric, no rebounding or guarding,
no HSM
Ext: no edema, mildly ttp right calf
Skin: diffuse nevi on neck, chest, abdomen, B arms, large nevi
on abdomen, echymoses on right knee, left arm
Pertinent Results:
[**2180-4-9**] 11:40AM PT-13.5* PTT-19.6* INR(PT)-1.2
[**2180-4-9**] 11:40AM PLT SMR-NORMAL PLT COUNT-250
[**2180-4-9**] 11:40AM NEUTS-88.3* BANDS-0 LYMPHS-9.5* MONOS-2.1
EOS-0.1 BASOS-0.1
[**2180-4-9**] 11:40AM WBC-9.4 RBC-3.05* HGB-8.8* HCT-26.5* MCV-87
MCH-28.7 MCHC-33.0 RDW-13.1
[**2180-4-9**] 11:40AM DIGOXIN-1.1
[**2180-4-9**] 11:40AM CK(CPK)-63
[**2180-4-9**] 11:40AM GLUCOSE-165* UREA N-92* CREAT-1.2* SODIUM-141
POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
[**2180-4-9**] 12:44PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2180-4-9**] 12:44PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2180-4-9**] 08:10PM HCT-26.9*
[**2180-4-9**] 08:10PM CK(CPK)-62
EGD Report: Impression: Angioectasia in the stomach body
Ulcers in the distal esophagus
Recommendations: EGD in 2 months: Scheduled with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) 7307**] for [**6-8**] (thursday) at 10:30 am. Pt to be on
[**Hospital Ward Name 121**] 8 at 9:30 am. Please hold asa and plavix for 1 week if ok
with primary team.
High dose (double dose) PPI
Additional notes: The attending physician was present for the
entire procedure. Biopsies of esophagus not performed due to
recent bleeding and recent ASA and plavix use. Will bring back
after therapy for reassessment.
Brief Hospital Course:
87yo woman with history of coronary artery disease, congestive
heart failure, presenting with diaphoresis, melana, and found to
have upper GI bleed. During her hospitalization, the following
problems were addressed:.
#. GI bleed: Patient was initially admitted to the ICU and
transfused three units PRBC. Emergent EGD was done in the MICU
showing an ulcer at the GE junction, but it was too obscured by
blood for further investigation. She was monitored overnight in
the MICU and then transferred to the floor. She underwent
repeat EGD which showed two distal esophageal ulcers. It was
later noted that the patient had been taking only a minimal
amount of water with her weekly Fosamax, and this was thought to
be the cause. Fosamax was held until further discussion with
the patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], can be had.
Aspirin and Plavis were also held, and she was treated with big
iv Protonix. Hct stabilized, and her diet was advanced. She
was discharged to home on Prevacid 30mg [**Hospital1 **], liquid formula. She
will resume taking Plavix 75mg daily on [**2180-4-19**]. She was
instructed to resume Aspirin 81mg daily 4 weeks after discharge.
She will follow-up with Dr. [**First Name (STitle) **] to review her hospital
course On [**2180-4-18**]. She will follow-up with Dr. [**Last Name (STitle) **] for
repeat endoscopy [**2180-6-8**], 8 weeks after initial
evaluation.
#. Leg twitching: On day two of her hospitalization the
patient began complaining of bilateral leg twitching. A
neurology consult was called and found her exam to be consistent
with myoclonus due to metabolic insult. Specifically they felt
the elevated urea level after her GI bleed likely resulted in
the muscle spasms. Other sources of metabolic insult were
evaluated including tests for thyroid function, and were
nondiagnostic. The neurology services believed it would resolve
spontaneously with clearance of the urea. The remainder of her
neurologic exam was within normal limits.
#. CAD: There were no acute issues. She was ruled out for
acute MI and continued on her outpatient regimen of captopril,
carvedilol, and statin for secondary prevention. Plavix will be
restarted [**2180-4-19**], aspirin 4weeks after discharge..
#. CRI: Baseline creatinine 1.0-1.1, and was elevated as high
as 1.3 during her hospitalization. It was thought to be
prerenal in etiology and treated with gentle iv fluids.
#. Hypothyroid: continued Synthroid per outpatient regimen. A
TSH was checked and was mildly elevated at 4.4; however, free T4
was within normal limits at 1.6.
#. Psych: continued citalopram, trazadone per outpatient
regimen
#. Osteoporosis: We discontinued weekly Fosamax out of concern
that this was related to the developed of GE ulcers. The
patient was instructed to discuss resuming Fosamax with her
primary care physician.
#. Dispo: The patient was discharged to home. She has full
time home health aides. Health care proxy is her daughter [**Name (NI) **]
[**Telephone/Fax (1) 94693**]. She will follow-up with Dr. [**First Name (STitle) **] [**2180-4-18**].
Medications on Admission:
Captopril 25mg [**Hospital1 **]
Citalopram 60mg daily
Coreg 6.25mg [**Hospital1 **]
Digoxin 0.125mg daily
Folate 4mg daily
Trazodone 50mg qHS
Fosamax 70mg qweek
Lasix 40mg daily
Levothyroxine 75mg daily
Plavis 75mg daily
Zocor 20mg daily
Discharge Medications:
1. Captopril 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Citalopram Hydrobromide 20 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
3. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QOD
().
6. Levothyroxine Sodium 50 mcg Tablet Sig: 0.5 Tablet PO QOD ().
7. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical
DAILY (Daily) as needed.
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety, sleeplessness.
10. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleeplessness.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day:
Please do not start taking this medication until [**2180-4-19**].
15. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO twice a day.
Disp:*qs mg* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper GI bleed
.
Secondary:
Coronary artery disease
Congestive heart failure
Discharge Condition:
stable
Discharge Instructions:
If you develop any further episodes of bleeding, or if you
develop dizziness, lightheadedness, chest pain, shortness of
breath, abdominal cramps, fever, or any other concerning
symptom, please contact your primary care physician [**Name Initial (PRE) **]/or
return to the emergency department.
.
Please follow-up for a repeat endoscopy on [**2180-6-8**].
.
Please do not restart your Plavix until next Wednesday [**2180-4-19**].
Please resume taking aspirin in 4 weeks.
Please do not take Fosamax again until you discuss this further
with Dr. [**First Name (STitle) **]. Taking Fosamax without sufficient water may
have been related to development of the ulcers.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]
COMPLEX) Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2180-6-8**] 8:30
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Where: GI ROOMS
Date/Time:[**2180-6-8**] 8:30
.
Please follow-up with Dr. [**First Name (STitle) **] Tuesday [**2180-4-18**] at
3:00pm. You can call [**Telephone/Fax (1) 40745**] with any questions or
concerns.
ICD9 Codes: 2851, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6507
} | Medical Text: Admission Date: [**2143-7-14**] Discharge Date: [**2143-8-2**]
Service: MEDICINE
Allergies:
Dilacor XR / Codeine / Rosuvastatin / lisinopril / Levofloxacin
Attending:[**Doctor First Name 3298**]
Chief Complaint:
fall with head strike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 4401**] is a [**Age over 90 **]y/o F h/o dCHF, CAD (CABGx2), HTN. She was
found in bed by her husband with a head laceration, amnestic to
event. Per Husband, they were getting ready for dinner with
family when the pt stated she was going to lie down for a bit.
The husband checked on her 15-30min later and he noticed blood
on her scalp and pillow. Pt did not recall falling. EMS was
initiated at that point and pt brought to ED. Her only
complaint in the ED was back pain, which she attributed to the
stretcher. On imaging, it was found that she had an intracranial
hemorrhage and SAH, for which she was originally admitted to the
neurosurgery service.
Pt denies any numbness, weakness, tingling. Denies HA, nausea,
vomiting. Denies neck pain. Denies CP, SOB. There was no bowel
or bladder incontinence, or tongue biting associated with the
event. She has no hx of seizures. She has no hx of syncope.
Pt was transferred to the MICU in the setting of respiratory
distress and intubated on [**7-16**]. Pt was extubated on [**7-25**] and
called out to the medicine floor on [**7-28**] (more details in
hospital course).
Past Medical History:
HTN
NIDDM
hypercholesterolemia
CAD
CABG x2 ([**2115**], [**2128**])
dCHF
Social History:
Previously independent in ADLs. Lives with husband. Denies
smoking, EtOH use and drug use.
Family History:
Her children are healthy.
Physical Exam:
On Admission:
O: BP: 159/89 HR: 60 R 18 O2Sats 98%
Gen: WD/WN, uncomfortable on stretcher. Cervical collar in
place, NAD.
HEENT: Pupils: equal and brisk EOMs full
Neck: Supple, no midline tenderness.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, re-oriented to place and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. decreased vision in left eye, cannot count
fingers (reported as baseline).
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: decreased bulk with normal tone bilaterally. No abnormal
movements, tremors. Strength full power [**5-16**] throughout. No
pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
No midline spine tenderness to palpation.
.
.
ON DISCHARGE:
General: Pt sitting in chair in NAD.
HEENT: MMM, no lymphadenopathy, no defects in the scalp or
cranium appreciated, oropharynx clear
Lungs: very mild stridor on inhalation, scattered mild crackles
bilaterally in lower lung fields
Cardiovascular: RRR, nl S1/S2, no m/r/g
Abdomen: soft, BS+, no organomegaly appreciated, no tenderness
to palpation
Extremities: warm, well perfused, no cyanosis, edema
Neuro: PERRL, alert, oriented to person, place and month. CN
II-XII intact w/out deficit. Strength 4/5 b/l in lower
extremities. No sign of Babinski b/l. Sensation intact
bilateral. One error on days of week backward.
Pertinent Results:
Labs on Admission ([**7-14**]):
WBC-14.7* RBC-3.79* Hgb-11.5* Hct-33.5* MCV-89 MCH-30.4
MCHC-34.4 RDW-16.0* Plt Ct-273
Glucose-131* UreaN-25* Creat-1.0 Na-143 K-4.7 Cl-108 HCO3-23
AnGap-17
ALT-13 AST-25 LD(LDH)-306* CK(CPK)-139 AlkPhos-62 TotBili-0.4
04:42PM BLOOD cTropnT-<0.01
01:48AM BLOOD CK-MB-5 cTropnT-0.01
08:06AM BLOOD CK-MB-4 cTropnT-0.01
.
([**7-15**])
Calcium-8.0* Phos-3.7 Mg-1.6
Lactate-4.0*
Arterial Blood Gas: pO2-70* pCO2-74* pH-7.11* calTCO2-25 Base
XS--7
.
Labs on Discarge:
WBC-14.4* RBC-2.98* Hgb-9.0* Hct-26.2* MCV-88 MCH-30.2 MCHC-34.4
RDW-17.1* Plt Ct-293
Glucose-108* UreaN-49* Creat-0.9 Na-129* K-4.2 Cl-101 HCO3-25
AnGap-7*
Calcium-6.3* Phos-2.8 Mg-2.2
.
URINE CULTURE (Final [**2143-7-18**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 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-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2143-7-17**] 11:15 am SPUTUM
**FINAL REPORT [**2143-7-20**]**
GRAM STAIN (Final [**2143-7-17**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2143-7-20**]):
MODERATE GROWTH Commensal Respiratory Flora.
.
Blood cultures on [**7-17**],9,10,11 all were no growth.
.
URINE CULTURE (Final [**2143-7-24**]):
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 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-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
GRAM STAIN (Final [**2143-7-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2143-7-24**]): NO GROWTH, <1000
CFU/ml.
.
[**2143-7-22**] 6:39 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2143-7-23**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2143-7-23**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2143-8-1**] 12:35 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2143-8-1**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2143-8-1**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2143-8-1**] 6:48 pm URINE Source: CVS.
**FINAL REPORT [**2143-8-2**]**
URINE CULTURE (Final [**2143-8-2**]): <10,000 organisms/ml.
.
CT C Spine [**7-14**]
1. no acute fracture or malalignment
2. multilevel DJD
3. right thyroid nodules can be evaluted by non-emergent
ultrasound if
clinically indicated.
.
CT Head [**7-14**]
Small intraparenchymal hemorrhage with SAH extension in the
right frontal and left parieto-occipital lobes. No midline
shift. No fracture.
.
CT Head [**7-15**]
1. Overall expected evolution of right frontal and left
occipital
subcentimeter hemorrhagic contusions with associated
subarachnoid hemorrhage. Less conspicuous parafalcine and left
tentorial subdural hemorrhage, with redistribution of blood
products into the occipital horns, also compatible with expected
evolution. No new focal hemorrhage.
2. Underlying small vessel ischemic disease and probable left
frontal lacune. Focal hypodensity in the mid brain could also
represent additional lacune. Once acute issues resolve, MRI
could be considered for further evaluation if not
contraindicated.
.
CT Chest ([**7-14**])
Negative for fracture or malalignment of thoraco-lumbar spine
.
CT ABD/PELVIS ([**2143-7-14**])
1. No acute intra-thoracic or intra-abdominal injury.
2. Small subcutaneous contusion at the level of the right
greater trochanter.
3. Indeterminant renal lesion is probably a hyperdense cyst but
can be
further evaluated by non-emergent renal ultrasound, if
clinically indicated.
4. Moderate hiatal hernia.
.
L Hand Xray ([**7-14**])
No fracture or dislocation. Diffuse demineralization with
osteoarthritic change as detailed.
.
ECG ([**7-14**]): Sinus rhythm, rate of 94. Left ventricular
hypertrophy with secondary repolarization abnormalities. No
previous tracing available for comparison.
.
ECHO ([**7-16**]):
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate to severe
(3+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
CXR ([**8-1**]): No pulmonary congestion or new pulmonary
infiltrates.
Brief Hospital Course:
==========================
HOSPITAL SUMMARY
==========================
Patient is a [**Age over 90 **] year old woman with history of CHF, CAD (CABG
x2) who was admitted to the ICU and the neurosurgery team after
CT head showed frontal contusions as well as a small ICH and SDH
on the right. She was transfered to the MICU for actue
respiratory failure requiring intubation and had protracted
course due to traumatic self-extubation.
.
On [**7-16**], the patient was found to be in respiratory distress,
with oxygen saturations in the 70s/80s%. A code was called and
she was intubated, then transferred to the MICU. CXR noted
pulmonary congestion. There was low suspicion of PE, as CT on
the day prior w/ contrast showed no evidence of PE. She was
treated w/ IV lasix, with good diuresis.
.
On [**7-18**], she was mildly agitated and self-extubated with
resultant desaturation to the low 80s. The patient was
reintubated and EKG changes slight showed T wave inversions in
the lateral leads. Following, she had normal Troponin Ts.
After intubation, CXR showed a potential new RLL infiltrate, ?
PNA. She received vanc/tobra/cefepime for potential VAP, for a
total of 2 days. Also of note, prior to transfer to the MICU,
she was treated for a UTI (received ceftriaxone), which she
ended [**7-26**] (7d course).
.
On [**7-25**] interventional pulmonology extubated the patient. She
had stridors following extubation. She was placed on racemic
epinephrine and Heliox. She was kept on Heliox overnight w/out
desats/hypoxemia.
.
On [**7-26**], a laryngoscopy was performed by ENT, which demonstrated
laryngeal edema, and no other structural abnl. She was placed on
Decadron 10ml q8hrs.
==========================
ACTIVE ISSUES
==========================
ICH and SDH: Patient was admitted after sustaining head truama
secondary to an unwitnessed, ?syncopal episode. Echo and
telemetry revealed no e/o cardiac reason for ?syncope. Likely
vasovagal and hypovolemic. CT head on admission ([**7-14**]) showed a
small IPH with SAH extension in the R frontal and L
parieto-occipital lobes without midline shift. The pt was
admitted to the SICU for close monitoring. In the SICU, repeat
head CT showed expected evolution the IPH and given her
stability she was transferred to the neurology floor under the
neurosurgery team. Afterwards, patient was subsequently
transferred to the MICU for respiratory distress and required no
intervention for ICH/SDH and had no interval change in neuro
exam triggering reassessment. Pt to follow with neurosurgery as
outpt in [**4-17**] weeks.
.
RESPIRATORY FAILURE: On [**7-16**] pt began to desat into the 70's and
was put on a nonrebreather, but she continued to desat into the
80's. A code was called and she was ultimately sedated and
intubated. Pt was transferred to the MICU. On the floor, her
lasix had been held and she was receiving 1L of maintenance
fluids. She was given 40mg of Lasix during her code, and 40mg
more on the MICU. CXR showed findings of pulmonary edema that
were not present on study from admission. Respiratory failure
was attributed to pulmonary edema in setting of dCHF
exacerbation. On [**7-18**] pt self-extubated in the setting of
delirium in AM, desatted into 80's and was reintubated. On
[**7-21**], pt was started on dexamethasone for laryngeal edema. On
[**7-22**] developed a question of new RLL opacification and was
treated with antibiotics for 2 days for presumed VAP. Over the
next few days, spontaneous breathing trials failed, and she
developed laryngeal edema. On [**7-24**] was extubated by
interventional pulmonology and was markedly stridorous without
hypoxia post-extubation, was given racemic epinephrine and
heliox with improvement in symptoms. ON [**7-26**] had laryngoscopy by
ENT which showed larygeal edema without other findings and
increased to 10 mg dexamethasone Q8h for 3 days. Pt was called
out to the medicine floor on [**7-28**]. Her breathing was mildly
stridorous, but 96% on 3L on transfer. Pt was weaned off of O2,
breathing 96% on RA by evening of [**7-31**]. Pt required no more O2
support throughout hospitalization. Dexamethasone was weaned
down starting on [**7-29**], with final dose of dexamethasone given on
[**7-31**]. In setting of very minor stridor (no work of breathing,
no O2 requirement), ENT re-evaluated, with no new
recommendations and instructions for ENT follow-up.
.
HYPERNATREMIA/Hyponatremia: In MICU, patient's Na was noted to
trend up to 148 in the setting of ARF, diuresis with lasix,
hypovolemia and inability to take POs. Patient was treated with
500 cc boluses of D5W as needed. When transferred to floor,
pt's Na was 148. Free water deficit was calculated to be
approximately 1L. When NPO, pt was placed on D5 1/2 NS
maintenance fluid and lasix held. When pt initiated PO intake
([**7-30**]), Na corrected into normal range. On day of discharge, Na
was 129, likely due to liberal PO fluid intake (was being
encouraged by family at bedside). Pt's Na will be followed at
rehab.
.
ARF: Creatinine rose to 1.2 on [**7-27**] from a baseline of 0.8,
thought to be prerenal in the setting of diuresis and NPO
status. When admitted to the floor on [**7-28**], home lasix was held
and patient recieved D5 1/2 NS maintenance for correction of
hypernatremia. Diovan was stopped from [**Date range (1) 40891**], with
restarting at half dose with resolution of ARF. Lasix was
restarted on day of discharge. Cr 0.9 on day of discharge.
.
HYPERTENSION: Pt was normotensive while in the MICU. WHile on
the floor, pt was intermittentely hypertensive to 150s-180s, in
the setting of lasix and diovan being held, there was never
signs of end organ damage or hypertensive urgency. Throughtou
her hospitalization,she was maintained on 25 mg Metoprolol [**Hospital1 **]
PO. After her diovan was started half dose (160mg) on [**7-30**], HTN
improved to 130s-150s. Pt was normotensive in two days prior to
discharge.
.
LEUKOCYTOSIS: Patient developed a leukocytosis to 23.5 ([**7-25**])
in the setting of dexamethasone administration. No evidence of
infection was appreciated (CXR no changes, no pyuria or pos
urine cxs). In setting of one day of loose stools ([**8-1**]), C.
diff was negative, and no repeat loose stools. No interventions
were taken aside from planned dex taper, and leukocytosis
resolving, to 14.4 on discharge.
.
DIABETES: Patient had been receiving metformin as an outpatient
and was switched to an insulin sliding scale while in the
intensive care unit. She developed worsening hyperglycemia in
response to steroids and was managed with an increased sliding
scale. Pt transiently hyperglycemic (FSs 300s-400s) during dex
taper, but hyperglycemia gradually resolved with end of
dexamethasone (FSs 120s-250 on day of discharge). Pt was
restarted on metformin at discharge.
.
CAD and DIASTOLIC CHF: Enzymes were negative on admission.
Echo on admission showed preserved ejection fraction and no wall
motion abnormalities (see full results in the RESULTS section of
this discharge [**Last Name (un) 17576**]). While in the MICU, on [**7-24**] ECG showed
increased T wave inversions in lateral leads (old) and anterior
leads (newer). Enzymes were negative and patient received TTE
which showed 3+ MR and an EF of >55%. She was restarted on
metoporol and valsartan when tolerating POs and received home
lasix once pulmonary edema had resolved.
.
#UTI: Klebsiella UTI while in MICU resolved, finished 7 days of
ceftriaxone [**2143-7-26**]. No growth on urine cx from [**7-28**].
.
#Nutrition: Speech and swallow evaluation on [**7-30**] = regular
diet, thin liquids. Pt took POs easily after [**7-30**] (more fluids
than solids).
.
#Anemia: Hct 33.7 on day of admission. Was 27.9 on transfer to
MICU, in the setting of lasix being held and IVF administered.
On transfer to floor, Hct was 25.6. Hct was 22.5 on [**7-31**], with
no source of bleeding (no pain, stools guaiac negative), likely
[**2-13**] marrow suppression in the setting of prolonged and
complicated hospital course. Pt received 1 unit pRBCs on [**7-31**],
Hct bumped to 27.9 on [**8-1**].
.
============================
INACTIVE ISSUES
============================
DEPRESSION: Patient continued to recieve her home Paxil 20 mg.
.
============================
TRANSITIONAL ISSUES
============================
1.) R thyroid nodule and L renal cyst identified on extensive CT
imaging during this hospitalization should be followed up on an
outpatient basis.
2.) Pt should receive intensive PT, due to deconditioning from
prolonged acute-care hospitalization.
3.) Pt was evaluated by specialists in speech and swallowing
during the hospitalization. Regular food and thin liquids, and
oral medications, are appropriate for this pt. She should be
encouraged to eat and drink (DMII, low salt, heart healthy diet)
liberally to discourage malnutrition.
4.) Pt has an appt with Dr. [**Last Name (STitle) **] (ENT) on [**8-13**].
5.) Pt needs to f/u with neurosurgery in [**4-17**] weeks, with a CT
scan before her appt. The patient has been given instructions.
6.) Pt is discharged to acute rehab ([**Hospital1 **] [**Hospital1 8**]).
Letter has been sent to PCP. [**Name10 (NameIs) **] to follow-up with PCP.
7.) Pt mildly hyponatremic on discharge (129), likely from
liberal PO fluid intake. Rehab to follow Na. Pt's leukocytosis
resolving, by time of discharge, in setting of stopping
steroids. Rehab to follow WBC.
Medications on Admission:
ASA 81
carteolol 1% on drop HS
paroxetine 20mg qd
nifedipine 60mg ER qd
atenolol 100mg qd
valsartan 320mg qd
atorvastatin 80mg qd
pantoprazole 40mg qd
lasix 40mg [**Hospital1 **]
Isosorbide Mononitrate 30mg twice per day
fluticasone 50mcg 2 sprays qd
metformin 1000 PO BID, with meals
glucosamine 1g qd
zetia 10mg qd
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) packet PO BID
(2 times a day).
Disp:*60 packet* Refills:*0*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
3. carteolol 1 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
5. paroxetine HCl 10 mg/5 mL Suspension Sig: Two (2) doses PO
DAILY (Daily).
6. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. psyllium Packet Sig: One (1) Packet PO DAILY (Daily).
Disp:*30 Packet(s)* Refills:*0*
9. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
spray Nasal once a day as needed for rhinitis: each nostril, as
needed.
15. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day: one pill with breakfast, one pill with supper.
16. Glucosamine 750 mg Tablet Sig: One (1) Tablet PO once a day.
17. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
18. Outpatient Lab Work
Please collect CBC, electrolytes (chem 10, with particular
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
Subarachnoid hemorrhage
Secondary Diagnoses:
respiratory failure
Acute kidney injury
hypertension
diabetes mellitus II
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 4401**],
.
It was a pleasure taking care of you.
.
You were admitted to the hospital because you fell, hit your
head and had a bleed within your head. Your hospital course was
complicated by respiratory failure in the setting of pulmonary
edema (fluid in your lungs). You had a prolonged stay in the
MICU, where you were intubated. You had some laryngeal edema
(swelling in your throat) from irritation from the breathing
tube. You made progress while in the hospital, changing from
the MICU to the general medicine floor. By the time of
discharge to your rehab facility, you were breathing fine on
your own, without the aid of oxygen; you were taking food and
fluid down; you were exercising with the aid of the physical
therapists.
.
You had a bit of diarrhea yesterday, which has resolved. Stool
tests were reassuring. In the rehab facility they will check
the sodium in your blood (was slightly low on discharge) and
also your white blood count (WBC) to monitor for infection.
They will also work on strengthening your body, and to get you
eating a good diet again.
.
We made the following changes to your medications:
CHANGES:
From Atenolol to METOPROLOL TARTRATE 25mg by mouth twice per day
From Valsartan 320mg to Valsartan 160mg per day
From Lasix (furosemide) 40mg twice per day to 40mg once per day
.
STOPPED MEDS:
Stop Isosorbide Mononitrate 30mg twice per day
OTHERWISE, YOU SHOULD CONTINUE YOUR HOME MEDICATIONS AS YOU HAD
TAKEN THEM BEFORE.
.
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Please follow up with your primary care physician regarding
follow up for CT findings including a renal lesion/cyst but can
be further evaluated by non-emergent renal ultrasound,Moderate
hiatal hernia and right thyroid nodules can be evaluted by
non-emergent ultrasound.
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:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in 6 weeks.
?????? You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
.
Please follow up with your primary care physician regarding
follow up for CT findings including a renal lesion/cyst but can
be further evaluated by non-emergent renal ultrasound,Moderate
hiatal hernia and right thyroid nodules can be evaluted by
non-emergent ultrasound.
.
Location: [**Hospital1 69**]
Specialty: Neurosurgery
Address: [**Location (un) **] [**Location (un) 86**] [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1669**]
**We are working on a follow up appointment with the
Neurosurgery department within 2-4 weeks. You will be called
with the appointment. If you have not heard from the office
within 2 days or have any questions, please call the number
above.**
.
Department: OTOLARYNGOLOGY (ENT)
When: TUESDAY [**2143-8-13**] at 2:15 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
ICD9 Codes: 5990, 2761, 2760, 5849, 4019, 2720, 4280, 2859, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6508
} | Medical Text: Unit No: [**Numeric Identifier 76435**]
Admission Date: [**2186-1-25**]
Discharge Date: [**2186-2-12**]
Date of Birth: [**2186-1-21**]
Sex: F
Service: NBB
PATIENT IDENTIFICATION: The patient's post-discharge name is
[**Name (NI) **] [**Name (NI) 40558**].
HISTORY OF PRESENT ILLNESS: This is the former 1.14 kilogram
product of a 29 and 1/7 weeks gestation pregnancy born to a
28-year-old G2, P1, now P2 woman. Prenatal screens: Blood
type O positive, antibody negative, hepatitis B surface
antigen negative, rubella equivocal, RPR nonreactive, group
beta strep status unknown. The mother's medical history is
notable for asthma which is treated with an inhaler. She also
had a chronic pain syndrome and abused the drug OxyContin.
She was treated at a rehabilitation center and was
transitioned to methadone. During this pregnancy she
developed pneumonia which was complicated by adult
respiratory distress syndrome. She required intubation and
was transferred from [**Hospital3 **] to the Intensive
Care Unit at [**Hospital1 69**]. On the day
of delivery the mother became encephalopathic and had a
generalized seizure. She was diagnosed with eclampsia. She
had received betamethasone. The mother was delivered by
emergent cesarean section for the worsening eclampsia. The
infant emerged vigorous with Apgars of 8 at 1 minute and 8 at
5 minutes. She was admitted to the neonatal intensive care
unit for treatment of prematurity. At that time due to census
issues she was transferred to [**Hospital3 1810**]. She
returned on day of life number 4, [**2185-1-25**].
Anthropometric measurements at the time of delivery: Weight
1.140 kilograms, 25th to 50th percentile, length 37.5 cm,
25th to 50th percentile, head circumference 26 cm, 25th to
50th percentile.
PHYSICAL EXAMINATION AT DISCHARGE: Weight 1.53 kilograms,
length 41.5 cm, head circumference 28 cm. General:
Nondistressed preterm infant in open crib, room air. Skin:
Warm and dry. Color pink, well perfused. Head, ears, eyes,
nose, and throat: Anterior fontanel open and flat,
soft. Symmetrical facial features. Palate intact. Oral
mucosa clear. Positive red reflex bilaterally. Neck: Supple
without masses. Chest: Breath sounds clear and equal.
Cardiovascular: Grade [**2-1**] soft systolic murmur left upper
sternal border consistent with peripheral pulmonic stenosis.
Femoral pulses +2. Normal S1, S2. Abdomen: Soft, nontender,
nondistended, no masses, active bowel sounds. Cord off.
Umbilicus healing. GU: Normal preterm female. Spine straight,
normal sacrum. Extremities: Moves all well. Hips stable.
Clavicles intact. Neuro: Alert with vigorous tone and cry.
Positive suck. Positive grasp.
HOSPITAL COURSE:
1. RESPIRATORY: This infant had transitional respiratory
distress requiring treatment with continue positive
airway pressure. She weaned to room air on day of life
number 2 and remained in room air for the rest of her
neonatal intensive care unit admission. She required
treatment for apnea of prematurity with caffeine
citrate. At the time of discharge she is breathing
comfortably with a respiratory rate of 30 to 60 breaths
per minute. Oxygen saturations on room air on greater
than or equal to 94%.
2. CARDIOVASCULAR: This infant has maintained normal heart
rates and blood pressures. A soft murmur has been noted
intermittently during admission and is well localized to
the left upper sternal border with characterization
consistent with peripheral pulmonic stenosis. At the
time of discharge her baseline heart rate is 140 to 160
beats per minute with a recent blood pressure of 75/31
with a mean arterial pressure of 46 millimeters of
mercury.
3. FLUIDS, ELECTROLYTES, NUTRITION: The infant had an
umbilical venous catheter placed for parenteral
nutrition. Enteral feedings were started on day of life
number 2 and gradually advanced to full volume. At the
time of discharge she is taking 150 milliliters per kilo
per day of preemie Enfamil or breast milk 28 calories
per ounce. Her feedings are by gavage. Serum
electrolytes were checked in the first week of life and
were within normal limits. Weight of the day of
discharge is 1.53 kilograms.
4. INFECTIOUS DISEASE: Due to the unknown group beta strep
status of her mother and her respiratory distress, this
infant was evaluated for sepsis on admission to the
neonatal intensive care unit. A complete blood count was
within normal limits. A blood culture was obtained prior
to starting intravenous ampicillin and gentamicin. The
blood culture was no growth at 48 hours and the
antibiotics were discontinued.
5. HEMATOLOGICAL: Hematocrit at birth was 58%. This infant
has not received any transfusions of blood products. She
is being treated with supplemental iron.
6. GASTROINTESTINAL: This infant required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life 2, a total of
5.9 milligrams per deciliter. She was treated with
phototherapy for approximately 5 days. Rebound bilirubin
on day of life number 8 was 4.6 milligrams per
deciliter.
7. NEUROLOGY: This infant showed signs of narcotic
withdrawal thought to be related to the mother's
methadone maintenance. She was treated with neonatal
opium solution initiated on [**2186-1-29**]. Her
initiating dose was 0.8 milligrams per kilo per day.
After her symptoms were controlled this dose was
gradually weaned. On [**2186-2-6**] the dose was
discontinued and the approximately dosing at that time
was less than 0.2 milligrams per kilo per day. At the
time of discharge her neonatal abstinence scale scores
are 0 to 2 and she has some anal excoriation. A head
ultrasound was performed on [**2185-1-26**] and all
results were within normal limits. A follow up head
ultrasound is recommended at 1 month and at 36 weeks
postmenstrual age. The infant's neurological exam is
appropriate.
8. SENSORY:
AUDIOLOGY: Hearing screening has not yet been performed,
but is recommended prior to discharge.
OPHTHALMOLOGY: This infant will require ophthalmological
exams, screening for retinopathy of prematurity. Her eyes
have not yet been examined. Her first eye exam is due at
4 to 5 weeks of age.
PSYCHOSOCIAL: [**Hospital1 69**] social
work has been involved with this family. Contact social
worker is [**Name (NI) 46381**] [**Name (NI) 36527**] and she can be reached at
([**Telephone/Fax (1) 24237**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 **] for
continuing level II care.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 5699**], Pediatric
Associates of [**Location (un) 1468**], ([**Telephone/Fax (1) 44940**].
CARE RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: 150 ml per kilo per day of breast milk 28
calorie per ounce or preemie Enfamil 28 calorie per
ounce formula. The breast milk is formulated 4 calories
by human milk fortifier, 4 calories by medium chain
triglyceride oil, and [**12-28**] teaspoon of beneprotein
powder per 100 ml of breast milk. Feedings are by
gavage.
2. Medications: Caffeine citrate 11.4 mg p.g. once daily,
ferrous sulfate 25 mg/ml dilution 0.1 ml p.g. once
daily, vitamin E 5 IU p.g. once daily.
3. Iron and vitamin D supplementation:
a. Iron supplementation is recommended for preterm
and low birth weight infants until 12 months corrected
age.
b. All infants feeding predominantly breast milk
should receive vitamin D supplementation at 200 IU ([**Month (only) 116**]
be provided as a multivitamin preparation.) daily until
12 months corrected age.
4. Car seat position screening is recommended prior to
discharge.
5. State newborn screens were sent on [**1-21**] and [**2-4**], [**2185**]. No notification of abnormal results have been
received.
6. Immunizations: No immunizations have been administered.
7. Immunizations recommended:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following four criteria: First - born at less than or
equal to 32 weeks; Second - born between 32 and 35 and
0/7 weeks with two of the following: childcare during RSV
season, a smoker in the household, neuromuscular
disease, airway abnormalities, or school age siblings;
thirdly - chronic Lyme disease; or fourth -
hemodynamically significant congenital heart disease.
b. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of
age. Before this age if in the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
c. This infant has not received rotavirus vaccine.
The American Academy of Pediatrics recommends initially
vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least weeks, but fewer than 12 weeks of
age.
DISCHARGE DIAGNOSES:
1. Prematurity at 29 and 1/7 weeks gestation.
2. Transitional respiratory distress.
3. Suspicion for sepsis, ruled out.
4. Unconjugated hyperbilirubinemia.
5. Apnea of prematurity.
6. Narcotic abstinence syndrome.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 75740**]
MEDQUIST36
D: [**2186-2-12**] 01:46:30
T: [**2186-2-12**] 15:58:27
Job#: [**Job Number 76436**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6509
} | Medical Text: Admission Date: [**2136-11-7**] Discharge Date: [**2136-11-10**]
Date of Birth: [**2057-1-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Pericardial effusion
Major Surgical or Invasive Procedure:
Drainage of a pericardial effusion
History of Present Illness:
79 yo female with h/o COPD on home O2, HTN, HLP, DM,
osteoporosis, morbid obesity who presented to an OSH with
worsening SOB. She had been treated with Z-pack without
benefit. She continued to have worsening SOB throughout her
admission there. She had an echocardiogram initially which
showed a pericardial effusion, which was fairly small without
any evidence of tamponade physiology, but she then had a repeat
echo cardiogram on [**11-5**] with which showed a large anterior and
posterior pericardial effusion which measured 17 mm in diastole
and 21 mm in systole. She was then transferred for further
evaluation and potential pericardiocentesis.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
COPD on home O2
Diverticulitis
Morbid Obesity
Hypothyroidism
Chronic LBP
Chronic Headaches
Glaucoma
Social History:
The patient is retired; used to work in a stitching factory;
lives alone.
-Tobacco history: [**11-23**] ppd x 10 yrs Quit smoking: quit 30 yrs
ago
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
VS: T=97.9 BP=132/94 HR=70 RR=16 O2 sat=100% on 2L
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. few bibasilar crackles
with a scattered expiratory wheezes throughout lung fields.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c. 2+ BLE edema [**11-23**] to knees. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 2+
Pertinent Results:
Admission labs:
[**2136-11-8**] 03:43AM BLOOD WBC-17.3* RBC-4.11* Hgb-11.4* Hct-33.7*
MCV-82 MCH-27.6 MCHC-33.7 RDW-14.4 Plt Ct-300
[**2136-11-8**] 03:43AM BLOOD Neuts-79.5* Lymphs-11.2* Monos-8.9
Eos-0.4 Baso-0
[**2136-11-8**] 03:43AM BLOOD PT-12.2 PTT-23.9 INR(PT)-1.0
[**2136-11-8**] 03:43AM BLOOD Glucose-86 UreaN-31* Creat-0.8 Na-137
K-4.3 Cl-98 HCO3-32 AnGap-11
[**2136-11-8**] 03:43AM BLOOD ALT-42* AST-14 LD(LDH)-224 CK(CPK)-27
AlkPhos-67 TotBili-0.7
[**2136-11-8**] 03:43AM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.6* Mg-2.5
[**2136-11-8**] 03:43AM BLOOD TSH-5.2*
[**2136-11-9**] 05:30AM BLOOD Free T4-1.5
Discharge labs:
[**2136-11-10**] 07:35AM BLOOD WBC-11.5* RBC-4.05* Hgb-11.6* Hct-33.8*
MCV-83 MCH-28.6 MCHC-34.3 RDW-14.3 Plt Ct-237
[**2136-11-10**] 07:35AM BLOOD PT-12.5 PTT-23.7 INR(PT)-1.1
[**2136-11-10**] 07:35AM BLOOD Glucose-115* UreaN-18 Creat-0.7 Na-138
K-5.3* Cl-100 HCO3-33* AnGap-10
[**2136-11-10**] 07:35AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.3
[**11-8**] Pericardial fluid:
GRAM STAIN (Final [**2136-11-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2136-11-9**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**11-8**] pericardial fluid cytology: Pending
[**11-8**] pericardial fluid
OTHER BODY FLUID ANALYSIS WBC Hct,Fl Polys Lymphs Monos
[**2136-11-8**] 02:30PM 889*1 21*2 48*3 44* 8*
PERICARDIAL FLUID
BLOODY, SUPERNATANT MODERATELY XANTHOCHROMIC
SPUN HCT
SPUN HEMATOCRIT PERFORMED
50 CELL DIFFERENTIAL
OTHER BODY FLUID CHEMISTRY TotProt Glucose Amylase Albumin
[**2136-11-8**] 02:30PM 4.4 127 26 3.1
STUDIES
EKG: NSR HR approx 70, left shift axis; slightly decreased
voltage on precordial leads, and possibly alternans in
precordial leads
2D-ECHOCARDIOGRAM: [**2136-11-5**]
1) RV systolic function is decreased
2) A large anterior and posterior pericardial effusion is
present, posteriorly measuring 17 mm in diastole and 21 mm in
systole.
TTE [**11-8**]: The left atrium is mildly dilated. The estimated
right atrial pressure is 10-20mmHg. 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 but aortic stenosis is not
present. The estimated pulmonary artery systolic pressure is
normal. There is a large circumferential pericardial effusion
with a small layer (0.9 cm) echo dense material on the right
ventricle consistent with blood, inflammation or other cellular
elements. No right ventricular diastolic collapse is seen. There
is brief right atrial diastolic collapse. The heart swings with
each cardiac cycle and the anterior echolucent pericardial
effusion varied between 2 cm and 0 cm. Apically, the effusion
varied between 2.1 cm and 0.8 cm.
IMPRESSION: Large circumferencial pericardial effusion with no
clear evidence of tamponade. There is significant cardiac motion
with variable local pericardial effusion size between cardiac
cycles.
Cath [**11-8**]: COMMENTS:
1. Resting hemodynamics revealed elevated right sided pressures
and
equalization of of RA, PCW and pericardial pressures consistent
with
tamponade.
2. Subxiphoid pericardiocentesis removed 820 cc of bloody fluid.
Pericardial pressure fell to 2 mmHg with RA pressure of 8 mmHg.
Fluid
was sent for cytology, culture, and chemistries. Echo confirmed
pericardial effusion was now only small post-pericardiocentesis.
FINAL DIAGNOSIS:
1. Large pericardial effsusion with tamponade physiology.
2. Successful pericardiocentesis with removal of 820 cc of
fluid.
Repeat TTE [**11-8**]:There is a small pericardial effusion (mostly
posterior to the LV).
Compared with the prior study (images reviewed) of [**2136-11-8**],
the amount of pericardial effusion has significantly decreased.
TTE [**11-9**]: Overall left ventricular systolic function is normal
(LVEF>55%). with normal free wall contractility. There is a
small pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
IMPRESSION: Very small residual echodense pericardial effusion.
Compared with the prior study (images reviewed) of [**2136-11-8**],
pericardial effusion size has further decreased.
TTE [**11-10**]: Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). There is
abnormal septal motion/position. The mitral valve leaflets are
mildly thickened. There is a small pericardial effusion. There
are no echocardiographic signs of tamponade.
IMPRESSION: Small pericardial effusion, located posterior to the
right atrium without evidence of tamponade. There is a septal
bounce seen which could be consistent with effusive-constrictive
pericardial disease.
Compared with the prior study (images reviewed) of [**2136-11-9**],
the size of the effusion is similar. The septal bounce may be
slightly more prominent.
Brief Hospital Course:
79 yo F with COPD, DM, HTN, hyperlipidemia, who was transferred
from an OSH for worsening SOB found to have a large pericardial
effusion with tamponade physiology on ECHO no s/p drainage.
# PERICARDIAL EFFUSION: The patient was admitted to the outside
hospital with increasing shortness of breath over weeks and was
found to have an increasing pericardial effusion with tamponade
physiology. She underwent pericardiocentesis during which 800
cc of bloody fluid was removed. The main differential for her
effusion includes malignancy, TB, post viral, autoimmune,
infectious. A TSH was checked and was slightly elevated at 5.2,
however her free T4 was normal at 1.5. Her fluid cultures have
been no growth to date and fluid cytology is pending.
Malignancy is highly possible given her age and size of
effusion. She remained hemodynamically stable during her
admission. She had several echos after drainage which showed no
reaccumulation of fluid. She will continue to undergo workup
for this as an outpatient with her cardiologist.
# CORONARIES: The patient has no known history of coronary
artery disease. She was transferred on a B-blocker from the
OSH, however she was not on one at home. This was stopped given
the concern for tamponade physiology and was not restarted. She
was started on 81 mg of ASA daily for primary prevention given
her history of DM and hypertension. She was continued on her
home statin.
# Acute systolic heart faliure: The patient had slight edema on
exam on admission and was thought to be in acute systolic heart
failure secondary to the pericardial effusion/tamponade
physiology. She was treated initally with 40 mg IV lasix and
then changed back to her home dose of lasix 40 mg po daily. Her
EF normalized on TTE after drainage of the effusion.
# RHYTHM: The patient remain in normal sinus rhythm during her
hospitalization.
# COPD: The patient had been treated for a COPD exacerbation at
the OSH, however her SOB was likely due to the pericardial
effusion and resolved once it was drained. She was continued on
her home medications including advair [**Hospital1 **], flonase, and
albuterol prn. She was also treated with atrovent while she was
hospitalized, but was not discharge on this. She had been
treated with prednisone at the OSH, so this was quickly tapered
and she will complete the taper the day after discharge.
# DM: The patient takes avandamet as an outpatient, however this
was held during her hospitalization. She was initally covered
with sliding scale insulin, however her sugars were elevated so
she was given a small dose of lantus in addition to the sliding
scale. She was discharged back on her home regimen of
avandamet.
# HTN: She was generally normotensive while hospitalized and was
intially given IV lasix for diuresis, but then was continued on
her home dose of 40 mg po lasix daily.
# Hyperlipidemia: The patient was continued on her home statin.
# Hypothyroidism: The patient was continued on her home
levothyroxine.
Medications on Admission:
MEDICATIONS AT HOME:
Lasix 40 mg daily
Antivert 25 mg TID
Lipitor 10 mg daily
Prilosec 20 mg daily
Synthroid 125 mcg daily
Xalatan 0.005% each eye qhs
Advair diskus 500/50 mcg [**Hospital1 **]
Nasonex 1 squirt in each nose [**Hospital1 **]
Avandamet 25/250 mg [**Hospital1 **]
Albuterol 2.5 mg q2H nebulized PRN
Claritin 10 mg QHS
Fosamax 70 mg daily
Hydroxyzine
MEDICATIONS AT TRANSFER:
Prednisone 50 mg daily - taper
Metoprolol tartrate 12.5 mg [**Hospital1 **]
Synthroid 125 mcg daily
Prevacid 30 mg [**Hospital1 **]
Nystatin powder daily
Lasix 40 mg daily
Lipitor 10 mg daily
Xalatan 0.005% QHS each eye
Nasonex [**Hospital1 **]
Claritin 10 mg daily
Heparin sc
Tylenol PRN
Lorazepam 0.5 mg Q6H PRN
Antivert 25 mg PO Q6H PRN dizziness
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for dizziness.
3. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily).
4. Claritin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Synthroid 125 mcg Tablet Sig: One (1) Tablet PO once a day.
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
11. AVANDAMET Oral
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
13. Fosamax 70 mg Tablet Oral
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
1 days.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary -
Pericardial effusion
Secondary -
Hypertension
Diabetes
Hypothyroidism
Chronic obstructive pulmonary disease
Hyperlipidemia
Discharge Condition:
Hemodynamically stable, without shortness of breath.
Discharge Instructions:
You were transferred to this hospital becuase you had a large
pericardial effusion. You underwent a pericardiocentesis
(drainage of the fluid around your heart). It is unclear what
caused the pericardial effusion, however tests on the fluid are
pending. You may need to undergo further tests and imaging
studies as an outpatient to figure out the cause of the
effusion. You were also treated for an exacerbation of your
chronic obstructive pulmonary disease prior to transfer to this
hospital. You will need to take one more day of prednisone to
complete treatment for this exacerbation.
You were started on aspirin 81 mg daily. You will need to take
10 mg of prednisone the day after discharge. Otherwise continue
your outpatient medications as prescribed.
Go to the emergency room or call your primary docotor if you
experience fevers, chills, chest pain, shortness of breath,
dizziness, blood in your stool, or black stool.
Followup Instructions:
You will need to follow up with Dr. [**Last Name (STitle) **] in [**11-23**] weeks. His
office number is [**0-0-**]. Please call and make an
appointment on Monday. It is very improtant that you follow up
with him in this time frame.
You should also follow up with your primary doctor within in the
next month.
Completed by:[**2136-11-10**]
ICD9 Codes: 496, 4019, 2724, 2449, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6510
} | Medical Text: Admission Date: [**2184-9-9**] Discharge Date: [**2184-9-19**]
Date of Birth: [**2137-5-6**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Acetaminophen / Ultram / Oxycontin / Zantac /
Levofloxacin
Attending:[**Last Name (NamePattern1) 15344**]
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
Exploratory laparotomy, lysis of adhesions,
small bowel resection, primary repair of recurrent ventral
hernia, placement of left femoral vein triple lumen central
venous line, placement of PICC.
History of Present Illness:
The patient is a 47-year-old female with end
stage renal disease on hemodialysis, status post epigastric
ventral hernia repair in the distant past, who was noted
recurrence of the ventral hernia but without any symptoms.
The day PTA, during hemodialysis, she developed abdominal
discomfort and nausea, and thereafter, severe pain at the
side of the recurrent epigastric ventral hernia. She came to
the emergency room where a CT scan of the abdomen revealed a
small omental fat- containing ventral hernia above the
umbilicus with mild adjacent inflammatory fat stranding.
Adjacent to this region, there were multiple prominent loops
of small bowel with fecalization of bowel contents and
surrounding inflammatory fat stranding and fluid locally. The
loops of bowel distal to these prominent loops appeared
decompressed and the findings were suggestive of a recent
reduction of an incarcerated hernia with high grade
obstruction. She now presents for exploratory laparotomy.
Past Medical History:
1. Significant for end-stage renal disease secondary to
glomerulonephritis possibly secondary to IgA diagnosed in
[**2165**], and the patient has been on hemodialysis since [**2170**].
She is anuric and is on Monday, Wednesday, and Friday
dialysis schedule.
2. The patient has had bilateral below-the-knee amputations
secondary to calciphylaxis in [**2181-1-19**] as well as
multiple finger amputations during the same year.
3. She is status post a parathyroidectomy for previous
admissions for hypercalcemia.
4. The patient is status post a left arteriovenous fistula on
her left upper extremity placed in [**2179**], which became
injured during a fistulogram in [**2183-3-22**].
5. She has chronic pain.
6. She is status post a mitral valve replacement in [**2180-3-21**] with a mechanical Carbomedics 29-mm valve for
rheumatic heart disease; and she is on Coumadin for this
valve. She also has a history of endocarditis.
7. History of hypertension.
8. Anxiety.
Social History:
The patient smokes one-third of a pack per
day. She denies any EtOH and is disabled.
Family History:
Non-contributory
Physical Exam:
On admission:
99.8 100 90/49 19
A&Ox3 in obvious pain
MMM, w/o JVD
RRR, tachy, no murmur
CTAB
soft +BS, epigastric TTP, voluntary gaurding, non-distended, no
rebound
guaiac negative
s/p bilat BKA
Pertinent Results:
[**2184-9-17**] 01:10PM BLOOD WBC-4.6 RBC-3.30* Hgb-9.9*# Hct-28.9*
MCV-88 MCH-30.0# MCHC-34.2# RDW-18.4* Plt Ct-176
[**2184-9-15**] 06:05AM BLOOD WBC-6.3 RBC-2.66* Hgb-7.2* Hct-23.1*
MCV-87 MCH-26.9* MCHC-31.0 RDW-18.5* Plt Ct-148*
[**2184-9-14**] 06:48AM BLOOD WBC-5.6 RBC-2.72* Hgb-7.4* Hct-23.9*
MCV-88 MCH-27.1 MCHC-30.8* RDW-18.0* Plt Ct-142*
[**2184-9-13**] 08:10AM BLOOD WBC-6.2 RBC-2.69* Hgb-7.5* Hct-23.8*
MCV-89 MCH-27.8 MCHC-31.3 RDW-18.3* Plt Ct-146*
[**2184-9-13**] 05:39AM BLOOD WBC-5.9 RBC-2.73* Hgb-7.5* Hct-24.5*
MCV-90 MCH-27.4 MCHC-30.6* RDW-18.1* Plt Ct-135*
[**2184-9-12**] 06:15AM BLOOD WBC-6.9 RBC-2.99* Hgb-8.5* Hct-26.8*
MCV-90 MCH-28.6 MCHC-31.9 RDW-17.9* Plt Ct-127*
[**2184-9-11**] 03:03AM BLOOD WBC-7.2 RBC-3.17* Hgb-8.9* Hct-27.5*
MCV-87 MCH-28.2 MCHC-32.4 RDW-17.9* Plt Ct-120*
[**2184-9-10**] 07:43PM BLOOD Hct-30.2*
[**2184-9-10**] 03:08AM BLOOD WBC-12.5* RBC-3.66* Hgb-10.1* Hct-31.1*
MCV-85 MCH-27.6 MCHC-32.6 RDW-18.1* Plt Ct-118*
[**2184-9-9**] 02:15PM BLOOD WBC-16.1* RBC-3.51* Hgb-9.7* Hct-29.0*
MCV-83 MCH-27.7 MCHC-33.6 RDW-18.2* Plt Ct-114*
[**2184-9-9**] 08:00AM BLOOD WBC-15.9* RBC-3.61*# Hgb-10.0*#
Hct-31.1*# MCV-86 MCH-27.7 MCHC-32.2 RDW-18.6* Plt Ct-107*
[**2184-9-8**] 09:40PM BLOOD WBC-11.5*# RBC-5.47* Hgb-15.5 Hct-46.2
MCV-84 MCH-28.3 MCHC-33.5 RDW-17.9* Plt Ct-138*
[**2184-9-17**] 09:30AM BLOOD PT-23.8* PTT-49.4* INR(PT)-4.1
[**2184-9-16**] 05:40AM BLOOD PT-24.5* PTT-59.0* INR(PT)-4.4
[**2184-9-15**] 09:12PM BLOOD PT-23.6* PTT-48.0* INR(PT)-4.0
[**2184-9-15**] 06:05AM BLOOD PT-27.4* PTT-56.0* INR(PT)-5.5
[**2184-9-14**] 06:48AM BLOOD PT-24.3* PTT-54.4* INR(PT)-4.3
[**2184-9-13**] 08:55PM BLOOD PT-23.1* PTT-50.8* INR(PT)-3.9
[**2184-9-13**] 05:39AM BLOOD PT-22.9* PTT-104.3* INR(PT)-3.8
[**2184-9-12**] 06:15AM BLOOD PT-18.0* PTT-58.2* INR(PT)-2.3
[**2184-9-11**] 03:03AM BLOOD PT-16.8* PTT-56.5* INR(PT)-1.9
[**2184-9-8**] 07:00AM BLOOD PT-18.9* INR(PT)-2.5
[**2184-9-16**] 05:40AM BLOOD Glucose-68* UreaN-22* Creat-5.0*# Na-141
K-3.4 Cl-96 HCO3-28 AnGap-20
[**2184-9-15**] 06:05AM BLOOD Glucose-68* UreaN-43* Creat-7.3*# Na-141
K-3.7 Cl-102 HCO3-23 AnGap-20
[**2184-9-14**] 06:48AM BLOOD Glucose-86 UreaN-35* Creat-6.0*# Na-144
K-4.0 Cl-102 HCO3-25 AnGap-21*
[**2184-9-12**] 06:15AM BLOOD Glucose-70 UreaN-45* Creat-6.6*# Na-144
K-4.3 Cl-100 HCO3-24 AnGap-24*
[**2184-9-11**] 03:03AM BLOOD Glucose-92 UreaN-32* Creat-5.3*# Na-143
K-4.4 Cl-102 HCO3-24 AnGap-21*
[**2184-9-10**] 03:08AM BLOOD Glucose-74 UreaN-46* Creat-6.7* Na-139
K-4.5 Cl-98 HCO3-22 AnGap-24*
[**2184-9-9**] 02:15PM BLOOD Glucose-89 UreaN-37* Creat-5.9* Na-140
K-4.6 Cl-99 HCO3-25 AnGap-21*
[**2184-9-9**] 08:00AM BLOOD Glucose-141* UreaN-33* Creat-5.5* Na-141
K-4.2 Cl-100 HCO3-25 AnGap-20
[**2184-9-8**] 11:20PM BLOOD Glucose-142* UreaN-28* Creat-5.7* Na-141
K-4.5 Cl-94* HCO3-27 AnGap-25*
[**2184-9-8**] 09:40PM BLOOD Glucose-119* UreaN-25* Creat-5.7*# Na-139
K-4.7 Cl-90* HCO3-30 AnGap-24*
[**2184-9-8**] 09:40PM BLOOD ALT-66* AST-41* AlkPhos-468* Amylase-415*
TotBili-0.5
[**2184-9-16**] 05:40AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.4*
[**2184-9-15**] 06:05AM BLOOD Calcium-8.3* Phos-4.4 Mg-1.5*
[**2184-9-14**] 06:48AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.7
[**2184-9-13**] 08:10AM BLOOD Albumin-3.0* Calcium-8.7 Phos-5.8* Mg-1.7
UricAcd-6.7*
[**2184-9-12**] 06:15AM BLOOD Calcium-8.9 Phos-5.2* Mg-1.7
[**2184-9-11**] 03:03AM BLOOD Calcium-9.3 Phos-5.1* Mg-1.9
[**2184-9-10**] 03:08AM BLOOD Calcium-8.4 Phos-5.2* Mg-1.5*
[**2184-9-9**] 02:15PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.5*
[**2184-9-9**] 08:00AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.5*
[**2184-9-8**] 09:40PM BLOOD Albumin-4.9* Calcium-10.0 Phos-4.8*
Mg-1.8
[**2184-9-10**] 11:25AM BLOOD freeCa-1.14
[**2184-9-9**] 02:22PM BLOOD freeCa-1.15
[**2184-9-9**] 06:33AM BLOOD freeCa-1.04*
[**2184-9-9**] 05:23AM BLOOD freeCa-1.04*
Brief Hospital Course:
Pt admitted to surgery from the ED.
Ct showed:
1. Prominent loops of proximal small bowel adjacent to an
omental fat containing ventral hernia with fecalization of bowel
contents, adjacent inflammatory fat stranding, and small amount
of fluid and extraluminal air consistent with bowel ischemia and
contained perforation. There also is apparent caliber change
just below the level of the ventral hernia within the small
bowel loops, as the distal loops of small bowel are markedly
collapsed. All these findings are suggestive of interval
reduction of an incarcerated hernia with high-grade bowel
obstruction. At this time, no bowel loops are demonstrated
within the ventral hernia.
2. Patent mesenteric vessels.
3. 2, low-density lesions within the spleen, likely representing
hemangiomas.
4. Stable appearance of simple hepatic cyst within the dome of
the liver.
5. Diffuse increase in density of the osseous structures
consistent with renal osteodystrophy.
6. Collateral vessels within the right lateral chest wall. These
findings are suggestive of a right subclavian vein stenosis.
Clinical correlation is recommended.
Pt taken to the OR for operation. Taken to the ICU intubated.
Renal consulted for HD and recs. Pt extubated on POD1. Renal
was consulted for continuation of her hemodialysis, which went
on with out complication. She was kept NPO until bowel function
resumed on POD 3, She transferred out of the ICU once extubated
on POD 1. She was kept on heparin gtt due to her need for
anti-coagulation. Once she had resumed POs, coumadin was
started, and she was brought up to her normal coagulation level
of 2.5-3. She will follow up in the coumadin clinic and
hemodialysis for follwing her INR. Through the remained of her
postoperative course, she was advnced through sips, to clears,
fulls, then to a regular diet which she tolerated well. By POD
10, she was tolerating regular diet, having bowel movements and
her coumadin was theraputic. She was d/c'ed home.
Medications on Admission:
xanax
MS [**First Name (Titles) **]
[**Last Name (Titles) **]
protonix
fentanyl
levoxyl
dilaudid
coumadin
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO daily ().
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent ventral hernia with small
bowel obstruction and compromised bowel.
Chronic renal failure
Discharge Condition:
good
Discharge Instructions:
You may resume your home medications, please take all new
medications as prescribed.
You may resume your regular activities. You may shower, pat the
wound dry. Do not soak the wound for one week. The staples
will be removed at your follow up appointment. Please refrain
from driving while taking narcotic pain medication.
Please call your physician or return to the hoptial if you
experience:
- Increasing pain
- Fever (>101.5)
- Inability to eat/persistant vomiting
- Other symptoms concerning to you
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **]. Call ([**Telephone/Fax (1) 10820**] to make
an appointment.
Completed by:[**2184-9-19**]
ICD9 Codes: 5856, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6511
} | Medical Text: Admission Date: [**2145-7-19**] Discharge Date: [**2145-7-25**]
Service: MEDICINE
Allergies:
Acetaminophen
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Shortness of breath, fever
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation; central venous line
placement
History of Present Illness:
[**Age over 90 **] y/o F with PMHx of Afib, HTN, PNA in [**3-24**] who presented with
shortness of breath and fevers. Per NH report, pt at baseline
is very independent but was feeling unwell on sunday evening,
without specific complaints. Temp was 99.1 and pt did not
receive Tylenol due to allergy but po intake was encouraged.
Per pt's daughter, she may have received 2 tylenol at that time.
She ate breakfast well this am but had some shortness of breath
while walking back to her room after being weighed. She also
had some urinary incontinence at that time. Vitals were 98.6,
158, 180/100, 30 with 80-88% sats on 3L NC and EMS was called.
.
She was transported to the [**Hospital1 18**] ED with vitals 190/83, 144, 30
98% on NRB. Monitor showed sinus tach, and EMS exam found
crackles in lower lung fields with wheezing in upper lung
fields. Pt was tachypneic and sating in the low 80s on arrival
to the ED.
Past Medical History:
Paroxysmal Atrial Fibrillation
Hypertension
Malnutrition
General Weakness
h/o Cdiff colitis [**3-25**]
h/o CAP prior to c diff ("breathing problem" in [**3-25**] per
daughter)
Social History:
Pt lives at [**Hospital3 2558**] and at baseline is independent of
ADLs
Family History:
non-contributory
Physical Exam:
Physical exam at discharge:
Vitals: T: 97.3 BP: 118/42 P: 97 R: 18 Sats 94% on RA
General: not following commands, sedated
HEENT: Sclera anicteric, dry MM, pupils pinpoint but reactive
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral inspiratory rales, no wheezes appreciated
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: cool, 1+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
labs at admission [**2145-7-19**]:
WBC-22.0* RBC-3.85* Hgb-12.0 Hct-35.9* MCV-93 MCH-31.1 MCHC-33.3
RDW-14.3 Plt Ct-311
Neuts-69 Bands-11* Lymphs-14* Monos-6 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
PT-11.0 PTT-26.2 INR(PT)-0.9
Glucose-257* UreaN-29* Creat-1.1 Na-134 K-5.0 Cl-99 HCO3-20*
AnGap-20
ALT-64* AST-80* CK(CPK)-50 AlkPhos-128* Amylase-80 TotBili-0.9
CK-MB-NotDone cTropnT-0.02*
Calcium-8.4 Phos-4.0 Mg-2.3
calTIBC-130* Ferritn-328* TRF-100*
Cortsol-116*
.
Labs prior to discharge:
WBC-10.9 RBC-3.00* Hgb-8.9* Hct-27.9* MCV-93 MCH-29.5 MCHC-31.8
RDW-14.2 Plt Ct-298
Glucose-219* UreaN-16 Creat-0.6 Na-136 K-4.5 Cl-108 HCO3-20*
AnGap-13
CK-MB-5 cTropnT-0.04*
Calcium-7.4* Phos-2.8 Mg-1.8
.
Micro:
MRSA positive
Sputum cx: no growth
BCx [**2145-7-19**]: NGTD
UCx: no growth
Urine legionella: negative
.
CXr [**2145-7-22**]: Compared to the most recent study from approximately
an hour ago, increased left perihilar opacity likely represents
pulmonary edema or aspiration. Multifocal pneumonia as compared
to yesterday shows decreased consolidation in the right lower
lobe and unchanged consolidation in the left lower lobe.
Biapical opacities are minimally worsened. There is improved but
persistent small bibasal pleural effusions and atelectasis.
Allowing for rotation, the cardiomediastinal silhouette is
within normal limits. Extensive mural atherosclerosis of the
aortic arch and descending aorta is unchanged. There is no
pneumothorax.
.
EKG: sinus tachycardia with LVH and ST depressions seen
inferolaterally.
Brief Hospital Course:
In the ED, initial vs were: T 97.1 P 140 BP 170/100 R 30 O2 sat
99% on NRB. Pt was intubated for hypoxic respiratory distress
and was given a total of 5L of NS IVF. CXR revealed right lower
lobe infiltrates and pt was given Levo, Ceftriaxone and Vanc.
BP dropped to 56/40 after intubation and pt was given narcan
without any improvement. A right subclavian was placed with CVP
9-12 and levophed was started at 0.04 mcg/kg. Initial ABG was
7.33/45/136 on AC, FiO2% of 50, TV of 1200 and Lactate of 1.4.
Pt was intubated and sedated on arrival to the ICU. She was not
following commands, gag response was present and she was still
requiring low dose levophed.
.
# Hypoxic Resp Failure: Pt with fever and shortness of breath
who presented in resp distress and was found to have multifocal
infiltrates on CXR. Per HCP, pt had recent PNA in 4/[**2144**]. Pt
was started on vanc/zosyn/azithromycin for multifocal HAP (given
nursing home setting) and atypical pneumonia. Sputum cultures
were sent and remained negative for growth. She likely
sustained an NSTEMI with troponin peak of 0.25 in setting of
hypoxic respiratory distress on admission. Pt had difficulty
maintaining MAP>65 and required intermittent pressor support.
With no improvement in her condition, antibiotic coverage was
expanded to include meropenem and ciprofloxacin. Pt continued to
have difficulty being weaned from ventilator. Pt self-extubated
twice and required re-intubation with increasing sedation
requirements. Goals of care were then discussed with the family
given pt's lack of clinical improvement and her distress
associated with intubation. Five days after admission, the
family decided against escalation of care. Ms. [**Known lastname **] was
extubated and placed on comfort measures only. She expired from
cardiopulmonary arrest at 5:47am on [**2145-7-25**].
.
# NSTEMI: Pt had elevated cardiac enzymes with troponin peak to
0.25 before trending downwards. Pt was started on a statin and
EKG changes resolved.
Medications on Admission:
Milk of Magnesia prn
Bisacodyl prn
Ultram prn
Duoneb prn
Senna prn
Mag Oxide
MIV
Vitamin C
Synthroid 50mcg daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Cardiopulmonary arrest
.
2. Multifocal pneumonia
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 486, 2762, 5849, 0389, 2859, 2449, 4019, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6512
} | Medical Text: Admission Date: [**2194-12-12**] Discharge Date: [**2194-12-20**]
Date of Birth: [**2114-1-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Subdural Hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 80 yo male w/ PMHx sig for CABGx4, pacemaker,recent
hospitalization and rehab for R MRSA ankle infection who present
after falling at home, found to have a R SDH. The patient has
been at home for 1 week after a 5 week rehab stay. He was on his
porch walking into the house and tripped on a step an fell
backwards. Unclear if he hit his head. No LOC. The patient
was brought to an OSH where CT head showed a R frontal SDH along
falx. He was transferred to [**Hospital1 18**] for further management. In
[**Name (NI) **], pt was noted to have left facial droop. He was given 2
units of FFP. Repeat INR 1.8.
Past Medical History:
CABG x 4, L knee repair, MRSA infection of R ankle, pacemaker.
Social History:
Lives at home with wife.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: T 99.2; BP 127/81; P 70; RR 16; O2 sat 100%
General: lying in bed NAD
HEENT:dry mucous membranes
Extremities: no c/c/e.
Neurological Exam:
Mental status: Awake & alert, year [**2174**] corrects to [**2194**], month
-
[**Month (only) **], Fluent speech with no paraphasic errors. Adequate
comprehension.
Cranial Nerves:
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, L facial droop
[**Doctor First Name 81**]: SCM [**5-13**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift.
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham
C5 C7 C6 C8 L2 L3 L4-S1
RT: 5 5 5 5 5 5 5 4 5 4
LEFT: 5 5 5 5 5 4 5 4 5 4
Sensation: intact to light touch
Reflexes: Bic T Br Pa Ac
Right 2 2 2 1 -
Left 2 2 2 1 -
Upon Discharge:
right facial droop alert and oriented x3 (year only) limited ROM
left shoulder due to chronic injury.
Pertinent Results:
CT Head [**2194-12-12**]:
IMPRESSION:
1. New right frontoparietal subdural hematoma measuring 4 mm.
2. Interval enlargement of the right parafalcine subdural
hematoma layering along the right tentorium as well as
enlargement of the left frontal intraparenchymal hemorrhage as
described above. Areas of hypodensity within the right
parafalcine subdural hematoma are concerning for hyperacute
bleeding.
3. No shift of normally midline structures.
CT Head [**2194-12-13**]:
IMPRESSION: Stable appearance of parafalcine and right tentorial
subdural
hematoma, and left periventricular hemorrhage, with no new
bleeding and no
herniation.
CT Head [**2194-12-14**]:
IMPRESSION:
Unchanged right convexity, parafalcine and tentorial hematoma.
Unchanged left periventricular hemorrhage.
CT Head [**2194-12-15**]:
unchanged
Brief Hospital Course:
[**Known firstname **] [**Known lastname 9996**] was admitted to [**Hospital1 18**] Neurosurgery on [**2194-12-12**] who
is s/p fall and found to have a right subdural hematoma and left
frontal subcortical IPH. He was admitted to the ICU for close
observation. On [**12-13**] he was note to be more confused and it was
unknown if this was due to sundowning vs. worsening bleed and a
Head CT was repeated revealed no significant interval change.
On [**12-14**], he had left arm and leg jerking x3, self resolved, no
Ativan was required. He was on Keppra 500mg [**Hospital1 **] and it was
increased to 1000mg [**Hospital1 **] and he also received a 250mg IV bolus. A
STAT Head CT which revealed no evidence of interval hematoma
progression. He was kept in the ICU overnight and Neurology
consulted for seizure management. Neurology agreed with the
Keppra increase and recommended an EEG which was done on
[**2194-12-15**]. Pt was neurologically stable and transferred to the
Step Down Unit on [**2194-12-15**]. A repeat head CT showed stable
intracranial findings.
On [**12-17**], He had some intermittent right hemiparesis. Neurology
was again consulted. No stroke was identified on imaging. CTA
did not reveal any significant hemadynamic lesions. Work up was
notable only for a UTI for which the patient received a course
of Ciprofloxicin. He was started on ASA and closely followed by
neurology for these intermittent symptoms which persisted
through the remainder of his hospitalization. Ultimately, the
patient was cleared for discharge by the neurology consult. The
patient was transferred to a [**Hospital1 1501**] on [**2194-12-20**]
Medications on Admission:
Prilosec 20 mg q day, Cordarone 200 mg q day, ASA 81 mg q day,
Lopressor 50 mg [**Hospital1 **], Vit C 500 mg [**Hospital1 **], Zocor 80 mg qhs, Xalatan
OS qhs, HCTZ 25 qod, Coumadin 2 mg q day, Digoxin 125mcg q day,
Lasix 80 mg q day, MVI, KCl 20 meq q day, Vit D 800 units q day,
Vit E 200 units q day, Colace 100 mg q day.
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Vitamin E 100 unit Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Insulin Regular Human 100 unit/mL Solution Sig: RISS
Injection ASDIR (AS DIRECTED).
8. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold SBP<110 HR<60.
11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
19. Tobramycin Sulfate 0.3 % Ointment Sig: One (1) Appl
Ophthalmic [**Hospital1 **] (2 times a day) for 5 days.
20. Ondansetron 4 mg IV Q8H:PRN nausea
21. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for n/emesis.
Discharge Disposition:
Extended Care
Facility:
Aberjona Nursing Center - [**Hospital1 2436**]
Discharge Diagnosis:
Right Subdural Hematoma and Left frontal subcortical IPH
Urinary Tract Infection
Discharge Condition:
neurologically stable
Discharge Instructions:
General Instructions
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, please
refrain from taking until you are seen by Dr. [**First Name (STitle) **] in follow-up
??????You have been given Keppra to take. Please continue with this
medication until you are seen in follow-up with Dr. [**First Name (STitle) **]
??????No Driving. You had multiple seizures while in hospital.
Followup Instructions:
You will need to follow-up with Dr. [**First Name (STitle) **] in 4 weeks with a Head
CT w/o contrast. Please call [**Location (un) 3230**] for this appointment at
[**Telephone/Fax (1) 3231**]
Please call [**Telephone/Fax (1) 3231**] with any questions or concerns.
Completed by:[**2194-12-20**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6513
} | Medical Text: Admission Date: [**2140-4-5**] Discharge Date: [**2140-4-8**]
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: Briefly, this is an 82 year old
nonsmoker, active female who had undergone a right upper lobe
resection for T1 N0 adenocarcinoma in [**2139-12-20**], who
presented with right upper lobe mass found on routine
computerized tomography scan for follow up. It was discussed
with Dr. [**Last Name (STitle) 175**] and his plan was to do a resection at this
time.
PAST MEDICAL HISTORY: Past medical history is significant
for high cholesterol, osteoarthritis, and thrombocytosis.
She is status post appendectomy.
MEDICATIONS ON ADMISSION: Avapro, Lipitor,
Hydrochlorothiazide, Vioxx, Nexium, Os Cal, aspirin,
multivitamins, _______ eyedrops and Hydroxyurea.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a nondrinker, nonsmoker.
FAMILY HISTORY: Significant for lung cancer in her brother,
pancreatic cancer in another brother, colon cancer in a
sister.
PHYSICAL EXAMINATION: Physical examination shows her
afebrile with stable vital signs. Her lungs were clear.
Heart was regular. Abdomen was soft, nontender,
nondistended. Bowel sounds were present. Extremities were
warm and well perfused.
LABORATORY DATA: Laboratory studies were all within normal
limits.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2140-4-5**], for a video-assisted thoracoscopic wedge
resection of the right upper lobe mass, please see the
operative report for further details. The patient was
transferred to the floor postoperatively. She had an
epidural for pain. Her chest tubes were put in in the
Operating Room and these were kept to suction. The patient
continued to do well postoperatively. On postoperative day
#1, it was noted that her sodium had dropped from a normal
preoperative level in [**Month (only) 404**], to 123. Therefore, she was
followed for serial sodiums to monitor for changes. Her
sodium dropped to as low as 117. At this point in time, she
had mental status changes and it is decided the patient would
be transferred to the Intensive Care Unit. She was started
on a 3 percent sodium chloride drip for slow correction of
her sodium. She slowly improved from this and her sodium
improved. By postoperative day #2, the sodium had climbed up
to 123. Renal was consulted for evaluation for syndrome of
inappropriate antidiuretic hormone. They felt that the
management was correct and when her sodium was corrected up
to a level of mid 20s that she could be started on a fluid
restriction and salt tablets. Her sodium slowly corrected
over the next couple of days and she was put on fluid
restriction as well as a high sodium diet. Her sodium was
followed closely and on the day of discharge it had climbed
back up to 127. It was felt that this drop in sodium was
linked either to the long surgery itself or to the
possibility of the mass causing trouble and it was also felt
that this could be treated with sodium tablets and fluid
restriction. Physical therapy was consulted for evaluation
of her ambulation and her strength and it is found that she
was doing quite well and could be discharged home when
medically stable. She did well over the next couple of days
and her chest tubes were removed.
On postoperative day #3, she was doing well, tolerating a
regular diet and her sodium returned to a level of 127 prior
to discharge. Therefore it was decided that the patient
could be discharged home. The patient was discharged home in
stable condition. She was instructed to follow up with her
primary care physician for [**Name Initial (PRE) **] recheck of her sodium as well as
follow up with Dr. [**Last Name (STitle) 175**] in two to three weeks for
evaluation of her wounds. She was discharged on all of her
home medications as well as ________for pain, Colace, stool
softener and sodium chloride tablets, 2 gm p.o. t.i.d. The
patient is discharged in stable condition.
DISCHARGE DIAGNOSIS:
1. Right upper lobe mass, status post video-assisted
thoracoscopic wedge resection of the right upper lobe.
2. Severe acute hyponatremia, status post correction with 3
percent normal saline drip as well as sodium chloride
tablet.
3. Right upper lobe adenocarcinoma, status post right upper
lobe wedge resection.
4. High cholesterol.
5. Osteoarthritis.
6. Thrombocytosis.
7. Status post appendectomy.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 7082**]
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2140-4-8**] 19:21:26
T: [**2140-4-8**] 21:12:38
Job#: [**Job Number 14202**]
ICD9 Codes: 2761, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6514
} | Medical Text: Admission Date: [**2160-12-30**] Discharge Date: [**2161-1-1**]
Date of Birth: [**2108-5-5**] Sex: M
Service: MEDICINE
Allergies:
Phenergan / Zofran
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Torsades, ICD firing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 97106**] is a 52M with recent admission for Vtach [**2-5**] QT
prolongation s/p ICD placement and h/o narcotics abuse who
presented to [**Hospital1 18**] [**Location (un) 620**] for SOB concerning for COPD
exacerbation as well as N/V and was found to have QT
prolondation to 510. He was given steroids, abx, zofran. He
was given mag sulfate 2g IV preemptively for long QT of 510, Mg
1.8 and plans were made for admission for COPD exacerbation.
Shortly after Mag was hung, pt reports feeling short of breath
and lightheaded and had a witnessed episode of torsades, with
subsequent ICD firing. He was given lidocaine 100mg IV, 1mg drip
which was increased to 2mg. He had 4 episodes total. Per [**Hospital1 **]
cards, pacer rate was increased to 80 and he was transferred to
[**Hospital1 18**] for further management.
.
On arrival to our ED, vitals were 97.9 80 146/111 17 100% ra.
Labs were notable for phos of 1.8 and K of 3.3 without any other
abnormalities. QTc was 460. He was given additional Mg, 40meq
K in IVF, Ativan for anxiety and nausea. Lidocaine was
continued. He had another episodes of torasdes and his ICD
fired for the second time. On transfer to the CCU, VS: HR 92,
150/99, 20 98% 2L NC.
.
Currently, the patient denies any symptoms other than
significant diffuse chest pressure which he experienced both
after the first ICD firing and following the second ICD firing.
He continues to experience the chest pressure/pain without
change. He denies shortness of breath or lightheadedness,
denies arm or jaw pain, n/v.
.
Of note, the patient does note he had been experiencing green
loose stool x1-2 days, abdominal pain, and nausea/vomiting. He
reports experiencing these same symptoms every other week since
his gastric bypass, and denies any sick contacts, unusual food
intake, fevers, or changes to his typical GI symptoms.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, 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 baseline
dyspnea on exertion or exertional chest pain or pressure,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: s/p pacemaker/ICD placed [**2160-11-7**] during prior
episode of torsades [**2-5**] prolonged QT
3. OTHER PAST MEDICAL HISTORY:
-Asthma vs COPD
-Bronchitis
-Morbid obesity
-Gout
-Obstructive Sleep Apnea
-Depression/Anxiety
-Narcotic dependence/abuse
Social History:
Quit tobacco [**2154**], 30 pack-year history. Wife reports patient
is still currently smoking.
Social EtOH
Dependence on prescribed narcotics
Family History:
Father with CAD, s/p CABT in 40's; otherwise non-contributory.
Physical Exam:
VS: T=37.2 BP=145/107 -> 160/80 HR=97 R=15 PO2=100%RA
GENERAL: Alert, interactive, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa, white plaque on
tongue. No xanthalesma.
NECK: Supple with JVP of ~11 cm. No carotid bruits.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2161-1-1**] 06:10AM BLOOD WBC-12.2* RBC-5.01 Hgb-14.7 Hct-42.5
MCV-85 MCH-29.3 MCHC-34.6 RDW-15.7* Plt Ct-434
[**2160-12-31**] 09:38AM BLOOD WBC-14.8* RBC-4.74 Hgb-14.0 Hct-40.5
MCV-85 MCH-29.6 MCHC-34.6 RDW-15.9* Plt Ct-456*
[**2160-12-31**] 06:08AM BLOOD WBC-13.0* RBC-4.47* Hgb-13.3* Hct-38.7*
MCV-87 MCH-29.7 MCHC-34.3 RDW-15.9* Plt Ct-453*
[**2160-12-30**] 11:47AM BLOOD WBC-10.4 RBC-5.38# Hgb-15.8# Hct-46.6#
MCV-87 MCH-29.3 MCHC-33.9 RDW-15.9* Plt Ct-471*
[**2160-12-30**] 11:47AM BLOOD Neuts-91.6* Lymphs-7.0* Monos-0.4*
Eos-0.5 Baso-0.5
[**2161-1-1**] 06:10AM BLOOD PT-13.3 PTT-25.3 INR(PT)-1.1
[**2160-12-30**] 11:47AM BLOOD PT-12.9 PTT-23.2 INR(PT)-1.1
[**2161-1-1**] 06:10AM BLOOD Glucose-87 UreaN-2* Creat-0.5 Na-130*
K-3.9 Cl-95* HCO3-24 AnGap-15
[**2160-12-31**] 09:38AM BLOOD Glucose-109* UreaN-3* Creat-0.5 Na-134
K-4.0 Cl-99 HCO3-26 AnGap-13
[**2160-12-31**] 06:08AM BLOOD Glucose-95 UreaN-3* Creat-0.5 Na-137
K-4.0 Cl-101 HCO3-26 AnGap-14
[**2160-12-30**] 10:30PM BLOOD Na-137 K-4.1 Cl-104
[**2160-12-30**] 11:47AM BLOOD Glucose-120* UreaN-2* Creat-0.7 Na-138
K-3.3 Cl-99 HCO3-25 AnGap-17
[**2161-1-1**] 06:10AM BLOOD CK(CPK)-49
[**2160-12-31**] 05:35PM BLOOD CK(CPK)-59
[**2161-1-1**] 06:10AM BLOOD CK-MB-2 cTropnT-<0.01
[**2160-12-31**] 05:35PM BLOOD CK-MB-2 cTropnT-<0.01
[**2161-1-1**] 06:10AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9
[**2160-12-30**] 11:47AM BLOOD Calcium-9.3 Phos-1.8*# Mg-2.1
[**2160-12-30**] 10:30PM BLOOD TSH-0.99
.
[**2160-12-30**] ECG
Atrial paced, ventricular sensed rhythm with atrial premature
beats. Since the
previous tracing the atrial pacing then was associated with a P
wave and there
is no longer ventricular pacing. Perhaps the pateint was in
atrial
fibrillation on the prior two tracings. Clinical correlation is
suggested.
.
[**2160-12-31**] ECG
Atrial paced, ventricular sensed rhythm with a single atrial
premature beat.
Since the previous tracing the Q-T interval is shorter.
Otherwise, unchanged.
Brief Hospital Course:
52 yo gentleman with history of ventricular arrhythmias in the
setting of prolonged QT presents with torsades and ICD firing in
the setting of medication prolonging QT.
.
# RHYTHM: Mr. [**Known lastname 97106**] presented in [**Month (only) **] in the setting
of prolonged QT, believed to be secondary to Zofran and had an
ICD placed during that time. He presented again dyspneic and
developed torsades de [**Last Name (un) **] after receiving zofran. QT
interval was 510 at outside hospital and 460 in [**Hospital1 18**] ED after
receiving magnesium repletion prior to transfer. Episodes of
torsades appear to be provoked by QT-prolonging medications, and
threshold may also have been lowered by electrolyte
abnormalities. He was additionally repleted with magnesium and
potassium and was initially put on a lidocaine drip for
continued anti-arrythmic effect overnight. Daily EKGs performed
to monitor QT interval. He was discharged with close follow up
and no changes were made to his medications. He was instructed
to continue avoiding QT prolonging medications.
.
# CORONARIES: On recent catheterization prior to admission, no
intervenable lesions however patient with several narrowed
vessels as well as evidence of microvascular disease. No
history of chest pain on admission and cardiac enzymes cycled
and were unremarkable. He was continued on aspirin, statin ,
betablocker and ace inhibitor at home dose.
.
# Chronic CHF: History of mild systolic CHF post-torsades (last
EF 45%). Euvolemic on admission without evidence of
exacerbation. He was continued on home dose of betablocker and
lisinopril and put on a low sodium diet.
.
# HTN: Mildly blood pressures on admission. He was continued on
home regimen as outlined above.
.
# HLD: Continued Simvastatin.
.
# Thrush: White plaque on tongue consistent with flush. He was
started on nystatin swish and swallow.
.
# Hx COPD/Asthma: No wheeze or evidence of active flare.
Albuterol, flovent and ventolin were available.
.
# Depression/Anxiety: He was continued on celexa daily with
ativan as needed. He was encouraged to follow-up with his
primary care physician and former psychiatrist to address
underlying anxiety.
.
# Chronic pain: Continued on tylenol and cyclobenzaprine for
chronic pain in setting of past history of narcotics abuse.
.
Medications on Admission:
Zocor 20mg daily
Aspirin 81mg daily
Lisinopril 5mg daily
Lopressor 25mg [**Hospital1 **]
Celexa 40mg daily
Docusate 100mg [**Hospital1 **]
Miralax 1 packet daily
Ambien prn
Discharge Medications:
1. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
7. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day.
8. zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular Tachycardia/Torsades de Pointes related to prolonged
QT interval
Acute Systolic Dysfunction
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 management of an abnormal
cardiac rhythm, ventricular tachycardia or torsades de pointes
that caused your internal cardiac defibrillator (ICD)to fire.
This abnormal rhythm was likely caused by a medication that you
took for symptoms of nausea (zofran). You should avoid any
medicines
that make you more prone to ventricular tachycardia, please
continue to avoid these medications, you have been given a list
of these medications.
No changes were made to your medications.
Weigh yourself every morning, please call Dr. [**Last Name (STitle) **] if
weight goes up more than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) 97107**],[**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) **]
Address: [**Location (un) **]., [**Apartment Address(1) 25389**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 74684**]
Appt: [**1-7**] at 3pm
***Please ask dr [**Last Name (STitle) **] to assist you in establishing with a
psychiatrist during this office visit.****
Department: CARDIAC SERVICES
When: [**Last Name (STitle) **] [**2161-1-16**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4271, 496, 4280, 2724, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6515
} | Medical Text: Admission Date: [**2103-11-1**] Discharge Date: [**2103-11-5**]
Date of Birth: [**2027-5-26**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
Intubation (done at OSH)
Extubation
History of Present Illness:
[**Known firstname **] [**Known lastname 85686**] is a 76 year-old man with history
significant
for Left PCA-territory stroke in [**2101**] (details uncertain at this
time) and remote MI ([**2089**]) with ischemic cardiomyopathy (EF
reportedly 35% per OSH notes), as well as HTN, HL, and mild
COPD.
The patient is intubated and unresponsive at this time and no
family is present and there are no contact numbers for family,
so
the minimal history at this point is derived from ED transfer
note from [**Last Name (un) 63261**] Hospital, where ED physicians spoke with
his wife.
Per OSH note, he was in his USOH last night when he went to bed
around 8pm with no complaints except that he was "slightly
congested." Around 5:15am this morning ([**11-1**], [**Holiday 1451**]
Day),
his wife was awakened by a "screaming noise" and a loug bang.
She
found him on the floor, convulsing and unresponsive. He
reportedly has no seizure history. She called EMS. EMS
reportedly
noted on-going convulsions on arrival (but we do not have their
documentation), which resolved spontaneously. They brought him
to
the OSH within roughly 20 minutes of onset. He arrived with VS
of
afebrile, HR 124, BP 136/86 - 190/113, RR 20, SaO2 96% RA, FSBG
134 at 06:40am.
There, he had a convulsive episode not witnessed by the ED
phsycian, which again self-resolved. On exam, his eyes were
open,
but he was not looking or moving on command. He was thought to
have a stroke because, although he moved LUE/LLE spontaneously,
he would not move the RUE to noxious stimulation, and only
weakly
withdrew the RLE one time to noxious stimulation. His Right toe
was up-going. His EKG had frequent PVCs and sinus tachycardia at
115. Routine lab studies were unremarkable (CBC, BMP, Ca,
CK/MB/trop, coags), except for dig <0.4 (he was listed as taking
dig as of 10/[**2102**]).
They did a NCHCT, which was said to show no hemorrhage or acute
changes (it is being uploaded into our PACS at this time). He
had
another convulsive episode at CT, so they gave him 2mg Ativan,
after which they intubated him (paralyzed/sedated
rapid-sequence,
with succ and etomidate) for unclear reason. He was pulling at
the ETT, so he was given fentanyl 100mcg bolus IV, after which
he
became hyPOtensive to the 70s SBP, so he was given IVF and
started on dopamine gtt. He was sedated with MDZ and fentanyl
gtt
and med-flighted over to [**Hospital1 18**]. Apparently he was given 2mg
Ativan en route by Med Flight staff, for agitation.
He arrived here intubated, sedated with midazolam and fentanyl.
VS on arrival were: afebrile (97.5) HR 74 BP 144/76 (on 0.4
norepinephrine gtt). RR 18/SaO2 100% on PEEP 5 / 100% FiO2. He
was not opening his eyes and not responsive to command, and the
ED staff said he moved his Right hand and both legs now. We were
consulted re. diagnosis and management.
ROS: cannot obtain (non-responsive)
Past Medical History:
(by report from OSH ED transfer note)
1. Stroke, L-PCA territory in [**2101**] with no residual
2. CAD / MI, remote ([**2089**]; vessel(s) uncertain)
3. Ischemic cardiomyopathy with EF 35%
4. Hypertension
5. Hyperlipidemia
6. "mild" COPD
7. bilateral carpal tunnel syndrome, [**1-10**] inflammatory
arthropathy
(serologies negative) per Rheum notes here at [**Hospital1 18**]
reportedly no history of seizure
Social History:
current details unknown
per Rheum notes: lives at home with wife. Quit smoking [**2076**]. 4
drinks EtOH per week. Denied illicits.
Family History:
details unknown at this time
Physical Exam:
ADMISSION PHYSICAL EXAM:
97.5F
HR 55, reg
BP 161/9x on norepi 0.4 --> 132/98 @0.3 --> 111/XX off
norepi
RR 15-17 (set rate = 16)
SaO2 100% on FiO2 100% / PEEP 5
General: Intubated with OG tube. Lying in bed in NAD (sedating
meds -- fentanyl 50 and MDZ 1 were running, which I had stopped
on arrival). Smells of fresh (?cdiff) diarrhea.
HEENT: Normocephalic and atraumatic except for small lac below
left eye. No scleral icterus. Mucous membranes are moist. No
lesions noted in oropharynx.
Neck: exam limited by neck brace applied at OSH.
Pulmonary: Coarse lung sounds diffusely, bilaterally.
Non-labored; not overbreathing vent, but does buck briefly a
couple times after sedation is lifted.
Cardiac: RRR with occasional extra beat, normal S1/S2.
Abdomen: Mildly distended ++tympanic, esp epigastric / LUQ.
Non-tender. No bowel sounds appreciated in loud ED setting.
Extremities: Cool, but well-perfused with 2+ DPs bilaterally. No
clubbing or cyanosis. No edema.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
best GCS after lifting sedating meds: 7 (E2 V1 M4)
level of arousal - 2 (opens eyes briefly to sternal rub)
best verbal - 1 (no verbal response to pain)
best motor - 4 (withdraws to pain)
Mental Status exam:
Eyes closed. Grimaces, bucks torso, and withdraws all
extremities
to mild noxious stimulation (sternal rub, mild nail-bed
pressure). Does not regard, track, or blink to threat (with eyes
held open). Does not follow command to open eyes or open/close
fist or show thumbs-up.
-Cranial Nerves:
II: Pupils round, equal, sluggish (Right pupil eccentrically
positioned on [**Doctor First Name 2281**], ?post-surgical change), 3 to 2.5mm. Does not
blink to threat anywhere.
III, IV, VI: Does not track or look on command. Eyes are both
mid-position. Neck brace limits VOR/OCR testing.
V: Weak corneals bilaterally. Strong grimace to nasopharyngeal
stimulation with cotton swab, bilaterally similar.
VII: Face grossly symmetric at rest. Symmetric grimace to pain.
VIII: Unable to test (neck brace limits OCRs; pt not responsive
to loud noise on either side).
IX, X: RT says cough and gag are robust at this time (tracheal
suctioning immediately prior to exam).
[**Doctor First Name 81**]: unable to test.
XII: unable to test.
-Motor: Moderately reduced tone of all four extremities at rest.
No adventitious movements, no tremor, no posturing or clonic
movements. Vigorous, immediate withdrawal of all four
extremities
to pain (mild nailbed pressure) in that extremity. No gross
assymetry.
-Sensory: responsive to mild noxious stimuli x four and face as
above.
-Reflex examination (left; right):
Biceps (++;++)
Triceps (+;+)
Brachioradialis (++;++)
Quadriceps / patellar (++;++)
Gastroc-soleus / achilles (+;+)
Plantar response was EXTENSOR bilaterally, more rapidly up-going
on the RIGHT (left up-going with longer latency).
-Coordination: cannot test
-Gait: cannot test
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8, BP 142/70, HR 68, RR 18, 97%RA
General: AAOX3, very hard of hearing
HEENT: Normocephalic and atraumatic except for hematoma around R
eye. No scleral icterus. Mucous membranes are moist. No lesions
noted in oropharynx.
Neck: supple, mildly limited ROM
Pulmonary: CTA-B
Cardiac: RRR with occasional extra beat, normal S1/S2.
Abdomen: soft, NT, ND
Extremities: Cool, but well-perfused with 2+ DPs bilaterally. No
clubbing or cyanosis. No edema.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status exam:
AAOx3, follows commands, appropriately answers questions
-Cranial Nerves:
II: Pupils round, equal, and reactive (Right pupil eccentrically
positioned on [**Doctor First Name 2281**], ?post-surgical change), 4 to 2mm.
III, IV, VI: EOMI
V: facial sensation intact throughout
VII: Face grossly symmetric
VIII: Decreased hearing bilaterally R>L, per pt this is chronic
IX, X: tongue midline
[**Doctor First Name 81**]: uvula midline, palate rises symmetrically
XII: shoulder shrug [**4-12**] throughout
-Motor: 5/5 strength in all muscle groups symmetrically
-Sensory: intact to LT throughout
-Reflex examination (left; right):
2+ and symmetrical as biceps, triceps, brachioradialis and
patella, 1+ a bilateral achilles, Plantar response was EXTENSOR
bilaterally, more rapidly up-going on the RIGHT (left up-going
with longer latency).
-Coordination: FNF intact bilaterally
-Gait: deferred
Pertinent Results:
ADMISSION LABS:
[**2103-11-1**] 09:18AM BLOOD WBC-13.0* RBC-4.27* Hgb-13.4* Hct-40.1
MCV-94 MCH-31.3 MCHC-33.4 RDW-12.6 Plt Ct-215
[**2103-11-1**] 09:18AM BLOOD Neuts-87.9* Lymphs-7.5* Monos-3.9 Eos-0.5
Baso-0.2
[**2103-11-1**] 09:18AM BLOOD PT-13.4 PTT-23.5 INR(PT)-1.1
[**2103-11-1**] 09:18AM BLOOD Glucose-144* UreaN-20 Creat-1.0 Na-144
K-3.6 Cl-107 HCO3-25 AnGap-16
[**2103-11-2**] 02:24AM BLOOD ALT-14 AST-27 CK(CPK)-489* AlkPhos-48
TotBili-0.6
[**2103-11-1**] 09:18AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.1
[**2103-11-2**] 02:24AM BLOOD %HbA1c-5.2 eAG-103
[**2103-11-2**] 02:24AM BLOOD Triglyc-85 HDL-50 CHOL/HD-2.6 LDLcalc-64
[**2103-11-2**] 02:24AM BLOOD TSH-0.91
[**2103-11-1**] 09:01AM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-5
FiO2-100 pO2-420* pCO2-52* pH-7.32* calTCO2-28 Base XS-0
AADO2-247 REQ O2-48 -ASSIST/CON Intubat-INTUBATED
[**2103-11-1**] 09:35AM BLOOD Glucose-129* Lactate-3.3* K-3.7
DISCHARGE LABS:
No labs done at the time of discharge as patient was stable.
IMAGING:
[**2103-11-1**] CXR: IMPRESSION:
1. Standard position of endotracheal tube 4.5 cm from the
carina.
2. Nasogastric tube within the stomach, though side port above
the left
hemidiaphragm, and advancement is recommended.
3. Mediastinal widening, partly due to the AP technique though
is concerning for underlying mediastinal pathology. Recommend
dedicated PA and lateral chest radiographs or chest CT for
further characterization.
CT C-SPINE [**2103-11-1**]: IMPRESSION:
1. No acute fracture allowing for the osteopenia and deg.
changes. Multilevel, multifactorial degenerative changes with
mild-moderate canal stenosis and foraminal stenosis as above.
2. Moderate posterior disc protrusion at C5/6 with mild spinal
canal
narrowing. If concern for spinal cord/ligamentous injury, MRI of
the C-spine might be considered if not CI.
CTA CHEST [**2103-11-1**]: IMPRESSION:
1. No acute cardiothoracic process including no evidence of no
pulmonary
embolism, aortic dissection, aortic aneurysm formation,
mediastinal
hemorrhage, pneumonia or pneumothorax.
2. Incidentally found hypoattenuating left lobe liver lesions
likely
represent simple cysts, however, further workup with ultrasound
might be
considered on a nonurgent basis.
CT HEAD [**2103-11-1**]: IMPRESSION:
1. Symmetric linear hyperdensities in the cerebellar hemispheres
bilaterally- DDX: hemorrhage/ calcification, however, followup
CT in 24 hours might be considered for reassurance. No priors
are available. No obvious fracture.
2. No obvious acute territorial infarction.
3. Chronic left PCA infarct.
4. Soft tissue swelling with increased attenuation of fat in the
right
temporal and lateral orbital regions without fracture.
MRI/MRA [**2103-11-2**]: IMPRESSION:
1. No obvious acute infarction.
2. Thin linear increased signal intensity overlying the right
parietal and
the occipital lobes likely in the meninges on the FLAIR
sequence.
Non-scattered FLAIR hyperintense foci as described above.
Recommend
post-contrast images for better assessment for parenchymal or
meningeal
abnormal enhancement given the history of seizures.
3. Patent major arteries as above; study somewhat suboptimal and
MCAs are
better seen on the source images.
LUMBAR SPINE [**2103-11-2**]: IMPRESSION: Single AP view only, with
multilevel degenerative changes.
LUMBAR SPINE A/P [**2103-11-2**]: FINDINGS:
Two views of the lumbar spine demonstrate lumbar vertebral body
height to be maintained. There is no malalignment. There are
large osteophytes at all levels with loss of disc height. Aorta
is moderately calcified. There is facet arthrosis at all levels.
There are mild degenerative changes at the sacroiliac joints and
femoroacetabular joints.
VIDEO SWALLOW [**2103-11-2**]: IMPRESSION: Penetration with thin
liquids, but no aspiration.
MR W/ CONTRAST [**2103-11-3**]: IMPRESSION: Limited study with only T1
axial post-gadolinium images are obtained which are somewhat
degraded by motion. Mild streaky pachymeningeal enhancement is
seen in the parietooccipital region. This is a nonspecific
finding and could be related to prior lumbar puncture. No mass
effect seen. No definite intraparenchymal enhancement.
LIVER U/S [**2103-11-3**]: IMPRESSION:
1. 1-cm hepatic cyst within the left lobe. Further evaluation is
limited due to adjacent cardiac motion. The remainder of the
liver examination is normal.
2. Normal gallbladder.
Brief Hospital Course:
Mr. [**Known lastname 85686**] is a 76 yo man with a history of a left occiptal
lobe stroke, presenting with 3 seizures. He was intubated at
[**Hospital3 26615**] hospital and transferred to [**Hospital1 18**] for further care.
He was quickly extubated, and was stable in the ICU. He had an
MRI which showed meningeal thickening over the right occipital
lobe, which was felt to be likely from multiple LP attempts at
OSH.
# NEURO: we started pt on keppra 750mg [**Hospital1 **] to help prevent
further seizures. While here, he did not have any further
seizures. We did not obtain an EEG, as it would not change
management, because pt was to go home on an AED no matter what
the EEG showed. While there are no clear guidelines for length
of AED use in seizures likely caused by old strokes, we
recommend a 6 month course of keppra for Mr. [**Known lastname 85686**]. He is
going to f/u with his neurologist in [**Location (un) 5028**], who can
ultimately make the decision for length of medication treatment.
While here, we initially held pt's ASA and plavix until is
could be determined that the meningeal enhancement on MRI wasn't
a SDH. Post-contrast images were obtained and it was clear that
the enhancement was not a SDH, so his ASA and plavix were
restarted.
# Infectious Disease: pt did not demonstrate any infectious sx
while here. His BCx is NGTD and he remained afebrile. His WBC
was mildly elevated to 13.0 on arrival, but this quickly
normalized.
# Cardiovascular: We continued pt on his home cardiac
medications including amlodpine, digoxin, metoprolol succinate,
losartan and simvastatin. As above, we initially held his ASA
and plavix until it could be determined he didn' have a SDF. He
was monitored on tele while here, and there was no arrythmia
noted.
# Pulmonology: patient had a widened mediastinum noted on
initial CXR, but CTA was normal. Patient was able to be
extubated without incident.
# Endocrine: on this admission LDL was 64 and HgA1C was normal.
He was put on an ISS but his FS's remained WNL.
# GI/Liver: On pt's CTA he was noted to have a liver lesion,
which a dedicated liver U/S determined was a cyst. If he
develops any liver sx, he will need this followed.
PENDING RESULTS:
BCx [**2103-11-1**]
TRANSITIONAL CARE ISSUES:
His outpatient neurologist will need to detemine how long his
keppra should be continued for.
Medications on Admission:
1. albuterol inh PRN - 2 puffs oral 4 times a day PRN
2. amlodipine 5mg daily (taken q.AM)
3. clopidogrel 75mg daily (taken q.NOON)
4. DIGOXIN 0.125mg (taken QOD, not daily, changed recently to
QOD
by Cardiologist due to sedation with daily dosing)
5. losartain 50mg daily
6. metoprolol 25mg ([**12-10**] of 50mg tablet) taken q.SUPPERTIME
7. simvastatin 80mg (taken QHS)
8. sulfasalazine 1000mg (two 500mg tablets) q.AM and
q.SUPPERTIME
9. aspirin 81mg daily (taken q.AM)
10. multivitamin daily
Discharge Medications:
1. Tylenol Arthritis 650 mg Tablet Extended Release Sig: Three
(3) Tablet Extended Release PO once a day as needed for pain.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB,
wheezing.
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
10. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
11. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
NEURO EXAM: pt with impaired hearing bilaterally, easily
distactable, full strength throughout
Discharge Instructions:
Dear Mr. [**Known lastname 85686**],
You were seen in the hospital because of multiple seizures.
They were felt to be caused from some of your old strokes. You
were put on antiseizure medications to help prevent future
seizures.
We made the following changes to your medications:
1) We STARTED you on KEPPRA 750mg twice a day. Please take this
until your neurologist (Dr. [**First Name (STitle) **] tells you to stop. This
medication will help prevent seizures.
DO NOT DRIVE for 6 months from the date of your last seizure.
It is illegal to drive in the state of Massachussetts until you
have been seizure free for 6 months.
Do not bathe unsupervised, or stand near open flames without
supervision. Avoid any activities where a seizure could put you
in immediate danger.
Please continue to take your other medications as previously
prescribed.
If you experienc any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
You have an appointment with Dr. [**First Name8 (NamePattern2) 85687**] [**Last Name (NamePattern1) **] on Tuesday [**11-13**] at 10am; The office is located at [**Location (un) 85688**]in
[**Location (un) 5028**], MA. The phone number there if you have any
questions is [**Telephone/Fax (1) 85689**] and their fax is [**Telephone/Fax (1) 85690**].
Department: RHEUMATOLOGY
When: TUESDAY [**2104-1-15**] at 8:30 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], 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
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 412, 496, 4589, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6516
} | Medical Text: Admission Date: [**2148-11-25**] Discharge Date: [**2148-12-5**]
Date of Birth: [**2085-6-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lidocaine / Morphine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Recurrent right chest wall hernia.
Major Surgical or Invasive Procedure:
[**2148-11-25**]: Right thoracotomy and repair of chest wall hernia.
History of Present Illness:
Mr. [**Known lastname 13646**] is a 63 year old male s/p right chest wall hernia
repair with [**Doctor Last Name 4726**]-tex mesh on [**2148-10-25**] who presented to the
postoperative clinic in pain, with erythematous right thoractomy
and drainage out the chest tube site. A CT chest revealed
rupture of the [**Doctor Last Name 4726**]-tex mesh. Antibiotics were started. He
returns for redo right thoractomy and repair of the hernia.
Past Medical History:
-COPD
-OSA
-Diabetes II, complicated by neuropathy
-Chronic Sinusitis
-Obesity
-BPH
-GERD
-Cold induced asthma
-OA
-Allergic Rhinitis
-HTN
-PTSD
-Hyperlipidemia (on simvastatin)
.
Past Surgical History:
The patient had previous L4-L5 microdiscectomy
in [**2142-4-9**]. He has had multiple discectomies in the past in
[**2118**], [**2124**], and [**2133**].
-Status post operative fusion of his left ankle following a
bimalleolar ankle fracture
-Cervical C3-4 spine fusion with persisting cervical cord
compression and plexopathy
-Lumbar laminectomy for spinal stenosis.
Social History:
He lives at home with his wife and his son [**Name (NI) **]. [**Name2 (NI) **] 4 adult
children who live away and are all described as healthy. He
does not smoke. He uses wine or beer occasionally, and 2 cups of
coffee a day. He reports the use of a regular diet and sleeps 8
hours per night with nocturia interrupting his sleep every [**3-13**]
hours.
Family History:
He has a daughter today sutures old and two sons 19 and 33 years
old all of which are healthy.
Physical Exam:
VS: T: 98.6 HR: 77-95 SR BP: 108-112/60 Sats: 93% RA Wt: 119
kg
BS 121/154/161
General: 63 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Card: RRR. normal S1,S2 no murmur
Resp: bilateral diminshed breath sounds with bibasilar crackles
no wheezes
GI: obese, BS+ abdomen soft non-tender/non-distended
Extre: warm tr edema
Incision: right thoracotomy site with staples, mild erythema
extending downward
Neuro; Awake, alert, oriented. Walks with a walker
Pertinent Results:
[**2148-12-3**] WBC-6.4 RBC-3.37* Hgb-10.4* Hct-31.3 Plt Ct-467*
[**2148-12-1**] WBC-5.4 RBC-3.14* Hgb-9.8* Hct-29.4 Plt Ct-398
[**2148-11-29**] WBC-5.7 RBC-3.11* Hgb-9.8* Hct-29.1 Plt Ct-344
[**2148-11-28**] WBC-6.0 RBC-2.93* Hgb-9.1* Hct-27.2 Plt Ct-283
[**2148-11-25**] WBC-9.1 RBC-3.99* Hgb-12.2* Hct-37.3 Plt Ct-401
[**2148-12-4**] Glucose-113* UreaN-9 Creat-0.9 Na-136 K-4.7 Cl-97
HCO3-31
[**2148-12-3**] Glucose-171* UreaN-10 Creat-0.8 Na-135 K-4.6 Cl-95*
HCO3-32
[**2148-12-2**] Glucose-129* UreaN-8 Creat-0.8 Na-137 K-4.5 Cl-98
HCO3-30
[**2148-12-3**] Calcium-8.3* Phos-4.2 Mg-1.8
[**2148-11-29**] Glucose-117* UreaN-10 Creat-0.7 Na-137 K-4.3 Cl-103
HCO3-26
[**2148-11-28**] Glucose-129* UreaN-15 Creat-1.0 Na-131* K-4.3 Cl-102
HCO3-25
[**2148-11-26**] Glucose-254* UreaN-16 Creat-1.1 Na-125* K-4.9 Cl-95*
HCO3-24
[**2148-11-25**] Glucose-352* UreaN-13 Creat-0.9 Na-136 K-4.7 Cl-100
HCO3-25
[**2148-11-29**] Calcium-8.3* Phos-3.6 Mg-1.8
CXR:
[**2148-12-3**]: Surgical material is again noted along the
inferolateral right chest wall. The amount of pleural fluid
tracking along
the right chest wall and into the medial right apex,
posteriorly, appears to have increased over several days.
Heterogeneous opacities at the right lung base are unchanged.
The left lung remains well aerated. There is no left pleural
effusion or pneumothorax. The cardiomediastinal silhouette is
unchanged.
IMPRESSION:
Apparent increase in right pleural fluid layering along the
lateral right
chest wall, and in a loculated collection at the posterior right
lung apex.
[**2148-11-29**]: Moderate right pleural effusion is again seen that
tracks along the lateral chest wall and the major fissure. The
area of opacification at the right base remains constant. Left
lung is well aerated without evidence of definite effusion or
consolidation. Persistent cardiomegaly without evidence of
vascular congestion.
[**2148-11-27**]: Overall stable right pleural effusion and atelectasis
following
right chest tube removal with no pneumothorax or new
abnormality.
[**2148-11-26**]: some improved aeration bilaterally without evidence of
pneumothorax. Continued enlargement of the cardiac silhouette
with atelectatic changes at the bases. No evidence of pulmonary
vascular congestion.
[**2148-11-25**]: The large right pleural effusion may be
smaller in size, or fluid may have shifted to the medial
hemithorax.
Relatively diffuse opacity at the right lung base may represent
atelectasis. There is no left-sided consolidation or pleural
effusion. There is no pneumothorax. The cardiomediastinal
silhouette is grossly unchanged.
Echocardiogram: [**2148-12-2**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Pulmonary artery systolic hypertension. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function.
Brief Hospital Course:
Mr. [**Known lastname 13646**] is 63 year-old male admitted following right redo
thoracotomy and chest wall hernia repair. He was extubated in
the operating room, and monitored in the PACU prior transfer to
the floor. Once transfer to the floor he was found to be
hypovolemic with low urine output requiring large fluid
challenges. On [**2148-11-27**] he was transferred to the TSICU for
hypotension, which he was given more fluids. He transfer back to
the floor in stable condition on [**2148-11-29**].
Respiratory: The patient required aggressive pulmonary toilet
with around the clock nebulizers. He continued with his home
CPAP for OSA/COPD at night. Pulmonology followed him throughout
his hospital course. On [**2148-12-2**] it was felt he was volume
overloaded gently diuresed with good effect. He was weaned off
oxygen saturating mid 90's on room air. Goal oxygen saturations:
89-94%.
Chest tube was removed on [**2148-11-28**]. Followed by serial chest
films (see above report)
Cardiac: He was tachycardic in the ICU which responded to
Lopressor. On the floor he became hypertensive and his
tachycardia in low 100's persisted. An echocardiogram was done
and showed normal EF with moderate pulmonary artery systolic
hypertension of 45 mm Hg. His home dose lisinopril of 40 mg po
bid was restarted and up titrated his metoprolol to 37.5 mg po
tid, with good effect.
GI: He had normal bowel movements and remained on proton pump
inhibitors.
Renal: He was hyponatremic with sodium of 126, which improved
with normal saline to 137. Renal function remained within
normal range. The Foley was removed on [**2148-11-29**] once the
epidural was removed, and he voided well thereafter. He was
diuresed for volume overload on [**2148-11-29**] once and started daily
on [**2148-12-2**], with positive response in overall clinical status.
Endocrine: His blood sugar range varied 100-400. [**Last Name (un) **] was
consulted and adjusted his insulin to maintain adequate glucose
control.
Pain: Epidural Bupivacaine and morphine PCA was initially used
for pain control. The was transition ed to MS Contin and
lidocaine patch for good pain control. His pain improved on
[**2148-11-29**] the epidural and PCA were stopped. He continued with
MS Contin and morphine immediate release for breakthrough pain.
ID: incision with staples mild erythema extending downward. He
remained afebrile WBC within normal range. A 10 day course
Augmentin 875 [**Hospital1 **] was started for possible cellulitis in a
patient with Gortex mesh. During admission, pt noted tooth pain
and subsequently received panorex which did reveal abscess and
pt was cleared by dental consultation service.
Disposition: He was seen by physical therapy who recommended
short term rehab. He was discharged to [**Hospital1 19286**] in
[**Hospital1 3597**] ([**Telephone/Fax (1) 94339**]) on [**2148-12-5**] and will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
NPH 55 units QHS
Novolog 27 units before dinner
Glipizide 2.5 mg in AM and 7.5 mg in PM
Buspirone 10 mg [**Hospital1 **]
PER LAST D/C summary:
Lisinopril 40 mg [**Hospital1 **]
Oxybutynin Chloride 2.5 mg TID
Paroxetine HCl 50 mg Daily
Simvastatin 20 mg daily
Aspirin 81 mg DAILY
Omeprazole 40 mg daily
Cyanocobalamin (Vitamin B-12) 100 mcg daily
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Fluticasone-Salmeterol 250-50 mcg/Dose 1 puff [**Hospital1 **]
Pregabalin 25 mg TID
Prednisone 10 mg Tablets, Dose Pack Sig: dose pack, see
instructions Tablets, Dose Pack PO once a day for 6 days: take 4
tablets a day for 2 days, 2 tablets a day for 2 days, 1 tablets
a
day for 2 days then stop.
Azithromycin 250 mg for 4 day
Discharge Medications:
1. oxybutynin chloride 5 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. pregabalin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
11. paroxetine HCl 25 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
13. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: for a
week then reevaluate volume status. You should have electrolytes
checked on lasix and replaced as necessary.
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): if immobile in rehab.
16. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
17. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO Q 8H
(Every 8 Hours).
18. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
19. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
20. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
21. Humalog sliding scale
71-100 mg/dL 5 Units 5 Units 5 Units 0 Units
101-150 mg/dL 5 Units 5 Units 5 Units 0 Units
151-200 mg/dL 7 Units 7 Units 7 Units 0 Units
201-250 mg/dL 9 Units 9 Units 9 Units 2 Units
251-300 mg/dL 11 Units 11 Units 11 Units 4 Units
301-350 mg/dL 13 Units 13 Units 13 Units 6 Units
351-400 mg/dL 15 Units 15 Units 15 Units 8 Units
22. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
-COPD
-OSA
-Diabetes II, complicated by neuropathy
-Chronic Sinusitis
-Obesity
-BPH
-GERD
-Cold induced asthma
-OA
-Allergic Rhinitis
-HTN
-PTSD
-Hyperlipidemia (on simvastatin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Incision develops drainage or increased redness
-Shortness or breath or cough
Staples will be removed on your follow-up visit.
You may shower. No tub bathing or swimming until all incisions
healed
Antibiotics: Augmentin 875 mg [**Hospital1 **] for 10 days.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2348**] [**2148-12-17**] 1:00pm on
[**Hospital1 18**] [**Hospital Ward Name **] [**Hospital Ward Name 23**] 9
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD Phone:[**Telephone/Fax (1) 142**]
Date/Time:[**2148-12-11**] 3:30
Followup with your dentist if your right back gum lesions to do
disappear. You had a panorex in the hospital showing this area
was not absessed.
Completed by:[**2148-12-5**]
ICD9 Codes: 2762, 4280, 3572, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6517
} | Medical Text: Admission Date: [**2142-9-14**] Discharge Date: [**2142-9-21**]
Date of Birth: [**2070-7-26**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Generalized Malaise w/Fevers x 2 weeks, Hypoxia, and
pancytopenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 72 y/o M with a history of CAD, HTN, and BPH who
reports having fevers at home x2 weeks as well as urinary
urgency x 2 weeks that is new for him. Prior to the onset of the
patient's fevers, he reports being bitten by a long green bug
while in the parking lot of [**Company 10414**]. The bite area became
indurated, erythematous, but never necrotic. The day following
the bite, the patient reported feeling generalized malaise, then
began developing fevers, mainly at night, but continued working
throughout the day. Given his symptoms, the pt went to see his
PCP 3 times over the last week, and was prescribed Ciprofloxacin
on [**2142-9-11**] for his symptoms. He underwent an abdominal CT as
well as blood testing, which showed new pancytopenia as well as
splenomegaly on CT. Lyme serology sent as an outpatient was
negative. In addition, the pt's PCP had noted the pt's BP to be
slowly downtrending over the last week, and several of his
anti-hypertensives were held. The patient was then referred to
the ED to be evaluated for his persistent fevers, malaise and
new pancytopenia
Past Medical History:
CAD s/p stent placement in '[**35**] off Plavix/ASA
-->Exercise MIBI in [**2-19**]: IMPRESSION: 1. Moderate size and
intensity reversible perfusion defect in the LAD territory. 2.
Mild hypokinesis in the area of decreased perfusion, consistent
with post-stress stunning. Calculated EF 47%.
*HTN
*BPH
*Hematuria
*Infraaortic aneuysm: 3.4 x 3.2 cm
Social History:
Works as a psychologist. Divorced, but dating two women, which
has apparently become a stressful situation. Denies illicit drug
use, drinks 3-4 alcoholic drinks daily. No history of ETOH
withdrawl or seizures. 20 pk year history of tobacco, quit 20
years ago.
Family History:
none, one brother healthy
Physical Exam:
Vitals: T:97.4 BP:119/75 P:76 RR:24 O2Sat: 93%3L
Gen: Somewhat diaphoretic appearing, pleasant, elderly gentleman
HEENT: PERRL, EOMI, mild scleral icterus, pale conjunctiva.
NECK: supple, no LAD appreciated
CV: Regular, nl S1/S2 without audible murmur. No carotid bruits.
LUNGS: [**Hospital1 **]-basilar crackles without wheezing.
ABD: softly distended. No tenderness to palpation. Normal bowel
sounds. No hepatomegaly. Spleen tip not palpable. No ascites.
EXT/SKIN: No asterixis, no rashes, no petechiae. Skin appears
slightly jaundiced. No splinter hemorrhages, no [**Last Name (un) **] lesions.
Extremities warm, well perfused without lower extremity edema.
GU: Dried blood and external hemorrhoids visualized. Prostate
smooth and somewhat tender on exam. Guaiac +.
Pertinent Results:
[**2142-9-13**] 01:05PM BLOOD WBC-4.4 RBC-3.57* Hgb-11.0* Hct-30.6*
MCV-86 MCH-30.8 MCHC-35.9* RDW-15.5 Plt Ct-57*
[**2142-9-19**] 05:45AM BLOOD WBC-4.5 RBC-2.44* Hgb-7.3* Hct-21.5*
MCV-88 MCH-30.0 MCHC-34.1 RDW-16.4* Plt Ct-112*
[**2142-9-19**] 04:38PM BLOOD Hct-27.9*#
[**2142-9-21**] 06:50AM BLOOD WBC-8.1 RBC-2.87* Hgb-8.5* Hct-25.4*
MCV-89 MCH-29.8 MCHC-33.7 RDW-16.6* Plt Ct-197
[**2142-9-20**] 05:50AM BLOOD Neuts-72.9* Lymphs-22.4 Monos-3.6 Eos-1.0
Baso-0.2
[**2142-9-13**] 01:05PM BLOOD Neuts-70 Bands-4 Lymphs-14* Monos-10
Eos-0 Baso-2 Atyps-0 Metas-0 Myelos-0
[**2142-9-14**] 03:54PM BLOOD PT-14.4* PTT-66.4* INR(PT)-1.3*
[**2142-9-17**] 11:00AM BLOOD PT-13.4 PTT-32.1 INR(PT)-1.2*
[**2142-9-16**] 04:15AM BLOOD Fibrino-536*
[**2142-9-15**] 08:28AM BLOOD Parst S-POS
[**2142-9-20**] 05:50AM BLOOD Parst S-THICK SMEAR REVIEWED
[**2142-9-15**] 01:13AM BLOOD Ret Aut-0.6*
[**2142-9-18**] 05:25AM BLOOD Ret Aut-0.7*
[**2142-9-14**] 10:05AM BLOOD Glucose-137* UreaN-44* Creat-2.0* Na-136
K-3.2* Cl-99 HCO3-26 AnGap-14
[**2142-9-21**] 06:50AM BLOOD Glucose-113* UreaN-35* Creat-1.5* Na-138
K-4.1 Cl-104 HCO3-29 AnGap-9
[**2142-9-13**] 01:05PM BLOOD ALT-45* AST-99* AlkPhos-34* TotBili-2.1*
DirBili-0.8* IndBili-1.3
[**2142-9-17**] 11:00AM BLOOD ALT-276* AST-389* LD(LDH)-999* AlkPhos-40
TotBili-1.8*
[**2142-9-20**] 05:50AM BLOOD ALT-180* AST-116* LD(LDH)-574* AlkPhos-41
Amylase-68 TotBili-1.3
[**2142-9-14**] 03:54PM BLOOD Calcium-7.2* Phos-2.9 Mg-2.1
[**2142-9-21**] 06:50AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8
[**2142-9-15**] 01:13AM BLOOD calTIBC-164* Hapto-<20* Ferritn->[**2134**]
TRF-126*
[**2142-9-14**] 10:05AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HAV-NEGATIVE
[**2142-9-15**] 01:13AM BLOOD Type-ART Temp-37.5 O2 Flow-52 pO2-68*
pCO2-31* pH-7.51* calTCO2-26 Base XS-1
[**2142-9-18**] 12:18AM BLOOD Type-ART pO2-68* pCO2-34* pH-7.54*
calTCO2-30 Base XS-6
.
CXR
[**9-15**]
No acute intrathoracic process. Low lung volumes.
[**9-16**]
Low lung volumes. Bibasilar atelectasis.
[**9-17**]
In comparison with study of [**9-16**], there is substantial increase
in
the thick streaks of atelectatic change at both bases. The upper
zones are
essentially clear. No evidence of pleural effusion or vascular
congestion
[**9-18**]
In comparison with study of [**9-17**], some decrease in the thick
streaks
of atelectasis at both bases. However, some significant
atelectasis persists in this patient with even lower lung
volumes
.
CT abdomen
1. Interval development of splenomegaly with a
linear/wedge-shaped peripheral
hypodensity, most consistent with a perfusion abnormality.
Clinical
correlation is recommended. Given the patient's history of
fever, the
enlargement of the spleen may be secondary to a viral process.
2. Abdominal aortic aneurysm measuring 3.6 x 3.4 cm in size.
3. Colonic diverticulosis.
4. Enlargement of the prostate gland.
5. Atherosclerosis with involvement of the coronary arteries.
.
LE US
There is normal compressibility, augmentation, color Doppler
signal, and Doppler waveform within the common femoral vein,
superficial
femoral vein, popliteal vein bilaterally. Tibial and peroneal
veins also
demonstrate normal signal and compression.
.
ECHO
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
a trivial/physiologic pericardial effusion.
Brief Hospital Course:
Pt presented to the Ed from PCP office with fever, confusion,
down-trending BP pancytopenia and CT evidence of splenomegaly.
He also was found to have an oxygen saturation of 89%.
.
He was admnited to the MICU where he was found to have
babesiosis on peripheral smear. Lyme and Erlichia serologies
were sent. Lyme serology was negative, Elrichia is still
pending. ID and Hem/Onc consultations were obtained. He was
started on quinine, doxy and clindamycin. He was also found to
have hemolytic anemia, elevated liver enzymes and acute renal
failure. During his stay in the MICU the patient experineced
dyspnea and had cracles on PE. An echo showed EF of 55 and no
other acute processes. After two days in the MICU, the patient
admited to symptomatic improvement and he was transfered to the
floor. Both his pancytopenia, elevated liver enzymes and the
number of parasites on the smear were improved at this point in
time.
.
In the [**Hospital1 **] the patient was switched from quinine/clindamycin to
atovoquine/azithromycin.
.
The patient's leucopenia and thrombocytopenia continued to
improve, yet his HCT was trending down. His reticulocyte count
at this time was 0.9, while LDH was trtending down. The patient
was started on Folate and B12 to assist the marrow response. The
pateient reached a nadir HCT of 21.5 reuiring transfusion of 1
unit pRBCs. This lead to HCT elevation to 27.9, which then
stabilized at 25-26. The patient's ARF remained stable in this
setting, while his liver function test improved.
.
The patient's dyspnea improved with inhaled Albuterol and
Ipratropium bromide, as well as gentle diuresis. The patient had
bilateral LE U/S, negative for DVT. He was able to saturate in
the mid 90's in the absence of oxygen, and while ambulating
prior to discharge.
.
The patient is to continue atovoquine and azithromycin and
Doxycycline as outpatient therapy.
.
The patient is recommended to have outpatient follow up to
determine resolution of his anemia and ARF.
Medications on Admission:
Metoprolol 25 mg b.i.d. - reduced to 25mg daily
Lisinopril 20 mg daily - on hold
Lipitor 40 mg daily
HCTZ 25mg daily - on hold
Lorazepam prn
Cialis prn
.
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO BID (2 times a day).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2
times a day) for 11 days.
Disp:*22 Doses* Refills:*0*
6. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 doses.
Disp:*11 Tablet(s)* Refills:*0*
7. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO
twice a day for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*1 Inhaler* Refills:*3*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
Disp:*1 Inhaler* Refills:*3*
10. Outpatient Lab Work
Blood draw: CBC, ferritin, iron, TIBC, Vitamin B12, Folate. To
be drawn at the time of your outpatient follow-up apppointment
on [**2142-9-26**].
Discharge Disposition:
Home
Discharge Diagnosis:
Babesiosis
Discharge Condition:
Stable
Discharge Instructions:
You were admited with fever and hypotension and found to have
Babesia infection and may also have Ehrlichia - both tick borne
illnesses. You were started on an antibiotic regimen and your
infection is getting beter. Please complete a course of
antibiotics for this problem. Take Azithromycin and Atovaquone
until [**2142-10-1**] and Doxycycline until [**2142-9-24**].
You also had shortness of breath which is also getting better
with fluid removal. This likely was due to fluid overload plus a
component of reactive airway disease. You may continue to take
an albuterol and ipratropium inhaler as necessary for shortness
of breath. Please discuss this issue further with your primary
care doctor.
Your infection was complicated by anemia, which we attributed to
blood cell destruction secondary to infection. You required
transfusion of red blood cells while in the hospital. You must
have your blood checked early next week to monitor your blood
count to further work-up your anemia.
Please call your regular doctor or return to the ED if you
develop: fevers chills shortness of breath chest pain fatigue
lightheadedness bleeding or any other symptom that is unusual
for you.
Followup Instructions:
Please make sure to follow up with your regular doctor. [**First Name (Titles) 6**] [**Last Name (Titles) 10415**]t has been scheduled for you with Dr [**Last Name (STitle) 2903**] on Wed, [**9-26**]. Please call the office on Monday to determine the time of
appointment. Please have your blood drawn at that appointment to
monitor for anemia and further work-up this problem.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2142-9-21**]
ICD9 Codes: 5849, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6518
} | Medical Text: Admission Date: [**2147-11-13**] Discharge Date: [**2147-11-15**]
Service: NEUROSURGERY
Allergies:
Diovan / Fosamax / Prinivil / 4-Aminoquinolines / pecans and
fish
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for evacuation of the subdural hematoma
Major Surgical or Invasive Procedure:
[**2147-11-13**]: Left sided burr holes for evacuation of SDH
History of Present Illness:
Elective admission for evacuation of the left subdural hematoma
Past Medical History:
HTN
CAD
Hypothyroidism
Dementia
High cholesterol
Cardiac stent > 10 yrs ago
Social History:
Previously lived alone in an apartment with a daughter who lives
upstairs, but sent to rehab from her last admission.
Family History:
Non-contributory
Physical Exam:
On admission:
Awake, Alert, Oriented to self, place, and month. [**Last Name (LF) 2994**], [**First Name3 (LF) 2995**].
Upon discharge:
Neurologically intact
left sided cranial wound C/D/I with nylon suture closure
Pertinent Results:
[**2147-11-14**] Head CT w/o contrast:
S/p evacuation of septated left subdural hematoma. Decreased
posterior compartment of the hematoma with decreased mass effect
on the left parietal and temporal structures. In the anterior
compartment of the hematoma, fluid has been replaced by air, and
mass effect on the left frontal structures is unchanged.
Brief Hospital Course:
87F elective admission for surgical evacuation of the subdural
hematoma. Please see operative report for full details. Post-op
she was admitted to the ICU for monitoring. She remained stable
overnight. A post-op CT Head was performed on [**11-14**] which showed
decreased posterior compartment of the hematoma with decreased
mass effect on the left parietal and temporal structures.
She was transferred to the floor on [**11-14**] where she was assessed
by PT/OT for transfer back to rehab. Her neurological status
remained stable. She is discharged to extended care facility in
stable condition.
Medications on Admission:
levothyroxine, Plavix, One Daily Multivitamin, calcium, Aspirin,
Isordil Titradose, amlodipine, simvastatin, donepezil,
metoprolol tartrate
Discharge Medications:
1. pneumococcal 23-valps vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection NOW X1 (Now Times One Dose).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain fever.
3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34004**] Nursing & Rehabilitation Center - [**Location (un) 14663**]
Discharge Diagnosis:
Left subacute subdural hematoma with midline shift
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair in three days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? you have been prescribed Keppra (Levetiracetam), you will not
require blood work monitoring for this med, but continue to take
until directed to discontinue by your Neurosurgeon.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a Head CT w/o
contrast. Please call [**Telephone/Fax (1) 4296**] to make the appointment.
Please follow up with your PCP regarding this admission.
Completed by:[**2147-11-15**]
ICD9 Codes: 4019, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6519
} | Medical Text: Admission Date: [**2122-9-22**] Discharge Date: [**2122-9-29**]
Date of Birth: [**2059-1-8**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Motrin / Nsaids / Aspirin / Dilantin / Ativan
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
63F with multiple medical problems and multiple admissions for
altered mental status presenting with abdominal pain and altered
mental status. Ms. [**Known lastname **] [**Last Name (Titles) 1834**] exploratory laparotomy on
[**2122-9-11**] and was found to have benign cecal pneumatosis. The
patient presents now for progressive confusion and decreased
mental acuity. The family is not available to discuss their
concerns and the patient complains of unchanged abdominal pain.
In the ED her vitals were 98.2 99 123/39 17 99%RA. FSG was 86 on
arrival. Exam showed A+O x 1. Labs were c/w ESRD, with AG
acidosis, but no hyperkalemia. Neurology was consulted given the
AMS, and felt it was due to a toxic-metabolic encephalopathy and
not a central insult or seizure. CXR was unrevealing except for
LLL atelectasis. No urine able to be obtained but blood cultures
were sent. A CT head was negative. A CT abdomen and pelvis was
obtained which showed no acute process or abscess, but a small
hematoma/stranding in the anterior subcutaneous tissues and
likely also left rectus, c/w recent surgery. Her HR did increase
to the 140s in the ED, responded to IV labetolol, but pressure
dropped. This responded to IVF. She was given 250mg of
levetiracetam and admitted to medicine for further workup of AMS
and correction of electrolytes.
Past Medical History:
PMH:
1. Multiple admission with altered MS recently ([**10-13**]) - with
recent extensive neurological workup revealing multifocal
etiology likely due to HD fluid/electrolyte shifts, ? uremia
prior to HD, also component of vascular dementia. Started on
[**Month/Year (2) 13401**] [**9-14**].
2. Diabetes mellitus.
3 End-stage renal disease secondary to diabetes mellitus s/p
failed dual extended-criteria donor renal transplant (BK virus
nephropathy)
4. Hemodialysis.
5. Hypertension.
6. Hyperlipidemia.
7. Thrombosis of bilateral IVJ (catheter placement)-- DVT
associated with HD catheter RUE on anticoagulation (Coumadin)
--balloon angioplasty performed [**1-13**].
8. Osteoarthritis.
9. PER OMR NOTES (?) - Arthritis of the left knee at age nine,
treated with ACTH resulting in secondary [**Location (un) **]. She was
diagnosed with rheumatic fever.
10. h/o Trach and PEG [**1-13**] (reversed [**2-13**]).
11. h/o L tension pneumothorax [**2-7**] intubation
.
Past Surgical History:
1. Kidney transplant in [**2119**] b/l in RLQ
2. Left arm AV fistula for dialysis.
3. Removal of remnant of AV fistula, left arm.
4. Catheter placement for hemodialysis.
5. Low back surgery (unspecified)
Social History:
The patient smokes half a pack of cigarettes a day for the last
20 years. She does not drink alcohol or has ever experienced
with recreational drugs, has no tattoos. The patient has had
transfusions in [**2119**] and [**2120**]. The patient is a homemaker. The
patient has experienced economic problems lately.
.
Family History:
Family History: From prior d/c summary
Mother and sister with diabetic mellitus.
Kidney failure in mother, sister
Physical Exam:
On admission to ICU
PE: intubated, sedated, NAD
VS: T 98.0 BP 157/64--> 80s/40s with propofol HR 96 RR 12, 100%
AC 100% 500 x 20 5
General: intubated, sedated
HEENT: tongue is swollen and protruding from her mouth, blood
visible around ET tube, lips swollen. L pupil briskly reactive
to light from 3 mm --> 1 mm; R pupil is sluggish, 3 mm --> 2 mm.
anicteric .
NECK: no JVD, supple
CV: +s1s2 RRR 2/6 systolic murmur, no R/G. +L.sided tunnel cath
no erythema, C/D/I, currently accessed/receiveing IVF.
PULM: CTA B/L
ABD: +bs, midline inscision c/d/i, staples in place, soft, ND.
EXT: no C/C/edema 2+pulses b/l
NEURO: intubated/sedated. moves all 4.
Pertinent Results:
Admission labs:
[**2122-9-21**] 04:00PM PLT COUNT-415
[**2122-9-21**] 04:00PM NEUTS-67.4 LYMPHS-20.1 MONOS-9.8 EOS-2.6
BASOS-0.1
[**2122-9-21**] 04:00PM WBC-8.3 RBC-2.72* HGB-9.1* HCT-27.7* MCV-102*
MCH-33.3* MCHC-32.7 RDW-16.1*
[**2122-9-21**] 04:00PM ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
[**2122-9-21**] 04:00PM CALCIUM-9.7 PHOSPHATE-8.0*# MAGNESIUM-2.5
[**2122-9-21**] 04:00PM GLUCOSE-58* UREA N-49* CREAT-13.8*#
SODIUM-136 POTASSIUM-6.8* CHLORIDE-99 TOTAL CO2-21* ANION
GAP-23*
[**2122-9-21**] 04:09PM LACTATE-1.4 K+-4.6
[**2122-9-21**] 05:24PM PT-18.3* PTT-29.2 INR(PT)-1.7*
[**2122-9-22**] 06:50AM PLT COUNT-421
[**2122-9-22**] 06:50AM WBC-8.5 RBC-2.83* HGB-9.2* HCT-29.4* MCV-104*
MCH-32.7* MCHC-31.4 RDW-15.5
[**9-21**] CT ABD/PELVIS: no acute process, diverticulosis, extensive
atherosclerotic changes, left anterior subcutaneous tissue
stranding with hematoma-post surgical, extensive collateral
circulation, suggestive of an upper extremity thrombus.
CT HEAD (noncontrast) [**9-21**]: no acute intracranial process,
multiple lacunar infarcts, chronic small vessel ischemic disease
(unchanged)
EEG: This is an abnormal 24-hour video EEG telemetry in the
waking and sleeping states due to the occasional left
mid-temporal sharp
waves suggestive of a potential focus of epileptogenesis. In
addition,
there were bursts of generalized delta frequency slowing
suggestive of
midline subcortical dysfunction. Nonetheless, there were no
electrographic seizures and no pushbutton activations noted.
[**2122-9-29**] 01:30PM BLOOD WBC-6.4 RBC-3.28* Hgb-10.9* Hct-33.7*
MCV-103* MCH-33.3* MCHC-32.4 RDW-16.6* Plt Ct-470*
[**2122-9-29**] 01:30PM BLOOD Plt Ct-470*
[**2122-9-29**] 01:30PM BLOOD PT-27.6* PTT-131.8* INR(PT)-2.8*
[**2122-9-29**] 01:30PM BLOOD Glucose-134* UreaN-36* Creat-9.5*# Na-136
K-3.7 Cl-97 HCO3-26 AnGap-17
[**2122-9-29**] 01:30PM BLOOD Calcium-8.6 Phos-5.8* Mg-2.2
Brief Hospital Course:
1. Altered mental status/seizure/intubation: most likely
etiology is multiple missed hemodialysis sessions/uremia. It is
possible the Tylenol with codeine she was taking for post
operative pain control contributed. The morning following
admission she had an episode of decreased responsiveness, clonic
jerks, lip smacking and hand automatisms. She was evaluated by
neurology and was given Ativan and Depakote for complex partial
seizure. Approximately 1 hour after this she became unresponsive
and her tongue was swollen. She was intubated for airway
protection due to angioedema. Her mental status normalized
(thought to be related to post-ictal state and medications), EEG
was negative for status epilepticus, head CT and toxicology
screens were negative. The patient required daily dialysis from
[**Date range (3) 45315**] and her mental status normalized and was stable
for several days at discharge.
2. Angioedema/respiratory failure: Her tongue was noted to be
swollen prior to the administration of Depakote during
suctioning prior to intubation. The angioedema seemed to
correlate with the Ativan administration. There is a report of
angioedema in the past, attributed to Dilantin--but she received
Ativan at that time as well. She was treated for 24 hours with
steroids with remarkable improvement. Her lisinopril was also
discontinued. Her intubation was for airway protection in the
setting of altered mental status and angioedema. She had
persistent apneic episodes on the ventilator and never developed
a cuff leak. She has presumed tracheal stenosis from prior
tracheostomy. She was successfully extubated in the presence of
anesthesia on [**2122-9-25**]. It is recommended she have an outpatient
sleep study to evaluate for obstructive sleep apnea as well as
an outpatient allergy evaluation.
3. Seizures: The patient suffered a partial complex seizure on
the morning after admission. The neurology team followed the
patient throughout her admission.
She was initially loaded with depakote, however, this was then
tapered off and her [**Date Range 13401**] dosing was increased to 500 mg twice
daily and an additional dose following hemodialysis. She will
follow up with Neurology as an outpatient.
4. ESRD on HD: She missed two outpatient HD sessions prior to
admission. She was dialyzed daily in the MICU from [**Date range (1) 45316**]
then returned to her scheduled of T/T/Saturday.
5. Atrial fibrillation: Rate control with metoprolol. She had a
single episode of RVR in the ED prior to admission which
responded to labetalol, otherwise, she was effectively rate
controlled. Her INR was subtherapeutic at admission, but was
therapeutic at discharge. Her INR will need to be followed in
rehabilitation and outpatient monitoring set up prior to
discharge home.
6. Abdominal Pain: likely post operative, waxed and waned on
this admission. At the time of discharge, the pain was
controlled by Tylenol. Her staples were removed by the surgical
team during this hospitalization. She had increased discharge
from her abdominal wound noted on [**2122-9-28**]. The surgery team
evaluated and felt the wound was healing well and there was no
evidence of a wound infection. They recommended daily dry
dressing changes.
7. Benign Hypertension: continued on amlodipine and metoprolol.
Lisinopril discontinued in the setting of angioedema and not
restarted. The amlodipine was started in its place. Her blood
pressure ranged 110-140s/50-70s prior to discharge.
8. Disposition: the patient was discharged to a rehabilitation
facility. She will benefit from a home safety evaluation and
visiting nurses to evaluate medication understanding/compliance.
She requires INR monitoring. As an outpatient, she should have
an allergy evaluation for the recurrent angioedema as well as a
sleep study to evaluate sleep apnea.
Medications on Admission:
MEDS:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Date Range **]: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Atorvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Date Range **]: One (1) Cap
PO DAILY (Daily).
4. Cinacalcet 90 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
5. Sertraline 100 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
6. Lisinopril 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen-Codeine 300-30 mg Tablet [**Date Range **]: One (1) Tablet PO
Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
8. Warfarin 1 mg Tablet [**Date Range **]: Two (2) Tablet PO once a day:
Please restart [**2122-9-18**]. Do NOT dose on [**9-17**].
9. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a
day: Started with previous admission
10. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO following
HD.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID
(3 times a day).
2. Atorvastatin 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Year (2) **]: One (1) Cap
PO DAILY (Daily).
4. Cinacalcet 30 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO DAILY
(Daily).
5. Sertraline 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
7. Levetiracetam 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2
times a day).
8. Levetiracetam 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HD
PROTOCOL (HD Protochol).
9. Amlodipine 5 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily).
10. Acetaminophen 500 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed: not to exceed 4 grams/24 hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Altered mental status
Uremia
Angioedema
Respiratory failure
Complex partial seizure
Secondary
Hypertension
End stage renal disease on hemodialysis
Atrial fibrillation
Seizure Disorder
Failed renal transplant X 2
Hyperlipidemia
Discharge Condition:
At mental status baseline, pain controlled, tolerating diet
Discharge Instructions:
You were admitted with confusion in the setting of missed
hemodialysis sessions. In the hospital, you had a seizure and a
reaction to a medication which caused your tongue to swell and
necessitated a breathing tube. You had several daily dialysis
sessions and your confusion resolved. You had abdominal pain
which was controlled with Tylenol. Surgery evaluated your wound
and thought you were healing well. You are being discharged to
a rehabilitation facility to regain your strength after the long
hospitalization.
Followup Instructions:
Please call your primary provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 45317**] for
an appointment within 1 week of rehabilitation discharge.
Surgery Follow Up: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-10-16**] 2:00
Neurology Follow Up: Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-11-10**] 4:30
Renal Transplant Appointment: Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2123-1-15**] 9:00
Completed by:[**2122-9-29**]
ICD9 Codes: 5856, 2762, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6520
} | Medical Text: Admission Date: [**2128-11-22**] Discharge Date: [**2128-11-26**]
Date of Birth: [**2128-11-22**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 56602**] twin one is the
2385 gram product of a spontaneous twin, 34 and [**2-4**] week
gestation, born to a 29 year old gravida I, para 0, now II,
mother by cesarean section for preterm labor with breech
presentation of the second twin.
Prenatal screens included maternal blood type A positive,
antibody negative, RhoGAM given at 28 weeks, hepatitis B
surface antigen negative, RPR nonreactive, rubella immune,
GBS unknown. Pregnancy was complicated by hypothyroidism in
the mother and preterm labor at 29 weeks, treated with
Magnesium and made Betamethasone complete.
Delivery was uncomplicated and Apgar scores were eight at one
minute and nine at five minutes of life.
PHYSICAL EXAMINATION: On admission, in general, Baby [**Name (NI) **]
[**Known lastname 56602**] number one was well appearing, with an examination
consistent with his gestational age. Birth weight was 2385
grams, which is the 75th percentile, birth length was 47
centimeters, which is the 75th percentile, and head
circumference was 32.75 centimeters, again the 75th
percentile. Head, eyes, ears, nose and throat examination
was significant for some molding of the head with the
anterior fontanelle that was open, soft and flat. Red
reflexes were present bilaterally. His palate was intact.
Chest examination revealed lungs that were clear to
auscultation bilaterally with mild intercostal retractions.
His heart was regular rate and rhythm without a murmur. His
femoral pulses were two plus bilaterally, and his capillary
refill was less than two seconds. His abdomen was soft, with
active bowel sounds and no masses. His extremities were warm
but with acrocyanosis. Genitourinary examination revealed
normal preterm male with testes palpable in the canal. His
anus was patent. His spine revealed no clefts or dimples.
His hips were stable. His neurologic examination was
appropriate for his gestational age.
HOSPITAL COURSE: Respiratory: Baby [**Name (NI) **] [**Known lastname 56602**] number one was
in room air on admission and remained with good saturations
throughout the hospitalization.
Cardiovascular: Baby [**Name (NI) **] [**Known lastname 56602**] number one was
hemodynamically stable throughout the admission, with normal
perfusion and blood pressure.
Fluids, Electrolytes and Nutrition: Baby [**Name (NI) **] [**Known lastname 56602**] number
one was initially held NPO on D10W at 80 cc/kg/day. His
glucoses were stable. Enteral feedings were initiated at
about twelve hours of life with mother's milk or Special Care
20. Feeds were easily advanced and at the time of transfer,
he is on total fluids of 140 cc/kg/day, taking feeds p.o./PG.
On the morning of transfer, he took one full feed p.o. He
has been voiding and stooling appropriately. His
electrolytes at 24 hours of life were within normal limits.
Hematology: Bilirubin at 24 hours of life was 5.6 with a
direct component of 0.2. At 48 hours, it had risen to a
maximum value of 11.3, so he was placed on single
phototherapy. The following day it had fallen again to 8.9,
so the plan was made to discontinue phototherapy on day of
life four, [**2128-11-26**], and check a rebound bilirubin on
[**2128-11-27**]. Baby [**Name (NI) **] [**Known lastname 56602**] number one is blood type A
positive, Coombs negative. His initial hematocrit was 59.9
percent with platelet count of 223,000.
Infectious Disease: Secondary to prematurity and unknown GBS
status, Baby [**Name (NI) **] [**Known lastname 56602**] number one was begun on a rule out
sepsis course of Ampicillin and Gentamicin. His initial
white blood cell count was 7.8 with 22 percent polys and 0
bands and 71 percent lymphocytes. His cultures were negative
at 48 hours, so antibiotics were discontinued.
Sensory: Hearing screen was performed with automated
auditory brain stem responses on [**2128-11-26**], and was passed
in both ears.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To [**Hospital3 **], level II nursery.
PRIMARY PEDIATRICIAN: The family has not made their final
selection of pediatrician yet.
CARE/RECOMMENDATIONS:
1. At the time of transfer, Baby [**Name (NI) **] [**Known lastname 56602**] number one is
feeding Special Care 20 or breast milk 20 140 cc/kg/day
p.o./PG.
2. He is on no medications.
3. He has not yet had car seat position screening but should
have this prior to discharge home.
4. State Newborn Screen has been sent.
5. Hepatitis B vaccine was given on [**2128-11-26**].
6. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following
three criteria: Born at less than 32 weeks; born at
between 32 and 35 weeks with two of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings or 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 DIAGNOSES:
1. Prematurity at 34 and 1/7 weeks gestation.
2. Suspected sepsis, ruled out.
3. Hyperbilirubinemia.
4. Immature feeding.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Doctor Last Name 56737**]
MEDQUIST36
D: [**2128-11-26**] 09:55:39
T: [**2128-11-26**] 11:08:39
Job#: [**Job Number 57671**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6521
} | Medical Text: Unit No: [**Numeric Identifier 74607**]
Admission Date: [**2145-10-20**]
Discharge Date: [**2145-11-6**]
Date of Birth: [**2145-10-18**]
Sex: M
Service: Neonatology
HISTORY: This infant was referred to the NICU by the
pediatrician, Dr. [**Last Name (STitle) 52362**], for evaluation of cyanotic
episode while in the newborn nursery. He is the 3435 gram
product of a 38 week gestation born to a 32-year-old G2 P0,
now 1 mother by spontaneous vaginal delivery on [**2145-10-18**]. Prenatal labs were blood type O negative, antibody
negative, RPR nonreactive, rubella immune, HBSAG negative,
GBS negative.
This pregnancy was uncomplicated. Mother was on no
medications. At delivery, there was no maternal fever.
Rupture of membranes revealed clear fluid about 4 hours prior
to delivery. The infant was vigorous at birth and required
only warming, stimulation and bulb suction for resuscitation.
Apgars were 8 and 9. He was admitted to the newborn nursery.
At about 2-1/2 hours of life, he had a brief dusky spell that
responded to stimulation and blow-by O2. There was no apnea
noted. He was examined by [**Name8 (MD) **] NNP and was thought to be well
appearing so the decision was made for further observation in
the newborn nursery. He was well until the morning of
admission to the NICU at about 60 hours of life when he had
two more cyanotic episodes. They both occurred after crying.
He became quiet, developed shallow breathing and had facial
and oral cyanosis. He made swallowing movements shortly
afterward but had not fed for 3 to 3-1/2 hours before these
episodes. He was transferred to the NICU for further
evaluation and management of cyanotic spells. On admission to
the NICU, he had another cyanotic episode with a desaturation
to 65%.
PHYSICAL EXAMINATION: On admission, his birth parameters
were weight 3435 grams which is 75th-90th percentile. Length
50.2 cm which is 75th percentile. Head circumference 34 cm
which is 75th percentile. General: Alert, nondysmorphic, term
male on an open warmer. HEENT: Anterior fontanel soft and
flat. Sutures approximated. Red reflex deferred. Nares
patent. Mucous membranes moist. Palate intact. Neck: No
masses. CV: Normal rate and rhythm, no murmur. 2+ femoral and
radial pulses. Brisk cap refill. Pulmonary: Clear to
auscultation bilaterally. No increased work of breathing.
Abdomen soft, nontender, nondistended, bowel sounds present,
no mass, no hepatosplenomegaly. GU: Normal term male
genitalia, uncircumcised. Testes descended bilaterally.
Patent anus. Back: No cleft, tuft or dimple. Extremities:
Warm, well perfused. Hips stable. Neuro: Alert, normal tone.
Suck, gag, grasp, Moro reflex all within normal limits. Skin
pink with few petechiae scattered on forehead, minimal
jaundice.
HOSPITAL COURSE:
1. Respiratory: The infant has remained in room air. At
admission to the NICU although he had numerous episodes
of desaturations mostly with feedings but occasionally
drifts in desaturations at rest. At discharge, the
infant has been five days spell-free of any episodes.
The infant has required no methylxanthine therapy. A
chest x-ray was within normal limits.
2. Cardiovascular: The infant has maintained cardiovascular
stability but due to the cyanotic episodes, a cardiac
evaluation was done. Four extremity blood pressures were
within normal limits. Pre and post-ductal saturations
were also within normal limits. Heart size on chest x-ray
was within normal limits. Cardiology was consulted and an
echocardiogram was done. The echocardiogram revealed
essentially normal cardiac structure with a small PFO
with bidirectional shunt and the left superior vena cava
could not be completely excluded. Otherwise, the infant
has remained cardiovascularly stable. An EKG on [**10-20**], [**2145**] showed right axis deviation and prolonged
QTC-wave. The followup EKG on the 18th was normal.
However, the infant will still have follow-up with
Cardiology.
3. Fluid, electrolytes and nutrition: The infant has been
ad lib p.o. feeding throughout the hospital course while
in the NICU. At the time of discharge, the weight is 3855
grams. The infant is growing well, is feeding
approximately greater than 200 ml/kg/day of 20 cal
feedings, breast milk or Enfamil. The infant is voiding
and stooling normally. The infant was started on iron and
Tri-Vi-[**Male First Name (un) **] on [**2145-10-24**].
4. GI: Bilirubin was done on day of life 3 which was
7.6/0.3. The infant has required no phototherapy and has
had no further bilirubins checked.
5. Neurology: The infant has maintained a normal neurologic
exam other than the cyanotic episodes mentioned above.
6. Audiology: The hearing screen was performed with
automated auditory brain stem responses and the infant
passed in both ears.
7. Psychosocial: A [**Hospital1 18**] social worker has been involved
with the family. The contact social worker can be
reached at [**Telephone/Fax (1) 8717**] if there are any concerns.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents. Name of
primary pediatrician is [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) **]. Telephone number [**Telephone/Fax (1) 74608**].
CARE RECOMMENDATIONS: Ad lib p.o. feedings of breast milk or
breast feeding with Enfamil 20 cal/ounce as needed.
MEDICATIONS:
1. Tri-Vi-[**Male First Name (un) **] one ml a day.
2. Ferrous sulfate 0.3 ml p.o. daily (concentration 25 mg/mL)
which is 2 mg/kg/day.
3. Iron and vitamin D supplementation: 1. Iron
supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. 2. All
infants on predominantly breast milk should receive
vitamin D supplementation at 200 international units
which may be provided as a multivitamin preparation
daily until 12 months corrected age.
Car seat position screening: passed.
State newborn screens were sent on [**2145-10-21**] and
[**2145-11-1**]. No results have been received by the NICU.
Immunizations received: The infant has received no
immunizations thus far though the family had requested
waiting until an outpatient pediatric visit for the hepatitis
B vaccine to be given.
Immunizations recommended:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the 4
following criteria: 1: Born less than 32 weeks
gestation. 2: Born between 32 and 35 weeks with two of
the following: Either 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 congenital
heart defect.
2. 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.
3. This infant has not received the 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 or fewer than 12 weeks of age.
FOLLOWUP: Followup appointment will be made by the parents
for Monday, [**2145-11-8**]. DNA referral has been made.
Followup is recommended with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from cardiology at
[**Hospital3 1810**], [**Telephone/Fax (1) 74609**] at approximately 6 weeks of
age.
DISCHARGE DIAGNOSES:
1. Cyanotic spells.
2. Sepsis ruled out.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2145-11-5**] 23:07:00
T: [**2145-11-6**] 11:25:09
Job#: [**Job Number 74610**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6522
} | Medical Text: Admission Date: [**2175-7-14**] Discharge Date: [**2175-8-11**]
Date of Birth: [**2175-7-14**] Sex: F
Service:
DISCHARGE DIAGNOSES:
1. Premature female infant at 32 weeks gestation.
2. Transient tachypnea of newborn.
3. Peripheral pulmonary artery stenosis murmur.
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 51656**] is the former 1.265
kilogram female infant [**Known lastname **] at 32 weeks gestation to an O
positive, 34-year-old, primigravida, whose prenatal screens
were noncontributory. Maternal history was remarkable for
hypertension which was treated with Aldomet. The mother also
received betamethasone. She was also on Prozac during her
pregnancy. Fetal heart monitoring on the day of
delivery showed decelerations which prompted a cesarean
section.
The baby was [**Name2 (NI) **] with [**Name (NI) **] scores were 7 at one minute of
age and 8 at five minutes of age and was admitted to the
Neonatal Intensive Care Unit at [**Hospital1 188**] for prematurity.
On admission, the infant weighed 1265 grams (which was the
25th percentile), head circumference was 27 cm (which was the
10th percentile). and length was 37 cm (which was less than
10th percentile).
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
demonstrated some mild retractions with grunting and fair air
exchange.
SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: Problems
during this hospital stay.
1. RESPIRATORY ISSUES: The infant was initially placed on
continuous positive airway pressure which she remained on for
12 hours and then weaned directly to room air.
2. CARDIOVASCULAR ISSUES: The infant had stable blood
pressures throughout her hospital stay. A systolic murmur
was heard after the first days of life and remains.
It is a grade 2/6 systolic murmur and heard throughout the
precordium, out to the apex, and over both scapula. There
was no hepatosplenomegaly. No bounding pulses. The infant
remained asymptomatic. It was thought that this was
consistent with peripheral pulmonary stenosis. If the murmur
is still present two months status post discharge, the
patient will be followed up at [**Hospital1 **] Cardiology by
Dr. [**Last Name (STitle) 1537**].
3. FEEDING AND NUTRITION ISSUES: At the time of discharge,
the infant weighed 1785 grams, was ad lib feeding of NeoSure
26 calories per ounce; made up with 2 cals of corn oil. This
can be weaned as the infant demonstrates good weight gain at
home.
4. INFECTIOUS DISEASE ISSUES: The infant was initially
placed on ampicillin and gentamicin ;with a benign complete
blood count and negative blood cultures, the antibiotics
were discontinued at 48 hours.
5. HEMATOLOGIC ISSUES: Both mother and baby were O positive
and [**Name (NI) 36243**] negative. The infant had a peak bilirubin of 8;
for which she underwent several days of phototherapy. The
infant's hematocrit on [**7-15**] was 54. The infant is
currently Fer-In-[**Male First Name (un) **] 0.1 cc by mouth once per day.
6. AUDIOLOGY ISSUES: Hearing screening was performed on
[**8-2**] and was normal.
7. OPHTHALMOLOGIC ISSUES: Retinal examination performed and
revealed immaturity in both eyes zone III. A follow-up
appointment needs to be made in three weeks at [**Hospital1 35174**] Ophthalmology with Dr. [**Last Name (STitle) 40944**].
8. IMMUNIZATIONS ISSUES: Hepatitis B immunization was
deferred until the infant reaches 2 kilograms.
9. SCREENING: A screening head ultrasound done on [**7-24**]
was normal.
DISCHARGE STATUS: The patient was to be discharged in a
carseat.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The infant is to follow up at [**Hospital1 **] by Dr.
[**Last Name (STitle) **]. An appointment has been made for [**8-15**].
2. A visiting nurse will come to the home to check on the
infant one day status post discharge.
3. Dr. [**Last Name (STitle) **] to schedule and approve follow-up eye examination
of baby, for Dr. [**Last Name (STitle) 40944**] within three weeks of discharge.
4. Followup of peripheral pulmonary stenosis murmur with
Cardiology (Dr. [**Last Name (STitle) 1537**] in two months if murmur is still
present.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 38304**]
MEDQUIST36
D: [**2175-8-9**] 08:54
T: [**2175-8-10**] 08:50
JOB#: [**Job Number 51657**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6523
} | Medical Text: Admission Date: [**2156-5-5**] Discharge Date: [**2156-6-3**]
Date of Birth: [**2084-3-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Aleve / Codeine / Depakote
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Altered Mental Status after dialysis on [**2156-5-5**]
Major Surgical or Invasive Procedure:
Thoracentesis
Central Line Placement (left IJ)
Lumbar puncture
PICC line placement
Dialysis
History of Present Illness:
72F h/o T2DM, ESRD on HD, GAVE, HTN, MR, CAD, CHF w/ RV failure
and seizure disorder who presented to the ED on [**5-5**] after
experiencing somnolence at dialysis. It is not known how much
fluid was removed during HD. The pt has no recollection of being
at dialysis. In the ED, she stated that she felt fine, and
denied HA, vision changes, nausea, weakness, or sensory changes.
She also specifically denied any f/c/ns, abdominal pain, or CP.
She did report a non-productive cough for several days and
gradually worsening shortness of breath.
.
ED course: VS: 97.4, 121, 104/68, 14, 91RA
Ms. [**Known lastname **] mental status cleared throughout her course in the
ED.
She had no leukocytosis, and chem 7 was notable for K 2.7, Mg
1.5, Phos 0.5, with new mild elevations in her transaminases,
alk phos and Tbili. CT head was negative. CXR with improving
effusion but satting 91% RA. RUQ U/S was done given elevated
LFTs: there was a negative son[**Name (NI) 493**] [**Name2 (NI) **] sign, and
echogenic focus within GB wall c/w sludge, unchanged from [**Month (only) **]
[**2155**]. Levaquin was given for possible PNA. Pt also received
gentle IVF (1L NS), potassium and D50 as her BG was in the 60s
and her K was 2.7. HR improved slightly to the 100s at
admission.
Of note, shortly after being transfered to the floor, she
developed [**Year (4 digits) **]. She was triggered and transfered to the
MICU.
Past Medical History:
* Chronic Gastric Angiodysplasia (GAVE)and consequent chronic
low-grade UGIB, and has therefore been advised not to take
aspirin or other antiplatelet agents.
* DM type II: c/b nephropathy and neuropathy - currently not on
diabetic meds, has hypoglyemia [**12-27**] poor nutritional stores
* ESRD: HD MWF has fistula L arm
* CAD
* CHF, R-sided, [**Month/Day (2) 7216**] EF 50-55% with 4+ TR 2+ MR [**8-/2155**]
TTE, and in ICU with this admission
* Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB)
* colon polyps (hyperplastic) [**7-/2153**] colonoscopy
* gastritis and duodenitis [**7-/2153**] EGD
* gout
* pleural effusion s/p thoracentesis [**8-/2153**] negative cytology,
chemistry c/w exudate
* Seizure disorder -dose not know how seizures manifest
Social History:
Pt lives at [**Location **]. No ETOH, tobacco, or drugs.
Pt has four children, all involved in her care. There were
several family meetings during this admission with all her
children. They are very supportive and close family. No health
care proxy is assigned at this time ([**2156-5-31**]). She is aware that
she needs to choose one.
.
Family History:
[**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. Her mother
had an MI in her 80s.
Physical Exam:
At time of admission:
Physical exam:
VS: 97.3 102/palp 118 16 972L
Gen: elderly female in NAD.
HEENT: NCAT. Sclera icteric. PERRL, EOMI. No pallor or cyanosis
of the oral mucosa. No xanthalesma.
Neck: Supple with JVP not elevated.
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi. Decreased BS about [**11-27**] way up left
field w/ dullness to percussion.
Abd: Distended but soft. No HSM or tenderness. +BS, small
reducible umbilical hernia
Ext: No c/c/e. Good pulses, no asymmetry.
Skin: No rashes.
Neuro: non-focal, a&ox3, moving all ext's, 4-5/5 strength, 1+
reflex b/l, following commands
.
At time of transfer from ICU to Med floor:
VS: TM-97.2, TC-96.7 BP: 113/45 (85-132/31-50) HR: 81 (63-84)
RR: 20 SaO2: 100% 2L NC
Gen: elderly female, only resposive to some simple commands,
some moans
HEENT: NCAT. + Scleral ictertis, Mucous membranes slightly dry
Neck: Supple, no JVD, bandage from central line on the L neck
CV: irregular regular rhythm, normal rate, normal S1, S2. Unable
to ascultate a murmur (pt making noise)
Chest: Breathing comfortably, rhonchi bilaterally.
Abd: Soft, NT/ND. No HSM or tenderness. +BS, umbilical hernia
Ext: Pitting 1+ edema to the knees, peumatic compression devices
in place, 2+ DPs bilaterally
Skin: No rashes, or bed sores
Neuro: 1+ reflex b/l, will squeeze fingers bilaterally, PEERL,
unable to test other CN, pt does not move toes or open eyes to
command., pt moans occasionally, GCS of 9
Lines: PICC on rt arm, NGT, rectal tube (liquide dark green
stool)
Pertinent Results:
Admission labs:
[**2156-5-5**] 04:12PM GLUCOSE-66* LACTATE-1.7 K+-2.7*
[**2156-5-5**] 04:12PM HGB-12.5 calcHCT-38
[**2156-5-5**] 04:00PM GLUCOSE-66* UREA N-8 CREAT-1.8*# SODIUM-142
POTASSIUM-2.7* CHLORIDE-100 TOTAL CO2-35* ANION GAP-10
[**2156-5-5**] 04:00PM estGFR-Using this
[**2156-5-5**] 04:00PM ALT(SGPT)-43* AST(SGOT)-95* CK(CPK)-205* ALK
PHOS-249* TOT BILI-3.8* DIR BILI-2.3* INDIR BIL-1.5
[**2156-5-5**] 04:00PM LIPASE-112*
[**2156-5-5**] 04:00PM cTropnT-0.17*
[**2156-5-5**] 04:00PM CK-MB-4
[**2156-5-5**] 04:00PM ALBUMIN-2.5* CALCIUM-7.8* PHOSPHATE-0.6*#
MAGNESIUM-1.5*
[**2156-5-5**] 04:00PM WBC-5.5 RBC-3.62* HGB-11.9* HCT-36.7 MCV-102*
MCH-33.0* MCHC-32.5 RDW-20.0*
[**2156-5-5**] 04:00PM NEUTS-75* BANDS-0 LYMPHS-9* MONOS-16* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2156-5-5**] 04:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2156-5-5**] 04:00PM PLT COUNT-117*#
.
Discharge Labs:
.
.
Reports:
CXR [**5-5**] - AP upright and lateral views of the chest are
obtained.
Cardiomegaly is again noted with large tapering left pleural
effusion. Right lung is essentially clear and unchanged. There
is no evidence of
pneumothorax. Osseous structures reveal a compression fracture
in the upper- to-mid thoracic spine which is new since [**2156-1-19**].
CT head [**5-5**] - IMPRESSION: No hemorrhage, edema, or fracture.
US liver [**5-5**] - Moderate ascites with gall bladder wall
thickening and edema, unchanged from prior study, likely due to
third spacing. No evidence of acute cholecystitis. Echogenic
focus within the gall bladde possibley adherent sludge.
CT chest [**5-6**] - CONCLUSION:
1. No pulmonary embolism or aortic dissection. Extensive
atherosclerosis is present in the coronary arteries and there is
an aberrant origin of the right coronary artery which traverses
between the aortic root and the pulmonary artery.
2. Cardiomegaly, pleural and pericardial effusion as well as
ascites could
represent congestive cardiac failure. There has been significant
interval
increase in the right pleural effusion with almost complete
collapse/atelectasis of the left lung.
3. Enlarged mediastinal lymph nodes are unchanged since the
prior examination and may be assessed further to exclude
indolent lymphoma.
Echo [**5-13**] - A small secundum atrial septal defect is present
(cine loop #34). There is mostly left-to-right shunting, but
after injection of aerated saline into the right atrium,
right-to-left bubble transit is seen, as well. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. There is
abnormal [**Month/Year (2) 7216**] septal motion/position consistent with right
ventricular volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets fail to
fully coapt. Severe [4+] tricuspid regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Dilated and hypokinetic right ventricle. Preserved
left ventricular systolic function. Moderate mitral
regurgitation. Severe tricuspid regurgitation secondary to
annular dilation. Small secundum ASD with bidirectional flow.
.
CT of head [**5-13**] - IMPRESSION: No acute intracranial
abnormalities. Old infarct of the left frontal lobe and insula
as well as the left thalamus.
.
CT chest/abd/pelvis [**5-13**] - IMPRESSION:
1. No acute intra-abdominal process is seen. There is no
evidence of
ischemic bowel.
2. Moderate free intraperitoneal fluid is seen.
3. Reflux of contrast into the hepatic veins and intrahepatic
IVC does
suggest right heart failure.
4. Dilated common bile duct without evidence of an obstructing
lesion. This has in fact progressed in diameter since a prior
torso imaging. Therefore, an MRCP is recommended for further
evaluation of this finding.
5. Bilateral pleural effusions, decreased in size since the
prior exam.
6. Areas of consolidation at the lung bases as detailed above.
7. Endotracheal tube extends into the main stem bronchus.
.
MRI/MRA brain [**5-13**] - MRI of the Brain: The [**Doctor Last Name 352**]-white matter
differentiation of the brain is well
preserved. The ventricles and extra-axial CSF spaces appear
normal. There are old lacunar infarcts in the centrum semiovale
bilaterally visualized with adjacent view of this. There is no
evidence of an acute infarct. There is no evidence of
intracranial edema, mass effect, shift of normally midline
structures, or hydrocephalus. The posterior structures appear
unremarkable. The major vascular flow voids are well preserved.
There is hyperintensity visualized in both mastoid air cells
suggestive of fluid within the mastoid air cells. There are
multiple susceptibility artifacts visualized in the left
temporal lobe, right aspect of the pons, and in both cerebellar
hemispheres, which may represent multiple cavernomas or
dystrophic calcifications. Visualized orbits and paranasal
sinuses appear normal.
.
MRA OF THE BRAIN: The anterior circulation including the
intracranial
internal carotid artery, anterior and middle cerebral arteries
bilaterally
appear normal. The vertebrobasilar system and both posterior
cerebral
arteries appear normal. There is no evidence of an aneurysm
(greater than 3 mm), flow-limiting stenosis, or occlusion.
.
CXR [**5-22**] - Increased consolidation of left lung, which could be
compatible with pneumonia or aspiration.
.
EEG [**5-25**] - IMPRESSION: Possibly normal EEG in an extremely drowsy
patient.
Whether this is related to sleep deprivation or medications that
the
patient is taking or represents an early encephalopathy cannot
be
determined from this record. No definitive epileptiform
abnormalities
were, however, seen.
.
US upper extremity [**5-27**] - IMPRESSION: No evidence of DVT in the
right upper extremity. - (done because had erythma around PICC
site.)
.
EKG [**6-1**] - Compared to prior tracing irregular sinus mechanism at
rate about 55 has
replaced atrial flutter. There are occasional atrial premature
beats
and ventricular premature beats. Generalized low voltage
remains. In
addition, there is Q-T interval prolongation consistent with
drug effect and also rightward axis. Anteroseptal myocardial
infarction of indeterminate age cannot be excluded in either
tracing.
Brief Hospital Course:
71 yo F with DM, ESRD on HD, GAVE, HTN, CHF w/ RV failure, who
p/w altered MS [**First Name (Titles) **] [**Last Name (Titles) **]. Admitted to the ICU, intubated
and on vasopressors. Was successfully extubated and had several
days of altered mental status, where she was uncommunicative and
unable to eat. She was refusing NGT and PEG was contraindicated
with her ascites. Improved, started taking PO. Had intact
mental status with some memory problems upon discharge.
.
After admission and ICU course:
Admitted to floor after dialysis [**12-27**] somnolence. Transferred to
MICU after only a few hrs [**12-27**] [**Month/Day (2) **]. Pt had a an ECHO in
the ICU that showed dilated, hypokinetic RV w/ 4+TR. Pt was
emperically treated w/ Vanc/Meropenem, then was switched to
cefepime for possible PNA (now s/p 10-D course). Pt also has a
L-sided chronic pleural effusion (exudative), pt is s/p
thoracentesis of 1.5 L w/ exudate, but no infection. Pt had a
possible seizure during thoracentesis, so she was intubated and
started on neosynepherine. Neuro was consulted and EEG showed
no seizure activity. LP was performed w/o evidence of bacterial
meningitis, however pt was placed on acyclovir. HSV PCR was
negative and acyclovir was stopped.. Pt has gone in and out of
aflutter, but was transfered to the floor in sinus rhythm with
2-3 beat runs of NSVT. Pt was on heparin ggt briefly but this
has been stopped. She was extubated on [**2156-5-16**], and has been
off pressors since [**2156-5-17**]. Pt has stayed in ICU [**12-27**] mental
status which waxes and wanes, and at best the pt is resposive to
only some simple commands. Has NGT and on tube feeds. Pt does
reportely have some baseline altered mental status, but is
signifcantly changed from baseline. Pt was transfered to the
medicine floor on [**2156-5-19**], with vitals of 113/45, 84 (sinus),
20, 99% on 2L.
.
On the floor, the patient continued to have significantly
altered mental status. She was uncommunicative and would follow
some simple commands. She improved quite quickly over several
days and returned close to baseline mental status according to
her family. Her major issue for most of her time on the floor
was nutrition status. She had pulled out her NG tube and kept
not cooperating for replacement. Family did not want to have to
restrain her to place it. She was unable to get a PEG tube d/t
ascites. When she woke up, she was able to take PO and start
repleting nutrition deficits. She had episodes of atrial
flutter with [**Date Range 13223**] into the 110s/120s. Pt also had c.diff
infection diagnosed. Please see below for specific details of
each problem...
# Altered mental status: At baseline pt able to walk from chair
to bathroom, and communicate. Pt's mental status declined while
in pt when she became hypotensive. The differential consists of
seizure (EEG x2 did not show seizure activity) or encephalitis
(HSV-but PCR was negative, and CSF studies WNL) or a global
hypoxia or a metabolic encephalopathy. Also possible is adrenal
insuffiency, therefore, tx with IV steroids, without change, so
stopped steroids. No radiologic evidence of intracranial
pathology. Pt believed to have seizure during thoracotomy as
stated above. Pt remained in stuporous state until approximately
[**5-24**] when her mentation started to improve. Likely cause of
mental status changes was multifactorial - including metabolic
derangements from kidney and liver disease. She was continued
on her home dose of Keppra her entire stay in the hospital. She
is leaving the hospital back at her baselin.
.
# [**Month/Year (2) **]: Unclear etiology, originally thought due to
possible pneumonia, as stated above, pt required pressers in
ICU. CTA negative for PE. Echo showed no pericardial effusion or
tamponade. Pt improved in the ICU and was successfully weaned
from pressors. She maintained appropriate blood pressures, and
all her antihypertensive medicines were held, and are still
being held upon discharge, SBPs are in 140s upon discharge, but
often drop lower after [**Month/Year (2) 13241**]. She will be on no
antihypertensive medicines on discharge.
.
# Possible PNA, hypoxia: with coughs (though no leukocytosis, no
fever). CXR showed worsening pleural effusion and collapse of
LLL initially. Pt treated with empiric vancomycin and meropenem
(switched from imipenem due to lower seizure threshold from
imipenem)for 10 day course. Sputum cx was negative. Follow up
CXRs showed persisent effusions. Pt was breathing well on RA
upon discharge. No cough.
.
# Arrhythmia: In ICU pt had transient [**Month/Year (2) 13223**] which improved
with IVF, pt alternated between sinus tach and atrial tach.
Improved somewhat w/metoprolol, which was later stoped d/t
bradycardia into the 30s. [**Month/Year (2) **] most likely initially
reflected hypovolemia, but not compeletly clear. No PE on chest
CTA. Pt was monitored on telemetry and had intermitenty ectopic
beats, NSVT up to 3 beats, which may have been related to
hypokalemia. While on floor, patient converted into atrial
flutter with rates between 110 and 130. Pt was started on
metoprolol. Pt then converted to NSR with HRs in 60s.
Metoprolol was stopped at this time and she was not discharge
.
# Effusions: large left pleural effusion. Prior fluid analysis
showed exudative process, w/o identifiable cause, cytology
negative as well. Currently being followed by pulmonary, Dr.
[**Last Name (STitle) 2168**]. During this stay, thoracentesis was performed but
resulted in intubation as stated above. Pt continues to have
effusions, but not symptomatic. Pt breathing well on RA upon
discharge.
.
# Transaminitis: Likely due to congestive hepatitis in setting
of RV failure. Pt's LFTs trended down during her hospital
course. Pt does have elevated INR, likely d/t some liver
dysfunction. No evidence of liver pathology on any imaging
studies.
.
# Hyperlipidemia: statin was held in setting of transaminitis.
Still held on discharge.
.
# ESRD/HD: On HD MWF. HD was continued while in pt, pt on
Phoslo, and renal labs were closly monitored. Pt will need to
continue HD upon discharge MWFs for fluid status management.
Phoslo had been discontinued during admission. Upon discharge
phos level was low at 1.2. On the day of admission, pt was
given 4 packets of neutrapohs. The renal fellow was called
about her level and thought discharge was still appropriate. Pt
is scheduled for dialysis the day after discharge. Her phos
level will be checked there. Dr. [**Last Name (STitle) **], her nephrologist, will
be faxed the results and is aware of the problem.
.
# Hypoglycemia: Pt had several episodes of hypoglycemia in ICU,
likely in setting of NPO; got dextrose and FS improved after
adjusted RISS. Continued to have episodes of hypoglycemia while
on floor and there was no way to have nutritional support (no
NGT or PEG and somnelent). Was on D10W for several days and
still had blood sugars in 60s and 70s. Pt then started to have
improved mental status. She passed a speech/swallow test and
was started on ground food and thin liquids. She will go home
on a diet that remains ground. Per swallow team, she can have
repeat study with her denturs if she is to be made full diet.
Endocrine team was also following and ruled out insulinoma as
possible cause. Insulin level was low and c-peptide was likely
elevated because it is usually cleared by the kidney. Encourage
small and frequent meals to maintain blood sugar. Can use
glucose tabs if needed.
.
# DM: held all diabetic medicines due to hypoglycemia. See
above.
.
# C.diff - had diarrhea during most of her time on the floor.
Stool culture was positive for C.diff. On Flagyl PO tid. Needs
to complete 14 day course. Day 1 of antibiotics was [**2156-5-30**]. Pt
will be given prescription for rest of course upon discharge.
She was still having diarrhea at the time, but no white count,
fevers or abdominal pain.
.
# New thoracic compression fracture: pt asymptomatic, no
treatment.
.
# Megaloblastic anemia: B12 and folate levels are normal,
unclear etiology, was monitored and remained stable throughout
admission.
.
# Code: FULL. Had several family meetings during stay.
Palliative care was consulted and helped us coordinate the
meetings and discuss the patients prognosis. Family is aware of
her end organ failure and fragile state.
Medications on Admission:
Medications: from dc summary in [**1-24**]. Isosorbide Dinitrate 30 mg PO BID
2. Pantoprazole 40 mg Q24H
3. Metoprolol Tartrate 75 mg PO TID
4. Lisinopril 20 mg PO DAILY
5. Levetiracetam 250 mg PO BID ?? not on list from NH
6. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
7. Hydroxyzine HCl 25 mg PO Q6H as needed.
8. Atorvastatin 20 mg PO DAILY
9. Cinacalcet 30 mg PO DAILY ?? not on list from NH
10. Gabapentin 300 mg PO QHD ?? not on list from NH
11. Citalopram 20 mg PO DAILY ?? not on list from NH
12. Acetaminophen 325 mg 2tbl PO Q6H as needed.
13. Glipizide 2.5 mg 24hr PO once a day.
14. Phoslo 667mg po TID with meals
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 tube* Refills:*0*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
4. Keppra 100 mg/mL Solution Sig: Two [**Age over 90 1230**]y (250) mg PO
twice a day: Please take 2.5 ml twice daily to get a dose of 250
mg [**Hospital1 **].
Disp:*150 ml* Refills:*2*
5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 2X/WEEK (MO,TH) for 2 months.
6. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day: Start after 2 months of 50,000u twice weekly is completed.
7. Outpatient Lab Work
Please check phosphate level at [**Hospital1 13241**] on [**2156-6-4**]
and fax result to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: fax ([**Telephone/Fax (1) 8387**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**]
Discharge Diagnosis:
Primary Diagnosis:
1. Altered Mental Status of multifactorial etiology
2. chronic liver disease with ascites, likely secondary to R
heart failure
3. chronic kidney disease stage V
4. Pleural effusions of undetermined etiology
6. C.difficile colitis
Secondary diagnoses:
1. Siezure disorder
2. Anemia
3. Compression Fracture
4. GAVE syndrome with hx UGI bleed
Discharge Condition:
Pt was afebrile, stable vital signs. Pt was unable to ambulate
by herself, she was able to walk a short distance with the help
of physical therapy. She was A+Ox3. She was having diarrhea at
the time of discharge.
Discharge Instructions:
You were admitted for being somnulent after a dialysis session.
It was thought that you may have had a pneumonia, and there was
fluid in your lungs. The medical team tried to get the fluid
off of your lung with a procedure called a thoracentesis.
During this your blood pressure became very low and you had to
go to the ICU where they kept your blood pressure high with IV
medicine and helped you breathe with intubation. Your body
started to recover and you were brought to a regular medical
floor.
On the floor, you remained somnolent and confused. You were
unable to eat and we could not feed you through a tube.
Eventually you started to improve. You passed a swallow test
and started eating. We were worried because your blood sugar
kept dropping low, probably due to your kidney failure and poor
nutritional stores. You need to keep eating at regular
intervals to keep your blood sugars up.
You also had an irregular heart beat at times. Sometimes it was
too fast, and sometimes it was too slow. We monitored you on
telemetry because of that. When you left the hospital, your
heart rate was regular and going about 60 beats per minute (a
normal rate).
You also were diagnosed with an infection of your bowels call
c.diff. You need to take flagyl, an antibiotic for a total of
14 days to treat this infection.
We stopped some medicines you had been taking at home before
this hospitalization. Please see the discharge sheet for what
you will take now.
You must continue [**Hospital6 13241**] M, W, F or as your renal doctor
recommends.
You will continue physical therapy in rehab to try to regain
your strength.
Please call or return to the hospital for any chest pain,
shortness of breath, worsening diarrhea, or any other concerns.
You should see your doctor regularly. Call 911 for any
emergencies.
Followup Instructions:
Please make appointment with PCP for two weeks to follow up on
C.diff infections:
[**Last Name (LF) **],[**Known firstname **] L. [**Telephone/Fax (1) 7976**]
Please follow up with your renal doctor [**First Name (Titles) **] [**Last Name (Titles) 13241**]. You
need to go to dialysis tomorrow. Dr. [**Last Name (STitle) **], your nephrologist,
will continue to follow you.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2156-6-3**]
ICD9 Codes: 486, 5119, 5856, 4280, 4240, 3572, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6524
} | Medical Text: Admission Date: [**2190-9-18**] Discharge Date: [**2190-9-24**]
Date of Birth: [**2151-10-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
refractory AML, comfort measures only
Major Surgical or Invasive Procedure:
None
History of Present Illness:
38 yo F F AML s/p chemo, depression, asthma, who presents from
OSH with delta MS, fever, and intubation for airway protection.
per OSH records: Pt was c/o HA then began to hallucinate,
aggitated, and then c/o photophbia. She took 2 mg of ativan PO.
She then became unresponsive and apneic. She was intubated for
[**Month (only) **] consciousness and poor control of secretions. Pt admitted
with resp failure, HA and seziure like activity. Intubated in
the field. Head CT negative. Also noted to be in SVT, adenosine
unsucceful, lopressor 5 mg IV x 2 successful. VS 101.8, HR 145,
BP 165/92. PE with supple neck but some stiffness, neg Kernig or
Brudinski's. Given braod spectrum abx and steroids.
.
Of note pt, was recently admitted to [**Hospital1 18**] and d/c on [**9-16**]. She
was admitted with a dx of functional neutropenia and fever.
Initially treated with CTX/vanc, then changed to levofloxacin,
and then changed back to CTX/vanco which was d/c on. She
remained afebrile x 4 days and then send home. No clear source
was found. In addition she recieved two doses of high dose
ara-c.
.
Admitted to [**Hospital Unit Name 153**] for delta MS/seizures. On arrival, pt sedated,
Unable to obtain history.
.
Patient was extubated and transferred to floor today. Per family
she is [**Hospital Unit Name 3225**]. All meds were d/c'd and morphine drip started.
Past Medical History:
Onc hx:
She was initially diagnosed with AML in [**8-/2189**] after presenting
with fatigue and CBC was abnormal. She was treated with
idarubicin and ARA-C, standard 7+3 remission induction therapy.
She then underwent HIDAC consolidation chemo. The patient was
admitted [**2190-1-18**] through [**2190-1-19**] and finished her 3rd cycle of
HIDAC. She represented in [**4-12**] with hip pain and found to be in
AML relapse. She is now s/p allogeneic transplant from a sibling
donor with fludarabine and Cytoxan (2.5 months ago) for
conditioning regimen. The patient was noted to have disease
recurrence shortly after recovery of her counts. She has been
managed as an outpatient on Hydrea. She has been receiving
platelet and blood support as needed. Her last platelet
transfusion was [**7-5**]. A couple of weeks prior to this admission
she had severe left leg pain just below her knee and found to
having increasing white count with blasts. Her Hydrea was
increased and she received a week of subcutaneous Ara-C.
.
PMH:
s/p MVA [**5-11**] w/ long rehab course w/ residual chronic back pain
and R hip fracture, R wrist fracture, rib fractures
AML, M4 w/ normal cytogenetics, course as above
Depression
GERD
s/p Appendectomy
s/p ovarian cyst removal
Asthma
Social History:
Lives w/ husband, 3kids; smoked 1.5packs per day x 30(?) year;
still occasionally smokes, No ETOH
Family History:
Denies any family hx of heme malignancy. The patient's father
died in [**Country 3992**], her mother is currently being treated for
Breast CA. Mother with MI in late 30s
Physical Exam:
No thorough physical exam performed, pt is [**Name (NI) 3225**], on morphine
drip, not awake, RR 12/min.
Pertinent Results:
[**2190-9-18**] 11:15PM GLUCOSE-107* UREA N-16 CREAT-0.5 SODIUM-144
POTASSIUM-3.3 CHLORIDE-112* TOTAL CO2-20* ANION GAP-15
[**2190-9-18**] 11:15PM ALT(SGPT)-24 AST(SGOT)-64* LD(LDH)-1571*
CK(CPK)-35 ALK PHOS-218* TOT BILI-1.5
[**2190-9-18**] 11:15PM CK-MB-7 cTropnT-0.06*
[**2190-9-18**] 11:15PM ALBUMIN-3.3* CALCIUM-8.3* PHOSPHATE-4.1
MAGNESIUM-1.8
[**2190-9-18**] 11:15PM TSH-0.31
[**2190-9-18**] 11:15PM WBC-7.0 RBC-2.70* HGB-8.0* HCT-23.6* MCV-87
MCH-29.5 MCHC-33.8 RDW-16.4*
[**2190-9-18**] 11:15PM NEUTS-0 BANDS-0 LYMPHS-5* MONOS-0 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0 BLASTS-93* NUC RBCS-1*
[**2190-9-18**] 11:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL BURR-1+
[**2190-9-18**] 11:15PM PLT COUNT-20*
[**2190-9-18**] 11:15PM PT-20.3* PTT-25.4 INR(PT)-1.9*
Brief Hospital Course:
38 yo F with refractory AML s/p chemo, who presents from home
intubated with fever, delta MS, and tachycardia. Now extubated
and breathing , despite continued fevers and MS changes, [**Month/Day/Year 3225**]
per family. The patient passe away on [**2190-9-18**] in presence of her
family.
Medications on Admission:
morphine drip
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
refractory AML
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2190-10-19**]
ICD9 Codes: 486, 2760, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6525
} | Medical Text: Admission Date: [**2179-2-6**] Discharge Date: [**2179-2-22**]
Date of Birth: [**2110-11-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3513**]
Chief Complaint:
acute renal failure
Major Surgical or Invasive Procedure:
hemodialysis
PICC line placement
Hemodialysis line placement-tunneled catheter to left subclavian
Ultrasound guided renal biopsy
History of Present Illness:
[**Known firstname 97626**] [**Known lastname 174**] is a 68-year-old female with known
lymphoplasmacytic lymphoma. She initially presented in [**Month (only) 958**]
[**2177**] to the heme onc clinic with complaing of neck pain due to
bulky lymphadenompathy and CT scan revealed extensive
lymphadenopathy, more severe in the deep pelvis, but also
involved her paraspinal regions, retroperitoneum, inguinal
regions as well as porta hepatis. She also presented with an
elevated creatinine, and kidneys were normal in appearance and
there was no evidence of hydronephrosis. She also had a large
neck mass more prominent on the right side. The patient
presented to clinic today with a report of decreased urine
output over the last few months and was noted to have elevated
creatinine over 7. She also had increased bilateral leg edema
over the past three weeks, dyspnea on exertion, and increased
fatigue. She denied mental confusion, shortness of breath, chest
pain, abdominal pain or any bloating. Denied any fever, chills
or night sweats. She was eating and drinking okay. She
otherwise denied any
bleeding or bruising difficulties, any numbness or tingling in
her fingers or toes. She's had some difficulty with ambulation
due to the edema amd is currently using a cane.
.
She was sent from hem/onc clinic to the ED. In the ED, her
creatinine was significantly elevated (up to 8.1), CXR showed
L-sided effusion with atelectasis/failure. She stated that she
has been feeling more short of breath of late and has woken up
at times SOB in the middle of the night. She statedshe had more
confusion lately (difficulty with word finding) as well. She
denied any chest pain, abdominal pain, decreased appetite,
fever, chills; she states that her urne has been decreasing over
the past few weeks (but she still makes urine). She was
currently thinking about whether or not she wants to have
hemodialysis and/or chemotherapy for her lymphoma and is
admitted at this time for further management. This patient is a
[**Doctor First Name **] scientist and had refused any treatment in the past;
however, with support of her family she opted to commence
chemotherapy and was admitted to the heme/onc service.
.
She was transferred to the [**Hospital Unit Name 153**] for monitoring because of high
risk of TLS as she agreed to have chemotherapy initiated. In the
setting of her renal failure, hemodialysis was required during
chemotherapy to clear tumor lysis toxins and preserve renal
function during this time. She received the CVP (cytoxan,
vincristine, prednisone) regimen with daily hemodialysis without
complication. She was transferred to the medicine service for
monitoring for tumor lysis and for continued hemodialysis until
outpatient dialysis is arranged. At that time, she noted
increased confusion lately that is worse in the hospital but has
been improving in the past few days. She was tolerating a small
amount of renal prudent solid food and drinking nepro
supplements. She denied fever, chills, dysuria, nausea,
vomiting, diarrhea, or distention. She had intermittent
constipation. She denies any chest pain, cough, fever, chills.
.
Home Meds: Verapamil, Atenolol
.
ICU Meds: Acetaminophen, Allopurinol, Calcium Acetate, Docusate
Sodium, Dolasetron Mesylate, SC Heparin, Levofloxacin,
Metoprolol, Nephrocaps, Pantoprazole, Prochlorperazine,
Prednisone, Senna, . Verapamil HCl
Past Medical History:
Lymphoplasmacytic Lymphoma, diagnosed 1.5 yrs ago, had not
received any treatment until now, has significant bulky LAD.
Treatment was deferred until this visit when CVP protocol cycle
1 was started [**2179-2-12**]. Has significant bulky LAD.
Atrial Fibrillation
Hypertension
Social History:
She does not smoke and does not drink. She smoked tobacco for 2
years 48yrs ago. She is married, 2 sons and 2 daughters. [**Name (NI) **]
daughters are [**Name2 (NI) **]
Scientists; husband and sons are not, but are supportive of her
religious beliefs and of her decisions in the past and presently
about treatment.
She is a retired [**Doctor First Name **] Science nurse.
Family History:
There is no family history of cancer, renal disease, or MI. She
has 1
brother who is alive and well. Her mother is 86 years old and
alive. Her father died at the age of 38 at an accident. Her son
has atrial fibrillation
Physical Exam:
97.9 140/70 79 20 96% RA
Gen: NAD, A&Ox3
HEENT: few loose white plaques on inner cheeks, EOMI, MMM, no
petechiae
Neck: bulky LAD right neck (6x6 cm at least), soft, mobile;
smaller LAD left neck, NT
Lungs: faint crackles at bases, bibasilar [**Month (only) **] breath sounds
CV: irregularly irregular, nl S1/S2, no m/r/g
Chest: HD LSC line and L peri-aurealar ecchymoses improved.
Abd: soft, ND, nabs, mild tendermess in RUQ and epigastric
regions without guarding or rebound, no HSM
Extr: 2+ pitting edema to knees bilaterally, non tender,
negative [**Last Name (un) 5813**] sign bilaterally
Neuro: AOx3, moving all extremities, ambulating with cane,
sensation grossly intact, no tremor or asterixis
Skin: L chest ecchymoses improving. no petechiae.
Pertinent Results:
Admission Data:
PTH: 175
137 / 106 / 91
---------------< 82
3.6 / 23 / 8.1
Ca: 7.7 Mg: 2.2 P: 6.6 Uric Acid: 14.3
Vit-B12:Pnd Folate:Pnd
MCV= 103 WBC= 4.2 HgB= 8.6 Plt= 229 Hct= 27.5 N:56.0 L:36.9
M:4.0 E:2.3 Bas:0.7 Hypochr: 2+ Macrocy: 3+
PT: 14.9 PTT: 26.4 INR: 1.4
URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.020 Blood-LG
Nitrite-NEG Protein->300 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-0.2 pH-6.5 Leuks-MOD RBC-[**5-28**]* WBC-[**2-20**] Bacteri-FEW
Yeast-NONE Epi-[**2-20**]
.
CXR [**2179-2-5**]: L sided pleural effusion with discoid atelectasis,
failure; right paratracheal mass
.
CXR [**2179-2-13**]: No significant change since prior study.
Persistent bilateral atelectases and bibasilar consolidations as
described. No pneumothorax.
.
Renal US: no hydronephrosis; ?parenchymal renal disease
.
Hospital Course:
Lipase-41
URINE Hours-RANDOM Creat-127 TotProt-567 Prot/Cr-4.5*
02Hapto-71
calTIBC-308 Ferritn-75 TRF-237
VitB12-1077* Folate-9.6
[**Doctor First Name **]-NEGATIVE
HBsAg-NEGATIVE [**Name (NI) 97627**] [**Name (NI) 97628**]
PTH-175*
Osmolal-316*
HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HCV Ab-NEGATIVE
PEP-POLYCLONAL IgG-4368* IgA-299 IgM-53 IFE-NO MONOCLO
C3-54* C4-12
HIT antibody NEGATIVE
.
CT CHEST W/O CONTRAST [**2179-2-10**]
1) Marked progression of diffuse systemic lymphadenopathy,
particularly in the retroperitoneum and pelvis.
2) Diffuse soft tissue edema, bilateral pleural effusions,
ascites, and right atrial enlargement, all consistent with fluid
overload/anasarca.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2179-2-15**]
Duplex ultrasonography was performed at the level of the veins
and arteries of the bilateral upper extremities. There are
single brachial arteries in each arm, with normal triphasic
waveforms.
.
Discharge Labs:
BLOOD WBC-3.0* RBC-2.80* Hgb-8.9* Hct-27.3* MCV-97 MCH-31.7
MCHC-32.5 RDW-16.6* Plt Ct-158
PT-16.7* PTT-30.3 INR(PT)-1.8
Fibrino-187
Glucose-90 UreaN-32* Creat-4.1* Na-133 K-3.7 Cl-99 HCO3-28
AnGap-10
Calcium-8.8 Phos-3.3 UricAcd-5.6
Brief Hospital Course:
Acute Renal failure: The etiology of the acute renal failure is
unclear but likely lymphomatous infiltration, urate nephropathy,
glomerulonephritis, or acute tubular necrosis that may be
reversible after dialysis and reduction of her tumor burden. She
had a renal biopsy on [**2-9**] that showed glomerular sclerosis
consistent with end stage disease, likely from the lymphoma.
Urine lytes were consistent with renal pathology. Renal
ultrasound was without signs of hydronephrosis. The following
laboratory tests were performed: hepatitis serologies negative,
[**Doctor First Name **] negative, SPEP negative, UPEP with albumin band, C3 low at
54, C4 normal, HIT antibody negative. She decided to pursue
treatment for her lymphoma, so a tunnelled dialysis catheter was
placed in the interventional radiology suite, and she commenced
hemodialysis on [**2-11**]. She was transferred to the ICU on [**2-12**] to
undergo simultaneous chemotherapy (CVP; cytoxan, vincristine,
prednisone) and daily hemodialysis. On [**2178-2-13**], she was
transferred to the medicine service to continue monitoring and
continue dialysis, preparing for outpatient dialysis. She
finished her chemotherapy course and proceeded to get dialyzed
on a M, W, F schedule with concomitant laboratory testing. Tumor
lysis and disseminated intravascular coagulopathy laboratory
testing were stabilized at discharge and will be monitored at
hemodialysis. She underwent bilateral upper extremity venous
mapping to prepare for eventual AV fistula placement and will
contine dialysis at an outpatient facility after discharge. The
renal service provided recommendations throughout the hospital
stay.
.
Lymphoplasmacytic lymphoma: It is low grade but she has
significant disease, including bulky cervical lymphadenopathy.
She did not desire treatment in the past but decided to proceed
with therapy. Staging CT showed extensive disease. Allopurinol
was started for tumor lysis syndrome. She was transferred to the
[**Hospital Unit Name 153**] on [**2-12**] to begin chemotherapy coupled with hemodialysis and
then to the medicine service [**2-14**] for continued monitoring and
dialysis. Tumor lysis and DIC labs were monitored and were
stabilized at discharge, although they were briefly moderately
positive the week after completing chemotherapy. During her
hospital course, she was given renally dosed allopurinol.
Platelets and hematocrit briefly decreased secondary to
chemotherapy. HIT antibody testing was negative. She received 1
unit of PRBCs [**2179-2-18**] with hct increase from 24.9 to 28.9. She
did not require cryoprecipitate, FFP, or platelet transfusion
and had no acute bleeding. She was started on nystatin sw/sw
for thrush. The oncology service provided recommendations. She
will need CBC, chemistries, electrolytes, serum urate, and
PT/PTT drawn at hemodialysis and results should be faxed to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 21962**]. Phone ([**Telephone/Fax (1) 3936**]. Her next
outpatient chemotherapy will be [**2179-3-5**]. She will continue
hemodialysis every M, W, F. She was discharged to inpatient
rehab for continued physical therapy. She can ambulate with a
cane. She was tolerating an oral diet and bowel regimen for
occasional constipation.
.
Verapamil and Atenolol were continued for rate control of atrial
fibrillation. Anemia labs were consistent with anemia of chronic
disease/inflammation. Her hematocrit trended down slowly due to
chemotherapy and increased appropriately after transfusion of 1
unit PRBCs (see above).
.
A health care proxy was designated (her daughter) in the event
that she has complications of her disease at any point in the
future.
Medications on Admission:
Verapamil
Atenolol
ALL: PCN causes itching/rash
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Verapamil HCl 80 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 4 days.
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
18. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Lymphoplasmacytic Lymphoma on chemotherapy
Anemia, thrombocytopenia, hyperuricemia, hypocalcemia
Atrial Fibrillation
Hypertension
Discharge Condition:
in her usual state of health ambulating with cane and tolerating
oral diet
Discharge Instructions:
Please take all medications as prescribed. Call your doctor or
go to the ED for shortness of breath, chest pain, bleeding,
excessive bruising, abdominal pain, nasea/vomiting, diarrhea,
fever, chills, or other concerning symptoms.
Followup Instructions:
Please draw a CBC, chemistries, electrolytes, serum urate, and
PT/PTT [**2179-2-22**] and fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 21962**]. Phone
([**Telephone/Fax (1) 3936**].
Next outpatient chemotherapy will be [**2179-3-5**].
Continue hemodialysis every M, W, F.
Provider: [**Name10 (NameIs) **] Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2179-2-24**] 11:00
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2179-5-10**] 10:00
ICD9 Codes: 4280, 5849, 486, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6526
} | Medical Text: Admission Date: [**2164-3-27**] Discharge Date: [**2164-4-5**]
Date of Birth: [**2094-7-25**] Sex: M
Service: BLUE SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old man
with a history of coronary artery disease status post
coronary artery bypass graft times four, who presented to
[**Hospital1 69**] for an esophagectomy on
[**2164-3-27**].
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction in [**2158**].
2. Transient ischemic attack.
3. Hypothyroidism.
4. Hypercholesterolemia.
5. Hypertension.
6. Esophageal cancer.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft times four in [**2158**].
2. Back surgery.
3. Shoulder surgery.
4. Cholecystectomy.
5. Hernia repair.
ALLERGIES:
1. Tetracycline.
2. Zestril.
3. Ibuprofen.
4. Demerol.
5. Motrin.
6. Advil.
MEDICATIONS AT HOME:
1. Synthroid.
2. Lipitor.
3. Avalide.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is a former smoker and denies
any history of alcohol use.
HOSPITAL COURSE: The patient underwent an Ivor-[**Doctor Last Name **]
esophagectomy and feeding jejunostomy on [**2164-3-27**].
The patient tolerated the procedure well, received 8 liters
of intravenous fluids intraoperatively and estimated blood
loss was 700 cc. The patient was admitted to the surgical
Intensive Care Unit for management immediately
postoperatively. The patient had two chest tubes placed
intraoperatively, and the Foley catheter was placed as well
as an nasogastric tube. The patient was kept NPO with
intravenous fluids. The patient was placed on Kefzol and
Flagyl for infection prophylaxis. On postoperative day
number one the patient was hemodynamically stable. The
patient was started on tube feeds at 10 cc an hour. On
postoperative day number two the patient was determined to be
stable enough for transfer to the floor for care. The
patient was transferred to the floor on telemetry. The
patient's tube feeds were gradually increased to a goal of 70
cc an hour. On postoperative day number six the patient
underwent a barium swallow study. The barium swallow study
showed no leakage at the anastomosis site. The patient's
nasogastric tube was taken out. The patient was started on a
clear liquid diet. The patient tolerated the diet well and
was advanced gradually to a full diet. The patient's tube
feeds were cycled for nutritional support. The patient was
able to ambulate on his own. Chest tubes were discontinued
on postoperative day number eight with a follow up chest
x-ray showing no pneumothorax. The patient is stable for
discharge on [**2164-4-5**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS:
1. Lipitor 20 mg q day.
2. Synthroid .137 mg q.d.
3. Avalide 300/12.5 mg q.d.
4. Zantac 150 mg b.i.d.
5. Percocet one to two tablets po q 4 to 6 hours as needed
for pain.
6. Colace 100 mg b.i.d. when taking Percocet.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Transient ischemic attack.
3. Hypothyroidism.
4. Hypercholesterolemia.
5. Hypertension.
6. Carcinoma of the esophagus.
FOLLOW UP PLANS: The patient was instructed to follow up
with Dr. [**Last Name (STitle) 957**]. The patient was instructed to call Dr.[**Name (NI) 7012**] office for an appointment. The patient was
instructed not to lift heavy objects. The patient should
also follow up with the oncology service with Dr. [**First Name (STitle) **] as
well as Dr. [**Last Name (STitle) 776**] from radiation/oncology for
postoperative cancer management.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern1) 1909**]
MEDQUIST36
D: [**2164-4-5**] 10:38
T: [**2164-4-5**] 10:59
JOB#: [**Job Number **]
ICD9 Codes: 4240, 2449, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6527
} | Medical Text: Admission Date: [**2144-1-5**] Discharge Date: [**2144-1-21**]
Date of Birth: [**2059-8-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Tetracycline /
Novocain / Levaquin / Zoloft / Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2144-1-7**] 1. Left video-assisted thoracoscopic surgery converted
to left anterior thoracotomy. 2. Drainage of pleural and
pericardial effusion. 3. Pericardial window.
History of Present Illness:
84 year old female with history of mitral regurgitation and a
chronic pericardial effusion who was admitted for mitral valve
replacement with Dr [**Last Name (STitle) 914**] on [**12-13**], post op course c/b likely
thromboembolic ischemic event involving the frontal lobes and
parietal regions, she recovered significantly, was started on
Dilantin and Keppra and discharged to rehabilitation at
[**Hospital1 **]-[**Location (un) 86**] on [**12-21**]. She now returns w/chest pain and
hypotension. Echo done in ED c/w loculated pericardial
effusion-no evidence of tamponade.
Past Medical History:
1. Mitral regurgitation s/p mitral valve replacement [**2143-12-13**]
2. Atrial fibrillation s/p MAZE procedure [**2143-12-13**]
3. Complex partial seizures secondary to ischemic stroke after
surgery
4. Hypertension
5. Hyperlipidemia
6. Non-insulin dependent diabetes mellitus, type 2
7. Obesity
8. Fibromyalgia
9. Osteopenia
10. Irritable bowel syndrome
11. Obstructive sleep apnea
12. h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear ([**3-/2142**]) - Transfused with 4 Units of
RBC
13. Cystic pancreatic mass ([**9-/2142**]) - Bx negative
14. Mild coronary artery disease (no prior cath reports
available)
15. Congestive heart failure
16. Esophageal ulcers/GERD
17. Brain Schwannoma's (4 which are stable by MRI)
18. Left metatarsal fracture
19. Type 2 Diabetes
20. Anemia
Social History:
Race: Caucasian
Last Dental Exam: > 2 years ago
Lives with: Alone in [**Location (un) 5110**], MA
Contact: Daughter Phone #
Occupation: Alone
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: < 1 drink/week [X] [**12-31**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
No noted Premature coronary artery disease
Physical Exam:
Pulse: 96 AF Resp: 18 O2 sat: 96% 1L
B/P Right: 96/62 Left:
General: Lying in bed talking in full sentances
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: BS diminished bilat half way up
Heart: RRR [] Irregular [x] Murmur-no
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [] Edema [x]2+ bilat
Neuro: A&O x3. MAE, left sided weakness upper greater than lower
Pulses:
DP Right: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Pertinent Results:
[**2144-1-5**] Echo: Normal left ventricular wall thickness and cavity
size. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is mildly depressed (LVEF= 40%). The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic regurgitation. A well-seated
bioprosthetic mitral valve prosthesis is present. No mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a large, partically echofilled pericardial effusion
most prominent inferlateral to the left ventricle (2-2.6cm). The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
IMPRESSION: Suboptimal image quality. Large loculated ?bloody
pericardial effusion most prominent along the inferolateral wall
of the left ventricle and anterior to the right ventricle but
without echocardiographic signs of tamponade. Mildly depressed
global left ventricular systolic function. Well seated
bioprosthetic mitral valve replacement with no mitral
regurgitation.
Compared with the findings of the prior study (images reviewed)
of [**2143-9-8**], the pericardial effusion is slightly smaller and
appears more loculated. Global left ventricular systolic
function is now lower, and the patient is now in atrial
fibrillation. The mitral valve has been replaced.
.
[**2144-1-6**] Chest CT: 1. Status post mitral valve replacement and
Maze procedure with expected appearance of the mitral valve and
left atrium. 2. Small left and small-to-moderate right pleural
effusion. Substantial atelectasis of the left lower lobe, with
no evidence of central compression with not re-expanding left
lung and substantial left mediastinal shift. 3. Evidence of
substantial pulmonary hypertension.
.
[**2144-1-6**] Lower Ext. U/S: Left and right subclavian veins are
patent with normal flow and compressibility. Left internal
jugular vein is patent with normal flow and normal
compressibility. There is normal compression and augmentation of
the left axillary, left brachial, left basilic, and left
cephalic veins.
.
[**2144-1-7**] Echo: No spontaneous echo contrast is seen in the body
of the left atrium or left atrial appendage. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen. A
bioprosthetic mitral valve prosthesis is present. Mild (1+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is a large pericardial effusion. No
right atrial or right ventricular diastolic collapse is seen.
Dr. [**First Name (STitle) **] was notified in person of the results at time of
surgery. Post evacuation\window: no effusion, otherwise no
change.
.
[**2144-1-21**] 06:10AM BLOOD WBC-6.4 RBC-3.51* Hgb-10.1* Hct-30.7*
MCV-87 MCH-28.7 MCHC-32.8 RDW-15.4 Plt Ct-145*
[**2144-1-21**] 06:10AM BLOOD Plt Ct-145*
[**2144-1-21**] 06:10AM BLOOD Glucose-106* UreaN-31* Creat-0.6 Na-147*
K-3.7 Cl-105 HCO3-39* AnGap-7*
Brief Hospital Course:
84 yr old s/p MVR/MAZE on [**12-13**] discharged to rehab on [**12-21**]. She
returned from rehab to [**Hospital1 18**] on [**2144-1-4**] with complaints of chest
pain associated with hypotension. TEE showed loculated
pericardial effusion. On [**1-7**] she underwent pericardial window
via left anterior thoracotomy. In [**Name (NI) 13042**] PT was not able to be
extubated due to low o2 and high CO2. She was therefore
transferred to CVICU vented on Neo gtt and bilateral [**Doctor Last Name **]
drains. She eventually extubated and was transferred to floor
the following day, CTs' were removed prior to transfer. The
following day while on the floor she became hypoxic and CXR
revealed large left effusion with collapse. She was therfore
transferred back to the CVICU for care. Left pigtail placed by
IP for drainage of effusion and she required reintubation for
left lower lobe collapse. She was bronched and mucus plug was
extracted. She was rebronched the following day with improvement
in lung findings. However she remained intubated for several
days longer due to continued tachypnea and SOB. She eventually
self extubated on [**1-13**] and continued an 8 day course of
antibiotics for VAP coverage. She also received a short course
of steroids for possible reactive airway disease. She remained
hemodynaically stable. TTE revaled that she was underfilled and
was transfused to optimize her BP. During her ICU stay she was
in rapid afib and was started on amiodarone for rate contol. At
times she bacame bradycardic into the 30's therefore her
lopressor was adjusted. She was seen by speach and swallow and
was placed on modified diet for mild swallowing difficulties
regular with nectar thick. She was restarted on anticoagulation
for her a-fib with goal INR 20-2.5. Once her respiratory status
improved she transferred to floor on [**1-17**] where she continued to
progress slowly. Patient became resistent to care and very
depressed stating that she wanted to die. She was restarted on
her preopertaie doses of ativan, Zoloft and Keppra for her
seizure history. She was also seen by the social service
department for her depression which at the time of discharge was
improved. She required a lot of encourgement and support.
Patient has a history of IBS and has had persistent loose stool
but was c-diff negative and required immodium with good effect.
Her PA &lat CXR on [**1-20**] showed moderate right effusion the plan
is to continue with diuresis and CXR to be obtained at f/u with
Dr. [**Last Name (STitle) 914**]. She continues to have a metabolic alkalosis and is
being discharged short course of diamox. She will need to have
her renal function followed closely at rehab.
On POD#13 she was seen by ENT for worsening hoarseness. She was
determined to have a left cord hypomobility, bowing and
bilateral TVC nodules. She was compensating well and was
cleared for
cleared for a modified diet. Her injury was likely related to
her recent intubations and observation was favored for now with
close oral f/u:
- Voice rest
- Maximize PPI therapy
- Diet per speech and swallow
- Humidification
- Avoid use of nasal cannula oxygen if possible; trial oxygen
delivery via humified face mask.
- Nasal saline spray to both nostrils at least TID.
-F/U with Dr.[**First Name (STitle) **]
She was seen by the physical therapy department for strengtening
and conditioning and it was determined that due her continued
needs she would require rehab placement. She was discharged to
[**Hospital 100**] Rehab MACU all questions and concerns addressed.
Follow-up appts arranged
Medications on Admission:
1. potassium chloride 20 mEq Q12H for 10 days.
2. metoprolol tartrate 50 mg [**Hospital1 **]
3. aspirin 81 mg DAILY
4. acetaminophen 325-650 mg Q4H as needed for pain.
5. amiodarone 400 mg [**Hospital1 **] for 5 days: After 5 days decrease the
dose to 400 mg daily for 1 week, then after 1 week, decrease
dose to 200 mg daily.
6. levetiracetam 1500 mg [**Hospital1 **]
7. rosuvastatin 20 mg DAILY
8. fexofenadine 180 mg [**Hospital1 **]
9. Protonix 40 mg once a day.
10. furosemide 40 mg once a day for 10 days.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. alprazolam 0.25 mg TID as needed for anxiety.
13. Coumadin once a day: titrate to an INR of [**12-26**].5.
14. diphenoxylate-atropine 2.5-0.025 mg [**Date Range 8426**] Sig: One (1)
[**Date Range 8426**] PO Q6H (every 6 hours) as needed for loose stool.
Discharge Medications:
1. bisacodyl 5 mg [**Date Range 8426**], Delayed Release (E.C.) Sig: Two (2)
[**Date Range 8426**], Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg [**Date Range 8426**] Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. rosuvastatin 20 mg [**Date Range 8426**] Sig: One (1) [**Date Range 8426**] PO DAILY
(Daily).
5. amiodarone 200 mg [**Date Range 8426**] Sig: Two (2) [**Date Range 8426**] PO DAILY (Daily)
for 1 weeks: then decrease to 200mg daily until seen by
cardiology.
6. aspirin 81 mg [**Date Range 8426**], Delayed Release (E.C.) Sig: One (1)
[**Date Range 8426**], Delayed Release (E.C.) PO DAILY (Daily).
7. levetiracetam 500 mg [**Date Range 8426**] Sig: Three (3) [**Date Range 8426**] PO twice a
day.
8. acetaminophen 325 mg [**Date Range 8426**] Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. warfarin 1 mg [**Date Range 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily):
take as directed for INR goal 2.0-2.5.
10. fexofenadine 60 mg [**Last Name (Titles) 8426**] Sig: Three (3) [**Last Name (Titles) 8426**] PO BID (2
times a day).
11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
12. metoprolol tartrate 50 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO TID
(3 times a day).
13. sertraline 25 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO DAILY
(Daily).
14. ipratropium bromide 0.02 % Solution Sig: Two (2) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
15. guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every
6 hours).
16. alprazolam 0.25 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2
times a day).
17. alprazolam 0.25 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO QHS (once a
day (at bedtime)).
18. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-25**] Sprays Nasal
TID (3 times a day).
19. Protonix 40 mg [**Month/Day (2) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Month/Day (2) 8426**], Delayed Release (E.C.) PO twice a day.
20. Lasix 40 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO twice a day: for 1
week then decrease to daily and evaluate.
21. potassium chloride 25 mEq Packet Sig: One (1) PO twice a
day for 1 weeks: then decrease to daily while on lasix.
22. Diamox Sequels 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day for 1 weeks: while on
[**Hospital1 **] lasix.
23. immodium Sig: One (1) four times a day as needed for
diarrhea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Mitral regurgitation s/p mitral valve replacement [**2143-12-13**]
2. Atrial fibrillation s/p MAZE procedure [**2143-12-13**]
3. Complex partial seizures secondary to ischemic stroke after
surgery
4. Hypertension
5. Hyperlipidemia
6. Non-insulin dependent diabetes mellitus, type 2
7. Obesity
8. Fibromyalgia
9. Osteopenia
10. Irritable bowel syndrome
11. Obstructive sleep apnea
12. h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear ([**3-/2142**]) - Transfused with 4 Units of
RBC
13. Cystic pancreatic mass ([**9-/2142**]) - Bx negative
14. Mild coronary artery disease (no prior cath reports
available)
15. Congestive heart failure
16. Esophageal ulcers/GERD
17. Brain Schwannoma's (4 which are stable by MRI)
18. Left metatarsal fracture
19. Type 2 Diabetes
20. Anemia
Discharge Condition:
Alert and oriented x3 nonfocal
Out with bed with assistance
Incisional pain managed with Tylenol
Lungs: diminished Right greater than left
Incisions:
Sternal - healing well, thoracotomy incision clean, dry and
intact
Edema +1 lower extremity bilaterally
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
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:
Cardiac Surgeon: Dr. [**Last Name (STitle) 914**] on [**2144-2-17**] 1pm
Cardiologist: Dr. [**Last Name (STitle) **] on [**2144-2-3**] 1:30
Thoracic surgeon: Dr. [**First Name (STitle) **] on [**2144-1-28**]/12 @9AM
ENT: Dr. [**First Name (STitle) **] on [**2-21**] at 9:00 [**Telephone/Fax (1) 2349**]
Please call to schedule appointments with your
Primary Care: Dr. [**Last Name (STitle) **] in [**11-25**] 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 INR 2-2.5
First draw [**2144-1-22**]
Results to phone fax to PCP's office [**Hospital1 **] after
discharge from rehab
Completed by:[**2144-1-21**]
ICD9 Codes: 5119, 4168, 5990, 5180, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6528
} | Medical Text: Admission Date: [**2170-11-15**] Discharge Date: [**2170-11-17**]
Date of Birth: [**2140-5-11**] Sex: F
Service: MEDICAL ICU
HISTORY OF PRESENT ILLNESS: The patient is a 30 year old
female with a history of depression +/- suicide attempts who
presents after being found down and unresponsive by her
roommate on the evening of admission. The patient's friends
are worried that she may have ingested GHB (the patient has a
history of taking this recreationally) plus Ativan (the
patient for maintenance in caplets). The remainder of
history was unable to be obtained as roommates were not there
and the patient has no records or telephone numbers in the
electronic record of [**Hospital1 **] Hospital. Per the
patient's father, she is on probation in [**Name (NI) 108**] and has
violated her probation to come to [**Location (un) 86**]. For the past few
weeks, they have noticed her to be more "sleepy and
depressed". Per her roommate, the patient has had suicidal
ideations for the past two weeks, however, did not have a
plan. When the roommate found the patient down, a note was
present by report indicating that her suicide was
intentional. "[**Name (NI) 18659**] (son) will be better with my sister".
The patient's last contact was with her boyfriend around 5:00
to 6:00 p.m. the evening of admission over the telephone
where she stated that she was tired and needed to lay down.
In the Emergency Department, the patient was given Narcan
without effect and activated Charcoal 60 times one dose. The
patient was intubated in the field and vomited times one upon
intubation.
PAST MEDICAL HISTORY: Unknown. Per the patient's family,
the patient has a negative medical history with the exception
of depression and suicide attempts.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: None.
SOCIAL HISTORY: Positive tobacco, unclear amount. History
of Ecstasy, Klonopin, GHB and Valium.
PHYSICAL EXAMINATION: Temperature is 99.4, pulse 85, blood
pressure 110/70, oxygen saturation 100% on AC ventilator
mode, tidal volume 650, respiratory rate 12, FIO2 100%, PEEP
5. The patient is not responsive. The pupils are 2.0
millimeters bilaterally with minimal responsiveness. Head,
eyes, ears, nose and throat - The oropharynx is with
endotracheal tube in place, no response to voice or pain.
Chest - coarse bronchial breath sounds in right upper lung
zone. Cardiovascular is regular rate and rhythm, no murmurs,
rubs or gallops. The abdomen is soft, nontender, no
hepatosplenomegaly, hypoactive bowel sounds. Skin - no
edema, no rash, no tenderness, has old scars on wrists
bilaterally. She has 1+ dorsalis pedis, posterior tibial,
radial pulses bilaterally.
LABORATORY DATA: Upon admission, white blood cell count was
16.5, hematocrit 49.5, platelet count 288,000. Urinalysis
was negative. Chemistries showed sodium 143, potassium 3.4,
chloride 109, bicarbonate 15, blood urea nitrogen 6,
creatinine 0.9, glucose 108, anion gap 19. ALT 24, AST 68,
LDH 794, CK 2062, alkaline phosphatase 85, amylase 45, lipase
28, troponin negative, albumin 4.6. Initial blood gas showed
a pH 7.33, pCO2 35, pO2 98, lactate 1.3. Serum osmolarity
304, calculated osmolarity 294 with a gap of 10.
Electrocardiogram showed normal sinus rhythm, Q-T normal, QRS
90, normal axis and intervals. Chest x-ray showed a right
upper lobe infiltrate. Head CT showed no bleed or acute
process.
HOSPITAL COURSE:
1. Likely ingestion - Toxic ingestion was initially unclear.
The leading thoughts were GHB which correlated with the
patient's cyclical agitation and sedation. Ecstasy was a
possibility, however, the amphetamine toxicology was negative
and there was no pupil dilation, tachycardia or fever.
benzodiazepines were also thought to be a player as her
toxicology screen was positive for these. A toxic alcohol
screen was checked with negative findings for ethylene
glycol, ethanol, isopropanol, methanol, acetone. The patient
had no ketones in her urine and acetone was negative and thus
alcohol ingestion was unlikely. Due to the initial worry for
toxic alcohol ingestion, Fomepizole times one dose was given
without effect. The patient was supported overnight on the
ventilator and was closely monitored in the Intensive Care
Unit and remained hemodynamically stable.
2. Respiratory failure - The patient was intubated in the
field secondary to apnea. Aspiration likely occurred during
the intubation but was thought to be a pneumonitis.
Antibiotics were held and the patient was afebrile during
admission. Antibiotics were never started. The patient was
extubated on day after admission with ease. She was quickly
titrated to room air and maintained good oxygen saturation
during the rest of hospital course.
3. Suicide attempt - The patient is not helpful and denies
suicide attempt. Once extubated, a psychiatry consultation
was obtained. It was thought that although she disputes
suicidal thoughts, she made a serious attempt with a suicide
note after talking about suicide with her roommate. The
patient has never sought treatment for her depression and
requires involuntary commitment to a psychiatric
hospitalization. The patient was agreeable to this and did
not go to a psychiatry unit involuntarily. She wishes to
seek treatment for her depression.
4. Elevated CK - [**Month (only) 116**] have been due to a seizure that
occurred while the patient was unconscious. Serial CKs
trended down nicely with no evidence of renal failure.
DISPOSITION; The patient remained in the Intensive Care Unit
for 48 hours after admission, she stabilized and will be
transferred to a psychiatric inpatient unit, likely [**Hospital1 **]
Three.
DISCHARGE STATUS: Stable.
CONDITION ON DISCHARGE: To inpatient psychiatric unit.
MEDICATIONS ON DISCHARGE: None upon transfer from Medical
Intensive Care Unit.
FOLLOW-UP PLANS: The patient will follow-up with psychiatry
as indicated by her hospital admission. The patient will
continue with a one to one sitter upon discharge from the
Intensive Care Unit and will remain on suicide precautions.
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**], M.D. [**MD Number(1) 1178**]
Dictated By:[**Last Name (NamePattern1) 9244**]
MEDQUIST36
D: [**2170-11-17**] 12:06
T: [**2170-11-17**] 12:33
JOB#: [**Job Number 53826**]
ICD9 Codes: 5070, 2762, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6529
} | Medical Text: Admission Date: [**2160-7-16**] Discharge Date: [**2160-7-22**]
Date of Birth: [**2120-4-18**] Sex: M
Service: LIVER TRANSPLANT SURGERY SERVICE
ADMITTING DIAGNOSES: End-stage liver disease, admission for
possible liver transplant.
HISTORY OF PRESENT ILLNESS: Patient is a 40-year-old male
with history of hepatocellular carcinoma type 2 with
hepatitis. Patient underwent an ex-lap on [**2160-3-7**]
with attempts at resection. However, he had evidence of
cirrhosis. Resection was not performed. He underwent
radiofrequency ablation. Current MELD score is 22.
He has not had encephalopathy, [**2160-6-18**] aFP 1.8,
hepatitis A/B nonreactive, ALT 34, AST 34, alkaline
phosphatase 75, total bilirubin 0.7. PT 13.3. Platelets 141.
Albumin 4.5.
Currently taking adefovir 10 mg nightly. Thus, HB viral load
undetectable.
Feeling well. Denies recent illness.
REVIEW OF SYSTEMS: Denies fever, chills, cough, nausea,
vomiting, shortness of breath, chest pain, dizziness,
indigestion, rashes, constipation, diarrhea, dysuria, or any
mental status changes. On exposure, patient's sister-in-law
had pharyngitis, on antibiotics. Lives with brother and
sister-in-law.
PAST MEDICAL HISTORY: End-stage liver disease secondary to
hepatitis B cirrhosis stage 2, HCC, radiofrequency ablation
[**2160-3-13**].
PAST SURGICAL HISTORY: On [**2160-3-7**], ex-lap,
question tonsillectomy, question uvulectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: Adefovir 10 mg daily, Protonix 40 mg q.12.,
clotrimazole 5 times a day.
PHYSICAL EXAMINATION: Patient is alert, awake, and oriented,
pleasant. Pupils are equal, round, and reactive to light.
EOMs are full. Trace scleral icterus. Pharynx: No thrush, no
erythema, no soft tissue swelling. Neck: No JVD. Carotids are
2+, no bruits, no LAD. Lungs: Clear, nonlabored. CV: No S1,
S2 without murmurs, rubs, or gallops. Abdomen: Positive bowel
sounds, soft, nontender, and nondistended, well-healed ex-lap
incision. Vascular: Good femoral pulses, 2+ DPs, no lower
extremity edema, no rashes, no lesions. Neuro exam: Awake,
alert, and oriented x3. Cranial nerves II through XII:
Intact. Strength: Equal. No asterixis. Toes: Down
bilaterally.
Portable chest x-ray: There is no acute cardiopulmonary
process.
EKG: Normal sinus rhythm, no acute ischemia.
HOSPITAL COURSE: Bloods were obtained. Preop antibiotic was
given on call. Immunosuppressant medications were on call. So
patient went to the OR on [**2160-7-16**], which an orthotopic
liver transplant performed by Drs. [**Last Name (STitle) 816**], [**Name5 (PTitle) **], [**Name5 (PTitle) **].
Patient received 10 liters of plasma, 2 units of FFP, 1 unit
of pack red blood cells. Please see OR note from [**2160-7-16**] for more details.
Postoperatively, the patient went to the unit intubated.
Patient was given HBIG 10,000 units, CellCept [**Pager number **] mg b.i.d.,
and given 2 units of FFP for an INR of 1.5.
Postop day 1, patient was extubated. Patient was on
fluconazole, ganciclovir, Bactrim, and Unasyn. Patient was
given Solu-Medrol, continued on MMF. Patient was weaned off
propofol and morphine sulfate for pain control. Patient was
given another dose of hepatitis B immune globulin postop day
1.
On postop day 1, patient did get a duplex ultrasound of his
liver showing satisfactory ultrasound and Doppler appearance
on the recent liver transplant. There is good upstroke in the
right and left hepatic arteries and full patency of all
portal and hepatic veins. Small right pleural effusion was
noted, but there are no peritransplant fluid collections.
On [**2160-7-17**], line placement was attempted. Chest x-ray
was obtained after right internal jugular placed which
demonstrated a right internal jugular central venous catheter
overlies the right atrium and there was a small pneumothorax
on the right, and it was confirmed on a followup left lateral
decubitus. There was no need for chest tube because of the
small size of the pneumothorax.
On postop day 2, the patient continued with 2nd day of
Unasyn, awake, alert, and oriented x3. Lungs are clear
bilaterally. CV: Regular rate and rhythm. Making good urine
output. Patient had drain in place. Continued MMF, Solu-
Medrol 150 mg IV. Patient received tacrolimus 4 and 4 and
HBIG 5000 units.
On [**2160-7-19**], patient was transferred from the ICU to [**Hospital Ward Name 121**]
10. Patient continued on morphine with good pain management.
Incision was intact with staples. There was a scant amount of
JP drainage.
On postop day 4, patient doing very well. Moved his lateral
JP drain without complications. Continued on Solu-Medrol,
MMF, tacrolimus was tapered to level. [**Hospital Ward Name **] on [**2160-7-20**]
demonstrated WBC of 4.7, hematocrit of 28.7. PT of 12.7,
21.4, platelets 106, INR 1.1. Sodium 140, 3.8, 106, 23, 15,
BUN and creatinine 22 and 0.7, glucose of 149. ALT 1035, AST
1226, and alkaline phosphatase 230.
On hospital day 6, doing remarkably well, ambulating well,
eating well without problems, urinating. [**Name2 (NI) **] on [**7-22**]
demonstrate ALT of 483, AST of 48, alkaline phosphatase 180,
total bilirubin 0.7. Rest of the [**Month (only) **] are pending.
So patient should be able to go home today on the following
medications: Adefovir dipivoxil NF 10 mg oral daily,
fluconazole 400 mg p.o. q.24h., MMF 1000 b.i.d., Percocet [**1-20**]
p.o. q.4-6h. p.r.n. Patient should get HBIG immunoglobulin on
days 7, 14, and 28. Patient should continue with insulin-
sliding scale. Protonix 40 mg q.24, prednisone 20 mg daily,
Bactrim SS 1 tablet daily, and right now tacrolimus 4 mg
b.i.d., ursodiol 300 mg b.i.d., valganciclovir 900 mg daily.
Patient should have [**Month/Day (2) **] every Monday and Thursday starting
this Thursday in which CBC, Chem-10, AST, ALT, alkaline
phosphatase, albumin, total bilirubin, and Prograf should be
obtained and faxed immediately to [**Telephone/Fax (1) 697**]. Patient
should follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] in [**Hospital Unit Name **] on
[**2160-7-23**] at 3 p.m. Please call [**Telephone/Fax (1) 673**] if you have
any questions about your appointment. Also please follow up
with Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 673**] to make an appointment.
FINAL DIAGNOSES: End-stage liver disease secondary to
hepatitis B virus, hepatocellular carcinoma, status post
orthotopic liver transplantation on [**2160-7-16**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2160-7-22**] 08:52:59
T: [**2160-7-22**] 09:29:19
Job#: [**Job Number 59503**]
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6530
} | Medical Text: Admission Date: [**2130-2-14**] Discharge Date: [**2130-2-23**]
Date of Birth: [**2054-8-27**] Sex: F
Service: VSU
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This is a patient who has known
breast carcinoma with questionable metastatic disease who is
receiving radiation therapy and she was brought onto the
medical service and evaluated for shortness of breath. A CT
scan showed a large chronic dissection of her aorta with an
aneurysmal enlargement below the renal. Her left renal artery
is noted to come off the false lumen. The patient returns now
for elective aortic aneurysm repair.
PAST MEDICAL HISTORY: Congestive heart failure,
hypertension. The patient has a history of arthritis, history
of depression. The patient has undergone a cardiac
catheterization on [**2127-5-29**] which showed clear coronary
arteries. The patient is a type 2 diabetic, controlled. The
patient has pruritus and periorbital edema.
PAST SURGICAL HISTORY: Bilateral lumpectomies with radiation
therapy and CMP. The patient's ejection fraction is 25%. She
also has a history of hyperlipidemia. The patient is a known
smoker. She quit 20 years ago. She smoked 13 pack years. She
does admit to a gin and tonic at bed time.
ALLERGIES: Sulfa.
MEDICATIONS ON ADMISSION: Diovan, Coreg, Lasix, simvastatin,
Ativan, omeprazole, paroxetine, lisinopril, Colace.
PHYSICAL EXAMINATION: Unremarkable. She had Dopplerable DP
and PTs bilaterally and palpable DPs bilaterally.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2130-2-14**]. She underwent an
abdominal aortic resection. She was transferred to the PACU
in stable condition. Her postoperative hematocrit was 32.5,
BUN 6, creatinine 0.9. The patient was neurologically intact.
She had palpable DPs bilaterally. The patient went into flash
pulmonary edema on postoperative day 1 and was transferred to
the ICU for continued care from the PACU. The patient
remained intubated. The patient's postoperative pain was
controlled with epidural infusion. Pressors were weaned off.
Lasix for diuresis was begun. Her triple lumen catheter was
rewired. She remained in the SICU. Beta-blockade was
increased for heart rate management.
On postoperative day #3, the patient had an episode of mental
status change. A CT was done which was negative for acute
bleed or infarct. Ativan was discontinued. She continued to
be diuresed for a goal of 1.5 L/24 hours. The patient was
extubated on postoperative day 3 and transferred to the VICU
for continued monitoring and care. Lopressor was increased
and hydralazine was discontinued. Subcu heparin was
continued. Physical examination showed diminished breath
sounds at the bases. The remaining exam was unchanged. She
had palpable DP and PT bilaterally. She was afebrile. Her
white count was 8.7, hematocrit 31.8. The patient's EKG
postoperatively was without any ST changes. Her troponin was
less than 0.01.
Ambulation to chair was begun on postoperative day 4.
Physical therapy was requested to see the patient in
anticipation for discharge planning. The epidural was
discontinued. She was converted to oral agents. The patient
demonstrated on postoperative day 5 with a much improved lung
exam. Chest x-ray was improved. Ambulation was begun. Diet
was advanced as tolerated with aspiration precautions.
Hyperkalemia was repleted.
On postoperative day #6, the patient was weaned by physical
therapy. We felt the patient would be able to be discharged
to home with physical therapy. The patient continues to
progress. She will need to be evaluated for rehab. OT was
requested to see the patient to evaluate cognitive of
function. The patient will be discharged when medically
stable and cleared by physical therapy.
DISCHARGE MEDICATIONS: Pentamidine 20 mg b.i.d., metoprolol
50 mg t.i.d., valsartan 150 mg daily, simvastatin 20 mg
daily, acetaminophen 325-650 mg q.4-6 hours p.r.n. pain,
oxycodone immediate release 2.5-5.0 mg q.4 hours p.r.n. pain,
aspirin 81 mg daily, senna tablets 1 b.i.d. p.r.n., Colace
100 mg b.i.d. p.r.n.
DISCHARGE DIAGNOSIS:
1. Abdominal aortic aneurysm status post open resection.
2. Postoperative pulmonary edema, resolved.
3. Postoperative confusion, resolved.
4. Type 2 diabetes, diet controlled.
5. History of hypertension, controlled.
6. History of congestive heart failure, last episode prior
to this was [**2128-10-28**].
7. History of cardiomyopathy with systolic dysfunction and
diastolic dysfunction.
8. History of hypertension.
9. History of mild coronary artery disease.
10. History of cardiac evaluation status post catheterization
on [**2127-6-4**], no coronary artery disease, mild mitral
regurgitation with severe systolic ventricular
dysfunction, ejection fraction was 26%, mild pulmonary
hypertension.
11. Episode of syncope secondary to fall resulting in a
subdural hematoma and left wrist fracture on [**Month (only) 359**]
[**2128**], resolved.
12. History of breast cancer, bilateral, status post
lumpectomies with chemotherapy with CMP and radiation
therapy. The patient is a former tobacco smoker. Has not
smoked for 14 years. Prior to that was 10 pack-year
history.
13. History of mild depression with sleep disorder.
The patient should follow-up with Dr. [**Last Name (STitle) 1391**] in 2 weeks'
time. She may shower but no tub baths. No driving. She is
continued on all medications as directed. She should not lift
anything heavier than 2 pounds for the next 4 weeks. She
should call his office if she develops fever greater than
101.5, if the wounds become red or drain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2130-2-20**] 12:30:25
T: [**2130-2-20**] 14:13:42
Job#: [**Job Number 109690**]
ICD9 Codes: 2851, 4254, 4280, 4240, 4019, 4168, 2724, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6531
} | Medical Text: Admission Date: [**2108-6-19**] Discharge Date:
Date of Birth: [**2108-6-19**] Sex: M
Service: NB
IDENTIFICATION: Baby boy [**Known lastname 3825**] [**Known lastname **] is an 18 day old
term infant with respiratory distress syndrome who is being
discharged from the [**Hospital1 69**]
neonatal intensive care unit.
HISTORY: Baby boy [**Known lastname **] was born on [**2108-6-19**] as a 4900
gram product of a 38 and [**5-19**] week gestation pregnancy to a 37-
year-old gravida 5 para 1-2-2 mother with estimated date of
confinement of [**2108-6-29**]. Maternal history is notable for
Crohn disease treated with prednisone.
Prenatal laboratory studies included blood type O positive,
antibody negative, hepatitis B surface antigen negative,
rubella immune, RPR nonreactive and group B strep unknown.
The infant was born by repeat cesarean section without any
sepsis risk factors noted. At delivery, the infant was
vigorous with Apgar scores of 8 and 9. The infant was
initially admitted to the newborn nursing and was noted to
develop tachypnea and mild work of breathing. Oxygen
saturations were in the low 80s and the infant was brought to
the neonatal intensive care unit for admission.
GROWTH PARAMETERS AT BIRTH: Weight 4900 grams, greater than
90th percentile. Length 50 cm, 90th percentile. Head
circumference 37.5 cm, greater than 90th percentile.
HOSPITAL COURSE:
1. Respiratory: On admission, the infant was placed on nasal
cannula oxygen for mild hypoxia. The infant required up
to 150-200 cc of nasal cannula oxygen. The infant
initially was noted to have mild work of breathing with
mild tachypnea. These symptoms gradually improved over
the first 24-48 hours of admission. Chest x-ray revealed
hazy granularity in the basilar regions consistent with
mild hyaline membrane disease. Over the next several
days, the infant's respiratory status gradually improved
such that by day of life [**4-15**], the infant was comfortably
breathing with minimal work of breathing and was
requiring low nasal cannula oxygen at 25-50 cc of flow.
However, this oxygen requirement persisted with attempts
to wean the infant to room air failing due to drifting
oxygen saturations to the low 90s and high 80s. Repeat
chest x-ray at approximately 1 week of life was similar
to initial with mild haziness at the bases consistent
with mild respiratory distress syndrome. Chest x-ray at 2
weeks of life was largely normal. Arterial blood gas at 2
weeks of life was reassuring with a pH of 7.49, PCO2 38,
PO2 114. On day of life 16, due to generalized edema on
exam and persistent oxygen requirement, the infant was
given a dose of Lasix with a brisk diuresis. The infant
was successfully weaned to room air shortly thereafter.
The infant remained on room air for the next 48 hours and
was thus discharge to home on day of life 18.
2. Cardiovascular: The infant remained cardiovascularly
stable throughout admission. Due to persistent oxygen
requirement, a cardiac evaluation was performed with an
EKG that was normal, hyperoxia test that was normal and
4-extremity blood pressures that were normal. An
echocardiogram was finally done on day of life 14 that
revealed normal anatomy with a small atrial septal defect
with left to right flow, normal ventricular function and
no evidence of pulmonary hypertension.
3. Fluids, electrolytes, nutrition: The infant was initially
maintained on IV fluids due to mild respiratory distress
as well as initial D-stick in the 30s. Subsequent D-
sticks were all within normal limits. Enteral feeds were
begun on day of life 1 and advanced gradually.
By day of life [**4-15**], the infant was ad lib feeding Similac
20 without difficulty. The infant continued to feed well
with excellent intake and adequate weight gain. Urine and
stool output remained brisk throughout. Electrolytes were
measured on day of life 14 and these were within normal
limits. Weight at the time of discharge was 5200 grams.
4. ID: CBC and blood cultures were sent on admission. White
count was 15.8 with 68% polys and 1% bands. Hematocrit
50.7 and platelets were 223. Ampicillin and gentamicin
were started and these were discontinued at 48 hours with
negative blood cultures. The infant was noted to develop
a candidal rash in the diaper area, treated with
Miconazole powder.
5. GI: The infant was noted to develop mild
hyperbilirubinemia that did not require phototherapy.
Peak bilirubin was 15.6/0.3 on day of life 5.
6. Development: The infant's temperature remained stable in
an open crib throughout admission. The neurologic exam
remained normal throughout.
CONDITION ON DISCHARGE: The infant was stable on room air
with oxygen saturation greater than 94%. The infant was
feeding similac 20 on an ad lib basis with adequate intake and
adequate weight gain. Weight is 5.200 kg.
DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 37327**] [**Last Name (NamePattern1) 72857**]. Phone
number [**Telephone/Fax (1) 35938**].
ROUTINE HEALTHCARE MAINTENANCE: Hearing screen was performed
and passed prior to discharge. Car seat safety screening was
performed and passed prior to discharge. The infant received
first hepatitis B vaccination on [**2108-7-4**]. State screens
were sent on [**6-22**] and [**2108-7-3**] with no abnormal results
received to date.
FOLLOWUP: The infant will follow with the pediatrician three
days after discharge.
DISCHARGE DIAGNOSES:
1. Large for gestational age term infant.
2. Respiratory distress syndrome.
3. Testis evaluation negative.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2108-7-6**] 20:10:42
T: [**2108-7-6**] 22:41:52
Job#: [**Job Number 72858**]
ICD9 Codes: 769, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6532
} | Medical Text: Admission Date: [**2102-10-28**] Discharge Date: [**2102-11-2**]
Service: MEDICINE
Allergies:
Codeine / Ultram
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Vomiting x1 day and dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo Russian speaking female w/CML s/p gleevec, diastolic CHF
(EF > 55%), afib who presents from [**Hospital3 **] facility
after feeling lightheaded. She has also been having nausea with
one episode of vomiting. Patient denies CP, SOB, abd pain, back
pain, dysuria. Has chronic L shoulder and L knee pain. No falls,
fevers, abdominal pain, diarrhea.
.
In the ED: BP 67/40 (baseline SBP 90s per OMR notes) HR 101,
afebrile, sat normal. VERY dry MM. Patient received ketolorac IV
for pain. She was guaiac:neg. Got 3 lts of NS in ED. CXR showed
mild chf. Lactate was 2.8 and urine was dirty.
Past Medical History:
1. Chronic myelogenous leukemia, on Gleevec, followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**]. Gleevec held, Dr. [**Last Name (STitle) 2539**] aware and will follow as
outpt.
2. PAF - rate control, no anticoag by pt's choice
3. CHF- chronic diastolic
4. Spinal stenosis with chronic low back pain - s/p epidural
steroid injections in [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic
5. Chronic R shoulder pain
6. s/p R total knee replacement
7. s/p R total hip replacement
8. s/p L comminuted tibial fx repair
9. Unsteady gait
10. h/o Dizziness, on meclizine
11. Hypercholesterolemia
12. h/o Dyspepsia
13. s/p cataract surgery bilaterally
14. OA
Social History:
Pt lives alone in a senior community. She has a caregiver that
see her on a daily basis. She denies any tobacco, ETOH, or IVDU.
Family History:
Noncontributory.
Physical Exam:
97.8, 75/58, 90, 16, 100%/2L NC, pulsus 6-8 mm hg
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, dry MM
NECK: no supraclavicular or cervical lymphadenopathy, JVD ~10
cm, no carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, 2/6 systolic murmur at apex, LSB,
?diastolic murmur at LSB
ABD: epigastric/RUQ pain, no guarding/rigidity, BS+
EXT: 2+ bilateral edema
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. strength exam limited by pain
but able to move all extremities.
strength throughout. No sensory deficits to light touch
appreciated. No pass-pointing on finger to nose.
2+DTR's-patellar and biceps
RECTAL: guiac negative
Pertinent Results:
[**2102-10-28**] 12:35PM PT-15.0* PTT-32.3 INR(PT)-1.3*
[**2102-10-28**] 12:35PM PLT COUNT-201
[**2102-10-28**] 12:35PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-1+ BITE-OCCASIONAL
[**2102-10-28**] 12:35PM NEUTS-89* BANDS-6* LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2102-10-28**] 12:35PM WBC-9.5 RBC-2.84* HGB-8.7* HCT-26.5* MCV-93
MCH-30.6 MCHC-32.9 RDW-15.8*
[**2102-10-28**] 12:35PM ALBUMIN-3.1* CALCIUM-8.6 PHOSPHATE-3.2
MAGNESIUM-2.0
[**2102-10-28**] 12:35PM CK-MB-NotDone
[**2102-10-28**] 12:35PM cTropnT-0.05*
[**2102-10-28**] 12:35PM LIPASE-9
[**2102-10-28**] 12:35PM ALT(SGPT)-11 AST(SGOT)-23 CK(CPK)-50 ALK
PHOS-115 AMYLASE-21 TOT BILI-0.6
[**2102-10-28**] 12:35PM estGFR-Using this
[**2102-10-28**] 12:35PM GLUCOSE-101 UREA N-56* CREAT-2.5*# SODIUM-135
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-19* ANION GAP-20
[**2102-10-28**] 12:48PM LACTATE-2.8* K+-5.2
[**2102-10-28**] 12:48PM COMMENTS-GREEN
[**2102-10-28**] 02:15PM URINE RBC->50 WBC-[**1-30**] BACTERIA-MANY YEAST-NONE
EPI-[**1-30**] TRANS EPI-0-2
[**2102-10-28**] 02:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2102-10-28**] 02:15PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.021
[**2102-10-28**] 08:50PM URINE HOURS-RANDOM UREA N-279 CREAT-98
SODIUM-12
[**2102-10-28**] 09:30PM CORTISOL-17.9
[**2102-10-28**] 09:30PM CK-MB-4 cTropnT-0.03*
[**2102-10-28**] 09:30PM CK(CPK)-32
[**2102-10-28**] 10:23PM CORTISOL-36.3*
Brief Hospital Course:
* The following is the D/C summary as written by the attending
of record ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) from [**10-30**] through discharge [**11-2**] *
For details of her ICU STAY from admission ([**2102-10-28**]) until
transfer to the medical [**Hospital1 **] on [**10-30**], please refer to Dr.
[**Last Name (STitle) **] of Pulmonary and Critical Care.
[**Age over 90 **] yo Russian speaking female w/CML, diastolic CHF (EF > 55%),
afib, presented with symptoms of dizziness, found to be
hypotensive.
.
# Sepsis, source unclear, with bacteremia (group B strep) and
hypotension: Required pressors and 10 L volume repletion in the
ICU. Stabilized and called out to the medical floor. Blood
cultures positive for Group B strep, source unclear. Initially
maintained on Vancomycin and Zosyn. This was narrowed to
penicillin once the sensitivities returned. In lenthy
discussion with patient, family, palliative care, pt. stated
repeatedly that she did not want any care that would prolong her
life. On [**2100-11-1**], according to her wishes, abx. were stopped.
She was sent to [**Location (un) 582**] [**Hospital1 1501**] with Hospice care on [**2102-11-2**] in
stable contdition. She was afebrile, with stable vital signs,
and tolerating some po liquids.
.
#Pain Control: In conjuction with the palliative care service,
the patient was given fentanyl patch, lidocaine patch, oral
dilaudid and tyelenol. She was prescribed liquid morphine for
use in Hospice po, if she is unable to swallow the dilaudid
pills.
.
# Nausea - treated with oral ondansetron.
.
# ARF: felt due to ATN in the setting of hypotension from
sepsis. Renal function recovered toward baseline by the end of
admission, but, given the patient's wishes for comfort only
care, no labs were at the end of her stay and renal function was
no longer monitored by serum cr. assay.
.
# Atrial Fibrillation: Chronic, not on coumadin. BB initially
held in ICU given hypotension. Resumed on medical floor as BP
stable, and in order to control RVR.
.
# CHF w/ diastolic dysfunction, chronic: Pt. was overall volume
overloaded, with intravascular depletion after ICU volume
rescussitation as above. Given ARF, lasix was held; towards the
end of her hospitalization, once comfort only care was chosen,
lasix was not re-administered as she appeared to be
auto-diuresing, with large volumes of urine output, and her
respiratory status was stable.
.
# HTN: Hypotensive on admission. Will hold antihypertensives
until BP normalizes.
.
# CML - Pt. choses comfort only care, as above. No further
treatment for CML. Discharged to [**Location (un) 582**] with Hospice care, as
above.
Medications on Admission:
allopurinol 100 mg daily
Toprol-XL 50 mg daily
Lasix 40 mg twice a day
potassium 20 mEq daily
aspirin 81 mg daily
Gleevec 200 mg QD
oxycodone as needed for pain
iron daily
Celebrex 100 mg twice a day
Prilosec daily
Senokot as needed
trazodone 50 mg at bedtime
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical 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. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed. Tablet(s)
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
12. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
13. Morphine 10 mg/5 mL Solution Sig: 1-5 mg PO Q 2 H PRN ().
14. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed.
15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea, anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
CML
Bacteremia with sepsis
Chronic, diastolic, heart failure
Atrial fibrillation
Acute renal failure due to ATN
Chronic pain
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Follow up with Hospice Care at [**Location (un) 582**] Skilled Nursing Facility
as arranged.
Followup Instructions:
As above. [**Location (un) 582**] [**Location (un) 620**] [**Hospital1 1501**] with Hospice care.
ICD9 Codes: 5845, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6533
} | Medical Text: Admission Date: [**2103-8-21**] Discharge Date: [**2103-8-28**]
Date of Birth: [**2036-12-27**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Latex
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
I had the pleasure of seeing Mr. [**Known lastname 6330**] in orthopedic spine
clinic
for his chief complaint of back problems.
Major Surgical or Invasive Procedure:
1. C4-C5 anterior arthrodesis.
2. Application of interbody VG2 device.
3. Anterior cervical decompression C4-C5.
4. Posterior laminectomy, medial facetectomy, foraminotomy,
C3-C4, C4-C5, C5-C6.
5. Posterior arthrodesis C3-C4, C4-C5, C5-C6, C6-C7.
6. Posterior instrumentation C3-C7 segmental.
7. Application and removal of tongs.
8. Application of local autograft.
9. Application of morcelized allograft.
10. Spinal cord monitoring with motor evoked NSCCP's.
History of Present Illness:
As you know, he is a 66-year-old gentleman with acute and
chronic back pain. For the past six months, he states his back
pain has been increasing. At
this time, he states his back pain is [**8-7**] at rest and [**11-7**]
with activity. He does not complain of any changes in his
bowel, bladder, or balance. He denies any numbness or tingling
of the lower extremities. He also denies any weakness or calf
pain with walking. He states that there was no specific
accident but this has just gradually kind of come on. He also
complains of medial left thigh pain. He says any activity makes
it worse and he has not had any physical therapy prior to this
exam.
Past Medical History:
Significant for high blood pressure, which he states is under
control. He has had thyroid disease. Specifically, he does
have Addison's disease. In addition, he has been on steroid
medications for approximately fifteen years. He states that
over the last six months, due to his last hospitalization, they
upped his steroids to 150 mg per day, he has since backed off to
30 mg per day.
Social History:
He states he is currently working. He smokes a pipe and he has
approximately two or three drinks per week. He lives at home
with his wife.
Family History:
Family history is significant for cancer on his mother's side
and heart disease on his father's side.
Physical Exam:
On physical exam, he is approximately 5 feet 8 inches tall,
weighing 225 pounds with a blood pressure of 115/70. His gait
is quite antalgic. He is able to stand on his heels and toes.
His gait is very small steps steppage gait with a narrow base.
He has negative Romberg. Lower extremity strength is [**6-2**] in all
fields. He is neurologically intact to light touch in all
fields. Reflexes of his lower extremities when compared to his
reflexes of his upper extremity exhibit hyperreflexia. He does
have clonus x4 on the right and a sustained clonus on the left.
He also has a large degree of pitting edema in his lower
extremities. He states he believes that this is secondary to
the increase to his steroid medication and the removal
hydrochlorothiazide from his medical regimen. Physical exam of
his upper extremity, he has good strength 5/5 in all fields of
bilateral upper extremities and he is neurologically intact to
light touch. He does state he has some numbness and tingling in
his pinky of both hands.
Pertinent Results:
[**2103-8-22**] 03:00AM BLOOD WBC-13.7* RBC-4.17* Hgb-13.3* Hct-38.8*
MCV-93 MCH-31.9 MCHC-34.3 RDW-15.3 Plt Ct-229
[**2103-8-23**] 01:56AM BLOOD WBC-20.5* RBC-4.27* Hgb-14.0 Hct-41.1
MCV-96 MCH-32.8* MCHC-34.1 RDW-15.0 Plt Ct-252
[**2103-8-23**] 06:14AM BLOOD WBC-15.6* RBC-3.95* Hgb-12.7* Hct-38.3*
MCV-97 MCH-32.1* MCHC-33.1 RDW-14.9 Plt Ct-276
[**2103-8-24**] 01:08AM BLOOD WBC-12.5* RBC-3.62* Hgb-11.8* Hct-34.1*
MCV-94 MCH-32.7* MCHC-34.7 RDW-15.2 Plt Ct-221
[**2103-8-25**] 03:52AM BLOOD WBC-12.8* RBC-3.64* Hgb-11.9* Hct-34.8*
MCV-96 MCH-32.7* MCHC-34.2 RDW-15.1 Plt Ct-268
[**2103-8-23**] 06:15AM BLOOD CK(CPK)-575*
[**2103-8-24**] 01:08AM BLOOD ALT-30 AST-35 LD(LDH)-177 AlkPhos-211*
Amylase-49 TotBili-1.3
[**2103-8-23**] 06:15AM BLOOD CK-MB-13* MB Indx-2.3 cTropnT-0.03*
[**2103-8-24**] 01:08AM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.8 Mg-2.0
[**2103-8-25**] 03:52AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.2
[**2103-8-21**] 02:47PM BLOOD Type-ART PEEP-5 pO2-120* pCO2-46* pH-7.41
calTCO2-30 Base XS-4 Intubat-INTUBATED
[**2103-8-21**] 10:14PM BLOOD Type-ART pO2-187* pCO2-40 pH-7.41
calTCO2-26 Base XS-1
[**2103-8-22**] 03:07AM BLOOD Type-ART pO2-154* pCO2-46* pH-7.40
calTCO2-30 Base XS-3
[**2103-8-23**] 01:39AM BLOOD Type-ART pO2-97 pCO2-106* pH-7.07*
calTCO2-33* Base XS--2
[**2103-8-23**] 04:21AM BLOOD Type-ART Rates-20/ Tidal V-600 PEEP-8
FiO2-60 pO2-73* pCO2-41 pH-7.34* calTCO2-23 Base XS--3
Intubat-INTUBATED
[**2103-8-23**] 01:55PM BLOOD Type-ART pO2-169* pCO2-30* pH-7.52*
calTCO2-25 Base XS-2
[**2103-8-23**] 02:47PM BLOOD Type-ART pO2-116* pCO2-41 pH-7.42
calTCO2-28 Base XS-2
[**2103-8-23**] 06:11PM BLOOD Type-ART pO2-295* pCO2-41 pH-7.42
calTCO2-28 Base XS-2
[**2103-8-23**] 07:42PM BLOOD Type-ART Rates-0/10 FiO2-40 pO2-146*
pCO2-43 pH-7.42 calTCO2-29 Base XS-3 Intubat-INTUBATED
Vent-SPONTANEOU
[**2103-8-24**] 01:33AM BLOOD Type-ART Temp-38.6 Rates-/10 FiO2-40
pO2-184* pCO2-47* pH-7.40 calTCO2-30 Base XS-3 Intubat-INTUBATED
Vent-SPONTANEOU
[**2103-8-24**] 04:18AM BLOOD Type-ART Temp-38.1 Rates-/12 PEEP-8
FiO2-40 pO2-178* pCO2-47* pH-7.39 calTCO2-30 Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2103-8-24**] 06:22AM BLOOD Type-ART Temp-37.5 Rates-/13 Tidal V-560
PEEP-5 FiO2-40 pO2-163* pCO2-45 pH-7.42 calTCO2-30 Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2103-8-24**] 08:40AM BLOOD Type-ART pO2-177* pCO2-34* pH-7.48*
calTCO2-26 Base XS-3
[**2103-8-24**] 10:52AM BLOOD Type-ART pO2-89 pCO2-48* pH-7.38
calTCO2-29 Base XS-1
[**2103-8-24**] 06:55PM BLOOD Type-ART pO2-99 pCO2-44 pH-7.44
calTCO2-31* Base XS-4
Brief Hospital Course:
Mr. [**Known lastname 6330**] was brought to [**Hospital1 18**] for treatment of his cervical
stenosis with myelopathic changes.
Medications on Admission:
hydrocortisone 20 mg
Altace 10 mg
Norvasc 10 mg
Protonix 40 mg
testosterone 7 mL
Discharge Medications:
1. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
2. Hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Southeastern
Discharge Diagnosis:
1. Cervical myelopathy.
2. Cervical stenosis.
3. Morbid obesity.
4. Panhypopituitarism from pituitary tumor
5. Hypertension
Discharge Condition:
Stable to home with physical therapy.
Discharge Instructions:
Please keep your incision clean and dry. You may shower but
please do not soak the incision. Please reusme all your home
medication as prescribed by your primary care. If you notice
redness or drainage from your incision or if you have a fever
greater than 100.5, please call the office at [**Telephone/Fax (1) **].
Please refer to the discharge sheet for questions on activity
and follow up.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1352**] two weeks from the date of
surgery.
Completed by:[**2103-9-5**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6534
} | Medical Text: Admission Date: [**2165-3-12**] Discharge Date: [**2165-3-20**]
Date of Birth: [**2094-11-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
central venous line placement and subsequent removal
hemodialysis line removal
History of Present Illness:
70 yo M presented to ED from nursing home w/ altered mental
status and low grade fever. Per the patient's son, patient's
penile gangrene had worsened - prior dry gangrene isolated to
glans penis treated conservatively given not operative candidate
and followed closely by urology. On evaulation in the ED patient
was oriented only to self.
In the ER initial VS were: T 100.6 HR 53 BP 135/67 RR 14. VS
prior to transfer to the ICU 86, BP 146/65 98% on 2L RR 12. He
rec'd 20u sc insulin in total, he rec'd 500cc of IVF. Had a L SC
CVL placed.
He was transferred to the MICU for concern of sepsis. CT groin
showed sq air diagnostic for fournier's gangrene. He was treated
with vanc/zosyn/cipro and urology was consulted who had a long
discussion with son about patient not being an operative
candidate and the natural course of fournier's gangrene without
surgical intervention. Decision made to make patient DNR/DNI
with no escalation of care. Patient was hemodynamically stable
throughout MICU course.
He was transferred to the floor and upon evaluation patient
denied pain, CP, SOB, abd pain or other ROS.
Past Medical History:
-5/08 L BKA for gangrene
-[**12-30**] glans penis dry gangrene conservatively managed
-DM2
-Hypertension
-CKD baseline 3.5-4.2, up to 9 in [**6-28**]
-blindness
-neuropathy, possibly demyelinating polyneuropathy
-systolic CHF EF 50% as of [**4-28**]
Social History:
Originally from [**Location (un) 4708**]. Very remote tobacco use. Denies EtOH
or drugs. Wheelchair bound, lives at home with family who are
very involved - has nurse visit 3x/day.
Family History:
Diabetes, CAD in children. One son died of MI.
Physical Exam:
VS: 138/67 87 15 98.7 90-98% on RA
GEN: elderly gentleman, lying in bed,looking straight.
HEENT: R corenal haziness, reduced vision, EOMI, no icterus, MMM
NECK: no cervical lymphadenopathy
CV: RRR, no r/g/m
PULM: clear to auscultation bilaterally
ABD: soft, mildy distended, non tender
GROIN: deferred temporarily.
EXT:warm and well perfused. R foot with dorsal edema, dry
ulcer, well circumscribed, no drainage. left BKA.
NEURO: difficult to assess, patient able to verbalize. hard of
hearing. can follow some simple commands. could not move feet
when asked. unclear if he understood.
Exam at discharge:
T 96 HR 99 158/60 92% RA
GEN: elderly gentleman, lying in bed, alert and oriented to
person, comfortable
HEENT: R corenal haziness, reduced vision, EOMI, no icterus, MMM
NECK: no cervical lymphadenopathy
CV: RRR, no r/g/m
PULM: clear to auscultation bilaterally
ABD: soft, mildy distended, non tender
GROIN: gangrene of glans and shaft with some purulence at
coronal sulcus. Crepitus notable along lenth of penile shaft.
Urethra with some purulence but appears patent. Erythema
extending to suprapubic region
EXT:warm and well perfused. R foot with dorsal edema, dry
ulcer, well circumscribed, no drainage. left BKA.
Pertinent Results:
CT A/P:
IMPRESSION:
1. Extensive subcutaneous and soft tissue emphysema involving
essentially all compartments of the penis extending its entire
length, consistent with
Fournier's gangrene. Emergent surgical evaluation is
recommended.
2. Extensive diffuse atherosclerotic disease, with possible
right proximal
superficial femoral artery occlusion as described. Please
correlate
clinically for further evaluation. Current study is not tailored
for CT
angiography.
3. Moderate-to-large bilateral pleural effusions with
compressive
atelectasis, right greater than left.
4. High-density exophytic small lower pole right renal lesion,
new since
[**2160**], is not fully characterized. This may be further evaluated
by ultrasound on a non-emergent basis.
5. Diffuse severe anasarca.
6. Fat-containing umbilical hernia.
7. Moderate amount of fecal material throughout the colon.
CT HEAD:
No intracranial hemorrhage, large vascular territory infarct, or
large mass. Please note MRI with gadolinium is superior for
evaluation of
intracranial mass if not contraindicated.
LABS:
- CBC: WBC-20.9 Hgb-8.3 Hct-28.3 MCV-80 Plt Ct-556
- DIFF: Neuts-91.5* Lymphs-5.3* Monos-2.9 Eos-0.2 Baso-0.2
- COAGS: PT-13.3 PTT-28.6 INR(PT)-1.1
- CHEM 10: Glucose-393 UreaN-80 Creat-8.4 Na-137 K-5.3 Cl-97
HCO3-24 AnGap-21 Calcium-8.5 Phos-6.6* Mg-2.6
- LFT's: ALT-13 AST-15 CK(CPK)-49 AlkPhos-363 TotBili-0.3
- cTropnT-0.83*
- Lactate-1.4
Labs prior to discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
30.8* 3.89* 9.6* 30.8* 79* 24.7* 31.2 21.4* 475
Brief Hospital Course:
ASSESSMENT & PLAN: 70 year old male with h/o DM, HTN, ESRD on
HD and systolic CHF EF 30% presented with altered mental status,
fever, found to have Fourniers gangrene of the groin. He was
septic and started on Vanco/Zosyn/Clindamycin in the ICU. The
patient was a high surgical risk, and any survival and per
urology the benefit to be obtained from debridement would likely
be small and associated with significant pain and painful
dressing changes. He was continued on antibiotics and an
aggressive pain regimen. This alleviated his symptoms. His
mental status also cleared as his pain control improved. He was
hemodynamically stable and he was tranferred to the floor where
further discussion regarding goals of care were pursued with the
assitance of the palliative care team. During a family meeting,
it was made clear that the patient's Fournier's gangrene was
non-operative and was terminal. Following this discussion with
[**Hospital 228**] health care proxy, son [**Name (NI) 14175**], the decision was made
that the patient would want his care to be focused at home with
hospice without return to a health care facility if his
condition worsened. Hemodialysis was discontinued, and his HD
line was removed. Hospice care was arranged, and the patient
was discharged on [**2165-3-20**] home with hospice. He had a mid-line
placed so that he could continue to receive antibiotics for his
non-operative Fournier's gangrene. Pain control was optimized
with a fentanyl patch and sublingual morphine. The patient was
comfortable and alert upon discharge.
Medications on Admission:
HOME MEDICATIONS:
Amlodipine 5 mg daily
Aspirin 325 mg po daily
Atorvastatin 40 mg po daily
Insulin Lispro sliding scale
Metoprolol Succinate 25 mg SR daily
B Complex-Vitamin C-Folic Acid 1 mg po daily
Acetaminophen 325 mg 1-2 tablets q6hrs prn
Ranitidine HCl 150 mg po daily
Insulin Glargine 2 units daily
Docusate Sodium 100 mg po bid
Polyethylene Glycol 3350 17 gram/dose po daily
Bisacodyl 5 mg po daily
Senna 8.6 mg po bid
MEDICATIONS ON TRANSFER:
Acetaminophen 1000 mg PO/NG TID
Artificial Tears 1-2 DROP BOTH EYES Q4 HOURS
HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain
Clindamycin 600 mg IV Q8H
Piperacillin-Tazobactam 2.25 g IV Q12H
Vancomycin 1000 mg IV HD PROTOCOL
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-22**]
Drops Ophthalmic Q4 HOURS ().
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
3. Zosyn 2.25 gram Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 1 months.
Disp:*qs * Refills:*2*
4. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours.
Disp:*5 0* Refills:*0*
5. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours).
6. Morphine Concentrate 20 mg/mL Solution Sig: 1-2 mg PO Q1H
(every hour) as needed for breakthrough pain/dyspnea.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Hospice Care
Discharge Diagnosis:
Primary Diagnosis:
Forneir's Gangrene
End stage renal disease
Type II Diabetes Mellitus
Secondary Diagnosis:
Hypertension
Discharge Condition:
Mental Status: alert and oriented to person
Level of Consciousness: alert
Activity Status: bedrest, out of bed with assist
Discharge Instructions:
Mr. [**Known lastname 12543**] - It was a pleasure to care for you during your
hospitalization. You were admitted due to a very serious
infection of the skin and soft tissue of the penis. You were
evaluated by urology and surgery was thought to be very
dangerous. You were continued on antibiotics. The urologists
did not think that you would be able to tolerate a painful
surgery to cure the infection, which is a terminal infection.
The decision was made by you and your family to treat your pain
and other symptoms with pain medications and antibiotics.
Following a family meeting, arrangements were made for hospice
services at home to continue comfort measures. Dialysis was
discontinued, and your hemodialysis line was removed. You had
another IV placed to continue receiving antibiotics at home.
You went home on [**2165-3-20**] with the intent to continue comfort
measures only and not to return to the hospital.
See below for a list of medications you will given at home.
You will continue to receive hospice care at home.
Followup Instructions:
You will continue to receive hospice care at home.
ICD9 Codes: 0389, 5856, 2762, 4280, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6535
} | Medical Text: Admission Date: [**2171-9-11**] Discharge Date: [**2171-9-17**]
Date of Birth: [**2120-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
mitral [**Last Name (NamePattern1) **]
Major Surgical or Invasive Procedure:
mitral [**Last Name (NamePattern1) **] [**2171-9-13**]
History of Present Illness:
Patient is a 51 year old Cantonese speaking man with history of
rheumatic mitral stenosis, prior pulmonary embolism, and left
atrial clot. He presents today for admission for heparin drip in
preparation of TEE and mitral [**Month/Day/Year **]. Of note, patient
was admitted in [**2171-4-23**] for chest pain, and was found to
be in atrial fibrillation. During that admission, a
transthoracic echocardiogram demonstrated rheumatic mitral
stenosis with an ejection fraction of 40-50%. A transesophageal
echocardiogram demonstrated a left atrial appendage, and he was
started on Coumadin. A [**Year (4 digits) **] and cardioversion were
deferred at that time given the finding of the clot.
History done through an interpreter. Since [**Month (only) 547**] admission
patient's symptoms have been stable (not worse or better).
Describes shortness of breath with exertion. Tends to feel dizzy
when he bends over. Denies chest pain, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, or syncope.
Patient describes mild nausea, denies abdominal pain or
vomiting. Wife states he had an EGD which demonstrated ulcers
and was started on "medication" for 2 months. Denies black or
bloody stool. Patient aware he is in a hospital for a valve
procedure. He has not taken his warfarin since last saturday
night.
Past Medical History:
- Rheumatic mitral stenosis
- History of pulmonary embolism [**2169**]
- Atrial fibrillation
Social History:
Worked in a restaurant kitchen. Lives with wife. Smoked [**11-11**]
cigarettes daily for 10 years, not currently smoking. No EtOH or
drug use.
Family History:
Father with "enlarged heart" died at age 84. Mother has [**Last Name **]
problem, but patient does not know what it is.
Physical Exam:
On Discharge:
VS: T97.8, BP105/84, HR 85, RR12, 100% 2lNC
Gen: NAD, no resp dist. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3, 3/6SEM heart over precordium
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: soft, nt/nd, positive bowel sounds, no HSM or tenderness.
Ext: No c/c/e. No femoral bruits, L and R femoral sites without
signs of bleed or hematoma.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2171-9-11**] ALT(SGPT)-32 AST(SGOT)-24 LD(LDH)-199 ALK PHOS-93
AMYLASE-90 TOT BILI-0.4
[**2171-9-11**] WBC-6.3 RBC-4.31* HGB-13.4* HCT-40.2 MCV-93 MCH-31.1
MCHC-33.3 RDW-14.9
[**2171-9-11**] PT-15.1* PTT-32.9 INR(PT)-1.3*
H. pylori: POSITIVE
MITRAL [**Month/Day/Year **]/CARDIAC CATH [**2171-9-13**]:
1. Severe mitral stenosis with mean gradient of 15mmHg and area
of 0.68cm2.
2. Successful transeptal puncture with intracardiac echo
guidance.
3. Successful mitral [**Month/Day/Year **] using Inoue balloon inflated
to a maximum diameter of 30mm.
POST-PROCEDURE ECHOS:
TTE [**2171-9-13**] at 12:45:00 PM: Study immediately post balloon
mitral [**Year (4 digits) **]. Overall left ventricular systolic function
is normal (LVEF>55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic valve
leaflets are moderately thickened. The mitral valve shows
characteristic rheumatic deformity. There is moderate valvular
mitral stenosis (area 1.0-1.5cm2). Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen.
Compared with the prior study (images reviewed) of [**2171-4-29**], the
MVA area is greater and the mean mitral gradient has decreased.
There is now moderate mitral regurgitation.
TEE [**2171-9-13**] at 2:40:05 PM: The left atrium is dilated.
Moderate to severe spontaneous echo contrast and a layering
thrombus is present in the left atrial appendage. There is
organizinf thrombus in the LAA situated deep within the
structure and away from the mouth of the structure, measuring
2.2x 2.1cm in maximal diameter. The left atrial appendage
emptying velocity is depressed (<0.2m/s). The right atrium is
dilated. The right atrial appendage ejection velocity is
depressed (<0.2m/s). There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets that are
moderately thickened. The left and right leaflet appears fused
but frank aortic stenosis ids not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened and shows characteristic rheumatic deformity. There is
at least moderate valvular mitral stenosis (area 1.0-1.5cm2).
There is no chordal deformation/thickening. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2171-5-3**], the left atrial appendage
thrombus is consdierably smaller, not as mobile, and situated
away from the mouth of the atrial appendage.
CT Abdomen/Pelvis [**2171-9-13**]:
1. Resting hemodynamics revealed a mean mitral valve gradient of
15mmHg
and estimated valve area of 0.68cm2.
2. Successful transeptal puncture and mitral [**Month/Day/Year **] using
a an
Inoue balloon inflated to 26mm, 28mm and 30mm diameter.
3. Improvement of mean gradient to 6mmHG and valve area to
1.98cm2.
Patient left cathlab in stable condition.
CXR [**2171-9-14**]: Moderate-to-marked cardiomegaly is stable. Small
bilateral pleural effusions are unchanged. There is no overt
CHF. There are bibasilar atelectases.
ULTRASOUND [**2171-9-15**]: No evidence of bilateral groin hematoma,
fluid collections or vascular abnormalities in the common
femoral vessels.
Brief Hospital Course:
Mitral Stenosis secondary to Rheumatic disease: Mitral
[**Month/Day/Year **] [**2171-10-14**]. Intra-procedure SBPs 70s-110 and required
doputamine support. Post-procedure SBP 70s and was transferred
to CCU for observation. Hypotension differential included
tamponode vs. bleed (RP or groin). ECHO X 2 negative for
tamponode or effusion. Groin sites intact and CT ab/pelvis
negative for bleed. Most likely related to procedure medications
and new onset MR. [**Name13 (STitle) **] was stable in unit and transferred
back to the floor on [**2171-10-15**]. On [**2171-10-16**] patient developed
hematoma at R cath site, heparin was continued but coumadin was
held. Blood pressure and HCT were stable, ultrasound imaging on
[**2171-10-16**] was negative for hematoma b/l. Patient developed
mild-moderate MR [**First Name (Titles) 767**] [**Last Name (Titles) **]. Patient's SBP averaged 100s
and felt too low to start afterload reducer inpatient. Consider
outpatient afterload reducer if BP tolerates. Follow-up ECHO in
[**2-24**] weeks.
Rhythm: Atrial fibrillation. No RVR during entire admission,
heart rate < 100. TEE demonstrated persistant left atrial
thrombus, though smaller and less mobile since [**2171-5-3**] TEE.
Unable to convert due to thrombus. Continued Metoprolol Tartrate
50 mg PO BID for rate control during admission, discharged on
Toprol XL 100 mg.
Anti-coagulation: Required for 1) L atrial thrombus 2) History
of PE 3) A Fib. On weight-based heparin drip throughout
admission. Restarted Coumadin 4 mg qhs during admission,
discharged on Lovonex until therapeutic.
Mild Nausea: Patient reported mild nausea on admission. No
abnormalities on CT abdomen or pelvis. All stools guaiac
negative. Started and discharged on Omeprazole 20 mg qd. H.
pylori POSITIVE, pending at discharge. Will contact primary care
provider regarding results. Patient was discharged on
Omeprazole, but will require course of antibiotics.
Medications on Admission:
- Coumadin 4 mg qhs
- Metoprolol XR 100mg qd
Discharge Medications:
1. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous once a
day for 10 days: 10 day supply .
Disp:*10 syringe* Refills:*0*
2. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Take as instructed.
3. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Mitral stenosis status post valvuplasty
Secondary:
Atrial fibrillation with left atrial thrombus
History of Pulmonary embolism
Discharge Condition:
Ambulating with stable vitals. Pain free.
Discharge Instructions:
You were admitted for a mitral valvuplasty for your mitral
stenosis. It was necessary to give you heparin and stop your
coumadin due to your history of clot in your heart and lung. You
underwent the mitral [**Month/Day/Year **] and were monitored in the
cardiac intensive care unit afterwards. You were started on
Lovenox, a medication to thin your blood, until your coumadin
level (called INR) was therapeutic.
.
Please call your primary care physician or cardiologist if you
experience any bleeding, shortness of breath, chest pain, or
other concerning symptoms. You will need a follow up
echocardiogram to assess your heart function and valve function.
.
You will need to take the Lovenox injections once daily until
your Coumadin level (INR) is at goal. You will see Dr. [**First Name (STitle) **] [**Name (STitle) **]
on [**Name (STitle) 2974**] to have your Coumadin level (INR) checked.
.
You were started on Lovenox and should take this until
instructed otherwise.
You were started on a medication called omeprazole for symptoms
of reflux. Please take this for one month and discuss further
with your primary care provider.
No other medications were changed.
Followup Instructions:
Please attend the following appointments:
1) Cardiology: Please follow up with Dr. [**First Name (STitle) **] in the department
of cardiology at an appointment made for you on [**10-5**] at
4:15 PM. The number for Dr.[**Name (NI) 65972**] office is ([**Telephone/Fax (1) 65973**].
Please have them schedule a follow-up ECHO in [**2-24**] weeks for
mitral regurgitation.
2) Primary care provider: [**Name10 (NameIs) 357**] follow up with Dr. [**Last Name (STitle) **] at an
appointment made for you on [**Last Name (LF) 2974**], [**9-20**] at 10:00 AM. You
will need your Coumadin level (INR) checked at that time to
determine whether you should continue the Lovenox injections.
Completed by:[**2171-9-23**]
ICD9 Codes: 412, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6536
} | Medical Text: Admission Date: [**2168-12-29**] Discharge Date: [**2169-1-9**]
Date of Birth: [**2085-12-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Mr. [**Known lastname 76901**] is an 83 y/o M with a
h/o AF not on coumadin, CHF with an EF of 20%, severe AS, RA
(chronic prednisone 5), CKD (baseline Cr around 1.3) and ? COPD
on adviar with who initially presented to [**Hospital1 **] [**Location (un) 620**] on
[**2168-12-26**] after having episodes of painless BRBPR at home. On
[**2168-12-26**] he was admitted to the ICU at [**Hospital1 **] [**Location (un) 620**] and underwent
a colonoscopy that day which showed diverticuli but did not
reveal any active bleeding. On [**12-26**] his HCT dropped from 31.3
to 27.7 and he was give PRBCs. The night of [**12-27**] he had more
BRBPR and his HCT drifted down to 26, but he remained
hemodynamically stable. On [**12-28**] he underwent another
colonoscopy with no localized source of bleeding but did show a
large amount of blood in the colon. Also in the course of the
work up of his GI bleed he underwent a CTA of his abdomen on
[**12-28**] with no active GI bleeding seen. Got total of 7 units PRBC
to maintain Hct ~ 27 throughout his stay at [**Hospital1 18**], Surgery was
also consulted who agreed with the CTA and recommended a
transfer to [**Hospital1 18**] if the family wished to pursue a further work
up or aggressive treatment such as angio for embolization or
surgical resection. Prior to transfer he past 400 mL BRBPR with
associated clots. He reports [**2-7**] bowel movements per day.
.
Also during his stay at [**Hospital1 **] [**Location (un) 620**] given his history of
systolic heart failure and murmur heard on exam he had an
echocardiogram which showed an improvement in his EF to 55%, but
significantly worsening of his aortic stenosis. He notes some
shortness of breath with exertion at baseline but notes he
mobility is limited by his RA and not breathing. His AS was
previously characterized as mild but was found to be severe with
a valve area of 0.8 to 1.0 cm2.
.
On the floor patient comfortable denying any chest pain,
shortness of breath, fever, chills, night sweats, diarrhea,
constipation or vomiting. Does not chronic arthralgias due to
RA.
.
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 rashes or skin changes.
Past Medical History:
Severe AS (valve area 0.8 to 1.0)
Chronic Systolic CHF EF of 55%
Atrial Fibrillation off coumadin
Rheumatoid Arthritis
Chronic Kidney Disease
Social History:
Lives at home with his wife, denies any tobacco, drinks [**2-7**]
bottle of whiskey per week
Family History:
Maternal aunt with [**Name2 (NI) **], father with DM, no family history of
heart or valvular disease
Physical Exam:
ADMISSION EXAM
Vitals: T: 96 BP:123/67 P: 97 R: 18 O2: 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregularilty irregular, normal S1 + S2, III/VI systolic
murmur heard best at RUSB with radiation to the carotids
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, brisk capillary refill. Joint swelling in the MCPs, PIPs
bilaterally as well as bilateral feet consistent with RA. +
Rheumatoid nodules.
DISCHARGE EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mmm, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: irregular rate and rhythm, normal S1 + S2, [**4-10**] mid peaking
systolic murmur heard best at RUSB, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses. Joint swelling in the MCPs,
PIPs bilaterally as well as bilateral feet consistent with RA. +
Rheumatoid nodules. Left shoulder has dressing covering it,
incision C/D/I. Edema and bruising in left arm improved. Good
passive ROM of upper extremity joints with minimal pain, active
ROM improving.
Neuro: A&Ox3
Pertinent Results:
ADMISSION LABS
[**2168-12-29**] 03:30PM BLOOD WBC-11.8* RBC-3.81* Hgb-11.9* Hct-32.8*
MCV-86 MCH-31.2 MCHC-36.2* RDW-15.5 Plt Ct-145*
[**2168-12-29**] 03:30PM BLOOD Neuts-85.0* Lymphs-9.2* Monos-5.3 Eos-0.3
Baso-0.2
[**2168-12-29**] 03:30PM BLOOD PT-14.0* PTT-33.1 INR(PT)-1.2*
[**2168-12-29**] 03:30PM BLOOD Glucose-85 UreaN-20 Creat-1.1 Na-133
K-4.1 Cl-102 HCO3-21* AnGap-14
[**2168-12-29**] 03:30PM BLOOD ALT-10 AST-14 LD(LDH)-139 AlkPhos-62
TotBili-4.4*
DISCHARGE LABS
[**2169-1-9**] 06:07AM BLOOD WBC-6.7 RBC-3.29* Hgb-10.0* Hct-30.4*
MCV-92 MCH-30.5 MCHC-33.0 RDW-14.9 Plt Ct-322
[**2169-1-9**] 06:07AM BLOOD Glucose-81 UreaN-16 Creat-0.9 Na-138
K-3.7 Cl-104 HCO3-26 AnGap-12
[**2169-1-9**] 06:07AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.4*
.
CARDIAC ENZYMES
[**2168-12-29**] 03:30PM BLOOD CK-MB-2 cTropnT-<0.01
[**2168-12-30**] 04:04AM BLOOD CK-MB-2 cTropnT-0.02*
.
Digoxin level
[**2168-12-29**] 03:30PM BLOOD Digoxin-1.2
[**2168-12-31**] 03:07AM BLOOD Digoxin-0.9
[**2169-1-9**] 06:07AM BLOOD Digoxin-0.9
.
Vancomycin level
[**2169-1-4**] 09:10PM BLOOD Vanco-26.3*
[**2169-1-6**] 07:35PM BLOOD Vanco-23.9*
[**2169-1-7**] 06:23PM BLOOD Vanco-21.1*
Misc
[**2169-1-6**] 05:51AM BLOOD CRP-81.6*
[**2169-1-6**] 05:51AM BLOOD ESR-45*
IMAGING:
[**12-29**] TTE:
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
[**1-2**] CXR:
Lungs are clear. Heart size is normal, although the
configuration suggests
right atrial enlargement. Lungs are clear and there is no
pleural effusion.
[**1-2**] Left shoulder xray:
IMPRESSION: Degenerative changes in the AC and glenohumeral
joints but no
evidence of dislocation or fracture.
[**1-3**] CT abd/pelvis:
1. Small right pleural effusion with adjacent atelectasis.
2. Distal pancreatic ductal dilitation concerning for stricture.
Recommend
ERCP for further evaluation.
3. Colonic diverticulosis without diverticulitis.
4. Ectasia of the infrarenal abdominal aorta.
5. Near complete loss of L1 vertebral body height, new since
[**2162**] with
associated disc extrusion. No evidence of discitis.
6. Bilateral renal cysts.
[**1-4**] CXR:
FINDINGS: As compared to the previous radiograph, there is a
very subtle
newly appeared parenchymal opacity at the right lung base.
Simultaneously,
there is persistent peribronchial thickening at the left lung
base. Overall, the changes could reflect chronic aspiration or
early pneumonia
[**1-7**] ECHO:
The left atrium is dilated. The right atrium is moderately
dilated. The estimated right atrial pressure is 0-5 mmHg. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF 70%). Right ventricular chamber size
and free wall motion are normal. The aortic arch is mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. .
.
MICRO:
[**1-2**] blood cultures negative
[**1-3**] shoulder joint culture - 4+ PMNs, no growth on culture.
Brief Hospital Course:
PRIMARY REASON for ADMISSION
83 y/o M with a h/o AF not on coumadin, CHF with an EF of 20%,
severe AS, RA (chronic prednisone 5), CKD (baseline Cr around
1.3) and ? COPD on advair who initially presented to [**Hospital1 **] [**Location (un) 620**]
with BRBPR 7 likely [**3-9**] to a sigmoid diverticular bleed,
transferred to [**Hospital1 18**] for further management. Diverticular
bleed self-resolved, however course was complicated by septic
arthritis of the shoulder.
ACTIVE ISSUES BY PROBLEM:
# Lower GI bleed: Patient transferred from BIDN with a continued
GI Bleed without localized source. Colonoscopy at [**Location (un) 620**] were
suggestive of bleeding from sigmiod diverticuli. CTA did not
show active bleeding. Patient was transferred for potential IR
vs surgical intervention. On admission to the [**Hospital Unit Name 153**] patient was
noted to be hemodynamically stable. HCT was monitored and
remained statble between 28 and 30. He had received a total of
7 units of PRBCs at [**Location (un) 620**] and did not require further
transfusion while in the ICU. GI was consulted and recommended
IR procedure should bleeding recur. Patient was noted to be
intermittently hypotensive with SBPs
in the 70s which responded to bolus IVFs with improvement to the
90s-100s. He had no further episodes of bloody bowel movements
while in the ICU and was transferred to the medicine floor. His
bleeding then self-resolved with no further interventions.
Transfused a total of 2 units PRBCs during his stay.
# Septic arthritis: Patient triggered on [**1-2**] for fever to
103.7 axillary, WBCs rising, developed hypotension requiring
transfer to the MICU. Began complaining of shoulder pain, so
joint was aspirated by orthopedic surgery. Found to have likely
septic arthritis of left shoulder joint-- 122K WBCs on joint
aspiration and frank pus on washout, however no organisms on
gram stain and no growth yet on cultures. Cannot completely
rule out crystal disease because there was not enough specimen
for crystal analysis. Taken to OR on [**1-3**] for washout with no
complications, started on ceftriaxone and vancomycin. His
shoulder began to improve clinically at this point. ID was
consulted, recommended repeat TTE to rule out vegetations
(negative) and course of 4 weeks ceftriaxone 1g q24hours
(through [**1-31**]). A PICC was placed for outpatient abx
administration, and he will have weekly safety labs during his
abx therapy.
#Afib- Patient has a known history of afib on digoxin qod at
home, however level noted to be low on admission so digoxin
increased to [**Month/Year (2) 24018**]. He was noted to be intermittently
tachycardic with RVR to 170s when OOB, though he remained
asymptomatic at these times. He was started on metoprolol for
his frequent RVR, to be continued at rehab with close
monitoring.
# Diastolic CHF: Echo at OSH with EF of 55%, LVEF confirmed on
echo here with evidence of grade 1 diastolic dysfunction. Was
taking PRN lasix at home, however this was held initially given
transient hypotension. He had no evidence of fluid retention,
so this medication was not restarted and is not being continued
on discharge.
# Aortic stenosis: Last echo in [**2166**] showed mild AS, however
echo on this admission shiwed EF 55%, severe AS (valve area
0.8-1.O cm2), LVH, 1+ MR/TR. Notes he has some dyspnea on
exertion, but he denies any syncope or angina. Fluid status was
carefully monitored throughout his stay, given his AS.
# Acute renal failure: Creatinine at [**Location (un) 620**] was 1.4 on
admission. This was felt to likely be pre-renal in nature.
Creatinine improved to 1.1 with admistration of blood products
and remained stable throughout the remainder of his hospital
course.
# Elevated troponin and EKG changes: Patient was noted to have
elevated troponin elevation at OSH felt to be possibly [**3-9**]
demand ischemia with non specific EKG changes. ACS was felt to
be unlikely given patient remained symptom free with negative
troponin x 2 and normal CK MB.
.
# Rheumatoid arthritis: Patient was continued on home
prednisone. He was given tylenol for pain in place of his home
aleve.
.
TRANSITIONAL ISSUES
- Digoxin: changed dosing to [**Last Name (LF) 24018**], [**First Name3 (LF) **] need to have level
checked at next PCP visit
[**Name Initial (PRE) **] Septic shoulder: follow up appt made with surgeon on [**1-19**]
for follow up of I&D
- Will need to have weekly safety labs (CBCw/diff, CMP, ESR/CRP)
drawn while taking ceftriaxone, fax results to [**Hospital **] clinic at
[**Telephone/Fax (1) 1419**]. First due: [**1-16**]
- Pancreatic mass: incidentally found on CT, will need further
evaluation with if more work up is desired. Pt aware, family not
currently interested in pursuing.
Patient was DNR/DNI throughout this hospitalization
.
Pending results:
acid fast culture from shoulder joint.
Medications on Admission:
Home Medications (confirmed w/wife [**2168-12-31**]):
Lasix [**2-7**] 20 mg tablets QD
Prednisone 5 mg 1 tablet PRN (QD recently)
Digoxin 0.125 mg QOD
Advair 250-50 1 puff [**Hospital1 **]
ASA 81 mg QD
Aleve 2 tabs qAM PRN
Omeprazole 20 mg PRN
Potassium 20 mEq PO QD
Acidophilus 1 tab QD
(metoprolol stopped 2 years ago)
.
Medications on Transfer:
Magnesium Sulfate 2g IV daily
Advair 1 puff [**Hospital1 **]
Prednisone 5mg daily
Nexium 40mg daily
Digoxin 0.125mg daily
Vitamin B12 1000mcg daily
Colace prn
Zofran prn
Acetaminophen prn
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Please hold for SBP <100, HR <60.
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 22 days:
Please continue through [**2169-1-31**].
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Lower GI bleed
Septic arthritis
Atrial fibrillation with rapid ventricular response
Rheumatoid arthritis
Aortic stenosis
Pancreatic mass
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 76901**],
You were transferred to [**Hospital1 18**] due to rectal bleeding. You
stayed briefly in the ICU, but your bleeding slowed down
significantly and you were transferred to the medicine floor.
We believe your bleeding was due to diverticuli (small
out-pouchings) in your colon, many of which will stop bleeding
on their own like yours.
While you were here, you developed severe left shoulder pain and
fevers and were found to have an infection of the joint. You
were taken to the operating room for the surgeons to open up
your shoulder and clean it out. You will need to keep taking
intravenous antibiotics until [**1-31**] to fully treat this
infection. Physical therapy to improve your shoulder mobility
will also be important.
Changes to your medications:
STOP furosemide 20-40 mg daily
STOP potassium
INCREASE digoxin 125 mcg to daily (instead of every other day)
START ceftriaxone 1g every 24 hours through [**1-31**]
START metoprolol 12.5 mg twice daily
START oxycodone 2.5 mg tabe every 4 hours as needed for pain
START acetaminophen 650mg three times a day
START senna 8.6mg tab twice daily
START docusate 100mg twice daily
START bisacodyl 10mg daily as needed for constipation
Followup Instructions:
Department: ORTHOPEDICS
When: THURSDAY [**2169-1-19**] at 12:20 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2169-1-19**] at 12:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2169-1-25**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 0389, 2851, 5849, 4241, 4280, 5859, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6537
} | Medical Text: Admission Date: [**2110-3-31**] Discharge Date: [**2110-4-6**]
Date of Birth: [**2035-5-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Elective cardiac surgery
Major Surgical or Invasive Procedure:
3/1008 - CABGx2(Vein->Obtuse marginal, Vein->Posterior Left
Ventricular Branch); PFO Closure; AVR(21mm St. [**Male First Name (un) 923**] Epic Porcine
Valve)
History of Present Illness:
74 year old female who is currently asymptomatic who has been
followed the last 2 years for aortic stenosis. Her most recent
echo showed severe AS with an aortic valve area of 0.5cm2. She
is now admitted for surgical management.
Past Medical History:
AS
PFO
CAD
Hyperlipidemia
HTN
CVD
Social History:
Retired microbiologist. Never smoked. Denies drinking alcohol.
Lives with Husband and oldest son.
Family History:
Father died of stroke.
Physical Exam:
Admission
VS: HR 78 BP 162/77 RR 14 HT 62" WT 175lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM.
LUNGS: CTA bilaterally
HEART: RRR, III-IV/VI holsystolic murmur
ABD: Soft, ND/NT/NABS
EXT:warm, well perfused, no bruits, no varicosities, no
peripheral edema, pulses [**1-22**]+ peripherally. No carotid bruit
appreciated.
NEURO: No focal deficits.
Discharge
Pertinent Results:
[**2110-4-1**] CXR
The ET tube tip is 5.3 cm above the carina. The NG tube tip is
in the stomach. The Swan-Ganz catheter tip currently terminates
in right interlobar pulmonary artery. The patient is after
removal of chest tube and mediastinal drains. There is no
pneumothorax or increasing pleural effusion is identified.
Bibasilar left more than right atelectasis is unchanged.
[**2110-3-31**] ECHO
PRE-CPB:1. The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No spontaneous echo contrast or thrombus is
seen in the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium. No spontaneous echo contrast or thrombus is seen in the
body of the right atrium or the right atrial appendage.
2. A patent foramen ovale is present. A left-to-right shunt
across the interatrial septum is seen at rest.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal for the patient's body
size. Overall left ventricular systolic function is normal
(LVEF>55%). Transmitral Doppler and tissue velocity imaging are
consistent with Grade III/IV (severe) LV diastolic dysfunction.
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is
seen.
7. Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened.
8. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of phenylephrine. Well-seated
bioprosthetic valve in the aortic position. Mild residual
stenosis, no paravalvular leak. Atrial septum intact without
visible shunt. Biventricular systolic function is preserved.
Aortic contour is normal post decannulation.
[**2110-3-31**] 01:28PM UREA N-8 CREAT-0.3* CHLORIDE-119* TOTAL
CO2-20*
[**2110-3-31**] 01:28PM WBC-28.1*# RBC-3.52*# HGB-9.8* HCT-29.3*#
MCV-83 MCH-28.0 MCHC-33.6 RDW-14.2
[**2110-3-31**] 01:28PM PLT COUNT-195
[**2110-3-31**] 01:28PM PT-15.7* PTT-37.7* INR(PT)-1.4*
[**2110-3-31**] 12:57PM FIBRINOGE-197
[**2110-4-6**] 06:45AM BLOOD WBC-19.2* RBC-3.03* Hgb-8.8* Hct-26.7*
MCV-88 MCH-28.9 MCHC-32.9 RDW-16.1* Plt Ct-428
[**2110-4-6**] 06:45AM BLOOD PT-32.2* INR(PT)-3.3*
[**2110-4-5**] 06:10AM BLOOD PT-34.6* INR(PT)-3.6*
[**2110-4-4**] 05:00AM BLOOD PT-17.3* PTT-26.0 INR(PT)-1.6*
[**2110-4-5**] 06:10AM BLOOD UreaN-22* Creat-0.8 K-4.0
CHEST (PA & LAT) [**2110-4-4**] 10:04 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
74 year old woman s/p AVR/CABG/PFO closure
REASON FOR THIS EXAMINATION:
eval for pleural effusions
REASON FOR EXAMINATION: Followup of a patient after aortic valve
replacement, CABG and patent foramen ovale closure.
PA and lateral upright chest radiograph compared to [**2110-4-1**].
Patient was extubated in the meantime interval with removal of
the NG tube and Swan-Ganz catheter. The moderate cardiomegaly is
stable. The bibasal opacities are consistent with post-surgical
atelectasis, improved. Small amount of pleural effusion is
demonstrated, bilateral. There is no evidence of failure. There
is no pneumothorax.
Brief Hospital Course:
Mrs. [**Known lastname 78151**] was admitted to the [**Hospital1 18**] on [**2110-3-31**] for
surgical management of her aortic valve and coronary artery
disease. She was taken directly to the operating room where she
underwent coronary artery bypass grafting to two vessels, and
aortic valve replacement with a 21mm St. [**Male First Name (un) 923**] Epic Porcine valve
and a PFO closure. Please see operative note for details.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mrs.
[**Known lastname 78151**] awoke neurologically intact and was extubated. She
awoke mildly confused but slowly cleared mentally. She was
transfused with two units of packed red blood cells for
postoperative anemia. Mrs. [**Known lastname 78151**] developed atrial
fibrillation for which amioadrone and coumadin was started. On
postoperative day two, she was transferred to the step down unit
for further recovery. Beta blockade, aspirin and a statin were
resumed. She was gently diuresed towards her preoperative
weight. The physical therapy service was consulted to assist
with her postoperative strength and mobility. She became
confused and was pancultured given her WBC of 20. Her INR rose
quickly to 3.6. Her confusion improved and her INR stabilized
and she was ready for discharge home on POD #6.
Medications on Admission:
Vasotec 5mg [**Hospital1 **]
Aspirin 81mg QD
Lipitor 10mg QD
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
for 7 days, then decrease to 200 mg daily until d/c'd by
cardiologist.
Disp:*90 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: then as directed by Dr. [**Last Name (STitle) 58623**].
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
CAD/AS/ASD s/p AVR(21mm Porcine), PFO closure, CABGx2 [**2110-3-31**]
HTN
Hyperlipidemia
PVD
AF
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 40149**] in 2 weeks. ([**Telephone/Fax (1) 78152**]
Follow-up with Dr. [**Last Name (STitle) 58623**] in 1 week. [**Telephone/Fax (1) 58624**]. Coumadin
will be followed by the office of Dr. [**Last Name (STitle) 58623**] and INR should be
drawn on Monday [**2110-4-7**] and then called to her office. Plan
confirmed with Dr. [**Last Name (STitle) 58623**].
Please call all providers for appointments.
Completed by:[**2110-4-8**]
ICD9 Codes: 4241, 2724, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6538
} | Medical Text: Admission Date: [**2187-9-30**] Discharge Date: [**2187-10-8**]
Date of Birth: [**2119-12-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
UGIB, ?infection
Major Surgical or Invasive Procedure:
ERCP
Messenteric catheterization +/- embolization
History of Present Illness:
This is a 67 y.o male with h.o metastatic RCC to the pancreas,
recent ICU course for UGIB (12units pRBCs) who reports sudden
intermittent chills since wednesday for which he took tylenol.
Pt also reports R.side gnawing rib pain, while lying in bed
before the onset of chills. In addition, pt reports dark stools
for the last few days which started after taking "iron pills".
Pt states he went to [**Hospital1 2436**] ED because of a fever of 101.3,
however he felt better and did not want to wait to be seen. He
returned to [**Hospital1 2436**] today and was transferred to [**Hospital1 18**] after
a dose of zosyn, HCT 25. Pt denies headache/dizziness/blurred
vision, URI/cough, sick contacts, CP, +palp when anxious, -abd
pain/n/v/d/brbpr, dysuria/hematuria, joint pain, rash,
paresthesias.
.
At [**Hospital1 18**], pt found to be hypotensive to 75/40, asymptomatic. He
was given 3L IVF, lactate 6.8. HCT 22.8 from a baseline of 35 a
few weeks ago. He was found to have black, guaiac +stool. GI saw
pt, pt s/p stent to pancreatic ampulla, ?blocked from blood.
Plan is to transfuse, ERCP tomorrow. ED also treated for
possible cholangitis/sepsis and pt was given dose of vanco.
Vitals 99.2, BP 99/66 HR 88 sat 98% on RA. Access 3PIV's 2,
20's, 18. Pt also found to be in ARF.
.
Currently, pt reports that he is anxious.
.
Past Medical History:
# GIB [**2184**], EGD revealed duodenal ulcer c/w malignancy
# Hypertension.
.
1. Status post left nephrectomy followed by high-dose IL-2
[**2166**].
2. LAK therapy in [**2167**].
3. st. post resection of residual renal bed mass in [**2168**]
4. Recurrence in the left renal fossa and pancreas in [**4-/2182**]
5. Low-dose interleukin-2 in 12/[**2181**].
6. Atrasentan medication trial 11/[**2181**].
7. initiated on Nexavar 400 mg twice daily, dose reduced on
10/1005 in the setting of hypertension. His course has been
complicated by a GI bleed with possible small bowel obstruction,
and an admission to [**Hospital3 **] in [**8-/2185**] for anemia
and acute renal failure while on full dose Nexavar 400 mg given
twice daily.
8. Nexavar dose reduced to 400 mg q.a.m., 200 mg q.p.m.
9. Nexavar dose increased to 400 mg b.i.d. following CT in
[**9-/2186**], which showed progression of pancreatic metastases.
10. Enrolled in perifosine trial 06-408 on [**2187-2-28**].
11. Perifosine held since [**2187-6-13**] due to GI bleed.
12. ERCP on [**2187-6-20**] showed a malignant appearing mass in
duodenum, pathology consistent with metastatic renal cell Ca.
13. Perifosine restarted [**2187-6-27**] for one week, held on [**7-4**] due
toSBO requiring hospital admission in [**Hospital3 2783**], and
restarted again on [**7-11**].
14. Perifosine held due to elevated LFTs on [**2187-7-25**].
15. ERCP on [**2187-8-3**] - biliary stent placed to proximal CBD.
.
Social History:
He is married and has two children. He is retired from GM.
Reports quit smoking [**2186-11-21**], former 1/2ppd, quit ETOH as well in
[**Month (only) **], no drug use
Family History:
Non-contributory
Physical Exam:
Per admission note:
vitals:T. 96.9, BP 102/65, HR 92, RR 27, sat 96% on RA
gen-nad, lying in bed, appears stated age, cooperative, anxious
HEENT-perrla, eomi, anicteric, mmm, poor dentition
neck-no lad, no JVD, supple
chest-b/l ae no w/c/r
heart-s1s2 +2/6 systolic flow murmur, no r/g
abd-+bs,soft, NT, ND, +irregular hepatomegaly, ~2cm below costal
margin, +abdominal masses
ext-no c/c/e 2+pulses
neuro-aaox3, CN2-12 intact, non-focal.
.
Pertinent Results:
[**2187-9-30**] 07:36PM WBC-5.1 RBC-2.82*# HGB-7.5*# HCT-22.8*#
MCV-81* MCH-26.6* MCHC-32.8 RDW-18.1*
[**2187-9-30**] 07:36PM NEUTS-73* BANDS-14* LYMPHS-9* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2187-9-30**] 07:36PM PLT SMR-NORMAL PLT COUNT-142*
.
[**2187-9-30**] 07:36PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-1+ BURR-1+
.
[**2187-9-30**] 07:36PM PT-15.6* PTT-35.0 INR(PT)-1.4*
.
[**2187-9-30**] 07:36PM GLUCOSE-78 UREA N-28* CREAT-1.6* SODIUM-141
POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-13* ANION GAP-22*
[**2187-9-30**] 07:36PM ALT(SGPT)-59* AST(SGOT)-59* LD(LDH)-181
CK(CPK)-14* ALK PHOS-513* TOT BILI-2.5*
[**2187-9-30**] 07:36PM LIPASE-12
.
[**2187-9-30**] 07:36PM cTropnT-<0.01
[**2187-9-30**] 07:36PM CK-MB-NotDone
.
TRENDS:
HCT: Admit -> 23, 27, 22, 25, 27, 34, 28, 27, 26, 22, 28
.
Bands on Diff: Admit -> 14, 10, 7, 0
.
[**2187-9-30**] 07:42PM BLOOD Lactate-6.8*
[**2187-10-1**] 02:52AM BLOOD Lactate-4.8*
[**2187-10-1**] 05:30AM BLOOD Lactate-3.3*
[**2187-10-1**] 02:22PM BLOOD Lactate-1.8
.
ECG:sinus, poor baseline, similar morphology to [**2187-8-21**] EKG.
.
Imaging:
CXR: [**2187-9-30**]:
Added density behind the left heart border in the left lower
lobe may
represent a focus of pneumonic consolidation; alternatively
metastases from the known metastatic renal cell cancer cannot be
entirely excluded. CT would be of benefit for further
evaluation.
A CBD stent is seen in the upper abdomen.
.
Liver U/S [**2187-9-30**]:
Increase in size and number of hepatic mets. CBD or stent not
seen. Small perihepatic ascites. Portal vein remains occluded
with numerous collaterals. Gallladder wall thickening and edema
but no focal tenderness during scanning. Large hypoechoic mass
in the region of the pancreatic head not well assessed due to
overlying bowel gas.
"findings equivocal for cholecystitis, stones"
.
[**2187-10-1**] ERCP/Biliary:
IMPRESSION:
1. No filling defects within previously placed metallic common
bile duct
stent.
2. Smooth impression on the common bile duct, proximal to stent,
suggests
extrinsic compression. Correlate with real-time findings.
Please refer to GI procedural note for further details.
.
[**2187-10-3**] MESSENTERIC CATHETERIZAION +/- EMBOLIZATION:
***Prelim Report***
Gastrointestinal arteriograms demonstrated massive tumor
staining from
multiple feeding arteries originating from celiac artery,
superior mesenteric artery, and isolated pancreatic artery
without active ______.
Brief Hospital Course:
67 y.o male with metastatic RCC who presents with HCT drop,
melena, recent fever, hypotension.
.
#melena/HCT drop - Pt has h.o GIB in past that were secondary to
bleeding metastasis. Pt had recent admit to MICU course [**7-30**]
where angiography was performed to stop bleeding. Hct on admit
was 22.8, down from 35 on discharge. Patient underwent ERCP in
which showed ulcerated mass at duodenum, able to temporarily
stem blood flow. On day 3 of ICU stay he had more melena and was
taken by IR for messenteric catheterization +/- embolization,
but were unable to isolate source of bleeding. Melena continued
and ERCP, IR and surgery say pt is not eligible for further
interventions to stop the bleeding.
.
Pt continued to be transfused units of PRBC while H/H was being
followed. This was consistent with patient's stated goals of
living long enough to make it to hospice care, where he can be
closer to family.
.
# Infection - Pt with fever, normal white count but with
bandemia, recent RUQ/rib pain. Slightly elevated LFT's, elevated
bili -> RUQ u/s finding gallbladder wall thickening and edema,
"possible cholecystitis". Potentially transient cholangitis. Pt
completed a total of 7 days of Vancomycin and Pip/Tazo.
.
# Metastatic RCC - Pain controlled. Heme met with family offered
chemo for one final round but with the caution that this could
make the duodenal met bleed faster. The patient and family did
not want to pursue this.
.
# Lactic acidosis - likely from poor perfusion secondary to
recent hypotension and infection. Could also be secondary to
metastatic disease. Resolved within 2 days.
.
#ARF - baseline 0.9-1.0, admitted at 1.6. Likely prerenal in the
setting of hypotension, hypovolemia. Resolved with hydration.
.
#HTN-currently normotensive, hold home anti-HTN medications.
.
# Anxiety
- receiving scheduled ativan per pt request.
.
# Thrombocytopenia:
- PLT count now improving
- no heparin d/t bleed
- HIT Ab negative
- Transfused prn for bleeding
.
CODE: DNR/DNI
DISPO: discharged to hospice care:
[**Last Name (un) 1502**] Family Hospice House - [**Location (un) **]. [**Telephone/Fax (1) 21227**]
Medications on Admission:
allopurinol 100mg,2 tabs daily
atenolol 50mg daily
diltiazem 180mg, 2 capsules daily
nexium 40mg daily
lisinopril 40mg daily
lorazepam 0.5mg 1-2tabs q6h prn anxiety
compazine 5mg 1-2tab [**Hospital1 **] nausea
acetaminophen 500mg [**11-22**] Q6h prn
ferrous sulfate 325mg 1 daily.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
4. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1502**] Family Hospice House [**Location (un) **]
Discharge Diagnosis:
# Gastrointestinal bleed; ongoing
# Cholecystitis/Cholangitis
# Metastatic renal cell carcinoma
# Acute renal failure; resolved
# Thrombocytopenia
Discharge Condition:
poor; dying.
Discharge Instructions:
Patient is being discharged to hospice.
Please take medications as necessary for patient comfort.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-10-17**] 3:30
Provider: [**Name10 (NameIs) 11021**] [**Name11 (NameIs) 11022**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-10-17**] 3:30
ICD9 Codes: 5849, 2762, 5789, 2851, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6539
} | Medical Text: Admission Date: [**2177-4-25**] Discharge Date: [**2177-4-28**]
Date of Birth: [**2108-5-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
nausea, vomiting, decreased PO intake
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname **] is a 68 year old male with past history of
asthma/COPD and hypertension transferred from the MICU for
continued treatment of Acute Renal Failure.
.
Per the patient had been in USOH on Saturday evening at a
relatives house having dinner when developed acute onset nausea
and vomiting on Sunday morning. He cites that nausea and
vomiting peaked on Saturday and Sunday with roughly
2-3episodes/day. From Sunday to presentation to the ED developed
progressive lethargy and noted decreased to zero UOP from Sunday
to Thursday. feeling lethargic.
.
Pertinent +/-
Denies fevers, chills, night sweats, sick contacts, recent
travel, EtOH use, abdominal pain or distension, diarrhea,
constipation, chest pain, myalgias.
.
Progressive lethargy and confusion noted by family prompted
presentation to the ED.
.
In the ED, triggered on presentation for hypotension of 67/31.
Recieved 3L NS with improvment in BP to 110/70's. NG lavage
negative, guiac positive. Labs notable for acute renal failure
with creatinine 7.5 (baseline 1.5) and BUN 123. LFTS WNL, HCT
50.4. Admitted to MICU for hypotension and concern for GI bleed.
Vitals prior to transfer, 96 110/60 17 100% on 2L.
.
MICU course:
Received 3L of IVF; lisinopril and diuretic held. Mental status
cleared with hydration and creatinine improved from 5.6 -> 3.3
(baseline 1.5) with increased UOP. Of note though guaiac +; HCT
stable in house.
.
Prior to transfer to the floor patient with minimal complaint.
.
ROS at time of transfer:
Denies fevers, chills, sweats, anorexia, headache, vision
changes, abdominal pain, chest pain, palpitation, abdominal
pain, dysuria, flank pain, myalgias.
Past Medical History:
1. Asthma/COPD/bronchiectasis. - FVC 122% predicted, Lung
volumes >100% predicted, DLCO ~70% predicted
2. Pulmonary nodules.
3. Hypertension.
4. Chronic renal insufficiency with creatinine 1.5.
5. History of eosinophilia.
6. Vitamin D deficiency.
Social History:
Formerly worked at [**Hospital1 **] as chef.
Lives with wife; retired
Tobacco: smoked for about 20 years and quit 25 years ago.
EtoH: denies current use
Remote h/o drug abuse
Family History:
No history of GI pathology; no h/o malignancy
Physical Exam:
68 year old male with history of asthma/COPD, hypertension,
chronic kidey insufficiency admitted to the MICU for management
of acute kidney injury and hypotension in setting of 4 days
nausea, vomiting and decreased PO intake..
# Hypotension. Etiology likely hypovolemic in the setting of
nausea, vomiting and limited PO intake in days preceding
hospitalization. Alternative etiolgies entertained on admission
included hypotension secondary to septic shock, secondary to GI
bleed. Regarding potential for infection patient afebrile in
house with WBC wnl and without complaints of localized
infection. GI bleed on presenting differential as pt Guaiac
positive on admission, however patients HCT remained stable
after dilutional drop. Patient received total of 7L of IVF with
improvement in hemodynamics. Nausea resolved quickly after
admission and patient able to take in adequate PO prior to
discharge. Decision made to hold anti-hypertensives to time of
discharge with plan to likely re-implement after post-discharge
appt.
OUTPATIENT:
-- Continue to monitor hemodynamics
-- Re-initiate anti-hypertensives at [**Hospital 1944**] clinic after
both BP and renal function monitored.
.
# Acute on Chronic Renal Failure. Baseline creatinine 1.5.
Creatinine on Admission 7.5 -> 5.5 ->3.3 in the setting of IVF.
Etiology likely pre-renal in setting of decreased PO intake,
emesis as function has improved markedly with hydration. Urine
lytes: FeNa: 3.4 consistent with pre-renal -> ATN. Patient with
adequate urine output throughout stay so low clinical suspicion
for obstructive component. At time of discharge, creatinine 1.3;
decision made to hold lisinopril and HCTZ until renal function
monitored and stabilization ensured.
OUTPATIENT ISSUES
-- Repeat chemistry 7 as outpatient to monitor renal functino
-- Continue to hold lisinopril and HCTZ until repeat lab values
obtained.
# Persistent nausea, vomiting. Admission differential diagnosis
to Nausea/Vomiting broad with consideration of underlying
Cardiac, Neurologic, Hepatic, Gastric, Renal and Pancreatic
pathology. After work-up surmised that viral gastroenteritis was
likely causative factor for nausea, vomiting. Regarding
alternative diagnosis: LFTs wnl, Lipase 66. Patient without
overt cardiac history (only RF is HTN, HL), EKG without ischemic
changes and though admission Trop elevated it was in setting of
creatinine of 7.5. Cerebellar ischemia can manifest as n/v and
patient does describe gait unsteadiness but less likely than
viral gastroenteritis especially as patients neuro exam is
intact. It was possible that ARF preceded emesis and uremia
incited nausea/emesis however the fact ARF improved so rapidly
with IVF argues against intrinsic or post-renal etiology. During
hospitalization, anti-emetics were used as needed; nausea
resolved and prior to discharge patient tolerated full diet
without nausea, vomiting, abdominal pain.
#. Guaiac Positive Stool. On admission to the ED, rectal exam
guaiac + with initial concern for UGIB in setting of
hypotension. Subsequent NG Lavage negative. Hct hemoconcentrated
on admission; did downtrend in setting of aggressive IV
hydration which was attributed to dilution. Patient was started
on pantoprazole 40 mg [**Hospital1 **]. In house, patient did report one
black bowel movement in house however HCT remained stable and
decision made to work-up question of GI bleed as outpatient with
potential EGD/colonoscopy. Of note patient with last colonscopy
in [**2174**] which demonstrated diverticular disease as well as cecum
and sigmoid polyps s/p polypectomy (cecum path: fragments of
adenoma; sigmoid path: hyperplastic tissue).
OUTPATIENT ISSUES:
-- Continue PPI and enteric coated aspirin
-- Consider need for outpatient work-up: EGD, colonscopy.
.
#. COPD. Patient without respiratory complaints in house. Exam
demonstrated intermittent wheeze and patient treated with
nebulizers as needed. In house continued on home albuterol,
advair, spiriva and singulair. No need for supplemental oxygen
in house.
Pertinent Results:
On Admission:
[**2177-4-25**] 12:40PM BLOOD WBC-6.0 RBC-5.69 Hgb-16.8 Hct-50.4 MCV-89
MCH-29.5 MCHC-33.3 RDW-13.6 Plt Ct-395#
[**2177-4-25**] 05:19PM BLOOD WBC-5.9 RBC-4.82 Hgb-14.4 Hct-42.6 MCV-88
MCH-29.8 MCHC-33.7 RDW-13.6 Plt Ct-287
[**2177-4-26**] 04:24AM BLOOD WBC-4.2 RBC-4.31* Hgb-12.9* Hct-37.8*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.6 Plt Ct-310
[**2177-4-25**] 12:40PM BLOOD Neuts-50.6 Lymphs-38.7 Monos-7.7 Eos-1.0
Baso-2.1*
[**2177-4-25**] 12:40PM BLOOD PT-13.2 PTT-26.2 INR(PT)-1.1
[**2177-4-25**] 12:40PM BLOOD Glucose-129* UreaN-123* Creat-7.5*#
Na-135 K-7.4* Cl-98 HCO3-17* AnGap-27*
[**2177-4-25**] 05:19PM BLOOD Glucose-100 UreaN-109* Creat-5.6*# Na-140
K-5.3* Cl-107 HCO3-18* AnGap-20
[**2177-4-26**] 04:24AM BLOOD Glucose-100 UreaN-87* Creat-3.3*# Na-141
K-5.2* Cl-111* HCO3-19* AnGap-16
[**2177-4-25**] 12:44PM BLOOD Glucose-122* Lactate-2.5* Na-138 K-5.4*
Cl-103 calHCO3-15*
[**2177-4-25**] 05:29PM BLOOD Lactate-1.9
[**2177-4-25**] 02:49PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2177-4-25**] 02:49PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2177-4-25**] 02:49PM URINE RBC-2 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
[**2177-4-25**] 04:34PM URINE Hours-RANDOM Creat-125 Na-107 K-19 Cl-81
.
On Discharge [**2177-4-28**] 05:50
.
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
4.4 4.25* 12.5* 36.7* 87 29.5 34.1 13.6 286
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
113 28 1.3 142 4.8 112 19 16
.
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
15 20 53 0.4
.
CXR:
FINDINGS: Single frontal view of the chest is obtained. Lungs
are clear
without focal consolidation. No pleural effusion or pneumothorax
is seen.
Cardiac and mediastinal silhouettes are unremarkable. Please
note that
pulmonary nodules noted on prior chest CT are not as well
appreciated on the current study, as CT is more sensitive, and
recommendations per that study remain.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Mr [**Known lastname **] is 68 year old male with history of asthma/COPD,
hypertension, chronic kidey insufficiency who presented with
acute renal failure and hypotension in the setting of nausea,
vomiting and decreased PO intake x4-5days.
.
# Hypotension. Etiology likely hypovolemic in the setting of
nausea, vomiting and limited PO intake in days preceding
hospitalization. Alternative etiolgies to hypotension on
admission included septic shock in setting of infection,
hypovolemia secondary to GI bleed.Infectious trigger unlikely as
patient afebrile in house with WBC wnl and without complaints of
localized infection. Though GI bleed was on admission
differential as pt guaiac positive on admission, degree of
hypotension on admission would have necessitated brisk bleed
which was not present; bolstered by negative NG lavage. In house
received a total of 7L of IVF with improvement in hemodynamics.
Patient without need for IV hydration in 48hrs preceding
discharge. Decision made to hold anti-hypertensive at time of
discharge with likely re-implementation as an outpatient.
OUTPATIENT ISSUES
-- Continue to monitor hemodynamics
-- Re-initiate anti-hypertensives if pressures stable and renal
function at baseline
.
# Acute on Chronic Renal Failure. Baseline creatinine 1.5.
Creatinine on Admission 7.5 -> 5.5 ->3.3-> 1.5 ->1.3 in the
setting of IVF. Etiology likely pre-renal in setting of
decreased PO intake, emesis as function improved markedly with
hydration. Urine lytes: FeNa: 3.4 consistent with pre-renal
progression to ATN. Patient with adequate urine output
throughout stay making post-obstructive component less likely.
At discharge creatinine 1.3 and decision made to hold HCTZ and
lisinopril at time of discharge until post-discharge labs
ensured stable renal function.
OUTPATIENT ISSUES:
-- Post-discharge monitoring of renal function
-- Re-initiation of lisinopril and HCTZ if hemodynamics and
renal allow
.
# Persistent nausea, vomiting. Admission etiology to
Nausea/Vomiting broad and Cardiac, Neurologic, Hepatic,
Gastric, Renal or Pancreatic pathology in initial differential.
After work-up, surmised viral gastroenteritis likely prompted
n/v. Regarding alternative diagnosis: LFTs wnl, Lipase 66.
Patient without overt cardiac history (only RF is HTN, HL), EKG
without ischemic changes and though Trop elevated it was is in
setting of creatinine of 7.5. Though cerebellar ischemia can
manifest as n/v and patient did cite gait unsteadiness,
diagnosis is less likely than viral gastroenteritis especially
as patients neuro exam remained intact throughout. Though it is
possible that ARF preceded emesis and uremia incited
nausea/emesis the fact ARF improved so rapidly with IVF argued
against intrinsic or post-renal etiology. In house patient
received supportive care with IVF and anti-emetics. Prior to
discahrge tolerated a full diet without nausea, vomiting or
abdominal pain.
.
#. Guaiac Positive Stool. On admission, intially hypotension
concerning for UGIB in setting of guaiac + stool however NG
Lavage negative. Admission patient hemoconcentrated with
dilutional drop after aggressive hydration. HCT monitored daily
and remained stable after hydration. Patient did report one
black stool in house (not saved for inspection). Patient started
on PPI and ASA changed to enteric coated. As HCT stable,
decision made to forego inpatient work-up with plan for likely
GI work-up as an outpatient with potential EGD/C-scope to
evaluate for source of GI bleed. Of note, patient with previous
c-scope in [**2174**] which demonstrated diverticular disease as well
as cecum and sigmoid polyps s/p polypectomy; cecum path:
fragments of adenoma, sigmoid path: hyperplastic.
OUTPATIENT ISSUES:
-- Continue PPI and enteric coated ASA for primary prevention
-- Close follow-up with PCP to discuss future GI work-up
.
#. COPD. Patient without respiratory complaint in house. Did
demonstrate intermittent wheeze on exam that was controlled with
prn nebulizers. Continued on home albuterol, advair, spiriva
and singulair. No need for supplemental O2 in house.
.
Medications on Admission:
Albuterol inhaler 2-4 puffs q6h prn SOB
Albuterol nebulizer q6h prn SOB
Calcitriol 0.25 mcg every other day
Advair 500-50 1 disk ing [**Hospital1 **]
HCTZ 25 qday
Lisinopril 10 mg qday
Montelukast 10 mg qday
Viagra prn
Simvastatin 40 mg daily
Spiriva 18mcg qday
ASA 81 mg daily
Vitamin D 1000 unit daily
Benadryl prn
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every six (6) hours as needed for shortness
of breath.
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours.
8. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Viagra Oral
11. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
12. Outpatient Lab Work
Please have your hematocrit and creatinine checked this week.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Viral Gastrenteritis
Acute Kidney Injury
.
Secondary
Hypertension
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **] it was a pleasure taking care of you.
.
You presented to [**Hospital1 18**] due to progressive nausea, vomiting and
inability to take in food or water by mouth thought secondary to
a viral gastroenteritis. You were severely dehydrated and
subsequently your kidneys were not functioning properly. You
received IV fluids and your kidney function improved and it time
of discharge it had normalized.
.
While hospitalized you were noted to have dark stools with
concern for bleeding in your gastrointestinal tract. Your blood
counts remained stable and there was little concern for active
bleed. It will be important to continue to monitor your bowel
movements after discharge and discuss need for further work-up
with your PCP including potential GI follow and need for imaging
(EGD, colonscopy).
.
CHANGES TO YOUR MEDICATIONS:
Due to your recent episode of low blood pressures:
STOP taking your LISINOPRIL and HYDROCHLOROTHIAZIDE until you
are seen by your PCP.
[**Name10 (NameIs) **] decrease acid production in your stomach:
START taking PANTOPRAZOLE 40mg PO. Take on tablet daily
.
To prevent your stomach for excess irritation:
TAKE BUFFERED ASPIRIN 81mg tablets. Take one daily
.
Again it was a pleasure taking care of you. Please feel free to
contact with any questions or concerns.
Followup Instructions:
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
When: MONDAY [**2177-5-5**] at 10:00 AM
With: Dr [**First Name (STitle) **] [**Name (STitle) **]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular
primary care doctor in follow up.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2177-7-16**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2177-12-8**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2177-4-30**]
ICD9 Codes: 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6540
} | Medical Text: Admission Date: [**2173-11-10**] Discharge Date: [**2173-11-19**]
Date of Birth: [**2124-10-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Quinine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing fatigue
Major Surgical or Invasive Procedure:
[**2173-11-11**] Mitral valve repair with 26 millimeter [**Doctor Last Name 405**] band
History of Present Illness:
This is a 49 yo African - American male with severe MR [**First Name (Titles) **] [**Last Name (Titles) **]
HTN for past 10 years. This has progressed significantly and the
patient has had increasing fatigue. He was referred for MVrepair
vs. replacement and was admitted pre-operatively to the CSRU for
Swan placement. He had dialysis this morning prior to admission.
He has ESRD and is on dialysis for the past 2 years. He is also
anticipating renal transplant in the near future and his wife is
the planned donor. Catheterization prior to this admission
showed elevated RA pressures (17) with PA 92/38, and wedge 40,
CI 1.7, EF 42% with effective EF 29%. He also had global HK,
mod. MR, mod. TR, mild PR.
Past Medical History:
severe MR
[**Last Name (Titles) **]. HTN
CHF
HTN
IDDM
mild GERD
ESRD ( on HD 2 years)
s/p R index finger amp.
? eye surgery
Social History:
Mmarried. No ETOH/tobacco/drugs
Family History:
No premature CAD
Physical Exam:
General - NAD
HEENT - PERRL, EOMI, sclera non-iceric
Neuro - CN II-XII grossly intact, MAE [**6-10**] strengths
Lungs - CTA bilaterally
Heart - RRR with 2/6 diastolic murmur
abd - soft, nt, nd, + BS
Ext - no peripheral edema, DP 2+ nilat. with warm extrems
Pertinent Results:
[**2173-11-19**] 08:00AM BLOOD WBC-9.4 RBC-3.48* Hgb-11.2* Hct-33.1*
MCV-95 MCH-32.2* MCHC-33.8 RDW-15.1 Plt Ct-365
[**2173-11-10**] 03:32PM BLOOD WBC-11.0 RBC-3.73* Hgb-12.9* Hct-37.3*
MCV-100* MCH-34.6* MCHC-34.6 RDW-14.5 Plt Ct-177
[**2173-11-19**] 08:00AM BLOOD PT-14.3* PTT-29.9 INR(PT)-1.4
[**2173-11-19**] 08:00AM BLOOD Plt Ct-365
[**2173-11-19**] 08:00AM BLOOD Glucose-143* UreaN-51* Creat-9.3*# Na-134
K-5.2* Cl-92* HCO3-25 AnGap-22*
[**2173-11-10**] 03:32PM BLOOD ALT-22 AST-26 AlkPhos-141* TotBili-0.7
[**2173-11-10**] 03:32PM BLOOD Glucose-47* UreaN-25* Creat-6.5* Na-141
K-4.5 Cl-94* HCO3-36* AnGap-16
[**2173-11-19**] 08:00AM BLOOD Calcium-9.7 Phos-7.5*# Mg-2.7*
[**2173-11-10**] 06:27PM BLOOD freeCa-1.09*
Brief Hospital Course:
Just prior to admission, patient underwent hemodialysis. He was
then directly admitted to floor, then to the CSRU for Swan
placement and evaluation of pressures and volume status. He was
subsequently started on a Nitro drip for pulmonary hypertension.
He remained hemodynamically stable. The following day, he
underwent a MV repair with Dr. [**Last Name (STitle) **], and was transferred to
CSRU in stable condition on epinephrine, milrinone, insulin, and
propofol drips. He awoke neurologically intact and was extubated
on POD#2. He continued on his regular dialysis schedule. His
inotropic support was gradually weaned over several days. An
echocardiogram on POD#4 revealed only trivial MR and a LVEF of
55% - improved from prior studies. He otherwise maintained
stable hemodynamics and remained in a normal sinus rhythm.
Medical therapy was optimized and he was transferred to the
floor on POD#7. He was followed closely by the renal and
cardiology services. He worked daily with physical therapy. He
continued to make clinical improvements and was cleared for
discharge to home on POD#8. At time of discharge, he was
tolerating room air and his chest x-ray showed improved aeration
and CHF with only a small residual left pleural effusion. He had
adequate pain control with Dilaudid.
Medications on Admission:
digoxin 0.125 mg daily
glipizide 10 mg daily
insulin NPH 10 units [**Hospital1 **]
Avandia 4 mg daily
lopressor 75 mg [**Hospital1 **]
norvasc
trandolapril 4 mg daily
zantac 150 mg daily
nephrocap one cap daily
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:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
8. Zestril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. PhosLo 667 mg Tablet Sig: Two (2) Tablet PO qac.
Disp:*60 Tablet(s)* Refills:*0*
10. Glucotrol XL 10 mg Tab, Sust Release Osmotic Push Sig: One
(1) Tab, Sust Release Osmotic Push PO once a day.
11. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p MV Repair
End stage renal disease/ hemodialysis
Insulin dependent diabetes mellitus
[**Hospital **]. Hypertension
Congestive heart failure
Hypertension
Gastro-esoph. reflux disease
Right upper extrem AV fistula
Discharge Condition:
good
Discharge Instructions:
no lotions, powders or creams on incision
may shower, and pat wound dry
no lifting greater than 10 pounds for 10 weeks
no driving for one month
Followup Instructions:
see Dr. [**Last Name (STitle) 5456**] in [**2-7**] weeks
see Dr. [**Last Name (STitle) **] in office at 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2173-12-13**]
ICD9 Codes: 4240, 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6541
} | Medical Text: Admission Date: [**2110-6-30**] Discharge Date: [**2110-7-3**]
Date of Birth: [**2061-3-23**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Intubation
Insertion of right-sided internal jugular catheter
History of Present Illness:
49 yo F with h/o DM, CHF, sleep apnea, morbid obesity,
cholelithiasis, DM2, and HTN presented to [**Hospital3 3765**] with
confusion. She noted decreased urine output over the previous 4
days as well as fatigue. Per report, pt had recently started
Klonopin and had decreased PO intake with some nausea and
vomiting. She denied fevers, chills, or pain. At [**Hospital1 **],
patient was found to be in ARF with elevated Cr to 8.0 (from
0.9) and K of 6.8 but no EKG changes. Patient was subsequently
transfered to [**Hospital1 18**] ED where she was given 1 amp of bicarbonate,
70mg of Kayexalate, NS x 1 L, CaCl, insulin 10 units with
dextrose. She also had a RIJ placed. Patient was also found to
have pH of 7.16, pCO2 59 (baseline 50s). HCO3 20. She was
poorly responsive and incoherent. BIPAP was initiated in the
ED. Initial ABG showed improvement in pH.
.
ICU course: On repeat ABG, pH was again 7.16 and pt continued
to be poorly responsive. She was intubated for airway
protection and acidosis management. She was put on IV fluids
with HCO3 for her ARF and acidosis. Her hyperkalemia was
managed with Calcium, Insulin and Dextrose, and Kayexelate, and
her potassium normalized. At the time of transfer to the floor,
the patient had been extubated. Her mental status had improved,
and she was alert and oriented x 3. Her Cr had decreased to 1.4
Past Medical History:
1. Arthritis - on methadone for pain
2. Asthma
3. Diabetes Mellitus - oral antihyperglycemics
4. Obesity - considered too high risk currently for gastric
bypass
5. OSA - supposed to be on CPAP at home
6, ? R sided heart failure from pulm HTN
7. Cholelithiasis - recent bout of cholecystitis, tx w/ abx,
needs ccy
8. Dysfuntional uterine bleeding - refused exam in past
9. Anemia - Hct ranges from 29-34 since [**4-11**], MCV 82, iron 27
10. Anxiety
Social History:
Supportive family. Lives w/ "husband" [**Doctor Last Name **]. Has 3 children, but
not all of them live together. No tob, no EtOH. On disability,
not working.
Family History:
non-contributory
Physical Exam:
97.7 94/45 17 97 [**Telephone/Fax (1) 107364**] getting intubated
General: obese female, opening eyes to voice, following
commands, incoherent,
HEENT: PERRL, anicteric, clear OP
Neck: obese, no JVD visualized
CV: distant HS, rrr
Lungs: CTAB/L anteriorly
ABd: larger protruberant, soft, no fluid wave, non-distended
extremities: mild edema, no cyanosis, no evidence of rash or
cellulitis.
Pertinent Results:
[**2110-6-30**] 06:30PM GLUCOSE-107* UREA N-131* CREAT-7.7*#
SODIUM-131* POTASSIUM-6.0* CHLORIDE-96 TOTAL CO2-20* ANION
GAP-21*
[**2110-6-30**] 06:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2110-6-30**] 06:30PM URINE HOURS-RANDOM UREA N-351 CREAT-217
SODIUM-23 CHLORIDE-17 TOT PROT-61 PROT/CREA-0.3*
[**2110-6-30**] 06:30PM WBC-7.5 RBC-3.82* HGB-10.6* HCT-30.5* MCV-80*
MCH-27.8 MCHC-34.7 RDW-14.8
[**2110-6-30**] 09:28PM TYPE-ART TEMP-36.5 O2-20 PO2-61* PCO2-52*
PH-7.21* TOTAL CO2-22 BASE XS--7 INTUBATED-NOT INTUBA
COMMENTS-O2 DELIVER
Brief Hospital Course:
49 y.o. F with morbid obesity, OSA, DM2 who presented with
mental status changes from ARF with hyperkalemia and acidosis.
.
# ARF - Etiology likely prerenal from dehydration, although
NSAID use may suggest intrinsic component. Cr resolved to 0.8
at time of discharge. Patient was educated re: need to watch
hydration when taking lasix and she was discharged on a low dose
(lasix 40mg po bid) to prevent recurrence of prerenal failure.
In addition, her aldactone and ibuprofen were stopped to prevent
any damage to kidneys until she could be assessed as an
outpatient.
.
# Respiratory distress-- patient was intubated for acidosis that
did not respond to IV bicarb as well as airway protection given
her poor mental status. She was extubated 1 day later. During
her hospitalization, she returned to her baseline oxygen
requirement of 2L nasal cannula at night and intermittently
during the day.
.
# Hyperkalemia--patient was admitted with potassium 6.8. She
did not have EKG changes. She was given Calcium, Insulin and
Dextrose, and Kayexalate. As her kidneys recovered, her
potassium normalized.
.
# Acidosis--was felt to be both metabolic from her renal failure
and respiratory from her baseline hypoventilation/CO2 retention.
- resolved with intubation and recovery of renal function
.
# Chest pain--patient had an episode of chest pressure which she
says was brought on by anxiety.
- Cardiac enzymes negative x 2, no EKG ST segment changes
- pt was given oxygen, morphine, and aspirin while being ruled
out for MI
- pt has no h/o MI, states that she often experiences chest
pressure during episodes of stress
.
# Anxiety
- on Celexa
- started Clonazepam 0.5 mg PO BID PRN--discharged on 1mg
Clonazepam in accordance with OMR record.
.
# Hypernatremia--most likely secondary to post-acute tubular
necrosis diuresis. Patient was given 1/2 NS and her
hypernatremia resolved.
.
# DM2 - RISS; hold metformin until discharge given recent
acidosis.
.
# BP - hypertensive at baseline, but metoprolol and lisinopril
were held during admission to prevent renal damage and b/c her
systolic BP was <120 during her stay.
.
# OSA/obesity hypoventilation - pt was maintained on inhalers
during her stay. She was advised to continue using CPAP on
discharge.
.
# Arthritis--patient takes methadone 10mg [**Hospital1 **] at home--this was
held during hospital stay because of her altered mental status.
Medications on Admission:
Advair 250/50 1 puff [**Hospital1 **]
Aldactone 25mg daily
Ambien 5 qHs
ASA 325mg daily
Celexa 40mg daily
Alb/Atroven INH q6 prn
Lasix 120 PO BID
Ibuprofen 800 prn
Lisinopril 5mg daily
Ativan prn
Metformin 850 [**Hospital1 **]
Metoprolol 50 PO BID
Prilosec 20mg [**Hospital1 **]
Simvastatin 10mg daily
METHADONE 10 MG [**Hospital1 **]
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation twice a day.
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
Primary Diagnosis: Acute Renal Failure
Secondary Diagnoses: Hyperkalemia, Acidosis, Obesity,
Obstructive Sleep Apnea, Diabetes mellitus, Anxiety
Discharge Condition:
Patient was alert and oriented x 3. Her renal failure and
hyperkalemia had resolved at time of discharge. Vital signs
were stable and she was at her baseline oxygen requirement of 2L
nasal cannula. She was assessed by PT, who recommended she go
home with home physical therapy, which was arranged.
Discharge Instructions:
1. Please return to the hospital if you develop increased
shortness of breath, confusion, or any other concerning symptom.
2. Please attend all follow-up appointments as listed below.
3. Please take all medications as prescribed. You will notice
the following changes:
- Please do not take your aldactone, ibuprofen, metoprolol, or
methadone until you see your doctor and get further
instructions.
- Please take lasix 40mg in the morning and 40 mg in the evening
until you see your doctor in the outpatient clinic.
Followup Instructions:
Provider: [**Name10 (NameIs) 14876**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2110-7-8**] 2:50
Provider: [**Name Initial (NameIs) 703**] (C4) TCC RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2110-8-14**] 2:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2110-8-14**]
4:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2110-7-6**]
ICD9 Codes: 5849, 2762, 2760, 4280, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6542
} | Medical Text: Admission Date: [**2135-7-2**] Discharge Date: [**2135-8-23**]
Date of Birth: [**2081-3-20**] Sex: F
Service: MEDICINE
Allergies:
Nafcillin / Vancomycin
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Back pain due to epidural abscesses complicated by bacteremia
and acute respiratory distress
Major Surgical or Invasive Procedure:
1. [**2135-7-3**]. Cervical decompression via laminectomies C2-C6
bilaterally, insertion of 2 epidural drains. Laminectomy
T12-L1-L2, insertion of 2 drains
2. [**2135-7-5**] Right knee arthrocentesis and washout
3. [**2135-7-13**] Anterior cervical discectomy and fusion as well as
epidural abscess evacuation.
4. [**2135-7-25**] IR-guided paraspinal abscess drainage
History of Present Illness:
54 yo F presents to ED w/ 1 week of worsening back pain.
Pain reportedly started while riding a bike. Began in
lower back and has steadily risen up to her neck over the past
week. Also reports some shooting pain down right leg. + fevers
and chills. For the past 3 days, her legs have been feeling
weak, she has had difficulty urinating. Fevers and chills have
resolved. Reports tremors starting two days ago.
She denies fecal incontinence although this was reportedly
endorsed to ED staff. Denies any numbness or tingling in her
extremities.
Past Medical History:
None
Social History:
Works for a mission network. No IVDA. Social EtOH
Family History:
N/C
Physical Exam:
ADMISSION PHYSICAL EXAM:
T:98.7 BP: 155/100 HR:140-150s RR: 20 O2Sats 100% on NRB
Gen: Anxious, Uncomfortable
HEENT: Pupils: 4->3 EOMs - Full
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5-
L 5 5 5 5 5 5 5 5 5-
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: Pa Ac
Right 2+ Mute
Left 2+ Mute
Rectal exam - normal sphincter control, normal perianal
sensation
DISCHARGE PHYSICAL EXAM ([**8-17**]):
VS: Afebrile >36hr, Tc: 98.1 BP: 130/76 (140-170/80-92) 94% 2L
02 saturation yesterday: 97--100% on 1-2L; 94% RA
GEN: Sleeping but arousable, oriented, no acute distress
HEENT: non-icteric sclera, MMM
NECK: Gauze and tegaderm in place over former RIJ, no tenderness
HEART: RRR, nl S1 S2, 3/6 systolic murmur, heard best at LUSB,
radiating to neck bilaterally, no rubs
LUNGS: anterior lung fields clear, slightly decreased bs at
bases, no wheezes
ABD: ecchymoses on lower abdomen, +NABS, soft, non-distended,
non-tender, without rebound or guarding
EXT: warm, 1+ edema to ankle b/l, right knee with healed
surgical scar
T/L/D
- Left PICC line in place; no surrounding tenderness, erythema
Pertinent Results:
ADMISSION LABS:
[**2135-7-2**] 01:45PM URINE RBC-[**5-5**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2135-7-2**] 01:50PM WBC-21.2* RBC-4.70 HGB-14.2 HCT-43.9 MCV-93
MCH-30.2 MCHC-32.4 RDW-14.4
[**2135-7-2**] 01:50PM GLUCOSE-287* UREA N-51* CREAT-1.7* SODIUM-136
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-21* ANION GAP-23*
[**2135-7-2**] 02:17PM LACTATE-2.9*
DISCHARGE LABS ([**8-17**])
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
16.6* 2.87* 8.0* 24.4* 85 27.8 32.7 17.9* 227
DIFF Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos
Promyel NRBC
59 9* 8* 21* 0 0 1* 2* 0
Glucose UreaN Creat Na K Cl HCO3 AnGap
96 22* 0.5 141 3.7 102 32 11
Inflammatory Markers ([**8-16**])
ESR: 115*
CRP: 30.9
.
MICRO:
Micro:
[**7-2**] - Blood Cx - [**2-27**] MSSA
[**7-3**] - Epidural Swab - MSSA
[**7-5**] - Joint Fluid + Swab - MSSA
[**7-13**] - Epidural Swab - MSSA
[**7-25**] Abscess - MSSA
.
C. diff - [**8-1**] (-), [**7-30**] (-), [**7-26**] (-), [**8-16**] (-)
.
Antimicrobial History:
Vanco+Cefepime [**7-10**]->[**7-15**]
Vanco [**7-10**] -> [**7-15**]
Nafcillin [**7-15**] -> [**7-19**]
Vanco [**7-19**] -> [**8-8**]
Cefepime [**7-26**] -> [**8-2**]
Meropenem 1000mg IV Q8 ([**8-8**] - [**8-14**])
Daptomycin 600mg IV Q24 ([**8-8**] - present)
[**2135-8-17**] 10:22 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2135-8-18**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2135-8-18**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
IMAGING:
MRI Spine [**7-3**]:
1. Cervical anterior epidural collection, with severe narrowing
of the thecal sac from C2 through C5, without evidence of spinal
cord edema. Sagittal post-contrast images suggest that this
collection contains fluid at the level of C2, which would
indicate an abscess rather than a phlegmon. However, axial
post-contrast images suggest that the central hypoenhancing
portion of the collection at C2 may not be fully liquefied, or
that the fluid may be highly viscous.
2. Anterior epidural collection from T11 through the upper
sacrum,
compressing the thecal sac and crowding the cauda equina. This
collection
appears to contain fluid from T12 through L3, indicative of an
abscess rather than a phlegmon.
3. No evidence of discitis or osteomyelitis.
4. Bilateral posterior paravertebral muscle phlegmon at the
level of L4-5
with a possible 5 mm abscess on the right. Contrast enhancement
surrounding the L4-5 facet joints may represent inflammation
secondary to the severe degenerative facet arthropathy, but
septic facet arthropathy cannot be excluded
Echo [**7-4**]:
IMPRESSION: Suboptimal image quality. Mild mitral leaflet
thickening but without discrete vegetation or pathologic flow.
Mild pulmonary artery systolic hypertension. Normal left
ventricular cavity size with preserved global and regional
systolic function
MRI Spine [**7-4**]:
1. Cervical region: No STIR signal abnormality in the cord. No
evidence of
cord compression. Expected post-op changes.
2. Lumbar region: Small epidural signal abnormality, could
represent residual abscess collection from debridement or
post-surgical changes.
XRAY-Knee
IMPRESSION: Small to moderate-sized knee joint effusion.
CTA [**7-9**]
IMPRESSION:
1. No pulmonary embolism or acute aortic pathology.
2. Moderate bilateral pleural effusions with subtotal lower lobe
collapse.
Evidence of loculated pleural effusions tracking up in the right
upper lateral pleural space.
3. Multiple lung nodules likely infectious in this cl
inical setting. Follow-
up to resolution is recommended
4. No pneumothorax.
MR [**Name13 (STitle) **] [**8-12**]
Significant increase in volume of the epidural fluid
collection/abscess
extending from the uppermost C1 epidural space to the inferior
aspect of the study at L1, largest at the upper cervical spine
where it measures
approximately 1 cm in greatest thickness. The patient is status
post cervical laminectomy from approximately C2-C6 but the
epidural collection displaces the cervical cord posteriorly and
the cervical cord appears compressed against the posterior ring
of C1. There is increased signal within the cervical cord from
the medulla to C3.
2. The epidural collection/abscess within the thoracic spine
mildly
displaces the thoracic cord without evidence of cord signal
abnormality.
CT-Thoracentesis (drainage) [**7-13**]
IMPRESSION: Successful diagnostic and therapeutic thoracentesis
yielding 270 cc of serosanguineous fluid from the right pleural
cavity. An 8 French
pigtail catheter was placed within the pleural cavity and is
currently
attached to waterseal. Samples were sent for microbiology and
chemistry per the ordering team's request.
MR C/T/L-Spine [**7-21**]
IMPRESSION:
1. New soft tissue paraspinal pockets of fluid collection are
seen in the
lumbar region since the examination of [**2135-7-2**] and [**2135-7-4**],
visualized in the lower lumbar region involving the psoas
muscles and the erector spinae muscles. The largest collection
in the right erector spinae muscle is approximately 3 cm and the
largest collection in the right psoas muscle is approximately 2
cm. Additional left psoas muscle fluid pocket measures 2.8 cm.
Smaller foci are also visualized.
2. Lumbar epidural fluid collection ventral and dorsal to the
thecal sac in the lower lumbar region may be slightly smaller
compared to [**2135-7-2**].
3. Epidural collection in the cervical region extending from C2
inferiorly is not significantly changed since the MRI of
[**2135-7-14**]. Minimal indentation on the spinal cord in cervical
region is unchanged. Postoperative changes and laminectomies are
seen in this region.
4. Thoracic epidural collection has not changed and there is no
cord
compression in thoracic region.
4. Laminectomies are seen in the lower thoracic/upper lumbar
region. Thin
rim of epidural collection again seen in the thoracic region
which is
unchanged. No cord compression is identified in the thoracic
region.
CT-Chest/Abdomen/Pelvis [**7-26**]
IMPRESSION:
1. Overall, stable appearance of multiple small fluid collection
seen in the paraspinal muscles along with the erector spinae and
psoas muscles, as
described above. No new intraabdominal or intrapelvic
collections identified.
2. Stable bilateral pleural effusion with bibasilar airspace
disease.
3. Stable appearance of mediastinal and bilateral hilar
lymphadenopathy.
U/S Abdomen [**7-29**]
IMPRESSION:
1. Cholelithiasis with edematous and thick walled but contracted
gallbladder. No son[**Name (NI) 493**] evidence of acute cholecystitis.
Gallbladder wall thickening and edema may be caused by multiple
factors such as liver disease and hypoalbuminemia, and clinical
correlation is recommended.
2. Splenomegaly.
CT-Chest/Abdomen/Pelvis [**8-1**]
IMPRESSION:
1. Multiple soft tissue abscesses appear similar to prior
examination with
erector spinae abscess on the right, left iliopsoas abscess, and
fluid pockets overlying the lower lumbar spine spinous
processes.
2. Left posterior rotator cuff region possible new abscess, not
well seen on prior studies.
3. Bilateral basal pulmonary volume loss and consolidation,
similar to prior examination in lesion addition to bilateral
pleural effusions, more pronounced and somewhat loculated on the
right but similar to prior study.
4. Nonspecific gallbladder wall thickening. Cholecystitis is not
excluded,
although the appearance is stable compared to prior examination
and has been previously evaluated with ultrasound.
5. Nonspecific lesion in the right renal upper pole. This was
not well seen on prior examination. If there is clinical
suspicion for renal abscess, targeted ultrasound could be
performed to further assess.
6. Left proximal thigh abscess, incompletely assessed but
similar to prior
study allowing for difference in technique.
7. Splenomegaly.
MRI C-Spine [**8-6**]
IMPRESSION: Again, epidural enhancement and abscesses identified
in the
anterior cervical region. As described above, the fluid
collection around
C2-C3 level appears slightly increased in thickness, but the
differences in measurements are small and this could also be due
to partial volume averaging,
but continued followup is recommended. Otherwise, the
examination is stable
MRI T-Spine [**8-6**]
IMPRESSION: Overall stable appearance of the thoracic spine
compared to the previous MRI of [**2135-7-21**]. Again, lower thoracic
and upper lumbar
laminectomies and epidural enhancement is seen in the thoracic
region without epidural abscess.
CT Scan Abd/Pelvis ([**8-9**]):
with abdominal pain of unclear etiology, look for possible
underlying
abdominal abscess.
COMPARISON: CT torso from [**2135-8-1**].
TECHNIQUE: Non-contrast MDCT of the abdomen. The patient not
received any
oral or IV contrast.
FINDINGS: Of note, evaluation of abdominal organs is limited
without any
intravenous or oral contrast administered. Once again, there are
bilateral
pleural effusions with overlying collapse/consolidation that has
slightly
improved from previous study. Once again, the right is
significantly greater than the left and appears loculated. A
nodular density previously seen in the right middle lobe is not
visualized in the current study.
CT ABDOMEN W/O Contrast:
There is no focal liver lesion seen. There is evidence of a
large stone
within the gallbladder; however, there are no signs of
gallbladder wall
thickening or other associated signs to suggest inflammation or
infection. The spleen is enlarged. There is no focal splenic
lesion or abscess seen.
Pancreas appears normal. Adrenals appear normal. The kidney is
normal in
appearance. Right kidney appears normal in appearance. The small
area of
hypoattenuation seen in the left kidney on the previous study
was not
appreciated on the current exam. Small periaortic and portacaval
lymph nodes are again seen, however, they do not meet CT
criteria for lymphadenopathy. There is no bowel obstruction. The
appendix is normal. There is no significant mesenteric
lymphadenopathy or fluid collection seen.
CT PELVIS W/O contrast: Once again seen is a low-attenuation
fluid collection in the left iliopsoas muscle, extending from
the lower lumbar-upper pelvic regions along the psoas. This
collection appears unchanged, both in size and in character and
further characterization is limited without contrast. Once again
seen are the small areas of low attenuation, representing fluid
in the proximal thigh as well as stranding in the left greater
trochanter. This appears unchanged from the previous study of
[**2135-8-1**]. There is no epidural abscess seen in the
thoracic region.
The rectum, sigmoid colon, bladder, and uterus are normal.
3D reconstructions, coronal and sagittal reconstructions were
essential in
delineating the anatomy and pathology.
BONES: There is no osseous destruction seen. As mentioned,
evidence of priorlaminectomies at the lower thoracic spine and
upper lumbar spine are seen.There are no epidural collections
suggestive of epidural abscess in the lumbaror visualized
thoracic spine.
IMPRESSION:
1. Unchanged left iliopsoas abscess
2. Slight interval decrease in bilateral basal pulmonary volume
loss and
consolidation and pleural effusions.
3. Large gallstone within the gallbladder without sign of
gallbladder
inflammation.
4. Unchanged fluid collection in the left proximal thigh
compared to prior.
5. This study was discussed with Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) **] at 4:30 p.m.
on [**2135-8-9**].
.
Unilateral upper extremity venous ultrasound. ([**8-17**])
COMPARISON: Upper extremity venous ultrasound [**2135-7-11**].
FINDINGS: Color and grayscale son[**Name (NI) 1417**] of bilateral subclavian
and
left-sided internal jugular, basilic, brachial and cephalic
vessels were
evaluated. Evaluated vessels demonstrated normal flow,
compressibility and
augmentation. There is a PICC line in the basilic. There is
duplication of
the brachial vessels.
IMPRESSION: PICC in the basilic vein but no DVT.
.
Brief Hospital Course:
Ms [**Known lastname **] is a 54 yo female with no significant past medical
history who initially presented with back pain, urinary
retention on [**7-3**], found to have multiple epidural abscesses s/p
multiple surgical debridements with hospital course complicated
by episodes of flash pulmonary/respiratory compromise requiring
intubation and febrile neutropenia secondary to lasix and
vancomycin administration.
.
# Bacteremia/Abscesses/Antibiotic therapy
.
Patient initially presented with back pain, associated urinary
retention and LE weakness. Admission imaging positive for
cervical and lumbar epidural abscesses (though patient with no
known risk factors). She was empirically started on
vancomycin/cefepime/levofloxacin. She underwent C2-C6/T12-L2
bilateral laminectomies with insertion of 4 drains on [**2135-7-3**].
She subsequently developed a septic right knee and returned to
the OR on [**2135-7-4**] for right knee washout. Regarding further
initial infectious work-up at that time: a TEE was obtained
which showed no vegetations; CT head without evidence of
intracranial abscess.
.
On [**2135-7-6**], antibiotic coverage was narrowed to nafcillin when
cultures from abscesses, right knee, and blood grew MSSA.
However, due to signs and symptoms of leukocytosis, hypoxia
there was concern for hospital acquired pneumonia and antibiotic
coverage was broadened to vancomycin, cefepime, and
ciprofloxacin on [**7-10**]. Patient remained febrile. Surveillance
imaging obtained on [**7-12**] which demonstrated increased epidural
collection within anterior cervical epidural space and
displacement of the cervical cord. The patient returned to the
OR on [**7-13**] for abscess decompression and evacuation and fusion
of C3-4, C4-5, and C5-6. After reviewing microbial date with all
cultures + MSSA, her antibiotic coverage was again narrowed to
nafcillin.
.
Patient had been doing well with normalized temperature and WBC
however four days after starting nafcillin, developed a
abdominal rash. Derm was consulted, biopsies were taken which
were c/w drug rash secondary to nafcillin. Nafcillin was
subsequently discontinued and replaced by IV vancomycin.
.
Repeat MR spine with new paraspinal fluid collections, and mild
epidural fluid collection throughout the spine. Due to concern
for continued infection cefepime was added to antibiotic
regimen. On [**7-25**], the patient underwent paraspinal abscess
drainage by interventional radiology. Follow-up CT torso was
obtained on [**8-1**] due to persistent fevers on cefepime and vanc;
finding were stable to previous imaging and cefepime was
discontinued. On [**8-5**], her C-collar was removed. Surveilance MR
C/T-Spine on [**8-6**] showed stable epidural enhancement and
abscesses identified in the anterior cervical region, thoracic
region without epidural abscess. CT scan on [**8-9**] demonstrated
left iliopsoas abscess/phlegmen and left thigh fluid collection;
both of which were too small to be drained by IR.
.
Unfortunately side effects necessitated further antibiotic
adjustment. CBC with noted leukopenia on [**8-5**] with progression
to neutropenia [**8-8**]. Out of concern that vancomycin could be
contributing to decreasing counts, vanc d/c'ed and IV
daptomycin started. Per ID will plan to treat MSSA
bacteremia/abscesses with IV daptomycin to total of 6-8wk
course. At time of discharge utility of repeat imaging
discussed. Plan to repeat CT abd/pelvis; MRI spine further into
antibiotic treatment.
.
# Febrile Neutropenia
.
Patient's WBC count began to slowly decline on [**8-5**] with
progression to neutropenia on [**8-8**]. Neutropenia was felt
secondary to medication effect; subsequently omeprazole,
furosemide, vancomycin and seroquel were discontinued.
Hematology was consulted, and felt that furosemide or vancomycin
were likely offending agents. Antibiotic coverage altered on
[**8-8**]: vancomycin discontinued and daptomycin started for
treatment of MSSA. On [**8-9**] she was febrile 102.6 and meropenem
started for treatment of neutropenic fever. GCSF initiated.
After administration of GCSF counts slowly became to rise and
fevers abated. GCSF was stopped on [**8-14**] when ANC>1000 for more
than 48hrs.
.
Respiratory Distress
.
On admission patient found to be tachypnic. LENIs negative. On
[**7-8**], developed worsening tachypnea and hypoxemia (95% on 4L by
nasal canula). The patient diureased 500ml on IV Lasix and
improved slightly. CTA ruled out PE, however showed evidence of
bilateral loculated pleural effusions and multiple lung nodules.
Cardiac enzymes negative. Pro-BNP 2777 on [**7-8**]. Estimated EF by
TEE was >55%; 2 repeat echos without evidence of valvular
pathology. In MICU, IV Lasix and morphine lessened respiratory
distress. On [**7-10**], transferred to the floor; latered became
hypoxic and was transfered back to the MICU and started on
BiPAP. Pleural effusion studies suggested parapneumonic
effusion. Patient intubated and extubated several time while in
MICU. On [**7-16**], the patient was again extubated. She developed
hypertension to 180 SBP and respiratory distress secondary to
pulm edema, which responded to lasix and labetolol. On [**7-19**], she
was comfortable oxygenating with only nasal cannula. She was
electively intubated on [**7-25**] for paraspinal abscess drainage and
extubated post-procedure. Unfortunately, again developed
worsening hypercarbic respiratory distress, requiring
reintubation on [**7-27**]. She was gently diuresed, in an effort to
decrease the work of breathing. On [**8-3**] she was succesfully
extubated, satting well on face mask. On [**8-5**] she was weaned to
NC. CT on [**8-9**] showed improvement in pleural effusions and
basilar consolidations. She continued to do well on supplemental
oxygen by nasal cannula. On the floor her oxygen requirement was
weaned. She had one episode of flash pulmonary edema, during
which she desaturated to high 80s. She was diuresed with bumex
with good effect. For the remainder of her stay, team allowed
for auto-diuresis. At time of discharge patient saturating 94%
RA, >95% 1L.
.
# Blood Pressure
.
During MICU stay pt had repeated episodes of transient
bradycardia and hypotension as well as episodes of paroxysmal
hypertension into the SBP 180-200s. Her hypertension responded
to 5mg-10mg doses of IV labetalol. After significiant diuresis,
her SBP remained stable in the 150-160s. On the floor, BP ran
consistently high. Patient was started on metoprolol and
amlodipine. These medications were gradually uptitrated and at
time of discharge pressures were better controlled on metoprolol
50mg TID, amlopidine 10mg QD. She was transitioned to toprol xl
150mg daily at the time of discharge.
.
# Nutrition
.
Patient underwent severeal video swallowing evaluation due to
concern for silent aspiration. In the MICU, several methods of
nutrition employed: NG tube feeds as well as PPN. On transfer to
floor patient on NG tube feeds. Repeat speech and swallow on
[**8-15**] demonstrated improved oral and pharyngeal swallow with
continued swallow delay, premature spillover and reduced base of
tongue retraction. Patient continued to aspirate thin liquids
silently, but speech deemed it safe to initiate a PO diet of
nectar thick liquids and moist, ground solids with the
aspiration precautions documented below. It is important to note
aspiration is silent,
and she will need continued speech therapy follow up with likely
repeat video swallow before advancing her diet.
# Delirium
.
In the MICU observed waxing and [**Doctor Last Name 688**] mental status worse at
night and with spikes in fever. Symptoms improved with zyprexa
at night. The pt became more alert following extubation on [**8-3**],
however, she had some disorientation. She received several doses
of seroquel, which was discontinued when the patient became
neutropenic, as it can be a potential cause of leukopenia. Over
the course of the next few days, her became more alert and
interactive. By time of transfer from MICU to floor on [**8-10**],
she was fully oriented and had a good understanding of the
medical plan. On the floor, patients mentation continued to
improve. At time of discharge patient mental status was clear
and coherent.
.
# Elbow mass
.
Mass noted on right elbow. Derm consulted; felt to be
consistent with lipoma.
.
# UTI: She developed low grade fevers on [**8-21**] to 100.4,
prompting urinalysis, which demonstrated UTI. She will complete
a 10 day course of ciprofloxacin 500mg [**Hospital1 **] to end [**2135-9-1**].
Medications on Admission:
None
Discharge Medications:
.
1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Daptomycin 500 mg Recon Soln Sig: Six Hundred (600) Recon
Soln Intravenous Q24H (every 24 hours).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
8. Outpatient Lab Work
Please check weekly CBC with differential, BUN/Cr, LFTs, CK,
ESR/CRP
.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
12. OXYGEN
At time of discharge patient requires 1L nasal cannula for
comfort.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
PRIMARY
Methicillin Sensitive Staph Aureus Bacteremia
SECONDARY
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent
Discharge Instructions:
Dear Ms [**Known lastname **] it was a pleasure taking care of you.
.
You were initially admitted to [**Hospital1 18**] due to symptoms of back
pain. Upon imaging it was found that you had several abscesses
throughout your spine as well as in your right knee. You
underwent several surgeries to evacuate these infection and you
were also started on antibiotics. Your antibiotic regimen was
altered several times due to significant side effects. You
experienced a rash after Nafcillin, and Vancomyocin was thought
to contribute to low cell counts. You were placed on Daptomycin
without side effect for a planned 8week course. A PICC line was
placed prior to discharge to faciliate antibiotic administration
as an outpatient. You will receive repeat imaging after
completion of your antibiotic therapy for interval evaluation of
infection.
.
Unfortunately, side effects from various medications prolonged
your hospital course. It was thought that a combination of
vancomycin and lasix contributed to decreased white blood cells
(WBC). While your WBC counts were low you were placed on broad
spectrum antibiotics to protect you from infection. We
discontinued the medications we felt responsible for declining
counts (lasix and vancomycin) and also administered a medication
called Neupogen to increase WBC production. After several days
of Neupogen treatment your white cell counts increased and
stabilized. Neupogen as well as broad spectrum antibiotics were
discontinued prior to discharge.
.
We also found your blood pressures to be elevated at times
during your hospitalization. You were started on medications,
metoprolol and amlodipine, to better control your blood
pressure.
.
Regarding nutrition, after extubation you were noted to have
difficultly swallowing. Speech and swallow was consulted and
after several attempts you completed and passed your evaluation.
After completion, you were started on a thickened nectar liquid
regimen and a soft, ground solid diet. You will need repeat
speech and swallow evaluation at rehab.
.
CHANGES TO YOUR MEDICATIONS.
On arrival to the hospital you were no prescription medications.
.
MEDICATIONS WE STARTED
.
--To treat your infection we STARTED Daptomycin 600mg IV Q24
(start date: [**2135-7-26**], stop date: [**2135-9-19**] (total 8 weeks))
.
--To treat PAIN we STARTED:
1. FENTANYL 25 mcg/hr Patch, which can be reapplied every 72
hr;
2. Two LIDOCAINE 5 %(700 mg/patch) Adhesive Patchs, Apply each
Adhesive Patch daily to back
3. ACETAMINOPHEN 325 mg Tablet; you can take 1-2 tablets by
mouth every 6 hours.
.
--To treat your high blood pressure we started:
1. AMLODIPINE 10mg daily; you will take two 5mg tablets daily
2. Metoprolol succinate (toprol XL) 150mg tablet daily
.
-- To prevent blood clot formation while you heal and are
relatively limited in your movement you will continue to
receive: Heparin (Porcine) 5,000 unit/mL Solution Injections
three times a day
.
--To help treat your anxiety we started:
1. Lorazepam 0.5 mg Tablet, you can take one 0.5 tablet by
mouth at at bedtime as needed for anxiety.
.
You will need Outpatient Lab Work which your facility can obtain
and fax to [**Hospital **] clinic
.
New allergies: LASIX - contraindication - neutropenia
NAFCILLIN - contraindication - rash
VANCOMYCIN (relative contraindication) -
neutropenia
Followup Instructions:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2135-9-16**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5849, 7907, 5119, 2930, 5990, 2760, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6543
} | Medical Text: Admission Date: [**2141-12-19**] Discharge Date: [**2142-1-12**]
Date of Birth: [**2141-12-19**] Sex: M
Service: Neonatology
BIRTH HISTORY: This is a two-day old full-term 3,770 gram
infant with new onset of cyanotic episodes associated with
rhythmic jerking of upper extremities and lip smacking
consistent with seizure activity. The infant was admitted
to the Neonatal Intensive Care Unit at two days of age for
MATERNAL HISTORY: This was a 29-year-old gravida 2, para 021
mother, hepatitis negative, RPR nonreactive antibody
negative, rubella immune, GBS negative. There was no history
of maternal fever noted and there was spontaneous rupture of
membranes at seven hours prior to delivery. Fluid was
meconium stained at the time of delivery and there was no
PERINATAL HISTORY: Neonatology was called to the delivery
room due to meconium staining. The infant emerged with a
strong cry, very vigorous, pink, good tone, no intervention
was required. Apgar scores were 8 and 8 at one and five
minutes respectively. The patient was transitioned to the
newborn nursery for routine case. This baby then had an
uneventful postnatal course until the afternoon of admission
whereby the mother reported the infant had a dusky spell with
cyanosis around the lips. After another such episode, the
baby was transferred to the Neonatal Intensive Care Unit for
close observation, here he had two short-lived episodes of
upper extremity jerking and lip smacking. One of these
episodes was associated with a desaturation requiring blow-by
oxygen. The infant was loaded with phenobarbital and an
lumbar puncture was completed. An antibiotic was initiated.
Head CT was obtained and shown to be unremarkable with no
significant evidence of bleeding or infarct.
On physical examination the birth weight was 3,770 at the
73rd percentile. Head circumference was 34.5 cm at the 50th
percentile and the length was 20.5 inches at the 90th
percentile. Vital signs were stable. The patient was noted
to be alert with acceptable tone but not a very vigorous
infant. Color was pink. The infant was quiet and awake, and
the neurologic examination was nonfocal. Genitourinary
examination was within normal limits and the patient was not
dysmorphic. There was no heart murmur heard.
The lumbar puncture was unremarkable. The cerebrospinal
fluid results were as follows: White blood cells 6, red
blood cells [**Pager number **] with 17 polys, 17 lymphocytes, 67 monocytes.
The protein glucose was within normal limits and the
cerebrospinal fluid culture was negative. Electrolytes were
unremarkable as well as the liver function tests. The
ammonia was 83. Repeat testing showed NH3 levels that ranged from
70 to 103 during his hospital stay. The most recent level was 80
on [**1-10**] .
During the first NICU day the time the patient was loaded with
phenobarbital and put on maintenance phenobarbital for
seizure and neurology was consulted.
HOSPITAL COURSE: From a respiratory standpoint the patient
continued to do well without any need for supplemental oxygen
or mechanical ventilation. He did however require a brief
night of supplemental oxygen which was attributed to
hypoventilation. His CBG was within normal limits and the
phenobarbital level at that time was above 50. After
decreasing the phenobarbital dose which yielded a
phenobarbital level of under 50 the patient's need for oxygen
was resolved.
From a neurological standpoint the patient had a magnetic
resonance imaging scan that was unremarkable. He also had
three electroencephalograms, one of which was continuous.
The initial EEGs did not show frank seizure activity however
the continuous EEG upon reexamination did show electrical
activity that was very suspicious for electrographic
seizures. This was represented by sharp waves over the left
temporal and central regions. There were multiple movement
artifacts as well. The overall impression of the continuous
EEG was an abnormal bedside EEG telemetry due to multifocal
sharp discharges seen over the left posterior temporal
regions and over the right temporal and right central
regions. "On one occasion there appeared to be a brief
electrographic seizure emanating from the right posterior
temporal region with extension into the bilateral
parasagittal regions, however this interpretation is limited
due to subsequent movement artifacts seen near the same
region." Pertaining to the seizure control it was difficult
to control the seizures with monotherapy initially. The
patient continued to show seizure activity despite a
phenobarbital level in the high 40s. Dilantin was started in
order to capture the baby successfully. This Dilantin was
discontinued after about 48-72 hours of use and the patient
was left on monotherapy with good seizure control. However on
the day of planned discharge, the patient had clinical seizures
which were noted by his mother. EEG confirmed epiliptogenic foci
but no frank seizures. The phenobarb level at that time was in
the mid 30s. Pyridoxine and folinic acid were started at the
suggestion of the CH neuro team and the phenobarb level was
increased to acheive a level in the mid to high 40s. The moast
recent level on the 31st was 48.3. Alevel on the 30th was 44.3
on a stable dose. Phenobarb level is to be repeated on [**1-15**] by
Dr [**Last Name (STitle) 40493**].
During the course of his NICU stay, the patient also was put on a
course of acyclovir as the rule out herpes PCR test was underway.
The acyclovir was discontinued after the PCR result was negative.
The patient's metabolic work-up was nonspecific: The ammonia
was consistently slightly above normal in the nonspecific
range. The maximum was 123. The significance of this ammonia
level at this point is
unknown, as normal newborns in this period can sometimes show
a somewhat elevated ammonia level. The patinet ahs been seen in
consultation by the CH metabolism team.
Other metabolic laboratory studies were as follows: Repeat
RFTs on [**12-26**] were normal. Lactic acid was 1.6. Pyruvate
level was pending at the time of this dictation. Amino acid
panel was within normal limits. The cerebrospinal fluid
amino acid was nonspecific. The glycine was somewhat
decreased. Newborn screen was within normal limits. Organic
acids were notable for the presence of glycerol. This may be
artefact due to creams used in the diaper. Repeat testing has
been sent off.
FOLLOW UP CARE: The patient will be following up with
several services:
1. Neurology: The patient will have a follow-up neurology
appointment soon after discharge for follow up of seizure
management. Hopefully the pending metabolic laboratory
studies will be back by the time of the clinic appointment.
2. The patient will also be following with
metabolism/genetics soon after discharge for the rest of the
metabolic work-up.
OTHER SYSTEMS: During his hospital stay the patient
continued to do well with his feeds and continued to display
good growth. He passed a hearing screen. He did not have
any hematological issues and did not have any active
infectious disease issues. His electrolytes were within
normal limits. Cardiovascularly he did have an intermittent
soft ejection murmur that was not hemodynamically
significant. This was consistent with a probable flow
murmur. His pulses and his perfusion were within normal
limits at all times.
CONDITION AT DISCHARGE: The patient was well and with
seizures under control.
DISCHARGE DISPOSITION: To home.
Extensive conversation concerning the care and the
precautions for this baby were discussed with the mother.
She understands the conversation and all questions were
answered. The baby will follow up with the pediatrician on the
Monday following discharge. A phenobarb level will be done at
this time. FU with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46082**] has been arranged for [**1-19**].
DISCHARGE MEDICATIONS: Phenobarbital, Pyridxoine, Folinic Acid
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Name8 (MD) 46588**]
MEDQUIST36
D: [**2142-1-4**] 08:55
T: [**2142-1-4**] 09:03
JOB#: [**Job Number 46589**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6544
} | Medical Text: Admission Date: [**2198-2-20**] Discharge Date: [**2198-2-24**]
Date of Birth: [**2137-5-11**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Bilateral iliac artery dissections.
HISTORY OF PRESENT ILLNESS: A 60 year old nondiabetic
Russian-speaking white male with coronary artery disease,
status post myocardial infarction/coronary artery bypass
graft with hypertension and hypercholesterolemia, complained
of sudden onset abdominal and back pain. The patient
presented to the Emergency Room at [**Hospital6 649**]. Abdominal computerized tomography scan
showed isolated bilateral iliac artery dissections. There
was no history of recent trauma or instrumentation. The
patient was admitted for further evaluation.
PAST MEDICAL HISTORY:
1. Coronary artery disease: Myocardial infarction/coronary
artery bypass graft in [**2197-1-11**]; percutaneous
transluminal coronary angioplasty/stent of saphenous vein
graft in [**2197-5-11**].
2. Hypertension.
3. Hypercholesterolemia.
4. Severe, acute hemolytic anemia in [**2197-9-11**].
FAMILY HISTORY: Non-contributory.
SOCIAL HISTORY: The patient emigrated from [**Country 532**] in [**2193**].
He lives with his wife. [**Name (NI) **] is an engineer. He does not
drink alcohol. He has a history of cigarette smoking.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Plavix 75 mg p.o. q.d.
2. Aspirin.
3. Atenolol 25 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Percocet prn.
PHYSICAL EXAMINATION: Vital signs revealed temperature 97.1,
pulse 65, respirations 18, blood pressure 161/80. General:
Alert, cooperative white male in no acute distress. Chest:
Heart regular rate and rhythm, lungs have slight expiratory
wheezing. Abdomen, soft, nontender. No palpable masses.
Rectal examination, normal sphincter tone, stool guaiac
negative. Pulse examination, carotid, radial, femoral,
popliteal and pedal pulses are all palpable. Neurological
examination, nonfocal.
LABORATORY DATA: Laboratory data on admission revealed white
blood count 16.0, hemoglobin 14.5, hematocrit 41.6, platelets
311,000. PT 12.2, PTT 25.9, INR 1.0. Sodium 142, potassium
3.9, chloride 109, bicarbonate 26, BUN 21, creatinine 0.9,
glucose 90. ALT 27, AST 19. Alkaline phosphatase 71,
amylase 64, total bilirubin 0.4. CK 179. Electrocardiogram
showed a sinus rhythm at 68. No significant change from
tracing of [**2197-9-13**]. Chest x-ray showed no acute
pulmonary disease, status post sternotomy.
HOSPITAL COURSE: The patient was evaluated in the Emergency
Room for epigastric pain radiating to the back. He had a
thallium scan which showed normal perfusion at rest. The
stress MIBI portion was cancelled.
The patient was evaluated for aortic dissection with
computerized tomography scan of the chest, abdomen and
pelvis. The aorta was intact. There was dissection of both
the right and left common iliac arteries with extension of
the left common iliac dissection to the external iliac. The
patient was admitted to the Vascular Surgical Service and was
admitted to the SICU for observation.
The patient's peripheral pulses were strongly palpable and
equal throughout his hospitalization stay. His epigastric
and back pain resolved. His abdomen remained soft. His
peripheral pulses remained equal and strongly palpable.
Systolic blood pressure was 110 on his usual 25 mg of
Atenolol. His creatinine was 1.0. His hematocrit was stable
at 38.
The patient was to follow up with his cardiologist, regarding
the need to continue Plavix nine months after having a
percutaneous transluminal coronary angioplasty/stent of his
saphenous vein graft in [**2197-5-11**]. The patient will follow
up with Dr. [**Last Name (STitle) **] in the office in four weeks after
having a repeat computerized tomography scan of the chest,
abdomen and pelvis.
MEDICATIONS ON DISCHARGE:
1. The patient was to resume all preadmission medications.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Home.
PRIMARY DIAGNOSIS:
1. Isolated dissection of bilateral iliac arteries.
SECONDARY DIAGNOSIS:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2198-4-16**] 18:59
T: [**2198-4-16**] 19:25
JOB#: [**Job Number 24849**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6545
} | Medical Text: Admission Date: [**2151-12-23**] Discharge Date: [**2151-12-27**]
Date of Birth: [**2085-9-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
recurrent left effusion
Major Surgical or Invasive Procedure:
[**2151-12-23**] Left VATS pleural biopsy and talc pleurodiesis, and
flexible bronchoscopy by Dr. [**Last Name (STitle) **].
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname **] is a pleasant 66 year old male s/p
endostenting of his aortic aneurysm as well as left subclavian
to
left common carotid artery bypass and a left common carotid to
right common carotid artery bypass on [**2151-11-15**]. During his
hospitalization the patient had a left thoracentesis by Dr.
[**Last Name (STitle) **] on [**2151-11-17**] for large left exudative pleural
effusion.
Cytology was negative for maligant cells.
The patient was discharged from the hospital [**2151-11-19**] and returns
to see Dr [**Last Name (STitle) **] today for followup of his left effusion.
The patient states his breathing has improved, but he does not
exert himself much. He doesn't walk outside. He denies fevers,
chills, but has "some" nightsweats. He has yellow sputum
productive cough. He denies dizziness, or any other issues and
has multiple appointments to see various physicians.
Past Medical History:
Past Medical History:
- Coronary Artery Disease
- COPD
- Hyperlipidemia
- Hypertension
- Calcified aorta
- New finding of Left lingula lung mass
- Bilateral Pleural Effusions; s/p left thoracentesis [**2151-11-8**]
- Hypothyroidism
- Trauma to lower extremities
- Emphysema
Past Surgical History:
- coronary artery bypass grafting surgery x5 in [**2137**] - [**Hospital3 **] Dr.[**Name (NI) 43096**]
- Polypectomy [**2151**]
- Right elbow seroma, s/p debridement and drainage
- Appendectomy
Social History:
Occupation: retired
Last Dental Exam:has only 2 native teeth; no recent dental care
Lives with wife in [**Name (NI) 1411**]
Race:Caucasian
Tobacco:[**1-15**] cigarettes daily
ETOH:[**4-18**] glasses of wine daily
Family History:
Brothers with CAD. One brother died of MI at age 57, another
brother with CABG in early 50's.
Physical Exam:
VS: T98.6, BP 120/70, HR 94 SR, RR 18, O2 sats on RA 92%
Physical Exam:
Gen: pleasant in NAD
Lungs: rales BLL, clear B upper
CV: RRR, S1, S2, no MRG
Abd: distended, nontender
Ext: l>r edema 1+ in left leg, trace in right, warm extremities.
Uro: intact foley catheter.
Neuro: A and O x 4, ambulating halls.
Pertinent Results:
[**2151-12-27**] 06:35AM BLOOD WBC-9.0# RBC-3.09* Hgb-9.2* Hct-28.7*
MCV-93 MCH-29.6 MCHC-31.9 RDW-16.8* Plt Ct-202
[**2151-12-27**] 06:35AM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-133
K-4.7 Cl-96 HCO3-31 AnGap-11
[**2151-12-27**] 06:35AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2151-12-23**] where he underwent left VATs
pleurodiesis for recurrent pleural effusion. Initially he was
kept overnight in the PACU related to retained CO2, and required
CPAP, which was weaned off, and CO2 on ABG was per patients
baseline. The patient also required fluid bolus and albumin for
low urine output which eventually resolved itself. The patient
was transferred to the floor [**2151-12-24**]. Chest tubes were removed
on [**2151-12-25**] without issue. Unfortunately the patient had a foley
catheter placed with prostatic trauma, therefore urology was
consulted and recommended foley placement x 7 days with follow
up in one week. The patient's urine output has cleared.
Of note the pleural biopsy revealed a small amount of
enterococcus sensitive to only linezolid. ID approval was
obtained to discharge patient on such. The patient has adequate
pain control, is on room air, ambulating the halls, has had a
bowel movement, and has been cleared by Dr. [**Last Name (STitle) **] for
discharge home. The patient will have a CBC and urology visit in
one week, and see Dr. [**Last Name (STitle) **] with CXR in 2 weeks. He has
been given written and verbal discharge instructions. He has had
physical therapy home referral as recommended by Physical
therapy.
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
2. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours).
Disp:*30 Tablet(s)* Refills:*0*
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-15**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*28 Tablet(s)* Refills:*0*
10. Cyanocobalamin 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: follow
up with primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] panel in next 2 weeks
regarding dose.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Recurrent left pleural effusion s/p Left VATS pleurodiesis.
2. COPD
3. CAD
4. Hyperlipidemia
5. HTN
6. Endostenting of his aortic aneurysm as well as left
subclavian to left common carotid artery bypass and a left
common
carotid to right common carotid artery bypass on [**2151-11-15**]
Discharge Condition:
Stable.
Discharge Instructions:
-You may shower, but cover chest tube sites with a bandaid.
-Do not drive while taking narcotics.
-Walk with family three times a day.
-Keep urinary catheter in, and secure with leg bag. Make sure
you do not tug at this.
Followup Instructions:
1. Follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] office (urology - for your
urinary catheter) in one week. Please call for follow up
appointment ([**Telephone/Fax (1) 4376**]. Tell them when making your
appointment that you have catheter and you have just left the
hospital.
2. Follow up with Dr. [**Last Name (STitle) **] on [**2152-1-11**] at 10am in [**Hospital1 **]
116 on [**Hospital Ward Name 517**]. Please get chest xray 45 minutes prior in
clinical center [**Hospital Ward Name **] 3th floor radiology.
3. Follow up with your primary care physician in the next two
weeks.
4. You will need a CBC, and chemistry blood draw in one week.
Completed by:[**2151-12-27**]
ICD9 Codes: 5119, 496, 2724, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6546
} | Medical Text: Admission Date: [**2191-5-11**] Discharge Date: [**2191-5-20**]
Service: MEDICINE
Allergies:
Megace
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Shortness of breath
Hypotension
Major Surgical or Invasive Procedure:
Intubation
Chest tube placement
Femoral Line placement
History of Present Illness:
84 y/o M w/dementia, LE edema, and hyperlipidemia, who presented
to ED with acute SOB. This initially happened while he was on
the toilet. His wife called EMS, and he was initially
tachycardiac to 120, bp 112/76, rr 36 . He was diaphoretic,
denied CP. He had CXR at OSH which by report showed assymm pulm
edema R>L. Pt had ECG w/sinus tach, nl axis/int, ST depression
inf/lat. ABG 7.41/25/150 on NRB. He was started on CPAP, given
MS 2 mg IV, Lasix 80 IV, nitro gtt, heparin gtt for concern of
PE. LENI at OSH of swollen LLE neg for DVT. BP dropped from
126/65 to 71/37 with the nitro, which resolved when the drip as
stopped. He was intubated at noon after not tolerating CPAP, and
becoming tachypneic on NRB. Here, he was noted to have
anisocoria not previous noted. Head CT showed no bleed, no
shift. CXR showed widened mediastinum, so he had a CTA. This
revealed bilateral PEs as well as an apical ptx. He was
restarted on the heparin gtt and a chest tube was placed. Pt
admitted to MICU for stabilization. Pt was extubated on [**5-13**].
Past Medical History:
Althzeimers Dementia
Hyperlipidemia
Social History:
Lives at home with wife.
Family History:
Unable to obtain
Physical Exam:
VITALS: Afebrile, 108/60, 90, 98%RA
GEN: Pleasant elderly male, NAD, NRB on although pt is not
tachypeic and appears comfortable.
HEENT: Pupils are equal, round, reactive. Head is
normocephalic, atraumatic. Neck is supple, no lymphadenopathy.
LUNGS: R ant field clear, L ant field with rale and subQ
emphysema, R base with good air movement and occ rales, L base
with rale.
HEART: Regular rate and rhythm, no murmurs, rubs, or gallops.
Carotids: Normal pulsation without bruits.
Extremities: 3+ pedal edema to knee, non-palpable pulses, feet
are warm with good color.
Abdomen: soft, nondistended, and nontender, normoactive BS.
Neurologic exam: Alert, oriented to Person only. Babinskis are
equivocal.
Skin: No rash.
Pertinent Results:
CTA of chest: CT ANGIOGRAPHY OF THE CHEST: Multiple pulmonary
emboli are seen; in the proximal portion of the right pulmonary
artery posterior branch near the bifurcation, extending into the
superior segment of the lower lobe. A smaller amount of clot is
seen in the pulmonary artery feeding the right middle lobe
medial segment. On the left, clot is seen in the pulmonary
artery feeding the posterior left upper lobe, and also in the
segment feeding the anteromedial left lower lobe. The aorta is
normal in caliber, with wall calcifications. No dissection is
seen. There are calcifications within the coronary arteries. No
pericardial effusion is present.
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: A small
pneumothorax is seen on the left; additionally, there is a small
amount of mediastinal air along the left superior mediastinal
border, into the apex of the lung. Dependent atelectasis is seen
on both sides; additionally, a peripheral portion of
consolidation in the right lower lobe superior segment is distal
to the portion of largest clot, and may represent developing
pulmonary infarction. There are shotty mediastinal lymph nodes.
A nasogastric tube is seen coiling in the stomach. The patient
is intubated. The imaged portions of the abdomen, including the
superior aspect of the spleen and liver, are unremarkable. A
nasogastric tube is seen in the esophagus, which is mildly
thickened; some debris and air bubbles within it, without
obvious tear.
Osseous structures are remarkable for degenerative changes of
the spine. There is an old healed rib fracture of the anterior
aspect of right rib number seven. A small amount of air seen in
the subclavian vein on the left, probably due to phlebotomy.
Coronal and sagittal reformations were essential in delineating
the anatomy and pathology. MPR value 4.
IMPRESSION:
1. Segmental pulmonary emboli in bilateral pulmonary arteries.
Associated peripheral consolidation in the right lower lobe,
concerning for infarct vs consolidation.
2. Small left pneumothorax and pneumomediastinum in intubated
patient.
3. Nasogastric tube in mildly thickened esophagus, with debris
and small amount of air, but no obvious tear.
4. Aortic calcifications, without evidence of dissection or
dilatation.
.
.
ECHO: 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 probably normal
(LVEF>55%).
Right ventricular chamber size is normal. Right ventricular
systolic function is normal. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. The mitral
valve leaflets are mildly thickened. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
.
.
CT HEAD W/O CONTRAST [**2191-5-11**] 1:21 PM
No intracranial hemorrhage. Diffuse chronic changes. There
appears to be interval marked atrophic change since [**2185**] which
could represent an accelerated degenerative process.
Additionally, there is marked interval enlargement of the
ventricles which may in part represent hydrocephalus (partly
related to atrophy) - there is hypo-attenuation of the
periventricular white matter which may represent chronic
ischemic changes or trans-ependymal edema. Further evaluation
with MRI might be helpful if clinically indicated.
CTA CHEST W&W/O C &RECONS [**2191-5-11**] 2:46 PM
bilateral pulmonary emboli.
left lower lobe superior segment peripheral consolidation
suspicious for infarction.
right pneumothorax, pneumomediastinum.
endotracheal tube and ng tube; esophagus has some debris and a
few air bubbles in it but no obvious tear.
.
LABS ON ADMISSION:
[**2191-5-11**] 11:34PM TYPE-ART PO2-107* PCO2-33* PH-7.47* TOTAL
CO2-25 BASE XS-0
[**2191-5-11**] 11:34PM LACTATE-2.8*
[**2191-5-11**] 11:34PM HGB-10.6* calcHCT-32
[**2191-5-11**] 06:35PM PT-14.9* PTT-50.6* INR(PT)-1.5
[**2191-5-11**] 03:50PM TYPE-ART TEMP-37.2 RATES-/15 TIDAL VOL-550
O2-80 PO2-249* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0 AADO2-295
REQ O2-54 -ASSIST/CON INTUBATED-INTUBATED
[**2191-5-11**] 03:29PM PT-100* PTT-150* INR(PT)-66.1
[**2191-5-11**] 01:12PM GLUCOSE-234* UREA N-38* CREAT-1.5*
SODIUM-146* POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-18* ANION
GAP-24*
[**2191-5-11**] 01:12PM ALT(SGPT)-12 AST(SGOT)-35 CK(CPK)-102 ALK
PHOS-99 TOT BILI-0.7
[**2191-5-11**] 01:12PM CK-MB-4 cTropnT-0.04*
[**2191-5-11**] 01:12PM TOT PROT-7.2 ALBUMIN-3.3* GLOBULIN-3.9
CALCIUM-8.6 PHOSPHATE-4.4 MAGNESIUM-1.9 IRON-23*
[**2191-5-11**] 01:12PM calTIBC-205* VIT B12-412 FOLATE->20
FERRITIN-347 TRF-158*
[**2191-5-11**] 01:12PM WBC-5.1# RBC-4.00* HGB-12.5* HCT-38.7* MCV-97
MCH-31.3 MCHC-32.4 RDW-13.7
[**2191-5-11**] 01:12PM PLT COUNT-275
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM:
.
1. PE/DVT: Pt presented with resp failure and hypotension. Found
to have PE on CTA and subsequently found to have L leg DVT. Wife
reports that patient is very sedentary at home and only gets up
with assitance which may be once per day. In addition, he was on
Megase which can be prothrombotic. The patient was intubated in
the ED for ventilation and started on heparing gtt. The patient
was extubated within 48 hours and his respiratory status
continued to improve. On transfer from the MICU the patient had
an O2 sat of 95% on RA. IVC filter was considered for
prophylaxis, however it was felt that coumadin would be a better
long term management of his DVT and PE. The risk of fall was
considered, however the patient will be going to rehab and
likely a longterm care facility and would be able to ambulate
with assistance.
The patient was GUIAC neg which was checked prior to initiating
heparin. The patient was transitioned to Lovenox 50mg [**Hospital1 **] during
a bridge to a therapeutic INR. Goal INR is [**1-27**]. The Lovenox was
discontinued after the patient maintained an INR >2 for 48
hours. The patient should be maintained on coumadin for at least
6 months.
.
2. Ptx: Pt with PTX likely [**1-26**] barotrauma. Although this was a
very small PTX, pt was hypotensive in ED and thought that PTX
was expanding. Large bore needle was placed followed by a chest
tube and patiet received fluid resusciation. Pt had chest tube
removed on [**5-13**]. Serial CXR's showed PTX decreased in size and
was no longer present on [**5-18**]. Pt maintained O2 sats at 97% on
RA and SBP stable in 130's.
.
3. UTI: Pt found to have UTI after multiple days with foley
catheter in place. Foley was d/c'd and patient started on Cipro.
E.coli on cx was pan-sensitive but patient remained on quinolone
for complicated UTI. Pt should be treated for 7 days.
.
4. Hypotension: Pt was hypotensive on admission. Initially
thought to be due to sepsis vs volume depletion. Resolved with
IVF. Pt was volume repleted in MICU and BP's stable at time of
discharge. Pt is on no BP medications at home.
.
5. Anisocoria: On initial exam in ED, patient found to have
anisocoria. Pt had head CTA in MICU to assess for posterior
aneurysm. This was normal and anisocoria resolved on hospital
day 2. Unclear cause of inital exam findings.
.
6. Anemia: Pt was GUIAC neg during admission. Iron low but
ferritin elevated, likely reactive suggesting anemia of chronic
disease. Also likely decreased HCT from procedures and fluid
shifts from resucitation.
.
7. Dementia: Pt has an extensive history of Alzthiemers dementia
noted in past records. On this admission, MS improved after
infections treated and resp status stable. Pt was continued on
Exelon.
.
8. FEN: After extubation, pt was evaluated for ability to
swallow different consistencies given poor mental status. Pt
passed barium swallow study for ground solid food and thin
liquids. Pt should have a boost with every meal for added
nutritional supplementation.
.
8. Ppx: Pt was on a heparin gtt and then lovenox. Pt was started
on an PPI.
9. Code: DNR/DNI- While in MICU, wife and family physician had
long discussion with MICU team and decided to make patient
DNR/DNI.
Medications on Admission:
Exelon 0.6mg [**Hospital1 **]
Lipitor 10mg
Multivit
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary:
Pulmonary Embolism
Deep Vein Thrombosis
Urinary Tract Infection
Secondary:
Dementia
Hyperlipidemia
Discharge Condition:
Stable. Patient discharged to [**Hospital1 1501**]. Will probably require long
term placement.
Discharge Instructions:
Please return to the hospital if you experience shortness of
breath, chest pain, leg swelling, severe
nausea/vomiting/diarrhea or any other severe symptoms. Please
call your physician if you have any questions about your
symptoms.
- Please have your INR checked until a stable dose of coumadin
maintinas your INR between [**1-27**].
Followup Instructions:
Please follow-up with your PCP in one week.
Completed by:[**0-0-0**]
ICD9 Codes: 5990, 2765, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6547
} | Medical Text: Admission Date: [**2103-4-6**] Discharge Date: [**2103-4-7**]
Date of Birth: [**2052-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Placement of [**Last Name (un) 10045**] tube for variceal bleeding
Cardiopulmonary resuscitation
History of Present Illness:
Mr. [**Known lastname 51106**] is a 50M with history of hepatitis C s/p aborted
IFN treatment and alcohol cirrhosis, who is transferred from OSH
with GI bleed and hypotension. On transplant list. Discharged on
20th hepatic encephalopathy.
.
Presented yesterday morning to [**Hospital 792**]Hospital with
massive esophageal bleed with hgb 5, sbp 50s. [**Last Name (un) **] was
placed in the ED, had esoph banding x 5. A total 10u rbc, 8u
ffp, 15u platelets, 15mg vit K, 7L NS was given in the course.
Post banding he arrived to the OSH MICU. He was progressively
hypotensive and was started on 20 of levophed + vasopressin. He
was placed on protonix and octreotide drip. Decision to transfer
to [**Hospital1 18**] yesterday. This now on 2 of levophed, off vasopressin,
map 65. Intubated on pressure control 40 fio2, 22/5. This AM
prior to transfer hgb 8.8, plt 120--> 71 despite transfusion,
wbc 8.7. Was placed on cefotaxime for empiric sbp coverage but
climb from 1.2-2.6. Potassium to 6 this am-- got ca gluc,
insulin, d50, starting bicarb gtt, no peaked T wave changes on
EKG. INR from 5--> 1.8 after vit k, ffp. T bili 16.1, AST 1323,
314. Prior to tranfer map 65, hr 70 (L arm 20mm
difference),patient intubated sedated (morphine and ativan).
Note of a distended abdomen with report of kub with gas. No
further active hematemesis. Yesterday blood coming from mouth
and nasopharynx which was thought [**1-15**] trauma. [**Last Name (un) **] has been
discontinued. He received 4mg morphine, 4mg ativan over past
24h. Access included R IJ TLC, 2 periph 18, 1 20gg IV. They had
planned to order 2u RBC for transport. Discussion with [**Hospital1 18**]
hepatology service was done prior to transfer. Last MELD 42.
.
On arrival to the [**Hospital1 18**] ICU patient hypotensive to 70/40,
vasopressin added with good result MAP to 62. Abdomen markedly
distended.
.
Patient is known to the liver service at [**Hospital1 18**]. Hepatitis C
genotype 3 s/p IFN, treatment stopped due to thrombocytopenia,
participated in Eltrombopag study, last HCV VL 1,540 IU/mL, has
been decreasing w/o treatment. Cirrhosis with encephalopathy and
ascites with hx of SBP on norfloxacin prophylaxis, diuretics.
Esophageal varices s/p banding at [**Hospital 792**]Hospital [**2103-3-8**].
No EGD in [**Hospital1 18**]. Creatinine baseline 0.6-0.9. No hx of
hepatorenal.
Past Medical History:
- hepatitis C genotype 3 s/p IFN, treatment interrupted due to
thrombocytopenia, participated in Eltrombopag study, last HCV VL
1,540 IU/mL, has been decreasing w/o treatment
- cirrhosis c/b encephalopathy and ascites; workup started for
transplant
- varices (?type) s/p banding at [**Hospital 792**]Hospital [**2103-3-8**]
- bronchitis
- asthma
- h/o seizure in the setting of alcohol withdrawal
- h/o negative PPD
Social History:
He lives alone in a rooming house. His daughter lives 15 minutes
a way, and another daughter lives close by. He has a companion
who is supportive but is also a recovering alcoholic. He smokes
cigarettes. He has smoked for 35-40 years at 2-3 packs per day,
but now has cut down to less than 1 pack per day. He has been
drinking alcohol since age 14-15 with 6-12 beers a day with
shots of liquor, but has been sober for 21 months. He previously
used quite a bit of recreational drugs including marijuana,
cocaine, psychedelic drugs. Brief IVDA in the past.
Family History:
His father, uncle, brother and wife all died of alcoholic
cirrhosis. There is no history of heart disease, diabetes or
cancer in the family.
Physical Exam:
VS: 104, 80/40, 98.4, CVP 33, bladder pressure 25. AC PEEP 5, RR
14, TV 550.
GEN: ill appearing male with distended abdomen on ventilator,
jaundiced
HEENT: icteric difficult to assess JVP. Blood suctioned from
oropharynx, ET tube present
CV: RRR no MRG
CHEST: diminished breath sounds bilaterally
ABD: distended, tense, dullness to percussion. No bowel sounds
heard. Hepatosplenomegaly present. Site of previous para with
oozing of peritoneal fluid, echymoses.
EXTR: edema, cool LE, palpable distal pulses
NEURO: sedated.
Pertinent Results:
CHEST (PORTABLE AP) [**2103-4-6**]:
SINGLE PORTABLE AP UPRIGHT CHEST: Compared to CT of [**2103-4-1**]. The
extreme
lung apices are excluded on this study as is the left CP angle.
There is a NG tube in place with its tip in the fundus of the
stomach. The visualized lung parenchyma is clear. There is no
evidence of CHF/volume overload. The heart size is within normal
limits and the mediastinal and hilar contours are unremarkable.
ABDOMEN U.S. (COMPLETE STUDY) PORT [**2103-4-6**]:
IMPRESSION:
1. Findings consistent with cirrhosis.
2. Bidirectional Doppler waveform in the main portal vein,
indicating mixed hepatopetal and hepatofugal flow.
3. Gallstones with gallbladder wall thickening, stable.
4. Small amount of ascites.
CHEST (PORTABLE AP) [**2103-4-7**]:
SINGLE SUPINE PORTABLE RADIOGRAPH: Compared to study of one hour
prior. The [**Last Name (un) **] tube remains in place with its tip coursing
off the inferior aspect of the image. It loops on the superior
aspect of the image, perhaps residing outside of the patient,
but may be coiled in the hypopharynx. The balloon has been
deflated since the prior radiograph. There is no definitive
evidence of pneumomediastinum or pneumothorax. There remains
moderate volume overload. Right IJ tip is difficult to directly
visualize given technique.
ABDOMEN (SUPINE ONLY) PORT [**2103-4-7**]:
FINDINGS: There is a nasogastric tube and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube
identified. There is a large amount of gas seen within the
stomach. There are prominent loops of likely colon. There is
also increased density throughout the abdomen consistent with
known ascites. There is no definite evidence for free
intra-abdominal air or pneumatosis. This bowel gas pattern is
nonspecific. If there is high clinical concern, a CT scan could
be performed.
HEMATOLOGY:
[**2103-4-6**] 03:18PM BLOOD WBC-10.3# RBC-2.71* Hgb-9.0* Hct-23.7*
MCV-87# MCH-33.1* MCHC-37.8* RDW-19.6* Plt Ct-85*
[**2103-4-6**] 09:51PM BLOOD WBC-5.8 RBC-1.47*# Hgb-4.9*# Hct-13.2*#
MCV-90 MCH-33.0* MCHC-36.6* RDW-21.1* Plt Ct-46*
[**2103-4-6**] 11:14PM BLOOD WBC-5.8 RBC-1.54* Hgb-4.9* Hct-14.2*
MCV-92 MCH-32.1* MCHC-34.7 RDW-20.2* Plt Ct-41*
[**2103-4-7**] 12:06AM BLOOD WBC-4.6 RBC-2.03*# Hgb-6.4*# Hct-18.8*#
MCV-93 MCH-31.3 MCHC-33.7 RDW-17.0* Plt Ct-69*#
COAGS:
[**2103-4-6**] 03:18PM BLOOD PT-34.0* PTT-50.7* INR(PT)-3.6*
[**2103-4-6**] 09:51PM BLOOD PT-38.9* PTT-70.7* INR(PT)-4.2*
[**2103-4-6**] 11:14PM BLOOD PT-41.9* PTT-80.6* INR(PT)-4.6*
[**2103-4-7**] 12:06AM BLOOD PT-22.4* PTT-81.7* INR(PT)-2.1*
[**2103-4-6**] 03:18PM BLOOD Fibrino-113*
CHEMISTRIES:
[**2103-4-6**] 03:18PM BLOOD Glucose-82 UreaN-38* Creat-2.7*# Na-138
K-5.9* Cl-104 HCO3-21* AnGap-19
[**2103-4-6**] 09:51PM BLOOD Glucose-35* UreaN-37* Creat-3.3* Na-140
K-5.8* Cl-106 HCO3-17* AnGap-23*
[**2103-4-6**] 11:14PM BLOOD Glucose-94 UreaN-35* Creat-3.0* Na-139
K-6.3* Cl-106 HCO3-15* AnGap-24*
[**2103-4-7**] 12:06AM BLOOD Glucose-108* UreaN-31* Creat-2.7* Na-144
K-5.8* Cl-110* HCO3-14* AnGap-26*
[**2103-4-6**] 03:18PM BLOOD ALT-2844* AST-8550* AlkPhos-709*
TotBili-21.5*
[**2103-4-6**] 09:51PM BLOOD ALT-1794* AST-6158* LD(LDH)-4494*
AlkPhos-529* TotBili-15.9*
[**2103-4-6**] 11:14PM BLOOD ALT-1462* AST-4930* LD(LDH)-3660*
CK(CPK)-1274* AlkPhos-437* TotBili-13.6*
[**2103-4-6**] 03:18PM BLOOD Albumin-2.4* Calcium-7.7* Phos-8.6*#
Mg-1.8
LACTATES:
[**2103-4-6**] 03:34PM BLOOD Lactate-5.9*
[**2103-4-6**] 06:32PM BLOOD Lactate-7.1*
[**2103-4-6**] 10:00PM BLOOD Lactate-9.0*
[**2103-4-6**] 11:19PM BLOOD Lactate-10.8*
[**2103-4-7**] 12:15AM BLOOD Lactate-10.7*
ASCITIC FLUID STUDIES:
ASCITES ANALYSIS
[**2103-4-6**] 05:00PM WBC 80, RBC 3925, Polys 18, Lymphs 13
ASCITES CHEMISTRY
[**2103-4-6**] 05:00PM Glucose 100, LD(LDH) 154
Brief Hospital Course:
Following patient's admission he immediately required addition
of vasopressin to norepinephrine to support his blood pressure.
Hepatology service was aware of patient prior to transfer and
was consulted at time of admission. Due to low tidal volumes on
ventilator and a tense abdomen at admission, a therapeutic
paracentesis was performed with removal of 5 liters of ascitic
fluid and noted improvement in both tidal volumes and bladder
pressures. The fluid proved to have a high RBC count; however,
was not consistent with SBP as there were only 80 total WBCs.
100 grams of albumin were given at time of paracentesis in order
to support intravascular volume. Patient was also ordred for 2
units of PRBCs to be transfused at time of admission; however,
his HCT was stable upon transfer from outside hospital. Several
hours following admission, the patient's blood pressure began to
drop with MAPs in the mid-50s despite 1 L NS as well as the
previously mentioned 100 g albumin. PRBCs were unable to be
obtained for transfusion due to the patient having antibodies
making crossmatch exceedingly difficult. At this time 1 L NS was
infused and phenylephrine was initiated as a third vasoactive
[**Doctor Last Name 360**] to support blood pressure. In recognition of falling blood
pressure, NG tube was hooking to suction and appromiately 500
mLs of dark red blood were pulled to suction trap. Then in
recognition of likely repeat variceal bleeding, additional NS
was infused and blood bank was contact[**Name (NI) **] for emergency release
of blood prior to complete crossmatch. Hepatology service was
simultaneously contact[**Name (NI) **] and they came into the hosptial with
plans to place [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube to tamponade the bleeding.
Shortly after blakmore was inserted and prior to confirmatory
CXR or inflation of [**Last Name (un) **] balloon, the patient became
bradycardic and lost a pulse. CPR was initiated as indicated for
pulseless electrical activity. During code compressions were
done continuously save rhythm checks. Several rounds of atropine
and epinephrine were given. A femoral cordis was placed and many
units of blood were given via rapid transfuser. In all, patient
received 9 units of PRBCs, 8 units of FFP, 2 bags of platelets,
and 2 units of cryoprecipitate. He was shocked a single time
following identification of an unstable narrow-complex
tachycardia. A pulse and stable blood pressure were regained and
code was ceased. Despite the massive amount of blood products
transfused, the patient's HCT only changed from 13 prior to code
to 19 at the end of the code. Patient's two daughters had been
present for most of code. They were updated on the patient's
poor prognosis following the code and decided to make the
patient DNR/DNI as well as "comfort measures only". Prior to
being able to carry out cessation of supportive medication and
ventilation, the patient became bradycardic and lost his pulse
again. He was pronounced dead shortly following this second
episode of bradycardia and loss of pulse.
Medications on Admission:
MEDICATIONS AT HOME (per last D/C summary):
Albuterol 90 mcg 2 puffs every day
Advair 250/50 1 INH [**Hospital1 **]
Furosemide 40 mg once a day
Spironolactone 100 mg once a day,
Nadolol 20 mg once a day
Esomeprazole (Nexium) 40 mg once a day,
Lactulose 30cc QID
Norfloxacin 400mg daily
Trazodone 50 mg qHS
Magnesium oxide 400mg daily
Citalopram 40mg daily
Nicotine 21mg [**12-15**] patch daily
MEDICATIONS AT TIME OF TRANSFER:
Levophed gtt
Octreotide gtt
Protonix gtt
Morphine prn
Ativan prn
Discharge Medications:
None, patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Gastrointestinal bleeding
Secondary:
Hepatic cirrhosis
Hepatic failure
Discharge Condition:
None. Patient expired.
Discharge Instructions:
None. Patient expired.
Followup Instructions:
None. Patient expired.
Completed by:[**2103-4-18**]
ICD9 Codes: 5845, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6548
} | Medical Text: Admission Date: [**2156-5-28**] Discharge Date: [**2156-5-28**]
Date of Birth: [**2087-4-14**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
"My head hurts"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69M presents to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital with one week history of
left headache, tinnitus left ear and as of this am, nausea and
vomiting, worse when bending forward. He has not had any recent
trauma, but a head injury in [**2155-11-24**] but no residual
symptoms since then. He has not had any change in vision or
other focal neurological deficits. He was seen at OSH, where a
CT demonstrated bilateral SDH and he was transferred to [**Hospital1 18**].
Today, he reports of moderate headaches controlled on current
regimen. He denies any nausea or vomiting.
Past Medical History:
- HTN
- hypothyroid
- HLD
Social History:
Lives at home with wife, currently suffers from alcohol abuse,
+tobacco
Family History:
Non-contributory
Physical Exam:
Admission:
O: Tempo 97 HR 55 BP 149/70 RR 18 98% 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: equal and reactive to light EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-25**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-27**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On Discharge: Pt alert, awake oriented x 3, PERRL, EOM full,
face symmetric, Motor is full b/l, no pronator drift, sensory
intact, reflexe2+ bilaterally
Pertinent Results:
[**2156-5-28**] 03:48AM GLUCOSE-153* UREA N-21* CREAT-0.9 SODIUM-140
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2156-5-28**] 03:48AM CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-2.0
[**2156-5-28**] 03:48AM WBC-9.5 RBC-4.44* HGB-15.1 HCT-42.6 MCV-96
MCH-34.0* MCHC-35.4* RDW-12.7
[**2156-5-28**] 03:48AM PLT COUNT-235
[**2156-5-28**] 03:48AM PT-14.5* PTT-24.0 INR(PT)-1.3*
[**2156-5-27**] 11:45PM GLUCOSE-148* UREA N-20 CREAT-0.9 SODIUM-139
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2156-5-27**] 11:45PM estGFR-Using this
[**2156-5-27**] 11:45PM WBC-8.7 RBC-4.72 HGB-16.1 HCT-45.2 MCV-96
MCH-34.2* MCHC-35.7* RDW-12.7
[**2156-5-27**] 11:45PM NEUTS-89.2* LYMPHS-7.8* MONOS-2.3 EOS-0.3
BASOS-0.5
[**2156-5-27**] 11:45PM PLT COUNT-227
[**2156-5-27**] 11:45PM PT-14.6* PTT-23.2 INR(PT)-1.3*
Brief Hospital Course:
Patient was admitted to Neuro ICU overnight on [**2156-5-27**] for
frequent neuro checks. He was evaluated by Dr. [**Last Name (STitle) 739**]
and he remained stable during his course. It was recommend that
we would monitor his chronic subdurals on interval basis as an
outpatient. He was evaluated by PT as he has history of falls
and they recommend Home.
Now DOD [**2156-5-28**], pt is afebrile, VSS, neurologically unchanged
and tolerating a good PO diet. His headache was controlled with
tylenol and codeines. He is set for d/c home and will f/u with
Dr. [**Last Name (STitle) 739**] accordingly.
Medications on Admission:
diovan 80 mg daily; l-thyroxine 0.112 mg daily; vit D 1000 IU
daily; ASA 81 mg daily; Fish oil 1000 mg daily
Discharge Medications:
1. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
7. Dilantin Kapseal 100 mg Capsule Sig: One (1) Capsule PO three
times a day for 4 weeks: please f/u with PCP.
8. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
three times a day as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute of Chronic bilateral Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? 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:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks with a repeat head CT in 4
weeks
- Please follow up with your PCP [**Name Initial (PRE) 72304**] 2-3 days after
discharge.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2156-5-28**]
ICD9 Codes: 4019, 2449, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6549
} | Medical Text: Admission Date: [**2173-7-29**] Discharge Date: [**2173-8-13**]
Date of Birth: [**2099-12-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname 82732**] is a 73 you woman with squamous cell head and nexk
cancer currently undergoing XRT, COPD, HTN, CAD s/p MI and stent
implantation in [**2171**] who presents from [**Hospital 100**] Rehab with
delirium and fever.
.
She is a vague historian, but denies chest pain, fevers, cough,
sputum production, shortness of breath, chest pain, LE swelling,
blood in her stool or urine. She denies abdominal pain or
vomiting.
.
In the ED, her initial VSs were 102.4, 116, 145/81, 14, 98%RA.
She received IVF, levofloxacin and metronidazole.
.
PAST ONCOLOGIC HISTORY:
======================
The patient noticed a right neck mass approximately in [**3-15**]. She
brought the mass to the attention of her physician who obtained
[**Name Initial (PRE) **] CT of the neck, chest, abdomen, and pelvis at the [**Hospital1 16549**]. Neck, chest, and abdominal CT on [**2173-4-7**] showed
marked thickening of the right lateral oropharyngeal wall up to
approximately 2 cm and a 4.5 x 3 cm lobulated, heterogeneous,
right neck mass deep to the sternocleidomastoid muscle that
displaced the right carotid artery. No other lymphadenopathy was
visualized and there were no suspicious lung nodules. A 10 cm
right adnexal mass was visualized. This right ovarian mass has
been stable and was previously evaluated. Neck ultrasound on
[**2173-4-22**] at the [**Hospital6 2910**] showed a 5.5 x 4 cm
neck mass suspicious for neoplastic process. On [**2173-4-26**], Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 66245**] took the patient to the operating room for direct
laryngoscopy and tonsillar biopsy. The right tonsil contained an
ulcerative lesion, which was biopsied. The larynx and
hypopharynx appeared normal. Pathology was read at the [**Hospital1 **] as invasive moderately differentiated
squamous cell carcinoma. She is currently undergoing
radiotherapy.
Past Medical History:
PAST MEDICAL HISTORY:
====================
Chronic obstructive pulmonary disease
Hypertension
Hypercholesterolemia
Pernicious anemia
CAD s/p MI and stent implantation in [**2171**]
h/o GI bleed
Social History:
EtOH: Doesn't drink
Tobacco: quit in [**2171**], 60-75 PY history
Family History:
nc
Physical Exam:
Vitals - T: 98.4 BP: 130/70 HR: 100 RR: 16 02 sat: 93%RA/
GENERAL: NAD, alert and oriented x 2; "[**Hospital6 **]"
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, no LAD, no JVD, Reactive change in pharynx in
field of radiation. Dry MM.
CARDIAC: RRR regular skipped beats, normal S1/S2, no mrg
appreciated
LUNG: bronchial breath sounds and crackedin left middle lung
field.
ABDOMEN: soft, large echymossis on LLQ, G tube with moderate
amount of erythema surrounding it. 5 inch midline incision c/d/i
M/S: moving all extremities well, no cyanosis, clubbing. s, no
obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact.
Pertinent Results:
[**2173-8-11**] 05:50AM BLOOD WBC-10.6 RBC-3.06* Hgb-9.5* Hct-28.1*
MCV-92 MCH-31.1 MCHC-33.9 RDW-18.6* Plt Ct-344
[**2173-8-10**] 03:16AM BLOOD WBC-8.6 RBC-2.65* Hgb-8.2* Hct-24.6*
MCV-93 MCH-31.0 MCHC-33.3 RDW-18.8* Plt Ct-249
[**2173-8-5**] 02:25AM BLOOD WBC-8.9 RBC-3.63*# Hgb-11.0*# Hct-31.5*#
MCV-87 MCH-30.3 MCHC-34.9 RDW-17.8* Plt Ct-195
[**2173-7-29**] 05:00PM BLOOD WBC-8.4 RBC-2.38* Hgb-7.7* Hct-23.4*
MCV-98 MCH-32.3* MCHC-32.8 RDW-21.5* Plt Ct-244
[**2173-8-9**] 05:20AM BLOOD PT-14.8* PTT-26.2 INR(PT)-1.3*
[**2173-8-11**] 05:50AM BLOOD Glucose-97 UreaN-10 Creat-1.2* Na-142
K-3.0* Cl-104 HCO3-29 AnGap-12
[**2173-8-10**] 10:35AM BLOOD Creat-0.9 Na-141 K-3.7 Cl-104
[**2173-8-10**] 03:16AM BLOOD Glucose-78 UreaN-8 Creat-0.9 Na-143
K-2.8* Cl-105 HCO3-26 AnGap-15
[**2173-7-29**] 05:00PM BLOOD cTropnT-0.15*
[**2173-7-30**] 09:00AM BLOOD CK-MB-12* cTropnT-0.13*
[**2173-7-31**] 07:20AM BLOOD CK-MB-8 cTropnT-0.12*
[**2173-8-5**] 02:25AM BLOOD CK-MB-6 cTropnT-0.09*
Brief Hospital Course:
Patient was admitted from [**Hospital **] rehab on [**2173-7-29**] with delirium.
She denied all symptoms. In the ED, she was found febrile and to
have consolidation in her LLL. Additionally, she was then
discovered to be in ARF and anemic with a troponinemia and EKG
with various territories of mild ST depression. Accordingly, she
was treated for HAP with Vanc/Zosyn. Admitted on tele and
transfused with two units.
There was some concern for an aspiration PNA. She passed a
video-swallow and was put on a diet of thins and purees in which
her pills were crushed. The patient proceeded to improve rapdily
and in the AM of [**2173-7-30**], restarted XRT to the neck with Dr.
[**Last Name (STitle) 3929**]. She stayed in house, receiving IV abx and XRT.
While in hospital, the patient was restarted on tube feeds to
ensure proper nutrition and avoid the burden that PO was placing
on the friable mucosa of the pharynx in the field of the XRT.
She will be discharged on 55 ml/hour of fibersource per
nutrition consultation. The G tube site remained a persistent
concern, however. Accordingly, we asked consultants from both
surgery and then GI to evaluate the g tube. There was leaking of
a dark and viscous fluid from around the 20 french tubing. Given
how new it was and the fact that it was not placed by a [**Hospital1 18**]
practioner, the goals of gtube management shifted to wound care.
While the site remained irritated and bled about a tea-spoon per
day, it was stable and did not bother the patient.
Overnight on [**8-3**], the patient had three dark red bowel
movements with a hct that trended from 26 to 24.4 to 19.5. The
morning of [**8-4**], she had another large black tarry bowel movement
and was tachycardic to the 120s from a baseline fo 90-100. Her
g-tube was also flushed and demonstrated coffee grounds, and was
also noted to have an increase in BUN from 16 to 26 from the
prior day. The patient received 1.6L IVF and was ordered for 2
units PRBC prior to transfer to the [**Hospital Unit Name 153**].
On admission to the [**Hospital Unit Name 153**], the patient was evaluated for active
bleeding and transfused 2 unites PRBCs. Endoscopy was performed
to evaluate the bleeding around the G-tube site and clamping was
attempted, but not successful. Patient was sent for surgery
where the bleeding artery was oversewn and the G-tube was
replaced and re-sited with another G-tube. The patient recieved
two more units of PRBCs and was then transferred post-op back to
the ICU for monitoring. Post-operatively, the pt had episodes
of hypertension, which improved with pain control. On post-op
day 1, the patient was hemodynamically stable the entire day.
She was transferred back to the OMED service on [**8-6**]
hemodynamically stable with Hematocrit 29.3, pain well
controlled.
On the day of planned discharge, the patient began to experience
some tachycardia by tele. She was asymptomatic and clinically
better than ever before. Nevertheless, an EKG was ordered that
was improved when compared to the admission EKG and a unit of
blood was transfused over three hours.
On [**8-8**], the patient was transferred back to the [**Hospital Unit Name 153**] for acute
respiratory distress with increased oxygen requirements. A
large mucus plug was suctioned from the patient's oropharynx and
her respiratory distress resolved. A CXR showed no worsening
infiltrate although there was possibly increased pulmonary
edema/ atelectasis. The patient was continued on her antibiotic
course for HAP and was gently diuresed with fluid goal of -500
to -1L. During the night, the patient intermittently required
increased oxygen for saturations down to 88%- this was thought
to be related to inadequate clearing of oropharyngeal mucus
plugs with a component of sleep apnea. The patient continued to
have guiac positive stools, but this was felt to be residual
from her GI bleed and her hct remained stable. Overall, the
patient's respiratory status improved and she was transferred
back to the OMED service on [**8-10**].
On post-op day 2, the patient was noted to have a possible
expressive aphasia. Final review of a CT Head showed a right
parietal hypodensity. Neurology was consulted and suspected a
right temporal stroke. The patient's mental status improved,
but the patient had possible left sided hypesthesia and mild
left upper extremity motor weakness. ASA was restarted but her
plavix was held in light of the patient's recent GI bleed.
Initially there was concern that the right carotid artery may be
compressed by tumor, so neurology recommended permissive
hypertension until MRA of neck and CNS assessed patency of
vessels. TTE with bubble study showed no PFO or ASD as possible
source for emboli. Carotid dopplers and MRI looked good but
official reads were pending.
On the floor, we shifted focus and treated the patient for a CHF
exacerbation. After a negative balance of 1500 cc, she was
markedly improved clinically and we prepared her for discharge
to rehab.
<b> SUMMARY </b>
.
1. Delirium - while the patient has some baseline dementia, she
is fully oriented and interactive ([**Location (un) 1131**] the paper) at
baseline. She presents with delirium for Pneumonia, CHF, and GI
bleed
.
2. GI bleed - after the operative repair she is stable. It was
related to an exposed vessel. Continue tube feeding.
.
3. Arterial Disease - Patient should remain on Aspirin and
Clopidogrel. Also, continue lovenox. Most likely, the patient
did not have a CVA.
.
4. CHF - This patient has an EF of 45-50%. She is sensitive to
fluids. We used a short course of lasix to improve the balance
.
5 Respiratory Failure - the patient had some trouble clearing
secretions, requiring deep suction. We recommend regular
nebulizer treatments, oral care and suctioning.
.
6. Head and Neck cancer - The patient has completed her
treatment at present
Medications on Admission:
Enoxaparin 40 daily
Clopidogrel 75 daily
Hydrocodone-Acetaminophen 5 mg-500 mg
Nystatin 100,000 unit/mL 5 ml by mouth tid
Aspirin 81 mg daily
Acetaminophen prn
Captopril 25 mg tid
Alprazolam 0.25 mg tid prn
Simvastatin 40 daily
Metoprolol Tartrate 25 tid
Bisacodyl 10 mg prn
Albuterol prn
Lansoprazole 15 daily
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe [**Location (un) **]: One (1) Subcutaneous Q
24H (Every 24 Hours).
2. Clopidogrel 75 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY
(Daily).
3. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Location (un) **]: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
4. Nystatin 100,000 unit/mL Suspension [**Location (un) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
5. Aspirin 81 mg Tablet, Chewable [**Location (un) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet [**Location (un) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
7. Captopril 25 mg Tablet [**Location (un) **]: One (1) Tablet PO TID (3 times a
day).
8. Alprazolam 0.25 mg Tablet [**Location (un) **]: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
9. Simvastatin 40 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet [**Location (un) **]: One (1) Tablet PO TID
(3 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Location (un) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Location (un) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of rbeath, wheeze.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 12H (Every 12 Hours) for 4 days.
15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) for 4 days.
16. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
17. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.25 Tablet PO ONCE MR1 (Once
and may repeat 1 time) for 1 doses.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing or SOB.
19. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q4H (every 4 hours) as needed for wheezing or SOB.
20. Pantoprazole 40 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
21. Outpatient Physical Therapy
Patient with deconditioning and requiring help in building
strength/stability
22. Outpatient Lab Work
Patient should have chemistry (sodium, postassium, chloride,
bicarbonate, creatinine, BUN) and CBC checked in PM of [**2173-8-11**]
and AM of [**2173-8-12**] and as directed by rehab physicians thereafter
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Squamous cell cancer of the head and neck
Secondary: sp GI bleed, s/p Laparotomy and G-Tube replacement
COPD, HTN, Hypercholesterolemia, Pernicious anemia, CAD s/p MI
and stent implantation in [**2171**], G-tube placed
Discharge Condition:
tolerating po and tube feeds, afebrile, hemodynamically stable
Discharge Instructions:
You were admitted with confusion and fevers. We discovered that
you had a pneunomia, considered healthcare associated. We
worried about aspiration pneumonia, so we ordered a video
swallow test that showed you could tolerate purees and thin
liquids. We treated you for this. We also transfused you with
blood given your low blood count. Your gastric tube was leaking,
so we asked surgery and gastroenterology to help us manage it.
Eventually, you started bleeding from a large vessel around the
tube and this required an operation. After the operation you
went back and forth between the ICU and the floor because we
were worried about your breathing. You had a good deal of
secretions in your lung but also extra fluid because your heart
was overloaded. You were discharged to a rehab facility.
appointments
[**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 35276**]
[**Last Name (un) 27542**]
Return to the hospital if you develop confusion, fever or any
other symptoms that concern you
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 35276**]
Oncologist [**Last Name (un) 27542**]
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
Completed by:[**2173-8-11**]
ICD9 Codes: 5070, 2930, 5849, 5789, 2851, 2762, 4168, 496, 4019, 2720, 412, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6550
} | Medical Text: Admission Date: [**2161-4-22**] Discharge Date: [**2161-4-23**]
Date of Birth: [**2128-10-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
S/p arrest
Major Surgical or Invasive Procedure:
Arterial line placement
History of Present Illness:
32 yo M with PMH of alcohol abuse who is admitted s/p asysolic
arrest at home.
.
Per his family, around 8:45pm last night they heard a thump and
found the patient face down in the bathroom. Bystander CPR was
started immediately and EMS arrived 5 minutes later. He was
found to be in asystole. He was collared, boarded, intubated and
ACLS initiated. Per cardiology fellow note, on route to OSH, EKG
showed torsades at 9:07 s/p shock into VF/VT. In total, he
received 3 of Epi enroute to [**Hospital1 **] and was asystolic on arrival
there at 21:21. He was intubated, not sedated and was comatose
on arrival with no voluntary movements and fixed and dilated
pupils. He received 3 epi, 2 atropine 1 of bicarb and was
reportedly briefly in PEA, followed by VF and afib with "diffuse
ischemia" by 21:24. He was started on lidocaine gtt at that
time, followed for neo gtt for systolic blood pressures in the
60s. By 22:00 he was in sinus tachycardia. The multiple EKGs
from [**Hospital1 **] reveal a lot of baseline artifact but 21:48 reveals
sinus tach with STE in AVR, V1 with diffuse st depressions
inferolaterally. Labs there signifcant for trop <0.06, WBC 12,
h/H 11.6/35.6, K4.5 and Creat 0.9. AST 412ALT 160. Mg was not
ordered. The arctic protocol was initiated and he was
transferred to [**Hospital1 18**] for further care.
.
In the ED, initial vital signs were BP 169/117, HR 120, RR 22,
O2 sat 100% on RA. Patient was unresponsive off sedation and
hypertensive even off neo. Temperature was 34 degrees at 23:50.
He received 2 grams of magnesium and 100 thiamine. Initial labs
showed a hct of 35.9 with a MCV of 101, WBC of 7.3. Urine and
serum tox were negative. LFTs were notable for ALT 254, AST 859,
AP 248, Tbili 1.7. Lactate was 12. 5, CK was 782, troponin 0.04.
ABG showed pH7.30 pCO230 pO2>600 HCO315, with repeat lactate of
8.6. CT head showed occipital sub-galeal hemorrhage and loss of
the [**Doctor Last Name 352**]-white matter distinction suggestive of anoxic brain
injury. CT torso showed rib fractures anteriorly but no acute
intra-abdominal process. He was seen by the cardiac arrest team
who recommended inducing hypothermia to 33 degrees, elevating
HOB to >30 degrees to minimize ICP and keeping pCO2 around
35-45. He was then seen by cardiology who recommending d/c-ing
the lidocaine drip. He was admitted to the CCU for further
management. His vital signs on transfer were BP 198/134 HR84
RR23 O2 sat 100% on AC ventilation. He has 2IOs and 2PIVs for
access.
.
In the CCU, patient was intubated and unresponsive.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Alcohol abuse
Social History:
From [**Country 2045**]. Lives with parents in [**Location (un) 5110**], MA.
-Tobacco history: None per family.
-ETOH: Extensive. Family not certain as to how much he drinks,
but endorse excessive drinking for at least the past 10 years.
-Illicit drugs: None per family.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies,
syncope (except in the setting of alcohol use) or sudden cardiac
death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T=91 (on artic sun) BP=188/134 HR=78 RR=23 O2 sat=35%
GENERAL: well developed young man, unresponsive, not following
commands
HEENT: NCAT. Sclera anicteric. Pupils 3 -->2 mm b/l.
endotracheal and orogastric tubes in place.
NECK: C-collar on; appears to be extended
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. Active BS.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Cool to
touch.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Neuro: Decorticate posturing; pupils 3-->2 mm b/l; no corneal or
gag reflex w/ suctioning; spontaneous movements of the eyelids;
non-purposeful movement of upper extremities; no observed
movement of LEs; hyporeflexive throughout
Pertinent Results:
ADMISSION LABS:
[**2161-4-22**] 12:10AM WBC-7.3 RBC-3.57* HGB-12.3* HCT-35.9*
MCV-101* MCH-34.4* MCHC-34.2 RDW-15.0
[**2161-4-22**] 12:10AM NEUTS-83* BANDS-3 LYMPHS-12* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2161-4-22**] 12:10AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2161-4-22**] 12:10AM GLUCOSE-211* UREA N-10 CREAT-0.9 SODIUM-126*
POTASSIUM-4.6 CHLORIDE-91* TOTAL CO2-10* ANION GAP-30*
[**2161-4-22**] 12:10AM ALT(SGPT)-254* AST(SGOT)-859* CK(CPK)-782*
ALK PHOS-248* TOT BILI-1.7*
[**2161-4-22**] 12:10AM LIPASE-47
[**2161-4-22**] 12:10AM ALBUMIN-3.8 CALCIUM-9.4 PHOSPHATE-6.3*
MAGNESIUM-32*
[**2161-4-22**] 12:10AM cTropnT-0.04*
[**2161-4-22**] 12:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-4-22**] 12:10AM URINE HOURS-RANDOM
[**2161-4-22**] 12:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2161-4-22**] 12:10AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.006
[**2161-4-22**] 12:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
[**2161-4-22**] 12:10AM URINE RBC-8* WBC-10* BACTERIA-FEW YEAST-NONE
EPI-0
[**2161-4-22**] 12:11AM LACTATE-12.6*
[**2161-4-22**] 01:59AM LACTATE-10.2*
[**2161-4-22**] 01:59AM cTropnT-0.10*
[**2161-4-22**] 02:10AM LACTATE-8.6*
IMAGING:
[**2161-4-22**] EKG: Sinus tachycardia. Non-specific ST-T wave changes.
No previous tracing available for comparison.
[**2161-4-22**] CXR: Mild pulmonary vascular engorgement.
[**2161-4-22**] TTE: The left atrium is dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
moderate to severe global left ventricular hypokinesis (LVEF =
30-35%). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. Right ventricular chamber
size is normal. with borderline normal free wall function. 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 estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Moderate to severe global hypokinesis with evidence
of spontaneous echo contrast in left ventricle. No significant
valvular abnormality seen.
[**2161-4-22**] EEG: IMPRESSION: This is an abnormal continuous EEG due
to the presence of a burst suppression pattern, with runs of
high amplitude fast activity, occurring at a 0.5-1 Hz
periodicity, in runs up to 8 seconds, separated by extremely
prolonged periods of suppression up to 2 minutes. This pattern
is consistent with a severe diffuse encephalopathy, likely
secondary to hypothermia. However, as the patient is being
rewarmed,
the bursts gradually become lower voltage and the interburst
intervals
shorten, indicating a worsening encephalopathy. This pattern is
seen
after severe diffuse hypoxic injury, and portends a poor
prognosis.
There are no epileptiform features seen.
[**2161-4-22**] CT HEAD: 1. Poor [**Doctor Last Name 352**]-white differentiation, diffusely,
which, in the setting of cardiac arrest, is very concerning for
global hypoxic-ischemic injury.
2. No hemorrhage.
3. Large occipital scalp subgaleal hematoma, with diffuse edema
in the
extracranial soft tissues.
[**2161-4-22**] CT Torso: 1. No acute findings to explain the patient's
decompensation. 2. Fatty liver without focal lesions identified.
3. Pulmonary atelectasis.
[**2161-4-23**] EEG: IMPRESSION: This is an abnormal continuous EEG due
to the presence of a burst suppression pattern, with runs of
bursts of low voltage theta activity, separated by extremely
prolonged periods of suppression up to 1 minute. As the patient
is being rewarmed, the bursts gradually become lower voltage,
and the interburst intervals lengthen indicating a worsening
encephalopathy. This pattern is consistent with severe diffuse
encephalopathy, likely secondary to the patients known history
of severe diffuse hypoxic injury, and portends an extremely poor
prognosis. Between 1 pm and 5:30 pm, there is significant
shivering artifact. There are no epileptiform features seen. The
study is discontinued at 7:30 pm.
Brief Hospital Course:
32 year old M with history of alcohol abuse found down s/p
asystolic cardiac arrest.
.
# S/P Cardiac Arrest: Patient found asystolic in the field with
ROSC after ACLS. Initial rhythm strips were suggestive of
torsades and patient's EKG showed a long QT (between 460 and 490
depending on the rate and EKG). Cooling was started at the OSH,
and transferred to [**Hospital1 18**] for further management. On arrival, was
unresponsive and comatose in absence of sedating agents, with CT
head suggestive of global anoxic injury. Cooling process was
continued at [**Hospital1 18**], but EEG protended poor prognosis. He was
seen by EP and neurology. EP deferred futher workup and
evaluation pending neurologic recovery. Patient was rewarmed per
protocol and repeat EEG consistent with severe diffuse
encephalopathy, likely secondary to the patients known history
of severe diffuse hypoxic injury, portending an extremely poor
prognosis. Neurology felt that pending re-evaluation after
rewarming he would be brain dead. A family meeting was held, and
the patient's family decided to terminally extubate the patient.
He expired shortly thereafter.
Medications on Admission:
None
Discharge Medications:
None- Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2161-4-24**]
ICD9 Codes: 4275, 431, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6551
} | Medical Text: Admission Date: [**2161-3-28**] Discharge Date: [**2161-4-17**]
Date of Birth: [**2108-1-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Transfer from OSH with acute renal failure
Major Surgical or Invasive Procedure:
Renal biopsy [**2161-4-2**]
left nephrectomy [**2161-4-3**]
tunnelled HD line [**2161-4-16**]
History of Present Illness:
53M etoh cirrhosis (MELD 37), CAD, COPD, presents from OSH with
acute renal failure and confusion. He was diagnosed with
cirrhosis about a year ago. He has been followed by hepatology
at [**State 792**]Hospital. Recent meld was 24 in [**12-10**] with cr
1.2, INR 1.8, and t. bili 9.1. The patient routine labs drawn on
[**3-23**] which showed a Cr of 5.5. He was called by his physician
and asked to come to the ED on [**3-24**].
At OSH, he was being treated with vanc, although uncleear about
the actual or suspected source of infection. Paracentesis was
considered but not done as he did not have obvious ascites on
exam. The pt arrived in stable condition, satting 100 on RA,
appearing comfortable. He was A+O x3 and appropriate with very
mildly slurred speech, though no asterixis.
Seen and evaluated by transplant medicine team on [**3-28**]. The
patient states that he was feeling at his baseline. However, he
was unable to provide detailed history about his medical
problems. [**Name (NI) **] wife, he has been very forgetful over the past few
months with increasing confusion. He is fairly independent at
home and able to carry out routine ADLs. He always complains of
thirst and has been staying well hydrated with fluids. However,
he has had tea-colored urine for the past few months. Over the
last few weeks, he began to have decrease in appetite with
intermittent episodes of nausea, non-bilious, non-bloody emesis.
The wife feels the increased fullness is from an increase in
abdominal girth also over the same period of time. He has not
had alcohol since he stopped about 1 year ago. He denies any
SOB, fevers, chills, myalgias. ROS is positive for BRBPR which
has intermittently although he has had a negative w/u including
EGD/[**Last Name (un) **] which showed only hemorrhoids, adenomas and portal
gastropathy.
Past Medical History:
Cirrhosis
Hepatic encephalopathy
CAD
COPD
Social History:
Married, lives with wife. Worked as mechanic until he became
sick
smoker for 30 years. Abstinent from EtOH for 1 year, no drug
use.
Family History:
Father had EtOH cirrhosis, mother died from CA
Physical Exam:
97.3 142/64 58 22 98RA 86.5 kg I/O = [**Telephone/Fax (1) 71883**]
GEN: A+O x2, slurred speech, no asterixis
HEENT: scleral icterus, PERRL, EOMI, dry MM, OP clear
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g, JVP +12
ABD: soft, NT, no ascites, no caput medusae, no shifting
dullness
EXT: trace edema, 2+ DP pulses
SKIN: mild jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Brief Hospital Course:
Patient transferred from [**Hospital **] Hospital for further evaluation of
ARF, MELD 32.
Patient seen by Renal, Hepatology while on Medicine service.
Patient remained confused since his admission (encephalopathic).
Urine ouptut was low. Lasix was not helpful. He required
intermittent hemodialysis via temporary hemodialysis catheter.
On [**4-2**] (HD6) a renal biopsy was performed. He received 3 bags
of platelets and 3 units of FFP prior to the biopsy on [**4-2**] with
a platelet count of 86,000, INR 1.7.
Following the biopsy, he became diaphoretic with chest pain. His
Hct was 23.9% and dropped to 21% post-procedure with a platelet
count of 107,000. He received 2 more units of PRBC, 2 units of
plt, and DDAVP and was then transferred to the ICU.
In the first 24 hours of being in the ICU, he received 8 units
of PRBCs without
any response in his Hct (stable at 24%), 10 units of FFP, 4 bags
of platelets, DDAVP 75mcg (total), Vit K (5mg), and
cryoprecipitate administered. He went to IR for embolization of
suspected renal bleed, but tolerated this poorly with 9/10 chest
pain with ST depression in anterior leads. A nitro drip was
started. CK was 1326, MB 163 and troponin 5.[**Street Address(2) **]
depression. He sustained an anterior NSTEMI.
CT of abdomen done on [**4-3**] showed an unchanged large left
perinephric hematoma.
Due to his continued blood requirement, he was brought to the
operating room for urgent left nephrectomy. Patient transferred
back to the ICU post-op. PLease see the operative [**Last Name (un) **] for
further details. No obvious area of bleeding could be found on
the kidney. For further details of the procedure, see operative
dictation. Hct remained stable post nephrectomy. JP fluid output
was initially high. This decreased over time.
Of note, the kidney biopsy demonstrated IgA nephropathy.There
was also ongoing transplant evaluation for liver transplant. At
issue was cardiac clearance given PMH of angina. Cardia echo
revealed mild (1+) mitral regurgitation is seen. There was mild
pulmonary artery systolic hypertension. LVEF was >55%. Cardiac
cath was deferred. Stress MIBI was performed on [**4-15**]. Findings
showed no evidence of reversible ischemia or clinical symptoms
of angina. Recommendations included continuation of asa qd,
continuation of beta blockers, and initiation of captopril with
up titration of dose. If tolerated, captopril could be switched
to lisinopril 5mg qd. IV BB was recommended perioperatively
should he undergo further surgery.
Tube feedings were administered via an NG tube that was in place
postop nephrectomy. The nasogastric tube was self d/c'd. Calorie
counts suggested that he was only meeting 50% of his needs.
Ensure plus was given tid. Calorie counts were continued for
eval of further need for tube feedings. Calorie counts ________.
Neurologically he experienced varying degrees of
encephalopathy. Lactulose was given. A psyche consult was
obtained for evaluation of judgement given that he refused
treatments on [**4-13**]. Recommendations included 1:1 sitter,
identification of source of delerium and prn haldol. Haldol was
not given. Rifaximin was resumed to decrease encephalopathy. He
continued to present with a waxing/[**Doctor Last Name 688**]
delerium/encephalopathy. During this time he was verbally
abusive to his wife and staff.
On [**2161-4-16**] The temporary hemodialysis catheter was changed to a
tunnelled HD line without complications. An outpatient
hemodialysis center was located in [**Last Name (un) 30514**], R.I.
([**Telephone/Fax (1) 71884**]). Patient received hemodialysis on Friday [**4-17**]
prior to discharge.
Medications on Admission:
Vancomycin
Metoprolol 50"
Asa 81'
HCTZ 25'
Imdur 30'
Lipitor 10'
NTG SL
Protonix 40'
Lactulose
Thiamine
Mupirocin nares
Advair 250/50"
Combivent inahler
Lexapro 10'
Colace
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*1 * Refills:*1*
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): adjust to have [**3-8**] bowel movements per day.
Disp:*2700 ML(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
7. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Doctor Last Name 792**]VNA
Discharge Diagnosis:
Primary:
Renal failure
EtOH cirrhosis
Hepatic encephalopathy
Anemia
Thrombocytopenia
Coronary artery disease
.
Secondary:
COPD
Discharge Condition:
fair
Discharge Instructions:
Please call your doctor or return to the emergency room if you
develop chest pain, shortness of breath, decrease in or loss of
urination, fevers, chills, confusion, increasing abdominal girth
or significant weight gain, blood in your stool or dark, tarry
colored stools.
.
Please follow up with your appointments as outlined below.
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2161-4-30**] 10:30
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2161-4-30**] 11:00
Completed by:[**2161-4-17**]
ICD9 Codes: 9971, 5856, 496, 2851, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6552
} | Medical Text: Admission Date: [**2119-10-16**] Discharge Date: [**2119-10-26**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is an 84 year old female
with a known past medical history of hypertension and
borderline hypercholesterolemia, who presented at [**Hospital **]
Hospital two days prior to admission at [**Hospital6 649**] with one day history of chest pain. On the
evening of [**Holiday 1451**] she developed some chest pain that
radiated to her back and scapula with some slight
diaphoresis. She thought it was heartburn but the pain
persisted. The next day she went to the [**Hospital **] Hospital
Emergency Room. Electrocardiogram showed ST elevations. She
received Nitropaste, Oxygen, Lopressor and Aspirin. Repeat
electrocardiogram showed inferior T wave inversion with ST
segment resolution anteriorly. She ruled in for myocardial
infarction with peak creatinine kinase of 1182, MB 62, and
index of 52 and troponin of 14.2. She was started on Heparin
and Integrilin drip but they were discontinued on [**10-15**]
due to a large left antecubital hematoma and a symptomatic
scleral bleed of her right eye. She was painfree since
admission and was transferred in from [**Hospital **] Hospital [**Hospital6 1760**] today.
PAST MEDICAL HISTORY: 1. Hypertension; 2. Borderline
hypercholesterolemia.
PAST SURGICAL HISTORY: Status post dilatation and curettage
in her remote history.
ALLERGIES: She was allergic to Penicillin which causes
hives.
SOCIAL HISTORY: She was not a smoker and used alcohol
rarely.
MEDICATIONS: Medications at home revealed Lasix and
[**Doctor First Name 233**]-Ciel, although the patient was unable to give us the
doses. Medications on transfer include Lopressor 25 mg p.o.
q. 6 hours, Aspirin 325 mg p.o. q.d., Lisinopril 5 mg p.o.
q.d., Protonix 40 mg p.o. q.d.
LABORATORY DATA: Admission laboratory revealed white count
7.4, hematocrit 32.1, platelets 212,000, sodium 139,
potassium 3.9, chloride 110, bicarbonates 28, BUN 16,
creatinine 0.8. Her troponin was cycled as follows, 14.2,
11.6, 12.5, and 7.67.
HOSPITAL COURSE: Plan was that she would have cardiac
catheterization done. She was seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of
Cardiothoracic Surgery Service. On his examination she had
no bruits and no jugulovenous distension. She was alert and
oriented, neurologically she appeared to be intact. Her
heart was regular rate and rhythm, her abdomen was benign.
Her lungs were clear and she had weak peripheral pulses with
varicosities in her lower extremities. Her blood pressure on
the right was 145/84 and blood pressure on the left was
138/76 and she was sating 94% on room air. A Foley catheter
was in place on transfer. Cardiac catheterization took place
on [**10-16**], after transfer which showed an ejection
fraction of 50% with no mitral regurgitation. The 50% left
main lesion, proximal 50% left anterior descending lesion
with an 80% diagonal 1 lesion, 80% circumflex and 100%
thrombotic occlusion of the right coronary artery. On
[**10-17**], she underwent coronary artery bypass grafting
times three by Dr. [**Last Name (STitle) **] with left internal mammary artery
to the left anterior descending, vein graft to the obtuse
marginal 2 and vein graft to the right coronary artery. She
was transferred to the Cardiothoracic Intensive Care Unit in
good condition on Epinephrine drip at 0.01 mcg/min,
Neo-Synephrine drip at 1.5 mcg/kg/min and a Propofol drip
which was titrated. When she arrived in the unit she
initially had a fairly labile blood pressure. She required
significant volume. She received some packed red blood cells
for a hematocrit of 23%. She was waking up slowly in the
course of the evening. She was alert and oriented and
following commands but fell asleep very quickly when not
stimulated. She was switched to CPAP so that she could be
more awake when extubation was attempted. At approximately
2140 in the evening she was extubated without incident and
was able to clear her secretions and continue with deep
breathing. She had some hypotension in the 70s to 80s with a
little bit of exertion. She was given additional fluid and
her hemodynamics improved. Her heartrate dropped slightly.
She had some transient nausea but the Reglan treated this
successfully. On postoperative day #1 she had been extubated
over night. She was a little bit tachycardiac. She received
some fluid and some beta blockade and started her Aspirin.
Postoperatively her hematocrit was 29.3 and 31.0 with a BUN
of 7, creatinine 0.4. Her platelet count did drop to 57,000
and her lactate came back at 1.8. She remained on
Epinephrine drip at 0.01 and a Neo-Synephrine drip at 1.25.
Her Lopressor was started at 25 b.i.d. She was receiving
fluid boluses prn and continued on her perioperative
antibiotics. At approximately 9 PM in the evening, she
became distressed and sort of anxious with functioning and
thrashing in bed. Her heartrate went up to 150s and the
patient went into atrial fibrillation, and she did require
reintubation for hyperventilation. She also received some
more packed red blood cells to treat her hematocrit. On
postoperative day #2, she remained on epinephrine at 0.01 and
Neo-Synephrine adhesion been decreased to 0.75 with a good
blood pressure of 115/58. She remained on CPAP with pressure
support. Her hematocrit stabilized to 31.2, a BUN 9 and
creatinine 0.6. The decision was made to do a slower wean
today and decrease her pressure support and to wean off of
the epinephrine. Functioning was otherwise unremarkable.
She was neurologically intact, and the patient was extubated
on the fifth at noon and was doing well post extubation. On
postoperative day #3, she converted back into normal sinus
rhythm, was Amiodarone drip at 0.5 and a Neo-Synephrine drip
at .7. Epinephrine had been turned off. She had a
reasonable index of 2.49. Her hematocrit dropped slightly
26.7. Her examination was otherwise unremarkable. The
Swan-Ganz catheter was removed with plans to wean her
Neo-Synephrine during the day. She remained on the
Amiodarone drip to maintain sinus rhythm. She was seen by
the Clinical Nutrition Team for evaluation for tube feedings.
On postoperative day #4, she continued with Diuresis and
Amiodarone for atrial fibrillation. Her Metoprolol was
changed to 12.5 b.i.d. and she continued on Aspirin. She was
also receiving aggressive pulmonary toilet and she was
transferred out to Far 2. She was evaluated by the physical
therapy team there and also with the venous access team as
she had no reasonable peripheral intravenous site and still
had a left very large antecubital hematoma from her
Integrilin therapy at the outlying hospital prior to
admission. Her pacing wires were removed on the morning of
#7 and she was transferred out to Far 2. When she was alert
and oriented on the morning of [**10-21**], she was very
pleasant, jovial and was regaining her strength and was
mentating appropriately. When she was transferred out to Far
2 on [**10-23**] where she remained on Telemetry monitoring.
She slept periodically and napped throughout the day.
Physical therapy was reconsulted to continue her ambulation,
which she continued to improve at. On postoperative day #7,
which was the day of transfer she was in sinus rhythm in the
70s, 96% on 3 liters nasal cannula. Her creatinine was
stable at 0.7 with a hematocrit of 31.4, her white count was
normal. Her extremities continued to have 2 to 3+ pitting
edema but her incisions were clean, dry and intact. Her
sternum was stable. She continued diuresis and physical
therapy and screening for rehabilitation placement.
The addendum to the discharge summary will be dictated
tomorrow morning on [**10-26**], when she is discharged.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting times three
2. Hypertension
3. Borderline hypercholesterolemia
4. Postoperative atrial fibrillation
5. Congestive heart failure
6. Postoperative respiratory failure requiring reintubation
7. Preoperative and postoperative anemia requiring blood
transfusion
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2119-10-25**] 16:19
T: [**2119-10-25**] 16:45
JOB#: [**Job Number 54204**]
ICD9 Codes: 9971, 4280, 5185, 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6553
} | Medical Text: Admission Date: [**2175-4-30**] Discharge Date: [**2175-5-11**]
Date of Birth: [**2109-4-6**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 55 year old
female with a history of hemorrhagic cerebrovascular
accident, seizure disorder, hypertension, and hydrocephalus
who was admitted to the Medical Intensive Care Unit on [**4-30**], after being found unresponsive at the nursing home with a
temperature of 102.4.
In the Emergency Department her temperature remained 102.4,
her blood pressure was 210/100, her pulse was 132, her
respiratory rate 42 and she was 100% on 100% nonrebreather.
She was given Tylenol and Nitroglycerin paste, insulin drip,
tuberous normal saline Nipride drip, Rocephin, a triple lumen
was placed in the right groin. She was given Decadron 10 mg
intravenously. Ceftriaxone and Vancomycin were also given.
Head computerized tomography scan revealed new left
frontoparietal infarct.
She was admitted to the Medicine Intensive Care Unit.
Medicine Intensive Care Unit course was notable for: 1.
Infectious disease - Lumbar puncture was performed, 20,000
white blood cells, 4+ polys, 4+ gram negative rods, 909
protein, 0 glucose, consistent with bacterial meningitis. In
addition 1 out of 4 bottles of blood culture grew out gram
positive cocci. She was started on Ceftriaxone and Meropenem
to double cover for the gram negative rods as well as
Vancomycin to cover for the gram positive cocci in the blood.
She had an echocardiogram on [**5-1**] revealing no vegetations.
She also had a right upper quadrant ultrasound because of
possible sludge of the gallbladder. HIDA scan as well as
negative. Vancomycin was discontinued after four days
because the 1 out of 4 bottles of blood cultures grew out
coagulase negative Staphylococcus and it was felt to be a
contaminate. She spiked a temperature to 101.7 on [**5-4**].
Her femoral line at that point was discontinued and
Vancomycin was restarted. She had no repeat lumbar puncture
per the family's wishes as they decided not to be aggressive.
Ceftriaxone and Vancomycin were discontinued because the
patient spiked through them anyway. She was continued on
Meropenem for gram negative rod meningitis. Femoral line
grew back [**Female First Name (un) 564**] and she was started on Fluconazole.
2. Neurological - Bacterial meningitis and cerebrovascular
accident. Blood pressure maintained goal 170. Her head
computerized tomography scan revealed no left frontoparietal
infarct. She was unable to tolerate the magnetic resonance
given patient movement. She was continued on Dilantin given
her history of seizure disorder. Head computerized
tomography scan was repeated on [**5-4**] showing hydrocephalus
with prominent mass effect. Circulation Service suggested
multiple studies and neurosurgery evaluation but the
patient's family declined. Electroencephalogram showed
encephalopathy.
3. Oncology - Abdominal ultrasound was performed and it
showed a question of ovarian cancer with an ovarian mass.
This was discussed with the family and the decision was not
to proceed with further workup.
4. Heme - Her hematocrit decreased to 27 without obvious
source. Her stool guaiacs were negative.
5. Cardiovascular system - Hypertension, the patient with
systolic blood pressures elevated throughout the hospital
course. Initially she was treated with Labetalol and then
her Metoprolol was increased and Norvasc was added.
6. Endocrine - Diabetes mellitus, she was started on an
insulin drip and then changed to NPH and regular insulin
sliding scale.
7. Fluids, electrolytes and nutrition - She was started on
tube feeds via nasogastric tube. She was given free water
boluses. The patient was cleared to the floor on [**2175-5-5**].
PAST MEDICAL HISTORY: 1. Hemorrhagic cerebrovascular
accident with residual left hemiparesis eight years ago; 2.
Seizures disorder after the hemorrhagic cerebrovascular
accident; 3. Hydrocephalus with high intracranial pressure
by lumbar puncture in [**2171-11-30**] with opening pressure of
25, evaluated by Neurosurgery for ventriculoperitoneal shunt,
but the patient declined. 4. Hypertension; 5.
Hypercholesterolemia; 6. Depression; 7. Status post
gastrostomy.
ALLERGIES: Sulfa, Thiazide, diuretics, and Enalapril.
MEDICATIONS ON TRANSFER: NPH and regular insulin sliding
scales. Fluconazole, Aspirin, Meropenem, Lansoprazole,
Senna, Talwin, Colace and Metoprolol.
SOCIAL HISTORY: She is a [**Location 11785**] native and lives at
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Nursing Home.
PHYSICAL EXAMINATION: Examination on transfer to floor,
temperature 99.2, 198/82, 68, 11, 100% on 2 liters,
unresponsive. Eyes opened, right sided gaze. Moving right
arm. Pupils 3 cm and sluggish, reactive to light. Regular
rate and rhythm, no murmurs, rubs or gallops appreciated.
Coarse breathsounds anteriorly. No wheezes, no crackles.
Soft, moderately distended, hyperactive bowel sounds.
Positive upper extremity edema bilaterally, no lower
extremity edema. Neurological, left neglect, left pupil
deviation, no purposeful movements, no gag.
LABORATORY DATA: Laboratory data on admission revealed white
blood cell count 11.5, hematocrit 34.2, platelets 278, INR
1.4, 76% neutrophils, 8% bands, 10% lymphocytes, 4%
monocytes, 2% atypical study, 140,000, 4.6 potassium,
chloride 108, carbon dioxide 18, BUN 38, creatinine 2.8.
Blood cultures from [**4-30**] to [**Month (only) **] no blood cultures to date.
Micro data [**4-30**], cerebrospinal fluid, white blood count
20,000, red blood count 217, polymorphonuclear lymphocytes
93, bands 2, lymphocytes 3, monocytes 2, protein 909 and
glucose 0. Cerebrospinal fluid culture, 4% polys, 2% gram
negative rods, culture ultimately grew Klebsiella which was
Meropenem sensitive.
HOSPITAL COURSE: After being admitted to the Medical
Intensive Care Unit the patient was transferred to the floor
on [**2175-5-5**]. She continued to spike fevers despite being
on Meropenem and Fluconazole. Her culture from her
cerebrospinal fluid grew out Klebsiella that was sensitive to
Meropenem. Family meeting was performed with Neurology
present. The decision was made to make the patient
comfort-measures-only, to withdraw antibiotics, intravenous
lines and drains and to continue to only treat with seizure
prophylaxis. The patient remained stable, continued to spike
fevers and was starting on standing Acetaminophen and was
continued on Dilantin. Of note, she did have seizure
activity on [**2175-5-6**]. She was given a bolus of Dilantin
and her seizure ceased at that time. Her standing Dilantin
level was increased to 150 mg p.o. t.i.d. The decision was
made to discontinue her intravenous medications and she was
discharged on intramuscular Fosphenytoin b.i.d. and Diastat
p.r. prn for seizure activities as well as sublingual
Morphine.
CONDITION ON DISCHARGE: Poor.
DISCHARGE STATUS: Discharged to hospice.
FINAL DIAGNOSIS:
1. Seizure without status
2. Tachycardia
3. Hypertension
4. Klebsiella
5. Meningitis
6. Cerebrovascular accident
DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg p.r. q. 6 hours
2. Fosphenytoin 225 mg intramuscularly b.i.d., alternate
arms
3. Morphine Sulfate 1 to 5 mg sublingual q. 2 to 3 hours as
needed
4. Diazepam p.r. 15 mg q.d. as needed for seizures
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 29803**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2175-5-11**] 14:39
T: [**2175-5-11**] 15:30
JOB#: [**Job Number 29804**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6554
} | Medical Text: Admission Date: [**2125-8-22**] Discharge Date: [**2125-8-31**]
Date of Birth: [**2061-2-21**] Sex: M
Service: MEDICINE
Allergies:
Motrin / Codeine / Nortriptyline
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Gm + Bacteremia
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
64 yo M with multiple medical problems including hep C, HIV,
ESRD on HD who was recently hospitalized for MRSA bacteremia and
was evaluated in the ED on [**8-21**]. He presented to HD
febrile/tachy, he was dialized and subsequently sent to the ED
on [**8-21**] with hallucinations. Blood cultures were drawn. Work-up
was negative and he was sent back to [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **], NH on [**8-21**].
Pt called back on [**8-22**] to ED for further eval since for [**1-11**]
positive blood cultures with gm + cocci in clusters. Pt with
difficult access and indwelling cath/cuffed femoral line for
several months.
Past Medical History:
1) HIV: diagnosed in [**2106**], followed by Dr. [**Last Name (STitle) 1057**] at [**Hospital1 18**].
2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy,
charcot foot, nephropathy, and ? mild retinopathy.
2) ESRD on Hemodialysis and graft infections, thrombus: dx
approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues, thurs, sat at
[**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] / Nephrologist -
Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94989**]
3) [**Female First Name (un) 564**] esophagitis
4) Hepatitis C: genotype IB-> last viral load [**8-/2124**] 175,000
5) Congestive heart failure: echocardiogram [**10/2123**] w/ EF 60%.
6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and
circumcision during hospitalization.
7) Hypertension
8) Hypercholesterolemia
9) LE Diabetic ulcers
10) Herpes zoster of the left mandibular distribution of the
trigeminal nerve. [**2115**]
11) R suprapatellar abscess: [**2115**].
12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**]
13) Obesity
15) GI Bleed: [**2117**]. OB positive stool. No frank blood. Negative
colonoscopies.
16) Anemia: [**2117**]. Started Epogen.
18) Colonic Polyps
19) Gastritis with large hiatal hernia.
20) Lipodystrophy
21) Charcot foot: dx in [**9-12**].
22) Colonic AVM: seen on [**3-8**] colonoscopy on the ileocecal
valve. Treated with thermal therapy. At that time was also
offerred hormonal therapy, but this was deferred.
23) Positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No
abnormalities on CT chest in [**2121**].
24) MRSA- grew out from culture from L anterior chest wound, s/p
I+D
25) Peripheral neuropathy: on a narcotics contract
26) Diastolic CHF: [**2-/2125**] TTE: LV cavity is unusually small.
Hyperdynamic LV systolic fxn (EF >75%), trivial MR,
trivial/physiologic pericardial effusion
27) Thrombosis of dialysis line, on chronic anti-coagulation
28) Emphysema
Social History:
History of tobacco abuse (quit 20 years ago), alcohol abuse
(quit >20 years ago) and heroin and cocaine abuse (quit >20
years ago). Has a fiance who visits him frequently and is
involved in his care. Recently lost his home after several
hospitalizations and has been in an extended care facility for
5-6 months, but hopes to return home to his fiance. He has not
been ambulating for approximately one year. He has a wheelchair
and a walker, but reports that he is starting to ambulate slowly
with assistance.
Family History:
Non-contributory.
Physical Exam:
-VS: 99.0 BP 105/40 HR 104 16 100% on 2LNC
-GEN: awake, resting comfortably in bed, answering questions
appropriately, eyes closed but opens when told to
-HEENT: MMM, OP clear, no teeth upper/lower
-CV: Reg Nml S1, S2, no m/r/g
LUNGS: CTABL, No crackles or wheezing
ABDOMEN: Soft ND/NT +BS
EXT: Large left thigh mass encircling anterior left leg which is
warm and tender. L PICC with dressing over line no evidence of
oozing, L femoral line in place-no oozing, no peripheral edema;
R chest area without open wound, no purulent discharge currently
NEURO: A/O X3, no focal deficits, strength 4/5 throughout, no
tremors.
Pertinent Results:
.
CXR [**8-20**]: IMPRESSION: Diffuse airspace process, new since [**7-25**],
and most likely representing pulmonary edema; extensive
aspiration pneumonitis is a more remote consideration.
.
CT HEAD noncontrast [**8-21**]: IMPRESSION: Stable head CT examination
demonstrating chronic microvascular ischemic changes as above.
.
CT ABDOMEN, CHEST, PELVIS W/O CONTRAST [**2125-8-24**] 1:31 PM
1. No evidence of intraperitoneal or retroperitoneal bleeding.
2. Grossly unchanged appearance of large left groin hematoma,
which contains layering fluid-fluid levels suggestive of
hematocrit effect, likely reflective of recent bleeding.
3. New smaller right groin hematoma.
4. Moderate hiatal hernia.
5. Multiple sub 5-mm noncalcified pulmonary nodules. Followup
chest CT recommended in [**6-19**] months' time.
.
CHEST U.S. RIGHT Study Date of [**2125-8-28**] 3:54 PM
Right chest wall collection with apparently artificial tram
tracking tubular structure that likely represents foreign body.
.
SHOULDER [**2-10**] VIEWS NON Study Date of [**2125-8-29**] 5:49 PM There are
areas of sclerosis and lucency in the femoral head, probably
related to the previously seen osteoarthritic changes. If there
is strong clinical suspicion of septic arthritis, joint
aspiration may be of use.
Brief Hospital Course:
#. Mental Status changes: per OMR notes, pt with h/o delirium in
setting of infectious process, however, was oriented during MICU
stay and upon transfer to the floor. Was intermittently
somnolent without clear etiology - all electrolytes, glucose
levels, O2 saturations WNL, which was likely related to poor
sleep during stay. Continued to be oriented upon return to
floor. On day of discharge was alert and oriented, without
concern for mental status changes.
.
# HTN - Blood pressure was initially low in the MICU secondary
to acute blood loss. Upon transfer to the floor he was
restarted on his home dosing of metoprolol initially poorly
controlled upon admit to the floor. Started on metoprolol 25mg
po TID in MICU. Now on Metoprolol 100mg po TID, lisinopril 40mg
and Norvasc 10mg with much improvement. Was monitored
throughout stay and discharged on this regimen.
- Discharged on ACE, BB and CCB dosing, monitor.
.
# Gram + bacteremia- Was called to return to the hospital once
return of positive blood culture growing coag (-) staph on
[**2125-8-22**]. Being treated with vancomycin on HD protocol since
with good effect. Original source of infection remains unclear
- HD catheter, thigh hematoma, or right chest wall wound with
known foreign body. Additionally there were concerning changes
on prior spinal imaging, however pt refused MRI to assess for
osteomyelitis. He continually denied tenderness in low back on
exam. Infectious disease, renal and transplant surgery were
consulted and helped facilitate therapy. TTE to evaluate for
endocarditis was inconclusive, however TEE was not persued given
it would not change the duration of recommended therapy.
Ultimately the chest wall foreign body was removed by transplant
surgery. Wound consult was obtained and followed his chest
wound throughout his stay. Following this, a new HD catheter
was placed by Interventional Radiology as requested by Renal
given that he has a history of access problems. Infectious
disease recommended 6 weeks of Vancomycin therapy and he was
discharged on this medication.
- Vanc per HD protocol for 6 weeks per HD protocol, check vanco
level at HD
.
# Right chest wall wound - Discovered on admission with open,
nonpurulent drainage. Ultrasound evaluation of the area
revealed a foreign body consistent with prior wick or catheter
remnant. Transplant surgery was consulted and and attempted to
remove the foreign body while inpatient without complication.
He was followed by Transplant surgery throughout his stay. He
should have dressing changed daily and packed with [**Last Name (un) **]
packing strip and covered with dry sterile bandage.
.
# Right shoulder - Deformed on admit. Unable to raise arm past
7cm off of bed. Likely diagnosis include torn rotator cuff vs.
frozen shoulder. Not erythematous, warm or painful with
movement. Was considered to be possible site of
bursitis/infection. Xray with degenerative OA changes. Given
our low suspicion for septic arthritis and exam inconsistent
with diagnosis - shoulder tap was not pursued. Instructed to
follow-up with PCP for further management.
.
# Large left thigh hematoma: Prior to admit had L femoral HD
cath placed. Upon admit had falling Hct in setting of elevated
INR, and was transfused PRBC, FFP and Vitamin K. Surgery was
consulted but did not recommend intervention. Repeat CT imaging
revealed stable left groin hematoma. Hct was monitored at least
once daily and remained stable for the remaining of his
inpatient stay. He should have hematocrit checked the day after
line changed over wire which would be [**9-4**] (tuesday).
.
# CHF- echo [**10/2123**] w/ EF 60%, pt does not appear overloaded on
exam, no respiratory symptoms. Throughout stay he did not have
signs/symptoms consistent with CHF exacerbation. Was restarted
on metoprolol with the addition of lisinopril for improved BP
control as well as cardioprotection.
- Dishcarged on BB, statin, ACE.
- ASA held on discharge do to acute bleed, should restart next
week.
.
# HIV- last VL [**11/2124**] <50, CD4 290. Currently on HAART,
followed by Dr. [**Last Name (STitle) 1057**]. Confirmed his regimen with Dr. [**Last Name (STitle) 1057**] upon
admit and his medication was only adjusted per HD dosing.
- Continued current HAART regimen of indinavir, ritonavir,
lamivudine
.
# ESRD- Secondary to DM. On normal tues/thurs/sat HD schedule.
Was continued on his HD schedule inpatient and was continued on
nephrocaps and sevelamer.
- Continue nephrocaps and sevelamer.
- Continue current HD schedule Tues/Thurs/Sat
- Follow-up with Renal for continued line monitoring
.
# Diabetes- insulin dependent, last hgb A1c 6.3% in 11/[**2124**].
Was started on an ISS and his home dose of NPH on admit, but did
not require NPH. Throughout his stay his fingersticks were well
controlled with only rare ISS. Gabapentin was continued for his
peripheral neuropathy with a minor decrease in dose given his HD
dependent status.
- Continue gabapentin, renal dose adjusted
- Continue insulin, should follow-up with PCP concerning good
control without need for daily NPH while inpatient.
.
# Anemia- Secondary to acute blood loss. Mr. [**Known lastname 7493**] was
dialyzed [**8-23**] and given 2UPRBC. Simultaneously, while his L fem
HD line was being accessed, it began oozing. Pt noted to have a
large thigh hematoma and initial INR 9.0. He was then
transfused an additional 2 UPRBC and 1UFFP with inappropriate
response from HCT 18.3-->22.7-->19.5. Thus, he was transferred
to the MICU with an additional 1UPRBC transfused. On [**8-24**] his
Hct continued to drop to 19 despite 2UPRBC, he was given a dose
of Vit K and FFP. Surgery was consulted, recommended serial
exams but no surgical intervention. Once he coagulopathy was
reversed, he was followed with [**Hospital1 **] Hct for 3 days. He did not
require further transfusion. Upon discharge his Hct was stable,
and there was no evidence of acute bleed for several days.
- Transfused 5u PRBC
- INR elevation reversed with Vit K and FFP
- Thigh hematoma & Hct stable at discharge
.
#. Coagulopathy. History of multiple clots in grafts and IVC in
past, so is now on chronic coumadin. Upon admit he had a
supratherapuetic INR 9.0 that was reversed with VitK and 1unit
FFP to 1.5. He was then held at this level awaiting new HD
catheter placement. After having a stable Hct of three days
duration, a new HD catheter was placed in IR. Prior to
discharge he was restarted on anticoagulation with goal INR [**2-10**].
- Continue anticoagulation, goal INR [**2-10**].
.
# Access problems - [**Name (NI) **] renal team, pt with extensive h/o access
problems, [**Name (NI) 94992**] occluded, [**Name (NI) 94993**] thrombosed, IVC occlusion,
R-AVgraft failed. Thus, was consulted to replace his HD line in
a presumedly patent RIJ. Upon transport to Interventional,
however, it was found to be non-patent. Was discharged with
schedule to change the line on [**Last Name (LF) 766**], [**9-3**] in IR.
Medications on Admission:
1. Albuterol Sulfate
2. Methadone 80 mg daily
3. Indinavir 800 mg Capsule [**Hospital1 **]
4. B Complex-Vitamin C-Folic Acid 1 mg
5. Gabapentin 300 mg [**Hospital1 **]
6. Quinine Sulfate 325 mg PO HS
7. Ritonavir 100 mg [**Hospital1 **]
8. Oxycodone-Acetaminophen 5-325 mg
9. Senna 8.6 mg [**Hospital1 **]
10. Docusate Sodium 100 mg [**Hospital1 **]
11. Stavudine 20 mg daily
12. Metoprolol Tartrate 25 mg [**Hospital1 **]
13. Sevelamer 800 mg TID
14. Ammonium Lactate 12 % [**Hospital1 **]
16. Lamivudine 150 mg Tablet QHD
17. Insulin
18. cymbalta
Discharge Medications:
1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Inhalation Q6H (every 6 hours) as needed.
2. Indinavir 400 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID (2 times
a day).
3. B-Complex with Vitamin C Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
4. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Ritonavir 80 mg/mL Solution [**Hospital1 **]: 1.25 mL PO BID (2 times a
day).
6. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Sevelamer 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
10. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Psyllium 1.7 g Wafer [**Hospital1 **]: One (1) Wafer PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: ISS per scale
Subcutaneous ASDIR (AS DIRECTED).
15. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q24H
(every 24 hours).
16. Oxycodone 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
17. Stavudine 20 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q24H (every
24 hours).
18. Lamivudine 100 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
19. Amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
20. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
21. Lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
22. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
(3 times a day).
23. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Hospital1 **]: One (1) g
Intravenous HD PROTOCOL (HD Protochol) for 5 weeks: Levels to be
checked in HD and dosed appropriately.
24. [**Last Name (un) **] packing strip
please change right chest wall wound daily w/ [**Last Name (un) **] packing
strip.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary: GPC bacteremia, altered mental status
Secondary: HIV, Diabetes Mellitus, type 2, ESRD on
Hemodialysis, Hepatitis C, Congestive heart failure,
Hypertension, Hypercholesterolemia, LE Diabetic ulcers, Obesity,
acute blood loss anemia, Peripheral neuropathy, Diastolic CHF,
Hyperdynamic LV systolic fxn, Thrombosis of dialysis line,
Emphysema
Discharge Condition:
Good, hemodynamically stable and afebrile.
Discharge Instructions:
You have been hospitalized for fever and altered mental status
and were found to have Gram Positive bacteria in your blood.
You have been treated with antibiotics, specifically vancomycin
at hemodialysis. Your hospital course was complicated by acute
blood loss with an elevated INR (coagulopathy) that required
both transfusion of red blood cells and plasma. Once your blood
levels were stable, you were transferred to the floor. Since
that time, we attempted to place a new HD catheter but were
unable to because you have a clot in your neck vein. Thus, you
are being discharged back to your facility and instructed to
return to [**Hospital1 18**] for exchange of your catheter.
.
Return to the Emergency Department if you develop new fevers,
chills, altered mental status or any other symptoms for which
you are concerned.
.
Your medications were continued while inpatient with the
following changes.
- We held your aspirin and coumadin because you had acute blood
loss anemia
- Your blood pressure medications have been changed to the
following: Metoprolol 100mg po TID, lisinopril 40mg daily and
norvasc 10mg daily.
.
Please keep all scheduled appointments.
.
Please keep your HD schedule Tuesday, Thursday, and Saturday.
You will be given antibiotics at these sessions.
.
Please return to [**Hospital1 18**] [**Hospital Ward Name 121**] Building, [**Location (un) **], Day care unit
on [**Last Name (LF) 766**], [**9-3**] at 8:30am for placement of a new HD
catheter.
Followup Instructions:
Provider: [**Name10 (NameIs) 454**],SIX [**Name10 (NameIs) 454**] Date/Time:[**2125-9-3**] 8:30
.
Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**]
Date/Time:[**2125-9-3**] 10:00
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 7907, 2851, 5856, 2930, 4280, 3572, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6555
} | Medical Text: Admission Date: [**2153-5-23**] Discharge Date: [**2153-6-7**]
Date of Birth: [**2093-1-24**] Sex: F
Service: MEDICINE
Allergies:
Cefaclor
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
Confusion, fevers, right eye vision loss
Major Surgical or Invasive Procedure:
Lumbar puncture
TEE
History of Present Illness:
This is a 60-year-old woman with CLL, recently hospitalized for
anemia and fatigue, who presents today with severe headache,
blurry vision, high fever, and confusion.
About 1-year-ago, blood work at PCP's office showed evidence of
hematologic malignancy. Patient decided to forgo traditional
work-up and treatment at that time and instead pursued
homeopathic remedies with a naturalist (including injections of
[**7-18**]-X compound). According to her husband, patient was doing
well until about 1 month ago when she noticed profound shortness
of breath and fatigue. She sought medical care at [**Hospital1 18**] on
[**2153-5-16**] and was admitted to the BMT service for further work-up.
Bone marrow biopsy and flow cytometry were indicative of CLL.
Patient still refused treatment (was seen by psychiatry to
evaluate competence) but agreed to continue following with
heme/onc service.
About 4 days prior to admission, patient began experiencing
fevers, chills, and worsening malaise. She took her
temperatures on a few occasions, and had readings as high as
102. On day of admission patient developed a profound headache
and blurry vision/central vision loss in her right eye. Also
noticed crusted lesions on her lower lip. Husband called
oncologist who told her to go straight to the hospital.
In the ED the initial vitals were: 100.5 103 135/58 20 97.
However, according to ED notes, patient spiked a fever as high
as 105. A code stroke was called in context of acutely abnormal
neuro exam; CTA head showed possible filling defect in MCA
territory. Neuro was also concerned about possibility of septic
emboli on CT and recommended MRI. Patient was noted to have a
WBC count of 23.4 (which is significantly decreased from prior).
Patient was given Vancomycin 1g, Acyclovir 700mg, dexamethasone
10mg. Upon transfer, vitals were: 104, 144/54, 116, 32, 96% 2L.
ROS: Unable to obtain, as patient is alternately agitated and
somnolent and unable to answer questions appropriately.
Past Medical History:
--Hypertension (though improved since losing weight)
--Obesity: s/p 87 pound weight loss
--Anxiety
--s/p 2 C-sections
Social History:
Married, 4 children. Husband is [**Name (NI) 86**] [**Name (NI) **] Fighter. Former
smoker, quit in [**2113**]. No alcohol since [**2152-12-5**]. Used to
be a heavy beer drinker.
Family History:
Mother: Breast cancer
Father: [**Name (NI) **] cancer
Sister: [**Name (NI) **] cancer
No family history of myeloproliferative/lymphproliferative
disorders, easy bruising or easy bleeding. No FH or leukemia or
lymphoma
Physical Exam:
Vitals: T: 102.2 BP: 124/66 P: 113 R: 33 SPO2: 94% 3L
General: lethargic, moderate respiratory distress
HEENT: Sclera anicteric, MMM, multiple crusted lesions on bottom
lip.
Neck: massive lymphadenopathy bilaterally
Lungs: coarse breath sounds diffusly.
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: firm, splenomegaly, hepatomegaly, +BS, non tender,
nondistended.
GU: foley
Ext: trace edema
Pertinent Results:
EEG [**6-2**]:: This continuous record for a period of approximately
five
hours showed mild diffuse encephalopathy changes along with a
focal
abnormality over the right central region that was, at times,
somewhat
rhythmic suggesting there may be a convulsive component to it
but also
suggestive of structural pathology and rare independent slowing
and
sharp slow activity was noted from the left anterior sylvian
region.
EEG [**6-1**]::
IMPRESSION: This telemetry captured no pushbutton activations.
Routine
sampling showed a diffusely slow and disorganized background
consisting
of mixed theta and delta frequencies reaching up to [**6-11**] Hz.
There were
frequent periods of right hemispheric delta slowing as well as
less
frequent periods of bihemispheric delta activity. Spike
detection files
showed artifact. Seizure detection files also showed artifact as
well
as rhythmic delta activity. No electrographic seizures were seen
on
this recording and no epileptiform discharges were noted.
EEG [**5-31**]:
This telemetry captured no pushbutton activations. It
captured one clear electrographic seizure correlated with
twitches of
the left arm and tremor of the head. This seizure had an onset
in the
right parasagittal area and spread bilaterally. In addition,
there were
long periods of right PLEDs with a parasagittal predominance
during the
first half of the recording. During the second half of the
recording,
the activity was nearly normal during sleep and wakefulness with
intermittent focal slowing in the right parasagittal region
suggestive
of subcortical dysfunction in that area.
MRI [**2153-5-24**]:
1. No acute hemorrhage or ischemic stroke.
2. Possible pachymeningeal thickening/enhancement along the
frontotemporal
meninges and falx. The differential for this is broad including
infectious, autoimmune/inflammatory and more remote neoplastic
etiology.
3. Questionable small fluid level in the left lateral ventricle
which does not appear hemorrhagic, though other proteinaceous
material may be present. Attention of follow up imaging
recommended.
CSF [**2153-5-24**]:
Abundant neutrophils, lymphocytes and some macrophages,
consistent with acute menigitis.
ECHO [**2153-5-29**]:
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast at rest. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 40 cm from the
incisors. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. No vegetation/mass is seen on the pulmonic valve.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen. No PFO or ASD.
[**2153-5-24**] 04:04PM CEREBROSPINAL FLUID (CSF) WBC-7700 RBC-2400*
Polys-84 Lymphs-6 Monos-10
[**2153-5-24**] 04:04PM CEREBROSPINAL FLUID (CSF) WBC-8000 RBC-1700*
Polys-88 Lymphs-5 Monos-7
[**2153-5-24**] 04:04PM CEREBROSPINAL FLUID (CSF) TotProt-280*
Glucose-44
[**2153-5-24**] 04:04PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS:
negative
Brief Hospital Course:
This is a 60-year-old female with a history of untreated CLL who
presents with fevers, AMS and crusted lip lesions.
# FEVERS/ALTERED MENTAL STATUS:
# S. Pneumonia Meningitis
# Necrotic Lymphadenopathy
# Seizure Disorder
Clinical picture and lumbar puncture consistent with
meningitis; this is an immunocompromised patient with high
fevers, altered mental status, and abnormal neurologic exam.
Blood and CSF cultures were positive for strep pneumonia, while
HSV was suspected (had herpetic lip lesion). CT imaging of the
neck revealed large, necrotic lymphadenopathy, presumably
related to an intense lymphatic reaction to systemic disease.
Her broad spectrum abx were rationalized to ceftriaxone when
sensitivities permitted. ID reccomended a 14 day course, which
finished on [**2153-6-6**]. TEE was negative for vegetations. Upon
transfer to BMT, blood cultures had cleared. From [**5-29**] to [**6-1**],
bizarre, aggressive and often hypersexual behaviour was noted.
Continuous EEG, while at first unrevealing, ultimately found
evidence of seizures. Keppra was loaded and started on an
indeterminate course. Her AMS gradually improved.
RIGHT FACIAL DROOP/?RIGHT SIDED-NEGLECT: Upon first
presentation, a code stroke was called due to a right facial
droop, right eye blindness, and question of right-sided neglect.
A CTA of patient's head showed a question of an MCA infarct.
However, a subsequent MRI showed no evidence of acute ischemia.
There was also concern for septic emboli to the brain from a
valvular vegetation; however, this was ruled out by TEE. As
such, it was decided that Ms. [**Known lastname 85166**] did not have a stroke.
RIGHT EYE BLINDNESS: Unclear etiology, but according to
opthalmology, likely the result of CLL. Multiple fundoscopic
exams consistent with retinal hemorrhage. On [**2153-6-6**], after
having a stable eye exam over the course of her hospitalization,
patient had acutely painful and injected eye. She was evaluated
by ophthamology who felt the etiology was either infectious or
due to CLL infiltration (though rare). Right vitrectomy was
performed, and vitreous samples were sent for culture and
cytology. Patient will need f/u from these results, has schedule
appt with ophthamology.
# CLL: Diagnosed 1 year ago but untreated. It presented in an
advanced stage with marrow insufficiency. Extensive discussions
between BMT and patient regarding CLL therapy however, patient
and husband have refused chemotherapy in the past. Instead they
have pursued herbal treatments that involved the daily injection
of homeopathic preparations into the subcutaneous tissue of the
groin (brand name 714-X). She will follow with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
on discharge.
# RESPIRATORY STATUS: Patient presented with tachypnea but her
ABGs were within normal limits. She was eventually intubated in
order to perform diagnostic procedures such as an LP (she was
too agitated otherwise). Patient was succesfully extubated
without complications.
# TACHYCARDIA: Likely in setting of fever, infection, and
agitation. Tachycardia resolved with treatment of infection and
fluid resuscitation.
Medications on Admission:
Xanax 1mg every 6 hours prn anxiety.
Discharge Medications:
1. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) drop
Ophthalmic four times a day: to right eye.
Disp:*1 bottle* Refills:*0*
3. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
1. Strep pneumo meningitis
2. Right eye vision loss and possible endophthalmitis
3. Seizures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 85166**],
It was a pleasure taking care of you on this admission. You
came to the hospital because of fevers, confusion, and right eye
blindness. We found an infection in your blood and cerebral
spinal fluid. We treated you with a medication called
Ceftriaxone for 14 days.
We also discovered worsening of your CLL. You were closely
followed by the BMT doctors [**Name5 (PTitle) 1028**] in the hospital. It is
extremely important you follow up with your new oncologist, Dr.
[**Last Name (STitle) **].
You had problems with your right eye as well and had a procedure
requiring close follow-up with an eye doctor. DO NOT MISS [**First Name (Titles) **] [**Last Name (Titles) 85167**]T.
The following changes were made to your medications:
1. Start Keppra 500mg twice a day
2. Start Prednisolone eye drops four times a day to your right
eye
Please take all of your medications as directed. Please keep
all of your follow-up appointments.
Return to the hospital if you develop chest pain, shortness of
breath, confusion, fever, abdominal pain, nausea, vomiting,
diarrhea, cough, pain with urination, or any other concerning
signs or symptoms.
Followup Instructions:
Please follow-up with the neurologist, Dr. [**Last Name (STitle) **] on [**7-16**]
at 4pm. They are located in [**Hospital Ward Name 23**] 8. The phone number is ([**Telephone/Fax (1) 11299**].
Please follow-up with the ophthamologist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 7572**] on [**2153-6-13**] at 8am ([**Hospital Ward Name 23**] 4).
Please follow-up with your new oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], ([**Telephone/Fax (1) 58564**], his assistant will contact you in the next day for an
exact time. Please call them if you have any concerns or do not
hear from them somehow.
ICD9 Codes: 2761, 2760, 2875, 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6556
} | Medical Text: Admission Date: [**2130-9-1**] Discharge Date: [**2130-9-5**]
Service: MEDICINE
Allergies:
Vioxx / Bactrim / Codeine / Aspirin / Ranitidine
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
s/p cardiac catheterization
History of Present Illness:
88 year old female with PMH significant for HTN, DM who was
brought by EMS to [**Hospital1 18**] ER for chest pain and diaphoresis. Per
ED intake BP in field 68/p, ASA given. Patient's presenting
vitals in ED were HR 92, BP 148/91, 100 NRB, however shortly
after presentation patient became hypotensive with BP 50/30. EKG
demonstrated ST elevations lead I, lead aVL, V1, V2; ST
depression lead III, aVR. Patient was taken emergently to
cardiac cath which demonstrated thrombus with occlusion in
proximal LAD; wiring of this lesion restored flow, export
removed clot, however it traveled to LCx. Patient then began
having recurrent chest pain, respiratory distress, and
hypotension. She was intubated and an IABP was placed. A small
amount of residual thrombus remained in the LCx near the OM1. No
stents were placed as no underlying plaque apparent. Patient was
started on integrilin and heparin and transferred to the CCU for
further care.
.
While in the CCU RN noticed blood in the oropharynx, while
placing an OG patient regurgitated approximately 25 cc of bright
red blood with clots. Upon placement of OG approximately 10 cc
of bright red blood was suctioned. Patient was transfused 2
units pRBC, started on IV PPI and GI consulted. EGD demonstrated
diffuse friable mucosa with clotted blood in the lower third of
esophagus and GE junction. Blood clot felt to be partially
tamponading the bleed. For full report please see reports below.
GI recommended conservative care unless clinical picture changes
overnight.
.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes insulin dependent, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2116-6-18**]
1.)Coronary angiography of this codominant system showed single
vessel coronary artery disease. The left main was without
significant stenosis, and the LAD was also without stenosis, but
the first diagonal had an ostial 50% lesion. The circumflex had
no
significant disease. The RCA was also without any significant
stenoses.
2.) Resting hemodynamics showed normal right and left sided
filling
pressures (RVEDP 7, LVEDP 5) with a mean PCWP of 6. The cardiac
output was normal at 5.5 with an SVR of 1207 and a PVR of 58.
3.) Left ventriculograpy revealed a normal ejection fraction of
62%
with mild mitral regurgitation and no significant wall motion
abnormalities.
-PACING/ICD: None
3. OTHER 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
- 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:
VS: T=92.9 BP=118/39 HR=88 RR=vent O2 sat=100% on FiO2 1
GENERAL: Opens eyes to name. Intubated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Blood surrounding ET
tube.
NECK: No JVP appreciated.
CARDIAC: RRR, IABP noises, unable to appreciate murmurs, rubs,
gallops.
LUNGS: Coarse breath sounds bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Cold feet, pulses not palpable.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2130-9-1**] 08:45AM BLOOD WBC-9.8# RBC-2.75* Hgb-8.5* Hct-25.1*
MCV-91 MCH-30.8 MCHC-33.8 RDW-16.2* Plt Ct-193
[**2130-9-1**] 08:45AM BLOOD PT-19.2* PTT-43.3* INR(PT)-1.8*
[**2130-9-1**] 10:00AM BLOOD Glucose-273* UreaN-61* Creat-1.9* Na-134
K-3.8 Cl-107 HCO3-16* AnGap-15
[**2130-9-1**] 03:05PM BLOOD Calcium-8.0* Phos-4.0 Mg-1.8
Brief Hospital Course:
In summary, this is a 88 year old female with DM, HTN who
presented with STEMI and was brought emergently to cath lab, was
transferred to the CCU following procedure with IABP given
hypotension. Hospital course was complicated by upper GI bleed,
slow afib requiring cardiopulmonary resusitation. The pt was
made DNR during the admission and passed on [**2130-9-5**] at 12:08 AM
while in the CCU, cause of death noted to be cardiogenic shock
following STEMI.
.
# CORONARIES: Patient presented with STEMI. During cath patient
had successful thrombectomy of proximal LAD occlusion with 20%
residual stenosis. However, developed acute occlusion of OM (due
to an embolus) treated with thrombectomy and PTCA (2.5x12mm
balloon) with a 60% residual thrombotic occlusion but
restoration of flow. Patient was unstable during procedure and
consequently was intubated and IABP placed. No stent was placed
during procedure. She was transferred to the CCU on IABM,
integrillin, hepain. Attempts were made to wean the balloon
pump but were unsuccessful due to hypotension. On day 3 of the
hospitalization, family meeting was held and pt was made CMO,
IABP weaned, pt started on morphine gtt.
.
# PUMP: ECHO performed on the [**9-2**] showed EF of 30% to 35% with
mild regional left ventricular systolic dysfunction and dilated
right ventricle with moderate regional systolic dysfunction. New
changes secondary to ACS.
.
# RHYTHM: Sinus. Patient has history of A Fib, patient
presumably on Verapamil for rate control. No anti-coagulation
had been given in the past due to prior history of GI bleed.
During this admission, she developed slow afib and the family
was called and decided to make DNR after the first code, no
escalation of care.
.
# Upper GI bleed: EGD demonstrates friable esophagus with blood
clot at GE junction. Patient's HCT and hemodynamics currently
stable. Due to ballon pump patient was initially placed on
heparin, started on IV PPI. Crits were followed.
.
# Diabetes: Insulin sliding scale
.
# Hypertension: Outpatient Lisinopril, Lasix and Verapamil were
held due to hypotension after cath
.
# Chronic Renal Failure: Recent creatinine range as outpatient
1.3 - 1.9. During this admission, pt developed [**Last Name (un) **] with
creatinine rising to 2.3, unclear etiology but concerning for
pre-renal vs cholesterol emboli vs contrast-induced nephropathy
(less likely due to timing of onset).
.
# Shock: on day 2 of the admission, pt developed mixed
cardiogenic/septic shock, 2 blood cxs growing gram + cocci, was
started on vanc/cefepime for broad coverage.
.
# Coagulopathy: Pt with declining platelets, hct, concerning for
DIC, platelet distruction in the setting of IABP.
.
# Asthma: Patient intubated.
.
# Gout: Hold Allopurinol in acute setting.
.
# GERD: IV PPI given UGI bleed.
Medications on Admission:
MEDICATIONS: per OMR - unable to obtain from patient
ACETAMINOPHEN - 500 MG CAPLET - 2 TABS BY MOUTH Q 8 HRS
ALBUTEROL SULFATE [PROVENTIL HFA] - 90 mcg HFA Aerosol Inhaler -
2 puffs(s) inhaled tid prn
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth twice a day
ATORVASTATIN - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
FUROSEMIDE - 20 mg Tablet - one Tablet(s) by mouth every day
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet
IPRATROPIUM BROMIDE [ATROVENT]
LISINOPRIL - 10 mg Tablet - one Tablet(s) by mouth daily
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 (One) Tablet, Delayed Release (E.C.)(s) by mouth twice a day
TRAMADOL - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - 50 mg
Tablet - one Tablet(s) by mouth once a day as needed for prn
pain
VERAPAMIL - 120 mg Cap,24 hr Sust Release Pellets - 1 Cap(s) by
mouth once a day
ZAFIRLUKAST [ACCOLATE] - 20 mg Tablet - 1 (One) Tablet(s) by
mouth twice a day
.
Medications - OTC
CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider) - 500
mg Tablet, Chewable - Tablet(s) by mouth
DIPHENHYDRAMINE HCL [BENADRYL] - (OTC) - Dosage uncertain
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
14 units subcutaneous every morning and 10 units subcutaneous
every evening
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE] - 25 gauge X
1"
Syringe - as directed twice a day one ml syringe, brand name med
necessary, no substitutions - No Substitution
LACTASE [LACTAID] - (Prescribed by Other Provider) - Dosage
uncertain
LOPERAMIDE [IMODIUM A-D] - (Prescribed by Other Provider) - 2
mg
Tablet - 4 Tablet(s) by mouth every other day
MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Tablet -
1 Tablet(s) by mouth once a
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
STEMI/cardiogenic shock
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 5849, 2762, 2749, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6557
} | Medical Text: Admission Date: [**2103-10-3**] Discharge Date: [**2103-10-7**]
Date of Birth: [**2045-8-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
CAD
Major Surgical or Invasive Procedure:
CABG x4
History of Present Illness:
Mr. [**Name13 (STitle) 9955**] is a 65-year-old male, with worsening anginal
symptoms, who underwent catheterization that showed left main
disease with a small right coronary artery with no disease. He
also has LAD disease and ramus disease and is presenting for
revascularization
Past Medical History:
HTN, hyperlipidemai, back pain
Social History:
nc
Family History:
nc
Physical Exam:
AVSS
NAD
CTA b/l
RRR, S1S2
soft, NT/ND
AxOx3
Pertinent Results:
[**2103-10-3**] 12:39PM BLOOD WBC-12.4* RBC-3.15*# Hgb-10.0*#
Hct-27.3*# MCV-87 MCH-31.6 MCHC-36.4* RDW-12.9 Plt Ct-119*#
[**2103-10-6**] 05:20AM BLOOD WBC-13.5* RBC-2.90* Hgb-9.0* Hct-25.6*
MCV-88 MCH-30.9 MCHC-35.0 RDW-13.1 Plt Ct-163
[**2103-10-3**] 12:39PM BLOOD PT-14.4* PTT-39.4* INR(PT)-1.3*
[**2103-10-4**] 03:53AM BLOOD PT-13.9* PTT-32.7 INR(PT)-1.2*
Brief Hospital Course:
The patient was admitted on [**2103-10-3**] for a scheduled CABG with
Dr. [**Last Name (STitle) **]. Please see operative note for details. The
patient went to the ICU directly after his surgery. He did well
post-operatively and was transferred tot he floor POD 1. Chest
tubes were removed prior to transfer. On POD 3, we removed his
pacer wirse. PT saw him and thought he was safe to go home. He
was discharged home POD 4.
Medications on Admission:
ASA 325', zocor 40', atenolol 25', plavix 75'
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABGx4
Discharge Condition:
good
Discharge Instructions:
Please call or come to the ED with any worrisome symptoms,
including shortness of breath, chest pain, fevers over 100,
nausea, vomiting, increased redness of your incisions, or any
other isses that may arise.
Please continue all new medications as directed. Please let
your PCP know about any new medication changes.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow up
appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2103-12-14**] 10:00
Completed by:[**2103-10-7**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6558
} | Medical Text: Admission Date: [**2155-10-21**] Discharge Date: [**2155-11-27**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2155-10-21**] ERCP for stent placment
[**2155-10-26**] PICC line placement
[**2155-11-5**] exploratory laparotomy, lysis of adhesions
History of Present Illness:
Ms. [**Known lastname **] is an 88 year old woman with h/o HTN, who presented
to [**Hospital3 **] with abdominal pain and fevers, transferred to
[**Hospital1 18**] for management of cholangitis.
.
Patient presented to [**Hospital3 **] today with abdominal pain
and fevers x1 day. ASA 325mg PO x1 given by EMS. At the OSH ED,
VS: T 99.0 BP 120/44 HR 140 RR 21 O2sat 92% 2LNC, 95% 4LNC. She
was given 1LNS, Lopressor 25mg PO x1, Nitro 0.4mg SL x1, Zofran
4mg IV x1, Morphine 2mg IV x1, Tylenol 625mg PO x1, Imipenem
500mg IV x1, Flagyl 500mg IV x1. CT abd/pelvis concerning for
cholangitis vs pancreatitis, so the patient was transferred to
[**Hospital1 18**] for possible ERCP.
.
In the ED, initial vs were: 96.7 50 86/44 19 96% 4L Nasal
Cannula. Patient was AOx3 initially, complaining of severe
abdominal pain. Per ED report, patient wanted everything to be
done at that time. Given bradycardia and hypotension, patient
was intubated, sedated with Fentanyl/Versed, CVL was placed. HR
improved to the 70s with a dose of Atropine. She was started on
Dopamine and Levophed. Given a dose of Vanc and Zosyn, 4L IVF.
Surgery and ERCP were notified. Surgery recommends decompression
by ERCP. ERCP planning to intervene around 6am in the ICU. Given
concern for ?CCB/BB overdose, patient was given a dose of
Calcium chloride in the ED. Bedside ECHO showed poor
contractility. Vital prior to transfer: P 97 BP 133/60 RR 16
O2sat 100%. Patient has PIVs and CVL.
.
On the floor, patient is intubated and sedated.
.
Review of sytems:
unable to assess
Past Medical History:
HTN
Depression
COPD
MGUS
Osteopenia
GERD, treated for Hpylori in the past
Cardiac cath [**2151**] - minimal, non-obstructive disease
Social History:
No tobacco/EtOH. Lives alone in her home. Husband and son are
deceased. Friend [**Name (NI) 5969**] is HCP. Only family is nephew in
[**Name (NI) 2784**].
Family History:
unknown
Physical Exam:
On admission:
Vitals: T: 98.4 BP: 154/65 P: 108 R: 20 O2: 100%
Vent: FiO2 50%, TV 470, RR 20, PEEP 5
General: intubated, sedated
HEENT: Sclera anicteric, ETT in place
Neck: supple, no LAD
Lungs: Clear to auscultation anteriorly
CV: tachy, then brady, S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-distended, bowel sounds present, tender
abdomen
GU: foley
Ext: cool extremities, + distal pulses, no clubbing, cyanosis or
edema
Neuro: intubated, sedated
On discharge:
General: A&O, flat affect, speech clear and coherent
Lungs: bilateral wheezes occasionally
CV: normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, slightly distended, bowel sounds present, mildly
tender to palpation
Ext: + distal pulses, no clubbing or cyanosis, mild LE edema
Pertinent Results:
[**2155-11-16**] 05:00AM BLOOD WBC-8.5 RBC-3.01* Hgb-9.0* Hct-28.7*
MCV-96 MCH-29.9 MCHC-31.2 RDW-15.3 Plt Ct-168
[**2155-11-15**] 07:00AM BLOOD WBC-7.1 RBC-2.94*# Hgb-8.8*# Hct-27.4*
MCV-93 MCH-29.8 MCHC-32.0 RDW-15.1 Plt Ct-158
[**2155-11-15**] 04:59AM BLOOD WBC-5.7 RBC-2.35*# Hgb-7.0*# Hct-22.4*
MCV-95 MCH-29.9 MCHC-31.4 RDW-15.4 Plt Ct-122*
[**2155-10-21**] 02:53PM BLOOD WBC-26.9* RBC-2.73* Hgb-8.4* Hct-25.6*
MCV-94 MCH-30.9 MCHC-32.9 RDW-17.6* Plt Ct-235
[**2155-10-21**] 04:15AM BLOOD WBC-32.1* RBC-2.77* Hgb-8.6* Hct-25.7*
MCV-93 MCH-31.0 MCHC-33.4 RDW-16.9* Plt Ct-311
[**2155-10-20**] 11:20PM BLOOD WBC-33.9* RBC-3.06* Hgb-9.4* Hct-28.2*
MCV-92 MCH-30.8 MCHC-33.5 RDW-16.9* Plt Ct-304
[**2155-11-5**] 04:01PM BLOOD Neuts-86.5* Lymphs-7.5* Monos-5.5 Eos-0.3
Baso-0.3
[**2155-11-16**] 05:00AM BLOOD Plt Ct-168
[**2155-11-15**] 07:00AM BLOOD Plt Ct-158
[**2155-11-12**] 04:48AM BLOOD Plt Ct-72*
[**2155-11-11**] 09:47AM BLOOD Plt Ct-60*
[**2155-11-17**] 05:21AM BLOOD Glucose-119* UreaN-31* Creat-0.7 Na-139
K-4.1 Cl-103 HCO3-34* AnGap-6*
[**2155-11-16**] 05:00AM BLOOD Glucose-124* UreaN-28* Creat-0.7 Na-139
K-3.7 Cl-101 HCO3-34* AnGap-8
[**2155-10-23**] 04:51PM BLOOD Glucose-179* UreaN-39* Creat-2.0* Na-142
K-3.5 Cl-109* HCO3-19* AnGap-18
[**2155-10-23**] 04:07AM BLOOD Glucose-74 UreaN-36* Creat-1.8* Na-141
K-3.5 Cl-110* HCO3-20* AnGap-15
[**2155-10-20**] 11:20PM BLOOD Glucose-150* UreaN-24* Creat-1.3* Na-137
K-4.1 Cl-101 HCO3-26 AnGap-14
[**2155-11-4**] 05:50AM BLOOD ALT-6 AST-15 LD(LDH)-191 AlkPhos-90
TotBili-0.7
[**2155-11-2**] 05:52AM BLOOD ALT-10 AST-17 LD(LDH)-169 AlkPhos-69
TotBili-0.6
[**2155-10-21**] 04:15AM BLOOD CK-MB-3 cTropnT-<0.01
[**2155-10-20**] 11:20PM BLOOD cTropnT-<0.01
[**2155-11-16**] 05:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1
[**2155-10-31**] 05:49AM BLOOD calTIBC-185* VitB12->[**2143**] Folate-12.9
Ferritn-448* TRF-142*
[**2155-10-31**] 05:49AM BLOOD Triglyc-167*
[**2155-10-21**] 04:15AM BLOOD TSH-0.79
[**2155-11-6**] 02:52AM BLOOD Glucose-97
[**2155-11-5**] 02:46PM BLOOD Glucose-145* Lactate-2.4* Na-134 K-4.1
Cl-101
[**2155-11-6**] 02:52AM BLOOD freeCa-1.10*
[**2155-11-5**] 02:46PM BLOOD freeCa-1.10*
[**2155-10-20**]: EKG:
Baseline artifact. Probable atrial fibrillation with a
controlled ventricular response. Left axis deviation. Consider
left anterior fascicular block. No previous tracing available
for comparison. Clinical correlation is suggested.
[**2155-10-21**]: ERCP;
A periampullary diverticulum was seen and the papilla was
inverted within the diverticulum.
Multiple attempts were made to cannulate with the patient in
the supine position, however, it was not possible to approach
the ampulla en-face.
The patient was then rotated onto the left side.
Successful cannulation was achieved after manipulating the
diverticulum with the sphincterotome. The procedure was highly
difficult.
Fluoroscopic views were limited due to the portal C-arm and
patient positioning, so aspiration was performed to confirm
biliary location. Pus was aspirated from the bile duct.
Contrast medium was injected resulting in partial opacification.
The wire could not pass beyond the mid-CBD.
A 5cm by 10FR biliary stent was placed successfully in the bile
duct, with immediate passage of pus and small stone fragments
Otherwise normal ERCP to 3rd part of duodenum
[**2155-10-24**]: ECHO:
The left atrium is dilated. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%).
There is lipomatous hypertrophy of the interatrial septum. No
mass is seen in the left atrium. The prior study of [**2155-10-22**]
was also reviewed. Based on review of both studies, the
echodense region in the left atrium is consistent with artifact.
[**2155-10-25**]: X-ray of the abdomen:
FINDINGS: Technically limited radiograph. No safe evidence of
free air.
Upper abdominal endo-drain in situ. No pathological
calcifications. Moderate distention of bowel loops with multiple
air-fluid levels on the left lateral decubitus view. No bowel
wall thickening.
CT [**11-12**]- layering pleural effusions, atelectasis, PO contrast
through small and large bowel to rectum, normal bowel loops,
mesenteric haziness, perihepatic ascites, postERCP pneumobilia,
cbd stent, trace free fluid in pelvis
[**2155-11-20**]: x-ray of the abdomen:
Impression:
No ileus or obstruction
Brief Hospital Course:
Ms. [**Known lastname **] is an 88 year old woman with h/o HTN, who presented
with acute cholangitis s/p ERCP with stent, whose course has
been complicated by sepsis, with improving pressures throughout
the hospitalization. Her course has also been complicated by
respiratory failure, ARF, delirium, and partial SBO/ileus.
Medical course ([**Date range (3) 91498**]):
.
#. cholangitis/sepsis: ERCP was performed and stent placed in
biliary duct. Biliary tree was incompletely visualized however
stones and pus were released following stent placement. LFTs
downtrended and patient was treated with Zosyn, switched to
cefazolin when sensitivities returned with pan-sensitive e.coli
from OSH cxs, no further cxs positive at [**Hospital1 18**]. Pt did require
pressor support for a short amount of time initially while in
the ICU.
.
# Atrial fibrillation: New diagnosis during her stay. She was
initially managed with IV diltiazem drip in the ICU and then
shifted to diltiazem 90 mg four times a day. She was called out
of the ICU in stable condition. While on the medical floor, NG
tube was replaced given worsening of her abdominal pain and
distension. During relpacement, she went into Aflutter with RVR
at rate of 180's but remained hemodynamically stable and
asymptomatic. She was given diltiazem 10mg and rate decreased to
low 100's, then up to 150's and received another 10mg dilt.
Cardiology was consulted who recommended diltiazem 20mg IV,
given with HR into 90's however her HR went back to 150's. Her
BP was in the 140-150's. She was transferred to inpatient
cardiology floor for further management. There, she was
initiated on diltiazem drip along with iv metoprolol 5 mg every
six hours. The next day her rhythm was sinus in rate of
70's-80's with occasional bursts into Afib. IV diltiazem was
discontinued and metoprolol IV was resumed. Given she had bowel
movements and her residual after NG tube clamping was only 100
cc, She was given carvedilol 12.5 mg through the NG tube and
transferred back to the medical floor for further management of
her other comorbidities.
.
#. Respiratory failure: Patient intubated for airway protection,
as she was bradycardic and hypotensive in the ED. CXR with
bibasilar opacities c/w atelectasis and pleural effusion.
Initial ABG 7.27/48/114. She was extubated on [**10-22**] with
minimal difficutly; agitation controlled with seroquel/haldol.
She did desat after extubation, sats improved with diuresis.
.
#. Bradycardia/tachycardia: Likely [**1-8**] to BB - takes Bisoprolol
at home and given Lopressor at OSH. She subsequently became
tachycardic with new afib with RVR, requiring dilt drip and
eventually transitioned PO dilt. CHADs score of 2, risk/benefit
of anticoagulation to be discussed with PCP.
.
#. Acute renal failure: peaked at 2.1, however now downtrending,
likely pre-renal in the setting of hypotension. Cr now stable at
1.2-1.3.
.
# HTN: BP elevated later in the admission. Initially her HCTZ
was restarted. While on the inpatient cardiology floor, this was
held. Amlodipine 5 mg daily was given for 2 days ([**10-29**] and
[**10-30**]) through NG tube. Carvedilol PO 12.5 mg x1 was given [**10-30**]
morning for SBP of 150's-180. Can consider initiating ACEi or
[**Last Name (un) **] given her Cr is stable now at 1.2-1.3.
.
#. COPD: concern for exacerbation given wheezing
post-extubation, treated with prednisone x5 days
.
#. Depression: She expressed her wishes to die but no active
plans. home paroxetene which was held initially was restarted
while on the cardiology floor. She expressed her misery that her
husband and son are dead. Social work was consulted.
.
#. Concern for L atrial mass: seen on initial ECHO performed to
r/o cardiogenic cause of hypotension, not present on repeat
ECHO, likely lipomatous hypertrophy of the interatrial septum.
.
# Partial SBO/ileus: Pt with increasing abd pain on day 6 of the
admission. CT showed possible partial SBO, also concerning for
ileus secondary to cholangitis. Improved with NG tube with
suctioning and supportive care. She was treated conservatively
for approximately two weeks. On HD16 was then taken to the OR
for failure of conservative management. She underwent
exploratory laparotomy with extensive lysis of adhesions.
Postoperatively, her care was transferred to the Acute Care
Surgical service. Please see section below for hospital course
following this transfer.
The following describes the patients surgical course and
postoperative management up until [**2155-11-23**]. On [**11-23**], after
discussion with the patient and family, the decision was made to
withdraw medical interventions and transfer the patient to
hospice. On [**11-24**], paliative care became involved and she was
officially made CMO status.
On HD16 she was then taken to the OR for failure of conservative
management of her partial SBO. She underwent exploratory
laparotomy with extensive lysis of adhesions. Postoperatively,
she remained intubated and was thus admitted to the ICU. She was
successfully extubated on POD 1. She developed Afib, which was
rate-controlled with IV lopressor. She was additionally
hyperkalemic, which improved with continued fluid
administration. She was transferred to the floor in stable
conditon NPO, with an NGT to suction, and on TPN [**2155-11-6**].
On the floor her vital signs were monitored routinely along with
her oxygen saturations through until [**11-24**]. Prior to being made
CMO, she remained afebrile and hemodynamically stable with
intermittent hypertension in the 170s systolic and HR in the
90s. Her pain level was routinely assessed and she was given
analgesics as needed thoughout her entire hospitalization.
On [**2155-11-7**], her NG tube was removed and her diet was advanced
as tolerated. However, on [**2155-11-10**] she developed hypertension,
tachycardia and had bilious emesis. Her abdomen was distended
and an NG tube was replaced. Her NG output remained high over
the following few days, and she was repleted with IV fluids
along with the continuing TPN. On [**11-14**] her NG output decreased
and the tube was removed. On [**11-17**] she was started on regular
diet and her TPN was stopped. She was started on a bowel regimen
and also given fleets enemas as needed. She continued to have
evidence of bowel function, including passing flatus and stool
(also see abd xray from [**11-20**] under results section). However,
she displayed poor PO intake. Calorie counts were performed for
three days during her posoperative course, in which she did not
have adequate intake. The possibility of a PEG tube placement
was discussed with the patient, her nephew and her health care
proxy, all of whom decided that the patient did not want a PEG
tube (see last paragraph for details).
A foley was replaced perioperatively for urine output
monitoring. It was removed on POD2. However, she was incontinent
after and it was difficult to monitor her urine output, so it
was replaced on [**11-11**]. On [**11-24**], her foley was removed as her
care was transitioned to comfort measures only.
Her hematocrit was monitored throughout her postoperative course
and she was given blood transfusions in the initial
postoperative phase as needed, to which she responded
appropriately. Her electrolytes were also monitored and repleted
as needed. However, after being made CMO, all lab draws were
stopped.
Throughout her postoperative course she had evidence of pleural
effusions, atelectasis and pulmonary edema. She was diuresed as
appropriate and pulmonary toileting was encouraged. Her intake
and output was monitored closely. Her labs were continually
monitored, and she showed evidence of a metabolic alkalosis, and
diamox was used as a means of diuresis during this phase. She
continued to have an oxygen requirement however, and on [**2155-11-18**]
she was transferred back to the ICU for tachypnea and concern
for her respiratory status. In the ICU, diuresis was continued
with a lasix drip as her bicarb had normalized. On [**11-20**], her
pulmonary edema on chest xray showed improvement and she was
transferred back to the floor, where diuresis was continued with
PO lasix. Her respiratory status is currently stable on
supplemental oxygen via nasal cannula. However, at present she
is refusing most oral medications, including lasix.
Physical therapy was consulted postoperatively and she was
encouraged to mobilize out of bed as tolerated. However,
aggressive PT measures have been withdrawn at this time. She
began to develop thrombocytopenia on heparin postoperatively,
which was thought to be due to HITT, as her platelets trended
back upward to normal after discontinuing heparin. Therefore,
she was placed on fondaparinux and pneumoboots for DVT
prophylaxis. This has also been discontinued at this time.
Postoperatively, geripsych was involved in the patient's care as
the patient continued to expresses her wishes to die, but was
also exhibiting signs of delirium. Initially upon evaluation,
the psychiatry team deemed her without capacity to make medical
decisions. Her health care proxy was [**Name (NI) 653**] who stated to
proceed with medical treatment in the initial postoperative
phase. However, as the patient became more stable and her bowel
obstruction cleared (see above), she continued to express her
wishes to die and refused to eat or take oral medications.
Social work was involved throughout the hospitalization. The
patient's nephew who lives in [**Name (NI) 2784**] was [**Name (NI) 653**] who came to
[**Name (NI) 86**] to see the patient. A meeting was held with a member of
the surgical team, the social worker and the nephew, after the
nephew had a chance to meet with the [**Hospital 228**] health care
proxy. The proxy was involved in the meeting via telephone. The
decision was made at that time to honor the patient's wishes and
cease further medical interventions. Therefore, palliative care
was consulted and care was changed to comfort measures only and
admitted to hospice. The patient is being discharged to a
facility to pursue end of life care.
Medications on Admission:
Medications (per OSH records):
Bisoprolol/HCTZ 5mg/6.25mg PO daily
Hydrocodone/Acetaminophen 1tab PO BID
Mupirocin 2% cream TP [**Hospital1 **]
Paroxetine 30mg PO daily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
7. hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25-0.5 mg Injection
Q1H (every hour) as needed for pain.
8. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
0.25-0.5 mL PO Q1H (every hour) as needed for pain or dyspnea.
9. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: [**1-10**] mL Injection
Q8H (every 8 hours) as needed for nausea.
10. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
at bedtime as needed for constipation.
11. haloperidol 1 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) as needed for nausea.
Discharge Disposition:
Expired
Discharge Diagnosis:
1. pancreatitis
2. small bowel obstruction
3. postoperative ileus
4. atrial fibrillation
5. sepsis
6. acute renal failure
7. delirium
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You had a
CT scan of the abdomen done which showed pancreatitis. You
underwent an ERCP and placement of a stent into the bile duct.
Once the stent was placed you passed a few stones as well as
pus. You were started on antibiotics. During this time you
dropped your blood pressure and developed signs suggestive of
infection. Despite this procedure, your abdominal pain
continued and you were taken to the operating room for an
exploratory laparotomy and lysis of adhesions for a bowel
obstruction. Your bowel function has returned after this
procedure.
After discussion with you, your family and your health care
proxy, the decision was made to transfer you to a facility to
pursue end of life care.
Followup Instructions:
none- comfort measures only
Completed by:[**2156-10-27**]
ICD9 Codes: 5849, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6559
} | Medical Text: Admission Date: [**2175-6-4**] Discharge Date: [**2175-6-9**]
Date of Birth: [**2110-2-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65M with hx of hypertension, hypothyroidism presenting with
shortness of breath and fever. He was in his usual state of
health until ~2 weeks ago at which time he developed mild
shortness of breath and cough. He described cough as the
dominant symptom when he first came to the MICU; on transfer to
the medicine service he emphasized the history of dyspnea on
exertion. He denied sinus congestion, headache, rhinorrhea or
sore throat. His dyspnea on exertion continued; he says that
today he came to the emergency department because "my wife made
me" come. He had chest wall pain bilaterally by his history with
me (described as left-sided when he first came in), which he
says was worsened by deep breathing and coughing.
.
In the ED, his initial vital signs were 100.7 132 230/80 42 99%
NRB. He was initially placed on nitroglycerin gtt for blood
pressure control. A CXR was inconclusive for edema vs.
infiltrate. His BNP returned low so the nitroglycerin gtt was
discontinued in favor of labetalol. He received ceftriaxone and
levofloxacin; he grew out GPCs so was started on vancomycin;
these returned as pan-sensitive pneumococcus, so vanco was
d/c'ed and IV penicillin G was started while the patient was in
the MICU. He was called out to the floor as his clinical
condition improved.
.
ROS: no HA, abd pain, no dysuria, no rash, no leg swelling. no
weight gain. no increasing abd girth. + snores, no known apneic
spells during sleep.
Past Medical History:
hypertension
past hypothyroidism
?newly detected ascites
Social History:
Lives with wife and 18 year old grandson. distant smoking
history >40 years ago. On admission: Says he drinks alcohol
(shots Bourbon or vodka) 2-3x/week unless celebrating; last
drink 2 weeks ago. Later: history suggested a much heavier
consumption pattern prior to one year ago, and possibly heavier
at present.
Family History:
Father - deceased hx of stroke. Mother - deceased hx of
alzheimers. No cancers. no MI, no DM2
Physical Exam:
On arrival at [**Hospital1 18**]/MICU
VS: 99.6 96 120/72 28 100% (15L mask)
GEN: tachypneic. speaking in full sentences, obese male
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, dry MM, Neck supple, no LAD, no carotid
bruits, JVP not seen due to body habitus
CV: distant heart sounds RRR, nl s1, s2, no m/r/g. chest pain
reproduced with palpation.
PULM: late crackles at the bases with faint wheeze bilat.
ABD: soft, NT, mod distension, + BS, no HSM, + fluid
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
NEURO: alert & oriented x3, no right/left neglect, CN II-XII
grossly intact, 5/5 strength throughout upper and lower
extremities. No sensory deficits to light touch appreciated. No
asterixis
PSYCH: appropriate affect
.
Additional findings on transfer from the MICU:
PULM: Egophony at the left lower half of lung field; bronchial
breath sounds from right middle to bottom of lung field. Fair
air movement above these findings.
GENITAL: macerated, depigmented area on underpart of foreskin,
appears to be some constriction of foreskin around distal
portion of penis shaft; no isolated lesions
Pertinent Results:
[**2175-6-4**] 08:50PM BLOOD
WBC-17.4*# RBC-4.03* Hgb-11.7* Hct-35.1* MCV-87 MCH-28.9
MCHC-33.2 RDW-13.4 Plt Ct-557*# Neuts-73* Bands-3 Lymphs-16*
Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2175-6-5**] 03:46AM BLOOD
WBC-19.2* RBC-3.16* Hgb-9.2* Hct-28.1* MCV-89 MCH-29.1 MCHC-32.7
RDW-13.8 Plt Ct-454*
[**2175-6-9**] 06:50AM BLOOD
WBC-11.7* RBC-3.20* Hgb-9.9* Hct-28.7* MCV-90 MCH-30.8 MCHC-34.3
RDW-13.7 Plt Ct-508*
.
[**2175-6-5**] 01:30PM BLOOD PT-16.9* PTT-30.6 INR(PT)-1.5*
.
[**2175-6-4**] 08:50PM BLOOD
Glucose-159* UreaN-20 Creat-1.6* Na-136 K-4.3 Cl-98 HCO3-21*
AnGap-21*
[**2175-6-9**] 06:50AM BLOOD
Glucose-102 UreaN-16 Creat-1.3* Na-137 K-4.9 Cl-99 HCO3-27
AnGap-16
.
[**2175-6-4**] 08:50PM BLOOD
ALT-52* AST-38 LD(LDH)-265* CK(CPK)-223* AlkPhos-162*
TotBili-1.3
[**2175-6-8**] 06:40AM BLOOD ALT-87* AST-88* AlkPhos-223* TotBili-0.8
.
[**2175-6-5**] 05:43AM BLOOD calTIBC-161* VitB12-526 Folate-9.6
Ferritn-1309* TRF-124*
[**2175-6-5**] 12:05PM BLOOD %HbA1c-6.6*
[**2175-6-4**] 08:50PM BLOOD TSH-37*
[**2175-6-5**] 05:43AM BLOOD Free T4-0.45*
Brief Hospital Course:
A/P: 65M with hx of hypertension, hypothyroidism who presented
with fever, cough and respiratory distress.
.
# Respiratory Distress: Exam and imaging were very consistent w
pneumococcal pneumonia, and most conclusively, [**3-31**] blood
cultures from [**6-4**] were positive for strep pneumo. Urine
legionella was negative. There was a small left sided effusion
visualized on CT chest but this was too small for thoracentesis;
ultimately since Mr [**Known lastname **] was improving clinically, the team
felt there was no urgent need to pursue this further unless he
were to worsen. His cultures were no growth starting on [**6-5**]; he
had started on effective treatment in the emergency department
on [**6-4**]. He was continued on penicillin G while on the floor, and
ultimately after consulting the infectious disease service we
decided he would finish out his course on amoxicillin, with
eight more days of antibiosis after the six days he had received
in the hospital.
.
# Hearing loss: Mr. [**Known lastname **] complained of a sensation of
discomfort in his ear just prior to coming into the hospital,
and while here he noted decreased hearing in the left ear. On
examination, there were very small bullae in the upper portion
of the tympanic membrane, suggestive of early/mild bullous
myringitis which can be seen with strep pneumoniae. We set him
up with audiologic evaluation, and will refer him to ENT if
indicated based on the audiologic evaluation.
# Penile lesion: Mr [**Known lastname **] had a slightly bulbous and
circumferential depigmented lesion around the foreskin of his
penis. Originally we thought this might have been an unfortunate
effect of the condom catheter but it remained after
discontinuing the catheter. We referred him for [**Known lastname **]
follow-up with concern that this might represent a malignancy.
.
# Hypothyroidism: He had not been on medicines since he had lost
his health care insurance about 5 years prior; he reported
weight gain and poor energy and recalled a past diagnosis of low
thyroid. His TSH was elevated to 37 with FT4 low at 0.45. We
started levothyroxine at previous home dose of 75mcg; given that
his values were checked in the inpatient setting of critical
illness these should be followed up when he is more stable.
.
# Hypertension: He was hypertensive coming in to ED, was mostly
normotensive in the days after that, and then towards the end of
his admission was hypertensive again; he was sent out on a
starting dose of HCTZ. This should be followed up in subsequent
outpatient visits.
.
# Anemia: There was no evidence of blood loss. His labs were
consistent with an anemia of chronic inflammation. This might be
from the pneumonia or some more chronic cause and should be
followed.
.
# Acute renal failure: He was originally in acute renal failure,
likely from pre-renal state exacerbated by NSAIDs. His
creatinine had normalized by the time of discharge.
.
# Abdominal distension: Abdominal U/S showed no ascites or other
acute issues; it did show a possibly fibrotic/cirrhotic liver
but no ascites nor splenomegaly to suggest portal hypertension.
His LFTs were normal as was synthetic function and normal
platelets. His physical exam was benign and as he improved
clinically we saw no evidence of abdominal process, and his
abdominal appearance may simply be from disproportionate
abdominal obesity.
.
# FEN: He was given a heart-healthy diet and lytes were repleted
PRN.
.
#ACCESS: PIV
.
#PPx
- Heparin sub-q for DVT prophylaxis
.
#CODE: FULL
.
#COMMUNICATION: patient
.
#DISPO: to home with close follow-up.
.
Medications on Admission:
benadryl prn
advil 400 mg [**Hospital1 **] (for past 2 weeks)
.
previously prescribed: metoprolol, synthroid
Discharge Medications:
1. Amoxicillin 875 mg Tablet Sig: One (1) Tablet PO twice a day
for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumococcal pneumonia
Discharge Condition:
Good
Discharge Instructions:
You were diagnosed with pneumonia. You need to keep taking your
antibiotics for the prescribed time. It is extremely important
that you take ALL your antibiotics even if you are feeling
better.
.
You have had some high blood pressure. We've prescribed you some
blood pressure pills. You also had low thyroid levels, which
means you need to keep taking your thyroid medication. It's very
important that you take all the medicines that have been
prescribed to you.
.
You had some hearing loss. It's most likely that this was a
complication of the pneumonia you had, and we hope it will get
better, but it's important that this be followed up. Go to the
audiology appointment (hearing test) to check if your hearing
has got better.
.
You should go to the doctor's office next week to make sure that
everything is going OK. Call [**Telephone/Fax (1) 30910**] on Wednesday to make
an appointment for Thursday or Friday.
.
You'll then have another check up on [**7-5**], which will also
be where you have a complete history and physical to start your
primary care.
.
Come back to the emergency department if you have new fevers, if
you are having more difficulty breathing, if you are coughing up
blood, or if you are having other concerning symptoms.
.
We are concerned about the skin discoloration on your penis and
are concerned that it might be a sign of a problem that may need
treatment. We have set up a [**Month (only) **] appointment for you (a
doctor [**First Name (Titles) **] [**Last Name (Titles) 14903**] in this type of problem); please go to
this appointment as it will be important to follow up.
.
Follow up with your new primary care physician on [**7-5**]
(appointment shown below).
.
Followup Instructions:
.
Call on Wednesday or Thursday: [**Telephone/Fax (1) 30910**]--for visit at
[**Hospital3 **] for hospital visit follow-up.
.
AUDIOLOGY APPOINTMENT (hearing test) [**6-19**] 11:15 Dr [**First Name (STitle) 3175**]
.
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2175-6-21**]
9:00
.
Go to a follow-up appointment with your new primary care
provider:
[**Known firstname **] [**Last Name (NamePattern4) 15398**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2175-7-5**] 3:30
.
Provider: [**Name10 (NameIs) 6410**] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) **], AU.D. Phone:[**Telephone/Fax (1) 6411**]
Date/Time:[**2175-6-19**] 11:15
.
ICD9 Codes: 5849, 7907, 5119, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6560
} | Medical Text: Admission Date: [**2114-11-17**] Discharge Date: [**2114-11-23**]
Date of Birth: [**2035-1-11**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
transient gait unsteadiness, dysarthria.
Major Surgical or Invasive Procedure:
MRI/MRA with Gad
Echo
EEG
CTA head
lumbar puncture
Hemicraniectomy
History of Present Illness:
79y/o RH female here presented to ED with c/o unsteadiness,
slurred speech which started about
12:30pm today (Neurology consult at 4:35pm).
She was carrying shopping bags and about to get into the bus,
when she fell as her right leg gave in. Denied head hitting. She
noticed that she felt
unstable and listed towards to the right. Her friend
felt that her speech was slurred. The friend took her home
and there, while she was laundring, noticed difficulty
manipulating coins in her hands. Her friend brought her to [**Hospital1 18**]
[**Name (NI) **] for further evaluation.
Stated these symptom did not get worse. She herself did not
notice any slurring of speech. She understood well spoekn
speech. Denied any weakness, numbness.
She stated that this was her first episode. She noticed some
line
of colors floated in the sight last week. Denied any vision
loss,
changes.
She had light headache, which was almost resolved. She denied
any
history of migraine, just occasional light headache.
At [**Last Name (LF) **], [**First Name3 (LF) **] physician noticed left hemianopsia and right side
ataxia, called neurology consult for possible TIA/stroke.
ROS: No chest pain, SOB, palpiation, backache, neckache,
incontinence, fever, chill.
Past Medical History:
Autoimmunehepatitis
DM
Hypothyroidism
Social History:
Writer, retired educator (religious education)
Denied Smoking, drugs. Used to drink occasional etoh, but years
ago. Denied alcohol problems.
Family History:
Mother had some cancer. No stroke, heartattack, HTN, DM.
Physical Exam:
PEX: T-99.6 BP-120/80 HR-144, reg RR-12 SaO2 97%, r/a
Gen: Awake, alert, no distress
HEENT: Had bil hearing aid. clear ear canals, ear drums,
conjunctivas, oral membrane, no neck bruit, no goiter
Chest: vesicular sound, symmetrical, symmetrical chest
Heart: S1, S2 nl, no murmur
Abd: soft nt/nd no hepatosplenomegaly
Skin: no lesions, skin stigmata, moist, turgor nl
Exts: no arthralgia, cotraction. High arched Rt foot.
NEURO
MS: Awake and alert, cooperative with exam, normal affect.
Oriented to person, place, and date. Attentive, says name of
days of week backwards smoothly and correctly. Speech is
slightly slurred with normal comprehension and repetition. No
dysarthria. Good pronounciation of kakaka, lalala, papapa.
[**Location (un) **] intact. Registers [**4-13**], recalls [**4-13**] in 10 minutes. No
right left confusion. No evidence of apraxia or neglect.
CN: Fundus bil clear disc margin and color. Left homonimous
hemianopsia (both at mono-, biocular test), unclear if it spaced
macular region, Pupils round, equal, Pupils round and equal in
size, reactive to the light, bilaterally 3mm to 2mm. Symmetrical
facial sense, appearance, NLF, WFH, spontaneous and forced
smiles, uvla midline, no curtain sign, tongue full, SCM normal
volume and strength
Motor: Full throughout, normal tone
Reflex: DTR brisk, but no clonus, spread, symmetrical, planters
going down
Sensory: Symmetrical to the light touch, pin prick, vibration,
temperature throughout. Normal position sense at digits, toes.
Coordination: Smooth and accurate FNF. No DDK. Smooth accurate
heel-shin test. Normal, quick finger tapping. Stable sitting,
standing. At standing had shifted slightly towards to the right,
but no unstability at rest, pushed
Gait: Narrow based stable gait. Stable tandem gait.
Meningeal signs: No Brudzinski sign. No stiffen neck.
Pertinent Results:
Other Blood Chemistry:
%HbA1c: 6.8
[Hgb]: Done
[A1c]: Done
New Method (Dcct/Ngsp Traceable) As Of [**2113-4-28**];[**Doctor First Name **]
Recommendations:; <7% Goal Of Therapy; >8% Warrants Therapeutic
Action
CK: 109 MB: 4 Trop-*T*: <0.01
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
ALT: AP: Tbili: Alb:
AST: LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Cholesterol:157
Other Blood Chemistry:
Triglyc: 52
HDL: 74
CHOL/HD: 2.1
LDLcalc: 73
Ldl(Calc) Invalid If Trig>400 Or Non-Fasting Sample
[**2114-11-17**]
4:00p
SPECIMEN SLIGHTLY HEMOLYZED
126 86 12 223 AGap=21
4.0 23 1.0
Comments: Hemolysis Falsely Increases This Result
SPECIMEN MODERATELY HEMOLYZED
CK: 88
Comments: Hemolysis Falsely Increases This Result
ALT: 56 AP: 104 Tbili: 0.5 Alb: 4.2
AST: 64 LDH: 268 Dbili: TProt:
[**Doctor First Name **]: 109 Lip:
94
5.3 11.3 186
32.0
PT: 12.1 PTT: 29.3 INR: 1.0
Hematology
ANALYSIS WBC RBC Polys Lymphs Monos Macroph
[**2114-11-19**] 11 1100* 12 40 46 2
[**2119-11-19**]* 12 36 50 2
TUBE #1
1 HAZY,SUPERNANT - TRACE XANTHROCHROMIC
Chemistry
CHEMISTRY TotProt Glucose LD(LDH)
[**2114-11-19**] 12:16PM 564*1 64 47
TUBE #1; TUBE#3
1 VERIFIED BY DILUTION
PROTEIN ELECTROPHORESIS CSF-PEP
[**2114-11-19**] 12:16PM PND
TUBE #1; TUBE#3
MRI: No evidence of acute infarction. White matter changes
suggesting chronic small vessel ischemia.
EEG: This is an abnormal EEG in the waking and drowsy states
due
to the left anterior temporal slowing and bursts of generalized
slowing.
The first abnormality suggests a left anterior temporal
subcortical
dysfunction, while the second abnormality suggests a mild
encephalopathy, which may be seen with infections, medications,
ischemia
or toxic metabolic abnormalitites.
Echo: Normal global and regional biventricular systolic
function. No ASD
or PFO seen.
Brief Hospital Course:
Patient was at baseline on initial examination Day 1. On day 2,
had a 30 minute episode of dysarthria and left sided
weakness/neglect. Had a stat MRI/MRA within 30 minutes which
did not show any DWI abnormalities or vascular compromise.
Returned to baseline after 30minutes and had no further episodes
of change in speech, vision or weakness.
On day 1 and 2 was having low grade fevers up to 101.0 but was
asymptomatic. Had a lumbar puncture [**11-19**] which revealed an
openiing pressure 12cm H20. Xanthachromic throughout. 1200
RBC/1WBC in tube 1 and 1100 RBC/1WBC in tube 4. Protein was 564
and sugar was normal. Based on these results, she was treated
empirically for bacterial and HSV encephalitis with Vanc 1gm
Q12, Rocephin 2gm Q12 and Acyclovir 10mg/kg IV Q8. Antibiotics
were d/c'd after 24 hours of negative cultures and negative GS.
Acyclovir was continued to [**12-23**] after CSF HSV PCR returned
negative.
Regarding blood and xanthachromia in CSF, underwent CTA to r/o
aneurysm or other anomaly which was negative. Discussed utility
of doing Angio to further rule out any source of bleed or
cortical irritation. Was thought not to be of benefit after
long discussion with neurointerventionist.
EEG was performed to rule out seizure but showed no spikes. Was
focal left temporal slowing however and did MRI with Gad to r/o
mass lesion/infrection. See results secion.
On [**11-22**], the patient had acute onset of left hemiplegia, right
gaze deviation and hemineglect. She was examined closely and
repeatedly over one hour and seizure was considered as the
likely cause. She did not respond to ativan, however, and became
more difficult to arouse. She vomited and was taken emergently
to CT scan, which showed a large right temporal hemorrhage.
Neurosurgery was called and the patient was taken emergently to
the OR for hemicraniectomy. She was admitted postoperatively to
the ICU and started on mannitol and hyperventilation. However,
her exam showed no improvement, with fixed, dilated pupils with
no extraocular movements, clonus and extensor posturing.
The decision was made, in a family meeting, to make patient CMO,
which is in [**Location (un) **] with her wishes clearly stated in a living
will. They agreed to autopsy and wish to receive the remains for
cremation afterwards.
Medications on Admission:
PREDNISONE 3 MG QD
METFORMIN 850mg [**Hospital1 **]
ARCUPROL 20mg QD
Fosamax 70mg Q Sunday
LANTUS
MVI
CaMg
LEVOTHYROXINE 100 MCG QD
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Right intracranial hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2114-11-23**]
ICD9 Codes: 431, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6561
} | Medical Text: Admission Date: [**2102-3-26**] Discharge Date: [**2102-4-18**]
Date of Birth: [**2021-12-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Respiratory distress.
Major Surgical or Invasive Procedure:
Intubation
Mechanical Ventilation
Arterial Line Placement
History of Present Illness:
80 M with hx CAD s/p CABG presents with cough and SOB. The
patient reports that about a week ago he went to [**Country 4754**] for the
funeral of his brother. There he had fever/chills, and a
productive cough as well as rhinorrhea for the last week. He
decided to come back one week earlier and came back yesterday.
TOday his SOB worsened and he decided to come into the hospital.
He denied CP, pedal edema or calf pain.
In the ED, the patient was hypoxic to 81% on RA on arrival.
Other vitals included T 98.1, 71, 190/89, RR20. A CXR was done
with no significant infiltrates. A CTA was performed without PE
or infiltrate. The patient was then noted to be progressivley
more wheezing and short of breath. He was given several nebs
back to back with initial improvement but then continued with
laboured breathing. Methylprednisolone 125mg was given x1 and
Levofloxacin 750mg. The pt appeared progressively more tired and
in respiratory distress. A gas showed pH 6.93 pCO2 132 pO2 113.
THe patient was intubated with succinylcholin, etomidate and
ativan. Lactate was 1.2. He received a total of 2L of NS. Repeat
ABG: pH 7.14 pCO2 69 pO2 83.
ROS: pt intubated and sedated, unable to obtain. According to
nurse, pt received a double dose of his Atenolol today
Past Medical History:
1. Coronary artery disease.
2. Status post myocardial infarction thirty years ago.
[**2084**]- CABG: LIMA to LAD, SVG to LPL jump PDA
[**2089**]- Stent to LCx, occl noted SVG at LPL-PDA segment
[**2096**]- Stent SVG-OMB
[**2097**]- Stent SVG-PLV
[**2101**]- DES to the distal SVG-LPL and balloon angioplasty of the
proximal in-stent restenosis.
EF = 50%- Mild anterolateral hypokinesis
3. History of AAA, elective repair 6.6cm on [**3-19**].
4. Hypertension.
5. Peripheral vascular disease - [**2096**] angio: Severe bilateral
lower extremity peripheral vascular disease with severe
bilateral SFA disease and single vessel runoff bilaterally.
6. Appendectomy 50 years ago.
7. Diverticulitis.
8. PUD
9. Hypercholesterolemia
Social History:
Widower, he lives with his daughter. His is a retired auto
mechanic. Smokes [**7-25**] cigarettes/day. (1/2-1 PPD x 70 years)
Family History:
His brother died of an MI at 68 years of age.
Physical Exam:
T 97.2 BP 118/61 HR 102 RR 20 O2Sat 95 AC 0.3/550/20/5
Gen: NAD, comfortable and sedated
HEENT: NC/AT, PERRLA, mmm, hard exophytic mass over left
forehead
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, irregularly regular rhythm, no m/r/g
PULM: moderate air movement, mild diffuse wheezing, no rhonchi
ABD: + bowel sounds, soft, nd, nt
Skin: warm extremities, no rash, venostasis changes
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: moving all extremities, sedated, PERRLA, reflexes 2+ b/l
Pertinent Results:
EKG: NSR, HR 80, NA, NI, mild Tw changes in I, avl. (unchanged)
.
CXR: Single upright frontal bedside chest radiograph is compared
to [**2101-11-1**]. The lungs are clear. The heart,
mediastinal contours, and pulmonary vasculature are unchanged in
appearance, remarkable for tortuous aorta. The patient is
status post CABG.
IMPRESSION: No acute cardiopulmonary process.
.
CT CHEST WITH CONTRAST: The pulmonary arteries opacify without
filling defects. The patient is status post CABG, and there are
marked coronary artery calcifications within the LAD and
circumflex. The heart appears normal. There are multiple small
right hilar lymph nodes as well as a more prominent 12 mm lymph
node. There is no pathologic mediastinal or axillary
adenopathy. There is emphysema of the lungs, but lungs are
otherwise clear. Note is made of a tiny calcified granuloma in
the right base. There is no pleural effusion. The airways are
patent to the subsegmental level. There are multilevel
degenerative changes in the osseous structures. The patient is
status post median sternotomy. No suspicious lesions are
identified. The visualized portions of the abdomen are
unremarkable. There is atherosclerotic disease of the aorta
with multiple areas of mural thrombus.
IMPRESSION:
1. No evidence for pulmonary embolism.
2. Emphysema, but no evidence for pneumonia.
.
CT HEAD [**2102-4-11**] COMPARISON STUDY: [**2102-4-1**], head CT scan,
also performed for a history of mental status changes,
interpreted by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] as revealing "No acute
intracranial abnormalities detected. Unchanged expansile osseous
lesion consistent with an osseous hemangioma. Destruction of the
outer table suggests aggressive potential and further evaluation
is indicated."
FINDINGS: The images of the posterior fossa region are mildly
degraded by patient motion, although a repeat imaging sequence
is of reasonably good diagnostic quality in this region.
There is no definite interval change in either the appearance of
the brain or osseous lesion in the one-week interval between
scans. There is no intracranial hemorrhage or shift of normally
midline structures observed.
CONCLUSION: Stable, abnormal study as noted above. If acute
brain ischemia is a clinical consideration, MRI scanning, if
feasible, is a more sensitive diagnostic modality.
.
CHEST CT [**2102-4-17**]
1. Two 3-mm left upper lobe pulmonary nodules. Statistically,
these are most likely benign. However, given the patient's
history, followup CT in three to six months can be obtained if
clinically warranted to exclude an atypical distribution of
small metastases.
2. New bilateral lower lobe dependent centrilobular opacities
most likely secondary to aspiration or infectious bronchiolitis.
[**2102-4-18**] 05:34AM BLOOD WBC-8.5 RBC-3.82* Hgb-12.3* Hct-36.2*
MCV-95 MCH-32.3* MCHC-34.1 RDW-16.2* Plt Ct-209
[**2102-3-25**] 10:29PM BLOOD WBC-8.9 RBC-4.33* Hgb-14.0 Hct-40.1
MCV-93 MCH-32.3* MCHC-34.9 RDW-13.8 Plt Ct-185
[**2102-4-18**] 05:34AM BLOOD Glucose-152* UreaN-28* Creat-0.7 Na-137
K-3.7 Cl-98 HCO3-32 AnGap-11
[**2102-3-25**] 10:29PM BLOOD Glucose-175* UreaN-26* Creat-1.1 Na-130*
K-4.4 Cl-92* HCO3-29 AnGap-13
[**2102-4-10**] 04:46AM BLOOD ALT-25 AST-21 LD(LDH)-140 AlkPhos-59
TotBili-0.3
[**2102-4-8**] 03:04AM BLOOD Lipase-57
[**2102-3-30**] 03:05AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2102-3-29**] 08:18PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2102-3-29**] 12:03PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2102-3-31**] 08:14AM BLOOD TSH-0.13*
[**2102-3-31**] 08:14AM BLOOD Free T4-1.4
Brief Hospital Course:
A/P: 80 y.o. M with CAD s/p CABG, PVD & COPD who p/w hypercarbic
respiratory failure, likely [**2-18**] COPD exacerbation and flu, with
hospital stay complicated by DTs and prolonged AMS after being
off sedation.
.
# Hypercarbic respiratory failure: Pt presented with profound
acidosis [**2-18**] hypercarbic resp failure and was intubated, found
to have influenza complicated by newly diagnosed COPD. CT
consistent with emphysema and long standing tobacco abuse make
diagnosis very likely in the abscence of PFTs. Pt was extubated
after 5 days but required reintubation [**2-18**] recurrent hypercarbic
resp failure in setting of significant valium administration and
MS depression. Second intubation course was prolonged due to
depressed MS and likely delayed clearance of benzodiazpines.
Pulm status has been stable since extubation on standing nebs,
guaifenesin & pulm toilet. Pt has been afebrile, sating well on
RA and secretions have decreased with mobilization. Repeat Chest
CT was performed to evaluate for metastatic disease from left
frontal osteohemangioma. CT reported 2 X 3mm pulm nodules that
will require a follow up CT in 6mths but were thought to be
likely benign. Centrilobar opacities likely c/w aspiration that
have been clinically silent and may be residual from repeat
intubations. Pt will need to complete last three days of
Prednisone taper, Albuterol & Atrovent nebs & Guaifenesin TID.
.
# Altered Mental Status: Pt was initially treated with valium
due to possible DTs, then required re-intubation for hypercarbic
resp failure. Pt had a prolonged 2nd intubation due to sedation
that responded to flumazenil (likely benzo induced MS changes).
Pt was extubated on [**4-12**] and is currently alert & responding to
commands but still disoriented, no focal deficits on neuro exam,
though diffusely weak & deconditioned. Etiology of prolonged MS
changes thought due to prolong intubation and ICU stay. Per
neuro surgery, it is very unlikely that osteohemangioma mass is
contributing to MS. Steroids could also be contributing to MS.
Please continue with aggressive rehab.
.
# New onset Afib: Etiology unclear, TSH was mildly decreased but
T4 was WNL. There was initial problems with HR control in the
ICU, however, HR has been well controlled in 80-90s on
Metoprolol with can be increased prn. Pt has a CHADS score of 2
and will need to discuss the risks/benefits of initiating
anti-coagulation as an outpt. However, due to his recent h/o GI
bleed, decision was made not to anti-coagulate him while in
house. Pt was recently changed to Metoprolol 100mg [**Hospital1 **] & was
continued on ASA 325 & Plavix 75mg. Recommend f/u thyroid
function tests as outpt.
.
# Scull tumor: Neuro surgery was consulted for a CT read of
invasive osteohemangioma. Per neuro, this was not likely
contributing to any MS changes but recommended CT chest for
staging which showed two different 3mm pulm nodules, unlikely to
be metastatic, will need f/u CT in 6mths.
.
# CAD: Pt s/p CABG in [**2082**] and denied any CP throughout
admission. Pt was ruled out for MI on admission and was
continued on ASA, Plavix, Metoprolol, Pravastatin. Pt was
switched from Captopril to Lisinopril 10mg once daily.
.
# PVD: Pt is s/p mult peripheral vasc interventions, denied any
lower extremity pain thoughout admission, lower extremities warm
& PT pulses palpable bilaterally. Pt should continue ASA &
plavix.
.
# FEN: Pt had doboff placed on [**2102-4-12**] and has been managed with
pulm nutren tube feeds. Speech & swallow recommended continuing
TF for now & advancing a pureed diet with nectar thickened,
strict aspiration precautions and 100% monitoring with feeds.
.
# Prophylaxis: Heparin sc, bowel regimen & protonix
Medications on Admission:
Clopidogrel 75 mg PO DAILY
Aspirin 325 mg PO DAILY
Atenolol 25 mg PO DAILY
Lisinopril 40 mg PO once a day.
Pravastatin 40 mg PO once a day.
Norvasc 10 mg PO once a day.
Viagra
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Pravastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO TID (3 times
a day) as needed for cough.
12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1. Influenza B
2. Hypercarbic respiratory failure
3. Atrial fibrillation
4. Osteohemangioma of the skull
5. Hyponatremia
6. Acute renal failure
7. Incidentally noted pulmonary nodules
Secondary:
1. Coronary artery disease
2. Peripheral vascular disease
3. Chronic obstructive pulmonary disease
Discharge Condition:
Fair
Discharge Instructions:
You were admitted with influenza & COPD exacerbation. You were
intubated and required an ICU stay for respiratory failure and
mental status changes. You were noted to develop an arrythmia
called Atrial Fibrillation, this has been rate controlled with
medications. You will need to discuss long term plans regarding
anti-coagulation for A.Fib with your PCP and family.
You will likely require a long rehabilitation stay. Upon
discharge from rehab, it is important that you call Dr. [**Last Name (STitle) **] to
set up a follow up appointment.
You will need to obtain a follow up chest CT scan to evaluate
incidentally noted nodules in your chest. This scan should be
done 3-6 months from now. We would also recommend follow up
thyroid function tests as outpt.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 10688**] following your
rehabilitation.
Please discuss with your primary care physician to obtain [**Name Initial (PRE) **]
follow up chest CT scan in [**3-23**] months to evaluate pulmonary
nodules.
You should discuss the Atrial Fibrillation with your PCP and
discuss the risks/benefits of anticoagulation.
ICD9 Codes: 2762, 5849, 5180, 4019, 412, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6562
} | Medical Text: Admission Date: [**2159-7-27**] Discharge Date: [**2159-8-17**]
Date of Birth: [**2119-9-15**] Sex: F
Service: SURGERY
Allergies:
Vasotec / Metformin / Lactose
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
39 yo female who was sent home on [**2159-7-25**] with TPN/picc now
presenting with temp up to 103.
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
The patient is a 39F well-known to the Bariatric Surgery
service, who is s/p laparoscopic Roux-en-Y gastric bypass c/b
intra-abdominal hemorrhage requiring exploratory laparotomy with
omentectomy; also c/b a fall, which possibly contributed to a
left brachial plexus injury. She was readmitted on [**5-20**] for
failure to thrive and wound infection, and then subsequently on
[**6-1**] for wound care and pain control; she was discharged on [**6-6**]
with wound VAC. On [**6-11**] she began to have nausea and vomiting
and
was subsequently admitted on [**6-14**]. She had an EGD on [**6-15**], which
revealed a benign 8mm stricture at the G-J anastomosis, which
was
dilated to 13.5mm. Her VAC dressings were changed to wet-to-dry;
she was discharged on [**6-20**]. The following say she was readmitted
for nausea/vomiting/dizzinness. On [**6-22**], she had an EGD which
again showed an 8mm benign stricture, which was dilated to
13.5mm. She progressed well and tolerated a stage 3 diet at the
time of her last discharge on [**7-12**]. She was instructed to drink
only Isopure until follow up. Discharged on [**7-26**], readmitted on
[**7-27**] with presumed line infection.
Despite having obstructive sleep apnea, and recommendations for
CPAP she refused.
Past Medical History:
Nonalcoholic steatohepatitis, Insulin dependent DM: Questionable
Type I or Type II, Diabetitic nephropathy, HTN, Sleep Apnea,
GERD, Psoriasis, Morbid obesity, h/o VRE urinary tract
infection, brachial plexus injury s/p fall [**5-10**]
Social History:
Patient lives at home with her parents, husband, and two
children (age 4 and 1). Patient is a house wife, and her
husband is a waitor at a chinese restaurant. Patient denies
tobacco, alcohol or drug use.
Family History:
Family history of diabetes: father, paternal grandmother and
grandfather. Maternal grandmother with [**Name2 (NI) 499**] cancer.
Physical Exam:
103.8 146 104/82 20 97% RA
Mild distress, feel hot
AAOx3
Tachy reg
CTAB
soft NT/ND, small central wound opening - no signs of cellulitis
around wound
no edema, extrem warm, no calf pain
mild erythema at PICC site
Pertinent Results:
[**2159-7-27**] 10:41PM TYPE-ART PO2-86 PCO2-36 PH-7.41 TOTAL CO2-24
BASE XS-0
[**2159-7-27**] 08:43PM LACTATE-1.9
[**2159-7-27**] 08:33PM GLUCOSE-272* UREA N-8 CREAT-0.5 SODIUM-142
POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-22 ANION GAP-12
[**2159-7-27**] 08:33PM CALCIUM-8.1* PHOSPHATE-2.8 MAGNESIUM-1.5*
[**2159-7-27**] 08:33PM WBC-12.8* RBC-3.68* HGB-10.7* HCT-32.3*
MCV-88 MCH-29.1 MCHC-33.1 RDW-14.5
[**2159-7-27**] 08:33PM NEUTS-88.5* LYMPHS-7.9* MONOS-3.0 EOS-0.5
BASOS-0
[**2159-7-27**] 08:33PM PLT COUNT-237
[**2159-7-27**] 05:22PM COMMENTS-GREEN TOP
[**2159-7-27**] 05:22PM LACTATE-1.3
[**2159-7-27**] 05:20PM CALCIUM-7.2* PHOSPHATE-2.6* MAGNESIUM-1.3*
[**2159-7-27**] 05:20PM CORTISOL-25.3*
[**2159-7-27**] 05:20PM CRP-28.2*
[**2159-7-27**] 02:35PM TYPE-[**Last Name (un) **] PO2-46* PCO2-36 PH-7.44 TOTAL CO2-25
BASE XS-0
[**2159-7-27**] 02:35PM GLUCOSE-267* LACTATE-1.9 NA+-136 K+-3.8
CL--99* TCO2-24
[**2159-7-27**] 02:35PM freeCa-1.09*
[**2159-7-27**] 02:30PM GLUCOSE-281* UREA N-15 CREAT-0.6 SODIUM-134
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-12
[**2159-7-27**] 02:30PM ALT(SGPT)-26 AST(SGOT)-34 CK(CPK)-36 ALK
PHOS-69 TOT BILI-0.5
[**2159-7-27**] 02:30PM LIPASE-35
[**2159-7-27**] 02:30PM CK-MB-NotDone cTropnT-<0.01
[**2159-7-27**] 02:30PM ALBUMIN-3.9 CALCIUM-9.1 PHOSPHATE-1.6*#
MAGNESIUM-1.6
[**2159-7-27**] 02:30PM WBC-14.2*# RBC-4.26 HGB-12.2 HCT-36.4 MCV-86
MCH-28.7 MCHC-33.6 RDW-15.4
[**2159-7-27**] 02:30PM NEUTS-89.5* LYMPHS-5.4* MONOS-3.9 EOS-0.9
BASOS-0.2
[**2159-7-27**] 02:30PM PLT COUNT-278
[**2159-7-27**] 02:30PM PT-14.5* PTT-33.0 INR(PT)-1.3*
[**2159-7-27**] 02:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2159-7-27**] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-TR
[**2159-7-27**] 02:30PM URINE RBC-0-2 WBC-[**4-5**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2159-7-27**] 02:30PM URINE MUCOUS-MOD
Brief Hospital Course:
The patient is a 39F well-known to the Bariatric Surgery
service, who is s/p laparoscopic Roux-en-Y gastric bypass c/b
intra-abdominal hemorrhage requiring exploratory laparotomy with
omentectomy; also c/b a fall, which possibly contributed to a
left brachial plexus injury. She was readmitted on [**5-20**] for
failure to thrive and wound infection, and then subsequently on
[**6-1**] for wound care and pain control; she was discharged on [**6-6**]
with wound VAC. On [**6-11**] she began to have nausea and vomiting
and
was subsequently admitted on [**6-14**]. She had an EGD on [**6-15**], which
revealed a benign 8mm stricture at the G-J anastomosis, which
was
dilated to 13.5mm. Her VAC dressings were changed to wet-to-dry;
she was discharged on [**6-20**]. The following say she was readmitted
for nausea/vomiting/dizzinness. On [**6-22**], she had an EGD which
again showed an 8mm benign stricture, which was dilated to
13.5mm. She progressed well and tolerated a stage 3 diet at the
time of her last discharge on [**7-12**]. She was instructed to drink
only Isopure until follow up. Discharged on [**7-26**], readmitted on
[**7-27**] with presumed line infection.
Despite having obstructive sleep apnea, and recommendations for
CPAP she refused.
[**8-1**] Went for EMG, while she was gone the PICC nurse came by,
thus, TPN tonight will go through the central line and the PICC
will be placed tomorrow.
[**8-1**] [**Month/Day (4) 878**] consult: Please switch to long acting medication
such as MS Contin or Oxycontin. Give standing and not PRN meds.
We realize she came in intoxicated on narcotics, but this may be
in part due to increased absorption of the Fentanyl patch with
fever.
If OK from cardiac perspective, consider amitriptyline (25 mg
qHS, to go up to 50 qHS if tolerated. This may worsen her sleep
apnea, but so do all the sedating drugs.).
[**8-2**] D/c central line, PICC in SVC, no pneumothorax, had family
meeting where the patient and family agreed to go to a rehad
facility as long as it is clean and as long as the mother is
allowed to view it beforehand.
[**8-3**] Spoke to discharge planning, all the rehab offices are
closed for the weekend.
VASC C/S RECS [**8-4**]: d/c PICC, start lovenox (1mg/kg) [**Hospital1 **], bridge
to coumadin x3mo, re-U/S in 1 wk and again in 3 mo
[**8-6**] Has been having fevers into the 102 range for the past day
[**2159-8-8**]:
- We await the results of the B12, EBV, and CMV serologies
- Please minimize medications
- Please initiate neutropenic precautions including a
neutropenic diet if ANC < 500
- Do not start G-CSF or GM-CSF
- Please check CBC with differential daily
- Please check ANC daily
- Please check folic acid and B12 levels
- We strongly suggest finding an alternative to pip/tazo
CT neck: no sign of retropharyngeal or any other abscess
CT chest/abd/pelvis: minimal to no change from past CTs;
post-surgical changes in anatomy, no source of fevers or
infection found
[**8-9**] add cipro flagyl, has been without fever for 24 hours
TTE showed: Compared with the report of the prior study (images
unavailable for review) of [**2152-4-10**], the findings are similar.
No vegetations identified but the images are suboptimal.
Positive EBV.
RESPIRATORY CULTURE (Final [**2159-8-9**]):
sputum culture MODERATE GROWTH OROPHARYNGEAL FLORA.
YEAST. MODERATE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
urine negative
ID recs: - d/c vanc, cont fluconazole and zosyn, start
daptomycin, d/c all unnecessary meds, check monospot, CMV
IgG/IgM, check [**Last Name (LF) **], [**First Name3 (LF) **] diff, LDH, haptoglobin, and
fibrinogen, get neck/Abd CT
Abx (zosyn ([**8-7**]), fluconazole ([**8-7**]), dapto([**8-8**])) d/c'd [**2159-8-10**]
[**8-15**] No fevers for 2 days now, spoke to radiology about WBC
scan, they will rescan her tomorrow about questionable uptake in
the area of the symphysis pubis.
[**8-16**] US results: No evidence of right upper extremity deep
venous thrombosis. The previous thrombus has resolved.
[**8-17**] Pt is feeling well and has been afebrile for the last 72
hours
Medications on Admission:
Multivitamins
desonide
cozaar
fentanyl patch
regular insulin
lorazepam
Actos
oxycodone
simvastatin
ursodiol
Vit B12
omeprazole
Discharge Medications:
1. Oxycodone 5 mg/5 mL Solution [**Month/Year (2) **]: [**2-2**] PO every 4-6 hours as
needed for pain.
Disp:*500 mL* Refills:*0*
2. Multivitamins Oral
3. Thiamine HCl 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
1. Lovenox 80 mg/0.8 mL Syringe [**Month/Day (2) **]: One (1) syrine Subcutaneous
twice a day: Please continue for 2 more weeks.
Disp:*28 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Fever of unknown origin and dehydration
Discharge Condition:
stable
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have 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.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**11-15**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Followup Instructions:
[**Month (only) **] nutritionist [**2159-8-29**] at 2 pm [**Hospital Ward Name 23**] 3
Dr. [**Last Name (STitle) **] [**2159-8-29**] at 2:30 pm on [**Hospital Ward Name 23**] 3
Completed by:[**2159-8-17**]
ICD9 Codes: 7907, 5859, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6563
} | Medical Text: Admission Date: [**2143-2-3**] Discharge Date: [**2143-2-6**]
Service: Intensive Care Unit
CHIEF COMPLAINT: Bradycardia and hypotension.
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female who
has a history of Crohn's disease, dermatitis, and
gastroesophageal reflux disease with a history of a motor
vehicle accident approximately two months ago where she
sustained a left femur fracture which was compounded and open
fracture who had complications of that motor vehicle accident
including renal insufficiency. The patient also suffered
pelvic fractures at that time. The patient had her left
femur fracture with intramedullary nail on the right. The
[**Hospital 228**] hospital course at that time was also complicated
by enterococcus and pseudomonas wound infection and had been
treated with ceftazidime and vancomycin. The patient was
discharged to [**Hospital **] Rehabilitation on [**2143-1-23**]
for further rehabilitation.
At the time of her discharge from the [**Hospital1 190**] her creatinine at that time was 0.8, and
according to outside hospital records she had a decrease in
mental status and increasing creatinine and blood urea
nitrogen, at which time the [**Hospital **] Rehabilitation had
decided to initiate hemodialysis at their facility. The
patient had a peripherally inserted central catheter line
placed and plan was for hemodialysis on the day of admission
of [**2143-2-3**]. However, prior to hemodialysis the
patient became hypotensive and was taken to the Intensive
Care Unit where she was given fluids, and her blood pressure
returned. However, subsequent to her hypotension the patient
developed bradycardia at a rate of 30 and was given 0.5 mg of
Atropine and transferred to the [**Hospital1 188**] for further management. At that time the patient was
noted to have a temperature of 90 degrees, and the patient
was intubated for airway protection.
The patient was brought to the Emergency Room and was found
to have a right main stem intubation, and the ETT was
repositioned. Outside hospital notes on further review
revealed that the patient had been having decreased urine
output but normal temperatures until [**2-1**]. A review
of systems at that time was unobtainable. Outside hospital
laboratories revealed a creatinine of 1.9 on [**1-29**] and
a creatinine of 2.2 on [**2-2**].
PAST MEDICAL HISTORY: (Her past medical history includes)
1. A motor vehicle accident.
2. Dermatitis.
3. Crohn's disease.
4. Gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION: Her medications on arrival were
sodium, calcium carbonate, Protonix, total parenteral
nutrition, Tylenol, multivitamin, and levothyroxine 0.025 mg.
ALLERGIES: Her allergies included MORPHINE.
SOCIAL HISTORY: She denies alcohol and denies tobacco.
PHYSICAL EXAMINATION ON PRESENTATION: On examination to the
Intensive Care Unit the temperature was 32 degrees
centigrade, her blood pressure was 77/53. Her heart rate
was 77, and her SaO2 was 96%. In general, she was
comfortable-appearing. Her pupils were fixed and pinpoint.
Her lungs had diffuse rhonchi and wheezes. Her heart had
distant heart sounds. Her extremities showed 2+ pedal edema.
She had areas of open wounds on her left upper leg with
granulation. She also had an open wound on her left knee.
Her stool was green, guaiac-negative. Her neck was supple.
She withdrew all four extremities to pain.
LABORATORY DATA ON PRESENTATION: Her laboratories and other
data included a white blood cell count of 20, a hematocrit
of 23.7, and platelets of 41. Her white blood cell count at
the outside hospital was 32, hematocrit of 30.7, and
platelets of 62. Her sodium was 138, her potassium was 3.3,
her chloride was 114, her bicarbonate was 18, her blood urea
nitrogen was 60, and her creatinine was 1.5. Her calcium
was 6.5, and her total bilirubin was 1.4.
RADIOLOGY/IMAGING: Chest x-ray showed a left lower lobe
opacity with right pleural thickening and a right-sided
effusion.
Her electrocardiogram was regular rhythm and sinus
tachycardia.
HOSPITAL COURSE: This is a [**Age over 90 **]-year-old female with renal
failure, hypothermia, leukopenia, and hypotension with a
recent episode of bradycardia.
1. HYPOTHERMIA: Differential at that time included
infection, renal failure, hypothyroidism, hypoadrenalism, and
given leukopenia and renal failure sepsis was likely the
highest on that differential.
The patient had pan cultures, was given more intravenous
fluids, warm bags to her groin. She was given a warming
blanket and given Demerol for rigors. She was given
aggressive fluid resuscitation for hypotension and was
started on multiple pressors including Levophed and
vasopressin. She was continued on her ceftazidime and
vancomycin for underlying bacteremia, and a cortisol was
checked which was 16. Thyroid-stimulating hormone was found
to be 17, and her free T4 was 0.4.
2. RENAL FAILURE: The patient's creatinine remained
elevated with a creatinine of 2. Her GFR was estimated to be
less than 10. She was given aggressive hydration for her
presumed sepsis. Urine electrolytes suggested that her FENa
was 1.8, but it was more than likely that she had nephropathy
of sepsis. Hemodialysis was not indicated at this time.
3. INFECTIOUS DISEASE: The patient was pan cultured. Her
2/4 bottles grew out yeast which did not appear to be [**Female First Name (un) **]
albicans. It was still awaiting further identification. She
was started on Diflucan 200 mg intravenously q.d. She was
continued on her ceftazidime, levofloxacin, and vancomycin.
Her sputum has recently grown out coagulase positive
Staphylococcus; identification was still pending at this
time.
4. HEMATOLOGY: The patient with a drop in hematocrit to 20,
assuming it was a pancytopenia induced by sepsis. The
patient also received aggressive hydration and hemodiluting
out her blood volume. The patient also had a drop in her
platelets, likely due to overwhelming sepsis. Her DIC screen
was negative, but she also received a large amount of fluid
resuscitation which may also have diluted her platelet count.
5. PULMONARY: The patient was intubated for airway
protection. The patient was given Combivent as needed.
6. LINES: The patient had a right internal jugular placed
and right peripherally inserted central catheter line from
which cultures were sent, and grew 2/4 bottles of fungus.
The patient also had a Foley in and a right arterial line.
7. WOUND CARE: The patient had open left femur fracture
with an open wound which was colonized with multidrug
resistant Pseudomonas. The patient remained on broad
spectrum antibiotics including ceftazidime and received wound
dressings b.i.d.
8. COMMUNICATION: The patient's case was discussed at
length with nephew [**Name (NI) **] [**Name (NI) 98241**]. At that time the decision
on admission was made not to have cardiopulmonary
resuscitation or defibrillation should she suffer any
cardiopulmonary arrest.
On [**2-5**] Mr. [**Name14 (STitle) 98241**] and his other family members
decided to withdraw all aggressive care. The family was in
agreement with this and felt as though this would fulfill the
patient's wishes. At that time intravenous fluids,
antibiotics, and pressors were removed, and at approximately
12 hours to 15 hours after this decision was made the
patient's heart stopped. She did not generate a pressure,
and there was no evidence of conduction. Her examination was
notable for fixed dilated pupils. There were no heart
sounds. She did not withdraw to painful stimuli. The family
was alerted of her time of death which was at 1:33 on
[**2143-2-6**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2143-2-6**] 13:35
T: [**2143-2-10**] 12:11
JOB#: [**Job Number 98242**]
ICD9 Codes: 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6564
} | Medical Text: Admission Date: [**2124-12-4**] Discharge Date: [**2124-12-26**]
Date of Birth: [**2062-12-13**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
Arterial Line Placement
Bronchoscopy
History of Present Illness:
61 yo M with hypertension, COPD, alcoholism (unclear if active),
possible schizophrenia was admitted overnight through the ED.
His ability to relate a consistent hx is currently impaired, but
per prior notes, it seems that he was told by his neighbor to
come to the hospital as he appeared short of breath. The
initial assessment of ED staff was that the pt was massively
fluid overloaded in the setting of CHF and non-compliance with
lasix. He was treated with Lasix IV 40mg x 2, ASA 325 and nitro,
although no chest pain and EKG . Further review of OMR reveals
that the pt is no on lasix and has no clinical hx of CHF, last
echo in [**2119**] showed preserved LVEF of 55 with only mild Ao
dilation.
.
Initial labs were notable for Na of 116 with K of 6.6 (initial
7.8 was hemolyzed) and CR 2.7; no EKG changes. LFTs elevated AST
120, ALT 50, with bili 4.5, INR 1.6, albumin 2.6. With one dose
of kayexalate, potassium has trended down to 5.3. Serial
troponins 0.04. Initial CK 700 trending down with minimal MB
fraction.
.
In terms of his mental status, his PCP saw him one month ago at
which point he was at baseline A&OX3, independent for all ADLs.
MS not in ED not clearly documented. At 8AM this morning, he
trigerred for tachypnea with RR close to 30 and worsened MS
A&Ox1 only to self. [**Hospital **] transferred to the MICU. On
arrival, pt was on 2L and confused/somnolent. His audible
wheezing, tachypnea, and hypoxia improved rapidly with
albuterol. MS improved slightly when taken off supplemental O2.
ABG on room air: 7.4/35/73.
ROS: Denies any pain but unable to provide detailed ROS.
Past Medical History:
1. Multiple ED admissions for ETOH intoxication
2. HTN.
3. Emphysema.
4. Prostate hyperplasia
5. Nocturnal leg cramps
6. Finger reconstructive surgery
7. HIV? (per OMR note from [**2119**]) no ab tx in system
Social History:
-Tobacco history: 1ppd x 42 years
-ETOH: History of alcohol abuse but he claims he has not had a
drink in 2 years
-Illicit drugs: Patient denies, admission tox negative
Family History:
uanble to elicit
Physical Exam:
General Appearance: Overweight / Obese, total body anasarca
Eyes / Conjunctiva: PERRL, 3mm pupils reactive
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical
adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)
Resonant : , No(t) Hyperresonant: , No(t) Dullness : ), (Breath
Sounds: Clear : , Wheezes : greatly improved with albuterol)
Abdominal: Soft, Distended, pitting edema over entire abdomen
Extremities: Right lower extremity edema: 4+, Left lower
extremity edema: 4+, Clubbing
Skin: Cool, Rash: LE venous stasis BL
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Not assessed, Oriented (to): ONLY SELF, Movement:
Purposeful, Tone: Normal
Pertinent Results:
[**2124-12-4**] 10:25AM BLOOD WBC-11.4*# RBC-3.27* Hgb-10.7* Hct-32.3*
MCV-99*# MCH-32.6* MCHC-33.1 RDW-15.2 Plt Ct-218#
[**2124-12-11**] 04:26AM BLOOD WBC-12.4* RBC-2.55* Hgb-9.0* Hct-25.6*
MCV-100* MCH-35.1* MCHC-35.0 RDW-16.8* Plt Ct-88*
[**2124-12-16**] 03:40PM BLOOD WBC-36.4* RBC-2.91* Hgb-9.8* Hct-29.0*
MCV-100* MCH-33.8* MCHC-33.9 RDW-17.7* Plt Ct-45*
[**2124-12-26**] 04:00AM BLOOD WBC-16.3* RBC-2.58* Hgb-8.9* Hct-28.0*
MCV-109* MCH-34.6* MCHC-31.9 RDW-21.0* Plt Ct-33*
[**2124-12-4**] 10:25AM BLOOD PT-18.0* PTT-35.4* INR(PT)-1.6*
[**2124-12-10**] 01:02PM BLOOD PT-26.0* PTT-54.5* INR(PT)-2.5*
[**2124-12-21**] 04:33AM BLOOD PT-39.5* PTT-56.8* INR(PT)-4.1*
[**2124-12-22**] 10:16AM BLOOD PT-64.8* PTT-81.0* INR(PT)-7.4*
[**2124-12-22**] 06:40PM BLOOD PT-111.4* PTT-105.1* INR(PT)-14.2*
[**2124-12-23**] 03:52PM BLOOD PT-105.0* PTT-96.5* INR(PT)-13.2*
[**2124-12-25**] 03:52AM BLOOD PT-150* PTT-114.7* INR(PT)->20.2
[**2124-12-25**] 10:45AM BLOOD PT-150* PTT-150* INR(PT)->20.2*
[**2124-12-25**] 04:22PM BLOOD PT-150* PTT-150* INR(PT)->20.2
[**2124-12-26**] 04:00AM BLOOD PT-150* PTT-127.5* INR(PT)-27.4*
[**2124-12-4**] 10:25AM BLOOD Glucose-72 UreaN-66* Creat-2.8*# Na-116*
K-7.8* Cl-87* HCO3-24 AnGap-13
[**2124-12-18**] 04:24AM BLOOD Glucose-112* UreaN-83* Creat-6.4*# Na-138
K-3.3 Cl-99 HCO3-23 AnGap-19
[**2124-12-26**] 04:00AM BLOOD Glucose-80 UreaN-8 Creat-0.9 Na-130*
K-3.7 Cl-97 HCO3-20* AnGap-17
[**2124-12-26**] 09:41AM BLOOD Glucose-48* Na-131* K-4.1 Cl-98 HCO3-17*
AnGap-20
[**2124-12-4**] 10:25AM BLOOD CK(CPK)-693*
[**2124-12-6**] 06:29AM BLOOD ALT-35 AST-71* LD(LDH)-246 CK(CPK)-225*
AlkPhos-86 TotBili-4.0*
[**2124-12-15**] 04:27AM BLOOD ALT-84* AST-230* AlkPhos-87 TotBili-8.4*
[**2124-12-17**] 04:21AM BLOOD ALT-589* AST-1196* LD(LDH)-506*
AlkPhos-151* TotBili-9.8*
[**2124-12-20**] 06:21PM BLOOD ALT-348* AST-387* CK(CPK)-14*
AlkPhos-171* TotBili-14.9*
[**2124-12-22**] 05:36AM BLOOD ALT-271* AST-344* AlkPhos-162*
TotBili-14.6*
[**2124-12-23**] 12:30AM BLOOD ALT-1307* AST-5023* LD(LDH)-2880*
AlkPhos-246* TotBili-13.3*
[**2124-12-23**] 03:52PM BLOOD ALT-2172* AST-7388* LD(LDH)-2712*
CK(CPK)-45 AlkPhos-412* TotBili-13.4*
[**2124-12-24**] 05:11AM BLOOD ALT-2203* AST-6404* AlkPhos-492*
TotBili-14.6*
[**2124-12-25**] 04:22PM BLOOD ALT-1549* AST-2710* LD(LDH)-878*
AlkPhos-564* TotBili-16.1*
[**2124-12-26**] 04:00AM BLOOD ALT-1325* AST-[**2071**]* LD(LDH)-824*
AlkPhos-589* TotBili-16.8*
[**2124-12-4**] 10:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2124-12-4**] 10:00PM BLOOD Ethanol-NEG
[**2124-12-8**] 05:22AM BLOOD C3-19* C4-6*
[**2124-12-20**] 05:26AM BLOOD IgG-2123*
[**2124-12-5**] 06:08PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2124-12-5**] 06:08PM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2124-12-8**] 04:16PM BLOOD ANCA-NEGATIVE B
[**2124-12-23**] 03:52PM BLOOD Smooth-POSITIVE A
[**2124-12-5**] 06:08PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE
[**2124-12-12**] 02:34PM BLOOD Cortsol-12.1
[**2124-12-12**] 03:15PM BLOOD Cortsol-17.8
[**2124-12-5**] 06:08PM BLOOD calTIBC-163* Hapto-<20* Ferritn-1368*
TRF-125*
[**2124-12-5**] 10:29AM BLOOD Lactate-1.7 K-5.0
[**2124-12-20**] 11:10AM BLOOD Lactate-2.3*
[**2124-12-21**] 04:58AM BLOOD Lactate-3.0*
[**2124-12-23**] 04:14PM BLOOD Lactate-5.9*
[**2124-12-23**] 11:27PM BLOOD Lactate-7.7*
[**2124-12-24**] 04:11PM BLOOD Lactate-6.1*
[**2124-12-25**] 04:01AM BLOOD Lactate-7.2*
[**2124-12-26**] 04:07AM BLOOD Lactate-7.6*
IMAGING:
[**2124-12-5**]:
PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH: Low lung volumes and
body habitus
limits the film. Heart size is probably top normal. There is
right hilar
fullness and a prominent azygous vein suggested volume overload.
Retrocardiac opacification may be dud to suboptimal film. No
pneumothorax. Recommend convention PA and lateral with
encouraged increased respiratory effort.
[**2124-12-5**]:
CT Head:
IMPRESSION: Limited study secondary to patient motion without
evidence of
gross acute intracranial abnormality. Global diffuse atrophy
[**2124-12-5**]:
CT Chest Abd/Pelvis:
IMPRESSION: Markedly limited examination secondary to patient
body habitus
and lack of intravenous contrast.
1. Nodular liver suggestive of cirrhosis. Splenomegaly, likely
indicative of portal hypertension.
2. Mild intra-abdominal ascites.
3. Mild centrilobular emphysema.
4. Cholelithiasis.
[**2124-12-11**]:
CT Chest/Abd/Pelvis:
IMPRESSION:
1. Interval development of bilateral lower lobe consolidations
with air
bronchograms concerning for aspiration pneumonia. Diffuse ground
glass
opacity throughout both lungs is also identified and may
represent
superimposed pulmonary edema.
2. Interval development of mediastinal and axillary lymph nodes
which may be reactive.
3. Cirrhotic-appearing liver with splenomegaly, unchanged.
4. Interval decrease in intra-abdominal ascites.
5. Cholelithiasis with gallbladder distention.
6. Emphysematous changes.
[**2124-12-20**]:
Liver U/S:
IMPRESSION: No evidence of acute gallbladder process. Gallstones
again
noted.
[**2124-12-21**]:
CT Chest/Abd/Pelvis:
IMPRESSION:
1. Interval improvement of bilateral lower lobe consolidations,
with
remaining basilar consolidation and small bilateral pleural
effusions.
2. Cirrhotic-appearing liver with splenomegaly, unchanged.
3. Interval increase in intra-abdominal ascites.
4. Cholelithiasis with gallbladder distention.
5. Mild fat stranding around the pancreas. Suboptimal evaluation
due to lack
of IV contrast.
6. Emphysema.
7. Low attenuation right renal lesion, most consistent with a
cyst.
Pathology:
Liver Biopsy [**2124-12-21**]:
Liver, transjugular needle core biopsy:
Markedly fragmented biopsy demonstrating:
1. Predominantly fragments of broad, fibrous septa with mild,
mixed inflammation and focal cholangiolar proliferation,
consistent with established cirrhosis (confirmed by trichrome
stain).
2. Scant, nodular foci of hepatic lobular parenchyma (totaling
only 20% of the total biopsy volume), with focal microvesicular
steatosis and moderate canalicular cholestasis.
3. No central veins or native portal tracts present for
evaluation in this limited sample.
4. Iron stain shows moderate iron deposition within
hepatocytes.
Note: The biopsy consists almost exclusively of fibrous tissue,
consistent with established cirrhosis. The scant lobular
parenchyma present shows only minimal, non-specific changes of
end stage liver disease. Dr. [**First Name (STitle) 4370**] [**Name (STitle) **] was notified of the
findings on [**2124-12-22**].
Brief Hospital Course:
This is a 61 yom with hx of HTN and COPD who initially presented
to the ED c/o SOB and noted to be massively fluid overloaded, in
ARF with hyponatremia/hyperkalemia, with transaminitis and
synthetic dysfunction who was then admitted to the MICU for
altered mental status and eventually intubated for respiratory
distress and fluid overload.
# Acute on Chronic Liver Failure: Mr. [**Known lastname **] presented with
total body fluid overload. He had a transaminitis which
improved and worsened several times throughout his hospital
stay. He had synthetic dysfunction of the liver manifested by
thrombocytopenia and coagulopathy. All of these findings were
consistent with cirrhosis. A CT scan on admission confirmed a
nodular liver. He slowly developed worsening liver failure
during his hospitalization. A liver biopsy was done on [**2124-12-21**]
which confirmed cirrhosis. Hepatitis serologies were sent and
were negative for Hep B and Hep C. Hep A antibody was positive.
Hepatology was consulted and cirrhosis was thought to be [**3-6**]
history of EtOH abuse. Tranaminitis in the hospital was unclear
but possibly [**3-6**] shock liver in the setting of hypotension. INR
continued to rise and peaked to a level of 27 today. Family was
involved and a family meeting was held today given his
worsensing liver failure and shock which was requiring 4
pressors. He was made CMO by his father, [**Name (NI) **] [**Name (NI) **], and the
patient passed away peacefully today at 225pm.
# Hypoxic respiratory failure/Pneumonia: Mr. [**Known lastname **] was
initially intubated for respiraroty distress in the setting of
hypoxemia [**3-6**] fluid overload. He was treated with diuretics
with minimal urine output. Renal was consulted and he was
diagnosed with Hepatorenal syndrome and required dialysis for
fluid removal. He was placed on HD with good removal of fluid
intitially. WBC then began to elevate and CXR was consistent
with Pneumonia so he was started on Vanco/Zosyn/Levo for
treament of hospital acquired pneumonia. He completed a 7 day
course for his PNA. He self extubated while in the MICU and was
then reintubated for respiratory distress. He then developed
VAP while intubated and was treated with Vanco/Zosyn/Cipro.
# Shock: Patient had acute decompensated liver failure along
with pneumonia which were likely contributing to his shock.
Broead infectious workup was done and workup remained negative
while in the hospital. He was treated with Vanco/Zosyn/Cipro
for treatment of HAP. Flagyl was started out of concern for
c.diff although c.diff cultures remained negative.
# Altered mental status: Thought to be secondary to hepatic
encephalopathy. Initially improved with lactulose. Patient was
treated with lactulose and rifaximin throughout his stay.
# Acute Renal Failure: Thought to be [**3-6**] hepatorenal syndrome.
He developed anuria while in the hospital. Given his fluid
overload and pulmonary edema requiring intubation, renal was
consulted and a dialysis line was placed. He was placed on HD
for removal of fluid. This was changed to CVVH when he became
hypotensive to allow for gentle fluid removal.
# Hyponatremia: Thought to be [**3-6**] fluid overload in the setting
of cirrhosis
# Coagulopathy: Likley [**3-6**] cirrhosis and liver failure
Medications on Admission:
1. COMBIVENT INHALER
2. CYCLOBENZAPRINE 10 MG TABLET
3. DOXAZOSIN MESYLATE 8 MG TAB
4. FINASTERIDE 5 MG TABLET
5. FLUCONAZOLE 200 MG TABLET
6. GABAPENTIN 100 MG CAPSULE
7. HYDROCHLOROTHIAZIDE 25 MG TAB
8. KETOCONAZOLE 2% CREAM
9. LACLOTION 12% LOTION
10. NYSTATIN 100,000 UNIT/GM POWD
11. UREA 40% CREAM
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 5845, 2761, 2851, 5990, 5789, 5180, 4275, 4019, 3051, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6565
} | Medical Text: Admission Date: [**2181-12-20**] Discharge Date: [**2181-12-29**]
Date of Birth: [**2130-2-2**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 51 year-old
male with a chief complaint of diffuse aches and stabbing
pain across the chest radiating to back down the right arm.
The patient also had palpitations, nausea, and diaphoresis.
The patient had these similar symptoms one to two weeks prior
to presentation, but did not seek medical attention at that
time. At the outside hospital the patient had a
catheterization, which revealed significant left anterior
descending stenosis. It was felt that stenting of this lesion
was not possible. The patient was transferred to the [**Hospital1 1444**].
PAST MEDICAL HISTORY: Hypercholesterolemia, hypertension.
MEDICATIONS: Vitamin E.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Tobacco one pack per day for forty years.
PHYSICAL EXAMINATION: Temperature 97.1. Heart rate 72.
Blood pressure 111/33. Respiratory rate 16. 98% on room
air. General no acute distress. HEENT sclera anicteric.
Cor regular rate and rhythm. No murmurs. Lungs clear to
auscultation bilaterally. Abdomen soft, nontender,
nondistended. Extremities edema.
LABORATORY: From outside hospital, white blood cell count
13.7, hematocrit 46.4, platelets 237, CK 532, MB 65, MB index
8.1, troponin 81. Electrocardiogram ST elevations with T
wave inversions i V1 through V4.
HOSPITAL COURSE: It was decided that the patient would have
a coronary artery bypass graft done at the [**Hospital1 346**]. The patient was brought to the
Operating Room on [**2181-12-21**] where he had a coronary
artery bypass graft times two with a left internal mammary
coronary artery to the left anterior descending coronary
artery and saphenous vein graft to diagonal.
Postoperatively, the patient was brought to the Intensive
Care Unit. There he was rapidly extubated. By postoperative
day one a neo-synephrine drip was appropriate weaned. The
patient was deemed stable and transferred to the floor on
postoperative day one. By postoperative two due to minimal
output of the chest tubes, the chest tubes were removed. A
chest x-ray revealed no pneumothorax and no consolidations or
effusions. The patient had a chest CT for question hilar
enlargement seen on a prior chest x-ray. An official [**Location (un) 1131**]
on this film revealed no hilar pathology with no enlarged
mediastinal lymph nodes. By postoperative day three the
patient's pacing wires were removed. Low dose Coumadin was
started per the patient's cardiologist for question inferior
wall hypokinesis. On postoperative day four small amounts of
drainage was seen from the sternal incision at the inferior
aspect. The patient was started on Vancomycin and daily
white blood cell counts were checked. Drains persisted for a
few days until [**12-29**] the drain was stopped. At that
time Vancomycin was discontinued.
It was decided at that point that the patient should be sent
home on oral antibiotics.
CONDITION ON DISCHARGE: Stable.
DISCHARGE LABORATORIES: Sodium 134, potassium 4.1, chloride
98, bicarbonate 31, BUN 21, creatinine .8, glucose 92, white
blood cell count 11.1, hematocrit 37.4, platelet 503.
Multiple swabs from the sternal wound revealed growth of no
organisms.
DISCHARGE MEDICATIONS: Lopressor 75 mg po b.i.d., Coumadin 2
mg q.d., Keflex 500 mg q.i.d. times seven days, aspirin 325
mg, Percocet one to two tabs po q 4 to 6 hours prn, Colace
100 mg po b.i.d.
DISCHARGE STATUS: The patient will go home. The patient
will follow up with cardiologist for INR checks in one week.
The patient will again follow up with the cardiologist in
three weeks. He will follow up with Dr. [**Last Name (STitle) **] in four
weeks.
DISCHARGE DIAGNOSES:
Status post coronary artery bypass graft times two.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2181-12-31**] 10:58
T: [**2181-12-31**] 11:12
JOB#: [**Job Number 38459**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6566
} | Medical Text: Admission Date: [**2152-2-12**] Discharge Date: [**2152-3-21**]
Date of Birth: [**2110-11-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Respiratory failure, hepatitis
Major Surgical or Invasive Procedure:
Central Venous Line Placement
Arterial Line Placement
Intubation
Mechanical Ventilation
History of Present Illness:
Patient intubated & unable to answer questions. History obtained
from medical chart and patient's mother, [**Name (NI) 1258**] [**Name (NI) 5261**].
Ms. [**Known lastname 30949**] is a 41 y/o F with PMH of hepatitis C and IVDU who
presented to OSH with several days of abdominal pain, N/V, and
jaundice. She described the pain as constant and diffuse. She
reported subjective fevers with cough. Denied urinary symptoms
or change in stool color. Per the patient's mother, Ms.
[**Known lastname 30949**] was seen by her stepfather four days ago and he
noticed that she "looked ill and yellow." Reportedly took 4
tylenol tables (unknown strength yesterday morning). At the OSH,
she received 3 mg IV dilaudid, 12.5 mg phenergan, and 1 L NS.
Blood pressure reported at 106/59 at OSH with tachycardia to
101. Reported CXR no infiltrates (?). Blood cultures were sent
and she was found to have transaminases AST > [**Numeric Identifier 3301**], ALT > 8000
and transferred to [**Hospital1 18**] for treatment of liver failure. Of
note, in OSH ED, patient reported prolonged sobriety but recent
use of opiates and alcohol but stopping 4 days prior to
presentation; reported not being able to keep down POs since
that time.
Initial vitals in [**Hospital1 18**] ED: T 96.8, HR 122, BP 84/32 --> 58/18,
O2 98%. She was noted to be lethargic and was given Narcan. She
was intubated with succinylcholine, etomidate, vecuronium; she
received a repeat dose of etomidate at 0345. She received a
total of 5 L NS and code sepsis was initiated. Right IJ was
placed. She received vancomycin 1 g IV X 1, levofloxacin 750 mg
IV X 1, flagyl 500 mg IV X 1, zofran 4 mg, and zosyn 4.5 mg IV X
1. She was on levophed gtt but this was weaned to off at 0430
due to hypertension (160s systolic).
ROS (obtained at OSH): + subjective fever, no chills. no chest
pain, diaphoresis, DOE, orthopnea, edema. + cough but
nonproductive. + nausea/diarrhea, jaundice, vomiting, anorexia.
Denies hematemesis, hematochezia, melena. + dizziness. + cold
intolerance. + easy bruising/bleeding. Denied suicidal ideation.
Past Medical History:
hepatitis C
h/o hepatitis B (per records from OSH)
h/o pancreatitis
h/o IVDU
depression/anxiety
h/o kidney stones per mother
Social History:
Recently in prison for DUI/reckless driving and drug
convictions. Then let out of prison to rehab in [**Location (un) 86**] and
returned to home about one week ago. No permanent housing at
present. Living at a shelter or with a male friend per mother. +
alcohol use this week, though until last week was at a
rehab/shelter in [**Location (un) 86**] and presumably was not drinking. +
heroin use (within last 24-96 hours by report). + tobacco, 1
ppd.
Family History:
Noncontributory.
Physical Exam:
T: 95.9 BP: 128/51 HR: 127 RR: O2 100% on A/C FiO2 80, Tv 500,
RR 20, PEEP 5
Gen: intubated, sedated
HEENT: + scleral icterus & conjunctival edema. tongue dry, op
clear, poor dentition
NECK: supple, no palpable lymphadenopathy, R IJ catheter in
place
CV: tachycardic, regular, no appreciable murmur
LUNGS: no wheeze, crackles R > L
ABD: slightly distended, hyperactive bowel sounds
EXT: feet & hands cool, good cap refill, no peripheral edema
SKIN: no rash
NEURO: sedated. able to move all four extremities. pupils small
but reactive bilaterally. eyes remain toward ceiling when head
moved side to side (+ doll's eyes), withdraws to pain
Pertinent Results:
OSH LABS:
=========
WBC 8.9 (87%N, 6% lymphs, 5% bands), Hct 38, Plt 129
lipase 145
amylase 48
glucose 77
Na 138, K 3.6, Cl 100, CO2 26, BUN 9, Cr 0.8
protein 7.3, albumin 3.7
Bili 3.2
Ca 9.1
AST [**Numeric Identifier 30950**]
ALT 8040
Alk phos 141
serum pregnancy negative
INR reportedly 3
ADMISSION LABS:
===============
[**2152-2-12**] 01:00AM BLOOD WBC-16.3* RBC-4.24 Hgb-13.5 Hct-38.1
MCV-90 MCH-31.9 MCHC-35.4* RDW-12.4 Plt Ct-131*
[**2152-2-12**] 06:00AM BLOOD WBC-23.6* RBC-3.54* Hgb-10.7* Hct-33.6*
MCV-95 MCH-30.2 MCHC-31.9 RDW-12.4 Plt Ct-120*
[**2152-2-12**] 01:00AM BLOOD Glucose-23* UreaN-16 Creat-1.2* Na-143
K-3.2* Cl-103 HCO3-20* AnGap-23
[**2152-2-12**] 06:00AM BLOOD Glucose-94 UreaN-13 Creat-0.8 Na-144
K-3.3 Cl-115* HCO3-14* AnGap-18
[**2152-2-12**] 01:00AM BLOOD ALT-6760* AST-[**Numeric Identifier **]* AlkPhos-142*
TotBili-3.5*
[**2152-2-12**] 12:12PM BLOOD ALT-4216* AST-7188* LD(LDH)-3595*
AlkPhos-84 TotBili-3.9*
[**2152-2-12**] 01:00AM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.9 Mg-1.6
MICROBIOLOGY:
=============
[**2152-2-17**] BLOOD CULTURE Blood Culture, Routine-FINAL {[**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 30951**], [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30951**]}; Aerobic Bottle Gram
Stain-FINAL INPATIENT
[**2152-2-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STREPTOCOCCUS PNEUMONIAE}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2152-2-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STREPTOCOCCUS PNEUMONIAE}; Anaerobic Bottle Gram Stain-FINAL
[**2152-3-13**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE
NEGATIVE}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle
Gram Stain-FINAL
STUDIES:
========
CT Abd / Pelvis [**2152-2-12**]
1. Dense bilateral large consolidations with small associated
pleural effusion, worrisome for pneumonia.
2. Abdominal fluid, periportal edema and pericholecystic fluid,
consistent with volume overload.
3. Left renal cortical defect probably indicative of remote
pyelonephritis.
4. Heterogenous liver consistent with hepatitis.
5. Retroperitoneal edema.
.
[**2-13**] RUQ US
RUQ focused ultrasound: There is a small amount of perihepatic
ascites. The right, left, and middle hepatic veins demonstrate
appropriate flow, although waveforms are not triphasic. The
portal vein demonstrates normal hepatopetal flow.
IMPRESSION: The hepatic veins demonstrates normal flow but
non-triphasic waveforms that may be due to decrease complicance
secondary to diffuse hepatic disease.
.
CTA ABD / PELVIS
[**2-15**]
IMPRESSION:
1. Interval improvement in bibasilar pulmonary consolidations
suggests an interval improvement in the underlying pneumonia.
2. Interval development of the anasarca, bilateral pleural
effusion, and progression of the ascitic fluid suggests volume
overload status.
3. Mild thickening of sigmoid and descending colon. This most
likely reflects colitis-probably C Diff. . No evidence of bowel
ischemia is noted.
4. Stable left renal cortical defect probably indicative of
remote pyelonephritis.
.
tte [**2-18**]
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF 60-70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. The estimated pulmonary artery systolic
pressure is normal. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
IMPRESSION: no obvious vegetations seen on this technically
suboptimal study
.
CT ABD /PELVIS 3.21
1. Interval improvement in both bilateral consolidations and
pleural effusions.
2. Anasarca with no significant change in ascites and pelvic
free fluid.
3. Cortical thinning at the site of likely old infection in the
left kidney.
.
TTE [**2-25**]
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. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal. 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. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. There is a trivial/physiologic pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis. Mild
tricuspid regurgitation.
.
CTA CHEST [**3-14**]
FINDINGS: Direct comparison is made to prior examination dated
[**2152-3-3**]. Current examination reveals a stable appearing
right-sided pneumatocele. Small area of dependent soft tissue
attenuation is again identified, as on prior CT. Given the
patient's clinical history, fungal ball should be a differential
consideration for this finding. Overall, there is significant
improvement in the appearance of the lung parenchyma, which do
demonstrate a persistent areas of bilateral, diffuse air
trapping. Areas of increased interstitial markings seen at the
left lung base. This likely represents areas of pulmonary
fibrosis. Focal, confluent area of opacity is also seen at the
right lung base, which may represent a persistent area of
infection or atelectasis.
There is no evidence of main, central, or segmental pulmonary
embolism. The main pulmonary artery measures 3.1 cm. This
enlargement suggests underlying pulmonary arterial hypertension.
There is a small-to-moderate sized pericardial effusion. No
significant hilar or mediastinal lymphadenopathy is identified.
Visualized portions of the upper abdomen are grossly
unremarkable.
No suspicious lytic or blastic bony lesions are identified.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Continued improvement in the patient's pulmonary disease with
pneumatocele identified. Dependent soft tissue attenuation
suggests the possibility of a fungal ball. Recommend clinical
correlation. Also, area of possible fibrosis seen at the left
lung base.
Brief Hospital Course:
41 yo female with history of alcohol and IV drug abuse presents
with sepsis and hypoxia.
.
The patient was in the [**Hospital1 18**] MICU from [**2152-2-12**] through [**2152-2-28**].
During this time, she was treated for:
-Sepsis: required intubation, siginficant ventilatory support
and 3 pressors. DIC. Resp failure/ARDS from presumed
aspiration event/s.pneumo pneumonia. She had S. pneumoniae
bacteremia, enterococcal UTI, and candidal fungemia during her
MICU course.
-S. pneumo pneumonia and bacteremia with ceftriaxone, then
meropenem because of elevated bilirubin. There was a concern
about prolonged altered mental status off all sedation in the
periextubation period, raising a concern about meningitis. No LP
performed, and her mental status improved without other
intervention. The plan was to treat the patient empirically for
meningitis.
-She also was persistently febrile despite broad spectrum
antibiotics. Blood cultures grew [**Female First Name (un) 564**] and the patient was
treated with IV caspofungin given her LFT abnormalities. Once
her LFTs normalized/returned to baseline, the plan was to change
to fluconazole (although she only completed 16 d course of
caspofungin). Ophthalmology was consulted, and no evidence of
fungal infection was discovered via fundoscopic exam.
-Fulminant hepatic failure with INR to 5.9, AST>15,000,
ALT>8,000. Thought to be shock liver, also a possible tylenol
component and the patient was treated with NAC initially.
-Anemia: thought to be a slow drift, guaiac negative, no
evidence of hemolysis on most recent labs
-Altered mental status: prolonged somnolence off sedation,
likely related to liver failure and use of benzos during
sedation. Treated with lactulose and MS improved slowly.
Methadone held.
-Volume overload: patient ~19 L positive at transfer, had been
autodiuresing. Cr stable
.
[**Hospital 30952**]
MEDICAL FLOOR COURSE:
.
She was transferred to the floor, autodiuresed and continued to
show significant improvement in her LFTs, when she developed
another fever and hypoxia and was transferred back to the MICU
for a likely aspiration event. She was re-intubated and
continued on treatment for her many infections. She was
followed closely by Infectious Disease, and she again improved
considerably and was extubated on [**2152-3-8**]. She had completed all
courses of antibiotics while in the MICU, and was off of
antibiotics on re-transfer to the floor. Her liver enzymes also
continued to improve slowly, but remained elevated on transfer
to the floor.
.
On the floor (round 2), she primarily complained of generalized
weakness, which was likely due to her critical illness and
prolonged ICU course. She worked closely with physical therapy
and occupational therapy, and made significant improvement while
inpatient. Neurology was consulted for right arm numbness and
weakness, which was contributed to possible injury experienced
with arterial line placement while in the ICU; it was
recommended that she follow up with physical therapy for
continued strength training. She was also significantly anxious
during this hospital stay. She was seen by social work and
addictions consult, and being treated with Xanax initially for
her significant anxiety. Psychiatry was consulted for
assistance in management of anxiety; she was put on clonazepam
[**Hospital1 **] instead.
.
After [**Hospital1 13835**] 1 week on the floor she developed
progressive leukocytosis. Surveillance cultures were obtained
and revealed coag negative staph, the source of which was
considered to be her PICC line. The line was pulled and she was
started on vancomycin for 7 day course. After blood cultures
were negative for 48 hrs another PICC line was placed to
complete treatment. This second PICC line was pulled on
discharge. Furthermore, a CTA was performed to evaluate
pleuritic chest pain, which did show improvement of airspace
disease with a pneumatoceole. Given her hx of fungemia, this
raised concerns for a fungal ball in the right lung. ID and
Pulmonary were contact[**Name (NI) **] regarding this issue, and it was
determined that the airspace was unchanged, unlikely represented
an active infection, and may represent sequelae from previous
infection (likely bacterial). She was encouraged to follow up
with pulmonary regarding this issue in [**Name (NI) 13835**] 8 weeks
time. She also had a progressive eosinophilia upon discharge;
this was considered secondary to vancomycin. She will require a
follow up CBC with differential in [**Name (NI) 13835**] 5 days post
discharge to ensure the leukocytosis / eosinophilia has
resolved.
.
Medications on Admission:
None per report.
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day): patient should have [**1-9**] loose bowel movements a
day.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
1) S. Pneumonia Pneumonia
2) ARDS
3) Candidemia
4) Hepatic Failure
5) Substance Abuse
6) Staph bacteremia
7) Pneumatoceole
Discharge Condition:
Weak physically, with numbness of right hand. Mildly jaundiced.
Highly anxious. Left sided PICC line in place.
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted to the hospital with a severe lung and blood
infection. You were treated in the intensive care unit, and
maintained on life support. You also experienced a fungal
infection of the blood and a repeat bacterial infection of the
blood. You completed treatment for the first bacterial
infection and the fungal infection. You are currently being
treated with an antibiotic for the most recent bacterial
infection (which was likely caused by the first PICC line). You
should follow up with infectious disease as below.
.
You were noted to have liver dysfunction from underlying
hepatitis. You should continue to follow up with a liver
specialist regarding your care.
.
You were noted to have anxiety and a history of substance abuse.
You will benefit from therapy and a treatment program. Please
continue your new medication clonazepam for anxiety as
prescribed. Please follow up with psyciatry.
.
You were also found to have an air pocket in your lung. You
should follow up with a lung doctor [**First Name (Titles) **] [**Last Name (Titles) 13835**] 2 months to
ensure that this is unchanged.
.
Please start below attached medications.
.
If you experience shortness of breath, chest pain, cough,
fevers, chills, diarrhea, abdominal pain, please contact your
doctor or return to the [**Name (NI) **] for help.
Followup Instructions:
Please see your primary care physician, [**Name Initial (NameIs) **] pulmonologist,
infectious disease doctor, substance abuse counseling/behavioral
therapist.
.
You have an appointment with your infectious disease doctor on [**4-17**] at 9:30am with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7443**], phone #
[**Telephone/Fax (1) 457**].
.
You have an appointment with your pulmonologist on [**4-20**] at
1:30pm, phone# [**Telephone/Fax (1) 612**]. Clinic located at [**Hospital1 18**] [**Hospital Ward Name **], [**Location (un) 436**] [**Hospital Ward Name 23**] building. Please show up at 1:00pm for
testing at PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**].
.
You have an appointment with your primary care physician on [**6-19**], [**2151**] at 8:00am at [**Hospital 189**] Community Health Center, phone#
[**Telephone/Fax (1) 30953**].
.
You should follow up with Psychiatry. Call [**Telephone/Fax (1) 30954**] for
referral to see a psychiatrist for treatment of your anxiety.
ICD9 Codes: 5070, 5990, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6567
} | Medical Text: Admission Date: [**2194-11-17**] Discharge Date: [**2194-12-25**]
Date of Birth: [**2145-9-22**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: This is a 48 year old male with
adenocarcinoma of the distal esophagus. He underwent
neoadjuvant therapy with chemotherapy and radiation. He
completed chemotherapy four weeks prior to admission and
radiation therapy two weeks prior to admission. The patient
had a significant weight loss of approximately 30 pounds.
CT scan per Oncology demonstrated partial resolution of the
tumor.
PAST MEDICAL HISTORY:
1. Nephrolithiasis in [**2172**].
2. Chronic low back pain.
PAST SURGICAL HISTORY:
1. J-tube placement.
2. Porta-Cath placement.
ALLERGIES: Erythromycin.
PHYSICAL EXAMINATION: Afebrile, vital signs stable. HEENT:
No lymphadenopathy. Lungs are clear to auscultation.
Cardiac: Regular rate and rhythm. Abdomen soft, nontender,
nondistended.
HOSPITAL COURSE: The patient was admitted on [**2194-11-17**], where he went to the Operating Room and had an
esophagogastrectomy with mediastinal lymph node dissection.
Postoperatively, the patient had a mild episode of
hypotension which was attributed to the epidural catheter.
The patient was doing well until he became febrile on
[**2194-11-20**]. On [**11-21**], some wound drainage was
seen from the abdominal incision. A CT scan was obtained
after several days of monitoring the drainage and the scan
revealed a wound dehiscence.
The patient went to the Operating Room on [**11-25**], for
debridement of fascia and a buttress repair of the wound
dehiscence. Postoperatively, the patient had hypotension and
was transferred to the Intensive Care Unit. The patient was
started on Vancomycin, Levofloxacin and Flagyl.
On [**11-29**], the patient had an episode of tachycardias in
to the 160s. Copious amounts of green drainage was seen from
the right chest tube. Another chest tube was placed which
revealed also copious amounts of drainage. The patient was
placed on multiple pressors and was intubated.
On [**11-30**], the patient was brought to the Operating Room
again for esophageal diversion of his split fistula.
Infectious Disease consultation was obtained and he was
placed on Imipenem, Vancomycin, Fluconazole, Levofloxacin,
for multiple organisms. He was started on total parenteral
nutrition.
On [**12-2**], the patient grew out Methicillin resistant
Staphylococcus aureus from his sputum. Gradually, in the
Intensive Care Unit his pressors were weaned. Tube feeds
were started on [**12-5**]. A follow-up chest CT scan was
obtained which revealed a small right fluid collection which
was significantly improved from the prior.
Tube feeds were advanced to goal and the TPN was discontinued
[**12-8**]. On [**12-8**] also, all antibiotics were
discontinued except for Vancomycin which was kept for MRSA.
The patient had a CT scan guided procedure of a fluid
collection by Interventional Radiology on [**12-13**].
After multiple attempts of extubation and weaning, the
patient was finally extubated on [**12-18**]. On [**12-19**],
all of the chest tubes were removed due to minimal amounts of
drainage. On [**12-21**], the patient was transferred to the
Floor.
On the Floor, the patient did well, had no complaints. Tube
feeds were at goal. The patient was afebrile.
LABORATORY: Laboratory values upon discharge are as follows:
Sodium 141, potassium 3.5, chloride 101, bicarbonate 29, BUN
14, creatinine 0.3, glucose 137, white blood cell count 18,
hematocrit 30.6, platelets 446. The patient's white blood
cell count significantly decreased from higher values
obtained during the admission.
CONDITION AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Epogen 40,000 units subcutaneously q. week.
2. Heparin 5000 units subcutaneously twice a day.
3. Zinc Sulfate 220 mg per J-tube q. day.
4. Clonidine patch 0.2 mg q. week.
5. Vitamin C 500 mg twice a day via NG tube.
6. Vancomycin 2 grams intravenously q. 12 hours.
7. Lopressor 25 mg per J-tube twice a day.
8. Celexa 20 mg per J-tube q. day.
9. Oxy-Codon Elixir 5 to 10 cc q. six hours p.r.n. via
J-tube.
10. Haldol Elixir 1 mg per J-tube q. eight hours p.r.n.
11. The patient was also on Impact with fiber tube feeds at
75 cc per hour which was his goal.
DISCHARGE STATUS: Rehabilitation facility.
DISCHARGE INSTRUCTIONS: The patient will follow-up with the
following people:
1. Dr. [**Last Name (STitle) 175**] in two weeks.
2. Dr. [**Last Name (STitle) 1305**] in two weeks.
3. His primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
4. Infectious Disease Clinic in two weeks.
DISCHARGE DIAGNOSES:
1. Status post esophagogastrectomy complicated by wound
dehiscence and anastomotic leak.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2194-12-25**] 10:40
T: [**2194-12-25**] 10:56
JOB#: [**Job Number 35105**]
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6568
} | Medical Text: Admission Date: [**2133-8-22**] Discharge Date: [**2133-8-29**]
Date of Birth: [**2055-1-25**] Sex: F
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 46126**]
Chief Complaint:
nausea/vomiting, abdominal pain
Major Surgical or Invasive Procedure:
[**2133-8-27**] laparoscopic cholecystectomy
[**2133-8-23**] ERCP with sphincterotomy and stone extraction
History of Present Illness:
78F with history of NIDDM, HTN, recent UTI and fall presenting
with n/v, increased fatigue, RUQ abdominal pain and poor PO
intake for the last three days. Patient reports feeling unwell
after starting her nitrofurantion for her UTI diagnosed in ED on
[**8-20**]. Began to feel increased fatigue with associated
nausea/vomiting and diarrhea last night. Continued this morning.
NB/NB. Found by friend who called EMS after 2 hours of continued
symptoms. Febrile yesterday. No chest pain. SOB with vomiting. +
dysuria.
Vital Signs in the ED: Pulse: 115, RR: 34, BP: 99/52, O2Sat: 95,
O2Flow: r/a. PT became hypotensive in ED to 76/54. She was
given 2L of NS with poor response in BP. She was started on
levophed and given vancomycin/zosyn. WBC 20.2 (N:90), ALT:200
AP:163 Tbili:5.3 Alb: 3.9 AST:145. RUQ US Sludge and stones
layering in the gallbladder, without evidence for acute
cholecystitis, CBD 9mm. Surgery and ERCP was consulted with plan
for ERCP tomorrow.
On arrival to the MICU, patient's VS were T 99.9, HR 73, BP
131/67 on 0.08 Levophed and 98% RA. Pt was complaining of
shoulder pain which she has had since the fall last week. She
denies any abdominal pain, nausea, SOB, or CP currently.
Past Medical History:
-DM II
-Hypertension
-Hypothyroidism
-Urinary incontinence
-Venous insufficiency
-osteoporosis
-h/o DVT
-s/p umbilical hernia repair
-H/O ANEMIA
- [**2128**] colonoscopy: Adenomas
- EGD [**10-9**]: Duodenitis, angioectasia
- Capsule endoscopy [**2129**]: ileal polyps, consider ileoscopy
- Seen by [**Doctor Last Name 2161**], ileocopy/ further w/u deferred as anemia
Social History:
Has VNA. Originally from [**University/College **]. Lives on [**Social Security Number 94034**]social security.
She lives alone with no family near by but has support of
friends. [**Name (NI) 4084**] [**Name2 (NI) 1818**]. Denies EtOH/drugs.
Family History:
non-contributory
Physical Exam:
Admission Exam:
General: Alert, awake, no acute distress
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
tenderness to palpation, no rebound or guarding
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Pertinent Results:
[**2133-8-27**] 04:18AM BLOOD WBC-12.2* RBC-3.87* Hgb-11.0* Hct-32.6*
MCV-84 MCH-28.5 MCHC-33.9 RDW-15.4 Plt Ct-241
[**2133-8-26**] 04:14AM BLOOD WBC-12.0* RBC-3.83* Hgb-10.8* Hct-31.7*
MCV-83 MCH-28.2 MCHC-34.0 RDW-15.1 Plt Ct-177
[**2133-8-22**] 01:15PM BLOOD WBC-20.2*# RBC-4.23 Hgb-12.2 Hct-37.3
MCV-88 MCH-28.8 MCHC-32.7 RDW-15.0 Plt Ct-165
[**2133-8-26**] 04:14AM BLOOD Neuts-85* Bands-2 Lymphs-4* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0
[**2133-8-22**] 01:15PM BLOOD Neuts-90* Bands-5 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2133-8-27**] 04:18AM BLOOD Plt Ct-241
[**2133-8-26**] 04:14AM BLOOD Plt Smr-NORMAL Plt Ct-177
[**2133-8-26**] 04:14AM BLOOD PT-11.4 PTT-30.6 INR(PT)-1.1
[**2133-8-27**] 04:18AM BLOOD Glucose-103* UreaN-8 Creat-0.5 Na-133
K-4.2 Cl-103 HCO3-22 AnGap-12
[**2133-8-26**] 04:14AM BLOOD Glucose-104* UreaN-7 Creat-0.5 Na-134
K-3.7 Cl-102 HCO3-23 AnGap-13
[**2133-8-27**] 04:18AM BLOOD ALT-75* AST-34 AlkPhos-126* TotBili-0.9
[**2133-8-26**] 04:14AM BLOOD ALT-94* AST-40 LD(LDH)-187 AlkPhos-138*
TotBili-1.2
[**2133-8-22**] 01:15PM BLOOD ALT-200* AST-145* AlkPhos-163*
TotBili-5.3* DirBili-4.3* IndBili-1.0
[**2133-8-27**] 04:18AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
[**2133-8-22**] 01:28PM BLOOD Lactate-7.5*
[**2133-8-22**]: EKG:
Sinus tachycardia. Possible inferior wall myocardial infarction
of
indeterminate age. Compared to the previous tracing of [**2132-9-3**]
the rate has increased. Otherwise, findings are similar.
[**2133-8-22**]: Liver/gallbladder ultrasound:
IMPRESSION:
1. No intrahepatic biliary duct dilation with prominence of the
common bile duct to 9 mm.
2. Sludge and probable stones layering in the gallbladder,
without evidence for acute cholecystitis.
3. Mildly echogenic liver, suggestive of fatty infiltration,
particularly given the area of sparing around the gallbladder
fossa. However, other forms of liver disease including more
advanced liver disease such as significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
[**2133-8-22**]: chest x-ray:
IMPRESSION: Appropriately positioned right IJ central venous
catheter. Mild left basal atelectasis.
[**2133-8-22**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2133-8-24**]**
Blood Culture, Routine (Final [**2133-8-24**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2133-8-22**]):
Reported to and read back by DR. [**Last Name (STitle) 32434**] [**Name (STitle) 32435**] @ 2220,
[**2133-8-22**].
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2133-8-22**]): GRAM NEGATIVE
ROD(S).
[**2133-8-22**]:
[**2133-8-22**] 1:25 pm BLOOD CULTURE
**FINAL REPORT [**2133-8-24**]**
Blood Culture, Routine (Final [**2133-8-24**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
351-1469M
[**2133-8-22**].
Aerobic Bottle Gram Stain (Final [**2133-8-22**]): GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final [**2133-8-22**]): GRAM
NEGATIVE ROD(S).
Brief Hospital Course:
The patient was admitted to the acute care service with
abdominal pain, nausea and vomitting. Upon admission to the
emergency room, she was found to be hypotensive and tachycardic
requiring pressor support. She was made NPO, given intravenous
fluids, and underwent blood work and imaging. On blood work she
was reported to have an elevated white blood cell count and
elevated liver enzymes. She was started on vancomycin and
zosyn. Imaging of the abdomen showed a dilated CBD to 9mm as
well as sludge and stones in the gallbladder but no
cholecystitis. She was transferred to the intensive care unit
for monitoring.
Blood cultures drawn upon admission grew gram negative rods
which were sensitive to ceftriaxone and the vancomycinn and
zosyn were discontinued. Her vital signs, liver enzymes, and
white blood cell count were closely monitored.
On HD #2, she underwent an ERCP which showed a dilated CBD with
stones and sludge in the gallbladder. A sphincterotomy was done
with the removal of pus. After the liver enzymes decreased she
was taken to the operating room on HD #6 for a laparoscopic
cholecystectomy. The operative course was stable and the
patient was extubated after the procedure and monitored in the
recovery room.
The post-operative course has been unremarkable. Her diet was
gradually advanced as tolerated, her vitals were stable and she
remained afebrile. She received physical therapy for L leg and
shoulder pain from a fall prior to admission. She was discharged
home on post-operative day 2 (HD 8) with VNA and home PT
services.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. estradiol *NF* 0.01 % (0.1 mg/g) Vaginal 2x/week
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. risedronate *NF* 35 mg Oral q Thursday
6. Simvastatin 20 mg PO QHS
7. Sanctura *NF* (trospium) 20 mg Oral [**Hospital1 **]
8. Aspirin 81 mg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. camphor-menthol *NF* 0.5-0.5 % Topical PRN leg pruritus
11. Vitamin D 1000 UNIT PO DAILY
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. risedronate *NF* 35 mg Oral q Thursday
6. Sanctura *NF* (trospium) 20 mg Oral [**Hospital1 **]
7. Simvastatin 20 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Aspirin 81 mg PO DAILY
11. estradiol *NF* 0.01 % (0.1 mg/g) Vaginal 2x/week
12. camphor-menthol *NF* 0.5-0.5 % Topical PRN leg pruritus
13. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
At home VNA
Discharge Diagnosis:
sepsis
cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with right upper abdominal
pain, nausea and vomitting. Your white blood cell count was
elevated and you had a decreased blood pressure. You were
monitored in the intensive care unit. You underwent an
ultrasound of the abdomen and you were found to have stones and
sludge in your gallbladder. You underwent a special test called
an ERCP to remove the stones and sludge. After your liver
studies decreased, you were taken to the operating room to have
your gallblader removed. You are recovering nicely from the
surgery and you are preparing for discharge home with the
following instructions:
Home Care
??????Ask someone to drive you to your appointments for the next 3
days. [**Male First Name (un) **]??????t drive until you are no longer taking pain
medication.
??????Wash the skin around your incision daily with mild soap and
water. It's okay to shower the day after your surgery.
??????Eat your regular diet. It is wise to stay away from [**Doctor First Name **],
greasy, or spicy food for a few days.
??????Remember, it takes about 1 week for you to get most of your
strength and energy back.
??????Make an office visit to talk to your doctor if the following
symptoms [**Male First Name (un) **]??????t go away within a week after your surgery:
◦Fatigue
◦Pain around the incision
◦Diarrhea or constipation
◦Loss of appetite
??????Don't be alarmed if you have discomfort in your shoulder and
chest for up to 48 hours after surgery. This is caused by carbon
dioxide (gas) used during the operation. The discomfort will go
away.
Followup Instructions:
**Please follow up in Acute Care Surgery clinic in 2 weeks. Call
the Acute Care Surgery clinic at [**Telephone/Fax (1) 600**] to schedule this
follow-up appointment
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2010**]
Date/Time:[**2133-8-31**] 3:40
Provider: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 2010**]
Date/Time:[**2133-9-23**] 9:50
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2133-11-10**] 1:40
ICD9 Codes: 2762, 4019, 2449, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6569
} | Medical Text: Admission Date: [**2192-4-6**] Discharge Date: [**2192-4-11**]
Date of Birth: [**2105-12-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2192-4-6**]: Redo sternotomy, Aortic Valve Replacement (tissue)
History of Present Illness:
86 year old female with a history of aortic valve replacement 14
years ago and hypertension, hyperlipidemia who has noticed
dyspnea with minimal exertion and fatigue over the past [**4-24**]
months. Patient states she will fall asleep numerous times
throughout the day after any type of activity. She states she
will occasionally feel dizzy while walking which she attributes
to her vertigo. She will take her antivert and the dizziness
will subside. She underwent a cardiac catheterization in [**Month (only) 958**]
which revealed [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.6 and 20% LAD stenosis. She was seen
by Dr. [**Last Name (STitle) **] after her cardiac catheterization and returns
today for preadmission testing.
Past Medical History:
Aortic Stenosis
Hypertension
Hyperlipidemia
GERD
Vertigo
Basal Call s/p removal from temple x4 (hands and legs)
Anxiety
Arthritis
Hiatal Hernia
Past Surgical History:
Tonsillectomy
Appendectomy
Cholecystectomy
Pancreatomy
Bowel obstruction surgery [**2190**]
Right hip replacement [**2182**]
AVR (bovine) 14 years ago
Social History:
Lives with: alone, supportive family
Occupation: retired
Tobacco: none
ETOH: rare
Family History:
non-contributory
Physical Exam:
Pulse:90 Resp:15 O2 sat: 100% 2l NC
B/P Right: 105/67 Left:
Height: 4'[**90**]" Weight: 64 kg
General:
Skin: Dry [x] intact [x] Mild bruising noted.
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema
Varicosities: None [X] 2+ bilat. LLE edema
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: rad murmur Left: rad murmur
Pertinent Results:
Admission labs
[**2192-4-6**] 11:08AM PT-15.8* PTT-39.6* INR(PT)-1.4*
[**2192-4-6**] 11:08AM FIBRINOGE-132*
[**2192-4-6**] 10:27AM HGB-7.6* calcHCT-23
[**2192-4-6**] 12:31PM UREA N-21* CREAT-0.8 SODIUM-141 POTASSIUM-4.8
CHLORIDE-113* TOTAL CO2-20* ANION GAP-13
Discharge labs
[**2192-4-11**] 04:25AM BLOOD WBC-12.7* RBC-3.83* Hgb-12.0 Hct-35.5*
MCV-93 MCH-31.2 MCHC-33.7 RDW-14.0 Plt Ct-105*
[**2192-4-11**] 04:25AM BLOOD Plt Ct-105*
[**2192-4-8**] 04:27AM BLOOD PT-14.4* INR(PT)-1.2*
[**2192-4-11**] 04:25AM BLOOD UreaN-33* Creat-0.7 Na-136 K-3.9 Cl-99
[**2192-4-10**] 04:25AM BLOOD Glucose-78 UreaN-33* Creat-0.8 Na-139
K-4.0 Cl-102 HCO3-26 AnGap-15
Radiology Report CHEST (PA & LAT) Study Date of [**2192-4-10**] 11:39
AM
Final Report: Right lower lobe density has become more round
since [**2192-4-8**] and while it could represent confluent
atelectasis, evolving pneumonia is also considered possible.
Bilateral pleural effusions are small and have also developed
since [**2192-4-8**]. Mild cardiomegaly is unchanged since [**2192-4-5**]. The
right internal jugular central venous sheath has been removed.
Median sternotomy wires are in satisfactory position and
alignment.
IMPRESSION:
1. Worsening right lower lobe opacity which could represent
atelectasis, but consolidation is considered possible.
2. Bilateral enlarging small pleural effusions.
Brief Hospital Course:
The patient was a direct admission to the operating room on
[**2192-4-6**] where the patient underwent Redo Sternotomy, AVR
(porcine). Please see the operative report for details. In
summary she had: Redo aortic valve surgery with a 19-mm St. [**Hospital 923**]
Medical Biocor Epic tissue valve. Her bypass time was 93 minutes
with a crossclamp time of 50 minutes. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. The patient was noted to have afriable
aorta during the surgery and a decision was made to keep her
sedated until the morning after suregery. On
POD 1 the patient was weaned from sedation, woke neurologically
intact and was extubated. The patient remained hemodynamically
stable and weaned from vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. She was noted to be thrombocytopenic with
a platelet count of 61,000/uL. HIT antibody was sent and was
negative. Platelets would trend up by discharge. She remained
in the ICU to monitor hemodynamically until POD3 when she
wastransferred to the telemetry floor for further recovery. All
tubes lines and drains were removed per cardiac surgery
protocol.
The patient was seen by the physical therapy service for
assistance with strength and mobility. The remainder of her
hospital course was uneventful.
At the time of discharge on POD5, the patient was ambulating
freely, the wound was healing and pain was controlled with
Ultram. The patient was discharged to [**Hospital 11252**] [**Hospital 90193**]
Health Care in good condition with appropriate follow up
instructions.
Medications on Admission:
ALPRAZOLAM 0.5 mg Q8PRN, AMLODIPINE-ATORVASTATIN [CADUET] 5
mg-40 mg Tablet 0.5 Tablet daily, ESOMEPRAZOLE MAGNESIUM 40 mg
daily, HYDROCHLOROTHIAZIDE 12.5 mg daily, MECLIZINE 12.5 mg
Q8hr PRN, Toprol 25 mg daily, POTASSIUM CHLORIDE 20 mEq daily,
RALOXIFENE 60 mg daily, ASPIRIN 81 mg daily, CALCIUM
CARBONATE-VITAMIN D3 600 mg-400 unit daily, MULTIVITAMIN daily,
OMEGA-3 FATTY ACIDS-FISH OIL 360 mg-1,200 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheezes.
11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for heartburn.
12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily ().
13. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob/wheezes.
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
17. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
18. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for for bm.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11252**] Center
Discharge Diagnosis:
Aortic Stenosis
Hypertension
Hyperlipidemia
GERD
Vertigo
Basal Call s/p removal from temple x4 (hands and legs)
Anxiety
Arthritis
Hiatal Hernia
Past Surgical History:
Tonsillectomy
Appendectomy
Cholecystectomy
Pancreatomy
Bowel obstruction surgery [**2190**]
Right hip replacement [**2182**]
AVR (bovine) 14 years ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance- deconditioned
Sternal pain managed with Tramadol
Sternal Incision - healing well, no erythema or drainage
Edema trace
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:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Surgeon Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2192-5-3**] 1:15 [**Telephone/Fax (1) 170**]
Please call to schedule the following:
Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]-[**Doctor First Name 10588**] S. [**Telephone/Fax (1) 11254**] in [**2-21**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2192-4-11**]
ICD9 Codes: 5185, 4019, 2724, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6570
} | Medical Text: Admission Date: [**2190-6-5**] Discharge Date: [**2190-6-6**]
Service: #58
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 42654**] is a [**Age over 90 **] year-old
woman with a past medical history of hypertension, coronary
artery disease, status post myocardial infarction with
pacemaker, who presented with 35 minutes of generalized tonic
clonic activities suppressed by 15 mg of Valium. The patient
had reported been at her baseline in her usual state of
health, interactive, fluent until the day of admission when
she was last seen at 2:00 p.m. She had been resting in her
room and was found in convulsions at approximately 3:40 p.m.,
unresponsive with a systolic blood pressure of approximately
180 to 200. Emergency medical services arrived within twenty
minutes and she was given 5 mg of IM Valium followed by 10 mg
of intravenous before resolution of her symptoms. She was
reported at this time to hve copious secretions.
In the Emergency Room she was loaded with 1 gram of Dilantin
and intubated for airway protection. A left femoral central
line was initially placed and then removed secondary to a
hematoma, a right was later placed.
Per nursing home staff and family she had not been ill prior
to this. She had no history of prior seizures.
Upon admission to the Intensive Care Unit she was intubated
and not responsive.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Tremor. 3.
Coronary artery disease status post myocardial infarction.
4. Left humerus fracture. 5. Hypercholesterolemia. 6.
Status post cataract surgery. 7. Status post pancreatic
surgery.
MEDICATIONS ON ADMISSION: 1. Effexor 37.5 mg po q day. 2.
Lipitor 10 mg po q day. 3. Monopril 20 mg po q day. 4.
Multivitamins. 5. Plavix 75 mg po q day. 6. Prevacid 15 mg
po q day. 7. Pericolace one tab po b.i.d. 8. Celebrex 100
mg po q day. 9. Senokot two tabs q.h.s.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs significant
for a temperature of 98.8. Blood pressure 150/75. Heart
rate 95, intubated, sating 100% on 40% FIO2. Oral mucosa
moist. No lymphadenopathy. Lungs with diffuse crackles. No
wheezing. Cardiac examination with a 2 out of 6 systolic
ejection murmur heard best at the apex. Regular rate and
rhythm. No rubs. No gallops. Abdomen soft, nontender,
nondistended with positive bowel sounds. She was moving all
four extremities. She had a large left groin hematoma not
firm or indurated. She had no active bleeding at the site.
Her right dorsalis pedis pulse was not palpable. Posterior
tibial was not dopplerable on the left. Her dorsalis pedis
pulse was dopplerable, but her posterior tibial pulse was not
palpable or dopplerable. Her skin was without rashes.
Neurologically she was intubated and sedated. She withdrew
mildly to all extremities on examination. She had positive
dolls eyes. No corneal reflex was noted upon initial
examination. She had a surgical pupil, both were reactive.
Her tone was slightly increased. She had mild intermittent
tremor of the chin and right upper extremity when she tried
to bring it midline. Reflexes were 1+ and symmetric at
biceps, triceps, brachial radialis bilateral in upper
extremities 1+ at patellar and Achilles. Her toes were up
going bilaterally.
Ventilator settings upon admission were pressor support of 10
and 5, 40% FIO2, respiratory rates in the 20s with tidal
volumes in the 300s. Arterial blood gas at this point was
7.37/46/187.
ADMISSION FILMS: CT of the head showing low attenuation with
white matter at the junction of the right MCA and PCA
territories. Lack of associated mass factor atrophy
suggesting a possible subacute watershed infarct. Without
prior films for comparison. Acuity was noted to be difficult
to ascertain.
LABORATORIES ON ADMISSION: White blood cell count of 8.0,
hematocrit 33.2, platelets 162, sodium 142, potassium 3.6,
chloride 104, bicarb 24, BUN 29, creatinine 1.1, glucose 151.
Urinalysis with no nitrites and no ketones.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for monitoring. Left groin line placed
in the Emergency Department was discontinued secondary to
hematoma. She was transfused with 2 units of packed red
blood cells for a hematocrit drop in this setting. Post
transfusion hematocrit showed an appropriate bump. A groin
line was placed for access.
Dilantin level was therapeutic after an initial load in the
Emergency Department. Potassium, magnesium and calcium were
all repleted. She remained hemodynamically stable throughout
her Intensive Care Unit stay. She remained intubated during
her short stay in the Intensive Care Unit and extubation was
deferred secondary to transfer to the outside hospital. At
the time of discharge the patient remained intubated,
withdraws to painful stimulus in all extremities. Toes are
up going bilaterally and dolls eyes were intact.
She is to be transferred to [**Hospital3 **] Neurological step
down unit as all of her records are at [**Hospital3 **].
DISCHARGE DIAGNOSES:
1. Cerebrovascular accident.
2. Coronary artery disease.
3. Hypertension.
4. Hypercholesterolemia.
MEDICATIONS ON TRANSFER: Protonix 40 mg intravenous q.d.
Plavix 75 mg po/pngt q.d. Dilantin 100 mg po/pngt b.i.d.
Tylenol prn.
DISPOSITION: [**Hospital3 **] neurologic step down unit.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D: [**2190-6-6**] 15:05
T: [**2190-6-9**] 07:14
JOB#: [**Job Number 42655**]
ICD9 Codes: 2720, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6571
} | Medical Text: Admission Date: [**2155-4-9**] Discharge Date: [**2155-5-2**]
Date of Birth: [**2072-7-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2155-4-9**] 1. Emergency repair of type A aortic dissection with
ascending aorta and hemiarch replacement with size 30
Gelweave graft.
2. Aortic valve replacement with a size 23 St. [**Male First Name (un) 923**] Epic
tissue valve.
3. Right axillary artery cannulation.
[**2155-4-10**] Mediastinal exploration for bleeding
[**2155-4-15**] Sternal closure
[**2155-4-25**] Percutaneous tracheostomy (#8 cuffed)
[**2155-4-28**] 39cm double lumen heparin-dependant power PICC tip in
the lower SVC
[**2155-4-29**] PEG
History of Present Illness:
Mr. [**Known lastname 110450**] developed acute abdominal pain today while working
on his boat. He developed near syncope and 911 was called. He
was taken to the outside hospital where he had a non-contrast
abdominal CT scan which was negative for
abdominal aortic aneurysm. He was admitted to the hospital and
developed acute neuro changes with L sided paresis and L
neglect. He had CT scan of head/neck/chest and abdomen with
contrast wich showed acute aortic disection with extension into
the R carotid. His neuro symptoms nearly resolved and he was
transferd for surgical repair.
Past Medical History:
Type A aortic dissection
PMH:
HTN
cataracts
Past Surgical History
s/p cholecystectomy [**2118**]
s/p bilateral hernia repairs
Social History:
Not documented
Family History:
Not documented
Physical Exam:
Pulse:57 SR Resp:14 O2 sat:96% on RA
B/P Right: 70/40 Left: 105/56
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur-none
Abdomen: Soft [x] non-distended [x] mild epigastric tenderness
[x] bowel sounds +[x]
Extremities: cool [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: awake, alert, oriented to person, place, date, situation.
Moves all extremities, strength equal bilaterally, upper and
lower extremities, slight facial droop on L
Pulses:
Femoral Right: Left:
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Pertinent Results:
[**2155-5-2**] 03:35AM BLOOD WBC-9.5 RBC-3.32* Hgb-10.2* Hct-32.1*
MCV-97 MCH-30.6 MCHC-31.6 RDW-16.8* Plt Ct-382
[**2155-5-1**] 02:11AM BLOOD WBC-10.0 RBC-3.35* Hgb-10.1* Hct-32.6*
MCV-97 MCH-30.2 MCHC-31.1 RDW-17.1* Plt Ct-343
[**2155-4-30**] 01:00AM BLOOD WBC-9.5 RBC-3.23* Hgb-9.6* Hct-31.2*
MCV-96 MCH-29.6 MCHC-30.7* RDW-17.1* Plt Ct-297
[**2155-5-1**] 02:11AM BLOOD PT-12.6* PTT-29.0 INR(PT)-1.2*
[**2155-4-30**] 01:00AM BLOOD PT-12.3 PTT-27.3 INR(PT)-1.1
[**2155-5-2**] 03:35AM BLOOD Glucose-127* UreaN-27* Creat-0.5 Na-144
K-3.7 Cl-112* HCO3-24 AnGap-12
[**2155-5-1**] 07:57PM BLOOD Na-145 K-3.5 Cl-112*
[**2155-5-1**] 02:11AM BLOOD Glucose-110* UreaN-24* Creat-0.5 Na-144
K-3.3 Cl-114* HCO3-20* AnGap-13
[**2155-4-30**] 01:00AM BLOOD Glucose-84 UreaN-26* Creat-0.5 Na-148*
K-3.4 Cl-116* HCO3-23 AnGap-12.
.
[**2155-4-9**] ECHO
PRE-CPB:
The left atrium is moderately dilated. No thrombus is seen in
the left atrial appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is moderately dilated with severe
global free wall hypokinesis.
The ascending aorta is moderately dilated. The descending
thoracic aorta is moderately dilated. A mobile density is seen
in the ascending aorta consistent with an intimal flap/aortic
dissection, and this flap extends to the descending thoracic
aorta. The dissection flap appears to extend to the aortic root,
particularly in the right coronary cusp. The aortic valve
leaflets (3) are mildly thickened. Moderate to severe (3+)
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There appears to
be prolapse of the area in between the p1 and p2 scallops of the
posterior mitral leaflet. There is a central as well as an
[**Month/Day/Year 34486**] jet of MR. [**First Name (Titles) **] [**Last Name (Titles) 34486**] jet is anteriorly directed.
The MR appears to be moderate to severe (3+). Due to the
[**Last Name (Titles) 34486**] nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect).
There is a small pericardial effusion.
.
[**2155-4-23**] Carotids
Impression: Right ICA <40% stenosis.
Left ICA <40% stenosis
.
[**2155-4-24**] CT chest/abd/pelvis
IMPRESSION:
1. No retroperitoneal hematoma.
2. Bulbous, large spleen with areas of hypodensity may
represent splenic
infarct, possibly with liquefaction, incompletely evaluated on
this
noncontrast CT. If clinically indicated, this could be further
evaluated with
ultrasound or contrast enhanced CT.
3. Small-to-moderate right hydropneumothorax and small left
hydropneumothorax
with adjacent atelectasis.
4. Fluid-filled, nondilated small and large bowel may represent
ileus. No
obstruction.
5. Anasarca.
6. Tiny hyperdensity in the left renal superior pole is
nonspecific and may
represent a proteinaceous or hemorrhagic cyst. If clinically
indicated,
dedicated renal ultrasound could be performed for further
evaluation.
Dr. [**Last Name (STitle) 1603**] discussed findings with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] (PA) by
phone, 10:25am
[**2155-4-24**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**Last Name (STitle) 64299**] J. MORTELE
Approved: [**Doctor First Name **] [**2155-4-24**] 4:54 PM
Imaging Lab
There is no report history available for viewing.
.
[**2155-4-24**] ultrasound
IMPRESSION:
1. Limited study with suboptimal visualization of the superior
pole of the
spleen. No focal fluid collection is identified. However, if
clinical concern
persists further evaluation could be obtained with a contrast
enhanced CT
abdomen.
Findings were discussed with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] on [**2155-4-24**] by phone
with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8631**] at 16:00.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 8913**] SUN
Approved: [**Doctor First Name **] [**2155-4-24**] 5:42 PM
.
Brief Hospital Course:
Mr. [**Known lastname 110450**] was admitted to the [**Hospital1 18**] on [**2155-4-9**] via transfer
from [**Hospital **] Hospital. He was taken emergently to the operating
room where he underwent repair of his type A aortic dissection
by way of replacement of his ascending aorta and hemiarch and
replacement of his aortic valve. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
on several drips which include epinephrine, vasopressin,
levophed and milrinone. Mr.[**Known lastname 110450**] required maximum pressor
and inotropic support with continued hypotension and low C.I/
mixed venous O2SATs and elevated lactate. In addition - episodes
of VT occurred and he was placed on amio-lidocaine drips. Over
the next day, he had progressive right heart failure. On
[**2155-4-10**], sustained VT occurred and CPR was required. His chest
was re-opened, washed-out and left open. Aggressive diuresis was
initiated. From a renal standpoint: He was Oliguric with
worsening renal function from 1.2 to 2.4 and severely volume
overloaded. The patient developed acute kidney injury, renal was
consulted and CRRT was initiated.[**2155-4-11**] Electrophysiology was
consulted regarding continued rhythm problems. Amiodarone was
discontinued per EP. Slowly he was weaned off inotropic and
pressor support. No further events of Ventricular tachycardia
occurred. His rhythm did go into paroxysmal Atrial Fibrillation
which was treated with beta-blocker and Amio resumed. On [**4-15**] he
was taken back to the operating room and underwent chest
closure. Paralytics and sedation were discontinued. Mr.[**Known lastname 110450**]
took several days for his mental status to clear. He is
neurologically intact and moves all extremities to verbal cues.
[**4-23**] Thoracic team was consulted for respiratory failure and
ventilator dependence with difficulty weaning. On [**4-25**] Dr. [**First Name (STitle) **]
performed a tracheostomy. Please refer to operative report for
further details. [**4-25**] GI was consulted for possible bleed. Two
days prior his Hct dropped from 32 to 21, received 2 units of
PRBC and HCt increased up to 25.5. When given a 3rd unit, his
Hct remained at 25.4 along with significant melena. CT
abd-pelvis
without contrast was done and didn't reveal retroperitoneal
bleed. An upper endoscopy was performed and 2 duodenal ulcers
were apparant. A vessel required clip placement. Mr.[**Known lastname 110450**]
was placed on PPI drip, Tube feeds held and serial hematocrits
were followed. He remained stable. H. Pylori was negative. He
is to remain on [**Hospital1 **] PPI for 8 weeks, then daily thereafter.
Slow progress continued.
He remains neurologically intact and doing trach collar trials.
Episodes of paroxysmal AFib occur. He remains on Amiodarone. No
anticoagulation has been initiated due to his recent upper GI
bleed. Nutrition with tube feeds was initiated. His renal
function recovered and he makes adequate urine, no longer
requiring CRRT for volume removal. His Creatinine has returned
to 0.8. He was placed on antibiotics for ventilator acquired
pneumonia.
Right sided Pigtail catheter was placed for persistent
pneumothorax. Air evacuated and air-leak resolved. Tube was
discontinued without complication. Follow-up CXR revealed small
left pneumothorax which was stable over days.
The patient received a Passy-Muir valve on [**2155-4-28**]. On [**2155-4-29**]
he received a PEG.
He was noted to have ulcerations on his penis. Wound care was
consulted and recommendations made. If there is no improvement,
urology consult is recommended as an outpatient.
He continues to slowly progress and is discharged to [**Hospital1 69097**] in [**Location (un) **] on POD 23.
Medications on Admission:
Unknown
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheezes.
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QPM (once a day
(in the evening)) as needed for sleep.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
8. lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for mouth pain.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. CefePIME 2 g IV Q12H
thru [**5-5**]
13. Vancomycin 1000 mg IV Q 12H
thru [**5-5**]
14. Furosemide 40 mg IV BID
15. Pantoprazole 40 mg IV Q12H
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
17. potassium chloride 25 mEq Packet Sig: One (1) PO twice a
day.
18. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection four times a day: see attached sliding scale.
19. wound care
Penis/Scrotum:
elevate scrotum and penis on soft towel or pillow case ( fold
several times )
Cleanse wound with wound cleanser then pat dry,
apply aloe vesta as needed to moisturize dry skin,
apply Xeroform dressing to provide antimicrobial coverage and
dry out wounds, no need for gauze and no need to secure in
place, change daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Pavilion - [**Location (un) **]
Discharge Diagnosis:
Type A Aortic Dissection - s/p repair
s/p tracheostomy
s/p upper endoscopy with vessel clipping secondary to Upper GI
bleed
Hypertension
Cataracts
s/p cholecystectomy [**2118**]
s/p bilateral hernia repairs
Discharge Condition:
Alert and oriented x 3
Deconditioned
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Edema 2+ lower extremities, 4+ scrotal edema
penis with necrotic ulcerations- wound care recs attached
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) **] [**2155-6-3**], 1:00pm
Cardiologist: Dr. [**Last Name (STitle) 76338**], [**Telephone/Fax (1) 92020**], [**Location (un) 110451**],
[**Location (un) 1456**] Wed, [**2155-5-28**], 8:45am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 8448**] in [**3-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2155-5-2**]
ICD9 Codes: 5845, 4271, 2760, 2875, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6572
} | Medical Text: Unit No: [**Numeric Identifier 56787**]
Admission Date: [**2119-11-14**]
Discharge Date: [**2119-12-1**]
Date of Birth: [**2058-6-3**]
Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Father [**Name (NI) **] is a 61-year-old
man, with known CAD, status post coronary artery bypass graft
on [**2119-10-31**] with a LIMA to the LAD, saphenous vein graft to
OM1, saphenous vein graft to D1, and saphenous vein graft to
PDA. The patient was discharged home on [**11-5**], and returns
on the day of admission complaining of sternal drainage x
several days with increasing amounts on the day of admission.
The patient denies fever, chills, nausea, vomiting, or
malaise.
PAST MEDICAL HISTORY: CAD, status post CABG with an EF of 20
percent.
Diabetes mellitus, currently insulin dependent.
Hypercholesterolemia.
GERD.
ALLERGIES: None.
MEDS ON ADMISSION:
1. Colace 100 mg [**Hospital1 **].
2. Aspirin 81 mg once daily.
3. Plavix 75 mg once daily.
4. Carvedilol 6.25 mg [**Hospital1 **].
5. Simvastatin 40 mg once daily.
6. Lasix 40 mg [**Hospital1 **].
7. Lantus insulin 45 units q pm.
8. Percocet 5/325, 1-2 tabs q 4 h prn.
LABS ON ADMISSION: White count 18.6, hematocrit 33.9,
platelets 893, PT 17.5, PTT 24, INR 1.1, sodium 139,
potassium 4.2, chloride 101, CO2 25, BUN 14, creatinine 0.9,
glucose 246. Chest x-ray shows cardiomegaly with left-sided
effusion with atelectasis, multiple displaced wires. EKG:
Sinus rhythm with a rate of 100, Q's in III and AVF,
nonspecific ST changes with poor R wave progression.
PHYSICAL EXAM: Temperature 103, heart rate 116--sinus
tachycardia, blood pressure 100/47, respiratory rate 30, O2
sat 97 percent on 2 liters nasal prongs. Neuro: Alert and
oriented x 3, moves all extremities, follows commands,
nonfocal exam. Respiratory: Clear to auscultation with a
sucking chest wound. Cardiovascular: Regular rate and
rhythm. Sternum with surrounding erythema of about 10 cm,
with a positive click. Small draining hole in midincision
with milky serous drainage. Staples remain in place.
Abdomen is soft, nontender, nondistended with normoactive
bowel sounds. Extremities are warm and well-perfused with no
edema. Right calf with a healing wound and minimal erythema.
Left knee with an endoscopic site that is healing, open to
air, clean and dry.
HOSPITAL COURSE: The patient was admitted to the
Cardiothoracic Intensive Care Unit. He was begun on
vancomycin 1 gm q 12 h, as well as levofloxacin 500 mg once
daily. He was typed and screened and kept NPO for
mediastinal exploration plus/minus a flap closure.
On hospital day 2, the patient was brought to the operating
room. Please see the OR report for full details. In
summary, the patient had a sternal exploration and
debridement. He tolerated the operation well and was
returned to the Cardiothoracic Intensive Care Unit intubated
and sedated with an open chest wound. Plastic surgery was
also following the patient.
The patient did well in the immediate postoperative period.
His anesthesia was reversed. He was weaned from the
ventilator and successfully extubated. Several hours
following extubation, the patient was found to be in acute
respiratory distress and was emergently reintubated. From
that point forward, he was kept sedated and ventilated
awaiting plastics follow-up for flap closure.
On the [**11-19**], the patient returned to the operating
room. Please see the OR report for full details. In
summary, the patient was brought to the operating room by the
plastic surgery service for pectoral advancement with an
omentum flap. He tolerated the operation well and was
returned to the Cardiothoracic Intensive Care Unit. The
patient remained intubated following his surgery. However,
his sedation was minimized to allow the patient to
overbreathe the ventilator. During that period, the patient
had several episodes of coughing which led to a dehiscence of
his abdominal incision, and on the [**11-20**] the patient
again returned to the operating room for re-exploration and
closure of the fascia of his abdominal wound. He tolerated
this surgery well also and following that returned to the
Cardiothoracic Intensive Care Unit, again ventilated and
sedated. The patient remained ventilated and sedated for the
next several days in an attempt to give the wound a chance to
heal.
Ultimately, the patient was successfully extubated on the [**11-24**]. However, he stayed in the Cardiothoracic
Intensive Care Unit following extubation for close pulmonary
monitoring. It should be noted that during the patient's ICU
course, he had several intermittent episodes of atrial
fibrillation for which he was begun on amiodarone, as well as
heparin and ultimately Coumadin for anticoagulation. The
patient did well over the next several days, and ultimately
was transferred to the floor on [**11-28**], hospital day 15,
postoperative day 13. At that point, a PICC line was placed
for long-term antibiotic coverage.
Over the next several days, the patient's activity level was
increased with the assistance of the nursing and the physical
therapy staff. His antibiotic coverage was continued. His
anticoagulation was transitioned from intravenous to oral.
Finally, on the [**12-1**], the patient's final [**Location (un) 1661**]-
[**Location (un) 1662**] drain was removed from his chest, and it was decided
that he was stable and ready to be transferred to
rehabilitation for long-term antibiotic coverage, as well as
glucose control.
At that time, the patient's physical exam was as follows:
Vital signs: Temperature 98.4, heart rate 82--sinus rhythm,
blood pressure 113/66, respiratory rate 18, O2 sat 95 percent
on room air, weight day of dictation 106.6 kg, preoperatively
100 kg. Lab data: PT 17.1, INR 1.9, sodium 139, potassium
3.7, chloride 100, bicarb 27, BUN 11, creatinine 0.9, glucose
149, white count 9.1, hematocrit 28.4, platelets 830.
Physical exam - Neurologically: Alert and oriented x 3,
nonfocal exam. Pulmonary: Clear to auscultation
bilaterally. Cardiac: Regular rate and rhythm, S1, S2.
Sternum: Incision with staples, clean and dry. No erythema
or drainage. Abdomen was soft, nontender, nondistended with
normoactive bowel sounds. Abdominal incision with staples,
also clean and dry. Extremities were warm with no edema.
Right saphenous vein graft harvest site was healing well,
open to air, clean and dry.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass grafting complicated by sternal
infection requiring sternal debridement and flap closure.
Diabetes mellitus.
Hypercholesterolemia.
Gastroesophageal reflux disease.
FOLLOW UP: Follow-up with Dr. [**Last Name (STitle) 13797**] with plastic surgery
service in 1 week. He is to call for an appointment at [**Telephone/Fax (1) 56789**]. He is also to have follow-up with Dr. [**Last Name (STitle) **] in 4
weeks. The patient is also to call for that appointment; the
number is [**Telephone/Fax (1) 170**].
DISCHARGE MEDICATIONS:
1. Ranitidine 150 mg [**Hospital1 **].
2. Simvastatin 40 mg once daily.
3. Ferrous sulfate 325 mg once daily.
4. Ascorbic acid 500 mg [**Hospital1 **].
5. Zinc sulfate 220 mg once daily.
6. Aspirin 81 mg once daily.
7. Erythromycin ophthalmic ointment [**Hospital1 **].
8. Colace 100 mg [**Hospital1 **].
9. Metoprolol XL 100 mg once daily.
10.Glargine 24 units q at bedtime.
11.Humalog insulin sliding scale q ac and at bedtime.
12.Lasix 20 mg once daily.
13.Potassium chloride 20 mEq once daily.
14.Amiodarone 400 mg [**Hospital1 **] x 1 week, then 400 mg once daily x 1
week, then 200 mg once daily.
15.Oxacillin 2 grams q 4 h through [**12-28**].
16.Warfarin as directed to maintain a target INR of 2 to 2.5.
The patient's warfarin doses starting with 4 days ago - 3 mg,
5 mg, 5 mg, 5 mg. The patient is to receive 4 mg on the [**2032-11-29**].Albuterol 2 puffs qid prn.
DISPOSITION: The patient is to be discharged to
rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2119-12-1**] 13:31:57
T: [**2119-12-1**] 14:15:12
Job#: [**Job Number 56790**]
ICD9 Codes: 5185, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6573
} | Medical Text: Admission Date: [**2129-12-2**] Discharge Date: [**2129-12-6**]
Date of Birth: [**2078-8-16**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Headache and spinning
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 50483**] is a 51 yo right handed man who presents as a
transfer from [**Hospital **] hospital or evaluation of a subacute
cerebellar infarct. The patient states that his symptoms began
sometime on Tuesday. At that time he noted what he called a
"computer headache" which was dull, mostly in his left temple.
It was constant but not significantly painful. This continued
into Wednesday when around noon, he noted a second pain which
started below his left ear. This was again a dull pain, and the
patient thought he was developing an ear infection. He had no
other symptoms at that time and he continued his normal daily
routine which included going to his psychiatry appointments for
him and his daughter. Wednesday evening, he recalls eating ice
cream, taking his Requip and going to bed. At around 8:45pm, he
rolled from his right to his left and had the sudden onset of
uncontrollable spinning. He felt as though he was free-falling
and he needed to hold on to the bed. He felt as though he had
to
fight to maintain consciousness. He wanted to call for his
daughter who was across the [**Doctor Last Name **], but he couldn't speak
secondary to the fear of vomiting if he opened his mouth. He
began sweating profusely. He believes his symptoms lasted for
nearly 10 minutes and then they stopped, as quickly as they
came.
He was able to fall asleep without difficulty. The following
morning, he felt "fuzzy" and the symptoms from the night before
where somewhat fluttering in the background. When he went to
get
out of bed, he again noted slight room spinning. He reclined on
the bed for a few minutes and it passed. He was able to get up
and drive to work. Over the course of the morning, the patient
began to experience worsening head pain- the headaches he had
previously (the left temple, behind the ear), now seemed
confluent and the quality changed. It was now a sharp pain
which
was predominantly behind his left eye. At worse, the pain was a
[**2129-6-20**]. He called his PCP and was seen in the afternoon- at
that
point the doctor was wondering he had Meniere's disease. He was
started on meclizine and Fioricet as well as ear drops. He was
told to go to the emergency room if his symptoms did not
improve.
At 5:45, the patient was getting ready to go to a parent
teacher's meeting when he felt his symptoms were getting worse
and it was at this point he went to [**Hospital **] hospital for
evaluation.
On arrival to [**Hospital1 **], vitals were T98.3, HR 102, BP 125/85,
RR16, 110% on RA. He was given Percocet for pain and a CT of
the
head was performed which showed a subacute left inferior
cerebellar infarct as well as an old right BG lacunar. He was
given an aspirin and referred to [**Hospital1 18**] for further workup.
At this time, the patient continues to have significant left
sided face and neck pain. He feels congested. He denies any
additional vertigo. He does feel as if his hearing is less
sharp, describing a shallow quality to sounds in his left ear.
He also notes a strange background noise like a faucet running
off in the distance. He has pain in his neck when he brings his
chin to his chest and pain in his eyes when he looks to his far
left. Otherwise, neurologic review of systems was negative for
dysarthria, dysphagia, difficulties producing or comprehending
speech, focal weakness, numbness, parasthesiae, bowel or bladder
incontinence or retention. He notes he has been walking
cautiously out of fear that he might have vertigo, but he has
been able to ambulate without falling.
On general review of systems, the patient denied recent fever or
chills. He has no history of trauma, he denies lifting heavy
weights. He denied cough, shortness of breath, chest pain,
tightness or palpitations. Denied changes in bowel or bladder
habits. No dysuria. Denied arthralgias or myalgias. His wife
reports significant stress as the patient just recently returned
to work after 1 year. His wife was just recently diagnosed with
MS
and they have a daughter with significant behavioral issues.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Restless Limb Syndrome
-Heart Murmur
-Depression/ADD
-Sleep Apnea, s/p ulectomy, tonsillectomy [**2111**] prescribed but
does not use CPAP
-s/p ALIF of the spine (?Lumbar -s1) on [**10/2128**], complicated by
an abdominal seroma which required drainage.
-s/p right medial meniscus repair [**2109**]
per the medical record, also hx of positive PPD
Social History:
Mr. [**Known lastname 50483**] is married, has 2 daughters. [**Name (NI) **] works as a
professional housekeeper/maintenance. Just recently began
working for Environmental Services for a convent. He is
catholic. He smokes [**1-15**] PPD for 35 years. He denies alcohol
use. He occasionally smokes marijuana and last Friday he did do
several lines of cocaine (he had not used cocaine in many
years).
Family History:
Father- small cell adenocarcinoma of the lung
Brother- small cell adenocarcinoma of the lung just diagnosed
Mother- Hypertension, Depression
M.[**Name (NI) **] MI
Sister- cerebral aneurysm (not ruptured)
Family history of carotid disease
Physical Exam:
T 98.0 BP 114/80 HR 99 99 O2%
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormalities, no scleral icterus
though slightly injected. MMM. no lesions noted in oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity,
no paraspinal tenderness.
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm, [**3-19**] harsh SEM appreciated
throughout the precordium but best at RUSB.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: 2+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Speech was not dysarthric (though the
patient
was missed several teeth). Good knowledge of current events.
There was no evidence of apraxia or neglect, calculations
intact.
Registered [**3-16**] and recalled [**3-16**] at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. Visual fields full on bedside
testing with red pin. Funduscopic exam revealed sharp discs
bilaterally.
III, IV, VI: EOMI with nystagmus on bilateral horizontal gaze,
with larger amplitude on left [**Hospital1 **] gaze. Consistent overshoot on
saccadic movements to the left.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Possible subtle right
pronator drift. No rigidity. No adventitious movements, such as
tremors, noted. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout. Notes a mild decrease- 10%
less
then right- in pinprick in the left hand compared to right, only
affecting the dorsum of the hand to about the wrist. No
extinction to double simultaneous stimuli.
-Deep tendon reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF. Possible mild ataxia of the left leg on
HKS
testing.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Difficulty testing tandem gait has patient was in pain
when standing. Romberg initially stable but then patient with
sudden eye opening and slight [**Last Name (un) 50484**] to the left.
Pertinent Results:
[**2129-12-2**] 06:42AM TRIGLYCER-227* HDL CHOL-35 CHOL/HDL-5.3
LDL(CALC)-107
[**2129-12-2**] 02:16AM %HbA1c-5.9 eAG-123
MR head [**2129-12-3**]
IMPRESSION: Acute left cerebellar infarct with patent flow voids
of the
vertebral arteries and basilar artery. The medulla is not
involved. No
hydrocephalus or mass effect on the fourth ventricle.
CTA [**12-2**]
1. Left cerebellar stroke which may be acute/subacute.
2. No contrast opacification seen in the V1/V2 segment of the
left vertebral
artery indicating segmental occlusion. The underlying etiology
may be
dissection or atherosclerotic disease.
3. Extensive atherosclerosis and more than 50 to 60 % stenosis
of the right
internal carotid and 60 to 70 % stenosis of the left internal
carotid artery.
4. Apical fibrosis and bullous change predominantly on the
right.
Correlation with clinical history of smoking and further imaging
may be
performed as per clinical need.
Brief Hospital Course:
Mr. [**Known lastname 50483**] is a 51 yo right handed man with a history
ofvascualar risk factors including hypertension,
hyperlipidemia(poor compliance with treatment) and smoking who
present with progressively worsening left sided facial pain and
an episode of
extreme vertigo a little more than 24 hours ago. He underwent a
head CT at [**Hospital **] hospital which identified a subacute left
inferior cerebellar infarct without evidence of hemorrhage.
Repeat imaging here shows a stable infarct with minimal
effacement of the 4th ventricle. CTA demonstrates lack of flow
of the left vertebral artery at V1-V2 concerning for
atherosclerotic disease or dissection. Given his extensive
atherosclerosis in the extracranial carotids and given the
location of the left vertebral artery occlusion, it was thought
that the most likely cause of the left vertebral occlusion was
atherosclerosis.
The patient's exam is remarkably intact but is notable for
bilateral horizontal gazed evoked nystagmus with a more
prominent amplitude on leftward gaze as well as mild overshoot
when testing saccadic movements to the left. There may also be
a very ataxia of the left leg compared to the right on HKS
testing and an even more subtle right pronator drift, the latter
being inconsistent on multiple trials. The patient has no
history of trauma, no family history of vascular
abnormalitis/dissections which could have contributed to his
presentation. Given the cerebellar infarct and concern for
continued edema, we did the following:
Patient was admitted to the Neuro ICU for monitoring of
swelling. Patient was started on heparin and bridged to
coumadin. Patient has remained stable with normal exam. Heparin
was continued until coumadin was therapeutic at INR 2.2 on
[**2129-12-6**].
He should have repeat MRI brain imaging/MRA brain and MRA neck
imaging at 2.5 months.
Will consider switching him from coumadin to an anti-platelet
[**Doctor Last Name 360**] at that time.
CARDIOVASCULAR: Patient was allowed to autoregulate, initially
held lisinopril. and gave hydralazing for SBP >185. Bed was
kept <30 degrees. Restarted Lisinopril to lower dose on
discharge.
FEN: Patient was swallowing without difficulty and therefore
diet, was advanced.
HEME: LDL 106 Patient was inconsistently taking his simvastatin.
Will advise to continue on 40 mg daily and recheck with PCP for
[**Name Initial (PRE) **] goal of less than 70. Patient was started on heparin to
prevent extension of the clot, and bridged to a therapeutic INR.
ENDO: For glucose control patient was kept on SS insulin.
HgBA1c was 5.9
Psych: He was strongly advised to never use cocaine again.
Concerta was stopped because it is a risk factor for ischemic
stroke.
Medications on Admission:
Lisinopril 40mg daily
Requip 2mg 1 hour prior to sleep
Fluoxetine 60mg daily in AM
Concerta 54mg daily in AM
Simvastatin 40mg (does not take regularly)
Percocet PRN for back pain
Discharge Medications:
1. ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
2. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Left cerebellar infarct and left vertebral artery stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after developing severe headache and found to
have left cerebellar infarct and left vertebral artery stenosis
concerning for dissection. Given the large infarct, you were
initially admitted to the intensive care unit. You continued to
improve and were transferred to the neurology floor.
You underwent MRI of the brain which was consistent with the CT
head showing left cerebellar stroke in the left PICA
distribution. Given the stroke and the vertebral artery
stenosis, you were started on heparin and Coumadin. You were
continued on the heparin which was discontinued on the day of
your discharge when you INR was found to be therapeutic.
You will need daily INR checks per your PCP. [**Name10 (NameIs) **] spoke with the
office manager who said you can walk in Monday through Friday
for checks. [**Telephone/Fax (1) 50485**]
Medications changed
1. Started Warfarin 5 mg every night (have INR checked daily -
and then monitored by PCP)
2. decreased Lisinopril to 10 mg daily
3. Stopped Concerta
Followup Instructions:
Please follow-up with your primary care doctor within ~2 weeks
of discharge.
You are scheduled to see Dr. [**Last Name (STitle) **], neurologist who oversaw
your care during this admission:
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2130-1-11**] 3:00
[**Hospital Ward Name 23**] Building, [**Hospital1 18**] [**Location (un) 858**]
Completed by:[**2129-12-6**]
ICD9 Codes: 3051, 311, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6574
} | Medical Text: Admission Date: [**2116-3-22**] Discharge Date: [**2116-5-8**]
Date of Birth: [**2057-12-26**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Cefazolin / Nelfinavir / Morphine / vancomycin
/ Nafcillin
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
upper back/neck pain
Major Surgical or Invasive Procedure:
Mechanical Intubation
HD line insertion
Arterial Line Insertion
History of Present Illness:
Ms. [**Known lastname 11182**] is a 55 yo f with HIV ([**2-13**] CD4 375), [**Month/Year (2) **]
[**Month/Year (2) 106114**] pneumonitis, pulmonary HTN, ESRD on HD,
cardiomyopathy and emphysema on O2 at home who presents with 2
weeks of cough and increased SOB, and 3 days of upper back/neck
pain. She is more concerned about the back pain than the cough,
which did not bother her too much. She denies F/C at home. She
has produced some sputum; is on 3L home O2 at baseline. Last
rec'd HD on [**3-20**].
As to her back pain, it started gradually 3 days PTA, and is
located around her b/l shoulders, neck, and part of her L arm.
No trouble holding objects or moving the L arm. No h/o lifting
heavy objects or trauma. No lower back pain or trouble walking.
No photophobia although she says she has cataracts. Endorses HA
that she has had for 2 weeks or so, b/l frontal HA. She tried
using [**Doctor First Name **]-gay for her shoulders to no avail.
.
In the ED, initial vitals were 102.4, 116, 113/81, 20, 99% 4L .
Fiven Levaquin, was wheezing on arrival, received nebulizers and
prednisone, with improvement of wheezing. Given her significant
comorbidities, admitted to medicine for pneumonia. Got Tylenol,
also Percocet for chronic back pain.
.
Currently, she c/o persistent upper back/neck pain. No vomiting,
dysuria, diarrhea. Is hungry.
Past Medical History:
-HIV ([**2-13**] CD4 375)
-ESRD on HD MWF
-HTN
-severe Pulmonary HTN
-Cardiomyopathy [**12-10**] LVEF 31%, severe MR/TR
-[**Month/Year (2) 106113**] [**Month/Year (2) 106114**] pneumonitis (LIP) followed by Dr. [**Last Name (STitle) **]
[**Last Name (STitle) **] at [**Hospital1 2177**] ([**Telephone/Fax (1) 7799**] #6564
-anemia of chronic disease
-AVNRT diagnosed at [**Hospital1 2177**]
-Recent vaginal bleed s/p conization
-HCV - untreated
-Asthma/COPD on home O2
-h/o [**Hospital1 8974**] bacteremia and vertebral osteomyelitis
PAST SURGICAL HISTORY
-C-section
-R knee surgery
-Ovarian cysts removed
Social History:
She lives in [**Location 669**] with her 18 year old son. She has three
sons and one daughter.
Currently smokes a few cigarettes every few days. She has a
30-40 pack year smoking history.
Has used "every drug" including cocaine. Last drug use was
"eight years ago). She has never used IV drugs.
She has a history alcohol abuse and has not drank in many years.
Family History:
Her mother is living in her 70s and had a stroke, hypertension
and diabetes. Her uncle died of kidney disease. She never met
her father. [**Name (NI) **] sister was killed in a motor vehicle crash. Her
children are healthy. Her daughter has a single kidney.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 99.2, 115, 101/69, 24, 95% 3L NC
GEN: in NAD, resting in bed. alert. responds appropriately to
questions.
HEENT: PERRl, OP clear, MMM
CV: RRR, could not appreciate murmurs; tachycardic
PULM: CTAB but decreased breath sounds throughout
ABD: umbilical hernia, normal BS, no tenderness to palpation,
soft.
EXT: no clubbing or cyanosis, 1+ edema b/l. 1+ pedal pulses
Skin: diffuse dry and flaky skin on trunk, arms, scalp and less
so on legs.
Neuro: A/O x 3; CN2-12 intact b/l, strength 5/5 throughout b/l
.
DISCHARGE PHYSICAL EXAM:
Tcurrent: 36.7 ??????C (98 ??????F)
HR: 119 (104 - 125) bpm
BP: 124/55(70) {72/29(45) - 124/67(75)} mmHg
RR: 17
SpO2: 97% on 3LNC
GENERAL - Chronically ill appearing, no acute respiratory
distress at the time of my exam
HEENT - PERRL, EOMI, sclera icteric, Dry mucous membranes with
and cracked lips, OP clear, wrapped pressure ulcer on occiput.
NECK - supple, no [**Doctor First Name **] no thyromegaly, no JVD, no carotid bruits,
left IJ with mild oozing of blood but site non-tender, area of
soft fullness slightly larger to area on corresponding side and
disappears when she lays flat
LUNGS - Coarse breath sounds and crackles b/l, reasonable
movement throughout
HEART - Tachycardic, nl S1 S2 clear and of good quality, RR
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, soft but palpable peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact. Denies
sensation of her feet and decreased sensation of her lower legs,
describes burning sensation in her hands, diminished strength
but function grossly.
Pertinent Results:
ADMISSION LABS:
.
[**2116-3-22**] 03:00AM BLOOD WBC-6.2# RBC-3.95* Hgb-11.4* Hct-36.4
MCV-92 MCH-28.8 MCHC-31.3 RDW-17.7* Plt Ct-65*
[**2116-3-22**] 03:00AM BLOOD Neuts-73.8* Lymphs-22.7 Monos-2.4 Eos-0.7
Baso-0.4
[**2116-3-23**] 06:25AM BLOOD ESR-36*
[**2116-3-22**] 03:00AM BLOOD Glucose-95 UreaN-23* Creat-7.4*# Na-137
K-7.3* Cl-101 HCO3-26 AnGap-17
[**2116-3-23**] 06:25AM BLOOD ALT-14 AST-26 AlkPhos-139* TotBili-0.6
[**2116-3-22**] 03:00AM BLOOD cTropnT-0.05*
[**2116-3-22**] 03:00AM BLOOD proBNP-[**Numeric Identifier **]*
[**2116-3-23**] 06:25AM BLOOD Calcium-7.9* Phos-2.3*# Mg-1.7
[**2116-3-23**] 06:25AM BLOOD CRP-38.1*
[**2116-3-23**] 08:49AM BLOOD Lactate-1.9
[**2116-3-24**] 11:23AM BLOOD Lactate-1.1
[**2116-3-23**] 08:49AM BLOOD Type-ART pO2-111* pCO2-43 pH-7.38
calTCO2-26 Base XS-0
[**2116-3-24**] 11:23AM BLOOD Type-ART pO2-96 pCO2-48* pH-7.44
calTCO2-34* Base XS-6
.
DISCHARGE LABS:
.
[**2116-5-8**] 04:05AM BLOOD WBC-4.9 RBC-2.60* Hgb-7.8* Hct-27.3*
MCV-105* MCH-30.0 MCHC-28.6* RDW-21.4* Plt Ct-92*
[**2116-5-8**] 04:05AM BLOOD Glucose-105* UreaN-18 Creat-3.1*# Na-137
K-3.8 Cl-98 HCO3-31 AnGap-12
[**2116-5-8**] 04:05AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.9
[**2116-5-7**] 04:17AM BLOOD Type-MIX pO2-178* pCO2-61* pH-7.30*
calTCO2-31* Base XS-2 Comment-GREEN TOP
.
PERTINENT MICRO/PATH:
BLOOD CULTURES:
[**2116-3-22**]: 3 of 3 sets positive as below
[**2116-3-23**]: 1 of 1 set positive as below
Dates [**2116-3-24**] - [**2116-5-2**]: 17 of 17 sets negative
.
[**2116-3-22**] 3:00 am BLOOD CULTURE
Blood Culture, Routine (Final [**2116-3-30**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
BACTRIM (=SEPTRA=SULFA X TRIMETH) sensitivity testing
confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
DOXYCYCLINE AND RIFAMPIN SENSITIVITIES REQUESTED BY
[**First Name4 (NamePattern1) 2482**]
[**Last Name (NamePattern1) **],[**2116-3-28**].
SENSITIVE TO DOXYCYCLINE , sensitivity testing
performed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- =>16 R
.
ABSCESS CULTURE:
[**2116-3-25**] 10:30 am ABSCESS NECK/ABSCELL FOR CULTURE. STAPH AUREUS
COAG +
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- =>16 R
.
PREVERTEBRAL TISSUE CULTURE: STAPH AUREUS COAG +
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- =>16 R
.
ANAEROBIC CULTURE (Final [**2116-3-29**]): NO ANAEROBES ISOLATED.
.
BAL Culture [**2116-4-17**]: No growth, negative for PCP
.
PICC Tip Cx:
[**2116-4-8**]: No growth
[**2116-4-21**]: No growth
.
HIV VL [**2116-3-26**]: 183 copies
.
RPR [**4-20**]: Non-reactive
.
MRSA SCREEN [**3-24**] & [**4-13**]: Negative
.
SPUTUM:
[**4-5**]: PSEUDOMONAS AERUGINOSA
AMIKACIN-------------- 8 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
.
[**4-6**]: PSEUDOMONAS AERUGINOSA
AMIKACIN-------------- 16 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
.
[**4-15**]:PSEUDOMONAS AERUGINOSA
AMIKACIN-------------- <=2 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ 8 I
.
[**4-16**]: PSEUDOMONAS AERUGINOSA
AMIKACIN-------------- S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ 8 I
.
[**5-5**]: LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA
ISOLATED.
.
STOOL:
[**3-29**]: Cdiff Negative
[**4-30**]: Cdiff Negative
.
PATHOLOGY:
OR SPECIMEN OF PREVERTEBRAL TISSUE: [**2116-3-25**]
DIAGNOSIS:
1. Prevertebral tissue, excision (A):
A. Fibrocartilage with focal acute and chronic inflammation and
necrosis. See note.
B. Fragments of bone.
2. Intervertebral disc, C4-C7, excision (B):
A. Fibrocartilage with degenerative change and crushed cells,
cannot exclude inflammatory cells.
B. Fragments of bone.
.
IMAGING STUDIES:
-CARDIOLOGY:
TTE [**3-26**]:
IMPRESSION: no echo evidence of endocarditis. Relatively small,
hyperdynamic, left ventricle. Dilated and hypokinetic right
ventricle with moderate to severe pulmonary hypertension. Mild
mitral and moderate tricuspid regurgitation.
.
Compared with the prior study (images reviewed) of [**2114-4-16**],
the degree of mitral regurgitation has increased. The right
ventricle appears similar - moderately dilated with mild
hypokinesis. The degree of tricuspid regurgitation has
increased. Left ventricular function is more hyperdynamic on the
current study.
.
TTE [**4-16**]:
IMPRESSION: No echocardiographic evidence of endocarditis.
Cannot exclude due to suboptimal image quality. Normal regional
left ventricular systolic function. Mildly dilated and mildly
hypokinetic right ventricle. If clinically indicated, a
transesophageal echocardiogram may better assess for valvular
vegetations.
.
Compared with the prior study (images reviewed) of [**2116-3-26**],
pulmonary artery pressures could not be estimated on the current
study. The other findings are similar.
.
RADIOLOGY:
-[**2116-3-22**] CXR:
IMPRESSION: Overall similar appearance of mild [**Month/Day/Year 106114**]
edema and
bibasilar scarring and/or atelectasis. Correlate clinically for
possibility
of early infection. No radiographic evidence of confluent
consolidation.
.
-[**2116-3-23**] C-spine MRI:
IMPRESSION:
1. C4-5: Marked narrowing of the disc space, with kyphosis and a
disc
osteophyte complex indenting the thecal sac with
mild-to-moderate canal
stenosis. Multilevel foraminal narrowing as described above. New
small area of increased signal intensity in the C6-C7
intervertebral disc,
-?edema/inflammation/infection.
2. Extensive pre, paravertebral and retropharyngeal T2
hyperintense signal
which relates to fluid with or without abnormal enhancement from
inflammation or infection. Assessment is limited given the lack
of post-contrast images. This is seen to extend from the level
of the clivus extending into the thorax, lower limit is not
included. There is also mild increased signal intensity in the
lateral atlantoaxial joints.
.
[**2116-3-23**] C-spine CT:
IMPRESSION:
1. Findings consistent with C6-7 discitis/osteomyelitis with 1.4
x 1.0- cm
prevertebral abscess anterior to C6 vertebral body. Massive
likely reactive prevertebral effusion/phlegmon spanning the
entire extent of cervical spine without rim enhancement.
2. Evaluation of epidural space is highly limited on CT. When
patient able, recommend repeat MRI with gadolinium for further
assessment of the epidural space and cord.
3. Prior C4-5 osteomyelitis with disc space destruction and
fusion of
vertebral bodies with mild 3 mm retropulsion of posterior
inferior corner of C4, narrowing the canal at this level.
4. Medialization of internal carotid arteries, which are
immersed within the prevertebral fluid/phlegmon. Vascular
structures appear patent at this time.
5. Right maxillary mucosal disease.
6. Emphysema and evidence of mild [**Month/Day/Year 106114**] edema.
.
-[**2116-3-23**] T and L-spine CT:
IMPRESSION:
1. Known large prevertebral fluid collection does not extend
below
cervicothoracic junction.
2. No definite CT evidence of acute process within the thoracic
and lumbar
spine.
3. Multilevel degenerative disease, worst at L4-5.
4. Precarinal adenopathy and splenomegaly, which may be related
to HIV
status.
5. Pulmonary arterial hypertension.
6. Small bilateral pleural effusions.
7. Moderate centrilobular emphysema with mild fluid overload.
.
CT Abdomen/Pelvis [**3-26**]:
1. Cirrhosis, ascites, and splenomegaly.
2. Renal atrophy and multiple hypodense lesions, consistent with
cysts in
keeping with prior ultrasound.
3. Cholelithiasis.
4. Bilateral adnexal cystic lesions, which should be evaluated
by pelvic
ultrasound.
.
Liver/Gallbladder U/S [**3-26**]:
1. Coarse nodular liver, consistent with underlying chronic
liver disease
with findings of portal hypertension. No definite hepatic
lesion, though
periphery of the liver was incompletely evaluated.
2. No intra- or extra-hepatic biliary ductal dilatation.
3. Bilateral pleural effusions and moderate ascites.
4. Stable splenomegaly.
.
CXR ([**2116-3-27**]):
1. Moderate pulmonary edema, not significantly changed since
[**2116-3-26**].
2. Moderate bilateral pleural effusions, slightly increased
since prior.
3. Left lung base consolidation, likely atelectasis.
.
CT Neck/Spine ([**2116-3-31**]):
1. The small residual fluid collection in the cervical spine
does not extend below the cervicothoracic junction. No acute
abnormality identified in the thoracic spine.
2. Bilateral pleural effusions, increased in size compared to
[**2116-3-23**].
.
CXR ([**2116-4-1**]):
1. Interval placement of left subclavian line with tip at the
mid to distal SVC. Right-sided PICC line in right atrium is
withdrawn 3 cm to terminate at the cavoatrial junction.
2. Nasogastric tube with side port at GE junction could be
advanced 3-4 cm.
3. Significantly worsened pulmonary edema with worsened
bilateral pleural
effusions.
.
CXR ([**2116-4-3**]):
Lung volumes have improved, and mild pulmonary edema has
decreased. Small
right pleural effusion, moderate cardiomegaly and generalized
pulmonary
vascular congestion persist. Tracheostomy tube in standard
placement.
Dual-channel left subclavian catheter ends in the mid SVC and a
right PICC
line extends to or just beyond the superior cavoatrial junction.
.
CXR ([**2116-4-5**]):
There are low lung volumes. Cardiomegaly is stable. There is
improved
aeration in the lower lobes bilaterally. Small bilateral pleural
effusions
have decreased. Lines and tubes are in unchanged position
including a right central catheter with tip in the upper right
atrium. There are no new lung abnormalities or evident
pneumothorax. There is mild vascular congestion. Rounded
opacities in the right upper lobe could be due to vessels on end
and/or lung nodules. Attention in followup studies is
recommended, and if they are truly lung nodules they will be
suspicious for septic emboli.
.
CXR ([**2116-4-8**]):
Improved bibasilar atelectasis with improved lung volumes.
Unchanged mild pulmonary edema.
.
RUQ U/S [**2116-4-13**]:
IMPRESSION:
1. Nodular liver consistent with the patient's known cirrhosis
with portal
hypertension signs that include splenomegaly and ascites.
2. Cholelithiasis without signs of cholecystitis.
3. No evidence of intra- or extra-hepatic biliary duct
dilatation.
4. Right adnexal cyst for which a dedicate pelvis US or MR are
recommended.
.
CTA CHEST [**2116-4-16**]:
IMPRESSION:
1. No pulmonary embolism or aortic pathology. No focal
opacification
concerning for pneumonia.
2. Malignant course of the right coronary artery that is seen
passing between the aorta and pulmonary artery, but is not
definitively seen arising from the left coronary sinus.
3. Bilateral pleural effusions, both small right greater than
left.
Findings consistent with provided history of [**Month/Day/Year **]
[**Month/Day/Year 106114**]
pneumonitis as well as background emphysematous changes.
4. Partially imaged perihepatic ascites.
5. Soft tissue swelling evident in the anterior tissues of the
neck, similar to [**3-31**] neck CT.
.
CT CHEST Non-Con [**4-21**]:
IMPRESSION:
1. Small bilateral pleural effusions, right larger than left,
are increased in size from [**2116-4-16**]. RLL consolidation very
little aerated right lower lobe due to a combination of
atelectasis and pneumonia has also worsened in the last 5 days.
2. Atelectasis or scarring in the lingula and left lower lobe is
unchanged.
3. Mild centrilobular emphysema is unchanged. Right thin-walled
cysts are
compatible with provided history of [**Year (4 digits) **] [**Year (4 digits) 106114**]
pneumonitis,
though not to the degree expected for this diagnosis.
4. Increased perihepatic ascites since [**2116-4-16**].
.
RUE U/S & Doppler [**4-21**]:
IMPRESSION: Non-occlusive thrombus (DVT) seen surrounding the
PICC line
within one of the two brachial veins.
Findings of non-occlusive thrombus were noted at 2:00 p.m. on
[**2116-4-21**] and conveyed by telephone to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 106124**] at 2:48 p.m. on the same day.
.
CT Torso with Contrast [**2116-5-3**]:
IMPRESSION:
1. Stable to minimally improved right lower lobe consolidation.
2. Bilateral pleural effusions and small pericardial effusion.
3. Cholelithiasis.
4. Multiple renal hypodensities lesions incompletely
characterized in this
study, previously noted to represent cysts.
5. Right adnexal cystic lesion, for which pelvic ultrasound is
recommended.
6. Cirrhosis, ascites, and splenomegaly with splenic varices
consistent with portal hypertension.
7. Nonspecific ileal thickening which may represent sequelae of
portal
hypertension.
.
Brief Hospital Course:
Ms. [**Known lastname 11182**] is a 55 yo f with HIV ([**2-13**] CD4 375), [**Month/Year (2) **]
[**Month/Year (2) 106114**] pneumonitis, pulmonary HTN, ESRD on HD,
cardiomyopathy and emphysema on O2 at home admitted for [**Month/Year (2) 8974**]
sepsis from a prevertebral abscess s/p anterior discetomy with a
hospital course complicated by pseudomonal pneumonia, multiple
intubations, and 40+ day MICU stay.
.
ACTIVE ISSUES:
.
# [**Month/Year (2) 8974**] Sepsis from Prevertebral Abscess s/p Anterior Cervical
Diskectomy: Patient was found to have blood cultures positive
for [**Month/Year (2) 8974**] on [**3-22**] so she was initially started on daptomycin due
to potential allergy to vancomycin but then switched to
nafcillin, cefepime, and flagyl for broad coverage. Source was
felt to be prevertebral fluid collection noted on CT of the neck
on [**3-23**]. She triggered on the floor for hypotension with SBP 80
which was initially fluid responsive but eventually persisted
despite boluses so she was transferred to the ICU for further
management. After discussion between ENT, ortho spine, and
neurosurgery, the patient went for anterior neck exploration by
ENT and ortho spine and anterior cervical diskectomy and fusion
was performed at C5-6 and C6-7 along with incision and drainage
of prevertebral abscess on [**3-25**]. Patient remained intubated
post-procedure due to significant procedure-related edema and
her antibiotics were narrowed to nafcillin single-[**Doctor Last Name 360**] therapy.
Patient's blood pressures were persistently low and she remained
pressor dependent until [**2116-4-7**], when she was extubated. Due to
patient's persistent hypotension despite resolution of
bacteremia and drainage of abscess, studies were undertaken to
evaluate for other potential sources of infection and she was
broadened to Dapto/Meropenem. U/S of the fistula showed no signs
of thrombus, TTE showed no vegetations, and CT Abdomen/Pelvis
showed no abscesses or other acute infectious process. Despite
persistent hypotension and elevated lactate, patient remained
arousable and consistently able to follow commands. After 5 days
of Dapto/[**Last Name (un) **] her antibiotics were changed to Nafcillin
monotherapy due to improving BP, absence of a 2nd infectious
source and decreasing pressor requirement. However, she
developed a cholestatic hepatitis and her Nafcillin was switched
back to Daptomycin. ID then recommended transitioning Daptomycin
to Cefazolin. The pt has a documented Cefazolin allergy, so
desensitization was undertaken but the patient developed
anaphylaxis (see below). She was planned to have a 8 week total
course (last day = [**5-19**]) of Daptomycin for her abscess and will
follow up with Ortho Spine and ID for ongoing management. Her
surgical wound had intermittent trace bleeding, though her HCT
remained stable and her incision appeared well healing at the
time of discharge.
.
#Cefazolin Desensitization/Anaphylaxis: Patient developed
cholestatic hepatitis thought to be secondary to nafcillin
therapy prompting switch to daptomycin to cover [**Month/Year (2) 8974**] sepsis.
Patient had documented cefazolin allergy and desensitization
protocol was attempted which she tolerated initially but she
then developed anaphylaxis to 1mg of Cefazolin characterized by
wheezing, SOB, tripoding, stridor and received Epinephrine,
Hydrocortisone, Benadryl and Ranitidine with resolution of her
symptoms without recrudescence of symptoms in 48 hours.
.
# Pseudomonal Pneumonia c/b Respiratory Failure and Sepsis: Pt
became stridorous in the setting of a retropharyngeal abscess
and was intubated on [**2116-3-24**] for airway protection. She required
massive fluid recussitation for sepsis and developed pulmonary
edema, which may also have contributed to her failure. She also
has underlying COPD, which was a likely contributing factor to
her poor pulmonary substrate and respiratory failure. Her
abscess was evacuated and she had ACDF of C5-C6 and C6-C7 with
ortho spine. She remained intubated due to concern for airway
edema until [**2116-4-7**], when she was extubated without event. She
then developed fevers, relative hypotension, and respiratory
distress with sputum cultures growing pseudomonas. She
ultimately required a second intubation and pressors for a priod
of time. She was treated with a course of meropenem and amikacin
per ID recommendation and improved. She was extubated without
further significant issues and weaned off pressors for >2 weeks
prior to discharge. She was satting well on nasal cannula,
afebrile, and without respiratory distress at the time of
discharge.
.
# Cholestatic Hepatitis: Patient's direct bilirubin and
transaminases started to acutely rise on [**3-27**]. On exam, patient
was also noted to have increased distention and tenderness. U/S
of the gallbladder and CT of the Abdomen showed only cirrhosis
and no acute pathology. Cefepime was discontinued due to concern
for liver toxicity. Etiology was initially thought to be due to
acute hepatic decompensation in the setting of critical illness.
Her LFTs remained persistently elevated, and acutely worsened
with initiation of Nafcillin therapy, which was subsequently
discontinued (see above). Her hepatitis was felt to be [**3-5**]
medication effect, though would note that she has underlying
HCV. HBV serologies were negative.
.
# Multifactorial Anemia: Likely anemia of chronic disease and
anemia of ESRD. She required intermittent blood transfusions
throughout her course, though had no evidence of active
bleeding. Stool guiac was repeatedly negative. She should
continue receiving Epo with HD per renal.
.
# Ileus: In the setting of her acute illness and opiate use for
pain control, Ms [**Known lastname 11182**] developed an ileus. For this she
received Naloxone x1 as well as an aggressive bowel regemin. Her
ileus was intermittent and resolved; at the time of discharge
she was tolerating her tube feeds and a PO diet of clear
liquids.
.
# Hypotension: Ms [**Known lastname 11182**] was intermittently hypotensive and
requiring pressors throughout her course. Initially, her
hypotension was almost certainly due to sepsis, which was
treated with appropriate antibiotics. Later in her course she
continued to require pressors with HD and her Midodrine was
increased to 15mg TID. She was also started on high dose
Thiamine due to concern for dry Beri-Beri, with marked
improvement in her BPs.
.
# PICC Associated RUE DVT: Given her Heparin allergy, Ms [**Known lastname **]
was started on an Argatroban gtt for her DVT after her PICC was
removed. Hematology was consulted and recommended an Argatroban
normogram, which was continued for the duration of her MICU
stay.
.
# HIV versus Critical Illness Neuropathy: Given her multiple
medical problems, poor nutrition, prolonged hospital course and
peipheral neuropathy, there was concern for dry Beri-Beri. For
this she was started on high dose Thiamine with initial
improvement in her neuropathy. However, her neuropathy
subsequently returned and neurology was consulted who felt it
may be consistent with critical illness polysneuropathy. Her
primary team felt her symptoms were likely related to her
chronic HIV. She was trialed on low dose gabapentin but
intermittently appeared sedated so that medication was
discontinued.
.
CHRONIC ISSUES:
.
# HIV ([**2-13**] CD4 375): Her home HAART regemin was continued
throughout her course. Viral load early on in her admission was
183.
.
# LIP/COPD/Asthma: Her home Albuterol/Ipratroprium were
continued throughout her course. At the time of discharge, she
was breathing comfortably on nasal cannula.
.
# Pulm HTN: Her Sildenafil 50mg PO TID was initially held for
hypotension, but was restarted once she was off pressors.
.
# ESRD: Started on CVVH while on pressor support. She had a L
subclavian temp HD line placed and received intermittent CVVH
until weaned off pressors. Her temp HD line was pulled on [**2116-4-7**]
she thereafter she received intermitted HD through her fistula
in order to take off acumulated volume. She was transistioned to
T/Th/Sat schedule prior to discharge.
.
# Chronic Thrombocytopenia: Ms [**Known lastname 11182**] is chronically
thrombocytopenic, though her platelet counts on this admission
were markedly lower. Her chronic thrombocytopenia may be related
to her liver disease, and her acute decompensation may be
multifactorial and due to acute hepatic decompensation and CVVH.
She had intermittent, small volume bleeding through her surgical
incision and from her occipital pressure ulcer.
.
# Elevated INR: Felt to be partly due to decompensation of
patient's underlying cirrhosis but also due to antibiotic use.
Patient was intermittently repleted with vitamin K.
.
TRANSITIONAL ISSUES:
.
#GOALS OF CARE: After significant discussions with the patient's
family (primarily her daughter), she was remained FULL CODE
throughout this admission.
.
#Consider outpatient pelvic US for 4.3 x 3.8 cm right ovarian
cyst seen on abdominal CT, which is unchanged since [**2113**].
.
#Please follow Q3 month CD4 counts and re-initiate bactrim
prophylaxis for CD4 count below 200.
Medications on Admission:
Discharge Medications from [**11-12**] (pt does not recall any of her
Rx, but says takes 4 HIV Rx and then a number of other Rx)
1. sildenafil 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
2. sildenafil 20 mg Tablet Sig: Five (5) Tablet PO QPM (once a
day (in the evening)).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMON,WED,FRI ().
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
5. lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO
QTUE,[**Last Name (un) **],SAT ().
7. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebs Inhalation Q6H (every 6 hours) as
needed for SOB.
Disp:*35 nebs* Refills:*0*
12. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*35 nebs* Refills:*0*
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 4 doses: Tale: Sat [**11-23**], Mon [**11-25**], Wed
[**11-27**], Fri [**11-29**].
Disp:*4 Tablet(s)* Refills:*0*
15. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical QHD (each hemodialysis).
16. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO QFRI (every Friday).
17. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: 40mg on [**11-17**] and [**11-25**]
20mg daily on [**11-26**] and [**11-27**]
10mg daily on [**11-28**] and [**11-29**]
Discharge Medications:
1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
2. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain/fever.
5. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: 15-30 mL Mucous membrane four times a day as
needed for mouth pain.
6. lamivudine 10 mg/mL Solution Sig: 2.5 mL PO DAILY (Daily):
Total daily dose is 25 mg. .
7. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO QMON (every Monday).
8. sildenafil 20 mg Tablet Sig: 2.5 Tablets PO TID (3 times a
day).
9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for wheeze.
12. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
13. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q6H (every 6 hours) as needed for irritation.
14. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for Rash.
15. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed for wheezing, SOB.
16. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
17. thiamine HCl 100 mg Tablet Sig: Two (2) 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).
19. midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
20. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q
DIALYSIS, FOR NEEDLE INSERTION ().
21. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
22. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for diarrhea.
23. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)) as needed for anxiety/agitation.
24. daptomycin 500 mg Recon Soln Sig: Four Hundred (400) Recon
Soln Intravenous Q48H (every 48 hours): To be given AFTER
dialysis on the day of dialysis. Last dose is [**2116-5-19**]. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Prevertebral Abscess
[**Hospital1 8974**] Bacteremia
Hypoxic Respiratory Failure
Hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 11182**]:
You were admitted to [**Hospital1 **] with an infection in
your neck. An operation was performed to remove this infection.
You also developed a blood stream infection from a bacteria.
Lastly, your hospitialziation was complicated by respiratory
distress. You were in the intensive care unit for many weeks and
are being discharged to a rehab center.
.
The following changes were made to your medications:
1. Your Sildenafil was changed to 50 mg by mouth three times a
day.
2. You were started on Daptomycin 400 mg by IV infusion to be
given after each dialysis session. The final dose is to be given
on [**2116-5-19**].
3. Prednisone was stopped.
4. Bactrim (Sulfamethoxazole-Trimethoprim) was stopped as well
because your CD4 count has improved.
5. Calcitriol was stopped per renal recommendations.
6. Lamivudine was decreased to 25 mg by mouth daily.
7. Cinacalcet was stopped per renal recommendations.
8. Quetiapine was changed to 12.5 mg by mouth each morning as
needed for anxiety and 50 mg by mouth at night.
9. Nephrocaps were started. Take 1 capsule by mouth daily.
10. Folic acid was stopped.
11. Tenofovir was changed to every Friday to every Monday. The
dose was not changed.
12. You were started on Midodrine 15 mg by mouth three times a
day to increase your blood pressure.
Followup Instructions:
** Right adnexal cyst for which a dedicate pelvis US or MR are
recommended in the outpatient setting. **
.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2116-5-12**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Please make an appointment to see Dr. [**Last Name (STitle) 363**] in Orthopaeidc
Surgery PH: [**Telephone/Fax (1) 106125**] once you are in better condition
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2116-5-8**]
ICD9 Codes: 5856, 4271, 4254, 2875, 4168, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6575
} | Medical Text: Admission Date: [**2101-10-25**] Discharge Date: [**2101-10-28**]
Date of Birth: [**2064-10-2**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Floxin / Penicillins
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Xanax, Tylenol & Klonopin Overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37 yo F with history of depression and suicidal attempt in the
past presented with obtundation. Of note, her prior attempt was
about 15 years ago during which she OD on theophylline,
requiring intubation. She has been feeling more depressed over
the last few months and has been seeing a therapist, on the ECT
waiting list with recent evaluation by Dr. [**Last Name (STitle) 2109**], [**First Name3 (LF) **] her
partner. [**Name (NI) **] reports taking 120 mg of Xanax and 80 mg
Klonopin in the afternoon of [**2101-10-25**] as well as at least [**4-7**]
g of Tylenol daily over the last 2 weeks. She also admitted to
taking 20 mg of Ambien. She says that she was taking the
tylenol intentionally to worsen her liver function. She says
that she decided to do this because she wanted to commit
suicide. She also reports having had 1 glass of wine on the day
of these medication ingestions. She then called one of her
friends afterwards, and her therapist ([**First Name8 (NamePattern2) 2110**] [**Last Name (NamePattern1) **]) was
subsequently involved and called the EMS for patient.
In the ED, her initial VS were HR 99, BP 102/56, RR 20, and 98%
on RA. She arrived with her friend, very lethargic. Per
report, was only responsive to sternal rub and GCS of 8
throughout. Tox screen showed positive benzos and acetaminophen
only. ECG showed sinus tachycardia. UA was negative. CT head
did not show ICH. Her initial Tylenol level was 40. Toxicology
was consulted and recommended NAC for 21 hours until level is
undetectable and LFT stabilizes. She started NAC in the ED and
her repeat level was 29. VS prior to transfer were T95, HR 66,
BP 121/73, RR 22, O2Sat 98% RA.
She was transferred to the ICU for her poor mental status.
While on the floor, appears comfortable, denies any SOB, chest
pain/discomfort, abdominal pain/discomfort, urinary symptoms or
URI symptoms. She does have some throat tightness and
discomfort when swallowing. Her partner reports that patient's
mental status seems to have improved since her initial arrival
to the ED.
Past Medical History:
- Asthma, requiring 1x intubation in late teen (unclear if this
was related to the theophylline)
- GERD with severe esophagitis ([**2098**])
- Insomnia
- Bipolar Type 2, currently severe depression, requiring
hospitalization at [**Doctor First Name **] in the past
- Depression
- Suicidal attempts (last [**1-/2099**] following impulsive suicide
attempt in which she crashed her cars, 2 other ones with OD in
her late teens)
Social History:
Occupation: a nurse mid-wife at [**Name (NI) 2025**] x 10 years
Drugs: Marijuana, last used about 1 week ago
Tobacco: None
Alcohol: occasionally
Married to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 976**] [**Telephone/Fax (1) 2111**], live in [**Location (un) 538**].
Family History:
- mother- depression
- maternal grandmother- EtOH abuse, benzodiazepine abuse
- maternal uncle- bipolar affective d/o
Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 2112**]: Temp: 36.9 BP 116/51, HR 65, RR25, O2Sat 99% RA
General: lethargic, answers questions appropriately but in
whispers, follows commands, NAD
HEENT: PERRL, EOMi, anicteric, Mucous membrane moist
NECK: no supraclavicular or cervical LAD, no JVD, no carotid
bruits, no stridor
Resp: CTAB with good air movement throughout, no wheeze,
crackles, or rhonchi
CV: RR, S1 and S2 wnl, no m/r/g
ABD: soft, ND, mildly tender in the umbilical area, no
hepatosplenomegaly, no guarding.
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
[**2101-10-25**]
- CT head: There is no acute intracranial hemorrhage, acute
large major
vascular territory infarction, discrete masses, mass effect,
brain edema or
shift of normally midline structures. The ventricles and sulci
are normal in size and configuration. The visualized osseous
structures are unremarkable. The visualized paranasal sinuses
are within normal limits. Incidentally noted is a
faintly-calcified likely sebaceous cyst in the left
paramedian frontovertex scalp soft tissues (2:26-27); correlate
with physical examination.
IMPRESSION: No acute intracranial process
[**2101-10-27**] 06:50AM BLOOD WBC-4.7 RBC-3.78* Hgb-11.8* Hct-32.8*
MCV-87 MCH-31.2 MCHC-36.0* RDW-13.5 Plt Ct-238
[**2101-10-25**] 03:00PM BLOOD WBC-6.0 RBC-4.03* Hgb-12.6 Hct-36.0
MCV-90 MCH-31.4 MCHC-35.1* RDW-12.8 Plt Ct-275
[**2101-10-26**] 05:39AM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2*
[**2101-10-27**] 06:50AM BLOOD PT-12.4 INR(PT)-1.0
[**2101-10-25**] 03:00PM BLOOD Neuts-66.7 Lymphs-26.5 Monos-3.5 Eos-2.2
Baso-1.0
[**2101-10-27**] 06:50AM BLOOD Glucose-82 UreaN-6 Creat-0.6 Na-139 K-3.8
Cl-106 HCO3-26 AnGap-11
[**2101-10-25**] 03:00PM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139
K-3.8 Cl-104 HCO3-26 AnGap-13
[**2101-10-27**] 06:50AM BLOOD ALT-21 AST-13
[**2101-10-26**] 02:23AM BLOOD ALT-25 AST-24 LD(LDH)-340* AlkPhos-39
TotBili-0.3
[**2101-10-25**] 03:00PM BLOOD ALT-28 AST-22 LD(LDH)-161 AlkPhos-56
TotBili-0.4
[**2101-10-27**] 06:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
[**2101-10-25**] 03:00PM BLOOD HCG-<5
[**2101-10-25**] 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-40*
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2101-10-25**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-29
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2101-10-26**] 02:23AM BLOOD Acetmnp-6*
[**2101-10-26**] 07:00PM BLOOD Acetmnp-NEG
Brief Hospital Course:
37 yo F with depression on ECT waiting list and remote history
of suicidal attempts presents with OD of benzodiazepine and
Tylenol
Medicaion Overdose, an attempt to suicide. The patient was
treated supportively for benzodiazepine overdose and did not
require mechanical ventilation. In regards to tylenol toxicity
she required a N acetylcysteine drip for a tylenol level of 40
and normal liver function tests, after stopping the NAC drip her
tylenol level was negative and LFTs remained normal. She was
medically cleared for discharge to a psyhiatric inpatient
facility as of the a.m. of [**2101-10-27**], she is also medically
cleared for ECT. In regards to her bipolar disorder and suicide
attempt psychiatry was consulted and suggested the following
medication regimen: Wellbutrin 150mg po bid, duloxetine 60mg po
daily, lamotrigine 350mg po daily, risperdal 0.5mg po bid prn,
and ambien 10mg po qhs prn insomnia.
Asthma. Does not appear to be active currently. prn albuterol /
atrovent nebs.
GERD: continued home omeprazole
Communication/Emergency Contact: partner [**Name (NI) **] [**Name (NI) 976**]
[**Telephone/Fax (1) 2111**]
Medications on Admission:
Meds (at home):
cymbalta 60 mg PO daily
wellbutrin SR 450 mg PO daily
lamictal 350 mg PO daily
ambien 10 mg PO QHS
prilosec 20 mg PO daily and sometimes [**Hospital1 **]
risperdal 0.5 mg PO QAM and 1 mg PO QHS (not taking for 1 week)
klonopin 1 mg PO prn
was stockpiling xanax, so not taking
Meds (in ICU):
NAC 560 mg/h IV gtt
albuterol nebs prn
Wellbutrin SR 150 mg [**Hospital1 **]
duloxetine 60 mg PO daily
heparin subQ 5000 TID
lamictal 350 mg PO daily
omeprazole 20 mg PO daily
Discharge Medications:
1. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
6. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety/agitation.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
8. lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
Suicide ingestion
Tylenol overdose
Benzodiazepine overdose
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a suicide attempt and
treated to prevent organ damage. You were transferred to an
inpatient psychiatric facility. Please take your medications as
prescribed and make your follow up appointments.
Followup Instructions:
Please follow up with your psychiatrist within 2 weeks of your
discharge from the psychiatric facility.
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week
of your discharge from the psychiatric facility: [**Last Name (LF) 2113**],[**First Name3 (LF) 2114**] R.
[**Telephone/Fax (1) 2115**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6576
} | Medical Text: Admission Date: [**2137-4-18**] Discharge Date: [**2137-4-22**]
Date of Birth: [**2076-12-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2137-4-18**]
1. Coronary artery bypass grafts x3, left internal mammary
artery to left anterior descending artery and saphenous
vein grafts to right coronary artery and obtuse marginal
arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
60 year old female for the past two years she has been
experiencing shortness of breath and dyspnea with exertion. This
occurs after walking approximately 10 minutes starts in her
epigastric area and radiates up to her upper chest.
It resolves with rest. She had been trying to lose weight
recently and was using a treadmill and was experiencing
shortness of breath and chest pain. She underwent a stress test
which was abnormal. She was referred for a cardiac
catheterization and was found to have coronary artery disease.
She was referred to cardiac surgery for revascularization.
Past Medical History:
Coronary Artery Disease
PMH:
Paroxysmal Atrial Fibrillation, reported PAF or palpitations
since [**2133**]
Depression/Anxiety
Vitamin D Deficiency
Chronic bilateral Leg/Joint pain
Dyslipidemia
Frequent Headaches
Past Surgical History:
Tonsillectomy
Appendectomy
Social History:
Lives with:Husband
Contact:[**Name (NI) **] (daughter) Phone# [**Telephone/Fax (1) 92267**]
Occupation:skin care specialist
Cigarettes: Smoked no [] yes [x]Hx: quit 6 years ago, smoked
<1ppd x13-15 years
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-26**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Mother had MI
at 65, Sister died at 60 with HTN and ?MI
Physical Exam:
Pulse:65 Resp:13 O2 sat:98/RA
B/P Right:120/72 Left:127/68
Height:5'1" Weight:186 lbs
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
Intra-op TEE [**2137-4-18**]
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results at time of surgery.
POST-BYPASS: The patient is A paced. The patient is on a
phenylephrine infusion. Biventricular function is unchanged.
Mitral regurgitation is unchanged. Tricuspid regurgitation is
moderate (2+). The aorta is intact post-decannulation.
[**2137-4-22**] 04:17AM BLOOD WBC-9.2 RBC-2.84* Hgb-8.3* Hct-26.9*
MCV-95 MCH-29.3 MCHC-31.0 RDW-13.8 Plt Ct-287
[**2137-4-21**] 04:52AM BLOOD Hct-26.2*
[**2137-4-20**] 11:26PM BLOOD Hct-25.9*
[**2137-4-22**] 04:17AM BLOOD Glucose-97 UreaN-14 Creat-0.8 Na-137
K-4.3 Cl-103 HCO3-29 AnGap-9
[**2137-4-21**] 04:52AM BLOOD UreaN-15 Creat-0.8
[**2137-4-20**] 02:51AM BLOOD Glucose-122* UreaN-11 Creat-0.9 Na-138
K-4.4 Cl-105 HCO3-25 AnGap-12
[**2137-4-19**] 02:52AM BLOOD Glucose-118* UreaN-9 Creat-0.5 Na-135
K-4.0 Cl-105 HCO3-23 AnGap-11
Brief Hospital Course:
The patient was brought to the Operating Room on [**2137-4-18**] where
the patient underwent CABG x 3 with Dr. [**First Name (STitle) **]. Initial attempt
at endoscopic approach was aborted and converted to open CABG.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Left sided
chest tube was placed for pleural effusion via endoscopic port
site on post operative night before extubation. 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. POD 1 OR
chest tubes were removed and left chest tube remained in place.
She has paroxysmal atrial fibrillation which she had
preoperatively but was in sinus rhtyhm at the time of discharge
and was not anticoagulated. Beta blocker was initiated at a low
dose with SBP 90's and the patient was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Left Chest tube was
removed at this time and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4 the patient was ambulating freely, she was
hemodynamically stable in sinus rhythm, the wound was healing
and pain was controlled with oral analgesics. The patient was
discharged home with VNA services in good condition with
appropriate follow up instructions.
Medications on Admission:
ASPIRIN 81 mg Daily
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**1-21**]
Puffs Inhalation Q6H (every 6 hours) as needed for sob,
wheezing.
Disp:*1 1* Refills:*0*
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-26**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease
PMH:
Paroxysmal Atrial Fibrillation, reported PAF or palpitations
since [**2133**]
Depression/Anxiety
Vitamin D Deficiency
Chronic bilateral Leg/Joint pain
Dyslipidemia
Frequent Headaches
Past Surgical History:
Tonsillectomy
Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- 1+
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:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2137-4-30**]
at 10:15a
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2137-5-28**] at 1:00p
Cardiologist Dr. [**Last Name (STitle) 3357**] on [**2137-5-3**] at 11:30
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 92268**],[**First Name3 (LF) **] V. [**Telephone/Fax (1) 26774**] in [**4-25**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2137-4-22**]
ICD9 Codes: 5119, 2762, 311, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6577
} | Medical Text: Admission Date: [**2173-11-15**] Discharge Date: [**2173-11-18**]
Date of Birth: [**2112-8-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
ONCO-MED HOSPITALIST ADMISSION NOTE
.
61 year old gentleman with COPD, stage IV NSCLC mucinous
adenocarcinoma and recent PE who presents with dyspnea. He
reports sudden-onset worsening of respiratory status on the
morning of admission without associated productive cough,
fevers/chills, CP, or other symptoms.
.
Of note, patient was recently readmitted in early [**2173-10-28**]
for SOB/dyspnea, at which time a new LLL consolidation was seen.
He was provided with one dose of Vanc/Cefepime, and started on
a morphine drip in concert with patient's HCP as well as patient
wishes. Improvement in clinical status was noted overnight and
his morphine drip was discontinued. His acute respiratory
decompensation was attributed to a mucus plug, aspiration,
perhaps with contributing atalectasis. He was continued
albuterol/ipratropium nebulizers, as well as enoxaparin [**Hospital1 **] for
his recent PE's. Antibiotics were not resumed at time of
discharge. After discharge, blood cultures from [**2173-11-3**] grew
Fusobacterium Nucleatum in one out of two bottles. The patient
was contact[**Name (NI) **] on [**2173-11-6**] regarding this lab result, and did not
feel any different since discharge from the hospital. Repeat
blood cultures at his outpatient oncologist failed to reveal
positive cultures. Since his recent discharge, discussion
regarding hospice care has been continued with his oncologist
Dr. [**Last Name (STitle) 45322**], given the patient's poor prognosis.
.
In the ED, initial vitals recorded were a RR of 32. Labs showed
hyponatremia with a sodium of 129, otherwise unremarkable CMP.
CBC with WBC count of 16.0 with 97.3 PMN's and 2.4 %
lymphocytes. HCT of 30.6, platelets of 508. Coags showed INR of
1.2, PTT of 31.8. CXR showed Stable right-sided pleural effusion
and post-obstructive consolidation, increasing left pleural
effusion with basal atelectasis. Patient had his pleurex
catheter drained with 300 cc's of straw colored fluid aspirated.
He was administered albuterol/ipratropium nebs,
vancomycin/zosyn, as well as lorazepam and methylprednisolone.
.
In MICU, VS: 96.9 103 131/74 14 90%4L NC. He endorsed feeling
hungry. His respiratory status stabilized after clearing mucous
plug, but still requiring 4-5L NRB. No antibiotics were given as
low suspicion for acute infection. He improved with time,
albuterol/ipratropium nebs. He was continued on lovenox for
recent PE. In addition, as a large component of dyspnea was
anxiety, patient was placed on standing clonazepam 1mg TID.
Palliative care was consulted for assistance with pain control
and was made DNR/DNI. Of note, he was found to be growing G+
cocci in 1 of 2 Bcx bottles, was started on IV vancomycin and
was transferred out of ICU.
.
ROS: He denies F/C/S, N/V, headache, dizziness, chest pain,
abdominal pain, back pain, constipation, diarrhea, hematochezia,
urinary symptoms, or rash. All other ROS were negative.
Past Medical History:
1. Metastatic NSCLC to [**Last Name (LF) 500**], [**First Name3 (LF) **], with malignant effusion,
Pleurex placed [**2173-9-16**], s/p carboplatin/paclitaxel x2 cycles,
then pemetrexad x2 cycles (last given [**2173-11-11**]).
2. PE, 9/[**2172**].
3. CVA.
4. Carotid stenosis s/p CEA [**2173-7-31**].
5. Hypertension.
6. Ocular migraine.
7. Alcohol abuse.
8. Hyperlipidemia.
Social History:
- Tobacco: Smoked 2 PPD age 20 to 61.
- Alcohol: Former heavy drinker, drinks [**11-29**] bottle of wine per
night.
- Illicits: Denies.
- Occupation: ECG engineer.
- Exposures: Denies.
Family History:
Mother - colon cancer at 83 s/p resection, still alive at 88,
hypertension.
Father - died of multiple myeloma at age 80, high cholesterol.
Sister 1 - died of malignant brain tumor at age 24.
Sister 2 - hypertension.
No FH of stroke, diabetes.
Physical Exam:
Admission to Floor Physical Exam
Vitals: 97.8 108/62 111 21 97%NC 5L, 0/10 pain
General: Alert, oriented, no acute distress, dyspnia
occasionally interferes with his ability to complete sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Diminished BS at bases b/l, R>L
CV: Tachycardic ~110, regular rhythm, normal S1 + S2, no m/r/g
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:
ADMISSION LABS:
[**2173-11-15**] 11:30AM WBC-16.0*# RBC-3.16* HGB-9.3* HCT-30.6*
MCV-97 MCH-29.6 MCHC-30.5* RDW-17.8*
[**2173-11-15**] 11:30AM NEUTS-97.3* LYMPHS-2.4* MONOS-0.2* EOS-0.1
BASOS-0
[**2173-11-15**] 11:30AM PLT COUNT-508*
[**2173-11-15**] 11:30AM PT-12.9* PTT-31.8 INR(PT)-1.2*
[**2173-11-15**] 11:30AM GLUCOSE-124* UREA N-12 CREAT-0.4* SODIUM-129*
POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-31 ANION GAP-10
.
Thoracentesis Fluid
[**2173-11-15**] 12:00PM PLEURAL WBC-50* RBC-2725* POLYS-67* LYMPHS-24*
MONOS-7* MESOTHELI-2*
.
[**2173-11-15**] CTA CHEST: IMPRESSION:
1. Extensive right lung mass with post obstructive collapse of
the right upper and middle lobes.
2. No pulmonary emboli. The right upper and middle lobe
pulmonary arteries are attenuated by the mass.
3. Pleural effusions increased since the preceding exam 14 days
ago.
4. Extensive sclerotic metastases to the spine and sternum.
5. Ground glass opacity in left apex is non-specific but could
represent infectious process.
.
[**2173-11-15**] CXR: IMPRESSION: Stable appearance of right-sided
pleural effusion and post-obstructive consolidation in the
setting of a known right chest mass; increasing left pleural
effusion with basal atelectasis.
.
[**2173-11-15**] CXR: IMPRESSION: Interval decrease in left pleural
effusion with associated atelectasis and no pneumothorax.
.
DISCHARGE LABS:
[**2173-11-17**] 07:25AM BLOOD WBC-10.0 RBC-2.87* Hgb-8.9* Hct-28.7*
MCV-100* MCH-31.2 MCHC-31.2 RDW-17.6* Plt Ct-382
[**2173-11-16**] 06:36AM BLOOD Neuts-96.7* Lymphs-2.3* Monos-0.6*
Eos-0.2 Baso-0.1
[**2173-11-17**] 07:25AM BLOOD PT-12.2 PTT-27.8 INR(PT)-1.1
[**2173-11-17**] 07:25AM BLOOD Glucose-93 UreaN-9 Creat-0.2* Na-129*
K-4.0 Cl-92* HCO3-31 AnGap-10
[**2173-11-17**] 07:25AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.5*
Brief Hospital Course:
61yo man with metastatic NSCLC to ribs, malignant effusion, and
encasement of right hilum, on enoxaparin for PE, Pleurex
catheter for malignant effusion, hx of CVA admitted to the ICU
for acute dyspnea. He initially required non-rebreather O2m byt
after expectorating a mucous plug, his O2 requirement decreased
to 5L. Palliative care consulted. Clonazepam added for
anxiety. Code status changed to DNR/DNI. Blood cultures grew
GPC in clusters and GPC in chains, two separate species.
Started on vancomycin. He continued to decline requiring more
oxygen again despite suctioning. He was placed on a morphine
gtt for comfort and died [**2173-11-18**] at 16:20PM.
.
# Dyspnea/hypoxia: Due to malignancy and malignant effusion +/-
post-obstructive pneumonia. Required non-rebreather in ICU, but
improved after mucous plug expectorated. Blood cultures growing
GPC in clusters and GPCs in chains. Started vancomycin [**2173-11-16**]
for GPC bacteremia, leukocytosis, increased mucous production,
leukocytosis, tachycardia, and tachypnea --> sepsis. Continued
albuterol prn, fluticasone-salmeterol. Tiotropium changed to
ipratropium nebs. Continued guaifenesin/codeine and benzonatate
for cough. O2 support as needed. Morphine for dyspnea.
Lorazepam for respiratory distress. Suctioned for worsening
hypoxia, but no improvement. Trigger for hypoxia 88% on 6L
[**2173-11-18**]. Mr. [**Known lastname **] and his girlfriend agreed to comfort care
only and inpatient hospice. He was placed on a morphine gtt for
comfort and died [**2173-11-18**] at 16:20PM.
.
# Metastatic NSCLC: Last given pemetrexad [**2173-11-11**]. Palliative
care consulted. Stopped folate considering goals of care.
.
# Leukocytosis: Due to sepsis. No labs considering goals of
care.
.
# Anemia: Likely chemo induced and anemia of inflammation. No
labs.
.
# Chronic PE: Stopped enoxaparin for [**Month/Day/Year 3225**].
.
# HTN: Held metoprolol and hydralazine due to hypotension.
.
# Anxiety: Added clonazepam.
.
# Pain (rib): Continue MSContin. Increased morphine IV PRN for
pain and dyspnea.
.
# FEN: Regular diet. Hyponatremia possibly SIADH stable.
Repleted hypomagnesemia.
.
# GI PPx: PPI and bowel regimen.
.
# DVT PPx: Enoxaparin for PE stopped for [**Month/Day/Year 3225**].
.
# Precautions: None.
.
# Lines: Peripheral.
.
# CODE: DNR/DNI, [**Month/Day/Year 3225**].
Medications on Admission:
Benzonatate 100 mg Capsule Sig: [**11-29**] Capsules PO TID prn
Metoprolol succinate 50 mg Tablet Extended Release 1 tab po BID
Morphine 30 mg Tablet Extended Release 1 po q12hrs
Docusate sodium 100 mg Capsule 1 po BID
Tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: 1
cap qday
Oxycodone 5 mg Tablet 1 po q6hrs prn
Folic acid 1 mg Tablet 1 po qday
Fluticasone-salmeterol 100-50 mcg/dose Disk 1 inh [**Hospital1 **]
Enoxaparin 80 mg/0.8 mL Syringe 1 SC q12 hrs
Albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler PRN SOB
Dexamethasone 4 mg Tablet daily
Lorazepam 0.5 mg Tablet 1 po q4 hours as needed for anxiety.
Hydralazine 50 mg Tablet 1 PO TID
Megestrol 20 mg 1 po qday
Ondansetron 8 mg Tablet ODT PO three times a day PRN
Prochlorperazine maleate 10 mg Tablet 1 PO three times PRN
Pantoprazole 40 mg Tablet 1 tab PO twice a day.
Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Transdermal qday
Discharge Medications:
N/A.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Sepsis (severe blood infection)
Hypoxia (low oxygen levels)
Shortness of breath
Non-small cell lung cancer
Malignant effusion (fluid in the lungs from cancer)
Anxiety
Death
Discharge Condition:
Deceased.
Discharge Instructions:
N/A. Deceased.
Followup Instructions:
N/A. Deceased.
ICD9 Codes: 486, 0389, 5180, 496, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6578
} | Medical Text: Admission Date: [**2191-1-7**] Discharge Date: [**2191-1-13**]
Date of Birth: [**2123-10-24**] Sex: M
Service: MEDICINE
Allergies:
Cephalexin / Heparin Agents
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD [**2191-1-8**]
History of Present Illness:
67 year old male with alcoholic cirrhosis who was admitted in
[**2190-6-24**] to [**Hospital1 18**] for alcoholic hepatitis treated with
prednsione 40 mg po qdaily for five days.
.
He reports having progressive shortness of breath for past few
days with inability to even walk to block from unlimited
activity a week ago. He reports no abdominal pain, nausea,
vomiting, hematemesis, BRBPR, dark stools, dysuria, fever,
cough, chest pain, dizziness, palpatations or alcohol use (last
drink 3 weeks ago).
.
He presented to OSH today where he as noted to have dark bloody
stool and hematocrit of 15 along with elevated LFTs.
Unfortunately he refused NG lavage. He was transfused one unit
of PRBC and 2 units of FFP. He was given 750 mg levaquin
emperically and transferred to [**Hospital1 18**] ED with octreotide and
protonix started.
.
In the ED, his intial vitals were 99.0 94 118/76 18 98% RA. He
had guiaic positive but not grossly bloody stool in the vault in
the ED. He was continued on his octreotide and protonix gtt
while switched to ceftriaxone 1 gm q24. His labs were
significant for HCT of 15.4, INR of 2.1, T.Bili of 8.7, lactate
of 7.1, WBC of 17.2, Creatinine of 1.6 and sodium of 131. He was
transferred to [**Hospital1 18**] MICU for futher evaluation and management.
.
In the MICU, he reports feeling well except for right shoulder
pain which hurts with movement.
Past Medical History:
Alcoholic Cirrhosis
Social History:
Last alcoholic beverage was 3 weeks ago. He stopped smoking
twenty years ago. No illicit drug use. Lives alone at home.
Separated from his wife. Retired.
Family History:
No family history of liver disease
Physical Exam:
ADMISSION EXAM
Gen: Male in no acute distress
Vitals: 98.7 128/59 120 100%RA
HEENT: Normocephalic. Nontraumatic. Icteric.
Chest: Clear to auscultation bilaterally. No crackles or
wheezing noted
Heart: Regular rate and rhythm. Systolic murmur heard throughout
Abdomen: Soft and distended. Tenderness to deep palpation.
Shifting dullness to percussion noted.
External: 1+ pitting edema to the knee
Neuro: Alert and oriented to person, place and time. Mild
confusion with recall. Could not tell me who the current
president is. CN 2-12 intact. [**3-29**] muscles strength throughout
except R shoulder strength which was limited due to pain.
Skin: Jaundiced. B/l upper extremity bruises
DISCHARGE EXAM
Vitals: Tm/Tc 99.4/97.5, BP 150/85 (135-155)/(65-85), HR 85
(80-90), RR 20, SaO2 96-100%RA
In: 1560 PO, 100 IV ... Out: 2450, BM x0 (net fluid bal -800)
Gen: NAD
Chest: Clear to auscultation bilaterally. No crackles or
wheezing.
Heart: Regular rate and rhythm. Systolic murmur heard
throughout.
Abdomen: Soft and distended. Tenderness to deep palpation.
Shifting dullness to percussion noted.
Extrem: 2+ pitting edema to the knee bilaterally; RUE now
symmetrical to the LUE but with limited ROM [**1-26**] pain
Neuro: Alert and oriented to person, place and time. [**3-29**] muscle
strength throughout except R shoulder strength which was limited
due to pain.
Skin: Jaundiced. B/l upper extremity bruises.
Pertinent Results:
ADMISSION EXAM
[**2191-1-7**] 08:30PM BLOOD WBC-17.2* RBC-1.57*# Hgb-5.2*# Hct-15.4*#
MCV-98# MCH-33.2* MCHC-34.0 RDW-16.3* Plt Ct-124*
[**2191-1-7**] 08:30PM BLOOD Neuts-90.2* Lymphs-6.8* Monos-2.2 Eos-0.3
Baso-0.4
[**2191-1-7**] 08:30PM BLOOD PT-22.1* PTT-43.9* INR(PT)-2.1*
[**2191-1-7**] 11:35PM BLOOD Ret Aut-4.5*
[**2191-1-7**] 08:30PM BLOOD Glucose-160* UreaN-48* Creat-1.6* Na-131*
K-4.8 Cl-101 HCO3-18* AnGap-17
[**2191-1-7**] 08:30PM BLOOD ALT-17 AST-27 AlkPhos-77 TotBili-8.7*
[**2191-1-7**] 08:30PM BLOOD Lipase-22
[**2191-1-7**] 11:35PM BLOOD Albumin-2.0* Calcium-8.1* Phos-4.1#
Mg-1.6 Iron-123
[**2191-1-7**] 11:35PM BLOOD calTIBC-135* VitB12-GREATER TH
Folate-14.9 Hapto-30 Ferritn-250 TRF-104*
[**2191-1-7**] 08:30PM BLOOD Ammonia-43
[**2191-1-9**] 05:25AM BLOOD AFP-3.6
[**2191-1-7**] 11:46PM BLOOD Lactate-5.2*
[**2191-1-7**] 08:39PM BLOOD Lactate-7.1*
DISCHARGE LABS
[**2191-1-13**] 05:48AM BLOOD WBC-6.9 RBC-3.21* Hgb-10.0* Hct-29.6*
MCV-92 MCH-31.1 MCHC-33.7 RDW-17.0* Plt Ct-70*
[**2191-1-13**] 05:48AM BLOOD PT-23.3* PTT-45.2* INR(PT)-2.2*
[**2191-1-13**] 05:48AM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-133
K-3.7 Cl-101 HCO3-30 AnGap-6*
[**2191-1-13**] 05:48AM BLOOD ALT-20 AST-38 AlkPhos-117 TotBili-7.2*
[**2191-1-13**] 05:48AM BLOOD Albumin-1.9* Calcium-7.9* Phos-2.1*
Mg-1.8
EKG [**2191-1-7**]
Normal sinus rhythm with low limb lead voltage. Non-specific
ST-T wave
abnormalities. No previous tracing available for comparison.
CXR [**2191-1-8**]
No active disease.
SHOULDER X-RAY [**2191-1-8**]
Mild degenerative arthritic change.
RUE ULTRASOUND [**2191-1-10**]
No evidence of DVT in the right upper extremity.
RUQ ULTRASOUND [**2191-1-10**]
1. Fatty liver with no focal lesions seen. Additionally, there
is a reversal
of portal venous flow in the right and left system as seen on
prior.
2. There is mild intra-abdominal ascites around the liver as
well is in
bilateral lower quadrants, right greater than left.
3. Gallstone with no evidence of cholecystitis. The common bile
duct is
normal in caliber.
4. Splenomegaly.
CT HEAD W/O CONTRAST [**2191-1-12**]
1. No hemorrhage, edema, or evidence of other acute process.
2. Global atrophy, greater than expected for patient's age,
likely related to
history of ethanol abuse, and sequelae of chronic small vessel
ischemic
disease.
TTE [**2191-1-13**]
no vegetations seen
EGD [**2191-1-8**]
Impression: Ulcer in the first part of the duodenum (thermal
therapy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Mr. [**Known lastname **] is a 67y/o gentleman with alcoholic cirrhosis who was
admitted with dark stools/anemia and was found to have duodenal
ulcer that was treated with gold probe, with stable Hct. His
course was complicated by Strep viridans bacteremia for which he
was treated with antibiotics and he was discharged home.
.
ACTIVE ISSUES
.
# GI bleed: Duodenal ulcer, Hct stable now.
EGD revealed duodenal ulcer which was treated with gold probe.
H. pylori negative. He was treated with PPI, Sucralfate, and
prophylactic Ceftriaxone. His Hct remained stable and he had no
more signs of active bleeding.
.
# Strep viridans bacteremia: unclear source.
He had 1 positive blood culture on [**1-7**], the day of admission.
He was initially started on Vanc but after speciation and
sensitivities returned, he was kept on Ceftriaxone (which he was
on for prophylaxis in the setting of GI bleed anyway). ID
consult was obtained; His access at the time was a right IJ
which was pulled (and cultured), and when blood cultures were
cleared, a PICC line was placed for outpatient antibiotics. TTE
was negative for vegetation and he remained afebrile without any
other psitive culture data. The plan is to treat with
Ceftriaxone for 2 weeks (last day is [**2191-1-21**]). He was
discharged home with VNA and he will follow up with his PCP and
Hepatologist.
.
# Alcohlic cirrhosis with ascites and total body volume
overload: MELD 27.
His diuretics had been held in the ICU and on arrival to the
floor he was total body volume overloaded. He was continued on
his home dose of diuretics: Lasix 40 daily, Aldactone 100 daily
with very good urine output. He will continue on this dose and
follow up with his Hepatologist.
.
# Hyponatremia: likely hypervolemic as well as hypovolemic.
While holding home lasix and aldactone, his hyponatremia
improved slightly, but it was still stable in the setting of
adding back diuretics. Sodium at the time of discharge was 133.
.
# Thrombocytopenia: Due to ESLD
His platelets were monitored and were 60-100 throughout
admission; level was 70 at the time of discharge.
.
# Acute kidney injury: Resolved.
Cr peaked at 1.6, likely was due to prerenal state from volume
depletion vs. ischemic ATN. His Cr was monitored and up to 1.6
but was 0.8 at the time of discharge.
.
# Right shoulder pain: Seems to be rotator cuff in nature but
unable to do an exam limited by pain. X-ray revealed just
arthritic changes. He was seen by PT and was cleared to go home
with PT. He may benefit from an outpatient MRI to assess for
rotator cuff injury.
Medications on Admission:
Lasix 40 mg po qdaily
Aldosterone 100 mg po qdaily
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO qAM.
2. spironolactone 100 mg Tablet Sig: One (1) Tablet PO qAM.
3. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
4. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) pack Intravenous Q24H (every 24 hours) for 2 weeks:
total 2 week course (last day is [**2191-1-21**]).
Disp:*14 pack* Refills:*0*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. sucralfate 1 gram Tablet Sig: One (1) Tablet PO qPM: (please
take this separately from your other medications because it can
affect the absorption of other medications.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
GI bleed (duodenal ulcer)
alcohol cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to bloody stools, and you were found to
have an intestinal ulcer that was treated. We restarted your
diuretics (Lasix and Aldactone) and the extra fluid in your body
is being removed well.
.
During the admission, you had right shoulder pain, which you had
before admission as well. X-ray showed that you do not have a
fracture. Please follow up with your PCP to discuss this
(appointment listed below).
.
We made the following changes to your medications:
-start Sucralfate
-start Pantoprazole
-start Ceftriaxone (last day is [**2191-1-21**])
Followup Instructions:
PRIMARY CARE
Name: [**Last Name (LF) **],[**Known firstname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 3947**].
Location: [**Hospital **] MEDICAL CENTER
Address: 1 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 72762**]
Phone: [**Telephone/Fax (1) 8572**]
Appt: [**1-20**] at 2pm
HEPATOLOGY
Department: LIVER CENTER
When: FRIDAY [**2191-1-28**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5849, 2761, 7907, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6579
} | Medical Text: Admission Date: [**2131-5-10**] Discharge Date: [**2131-6-20**]
Date of Birth: [**2081-3-24**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / Erythromycin Base / Penicillins / Influenza
Virus Vaccine / Latex
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
COPD, T7-T9 epidural abscess
Major Surgical or Invasive Procedure:
PROCEDURES: [**2131-5-10**] by: Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
1. Fusion T2-L1.
2. Extra cavitary decompression T7-T8.
3. Multiple thoracic laminotomies.
4. Multiple lumbar laminotomies.
5. Osteotomy T7, 8, 9
6. Instrumentation, T2-L1.
6. Autografts.
[**2131-5-10**] by Thoracic Surgery Dr. [**Last Name (STitle) **]
Placement of bilateral chest tubes for bil pleural effusions
[**2131-5-10**] Vascular Surgery
1. Ultrasound-guided puncture of right common femoral vein.
2. Inferior vena cavogram,
3. Placement of Gunther Tulip IVC filter.
[**2131-5-20**] Dr. [**Last Name (STitle) 363**] and Dr. [**First Name (STitle) **]
1. Partial vertebrectomies of T6, 7 and 8.
2. Fusion T6-T9.
3. Anterior spacer.
4. Autograft, bone morphogenic protein, and allograft.
5. Bronchoscopy and:
Left posterolateral thoracotomy, partial
vertebrectomy of T6, T7 and T8; fusion of T6 to T9; anterior
spacer; autograft bone morphogenic protein and allograft; and
finally bronchoscopy.
[**2131-5-23**] Dr. [**Last Name (STitle) 363**]
Revision laminectomies T6, 7 and 8.
2. Incision and drainage.
3. Debridement.
[**2131-5-24**] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
Flexible bronchoscopy.
Therapeutic aspiration of secretions.
[**5-30**] swallow eval:
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of level 4, mild to moderate
dysphagia.
[**2131-6-5**] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 67965**]
Flexible bronchoscopy with aspiration and 8-0
Portex tracheostomy tube placement.
History of Present Illness:
50F with with history of severe COPD
requiring oxygen, colon CA s/p resection and colostomy recent
MRSA osteomyletis of MTP joint s/p resection in [**1-19**]; this AM at
rehab noted to have SOB with sats as low as 45%. EMS placed her
on 100% nonrebreather and gave 40mg lasix. O2 sat improved to
99%. Taken to [**Hospital3 **] ED and received levaqiun and BiPAP. She
c/o weakness in her legs, weakness with walking. CT chest showed
T7-T9 destructive changed associated with swelling, concerning
for abscess. MRI, per report, shows evidence of spinal cord
compression. She presents for surgical evaluation.
Past Medical History:
MRSA, sepsis due to osteomyelitis of the MTP joint s/p resection
s/p long term tx with vancomycin
COPD, severe, O2 dependent; h/o hypercapnic respiratory failure
requiring intubation
Costocondritis
History of PE (on coumadin)
Chronic anemia
DM with neuropathy
CHF
Diverticulosis, Colon CA s/p colostomy
h/o SBOs
s/p hysterctomy c/b abd wound dehiscence
h/o Cdiff colitis
HTN
IgA and IgG deficiency
hypercholesterolemia
Gout
Restless leg syndrome
Social History:
does not smoke, drink alcohol; widow
Family History:
Her father had diabetes. Her mother died of CAD and HTN.
Physical Exam:
On transfer to MICU on [**2131-6-14**]:
Vitals: Tc: 99.4 Tm: 101.2 at MN BP: 161/76 P: 116 R: 29 O2: 98%
on CPAP 10 PEEP 5 40% FIO2
General: trached, minimally arousable to verbal stimuli and
sternal rub
Skin: scattered ecchymoses, no rash, left thoracotomy w/
staples, small yellow wound at incisional end overlying L-spine
w/ scant yellow discharge
HEENT: Sclera anicteric, pupils 2mm and sluggish, MMD, poor
dentition w/ gingival inflammation, oropharynx clear
Neck: supple, JVP unable to assess [**2-12**] trach collar, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachy, Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, LLQ ostomy w/ brown liquid stool, mild line
incisional scar healed, soft, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly appreciated
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
PICC line in R antecub
Neuro: Drowsy [**2-12**] recent narc dosing, reflexes 2+ b/l,
withdrawling to pain in all four extremities, intermittent fine
motor tremor noted in right lower extremity
foley w/ yellow clear urine
Pertinent Results:
[**2131-5-10**] 01:22AM BLOOD WBC-13.4* RBC-3.26* Hgb-9.0* Hct-30.6*
MCV-94 MCH-27.7 MCHC-29.5* RDW-17.8* Plt Ct-569*
[**2131-5-10**] 01:22AM BLOOD Neuts-96.5* Lymphs-2.1* Monos-1.4* Eos-0
Baso-0
[**2131-5-10**] 01:22AM BLOOD PT-21.4* PTT-31.1 INR(PT)-2.0*
[**2131-5-10**] 01:22AM BLOOD Glucose-221* UreaN-17 Creat-0.5 Na-144
K-4.4 Cl-99 HCO3-30 AnGap-19
[**2131-5-10**] 01:22AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.8
[**2131-5-30**] 10:35AM BLOOD Albumin-2.4* Iron-9*
[**2131-5-30**] 10:35AM BLOOD calTIBC-117* Ferritn-367* TRF-90*
[**2131-5-30**] 10:35AM BLOOD Triglyc-260*
[**2131-6-14**] 07:24AM BLOOD TSH-4.2
[**2131-5-12**] 02:33AM BLOOD CRP-290.6*
[**2131-5-23**] 12:02AM BLOOD IgG-561* IgA-158
.
[**2131-5-10**] 12:00 pm TISSUE T8.
STAPH AUREUS COAG +. RARE GROWTH.
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
[**2131-6-13**] 12:15 am URINE Source: Catheter.
.
[**2131-5-12**] 5:16 pm STOOL CONSISTENCY: LOOSE
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2131-5-25**] 4:05 pm BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE.
RESPIRATORY CULTURE (Final [**2131-5-28**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
[**2131-6-1**] 8:27 am SPUTUM Source: Endotracheal.
RESPIRATORY CULTURE (Final [**2131-6-4**]):
THIS IS A CORRECTED REPORT [**2131-6-4**].
OROPHARYNGEAL FLORA ABSENT.
YEAST. RARE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
.
[**2131-6-2**] 3:48 pm URINE Source: Catheter.
URINE CULTURE (Final [**2131-6-6**]):
PSEUDOMONAS AERUGINOSA.
>100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
.
[**2131-6-11**] 5:09 pm URINE Source: Catheter.
URINE CULTURE (Final [**2131-6-12**]):
YEAST. >100,000 ORGANISMS/ML..
.
[**2131-5-10**] PATH
SPECIMEN SUBMITTED: T8 bone, disc T7-8/bone.
I. T8 bone (A): Fragments of cartilage and bone with acute
osteomyelitis and osteonecrosis.
II. Disc T7-8/bone (B): Fragments of skeletal muscle, fibrous
connective tissue and bone with acute osteomyelitis and
osteonecrosis.
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 8 I
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
.
[**2131-5-10**] MRI T & L-SPINE W/ & W/O CONTRAST: IMPRESSION: Limited
examination secondary to motion artifacts, vertebral mass lesion
identified at T7, T8 and T9 levels, possibly consistent with
metastatic disease, versus an over-imposed infectious process
with discitis, additionally, there is also spinal cord
compression and with edema at T9 level. Compression fracture
identified a T11, T12, L1, L2 and L4 levels. Multilevel disc
degenerative disease in the cervical, thoracic, and lumbar
spine as described above.
.
[**2131-5-22**] CT T & L-SPINE W/O CONTRAST:
1. Osseous hardware in grossly stable alignment with new
vertebral body
spacer at T7-T8. Evaluation of intrathecal detail is extremely
limited given artifact and thus epidural collection/hematoma
cannot be excluded. MRI recommended to evaluate for these
findings as indicated.
2. Progression of consolidation/collapse within the left lower
lobe of the
lung not fully evaluated on this spine study.
.
[**2131-5-22**] MRI T & L-SPINE W/ & W/O CONTRAST: 1. Significantly
limited study due to extensive artifacts from the posterior
spinal hardware from T2-L1 levels. Within these limitations,
there is posterior spinal T2 hyperintense area extradural in
location, at T8-T10 levels, causing displacement of the thecal
sac anteriorly with mild deformity of the cord but no definite
cord compression. The posterior spinal canal abnormality may
relate to fluid collection like seroma/hematoma with or without
granulation tissue.
2. Extensive artifacts noted in the upper thoracic spine,
significantly limiting evaluation of the cord at this level from
T1-T8 as the thecal sac and cord are obscured. There is
possibility of soft tissue material in the spinal canal in this
location, with mass effect on the cord until proven otherwise.
Assessment of the cord at this level is significantly limited
due to artifacts.
This can be further evaluated with the CT myelogram to assess
the outline of the thecal sac and any mass effect on the thecal
sac, and the intrathecal contents, if there is continued concern
based on the clinical symptoms.
3. Multilevel extensive degenerative changes in the cervical and
the lumbar
spine as described before causing moderate spinal canal stenosis
or neural foraminal narrowing in the lumbar spine. Please see
the detailed report on the prior study done on [**2131-5-10**].
4. Evaluation for prevertebral soft tissue or abnormal
enhancement is limited on the present study due to lack of fat
saturated sequences. There is increased STIR signal noted in the
prevertebral soft tissues at the level of T8-T10, representing
prevertebral soft tissue swelling, the cause of which can relate
to edema, fluid collection, or abscess. Post-surgical changes in
the thoracic spine at multiple levels, most prominently at T7-T9
levels, not adequately assessed due to artifacts.
.
[**2131-6-2**] UNIL HIP XRAY: Three views of the left hip were
reviewed. There is no evidence of fracture. There is no evidence
of dislocation. There is no evidence of pathological sclerosis.
The vascular calcifications are demonstrated in the femoral
artery.
.
[**2131-6-3**] CT ABD/PELVIS: 1. Large amount of stranding as well as
several fluid collections seen along the posterior spine
extending from the lower cervical level to the upper thoracic
spine level, likely postoperative in nature. No CT sign of
infection, however this cannot be completely excluded by imaging
alone.
2. Small bilateral pleural effusions, greater on the right with
bilateral
lower lobe atelectasis.
3. No acute intra-abdominal process.
4. Postoperative thoracic spine changes as described.
.
[**2131-6-15**] EEG: This is an abnormal portable EEG recording due to
the slow
and disorganized pattern and the bursts of generalized slowing.
This abnormality suggests a widespread encephalopathy.
Medications, metabolic disturbances, and infection are among the
most common causes. Of note is that although the right leg
twitching had no EEG correlate it does not completely exclude
the possibility of the patient having focal motor seizures.
There are no epileptiform features seen in this recording and no
lateralized features. Note is made of a tachycardia with a
single ectopic beat.
.
[**2131-6-16**] CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST: Pansinus
mucosal thickening, most prominent in the right maxillary sinus
where a combination of mucosal thickening and inspissated
secretions are observed. The findings may represent sinusitis.
No focal fluid collections are seen.
.
[**2131-6-16**] MRI T-SPINE W/ & W/O CONTRAST:
1. Since the previous MRI of [**2131-5-22**], there is now increased
fluid seen surrounding the interbody device placed following
corpectomy with fluid extending into the anterior epidural space
on the left side, narrowing the
spinal canal at T7 and T8 level with compression of the spinal
cord.
2. Superficial fluid collection in the left upper thoracic
region and also
fluid extending from laminectomy site to subcutaneous fat in the
upper thoracic region. The fluid extending from the laminectomy
site to the subcutaneous fat has considerably decreased since
the previous study.
3. Extensive bilateral pleural parenchymal changes in the lungs,
which can be further evaluated with CT of the chest.
.
[**2131-6-16**] MRI L-SPINE W/ & W/O CONTRAST: Compressions of T12 and
L1 vertebral bodies identified. The compressions may have
slightly increased since the previous study. Multilevel
degenerative changes are seen in the lumbar region. No
intraspinal fluid collection in the lumbar region. Small fluid
collection left of the midline at L3-4 level within the
subcutaneous fat as described above.
Brief Hospital Course:
HPI:
50 y.o female with COPD, htn, DM2, IgG, IgA deficiency, hx colon
CA w/ colostomy, from [**Hospital3 **] Hospital from rehab [**5-9**] with
SOB, hypoxia though to be secondary to COPD exacerbation. There
she complained of LE weakness. Chest CT there showed T7-T9
destruction with soft tissue swelling and concern for
disciitis/epidural abscess and MRI T spine showed evidence of
cord compression with epidural abscess seen from T7-T10.
Brief Hospital Course:
Pt transferred from OSH on [**5-10**] underwent Fusion T2-L1, Extra
cavitary decompression T7-T8, Multiple thoracic laminotomies,
Multiple lumbar laminotomies, Osteotomy T7, 8, 9,
Instrumentation, T2-L1, Autografts. Subsequent osteo w/ MRSA
growing from T7-T10 to OR [**5-20**]: Partial vertebrectomies of T6, 7
and 8, Fusion T6-T9, Anterior spacer, Autograft, bone
morphogenic protein, and allograft, bronchoscopy. Developed
hematoma [**5-23**] went back to OR for Revision laminectomies T6, 7
and 8, Incision and drainage, Debridement. [**5-24**] she was
bronched w/ Left lung collapse secondary to mucus retention. Pt
failed weaning trials off vent and underwent trach [**6-5**]. Low
grade temps w/ known MRSA spine osteo, Pseudomonas VAP & UTI,
C.Diff. On Vanc + Rif 6wk course to d/c [**7-5**]. On 25mg
prednisone since COPD exac [**5-9**], weaning started [**6-12**].
Persistently agitated, q/ questionable pain control during
course. Psych, neuro, CPS consults. Neuro rec EEG r/o seizures
[**6-13**]. IVC filter placed during hospital course d/t risk of
anticoagulation. PEG placed [**6-12**] for TF. Repeated failed trach
collar trials, ? vent rehab, but persistent fevers w/ most
recent culture sputum pos sparse pseudomonas. blood and urine
cultures pending. Known persistent peri-spinous fluid
collection, no imaging or surgical procedures intended, per
neurosurg.
Operative Dates:
[**2131-6-12**] PEG (bedside)
[**2131-6-5**] trach, bronch
[**2131-5-24**] bronch
[**2131-5-22**] epidural evac
[**2131-5-20**] L thoracotomy, ant T6-8 corpectomies, ant cage T6-T9
[**2131-5-10**] Fusion T2-L1, mulit T-L lami, IVC filter, CT R and L
Antibiotic:vanco/cefepime/flagyl/rifampin
Anticoagulant:SQH
TLD:IVC filter:Day37
Foley:Day4
PMH: MRSA, sepsis due to osteomyelitis of the MTP joint s/p
resection
s/p long term tx with vancomycin; COPD, severe, O2 dependent;
h/o hypercapnic respiratory failure; requiring intubation,
Costocondritis
History of PE (on coumadin), Chronic anemia, DM with neuropathy
CHF, Diverticulosis, Colon CA s/p colostomy, h/o SBOs, s/p
hysterctomy c/b abd wound dehiscence, h/o Cdiff colitis
HTN, IgA and IgG deficiency, hypercholesterolemia, Gout,
Restless leg syndrome
Meds: Albuterol 2.5 QID, atrovent 0.5 QID, cardizem 60 QID,
prilosec 20', SSI; prednisone po 25', vit C 500", gabapentin
300"; requip 0.25 po tid; mvi, oxycontin cr 40", colace prn;
maalox prn; bisacodyl prn; percocet prn
ID - flagyl PO until leaves; at that point, switch to PO vanco
AND stays on IV vanco - total 6 weeks; rifampin for hardware,
will need weekly LFTs
Micro/Imaging:
[**2131-6-13**] urine pending
[**2131-6-13**] blood NGTD
[**2131-6-12**] blood NGTD
[**2131-6-11**] sputum Pseudomonas, Yeast
[**2131-6-11**] urine >100k yeast
[**2131-6-11**] blood x2 NGTD
[**2131-6-4**] sputum Pseudomonas
[**2131-6-2**] blood ngtd
[**2131-6-2**] urine GNRs, yeast
[**2131-6-2**] sputum Pseudomonas
[**2131-6-2**] cath tip ngtd
[**2131-6-2**] cdiff neg
[**2131-6-1**] sputum Pseudomonas
[**2131-5-27**] BAL no PMN, no micro; MRSA
[**2131-5-25**] BAL RLL 1+PMN, no micro; MRSA
[**2131-5-25**] BAL LLL 1+ PMN, no micro; MRSA
[**2131-5-21**] BAL No PMNs, no micros; 3000 yeast
[**2131-5-21**] BAL 2+ PMNs, no micros: 3000 yeast
[**2131-5-21**] tip NG
[**2131-5-18**] cdiff neg
[**2131-5-12**] cdiff POSITIVE
[**2131-5-12**] sputum >25 PMNs, <10 epis, GPC, GPR; +yeast (sparse)
[**2131-5-12**] blood ng final
[**2131-5-11**] picc tip ng final
[**2131-5-11**] blood ng final
[**2131-5-10**] T7 2+ GPC, MRSA
[**2131-5-10**] T8 4+ PMN, 1+ GPC, MRSA
[**2131-5-10**] blood x2 ng final
Events:
[**2131-6-14**] transferred to medicine
[**2131-6-13**] febrile, recultured, ID reconsulted
[**2131-6-12**] PEG, febrile again, foley changed -lots yeast per nsg,
ID rec'd surv.clx
[**2131-6-12**] psych -rec'd EEG/neuro c/s for jerking, stop zyprexa,
check CK
[**2131-6-11**] awaiting PEG placement, pancultured for fever - UClx >
100K yeast
[**2131-6-10**] diuresing, IP - unable to tap effusions, preop for PEG
[**2131-6-10**] episode hypotension after meds?? resolved w/IVF, time
[**2131-6-8**] CPS consult
[**2131-6-6**] bronch, diuresis, rehab screen - unable to wean off
vent
[**2131-6-5**] OR for open tracheostomy; ID rec'd no double coverage
for pseudomonas
[**2131-6-4**] GYN c/s - no vaginal bleeding
[**2131-6-3**] CT torso - no intraabd process; vag bleeding
[**2131-6-2**] T spike to 101.6 -> started cefepime for presumed VAP
[**2131-6-1**] intubated
[**2131-5-31**] diamox stopped; ?PICC
[**2131-5-30**] passed swallow - thin liquids
[**2131-5-28**] extubated; started on rifampin; L CT pulled; ID - add
rifampin, weekly LFTs
[**2131-5-26**] L chest tube pulled back 4cm
[**2131-5-25**] reintubated, bronch
[**2131-5-24**] L white out; bronch - mucous plugs, 20 lasix
[**2131-5-23**] R CT pull,ed post pull R apical PTX; 3upRBC
[**2131-5-22**] new LLE weakness, ?epidural collection
[**2131-5-21**] BAL - plugs
[**2131-5-20**] OR; 800 EBL, resite L CT; got dose of lovenox
[**2131-5-16**] extubated
[**2131-6-5**] Trach placed-respl failure secretions.
Assessment:
50F epidural abscess on MRI T7-10, s/p T2-L1 fusion, bilat CT
placement s/p epidural evac s/p trach/bronch now s/p PEG
placement
Plan:
Neuro: pain regiment per CPS
CV: home dilt, PO lopressor, stable hemodynamically thus far
Pulm: cont pred taper, remains vent dependent
GI: cont TF, advance to goal
ID: febrile once again, f/u ID consult recs; d/c hydral/reglan -
??drug fever, cont vanc x 6 wks; per ID; cefepime for VAP;
flagyl for CDiff; Rifampin for hardware - weekly LFTs; cont
surveillance clx, ??scan back
GU: urine > 100K yeast -rec treatment
Transferred to medicine [**6-14**]- thank you for your care
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Hospital course after transfer to MICU service (SICU above
completed by surgical RN):
#. Fevers: Patient had had multiple infectious processes during
prolonged hospitalization and had defervesced for several days
before again starting to spike fevers. Initial concern was for
recurrent epidural process because of persistently draining
superficial wound. MRI T and L spine showed with new fluid
collection concerning for abscess tracking back to epidural
space. An attempt by interventional radiology was made to drain
this fluid collection, but was unsuccessful. She was continued
on Vancomycin and rifampin for at least a 6 week course (last
day [**2131-7-5**]) for her epidural abscess. Will continue flagyl
while on this regimen to prevent CDiff. In addition she had
copious secretions and completed an 8 day course of cefipime for
VAP (last dose [**2131-6-16**]). Also, her urine grew yeast on two
different occasions despite changing of the foley and she was
treated with fluconazole for 7 days (last dose [**2131-6-20**]). In
addition to infectious etiologies, drug fever was also
considered and medications that could potentially contribute
were discontinued including gabapentin, famotidine, and
hydralazine. The patient remained afebrile after these
interventions for > 5 days prior to discharge.
#. Epidural abscess: Pt continued on vanc and rifampin (last
dose [**2131-7-5**]). Pt noted to have continued purulent drainage from
surgical site. MRI T and L spine on [**6-15**] showed new fluid
collection concerning for abscess tracking back to epidural
space with evidence of cord compression on Radiology read. Ortho
Spine attending felt that this was mild and recommended
CT-guided aspiration on [**2131-6-18**] however per radiology the fluid
collection was too small to tap and may all be related to
post-op changes so no tap was done. Vanc and rifampin to
continue until [**2131-7-5**] and while on these she will remain on
flagyl for CDiff. Will f/u with Dr. [**Last Name (STitle) 363**] for further treatment
as outpatient in 10 days.
#. VAP: Patient had been diagnosed with VAP a few days prior to
transfer to medical service and completed 10 day cefepime course
for pseudomonal VAP.
#. Yeast UTI: Patient was noted to have yeast in the urine even
after foley changed. She was treated with fluconazole X 7 days.
#. Weakness: The patient noted to have low tidal volumes leading
to difficulty with weaning off vent. Thought to have components
from both critical illness myopathy as well as oversedation from
polypharmacy. She was placed on tapers of clonidine, neurotin,
and steroids and was able to be weaned off vent to trach mask
for several hours daily at time of discharge.
#. Agitation/altered mental status: Had some upper extremity
"twitching" after starting zyprexa. EEG consistent with
widespread encephalopathy. Evaluated by psych/neuro. Tapered off
of nonessential medications including steroids, clonidine,
ativan, and neurontin with improvement in mental status. Also
started on fentanyl patch for better pain control.
#. Tachycardia: Sinus on multiple EKGs with rates 100-130s.
Likely [**2-12**] agitation and pain. Has been treated with pain meds
and with sleep does come down. Would continue to treat pain and
agitation PRN and check EKG if irregular or rate >130.
#. Hypercarbic respiratory failure: In setting of VAP and volume
overload. Has been tolerating trach mask for 3-4 hours twice
daily. PCO2s at baseline on vent are in 70s. Has been receiving
lasix (10 mg IV daily PRN for diuresis if appears overloaded on
exam.
#. Hypercalcemia: Has had slowly trending up calcium. Suspect
immobilization. Will need to check calcium at least weekly and
more often if symptoms of hypercalcemia develop and treat
appropriately.
Medications on Admission:
Albuterol 2.5mg neb 4x daily
Atrovent 0.5 4x daily
Cardizem 60mg 4x daily
Prilosec 20 po daily
ISS
Prednisone po 25'
Vitamin C 500 po bid
Gabapentin 300 [**Hospital1 **]
Requip 0.25 po tid
MVI
Oxycontin cr 40 po q12h
Colace prn
maalox prn
bisacodyl prn
percocet prn
Discharge Medications:
1. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]:
15-30 MLs PO QID (4 times a day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
4. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for to affected skin.
5. Rifampin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q12H (every
12 hours).
6. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
7. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
2-4 Puffs Inhalation Q2H (every 2 hours) as needed for wheezing.
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: [**2-14**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Insulin Regular Human 100 unit/mL Solution [**Month/Day (3) **]: per sliding
scale units Injection ASDIR (AS DIRECTED).
11. Lorazepam 0.5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO TID (3 times
a day).
12. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (3) **]: One (1)
injection Injection TID (3 times a day).
13. Prednisone 10 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily)
for 3 days: switch to 5mg x3 days once this has been completed
then off.
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
gram Intravenous Q 24H (Every 24 Hours): course to continue
until [**2131-7-5**].
20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
21. 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.
22. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
23. Transportation
Please book transportation to [**Hospital1 18**] for follow-up appointments
listed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Pseudomonal Ventilatory Associated Pneumonia
hypercarbic respiratory failure
malnutrition
spine methacillin-resistant staph aureus osteomylitisepidural
abcess
clostridium deficile colitis
Delirium
fungal urinary tract infection
anxiety
diabetes mellitus
Discharge Condition:
Hemodynamically stable, requiring CPAP w/ PS from ventilator.
Discharge Instructions:
You were treated for your epidural abcess and MRSA osteomyelitis
of the spine. You required multiple surgical interventions to
treat this and will continue to require long-term antibiotics to
treat your osteomyelitis and clotridium deficile colitis. During
your stay, you also had respiratory failure and continue to
require ventilatory support.
Medications:
- Vancomycin/Rifampin until [**2131-7-5**], with likely plan for
bactrim suppression to follow
- Flagyl 1 week after vancomycin has been discontinued
Followup Instructions:
It is essential that you follow up with the infectious disease
team as scheduled below in order to continue to insure proper
antibiotic treatment:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2131-7-2**] 11:30
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] (spine surgery) on [**2131-6-28**] 1:30pm at [**Hospital1 18**]
[**Hospital Ward Name 23**] 2 [**Hospital **] Clinic. Please call ([**Telephone/Fax (1) 3573**] with
questions.
Completed by:[**2131-6-20**]
ICD9 Codes: 5119, 4280, 4019, 2749, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6580
} | Medical Text: Admission Date: [**2147-10-6**] Discharge Date: [**2147-10-12**]
Date of Birth: [**2091-5-23**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2147-10-9**]: Left occipital craniotomy for biopsy and debulking
of brain mass
History of Present Illness:
This is a 56 year old gentleman without significant PMH with
complaint of 3 weeks of headache. He was evaluated by his PCP.
[**Name10 (NameIs) **] was given ativan for headache and anxiety without relief. CT
done revealed a left parietal mass. He was instructed to go to
the ED ([**University/College **] Hitchcock). Was evaluated
there and given Dilaudid for pain. His mental status was
declining so
patient given decadron x10 and medflighted to [**Hospital1 18**].
Neurosurgery
consult requested for evaluation.
Past Medical History:
HL
s/p appy
s/p vasectomy
Social History:
He is married. He lives with wife in [**Name (NI) **],
[**Name (NI) **]. He works in a chemical comapny. He does not smoke
cigarettes or use illicit drugs. He drinks alcohol
occasionally.
Family History:
His parents are alive and well. His mother has
memory problems while his father has a history of coronary
artery
disease and underwent bypass surgery. His sister died in her
40's with a glioblastoma. He has 2 other siblings and they are
healthy. He has 3 children; one was born premature and has
cerebral palsy while the other two are healthy.
Physical Exam:
Admission examination:
PHYSICAL EXAM:
O: T: 97 BP: 127/65 HR: 60 R 12 O2Sats 99%RA
Gen: laying on stretcher, asleep
HEENT: Pupils: 2.5-2mm
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: lethargic. arouses to voice/light stimuli
Orientation: Oriented to self only
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-4**] throughout.
PHYSICAL EXAM UPON DISCHARGE-
awake, alert to self, hospital.
PERRL, EOMI
face symmetric, tongue midline
full strengths x4
Incision- staples intact, well healing
Pertinent Results:
Admission labs:
[**2147-10-6**] 12:35PM BLOOD WBC-10.3 RBC-4.50* Hgb-14.4 Hct-42.5
MCV-95 MCH-32.1* MCHC-33.9 RDW-12.4 Plt Ct-298
[**2147-10-6**] 12:35PM BLOOD Neuts-90.8* Lymphs-6.8* Monos-1.9*
Eos-0.4 Baso-0.2
[**2147-10-6**] 12:35PM BLOOD PT-13.4 PTT-21.4* INR(PT)-1.1
[**2147-10-6**] 12:35PM BLOOD Glucose-123* UreaN-16 Creat-0.9 Na-137
K-4.4 Cl-102 HCO3-23 AnGap-16
[**2147-10-6**] 12:35PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
[**2147-10-6**] 12:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Radiology:
CT HEAD W/O CONTRAST Study Date of [**2147-10-6**] 12:40 PM
IMPRESSION: Large ill-defined left occipitoparietal mass with
associated
vasogenic edema and hemorrhage exerting mass effect including
subfalcine and
uncal herniation. Early signs of hydrocephalus.
.
MR HEAD W & W/O CONTRAST Study Date of [**2147-10-6**] 4:37 PM
IMPRESSION: Left occipital irregularly enhancing mass with
chronic blood
products and several low-signal areas indicative of areas of
necrosis. The
findings are suggestive of an infiltrative primary neoplasm such
as glioma. There is extensive surrounding edema seen with
left-sided uncal herniation and distortion of the midbrain
resulting in moderate obstructive hydrocephalus. No restricted
diffusion is seen.
.
CTA HEAD W&W/O C & RECONS Study Date of [**2147-10-7**] 12:56 AM
IMPRESSION: Left occipital mass demonstrates no evidence of
acute hemorrhage. Increased vascularity is seen predominantly
from the left posterior cerebral artery with no large draining
veins identified or arteriovenous malformation is seen. Vascular
displacement is seen but no aneurysm is identified.
.
CT HEAD W/O CONTRAST Study Date of [**2147-10-9**] 5:08 PM
FINDINGS: There has been interval left parieto-occipital
craniotomy, with
overlying skin staples and mild pneumocephalus. Changes of tumor
debulking
are noted in the left parietal region, with adjacent hyperdense
material
representing hemorrhage and/or post-surgical changes. Just
inferior to this region, there is evidence of residual
hyperdense tumor involving the left occipital lobe, temporal
lobe, and splenium. Persistent surrounding vasogenic edema
extends superiorly into the left parietal and posterior frontal
lobes, and inferiorly into the left temporal lobe. Left cerebral
sulci are diffusely effaced, and the left lateral ventricle is
compressed. There is continued 9-mm rightward subfalcine
herniation, and 8-mm rightward shift at the level of the third
ventricle. Continued slight widening of the left ambient cistern
relative to the right is suggestive of impending uncal
herniation.
Coarse calcifications are noted in the bilateral cavernous
carotid arteries. Middle ear cavities and mastoid air cells are
clear. Paranasal sinuses are well aerated. The orbits and
intraconal structures are intact.
IMPRESSION: Tumor debulking, with stable rightward mass effect
and subfalcine herniation.
.
MR HEAD W & W/O CONTRAST Study Date of [**2147-10-10**] 10:22 AM
IMPRESSION: Status post left occipital craniotomy and tumor
resection with
expected postoperative changes. Areas of enhancement within the
left
occipital and left temporal lobes are consistent with residual
tumor.
Rightward shift of midline structures and left uncal herniation
is unchanged.
Brief Hospital Course:
This is a 56-year-old left handed man, with no significant past
medical history with progressive forgetfulness, confusion, right
parietal headache and nausea and voomiting who eventualy
developed right-sided weakness and initiallty presented to the
[**University/College **] Hitchcock ED on [**2147-10-6**]. CT head scan there revealed
a large left parietal mass with signifcant mass effect. Given a
decrease in conscious level following narcotics for headache, he
was MedFlighted to the [**Hospital1 18**]. He was assessed by neurosurgery,
loaded with phenytoin and admitted to the neurosurgery ICU on
[**2147-10-6**]. His cognitive symptoms improved somewhat and MRI
revealed a left occipital irregularly enhancing mass with
chronic blood products and areas suggestive of necrosis in
addition to extensive edema with left uncal herniation and
distortion of the midbrain resulting in moderate obstructive
hydrocephalus. He was administered mannitol and dexamethasone
and a CTA head showed increased vascularity is mainly from the
left PCA. Neuro-oncology were consulted and he proceeded to a
left parietal craniotomy with subtotal tumor debulking and
decompression. Postoperatively the patient was extubated and
transferred to the ICU for Q1 hour neurochecks and SBP control
less than 140. Post op CT was stable, without evidence of
hemorrhage and postop MRI demostrated subtotal resection of
tumor. He did well post-operatively and was transferred to the
floor on [**2147-10-10**]. Decadron was weaned to 2mg TID which he
will continue on until follow up. He was seen on PT/OT on [**10-11**].
It was recommended that he be discharged to inpatient rehab. On
[**10-12**] he was cleared for discharge.
Medications on Admission:
Lipitor
Ativan
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, T>38.5.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8hrs ().
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
10. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for no bm .
12. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for no bm.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 12017**] VNA
Discharge Diagnosis:
Left Occipital Brain Tumor
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
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.
?????? Dressing may be removed on Day 2 after surgery.
?????? Your wound was closed with staples. You must wait until after
they are removed to wash your hair. 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) &
Senna while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed 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**].
?????? If 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.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2147-10-16**]
at 11:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2147-10-12**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6581
} | Medical Text: Admission Date: [**2195-12-31**] Discharge Date: [**2196-1-6**]
Date of Birth: [**2111-7-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Multiple blood transfusions
Upper endoscopy
History of Present Illness:
Briefly, patient is an 84 year-old man with CAD s/p CABG, DM,
and HTN who presented with 2 days of black stools and coffee
ground emesis. He had been feeling lethargic and lightheaded.
He has not been using any new medications and has not had a
prior GIB.
.
In the ED, initial VS: 98.7 88 65/47 98%/RA. He had an NG
lavage with coffee ground emesis that cleared with 600 cc of
flushing. During the lavage he had chest pressure and an EKG
showed STD in V2-4. He did not have radiation, pain, or
diaphoresis. EKG was reviewed with cards. His chest pain
resolved after getting 1 unit of PRBCs and 1.1 L NS. Subsequent
EKGs showed resolution of changes. He was also treated with
zofran and protonix bolus + gtt 80/8. Initial Hct 18.7.
.
In the MICU, his chest pressure and lightheadedness resolved.
Patient received 4 more units of PRBCs (total of 5). Pt has not
had any further bleeding. He has been hemodynamically stable in
the MICU. Access: 2PIVs--18, 20.
.
Here, he had an upper endoscopy that revealed a duodenal ulcer
with stigmata of recently bleeding. He has been hemodynamically
stable. He has no complaints at this time except hunger.
Past Medical History:
Coronary artery disease s/p triple-vessel coronary artery bypass
in [**9-/2182**]
Hypertension
Peripheral arterial disease
Hypercholesterolemia
Diabetes
Osteoarthritis
Gout
Anemia Baseline 32-35 with unrevealing w/u by heme
Right hernia repair in [**2161**]
Appendectomy in [**2125**]
Prostate disease
Physical Exam:
GENERAL: NAD, comfortable, A&Ox3
HEENT: [**Last Name (LF) 12476**], [**First Name3 (LF) 15315**] cheeks
CARDIAC: RR 2/6 systolic murmur loudest at apex
LUNG: CTAB no w/r/r
ABDOMEN: +BS, soft, NT, ND
EXT: WWP, 2+ PT/DP pulses
NEURO: grossly nonfocal
DERM: no rashes
Pertinent Results:
[**2195-12-31**] 06:15PM BLOOD WBC-9.9 RBC-1.98* Hgb-6.3* Hct-18.7*
MCV-94 MCH-31.6 MCHC-33.5 RDW-15.8* Plt Ct-139*
[**2196-1-1**] 11:25AM BLOOD WBC-8.9 RBC-3.36*# Hgb-10.5*# Hct-29.4*#
MCV-88 MCH-31.4 MCHC-35.8* RDW-16.0* Plt Ct-100*
[**2196-1-1**] 11:25PM BLOOD Hct-27.3*
[**2196-1-6**] 06:50AM BLOOD WBC-6.8 RBC-3.85* Hgb-11.9* Hct-34.3*
MCV-89 MCH-30.9 MCHC-34.6 RDW-16.1* Plt Ct-125*
[**2196-1-3**] 07:05AM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2195-12-31**] 06:15PM BLOOD Glucose-300* UreaN-95* Creat-1.7* Na-145
K-4.6 Cl-108 HCO3-17* AnGap-25*
[**2196-1-3**] 07:05AM BLOOD Glucose-175* UreaN-14 Creat-1.0 Na-143
K-4.0 Cl-112* HCO3-24 AnGap-11
[**2196-1-6**] 06:50AM BLOOD Glucose-156* UreaN-17 Creat-1.3* Na-141
K-3.2* Cl-105 HCO3-23 AnGap-16
[**2195-12-31**] 09:27PM BLOOD ALT-12 AST-13 LD(LDH)-183 AlkPhos-25*
TotBili-1.0
[**2196-1-1**] 02:44AM BLOOD CK(CPK)-72
[**2196-1-1**] 11:25PM BLOOD CK(CPK)-130
[**2195-12-31**] 06:15PM BLOOD Lipase-72*
[**2195-12-31**] 06:15PM BLOOD cTropnT-<0.01
[**2196-1-1**] 02:44AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2196-1-1**] 11:25PM BLOOD CK-MB-5 cTropnT-0.09*
[**2196-1-5**] 07:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8
[**2196-1-2**] 02:58PM BLOOD %HbA1c-6.1*
[**2195-12-31**] 09:35PM BLOOD Lactate-2.5*
**FINAL REPORT [**2196-1-4**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2196-1-4**]):
POSITIVE BY EIA. (Reference Range-Negative).
ECHO [**2196-1-5**]
The left atrium is elongated. The left ventricle is not well
seen. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is mild moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mitral
regurgitation was seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild to moderate aortic
stenosis (valve calculation may overestimate severity due to
underestimation of outflow tract velocity). Preserved
biventricular global systolic funcction.
Endoscopy Report
Ulcer in the apex of duodenal bulb (injection)
Tortugas esophagus
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
ASSESSMENT & PLAN: Mr. [**Known lastname 4612**] is an 84 man with CAD s/p CABG,
DM, HTN who presented with a GI bleed and developed chest
pressure.
.
# Bleeding duodenal ulcer: Duodenal ulcer with stigmata of
recent bleeding seen on EGD [**1-1**]. In total, he required 6 units
of pRBC's. His hematocrit was stable prior to discharge. He was
having dark stools that were gradually clearing. He was
tolerating a regular diet. He had plans to re check his
hematocrit shortly after discharge. His was discharged on high
dose pantoprazole. His serum was positive for H. pylori. He was
treated with a course of two weeks of clarithromycin and
amoxicillin.
.
# NSVT: Patient had several runs of NSVT. These were less
frequent after optimization of electrolytes.
.
# Chest pain: No further episodes were present during the
hospitalization. Inferior/lateral EKG changes were concerning
for demand ischemia. This was not ACS. We continued his home
statin. No aspirin was given considering his recent bleeding.
His beta blocker was restarted. An echo was repeated whiched
showed mild to moderate aortic stenosis. However, the image
quality was suboptimal and should be followed up. Of note, Mr.
[**Known lastname 4612**] was told to stop his statin for the two weeks he is on
clarithromycin. He was told to restart following completion of
his antibiotic course.
.
# Acute renal failure: Given his significant volume depletion,
he had acute renal failure. This improved by the time of
discharge, but was not at his baseline.
.
# Diabetes: He was placed on an insulin sliding scale. His oral
medications were restarted on discharge.
.
# Hypertension: On initial presentation all oral medications
were stopped. Gradually his home regimens were titrated up. Even
on his home doses, he was having blood pressures elevated to
200. His metoprolol dose was increased to 75 mg [**Hospital1 **] which
resulted in improved control.
.
# Thrombocytopenia: Patient's platelet counts decreased to a low
of 88. They gradually increased to 125 on the day of discharge.
.
# PPX: He received high dose pantoprazole and pneumoboots.
.
# CODE: He was a full code during this admission.
Medications on Admission:
confirmed with pharmacy on [**1-2**] at 1800
ALLOPURINOL 300 mg Tablet by mouth daily
GLIPIZIDE 5 mg Extended Rel by mouth twice as day
LOSARTAN [COZAAR] 100 mg by mouth [**Hospital1 **]
METFORMIN 500 mg by mouth [**Hospital1 **]
METOPROLOL TARTRATE 50 mg [**Hospital1 **]
SIMVASTATIN 80 mg Tablet by mouth daily
ASPIRIN 81 mg Tablet by mouth daily
Discharge Medications:
1. Losartan 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. 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*
3. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO twice a
day for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
4. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO twice a day.
8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Final Diagnosis:
Upper gastrointestinal bleed
Duodenal Ulcer
Secondary Diagnosis:
Hypertension
Coronary Artery Disease
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital with bleeding in your stool.
You had a procedure called an endoscopy to look at the source of
bleeding. An ulcer was found in your duodenum, the first part of
your intestine. A medicine was injected into the area to help
stop it from bleeding.
It is very important that if you notice any new blood from your
rectum to notify your doctor of come to the emergency department
immediately.
We have changed several of your medications.
We stopped your aspirin because of your bleeding. Do not restart
this until you discuss it with your GI physician.
[**Name10 (NameIs) **] increased your metoprolol to 75 mg twice a day.
We are giving you two antibiotics: clarithromycin and
amoxicillin. It is important to take these for two weeks. These
are treating an infection which may have caused your ulcer to
form.
Please stop your simvastatin (cholesterol medicine) for two
weeks. You can restart this after you are finished with the
antibiotics.
We started pantoprazole 40 mg twice a day. It is very important
to continue to take this until you discuss it with your GI
physician.
[**Name10 (NameIs) **] needed to help move your bowels, you can take docusate twice
a day.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name (STitle) 15316**] [**Name (STitle) 12646**]
Specialty: PCP
Date and time: Monday, [**1-11**] at 1:00pm
Location: [**Street Address(2) 15317**], [**Location (un) **],[**Numeric Identifier 809**]
Phone number: [**Telephone/Fax (1) 4615**]
Appointment #2
MD: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: Gastroenterology
Date and time: Tuesday, [**2-9**] at 2:00pm
Location: [**Last Name (LF) **], [**First Name3 (LF) 452**] Bldg [**Location (un) **], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 463**]
Please have your blood checked at Dr.[**Name (NI) 12754**] office
tomorrow ([**1-7**]) at 10 AM.
ICD9 Codes: 5849, 2851, 4271, 2762, 4241, 2875, 4019, 2749, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6582
} | Medical Text: Admission Date: [**2132-11-27**] Discharge Date: [**2132-11-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88 F w/ severe Alzheimer's dementia, CAD w/ severe anterior
reversible defects on MIBI in '[**29**] on medical management, now w/
rest pain and ECG changes. Per daughter (HCP) pt is not an
invasive candidate and DNR/DNI. In [**Name (NI) **], pt recieved asprin 325
and heparin gtt.
.
Currently, pt feels well and denies SSCP or SOB.
Past Medical History:
1. AD
2. HTN
3. Chronic anemia, + thal trait
4. CAD, + angina, stress test [**4-18**] w/ ischemic EKG changes w/o
angina, mild reversible perfusion defect at apex and entire
anterior wall, EF approx 60%, fam decided for med treatment
only.
5. S/p chole
6. S/p appy
7. S/p facelift
8. psoriasis
9. S/p B cataract [**Doctor First Name **]
Social History:
Lives with daughter.
[**Name (NI) 6934**] without assistance.
Distant tobacco.
No etoh.
She is a retired nurse's aid.
Family History:
m- dm
f- asthma
Physical Exam:
AF 78 104/65 14 98%RA
Gen: NAD, A&O X 3
Heent: EOMI, PERRL, MMM
Neck: JVP ~7cm H20
Heart: RRR no mr. + S4
Lungs: Clear, no crackles
Abd: Benign
Ext: No edema, warm extremities, 1+ dp/pt's bilateral.
Pertinent Results:
Hematology:
[**2132-11-27**] 04:00PM BLOOD WBC-7.0 RBC-4.93 Hgb-10.4* Hct-30.6*
MCV-62* MCH-21.2* MCHC-34.1 RDW-13.9 Plt Ct-280
[**2132-11-27**] 04:00PM BLOOD PT-11.6 PTT-23.1 INR(PT)-1.0
.
Chemistry:
[**2132-11-27**] 04:00PM BLOOD Glucose-101 UreaN-17 Creat-1.1 Na-137
K-4.8 Cl-101 HCO3-28 AnGap-13
[**2132-11-27**] 04:00PM BLOOD CK(CPK)-29
[**2132-11-28**] 12:35AM BLOOD CK(CPK)-26
[**2132-11-28**] 07:35AM BLOOD CK(CPK)-29
[**2132-11-29**] 07:30AM BLOOD CK(CPK)-34
[**2132-11-27**] 03:59PM BLOOD cTropnT-<0.01
[**2132-11-27**] 04:00PM BLOOD CK-MB-2
[**2132-11-28**] 12:35AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2132-11-28**] 07:35AM BLOOD CK-MB-3 cTropnT-<0.01
[**2132-11-29**] 07:30AM BLOOD CK-MB-NotDone cTropnT-LESS THAN
.
ECG: NSR, 2mm STE in aVR, diffuse ST depressions and TWI
including II, aVF, V3-V6. LAFB. No STE in V4R. No ST depressions
in V7-V9.
.
CXR: Clear.
.
Brief Hospital Course:
87 yo fem c alzheimer's disease, known uncontrolled HTN and
known CAD now p/w ACS and ECG worrisome for diffuse
subendocardial ischemia.
.
# CAD/ISchemia: ECG shows diffuse subendocardial ischemia with
elevation in aVR and diffuse ST depressions. Spoke to daughter
(HCP) today and risks/benefits of cardiac catheterization were
discussed in depth. Daughter feels medical management is
appropriate. Patient was initially chest pain free but did
develop episodic chest pain relieved with nitroglycerin. Treated
with no intention for interventional procedure unless SSCP
becomes incessant. She was continued on ASA/plavix/BB/statin.
Heparin gtt was discontinued after it was determined that there
would be no intervention. She was successfully weaned from the
nitro gtt. She was started on isordil which her BP tolerated
well.
.
#Pump: Euvolemic. Borderline normal BP. Held ACE intially to
leave room for BB/nitro.
.
# Rhythm: NSR, no issues.
.
# Anemia: Previous records show Hb EP c/w Thalassemia trait as
well as iron deficiency. Fe/TIBC 15.7% with ferritin of 47 in
[**1-20**]. She was continued on iron supplements with ascorbic acid
while on PPI. Her hematocrit remained low but stable.
.
# Dementia: Advanced dementia although still alert and very
pleasant.
Medications on Admission:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Isosorbide Dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
10. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
three times a day.
Disp:*270 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
primary: unstable angina
.
secondary:
alzheimers disease
hypertension
chronic anemia with thalassemia trait
coronary artery disease
status-post cholecystectomy
status-post appendectomy
status-post facelift
psoriasis
status-post bilateral cataract surgery
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2000ml
.
Please take all medications as prescribed.
.
Changed medications: imdur
.
If you experience worsening chest pain, shortness of breath,
nausea, vomiting, dizziness, or other concerning symptoms call
your doctor or return to the Emergency Department immediately.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
.
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB)
Date/Time:[**2132-12-11**] 11:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 4280, 4275, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6583
} | Medical Text: Admission Date: [**2159-8-17**] Discharge Date: [**2159-8-20**]
Date of Birth: [**2129-2-5**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
"tylenol overdose"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30F with a history of depression presents upon transfer from an
OSH following an acetaminophen overdose. Ms. [**Known lastname 71430**] reports
being treated over the recent weeks for a tooth infection, for
which she was prescribed Tylenol 650mg tabs. Two nights prior to
admission (evening of [**8-15**]) she had quite significant pain and
reportstaking 1-2 tabs every time she awoke from her sleep with
pain. In the morning she realized that she had taken 23 tabs and
proceeded to have nausea/vomiting and lethargy. She also notes
that she had been increasing her nightly dose of clonazepam to
help her sleep. On day prior to admission she took 2 oxycodone
5mg tabs (leftover from previous surgery) and then presented to
[**Hospital3 **] with persistent nausea/vomiting and increasing
somnolence. She was found to have ALT/AST >7000 and started on
N-acetylcysteine per protocol. She was transfered to [**Hospital1 18**] for
further management.
In the ER here, the patient was noted to appear "somnolent" with
a nonfocal neurologic examination. Asterixis was present.
Toxicology, hepatology and psych were consulted. Repeat labs
showed ALT 5742 AST 4322, INR 1.6, creatinine 1.2. Patient was
then admitted to the ICU and continued on NAC
Past Medical History:
Recent tooth infection
GERD
Hx esophageal ulcer, age 17
Anxiety
Depression
Asthma
Chronic abdominal pain attributed to uterine etiology, s/p
recent diagnostic laparoscopy in [**Month (only) **]
Dx laparoscopy [**1-/2159**] for chronic abdominal pain
Social History:
lives with fiance and her three children. smokes 1PPD. denies
EtOH, drugs.
Family History:
father died of stage IV colon cancer
Physical Exam:
ADMISSION EXAM
Temp: 98.3, HR: 62, BP: 116/77, RR: 16, O2 Sat: 99% RA
GEN: NAD. Lethargic. Oriented x3.
HEENT: Sclerae with mild icterus. Mucous membranes moist.
Dentition with multiple fillings, no obvious signs of infection.
CV: RRR. Systolic murmur heard best at LUSB.
PULM: Clear bilaterally. No w/r/r.
ABD: Well-healed infraumbilical incision. Soft, nondistended,
mild central abdominal tenderness with deep palpation. No R/G.
EXT: Warm. No edema.
NEURO: Oriented x3. CN 2-12 grossly intact. No focal deficits.
Minimal asterixis.
DISCHARGE EXAM
VS: 97.8 97/48 (97/45-133/71) 55 (55-73) 20 100% RA
GENERAL: comfortable, NAD
HEENT: PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no thyromegaly, no JVD, no LAD
HEART: RRR, no MRG, nl S1-S2
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored
ABDOMEN: Soft/ND, +mild RUQ ttp, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses
SKIN: no rashes or lesions
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, no astrexis
Pertinent Results:
ADMISSION LABS:
[**2159-8-17**] 10:10PM BLOOD WBC-6.2 RBC-4.69 Hgb-14.7 Hct-39.8 MCV-85
MCH-31.3 MCHC-36.9* RDW-12.2 Plt Ct-157
[**2159-8-17**] 10:10PM BLOOD Neuts-83.3* Lymphs-13.4* Monos-1.6*
Eos-1.5 Baso-0.3
[**2159-8-17**] 10:45PM BLOOD PT-17.5* PTT-30.0 INR(PT)-1.6*
[**2159-8-17**] 10:10PM BLOOD Glucose-104* UreaN-22* Creat-1.2* Na-141
K-3.5 Cl-105 HCO3-21* AnGap-19
[**2159-8-17**] 10:10PM BLOOD ALT-5742* AST-4322* AlkPhos-84
TotBili-1.0
[**2159-8-17**] 10:10PM BLOOD Albumin-3.8
[**2159-8-18**] 05:00AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.6
.
OTHER WORK UP
[**2159-8-18**] 09:30AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HAV
Ab-POSITIVE
[**2159-8-19**] 02:47PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2159-8-18**] 03:00AM BLOOD AFP-2.9
[**2159-8-18**] 03:00AM BLOOD HIV Ab-NEGATIVE
[**2159-8-17**] 10:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2159-8-18**] 09:30AM BLOOD HCV Ab-NEGATIVE
[**2159-8-18**] 04:17AM BLOOD Type-ART pO2-62* pCO2-34* pH-7.46*
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2159-8-18**] 04:17AM BLOOD Lactate-1.6
[**2159-8-17**] 10:10PM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2159-8-17**] 10:10PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-8-17**] 10:10PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-2
[**2159-8-17**] 10:10PM URINE Mucous-RARE
.
MICRO
urine cx negative
blood cx NGTD
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2159-8-21**]):
POSITIVE BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2159-8-20**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2159-8-20**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2159-8-20**]):
NEGATIVE <1:10 BY IFA.
Rubella IgG/IgM Antibody (Final [**2159-8-21**]):
POSITIVE by Latex Agglutination.
RAPID PLASMA REAGIN TEST (Final [**2159-8-20**]):
NONREACTIVE.
TOXOPLASMA IgG ANTIBODY (Final [**2159-8-21**]):
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
CMV IgG ANTIBODY (Final [**2159-8-21**]):
NEGATIVE FOR CMV IgG ANTIBODY BY EIA
.
IMAGING
ECG
Normal sinus rhythm. The Q-T interval is prolonged with low
voltage in the
limb leads and borderline voltage in the precordial leads.
Clinical
correlation is suggested for drug usage or history of ion
channelopathy.
ECG
Sinus bradycardia. Prolonged Q-T interval. Non-specific ST-T
wave changes.
Compared to the previous tracing of [**2159-8-18**] no change.
.
CXR
The lung volumes are normal. 3 mm calcified granuloma in the
right
upper lobe. Otherwise normal chest radiograph without evidence
of pulmonary edema or pneumonia. No pleural effusions. No
pneumothorax. Normal size of the cardiac silhouette. Normal
hilar and mediastinal contours.
.
RUQ ULTRASOUND: normal study
.
DISCHARGE LABS
[**2159-8-20**] 04:45AM BLOOD WBC-5.7 RBC-3.81* Hgb-12.1 Hct-33.2*
MCV-87 MCH-31.8 MCHC-36.5* RDW-13.0 Plt Ct-203
[**2159-8-20**] 04:45AM BLOOD PT-11.9 PTT-31.8 INR(PT)-1.0
[**2159-8-20**] 04:45AM BLOOD Glucose-109* UreaN-13 Creat-1.0 Na-144
K-3.4 Cl-111* HCO3-23 AnGap-13
[**2159-8-20**] 04:45AM BLOOD ALT-1622* AST-217* AlkPhos-69 TotBili-0.5
[**2159-8-20**] 04:45AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.8
Brief Hospital Course:
This is a 30yo F with h/o depression and previous suicide
attempt now here with acute liver failure [**1-10**] Tylenol overdose.
.
# Tylenol toxicity: Patient presented to [**Hospital 8125**] hospital with
nausea/abdominal pain and somnolence. She reported taking 23
tylenol for tooth pain. She was found to have ALT and AST >7000
and transferred to [**Hospital1 18**] for further evaluation and care. In the
ER here, the patient was noted to appear "somnolent" with a
nonfocal neurologic examination. Asterixis was present.
Toxicology, hepatology, transplant surgery, and psych were
consulted. Repeat labs showed ALT 5742 AST 4322, INR 1.6,
creatinine 1.2. Patient was then admitted to the SICU overnight
and continued on NAC at 6.25mg/kg/hr. Transplant evaluation was
initiated. However, she clinically improved overnight with
improvement in liver function. At this juncture, pt did not meet
any of [**First Name4 (NamePattern1) 3728**] [**Last Name (NamePattern1) 1688**] criteria. She was transferred from the
SICU to the hepatorenal service for further care the following
day. NAC was stopped as INR < 1.5. Liver enzymes continued to
improve and patient felt well. She was able to tolerate a full
diet and denied abdominal pain, n/v. No further transplant
evaluation was pursued. She was discharged with plans to have
repeat labs drawn the next week and follow up with her PCP.
.
# Depression and h/o suicide attempt: Given patient's
psychiatric history in the setting of taking 23 tylenol,
psychiatry was consulted for evaluation. Initially the patient
was felt to meet section 12 criteria as danger to self and was
placed on 1:1 sitter. Home medications of zoloft and clonazepam
were held. Recommended haldol for psychotic symptoms and ativan
for anxiety. The following day psychiatry re-evaluated patient
and did not believe that she met criteria for section 12. 1:1
sitter was stopped. Ativan was given for anxiety. At discharge,
zoloft was started at 25 mg with plans to titrate back up to 50
mg in one week. Clonazepam also restarted. Patient was
discharged with plans to follow up with her primary care doctor
and with her therapist.
.
# Tooth pain: Patient initially presented after taking too many
tylenol for tooth pain. She reportedly took one dose of
clindamycin prior to admission. Dentist was contact[**Name (NI) **] and
patient was restarted on clindamycin for wisdom tooth infection
with plans to complete 1 week course. She was given tramadol
for pain.
.
# Tobacco Abuse: given nicotine patch
.
Medications on Admission:
Tylenol
Aleve/Ibuprofen
ProAir
Clonazepam 0.5mg TID
Zoloft 50mg daily - stopped three days prior
Clindamycin (had been on cipro, and amoxicillin, no known
augmentin)
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-10**]
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Zoloft 25 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: when complete 7 days, please resume your home dose of
zoloft: 50 mg by mouth daily .
Disp:*7 Tablet(s)* Refills:*0*
5. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO twice
a day for 6 days.
Disp:*12 Capsule(s)* Refills:*0*
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
Please check AST, ALT, Total bilirubin, alkaline phosphatase,
PT, PTT, INR. Fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 91192**]
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: tylenol toxicity
secondary diagnosis: anxiety, depression, gastroesophageal
reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 71430**],
It was a pleasure caring for you while you were in the hospital.
You were transferred to [**Hospital1 18**] for further care after taking too
much tylenol. You were initially admitted to the intensive care
unit and given a medication to help your liver. Given your
improvement, you were transferred to the liver service the
following day. Your liver continued to improve.
You were also evaluated by psychiatry while in the hospital.
Your medications were stopped given your liver injury. You can
resume your zoloft at a lower dose (25 mg) and your clonazepam
when you leave the hospital. You will need to follow up with
your primary care doctor and your therapist as scheduled.
You will also need your blood work checked next week to follow
your liver function.
The following changes were made to your medication regimen:
Please START taking ranitidine.
You may take tramadol every 6 hours as needed for pain.
Please restart your zoloft at 25 mg (instead of 50mg ). This
will be increased back to your dose of 50 mg when you see your
primary care doctor.
Do not take more than [**2147**] mg of tylenol daily.
Continue taking clindamycin for 6 more days. Please ensure you
follow up with your dentist.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 91193**], MD
Specialty: Internal Medicine/OB-GYN
Address: [**Doctor Last Name 91194**], [**Location (un) 10068**],[**Numeric Identifier 10069**]
Phone: [**Telephone/Fax (1) 91192**]
We spoke with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. You
will be contact[**Name (NI) **] by his office to schedule an appointment
within 1 week. If you do not hear from his office by Wednesday
[**8-22**], please call to schedule an appointment at
[**Telephone/Fax (1) 91192**].
Completed by:[**2159-8-24**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6584
} | Medical Text: Admission Date: [**2146-5-19**] Discharge Date: [**2146-5-25**]
Date of Birth: [**2066-8-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
1. Ascending aortic and a total arch replacement with a
size 28 Gelweave medusa graft.
2. Aortic valve replacement with a size [**Street Address(2) 6158**]. [**Male First Name (un) 923**]
tissue valve.
3. Right axillary artery cannulation.
History of Present Illness:
70 year old asymptomatic female who states that earlier this
year she presented to PCP for routine annual exam and was found
to be hypertensive. As part of her
work-up she underwent an echocardiogram which revealed dilated
ascending aorta (6.9cm) and aortic insufficiency. Subsequently
underwent chest CT which revealed ascending aortic aneurysm
which measured 6.6cm. While being worked up for surgery at
another facility she was found to have elevated Amylase in the
[**2135**] range. Given patients family history (pancreatic cancer)
she was seen by GI and underwent additional studies. Abd CT
revealed multiple large renal cysts and dilatation of the common
bile duct and head of pancreas. Underwent ERCP at [**Hospital1 **] which was negative for pancreatic cancer (per
pt). She has had surgery cancelled multiple times at another
facility and
presents today for second opinion.
Past Medical History:
Aortic Aneurysm
Aortic Valve Insufficiency
Hypertension
Osteoporosis
Breast Cancer s/p mastectomy/chemotherapy (6 yrs ago)
Elevated Amylase/Lipase (underwent full work-up by GI)
Social History:
Lives alone
Occupation: cafeteria worker
Tobacco: quit 25 yrs ago
ETOH: rare use
Family History:
Family History: Sister with Pancreatic cancer
Physical Exam:
Admission PE
Pulse: 73 Resp: 18 O2 sat: 99%
B/P Right: - Left: 135/75
Height: 5'5" Weight: 117 lb
General: Well-developed female in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: - Varicosities:
B/L
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: - Left: -
Pertinent Results:
[**2146-5-19**] intraop echo
PREBYPASS
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is markedly dilated and aneurysmal
with a diameter of 6.6 cm. There is preservation of the
sinotubular junction. The descending thoracic aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
Mild to moderate ([**12-11**]+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
POSTBYPASS
The patient is receiving no inotropic support post-CPB. There is
a well-seated bioprothesis in the aortic position with good
leaflet excurion. There is no transvalvular or paravalvular
regurgitation. The mean transvalvular gradient is 16 mm Hg at a
cardiac output of 5 L/min. Biventricular systolic function is
preserved and all other findings are consistent with pre-bypass
findings. There is a tube graft as the ascending aorta measuring
2.8 cm in diameter. All findings communicated to the surgeon
intraoperatively.
[**2146-5-25**] 05:05AM BLOOD WBC-9.4 RBC-3.90* Hgb-11.3* Hct-33.4*
MCV-86 MCH-28.9 MCHC-33.8 RDW-13.3 Plt Ct-314#
[**2146-5-19**] 12:52PM BLOOD WBC-4.5 RBC-2.75*# Hgb-7.9*# Hct-23.5*#
MCV-85 MCH-28.9 MCHC-33.8 RDW-13.8 Plt Ct-125*#
[**2146-5-24**] 05:20AM BLOOD PT-13.9* INR(PT)-1.2*
[**2146-5-19**] 12:52PM BLOOD PT-17.8* PTT-53.9* INR(PT)-1.6*
[**2146-5-25**] 05:05AM BLOOD UreaN-17 Creat-0.6 Na-133 K-3.6 Cl-95*
[**2146-5-19**] 02:04PM BLOOD UreaN-11 Creat-0.8 Na-137 K-4.0 Cl-110*
HCO3-20* AnGap-11
[**2146-5-22**] 02:59AM BLOOD Glucose-98 Lactate-1.1 Na-128* K-4.3
Cl-94*
Brief Hospital Course:
[**2146-5-19**] Mrs. [**Known lastname 11461**] was taken to the operating room and
underwent Ascending aortic and a total arch replacement with a
size 28 Gelweave medusa graft/Aortic valve replacement with a
size [**Street Address(2) 6158**]. [**Male First Name (un) 923**] tissue valve/ Right axillary artery
cannulation with Dr.[**First Name (STitle) **]. Please see Dr[**Doctor First Name **] operative
report for further details. She tolerated the procedure well and
was transferred to the CVICU on Propofol and Phenylephrine. She
was kept intubated due to sedation induced encephalopathy with
associated angioedema. She was hemodynamically stable,weaned off
drips, and extubated on POD#2 without incident.
Beta-blocker/Aspirin/Statin and diuresis initiated. She
continued to progress and was transferred to the step down unit
on POD#3 for further monitoring. Physical therapy was consulted
for evaluation of strength and mobility. [**5-24**] Mrs.[**Known lastname 11461**]
reported her voice was "raspy". ENT and speech and swallow were
consulted. Left vocal cord paralysis evident. She was cleared
for regular diet and voice correction therapy and outpatient
follow up was advised. POD# 6 she was cleared by Dr.[**First Name (STitle) **] for
discharge [**Last Name (un) 85462**]Nursing and Rehab Center in [**Location (un) 29158**]. All follow up appointments were advised.
Medications on Admission:
Fosamax 70mg qweekly
Aspirin 81mg daily
Hydrochlorothiazide 25mg daily
Labetalol 100mg [**Hospital1 **]
Ativan 0.5mg prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**5-17**]
hours as needed for fever/pain.
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day: hold if K
> 4.5.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 5502**]Nursing & Rehabilitation Center - [**Location (un) 5503**]
Discharge Diagnosis:
aortic aneurysm, aortic insufficiency s/p AVR with Replacement
of Ascending Aorta and Total Arch
PMH:
Hypertension
Osteoporosis
Breast Cancer s/p mastectomy/chemotherapy (6 yrs ago)
Elevated Amylase/Lipase (underwent full work-up by GI)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
- Dr. [**First Name (STitle) **] on [**2146-6-20**] @ 130PM Phone:[**Telephone/Fax (1) 170**]
Please call to schedule the following appointments:
- Primary Care/Cardiology Dr. [**Last Name (STitle) **],[**First Name3 (LF) 251**] R [**Telephone/Fax (1) 40420**] in
[**12-11**] weeks
- ENT follow up as an outpatient:#[**Telephone/Fax (1) 6213**]
- Voice therapy as outpt. Speech and swallow # [**Telephone/Fax (1) 3731**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2146-5-25**]
ICD9 Codes: 5185, 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6585
} | Medical Text: Admission Date: [**2138-9-12**] Discharge Date: [**2138-10-29**]
Date of Birth: [**2063-11-20**] Sex: F
Service: MEDICINE
Allergies:
Oxycodone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
thoracentesis (left and right)
dialysis catheter (right IJ)
CVVH dialysis
chest tube (left)
pigtail catheter
right HD catheter removed [**10-15**]
left subclavian removed [**10-15**]
left IJ placed on [**10-15**]
right IJ placed on [**10-27**]
Picc line (left)
Art line x 2 (right and left radials)
History of Present Illness:
The pt is a 74-yo woman w/ hypertension, hyperlipidemia,
hypothyroidism, and a recent diagnosis of ovarian cancer vs.
lymphoma, who presented to the ED for evaluation today for acute
renal failure. The pt notes that she has been feeling
increasingly SOB and weak over the last couple days, with an
episode of dizziness / lightheadedness on the day prior to
admission. The pt has not been eating well over the last few
days and had an episode of nausea / vomiting on the day prior to
admission as well. She had an abdominal ultrasound done on the
day prior to admission for evaluation for paracentesis, and labs
drawn that day showed worsening renal function, so she was
called to come in to the ED today for evaluation.
.
On arrival in the ED: VS - Temp 97.5F, HR 100, BP 111/70, R 20,
O2-sat 91% RA. Labs were significant for K 7.8, BUN 116 / Cr
7.2, WBC 14.3 w/ 92% PMNs, and lactate 2.0. CXR revealed a large
left pleural effusion and ECG was low voltage. Pulsus was 10, so
a bedside TTE was done to eval for tamponade, which revealed a
mild pericardial effusion without tamponade physiology. She was
treated with IVF, calcium gluconate, insulin w/ dextrose,
Kayexelate, and albuterol nebs. She was also given levofloxacin
x1 for ? pneumonia. She is being admitted to the MICU for
evaluation and treatment of her hyperkalemia and acute renal
failure.
.
The pt has a recent dx of ovarian cancer vs. lymphoma. Approx 6
weeks PTA, the pt started to feel tired and developed swollen
legs and a distended abdomen. Evaluation revealed a mass on her
right ovary that was to be removed, but CT scan prior to surgery
also showed enlarged LNs, so the surgery was held off until a
biopsy specimen could be taken of the lymph nodes. There is some
thought that the cancer may be a lymphoma rather than primary
ovarian.
Past Medical History:
- Hypertension
- Gallstones
- Hyperlipidemia
- Hypothyroidism
Social History:
Occupation: Retired.
Drugs: Denies.
Tobacco: Denies.
Alcohol: Denies.
Other:
Family History:
sister w/ pancreatic cancer
Physical Exam:
Tmax: 37.9 ??????C (100.3 ??????F)
Tcurrent: 37.3 ??????C (99.1 ??????F)
HR: 119 (115 - 135) bpm
BP: 80/30(46) {60/15(36) - 122/88(76)} mmHg
RR: 22 (0 - 32) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 104.3 kg (admission)
General Appearance: Sedated, unresponsive, intubated
Eyes / Conjunctiva: Pupils mid, responsive to light.
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG
tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: throughout)
Abdominal: Rigid and distended
Extremities: Right: 4+, Left: 4+ lower. Upper warm with 3+.
Skin: Not assessed
Neurologic: Responds to: Unresponsive, Movement: No spontaneous
movement, Sedated, Tone: Not assessed, No response to sternal
rub. Positive corneal reflex
Pertinent Results:
Abd u/s:
Small amount ascites; Bilateral inguinal lymphadenopathy
Echo:
IMPRESSION: Suboptimal image quality. Normal global left
ventricular systolic function with preserved ejection fraction.
Small to moderate complex pericardial effusion with no obvious
echocardiographic signs of tamponade. Dilated right ventricle
with global hypokinesis.
CXR:
IMPRESSIONS: Large left pleural effusion with associated
atelectasis. Given size and recent diagnosis of cancer, this may
be a malignant effusion. The right lung is well aerated.
Renal u/s:
IMPRESSION: Moderate right-sided hydronephrosis. No renal
calculi. Moderate amount of ascites.
[**2138-10-29**] 03:49AM BLOOD WBC-30.1* RBC-3.26* Hgb-9.4* Hct-30.6*
MCV-94 MCH-28.9 MCHC-30.7* RDW-18.6* Plt Ct-172
[**2138-10-29**] 03:49AM BLOOD Neuts-85* Bands-3 Lymphs-3* Monos-5 Eos-0
Baso-0 Atyps-2* Metas-2* Myelos-0 NRBC-2*
[**2138-10-29**] 03:49AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Schisto-OCCASIONAL Burr-OCCASIONAL Fragmen-OCCASIONAL
[**2138-10-29**] 03:49AM BLOOD Plt Smr-NORMAL Plt Ct-172
[**2138-10-29**] 03:49AM BLOOD PT-46.4* PTT-54.8* INR(PT)-5.2*
[**2138-10-29**] 03:49AM BLOOD Glucose-203* UreaN-79* Creat-2.5* Na-125*
K-6.0* Cl-104 HCO3-12* AnGap-15
[**2138-10-20**] 01:44PM BLOOD LD(LDH)-261*
[**2138-10-17**] 03:17AM BLOOD ALT-23 AST-34 LD(LDH)-257* AlkPhos-73
TotBili-0.3
[**2138-9-30**] 05:13AM BLOOD Lipase-24
[**2138-10-11**] 08:00PM BLOOD CK-MB-8 cTropnT-0.10*
[**2138-10-29**] 03:49AM BLOOD Calcium-6.7* Phos-9.6*# Mg-1.9
[**2138-10-1**] 05:20AM BLOOD calTIBC-173* VitB12-1149* Folate-11.6
Ferritn-222* TRF-133*
[**2138-10-16**] 03:01AM BLOOD Triglyc-404* HDL-27 CHOL/HD-8.3
[**2138-10-23**] 04:45PM BLOOD Osmolal-283
[**2138-10-28**] 03:56AM BLOOD TSH-2.4
[**2138-10-28**] 03:56AM BLOOD T4-2.9* T3-33*
[**2138-9-27**] 04:23AM BLOOD Cortsol-30.8*
[**2138-9-26**] 08:44AM BLOOD Cortsol-20.9*
[**2138-10-24**] 03:53AM BLOOD CA125-43*
[**2138-10-2**] 04:56AM BLOOD CA27.29-212* CA125-70*
[**2138-9-16**] 04:00AM BLOOD CA27.29-574*
[**2138-9-13**] 01:40PM BLOOD CEA-<1.0 AFP-3.0 CA125-203*
[**2138-9-13**] 01:40PM BLOOD b2micro-27.8*
[**2138-10-29**] 05:29AM BLOOD Type-MIX Temp-38.4 pO2-60* pCO2-37
pH-7.07* calTCO2-11* Base XS--19 Intubat-INTUBATED Comment-99.1
F AXI
[**2138-10-29**] 05:29AM BLOOD Lactate-7.9*
[**2138-10-16**] 03:18AM BLOOD freeCa-1.14
[**2138-10-29**] 05:29AM BLOOD O2 Sat-84
Brief Hospital Course:
74 yo F w/ Stage IV metastatic ovarian cancer, ARF on CVVH, and
malignant pleural effusion. Course has been complicated by
hypotension requiring pressors (levophed). Originally presented
to ED [**2-22**] ARF and hyperkalemia. PMH includes hypothyroidism and
HLD.
#. Hypotension/shock. Has required Levophed for much of
admission. Last 2-3 days prior to leaving the MICU for the [**Hospital Unit Name 153**]
she tolerated several hours without pressors; however, she
received albumin or blood during these periods. Differential
dx for shock includes sepsis, metabolic causes, cardiogenic,
hypovolemia.
- [**Name (NI) 15305**] pt has a leukocytosis but has been afebrile. Started
on empiric abx to cover for HAP. D/c abx on [**9-25**]: pt received 6
days of zosyn, 9 days of cipro, and 4 days of vanc. Line
infections: changed HD cath over the wire on [**9-23**] and art line
was d/c??????ed. Will monitor PICC line for signs of infection.
- Metabolic- [**Last Name (un) 104**] stim was wnl so likely not adrenal
insufficiency. Consulted ID for evaluation of whether
hypothyroidism could cause shock. Increased dose of Synthroid
and transitioned to IV but endocrinology that it is unlikely for
hypothyroidism to be the cause. Endo also concerned because pt
had one episode of paroxysmal a. fib on [**9-20**] and increased dose
of synthroid may precipitate further episodes. Will continue to
monitor, however, this episodes appears to be isolated.
- Cardiogenic- Originally, was concerned for tamponade.
Although they have been suboptimal studies, multiple echoes have
only showed effusions without echocardiographic evidence of
tamponade with one exception. Her echo from [**9-15**] showed
impaired fillling/tamponade physiology. Most recent echo on [**9-24**]
again did not show evidence of tamponade, just small effusion.
Also, echo on [**9-24**] revealed normal RV size and motion which made
PE less likely. Throughout her course in the MICU, have
considered V/Q scan to r/o PE as a possible cause of hypotension
however, given her echo findings, the pretest possibility
remains equivocal.
- On [**9-22**], SVV (from Vigileo) suggested intravascular depletion,
and repleted pt with crystalloid and colloid. However, she did
not require pressors for much of that day. For last few days
prior to transfer to [**Hospital Unit Name 153**], have been running CVVH at a 0
balance. Gave albumin challenge again on [**9-25**] and her CVP bumped
to 12 and was thus able to be off of leveophed for several
hours. It appeared that she needs her CVP to be [**1-4**] to
maintain her BP. Goal has been to wean levophed and have
considered transitioning to midodrine as an oral pressor.
- At time of transfer, the etiology of her hypotension remains
elusive. Without an adequate explanation, team has hypothesized
that this may be a possible paraneoplastic syndrome.
# Bilat pleural effusions, cytology from left c/w malignancy.
Final cytology from right effusion still pending at time of
transfer but pH, cell counts, gluc, prot consistent with left
effusion and anticipate that it will also be malignant. Prior to
first thoracentesis, pt required BiPap but upon transfer, pt has
been satting well on only 1.5L NC for several days.
Underwent both chest tube and pigtail placement for left sided
effusion. Chest tube was removed early in course of stay
because it was extrathoracic and not draining but pigtail
(placed by IP) continues to drain serosang fluid. Was placed to
water seal by IP on [**9-25**]. A repeat CT on [**9-22**] showed increased
right sided effusion which was tapped on [**9-24**]. IP is considering
either Pleurodesis vs pleurex when stable. Has also used
bronchodilators for wheezing. On [**10-3**], chest tube fell out. Per
IP, Ok to leave out, re-image if symptomatic. Pleural effusion
should be responsive to chemo if tumor is. However, if
reaccumulates, will need pleurex catheter v pleurodesis. Should
follow-up with IP in [**Hospital 3782**] clinic with Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 3020**]
two weeks post-discharge or immediately if SOB.
#. Acute renal failure ?????? Persistent volume overload and
anasarca. Originally admitted with K of 7.8 and Cr of 7.2.
Hyperkalemia resolved quickly (see below). Held on dialysis for
a few days but CVVH was started on [**9-16**] but had to be stopped
temporarily on [**9-20**] [**2-22**] poor access. Line changed over the wire
by renal on [**9-23**] and restarted CVVH. Initial and repeat imaging
of kidneys has showed continued right hydronephrosis. Plan is
to transfer from MICU ([**Hospital Ward Name **]) to [**Hospital Unit Name 153**] in order to go to
the OR with urology on [**9-26**]. Urology will place a stent in the
right ureter. Goal of stenting is to relieve the obstruction
with the hope of regaining some kidney function. Acutely on
[**9-24**], she developed hyponatremia and hyperglycemia. Unclear
etiology but hyponatremia may be related to the ultrafiltrate
bath having a Na concentration of 130. Na corrected slightly
following initiation of insulin sliding scale for hyperglycemia.
Also, hyperglycemia seems to have occurred acutely. No prior
episodes of hyperglycemia during this admission. Also, [**Name8 (MD) **] RN,
finger sticks are consistently lower than serum glucose. Could
be related to diffuse extravascular volume. Pt was placed on
insulin sliding scale for the elev glucose. Initially, pt was
hyperphosphatemic but on the day of transfer pt required
repletion of phos. Used Na-Phos for added sodium benefit. Have
held home Lasix and ACE-I in setting of ARF.
# Metastatic ovarian cancer: cardiopulmonary status has been too
tenuous for treatment during this admission. Obtained tumor
markers which revealed borderline high CA-125 and elevated
CA27,29, but were overall non-specific. Heme onc is following
closely and feel that pt will require inpt palliative
chemotherapy, most likely carboplatinum. Family has been
supportive of continuing more aggressive means of treatment.
Have discussed transfer to OMED when stable and off pressors.
Gyn onc originally saw the pt but have not been following daily.
Also, on allopurinol to prevent tumor lysis syndrome.
#. Hypothyroidism ?????? Was diagnosed with hypothyroidism approx 2
weeks prior to admission and had been started on a low dose of
Synthroid. Consulted endocrinology to help elucidate if
hypothyroidism could be cause of persistent hypotension.
Preliminary thought is no, but increased dose to 100 mcg on [**9-25**].
Per endo, should re-check a Free T4 level in 3 to 4 days.
Anti-TPO ab < 10. Also, changed from oral to IV Synthroid to
ensure proper absorption despite this one episode of
questionable a. fib.
#. Hyperkalemia, resolved: Was most likely due to worsening
renal function, esp in setting of the medications she was
taking, including Lasix and ACE-I. Pt had K 7.8 on arrival to
ED, without ECG changes. Treated w/ Ca gluconate, insulin /
dextrose, albuterol nebs, and Kayexelate. Potassium has
appropriately responded to treatment and has remained wnl.
#. Hyperlipidemia - Taking home statin dose.
#. [**Name (NI) 8410**] Pt remains full code at time of transfer to [**Hospital Unit Name 153**].
[**Hospital Unit Name 153**] course:
#. Hypotension and Sepitc shock: the patient had been on-and-off
pressors for the length of her ICU admissions. She responded
well to albumin and IV fluids however the response was
short-lived. She was eventually weaned off pressors and started
on corticosteroids which improved her pressure significantly.
However, during her ICU stay she began to deteriorate and her
course was complicated by C. diff colitis tx with IV flagyl
po/pr vancomycin. Additionally, she developed a VAP w/
pseudomonas and was treated with ceftazidime. The patient's
[**Female First Name (un) **] fungemia was treated with caspofungin. The patient was
maintained and three pressors and remained intubated. Maximal
treat was administered, but the patients status continued to
decline and she remained pressor dependent. The family decided
to stop pressors on [**2138-10-29**] and the patient passed away at
7:50pm.
# Renal failure: Post stent placement by urology the patient's
urine output did not improve significantly. Due to patient's
labile blood pressure and tendency towards hypotension she was
started CVVH. She was subsequently tried on HD, given albumin
and fluids for volume, and eventually maintained a low but
steady blood pressure with concominant tachycardia. However, as
the patient's clincal course declined as did her renal function.
She was no longer a candidate for CVVH due to her hypotension
and worsening clincal picture. Her creatinine continued to
trend upwards and she had multiple electrolyte abnormalities
including continued hyperkalemia that was refractory to
treatment. The patient was essentially anuric and passed away
when her pressors were stopped.
# Tachycardia: the patient had several episodes of tachycardia
to 130-140s, with transition to NSVT. Cardiology consult felt
this was consistent with NSVT, started patient on amiodarone IV
overnight with good response. However since this was an isolated
episode it was not felt that keeping her on amiodarone was
necessary at this time.
#Pleural effusions: Patient had chest tube placement with
initial high output which eventually tapered off. This was
thought likely due to her malignancy. Several days post
admission to ICU the patient's chest tube fell out while moving
from chair to bed. IP was consulted but did not feel the tube
needed to be replaced at that time and serial CXR were indicated
to r/o PTX. The patient's chest tubes were removed on [**10-24**]. She
continued to have signifcant pleural effusions.
# Metastatic ovarian cancer: Patient was followed by the OMED
service. The option of chemotherapy was discussed which the
patient agreed to a trial of carboplatin. Steroids and
antiemetics were given as per oncology protocol during her
chemotherapy. Her WBC and fever curve were monitored. She
tolerated the course well and was maintained on HD throughout.
Tumor lysis labs were followed and allopurinol was started
prophylactically. However, given her clinical decline and
infections she no longer could tolerate additional treatment.
#Code Status: The patient was maintained on 3 pressors. After
a multiple family meets and discussions it was decided to
withdraw the pressors on [**2138-10-29**]. The patient passed away
shortly after at 7:50pm.
Medications on Admission:
- enalapril 20mg daily
- lorazepam 1-2mg QHS PRN
- simvastatin 20mg QHS
- oxycodone-acetaminophen 1-2tabs Q4hrs PRN
- furosemide 20mg daily
- trazodone 50mg QHS PRN
- levothyroxine 0.05mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac Arrest
Sepsis
C. Diff Colitis
VAP
Metastatic Ovarian Cancer
Discharge Condition:
Death
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2138-10-29**]
ICD9 Codes: 5845, 5180, 2762, 2761, 4280, 2449, 4019, 2720, 2767, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6586
} | Medical Text: Admission Date: [**2109-3-20**] Discharge Date: [**2109-3-29**]
Date of Birth: [**2051-5-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion.
Major Surgical or Invasive Procedure:
Mitral valve repair with resection of posterior leaflet [**2109-3-20**].
History of Present Illness:
This is a 57 year old male patient with known heart murmurs who
has been followed by serial echos since [**2093**]. In [**8-27**] he saw
his primary care physician with the complaint of progressive
dyspnea. A Cardiac catheterization in [**11-28**] showed severe mitral
regurgitation, an ejection fraction of 66% and a right coronary
artery with a 70% lesion which was stented. He was subsequently
referred for a minimally invasive mitral valve repair
Past Medical History:
Hypertension.
Addison's disease.
Hypothyroidism.
Melanoma.
BPH.
Social History:
Works as mechanical engineer. Lives with wife. [**Name (NI) 58972**] tobacco
use, reports [**12-27**] drinks of alcohol per week.
Family History:
Noncontributory
Physical Exam:
BP: (R) 135/76 (L) 149/79 HR 68 Weight 225
Gen: Tall young lad in no acute distress
Skin: well healed right shoulder incision
HEENT: EOMI intact, nl buccal mucosa, anicteric, oropharynx
benign.
Neck: supple, murmur transmitted, No JVD
Chest: Clear
Heart: RRR, III/VI systolic murmur.
Abdomen: Soft, Nontender, nondistended
Ext: warm and well perfused
Neuro: grossly intact
Pertinent Results:
[**2109-3-26**] 08:50AM BLOOD WBC-10.8 RBC-2.60* Hgb-8.0* Hct-23.3*
MCV-90 MCH-30.9 MCHC-34.5 RDW-15.0 Plt Ct-203
[**2109-3-26**] 08:50AM BLOOD Plt Ct-203
[**2109-3-21**] 03:04AM BLOOD PT-12.9 PTT-30.5 INR(PT)-1.1
[**2109-3-26**] 08:50AM BLOOD Glucose-81 UreaN-15 Creat-0.9 Na-133
K-3.7 Cl-95* HCO3-28 AnGap-14
[**2109-3-25**] 04:46AM BLOOD Calcium-8.0* Phos-3.9 Mg-1.9
[**2109-3-28**] 11:30AM BLOOD WBC-9.8 RBC-4.04* Hgb-12.1* Hct-36.4*
MCV-90 MCH-30.0 MCHC-33.3 RDW-15.3 Plt Ct-407#
[**2109-3-28**] 11:30AM BLOOD Plt Ct-407#
[**2109-3-28**] 11:30AM BLOOD Glucose-102 UreaN-19 Creat-1.0 Na-136
K-4.6 Cl-96 HCO3-27 AnGap-18
[**2109-3-25**] 04:46AM BLOOD Calcium-8.0* Phos-3.9 Mg-1.9
[**2109-3-22**] CXR
No evidence of pneumothorax, no significant CHF but bilateral
moderate amount of pleural effusions as seen on single view
chest examination.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 58973**] was admitted the morning of [**3-20**] and proceeded
directly to the operating room. He underwent a mitral valve
repair with resection of the posterior leaflet with a 28 mm
[**Doctor Last Name 405**] band with Dr. [**Last Name (Prefixes) **]. Please see OP note for full
details.
He was successfully weened and extubated on his operative
evening and was placed on a steroid taper with the help of
endocrinology given his addisons disease.
On postoperative day two he was transferred to the inpatient
telemetry floor for ongoing management and rehabilitation.
On postoperative day four he had a burst of atrial fibrillation
-- converted spontaneously and was noted to have a first degree
AV-block. Due to this AV block, his beta blockade was held.
On postoperative day five, with no furtehr episodes of afib but
with elevated BP and HR, a low dose beta-blocker was added with
no change in his AV block. He also continued to be
significantly edamatous, nearly 14 kg up from his pre-op weight
and he was actively diureses with lasix.
On postoperative days six and seven, we continued to diurese him
heavily. Endocrine also continued to follow with regards for
his steroid taper.
On postoperative eight, he cleared physical therapy and was
discahrged home with a visiting nurse to follow.
Medications on Admission:
Plavix 75 daily.
Prednisone 12.5 mg daily.
Flurinef 0.1 mg daily.
Levoxyl 0.025 mg daily.
Enalapril 10 mh [**Hospital1 **].
Lipitor 20 mg daily.
Aspirin 325 mg daily.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
11. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every [**2-27**]
hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 2 weeks.
Disp:*56 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*0*
14. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)): 5 mg on the PM.
Disp:*45 Tablet(s)* Refills:*2*
15. 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:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Mitral regurgitation.
Hypertension.
Addison's disease.
Hypothyroidism.
Discharge Condition:
Stable.
Discharge Instructions:
Shower daily with soap and water. Rinse well. [**Male First Name (un) **] not apply
any creams, lotions, powders, or ointments.
Take all new medications as prescribed.
Make follow-up appointments as directed.
No heavy lifting, greater than 10 pounds.
No driving x 6 weeks.
[**Last Name (NamePattern4) 2138**]p Instructions:
Call to schedule appointment with Dr. [**Last Name (Prefixes) **].
Call to schedule appointment with Dr. [**Last Name (STitle) **].
Completed by:[**2109-3-29**]
ICD9 Codes: 4240, 9971, 2761, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6587
} | Medical Text: Admission Date: [**2108-4-24**] Discharge Date: [**2108-5-10**]
Date of Birth: [**2030-11-10**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Excruciating right foot pain
Major Surgical or Invasive Procedure:
[**2108-4-25**]
1. Angiogram: Abdominal aortogram, Serial arteriogram of the
right lower extremity, Angioplasty of right above-knee popliteal
artery, angioplasty of right superficial femoral artery,
StarClose closure of left common femoral arteriotomy.
[**2108-4-27**]
1. Angioscopy
2. Right superficial femoral artery to distal anterior tibialis
artery bypass with nonreversed cephalic vein.
History of Present Illness:
Patient is a 77 year old male seen on day of admission by Dr
[**Last Name (STitle) 1391**] in clinic who told patient to come to ED for hospital
admission. He reports right foot pain starting back in [**Month (only) 404**]
when podiatrist diagnosed him with plantar faucitis and
prescribed unknown medication which made the patient nauseous
prompting discontinuation. The pain persisted while living in
[**State 108**] for the winter causing difficulty ambulating while
playing golf. He takes Advil regularly with some relief and
reports that hanging leg off bed, dependency, improves symptoms.
On [**4-19**] worsening pain and concern for toe infection
prompted podiatry visit where paronychia of the right hallux
nail was noted, started on Levaquin antibiotic and told to meet
with Dr [**Last Name (STitle) 1391**] in consult. Patient reports increasing in pain
over last week sharp, achy in nature. He reports no fever,
chills however has nausea and emesis 3-4x per week.
Past Medical History:
PMH:
DMII requiring insulin, HTN, hyper cholesterol, Thrombocythemia,
history of shingles.
PSH:
Fracture left elbow [**2055**], Appendectomy, Ulnar nerve repair left
elbow, carpal tunnel repair, right inguinal hernia.
All: Penicillin for which he has anaphylaxis
Social History:
Posting 1PPD tobacco hx quit 40 year ago, EtOH 1 vodka/day, no
ilicit drugs. Married with 5 children, retired registrar at
[**University/College 31355**]now gold coach.
Physical Exam:
on Admission
99.2 HR:65 BP:124/46 Resp:17 100%ra
GEN: NAD, AA0x3, clean well groomed man
Neuro: CNII-X11 grossly intact, equal motor strength
CV: RRR, possible carotid bruits, Notable systolic murmur
PUl: CTA, no respiratory distress
Abd: Apear distended-reports baseline, soft, NT, ND, umbilical
hernia noted.
Ext: Upper radial pulses palpable
......Fem.....[**Doctor Last Name **].....DP....PT
Lt.....Palp....Dop....Palp..Dop
Rt.....Palp....Dop....none...DopFaint
Right foot notable cold to touch, decreased hair growth in lower
extremities bilaterally, Rt first phalanx with mild swelling
erythema of lateral toe nail bed with minimal purulent
discharge.
Pertinent Results:
On addmision
137 100 43
-------------<213
4.1 24 2.5
102
28.7 > 11.3< 474
35.1
PT: 14.4 PTT: 38.3 INR: 1.2
On Discharge [**2108-5-10**]
141 105 85
--------------<111
4.4 24 3.9
Ca: 8.5 Mg: 2.2 P: 4.6
96
39.3 > 9.4 < 346
28.7
Imaging:
[**2108-4-28**] Renal Ultrasound
1. No hydronephrosis 2. Parvus tardus waveform on the left
kidney can represent a more proximal stenosis. 3. Complex 1.9 cm
cyst arising from the upper pole of the left kidney, likely a
hemorrhagic or proteinaceous cyst.
[**2108-4-25**] Arterial non-invasive studies
Severe outflow arterial disease in the right lower extremity.
Disease is
likely located at the right superficial femoral artery as well
as distal to it. 2. Mild outflow arterial disease in the left
lower extremity. Disease is likely located distal to the
popliteal artery.
Micro
WOUND CULTURE (Final [**2108-4-27**]):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
URINE CULTURE (Final [**2108-5-4**]):
YEAST. >100,000 ORGANISMS/ML.
Blood Culture, Routine (Final [**2108-4-30**]): NO GROWTH.
Brief Hospital Course:
The patient was admitted to the Dr[**Name (NI) 1392**] Vascular Surgical
Service for evaluation and treatment. On [**2108-4-25**] the patient
underwent angiography and on [**2108-4-27**] he underwent Angioscopy and
Right superficial femoral artery to distal anterior tibialis
artery bypass with nonreversed cephalic vein. (Please refer to
Operative Notes for details). The patient tolerated the
procedure well. After a brief, uneventful stay in the PACU, the
patient arrived to the VICU NPO, on IV fluids and antibiotics,
narcotic medication for pain control. The patient was closely
monitored throughout out his hospital stay which can be
summarized by following systems:
Neuro: The patient received IV narcotic medication with good
effect and adequate pain control. When tolerating oral intake,
the patient was transition ed to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI:Post-operatively, the patient initially NPO with IVFs.
Patient had nausea with diet advancement for which he was
closely monitor. He was encouraged to maintain his PO intake in
spite of decrease appetite at time. He was tolerating a regular
diet prior discharge. was advanced appropriately and was well
tolerated.
Post-operatively,
GU/FEN: Post-operatively, the patient initially was on IVFs and
foley in place. Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed and repeated when
necessary. Due to an increase in Creatinine and the patients
baseline stage III CKD caused by DM, nephrology was consulted to
help manage acute on chronic kidney insufficiencies. Patient
suffered from acute on chronic renal insufficiency during his
hospital stay which prolonged the hospital course and for which
he is deconditioned. On renal ultrasound, there was no evidence
of hydronephrosis. The patient creatinine, fluid balance and
electrolytes were closely monitored, his antibiotics and
hydroxyurea medication were appropriate changed or adjusted and
his renal insufficiency improved over time. He did not require
hemodialysis.His Creatinine plateau ed at 6.1 and at time of
discharge is 3.9. Due to renal insufficiency patient required
prolonged use of a foley catheter which was definitively
discontinued on [**2108-5-9**] at midnight. On day of discharge he was
unable to void and was straight cathed for 375cc. On discharge
he is due to void at 6pm. If patient unable to void please
bladder scan patient and consider foley placement and follow-up
with a urologist. Of note, his home dose Atenolol was
discontinue per Nephrology consult as desired SBP goal is >120
to facilitate renal perfusion. When re-ignition of beta-blocker
is deemed appropriate, it is advised that his PCP consider
metoprolol as oppose to Atenolol as it is cleared more
effectively from the kidneys. He will need to follow up with
long term kidney physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 10083**] at [**Last Name (un) **] as well as with
his PCP.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. He was started on broad
spectrum antibiotics Vanc/levo/Flagyl with admission which was
changed to Bactrim post operatively on [**5-1**] and subsequently
changed to Cipro [**5-3**] secondarily to Cipro ability to falsely
elevate creatinine. He is being discharged on 7 days PO Cipro
to complete course.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; the patient received 4 non reactive blood
transfusions during this hospitalization. He was noted to have
leukocytosis on admission and with his history of
thrombocythemia, hematology was consulted to facilitate proper
management. His hydroxyurea was decreased from 5x/week to
2x/week secondary to renal insufficiency. He is to follow with
his long term hematologist Dr [**Last Name (STitle) 17881**] on discharge.
Prophylaxis: The patient received subcutaneous heparin, asa,
Plavix and venodyne boots on non affected leg were used during
this stay; was encouraged ambulate when appropriate with the
assistance of physical therapy.
At the time of discharge, the patient had improved
significantly. From a surgical perspective he was doing very
well but was deconditioned secondary to recovering renal
insufficiency. He has been afebrile with stable vital signs,
tolerating a regular diet, ambulating minimally with much
assistance, patient is due to void and may require foley and
urology fup if unable and his pain was well controlled. At time
of discharge the patient, physicians, physical therapist and
nursing staff agreeded that he was safe for discharge to a
rehabilitative center. The patient received discharge teaching
and follow-up instructions with understanding verbalized and was
in agreement with the discharge plan.
Medications on Admission:
Insulin Before Breakfast Humalog 5 and NPH 25, Before Dinner:
Humalog 5 and NPH 20, Cilostazol 100mg [**Hospital1 **], Hydroxyurea 500mg
5x/wk, hydrocholrothiazide 25mg Q otherver day with 2pill (50mg)
Q other day alternating, Pravachol 20mg QHS, Viagra 100mg PRN,
Diovan 160mg', enalapril 20mg [**Hospital1 **], Atenolol 25mg', Prazosin 12mg
in am and 10mg in pm, Actos 30 mg', Vitamin D 1000 Unit Fish
oil, Asairin 325mg', Glucosamine 500mg [**Hospital1 **],Philostazol 100mg
[**Hospital1 **], Levaquin 500mg daily since [**4-19**].
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
3. Insulin and sliding scale
Breakfast Dinner
Humalog 5 Units
NPH 25 Units Humalog 5 Units
NPH 20 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol 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 2 Units
160-199 mg/dL 4 Units 4 Units 4 Units 4 Units
200-239 mg/dL 6 Units 6 Units 6 Units 6 Units
240-279 mg/dL 8 Units 8 Units 8 Units 8 Units
280-319 mg/dL 10 Units 10 Units 10 Units 10 Units
320-359 mg/dL 12 Units 12 Units 12 Units 12 Units
4. Pravastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release
(E.C.) PO DAILY (Daily) as needed for Constipation.
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Until patient appropriately euvolemic.
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): to affected areas.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for Constipation.
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain: Do not drive while taking this
medication.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Prazosin 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
16. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 2X/WEEK
(TU,FR).
17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 31356**] health care center-[**Location (un) **]
Discharge Diagnosis:
1) Right lower extremity critical limb ischemia with rest pain
2) Acute on Chronic kidney failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Division of Vascular and Endovascular Surgery Lower Extremity
Bypass Discharge Instructions
ACTIVITIES:
- ambulate essential distances untill FU with Dr. [**Last Name (STitle) 1391**]
- Ace wrap leg from foot-knee when ambulating, to prevent
swelling
- Your operated leg is expected to have some swelling and will
resolve over time
- Elevate leg when sitting
- no driving till FU
- may shower, pat dry your incisions, no tub baths
WOUND:
- Keep wound dry and clean, call if noted to have redness,
excess draining, swelling, or if temp is greater than 101.5
- Your staples have been removed and replaced with steri strips.
Leave seri strips in place, they will come off on [**Last Name (un) 1292**] own or
will be removed at FU. Ok to use dry guaze dressin if need for
ozzing.
- Pleaese use heal protection (waffle boot) on both legs while
in bed
- Use ace wrap foot to knee while ambulating to prevent swelling
DIET:
- Diet as tolerated eat a well balanced meal
- Your appetite will take time to normalize
- Prevent constipation by drinking adequate fluid and eat foods
[**Doctor First Name **] in fiber, take stool softener while on pain medications
MEDICATIONS:
- Continue all medications as directed
- Please follow up with your PCP regarding restarting beta
blocker- It is recommended that you take Metoporol inplace of
Atenolol for purposes of renal clearance. Ask your PCP to
address.
- Take your pain medications conservatively
- Your pain will get better over time
FU APPOINTMENTS:
- keep all FU appointments
- Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone
[**Telephone/Fax (1) 1393**]
- Follow-up with your Nephrologist Dr. [**First Name (STitle) 10083**] at [**Last Name (un) **]
- Follow-up with your hematology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17881**]. ([**Telephone/Fax (1) 31357**]
- Follow-up with your Primary Care Physician
Followup Instructions:
1) Please follow-up with Dr [**Last Name (STitle) 1391**] in 3 weeks. Call
[**Telephone/Fax (1) 1393**] to schedule an appointment.
2) Follow-up with your Nephrologist Dr. [**First Name (STitle) 10083**] at [**Last Name (un) **]
3) Follow-up with your hematology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17881**]. ([**Telephone/Fax (1) 31357**]
4) Follow-up with your Primary Care Physician
Completed by:[**2108-5-10**]
ICD9 Codes: 5849, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6588
} | Medical Text: Admission Date: [**2119-5-13**] Discharge Date: [**2119-5-16**]
Date of Birth: [**2059-6-26**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 32458**] is a 59 year old male with a history of major
depression, ethanol dependence and chronic suicidality who was
admitted for alcohol withdrawal. Pt first presented to the
emergency room on [**2119-5-12**] seeking inpatient admit for alcohol
detox and increasing suicidal ideation. He was evaluated by
psychiatry, placed under section 12, and transferred to an
inpatient detox center ([**Last Name (un) 4199**]). Pt was sent back to the ED for
bradycardia. Pt reports his HR was in the 30s but there was no
documentation provided. In the emergency room his inital vitals
were T: 98.1 BP: 151/89 HR: 94 RR: 16 O2: 98% on RA. He received
levofloxacin 750 mg IV x 1 and valium 20 mg IV. He was admitted
to the medical floor for alcohol withdrawal and possible
pneumonia.
.
On the floor, BP ranged 150/102 to 142/54, HR in 90s, RR 22, O2
sat 96% on 3L. He received 1L NS. For CIWA consistently at 28,
pt received 115 mg of valium (IV and PO) while on the floor.
.
The pt was transfered to the MICU for further management of
acute alcohol withdrawal. In the MICU the pt received Valium
50mg IV and 60 mg PO.
Past Medical History:
Depression, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], h/o SI attempt
Hypothyroidism
Bigemeny and Trigemny
Idiopathic L hemidiaphragm paralysis
.
Social History:
Pt is married with 4 children; formerly worked as a radiologist
and lost his medical license. Drinks 6 gin & tonics daily,
increased from 3 drinks daily 2 weeks ago, reports hx of
blackouts, denies w/d seizures or DTs until today, alcoholic for
15 years. Recreational drugs: h/o prescription drug abuse inc.
Vicodin, Percocet and Xanax. He has been clean for 2 years. He
denies use of IVDs. Tobacco: Denies use.
Family History:
Mother and son with depression. Per OMR first degree relatives
with [**Name (NI) **], but pt denies this.
Physical Exam:
VS: T97.6, P 87 (P 100's), 140/73, 97% on RA
GENERAL: Pleasant, fatigued man in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-3**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred. No
asterixis.
PSYCH: Listens and responds to questions appropriately, pleasant
.
Pertinent Results:
[**2119-5-12**] 02:10PM BLOOD WBC-8.8 RBC-5.36 Hgb-16.6 Hct-47.5 MCV-89
MCH-31.0 MCHC-35.0 RDW-15.6* Plt Ct-296
[**2119-5-15**] 06:45AM BLOOD WBC-5.4 RBC-4.62 Hgb-14.4 Hct-41.2 MCV-89
MCH-31.1 MCHC-34.9 RDW-15.5 Plt Ct-163
[**2119-5-15**] 06:45AM BLOOD Plt Ct-163
[**2119-5-12**] 02:10PM BLOOD Plt Ct-296
[**2119-5-12**] 02:10PM BLOOD Glucose-110* UreaN-11 Creat-0.9 Na-135
K-3.7 Cl-95* HCO3-21* AnGap-23*
[**2119-5-15**] 06:45AM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-141
K-3.4 Cl-106 HCO3-24 AnGap-14
[**2119-5-13**] 12:05PM BLOOD TSH-9.4*
[**2119-5-14**] 01:32AM BLOOD Free T4-1.0
[**2119-5-13**] 12:05PM BLOOD Osmolal-300
[**2119-5-12**] 02:10PM BLOOD ASA-NEG Ethanol-295* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
.
CXR: Elevated left lung base, which could be an elevated
hemidiaphragm of uncertain chronicity. Correlation with clinical
history or prior imaging will be very helpful.
.
EKG: normal sinus rhythm, normal axis, normal intervals,
frequent PVCs, no acute ST segment changes. No change from prior
dated [**2117-1-7**].
.
.
Brief Hospital Course:
Mr [**Known lastname 32458**] is a 59 year old man with alcohol abuse and major
depressive disorder with a history of a suicide attempt who
presented with alcohol withdrawal and suicidality.
.
# Alcohol withdrawal: The pt was placed on a CIWA scale with q4h
valium initially. The pt was requiring ample nursing attention
on the floor and was sent to the medical ICU where he received
q1h valium which led to an improvement in the pt's CIWA scores,
which had been in the 20's while on the floor. On transfer back
to the floor on [**2119-5-15**] the pt's CIWA scores were [**11-14**] and the
pt was tolerating q4h valium 10mg po.
.
# Depression: The pt was continued on his outpatient effexor,
and his seroquel was restarted. The psychiatry consult service
saw the pt and recommended inpatient psychiatric treatment for
his suicidal ideation. On discharge the pt had passive suicidal
ideation and was transfered to an inpatient psychiatry team.
.
# Bradycardia: During this admission the pt was not bradycardic,
and his pulse remained in the 70's, except while withdrawing
from alcohol, when the pt's pulse was in the 100's. The pt's
home metoprolol was held during this admission, and the pt was
instructed to hold metoprolol until he saw his primary care
doctor. The pt's potassium and magnesium were repleted.
Medications on Admission:
Per [**Company 25795**] pharmacy: ([**Telephone/Fax (1) 70215**]
Levothyroxine 200mcg daily
Metoprolol tartrate 50mg [**Hospital1 **]
Seroquel 400mg [**Hospital1 **] (ran out 4 days ago)
Geodon 80mg [**Hospital1 **] (ran out 1 week ago)
Klonopin 1 mg [**Hospital1 **] prn
Ambien 10 mg qhs prn
Simvastatin 10 mg daily (denied taking)
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Quetiapine 200 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for PRN CIWA > 10 .
Discharge Disposition:
Extended Care
Facility:
deaconness 4
Discharge Diagnosis:
Primary: Alcohol withdrawal.
Secondary: Major depressive disorder, hypothyroidism
Discharge Condition:
Breathing comfortably on room air, CIWA of 11.
Discharge Instructions:
Mr [**Known lastname 32458**]: You were admitted with a slow heart rate. Your heart
rate was found to be normal when you were evaluated in the
emergency department. Your heart rate remained normal during the
length of the hospitalization. You were also found to be in
alcohol withdrawal, which we treated you for with medications.
.
Your home medications remain the same. Please continue to take
your home medications as directed.
.
If you develop chest pain, shortness of breath, nausea and
vomiting, palpitations, or any other concerning symptom, please
call your doctor or return to the emergency room.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 70216**] [**Telephone/Fax (1) 40799**] to make a follow up
appointment within the next two weeks, or after you are
discharged from your psychiatric hospitalization.
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6589
} | Medical Text: Admission Date: [**2133-6-12**] Discharge Date: [**2133-7-1**]
Date of Birth: [**2073-11-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9569**]
Chief Complaint:
Lower Back Pain with LE weakness beginning [**2133-6-8**]
Major Surgical or Invasive Procedure:
Laminectomy T12-L2
Single wire pacemaker placed
History of Present Illness:
Pt is a 59 y/o Cantonese female with a h/o Atrial fibrillation
and mechanical MVR (Bjork-Shiley) secondary to RHD experienced
low back pain and LE weakness beginning on [**2133-6-8**]. MRI of the
lumbar spine revealed a cystic mass at the T12-L2, which was
found to be a hematoma upon surgical exploration on [**2133-6-12**] and
was subsequently evacuated. Pt has been on Coumadin and digoxin
due to her cardiac hx and initially her INR was 3.5. During the
operation the pt experienced episodes of bradycardia with right
neck manipulation and swan-ganz catheter placement c/w vagal
etiology, however bradycardia and pauses continued for following
the surgery. Permanent v-lead pacemaker was placed on [**2133-6-14**]. Pt
demonstrated NSVT believed to be d/t digoxin toxicity (1.1).
Currently pt c/o pain in right leg from the buttock down to the
ankle on the lateral calf, diminishing distally. No c/o CP other
than at the incision site for the pacemaker, no SOB, no LH.
Difficulty with using bedside commode due to pain and reports no
BM, but positive flatus.
Past Medical History:
MVR secondary to RHD with Bjork-Shiley valve in [**3-/2108**]
Atrial fibrillation
HTN
Social History:
Visiting brother in US, lives in [**Name (NI) 651**], speaks predominantly
Cantonese and some English. No tobacco, alcohol, or recreational
drugs.
Family History:
Mother with HTN.
Physical Exam:
VS: HR - 103 RR - 20 T - 98.8 BP - 124/78
O2 sat - 95% on RA Pain - [**4-21**]
Gen: WN, WD thin woman who appears her age. Appears to be
uncomfortable and is diaphoretic.
HEENT: EOMI
NECK: JVP noted b/l, no JVD
CV: Irregularly irregular, tachycardic; Loud S1, S2, no M/R/G/C
noted; heart beat noted visibly across the chest and by
palpation. No carotid bruits.
Resp: CTA b/l A/P, no W/R/R
Abd: +BSx4, soft, NT/ND, no HSM
Ext: PP present and symmetric, except dorsalis pedis R>L. Ext
warm, with no cyanosis or edema. No right leg tenderness.
Neuro: AOx3; observed exam by Dr. [**First Name (STitle) 1022**] (ortho) - weakness in
right hallux extension; left LE weakness improving, left knee
extension at 2/5 strength.
Pertinent Results:
[**2133-6-12**] 12:20AM DIGOXIN-1.1
[**2133-6-12**] 12:20AM PT-23.0* PTT-31.6 INR(PT)-3.5
[**2133-6-12**] 12:20AM WBC-8.8 RBC-4.13* HGB-13.6 HCT-39.2 MCV-95
MCH-33.0* MCHC-34.8 RDW-13.4
[**2133-6-12**] 12:20AM GLUCOSE-137* UREA N-18 CREAT-0.6 SODIUM-135
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15
MRI L-Spine [**2133-6-12**]:
IMPRESSION: Extramedullary hematoma, which may be intradural or
epidural, compressing the conus and cauda equina from T11/12
through L1/2. Associated large veins are suggestive of a
vascular malformation. If the hematoma is intradural, a spinal
cord arteriovenous malformation is likely. A conventional
angiogram is recommended for assessment of vascular
malformation. Follow-up lumbar spine MRI is also recommended to
evaluate the surgical decompression.
MRI L-Spine [**2133-6-13**]:
IMPRESSION: Status post decompression of a large dorsal epidural
hematoma, there is soft tissue swelling which continues to
impress the distal cord and proximal cauda equina.
CXR [**2133-6-15**]:
IMPRESSION:
1. Pacing leads in the expected position of the right ventricle.
No evidence of pneumothorax. 2. Massive enlargement of the left
atrium
Echo [**2133-6-16**]:
IMPRESSION: Normal functioning mitral valve prosthesis. Mild
aortic stenosis. Mild aortic regurgitation. Severe biatrial
enlargement. Preserved biventricular systolic function.
Pulmonary artery hypertension.
PM Interrogation [**2133-6-24**]:
PM functioning properly
Brief Hospital Course:
59 yo Cantonese F with history of Atrial fibrillation, Mitral
valve replacement presented with epidural hematoma and lower
extremity weakness. Patient is s/p epidural hematoma evacuation
on [**2133-6-12**] and s/p single wire pacer placement on [**2133-6-14**]
sceondary to periop brady/pause. Patient was found to have
NSVT/?junctional tachycardia likely secondary to digoxin
toxicity.
.
The patient p/w spontaneous epidural hematoma and LE weakness on
[**2133-6-12**]. Following diagnositic evaluation, the patient was taken
to surgery for a T12-L2 laminectomy and subsequent evacuation of
the hematoma. At the time of admission the patient's INR was 3.5
as she was taking 3.5mg coumadin PO Qhs for prophylactic
anticoagulation due to her h/o afib and MVR. Her coumadin was
held and her INR monitored following surgery. She was placed on
coumadin 3.0mg Qhs once her INR dropped below 2.0 and she was
bridged with a heparin drip. Coumadin was increased to 4.0mg on
[**2133-6-17**] and as her INR rose to 2.8 on [**6-22**], decreased to 3.0mg.
Subsequent to her INR dropping from 2.5 to 2.1 on [**6-25**] and then
to 1.9 on [**6-26**] the coumadin dose was increased to 4.0mg and
5.0mg repectively. Coumadin continued to be titrated to a dose
of 3.5mg (her dose PTA) giving an INR of 2.4 at discharge.
In the perioperative period the patient began having episodes of
bradycardia and pauses for which a single wire pacemaker was
placed on [**2133-6-14**], with confirmation of proper lead placement by
CXR. The PM was interrogated on [**2133-6-24**] and found to be
functioning properly. Additionally in this time she developed
mild anemia likely due to the spontaneous hematoma and surgical
blood loss for which she received a total of 2 units of PRBCs
and has since resolved.
During this time the patient was continued on Lanoxin for her
atrial fibrillation and developed a NSVT/? junctional
tachycardia likely due to digoxin toxicity. Her digoxin was
discontinued and per EP's recommendations was not restarted and
will be held indefinitely. In order to maintain K levels above
4.0 to avoid potential dysrhytmias from hypokalemia,
spironolactone 25mg PO daily was started. On this regimen the
patient required 40mEq of KCl PO daily to maintain her K levels
and this was reduced to 20mEq daily as the K level on the day
prior to discharge was 4.5. On discharge the K level was 4.3.
For heartrate control metoprolol was increased over time to an
eventual dose of 75mg PO BID the day prior to discharge, during
which time the patient's BP was stable at SBP=110s to 130s. On
the day of discharge metoprolol 75mg [**Hospital1 **] was increased to Toprol
XL 200mg to help control SBP that were in the upper 120s.
Following evacuation of her epidural hematoma she developed
right LE pain, which was attributed to a radiculpathy and was
successfully treated with Neurontin 100mg TID. Due to
predominately left LE weakness, PT was consulted and recommended
that the pt be discharged to an extended care factility where
she could receive further care from PT. The patient continued to
improve during the course of her stay, but was it was still
considered necessary that the pt receive rehab upon d/c. Prior
to discharge the patient was prescribed an AFO left foot splint.
In addition she spiked a temperature to 100.3, for which an
infection work-up was began. Urine Cx showed Proteus Mirabilis,
Bld Cx negative. She was treated impirically on Vacnomycin,
which was d/c after the Bld Cx came back negative, and
Ciprofloxacin. P. mirabilis was found to be intermediately
sensitive to ciprofloxacin and Tx was switched to a sensitive
antibiotic, Ceftriaxone 500mg po Q12H for 10 days. Ceftriaxone
was stopped on [**2133-6-29**] and the patient remained afebrile and
asymptomatic. Both incisions healed well without current
drainage, erythema, edema, or tenderness.
Lastly during her hospital course she developed some bladder
irritation/spasms and hematuria likely due to foley catheter
trauma. The catheter was d/c'ed and she was treated with Detrol
for a couple of days. She has since been asymmptomatic and
without hematuria.
Medications on Admission:
Lanoxin 0.25mg po daily
Coumadin
Flexeril
Vicodin
Mehtylprednislone dose back
Apo-amilizide 50/5 mg po daily
Tensiomin (Chinese med) 25 mg po daily
Take chinese herbs and teas
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Warfarin Sodium 1 mg Tablet Sig: 3.5 Tablets PO HS (at
bedtime).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
6. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
7. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Epidural hematoma s/p evacuation, periop brady/pause s/p single
wire pacemaker placement, non-sustained ventricular tachycardia
secondary to digoxin toxicity
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as prescribed. Contact primary care
physician or return to hospital if experience chest pain,
shortness of breath, palpitations, worsening lower extremity
weakness, or other concerns.
Followup Instructions:
The following appointments have been scheduled for you:
1. [**Company 191**] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name12 (NameIs) **], MD Where: [**Hospital 273**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2133-7-24**] 3:00
2.
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2133-8-10**] 11:30
Completed by:[**2133-7-1**]
ICD9 Codes: 2768, 2859, 4019, 9971, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6590
} | Medical Text: Admission Date: [**2154-11-20**] Discharge Date: [**2154-11-22**]
Date of Birth: [**2087-6-12**] Sex: F
Service: MEDICINE
Allergies:
Plavix
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 22833**] is a 67 year old female with a history of CAD s/p
LAD stents in [**2145**], type II diabetes, hypertension and
hyperlipidemia who presents with one day of dyspnea on exertion
and subscapular pain. Patient was in her usual state of health
until one day prior to admission. On the morning of presentation
she took her husband to the doctor for a routine visit. On the
way into the building she had to walk up a ramp and noticed that
she was short of breath. She stopped and caught her breath and
felt somewhat better. The sensation returned when they got home
and she had to climb the 7 stairs into her house. She got to
the top and had to reset. At this time she also noticed pain
between her shoulder blades which reminded her of the pain she
felt 10 years ago when she had her myocardial infarction. The
pain was not pleuritic. It was associated with exertion and
dyspnea. It was not associated with lightheadedness, dizziness,
diaphoresis and did not radiate. It resolved with rest. It
returned later in the evening and was more severe. She recalls
feeling as if she were going to die. She had her daughter call
EMS. In the ambulance she received aspirin 325 mg and SL
nitroglycerin x 1 which she says resolved her pain.
In the emergency room her initial vitals were T: 98.1 BP: 129/79
HR: 118 RR: 20 O2: 77% on RA which improved to 93% on 15L. She
had a CXR which showed no acute process. Her initial EKG showed
sinus tachycardia at 108 with left axis deviation, normal
intervals, no acute ST segment changes. Her first troponin was
0.05 with CK of 186. Cardiology was consulted who felt her
picture not consistent with acute coronary syndrome. Her
d-dimer was elevated at 1143 and she underwent a CTA which
showed bilateral subsegmental pulmonary emboli. She received
one liter normal saline and was started on IV heparin with a
bolus. She was admitted to the [**Hospital Unit Name 153**] for further management.
On arrival to the [**Hospital Unit Name 153**] she is awake, alert and speaking in full
sentences. She denies lightheadedness, dizziness, chest pain.
She continues to have dyspnea but this is improved with
supplemental oxygen. She denies nausea, vomiting, abdominal
pain, dysuria, hematuria, diarrhea, constipation, melena,
hematochezia, leg pain or swelling. She denies recent travel or
immobilziation. No recent surgeries. She is up to date on her
mammograms. No PAP smear in last 10 years. Due for
colonoscopy.
While in the [**Hospital Unit Name 153**] she was continued on IV heparin and started on
coumadin. She was initially requiring 6L nasal cannula and this
was weaned to 3L by hospital day two. She had an echocardiogram
which showed mild right ventricular cavity enlargement with mild
free wall hypokinesis and mild pulmonary artery systolic
hypertension. She had bilateral lower extremity ultrasounds
which were negative for DVT. At no time was she hemodynamically
unstable. She is transferred to the floor for further
management.
Past Medical History:
Type II Diabetes
Coronary Artery Disease s/p NSTEMI with 2 LAD stents placed in
[**2145**] with additional stent placed for acute thrombotic occlusion
Hypertension
Type II Diabetes
Hyperlipidemia
Social History:
Patient lives with her husband and two grown children. She has
a remote smoking history and quit as a teenager. Occassional
alcohol use. No illicits.
Family History:
Mother died suddenly at age 66 when she collapsed. Father died
of a traumatic accident at age 59. She has 12 siblings, 8 are
still living. One sister had a lower extremity DVT.
Physical Exam:
Vitals: T: 98.1 HR: 104 BP: 138/84 RR: 15 O2: 93% on 6L NC
General: Awake, alert, speaking in full sentences
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD, JVP not elevated
Cardiac: tachycardic, s1 + s2, no murmurs, rubs, gallops
Lungs: Clear to ausculatation bilaterally without wheezes,
rales, ronchi
GI: soft, non-tender, non-distended, +BS, no organomegaly
appreciated
GU: no foley
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Rectal: guaiac negative in ER
Pertinent Results:
Chemistries:
[**2154-11-19**] 10:14PM GLUCOSE-270* UREA N-16 CREAT-1.5* SODIUM-136
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-21* ANION GAP-19
[**2154-11-20**] 04:14AM CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-1.6
[**2154-11-19**] 10:14PM D-DIMER-1143*
Hematology:
[**2154-11-19**] 10:14PM WBC-10.5 RBC-4.37 HGB-11.0* HCT-33.5* MCV-77*
MCH-25.2* MCHC-32.8 RDW-16.2*
[**2154-11-19**] 10:14PM NEUTS-64.9 LYMPHS-26.5 MONOS-5.0 EOS-2.7
BASOS-0.8
[**2154-11-19**] 10:14PM PT-13.4 PTT-21.8* INR(PT)-1.1
Cardiac Enzymes:
[**2154-11-19**] 10:14PM BLOOD CK-MB-5 cTropnT-0.05* CK(CPK)-186*
[**2154-11-20**] 04:14AM BLOOD CK-MB-6 cTropnT-0.07* CK(CPK)-161*
[**2154-11-20**] 03:15PM BLOOD CK-MB-5 cTropnT-0.03* CK(CPK)-135
Urine Studies:
[**2154-11-20**] 10:16AM URINE Osmolal-407
[**2154-11-20**] 10:16AM URINE Hours-RANDOM Creat-64 Na-100 K-28 Cl-96
EKG: sinus tachycardia at 108 with left axis deviation, normal
intervals, no acute ST segment changes.
Imaging:
Chest XRAY [**2154-11-19**]: Single portable view of the chest in
upright position was obtained. The cardiac silhouette is
enlarged. There is no pneumothorax, consolidation, or large
pleural effusions. The pulmonary vasculature is normal. The
osseous structures demonstrate degenerative changes of the
thoracic spine.
CTA Chest [**2154-11-19**]: There are multiple bilateral filling defects
involving the lobar branches of the pulmonary artery consistent
with pulmonary embolism. The central airways are patent to the
segmental levels, bilaterally. There is motion artifact which
limits the study. There is no pneumothorax or consolidation. The
heart is normal in size and demonstrates right ventricular
strain. A coronary artery stent is seen in the LAD. There is no
mediastinal, hilar, or axillary lymphadenopathy.
The visualized portions of the upper abdomen demonstrate
vascular
calcifications. Atherosclerotic changes of the aorta without
evidence of
aneurysm.
Echocardiogram [**2154-11-20**]: The left atrium and right atrium are
normal in cavity size. The estimated right atrial pressure is
0-10mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 50%). The
right ventricular cavity is mildly dilated with mild global free
wall hypokinesis. There is abnormal septal motion/position. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mrs. [**Known lastname 22833**] is a 67 year old female with coronary artery
disease, hypertension, and diabetes who presents with
subscapular chest pain and shortness of breath found to have
bilateral segmental pulmonary emboli with evidence of right
heart strain.
.
Pulmonary Embolism: Diagnosed by CT chest. She was started on
IV heparin in the emergency room and coumadin on arrival to the
[**Hospital Unit Name 153**]. Her echocardiogram showed evidence of mild right heart
strain but at no time was she hemodynamically unstable. She was
initially requiring 6L of supplemental oxygen and upon transfer
to the floor she was requiring 3L. It was weaned off by
discharge. The etiology of her pulmonary emboli are unclear.
She had bilateral lower extremity ultrasounds whcih were
negative for DVT. She is up to date on her mammograms. She has
not had a recent PAP smear or colonoscopy. She has one sister
with a history of a DVT but no other history of clotting
disorders in her family. Patient will follow up with her PCP
for age appropriate cancer screening and consideration of
hypercoaguable workup. Patient was on heparin gtt until her INR
was within therapeutic range. The patient will follow up with
her PCPs office on Mon to check another INR.
.
Acute Renal Failure: On arrival to the [**Hospital Unit Name 153**] her creatinine was
elevated at 1.5 from a baseline in [**2145**] of 0.8. Urine
electrolytes were equivocal. Her creatinine improved to 1.2
with IVF administration. Her urine output has been good. Will
continue to monitor.
.
Hypertension: She has been hemodynamically stable during her
ICU course. Metoprolol was continued given her CAD history but
her other antihypertensive medications were held due to low
normal blood poressures. Patient was instructed to not continue
her benicar/HCTZ for now. She will follow up with her PCP to
determine if it needs to be restarted in the future.
.
Type II Diabetes: Patient was monitored on insulin sliding
scale. Her home oral agents were initially held but restarted at
discharge.
.
Coronary Artery Disease: s/p MI and LAD stents in [**2145**]. EKG on
admission without without ischemic changes. She had three sets
of negative cardiac enzymes and no arrythmias were noted on
telemetry. She was continued on her home aspirin, statin and
metoprolol as above. Her home statin and fibrate were
continued.
.
FEN: Cardiac/Diabetic diet, monitor electrolytes, no standing
IVF
.
Code: Full
.
Communication: Husband [**Name (NI) **] [**Name (NI) 22833**] [**Telephone/Fax (1) 31750**]
.
Disposition: Patient was cleared by PT to go home without
services.
Medications on Admission:
Aspirin 325 mg daily
Metformin 850 QAM and 1350 QPM
Toprol XL 100 mg daily
Benicar/HCTZ 40-12.5 mg daily
Tricor 145 mg daily
Glimepiride 2 mg daily
Lisinopril 40 mg daily
Lipitor 40 mg daily
Discharge Medications:
1. Metformin 850 mg Tablet Sig: One (1) Tablet PO qam.
2. Metformin 850 mg Tablet Sig: 1.5 Tablets PO at bedtime.
3. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
7. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolisms
Discharge Condition:
Good.
Discharge Instructions:
-Continue Coumadin to treat your blood clots.
-Go to your PCPs office on Monday to obtain a lab slip to have
your blood drawn to check your coumadin levels.
-On monday when you get the lab slip you should arrange a
hospitalization follow up appointment with your PCP [**Name Initial (PRE) **] [**12-19**]
weeks from now.
-Your PCP should facilitate further age appropriate cancer
screeening such as pap smear and colonoscopy.
-Do not take benicar/HCTZ for now as your blood pressure has
been running on the lower side. Discuss with your PCP about
whether or not to restart this medication in the future.
-Take all other medications as prescribed.
-Call your PCPs office or return to ED if you experience
worsening shortness of breath, chest or scapulaar pain,
fevers/chills or other worrisome signs/symptoms.
Followup Instructions:
Follow up with PCP 1-2 weeks
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2154-11-25**]
ICD9 Codes: 5849, 412, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6591
} | Medical Text: Admission Date: [**2187-2-17**] Discharge Date: [**2187-2-25**]
Date of Birth: [**2148-11-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Cellulitis/fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
38 yo with known hypertension/hyperlipidemia/Diabetes Mellitus
presents with a 4 day history of cellulitis RLE, started
cephalexin and bactrim the day prior to presentation without
improvement. On the day of admission, the temperature increased
to 101.4 at home and he called PCP who advised to go to ER.
Temperature at ED: 101, wbc 24, creat 2.7 (baseline 1.7). Pan
cultured, started iv vanco and unasyn, iv rehydration. u/s and
xray of RLE prelim were negative. The patient was admitted after
discussion with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
ROS
Denied any precipitant of cellulitis; no falls/abrasion, trauma.
No other complaints: No CP, SOB, palpitations. No GI/GU
complaints.
Past Medical History:
DIABETES TYPE 2 ([**First Name8 (NamePattern2) **] [**Last Name (un) **]; in [**Last Name **] problem list says type 1)
HYPERCHOLESTEROLEMIA
HYPERTENSION
OBESITY
ASTHMA; never been intubated
TOBACCO ABUSE
S/P APPY
TO THE ER
Chronic RENAL INSUFFICIENCY
OTITIS
Obesity
Social History:
He lives in [**Location 686**] with his wife, their 11 [**Name2 (NI) **] son and two
step sons. Pt states he is a long-time smoker, but has quit
several times in the past and does not see smoking as a problem
for him. Occasional EtOH at parties, no IVDU.
Family History:
Diabetes
Physical Exam:
T: 98.0 BP: 126/72 P: 86 RR: 22 O2 sats: 92RA FS: 181
Gen: NAD
HEENT: NC/AT, EOMI
Neck: supple, no [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: RRR, no m/r/g
Resp: CTAB
Abd: obese, soft, NT/ND
Ext:
- RLE with areas of blanching erythema bordered with pen on
anterior aspect. No erythema over posterior aspect. Warm and
tender on palpation. Proximal leg with trace erythema/swelling.
- LLE wnl.
Neuro: grossly wnl
Sensation: wnl
Strength: [**2-22**] dorsi/plantar flexion of R foot; 5/5 strength on L
Reflexes: 1+ b/l DTR
Pertinent Results:
[**2187-2-16**] 03:45PM BLOOD WBC-12.9* RBC-4.83 Hgb-13.1* Hct-38.9*
MCV-81* MCH-27.1 MCHC-33.7 RDW-13.8 Plt Ct-308
[**2187-2-17**] 01:30PM BLOOD WBC-23.6*# RBC-4.48* Hgb-12.4* Hct-35.7*
MCV-80* MCH-27.7 MCHC-34.8 RDW-14.5 Plt Ct-256
[**2187-2-18**] 06:55AM BLOOD WBC-15.9* RBC-4.04* Hgb-11.0* Hct-32.4*
MCV-80* MCH-27.3 MCHC-34.1 RDW-14.5 Plt Ct-261
[**2187-2-19**] 07:35AM BLOOD WBC-15.8* RBC-4.00* Hgb-10.4* Hct-32.4*
MCV-81* MCH-26.0* MCHC-32.1 RDW-14.4 Plt Ct-262
[**2187-2-17**] 01:30PM BLOOD Neuts-83.7* Lymphs-11.4* Monos-4.4
Eos-0.3 Baso-0.2
[**2187-2-19**] 01:05PM BLOOD PT-12.0 PTT-45.7* INR(PT)-1.0
[**2187-2-17**] 01:30PM BLOOD Glucose-186* UreaN-37* Creat-2.7* Na-135
K-4.1 Cl-96 HCO3-30 AnGap-13
[**2187-2-18**] 06:55AM BLOOD Glucose-172* UreaN-48* Creat-3.7* Na-136
K-4.1 Cl-97 HCO3-27 AnGap-16
[**2187-2-19**] 07:35AM BLOOD Glucose-133* UreaN-59* Creat-4.0* Na-137
K-4.3 Cl-100 HCO3-27 AnGap-14
[**2187-2-18**] 06:55AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.9 Cholest-207*
[**2187-2-19**] 07:35AM BLOOD calTIBC-225* VitB12-440 Ferritn-269
TRF-173*
[**2187-2-18**] 06:55AM BLOOD Triglyc-201* HDL-42 CHOL/HD-4.9
LDLcalc-125
[**2187-2-19**] 07:35AM BLOOD Vanco-8.8*
[**2187-2-19**] 03:59AM BLOOD Type-ART pO2-62* pCO2-56* pH-7.34*
calTCO2-32* Base XS-2 Intubat-NOT INTUBA Comment-NON-REBREA
[**2187-2-17**] 01:32PM BLOOD Lactate-1.1
- UNILAT LOWER EXT VEINS RIGHT [**2187-2-17**] 3:48 PM
FINDINGS: Color Doppler son[**Name (NI) 1417**] of the right common femoral,
superficial femoral, and popliteal veins were performed. There
was normal flow, augmentation, and waveforms demonstrated. There
was no intraluminal thrombus identified. Due to the patient body
habitus, compression images of the common and superficial
femoral arteries could not be obtained.
IMPRESSION: No evidence of right lower extremity deep vein
thrombosis. Somewhat limited study.
- RADIOLOGY TIB/FIB (AP & LAT) RIGHT [**2187-2-17**]
FINDINGS: There is a marked soft tissue edema and density, in
the proximal right lower extremity. There is no gas noted in the
subcutaneous tissue. There is no sign of fracture or dislocation
or degenerative change. There is no underlying cortical
reaction. There are no radiopaque foreign bodies.
IMPRESSION: Marked density and edema of soft tissues of the
proximal right lower extremity. Please note that absence of gas
does not rule out necrotizing fasciitis.
- RADIOLOGY CHEST (PA & LAT) [**2187-2-17**]
PA AND LATERAL CHEST RADIOGRAPH: The lung volumes are low.
Cardiomediastinal silhouette is unchanged. There is no evidence
of central lymphadenopathy. Lungs are clear, with the exception
of bibasilar atelectasis. There is no pleural effusion.
Pulmonary vascularity is normal.
IMPRESSION: No acute cardiopulmonary process
- RADIOLOGY Final Report CHEST (PORTABLE AP) [**2187-2-18**]
IMPRESSION: Stable appearance to the chest with no acute process
seen.
- RENAL U.S. [**2187-2-18**]
FINDINGS: Study is very limited secondary to large body habitus.
The left kidney measures 11.9 cm. The right kidney measures 10.7
cm. No hydronephrosis identified within the kidneys. No definite
mass lesion or stones identified.
IMPRESSION: Limited study secondary to increased body habitus.
No hydronephrosis identified and no definite mass lesion or
renal stones identified.
- LUNG SCAN [**2187-2-19**]
INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol
in 8 views
demonstrate mild decrease in tracer uptake in the posterobasilar
segment of the right lower lobe. Perfusion images in the same 8
views show a matched defect in the posterior right lower lobe.
No other perfusion defects are identified.
Chest x-ray shows an air space opacity in the right lower lobe
corresponding to the area of matched tracer defect.
IMPRESSION: Decreased perfusion and ventilation in the posterior
right lower lobe corresponding to an infiltrate on CXR. These
findings would be entirely compatible with air space disease,
but in the face of CXR findings, the possibility of pulmonary
embolism can not be fully excluded. No other segmental perfusion
defects are present.
- BILAT LOWER EXT VEINS [**2187-2-19**]
BILATERAL LOWER EXTREMITY ULTRASOUND: Compared to DVT study of
just two days prior. Grayscale and Doppler son[**Name (NI) 867**] were
performed of the bilateral lower extremity veins including the
greater saphenous, common femoral, superficial femoral,
popliteal, and deep tibial veins. Venous structures demonstrate
normal compression, flow, waveforms, and augmentation without
intraluminal thrombus. Note is made of large right groin lymph
nodes measuring up to 2.8 cm in long axis, demonstrating a
benign-appearing fatty hila, likely reactive given history of
cellulitis.
IMPRESSION:
1) No evidence of DVT.
2) Right groin adenopathy, likely reactive.
- CHEST (PORTABLE AP) [**2187-2-19**]
PORTABLE AP CHEST RADIOGRAPH: There is a new area of faint
opacity within the right lower lobe in comparison to the prior
study. The cardiac and mediastinal contours are stable. The
remainder of lungs are clear. There is no pulmonary vascular
congestion. No pleural effusions or pneumothorax seen.
IMPRESSION: New faint opacity in the right lower lobe may
represent an area of aspiration and/or consolidation.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2187-2-24**] 3:52 PM
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOP ABD/PEL LIMITED
Reason: evaluate for evidence of hepatitis, gallbladder disease,
por
[**Hospital 93**] MEDICAL CONDITION:
38 year old man with diabetes, hypercholesterolemia, HTN, CRI
admitted for PE and ? cellulitis, now with elevated LFTs (new
since [**2187-2-15**]).
REASON FOR THIS EXAMINATION:
evaluate for evidence of hepatitis, gallbladder disease, portal
vein thrombosis
INDICATION: Diabetes, chronic renal failure, and admitted for
PE. Now with elevated LFTs. Evaluate for hepatitis, gallbladder
disease, portal vein thrombosis.
COMPARISON: [**2185-6-17**].
ABDOMINAL ULTRASOUND: The liver is diffusely echogenic
consistent with fatty infiltration. No focal lesions are seen.
The gallbladder is unremarkable with no stones or wall
thickening. The common hepatic duct measures 4 mm. There is no
intrahepatic biliary dilatation. The portal vein is patent with
anterograde flow. There is no ascites. The pancreas was not well
visualized due to overlying bowel gas. Limited views of the
right kidney demonstrate no hydronephrosis.
IMPRESSION: Echogenic liver consistent with fatty infiltration.
Other forms of liver disease including significant
fibrosis/cirrhosis cannot be excluded. Additionally, ultrasound
is not very sensitive for detection of hepatitis. Please
correlate clinically.
TIB/FIB (AP & LAT) RIGHT [**2187-2-24**] 1:39 PM
TIB/FIB (AP & LAT) RIGHT
Reason: eval for evidence of osteomyelitis
[**Hospital 93**] MEDICAL CONDITION:
38 year old diabetic male with cellulitis, pain on RLE (anterior
shin).
REASON FOR THIS EXAMINATION:
eval for evidence of osteomyelitis
EXAMINATION: Tibia and fibular, right.
INDICATION: Diabetes. Pain. Possible osteomyelitis.
Views of the right tibia and fibula show normal bony alignment
with no acute bony injury. No plain film findings are seen to
suggest osteomyelitis. No soft tissue gas or foreign material is
visualized. There is mild soft tissues swelling anterior to the
proximal tibia.
IMPRESSION:
No plain final film findings to suggest osteomyelitis. If this
remains a clinical concern, then a nuclear medicine study or MRI
would be more sensitive.
Brief Hospital Course:
# Cellulitis
Pt was started on keflex and bactrim as an outpatient on the day
prior to admission, but had called PCP because of fevers on day
of admission. On arrival to [**Name (NI) **], pt had LENIs, R TIB/FIB XR, and
CXR performed, which were all negative. He received vanco and
unasyn in ED and continued on floor. Temperatures were
monitored, and noted to spike despite antibiotics. Blood
cultures were drawn for each spike. His wbc trended downwards
from 26->15. Pt received dilaudid for pain control.
Subsequently he was switched to a regimen of vancomycin,
levofloxacin and flagyl. He was discharged on keflex x one week
and asked to finish his course of levo and flagyl.
# Hypoxia
Pt had desaturated to the 66% on RA while sleeping on routine
vital sign check on HD#2. Pt's lungs were clear, without
wheeze/rales/crackles. Given his asthma hx, albuterol/atrovent
nebs were provided. An EKG and CXR were also performed which
showed no change from prior. His temperature was also elevated
at the time, and thus another set of blood culture was sent.
Blood cultures from [**2-19**] were again negative, and ASO negative as
well.
The patient then had an episode of shortness of breath early
morning of HD#3. Pt was noted to be saturating at 76% on RA
when he ambulated to the use the bathroom. Pt was placed on NC,
and was 85%. Thus, was placed on NRB and saturating 93%. He
was without CP, palpitations, or any other complaints. SOB was
improved on NRB. His vitals at the time of incident was: 102.3
108 118/70 22. Another CXR and LENIs were ordered, which were
negative, ABG was done: 7.34/56/62. Repeat EKG showed no acute
changes. Moreover, his creatinine had increased up to 4.0.
On exam, the patient's lungs had crackles, and thus lasix was
given with renal consult.
Pt had a V/Q scan performed and he was found to have decreased
perfusion and ventilation in the posterior right lower lobe
corresponding to an infiltrate on CXR. These findings would be
entirely compatible with air space disease, but in the face of
CXR findings, the possibility of pulmonary embolism could not be
fully excluded. No other segmental perfusion defects were
present. Pt remaind on NRB and was achieving low 90s. MICU
consult was obtained, and the patient was transferred to the
MICU for persistent hypoxia. Because the patient had remained
relatively immobile with his cellulitis, clinical suspicion for
PE warranted the initiation of anticoagulation with heparin
bridge to coumadin. Heparin was d/c on [**2-23**]. Coumadin was
initially given at 7.5 mg, then 5 mg, and he was discharged on 3
mg with instructions to see his PCP within [**Name Initial (PRE) **] day or two to
address the need for continued anticoagulation.
The patient was put on BIPAP for OSA in the ICU, and prior to
discharge it was arranged that he would get a BIPAP machine that
same day. He did not like the BIPAP but it was explained to him
that he required it for sleep apnea.
Prior to discharge, he ambulated on the floor and maintained his
oxygen sats >95% at all times.
.
# Acute renal failure
The patient has known chronic renal insufficiency with bsl
creatinine of 1.7-2.1. On admission at [**Name (NI) **], pt's creatinine was
elevated to 2.7. It was remeasured on the following day and
showed an increase to 3.7. Urinary Na, creatinine, osm,
protein, eos were measured, and results were suggestive of
prerenal picture. Renal U/S was performed, which was a limited
study secondary to increased body habitus, but no hydronephrosis
identified and no definite mass lesion or renal stones
identified. IVF was started overnight of HD#2. Renal consult
was obtained. Recommendations included: Holding ACE-I,
continuing to Vanco dose was obtained was 8.8. Vancomycin was
continued until the day of discharge, at which time he was put
on Keflex for one week.
# DIABETES TYPE II, followed at [**Last Name (un) **], the patient's sugars
were well controlled on sliding scale insulin.
.
# HYPERCHOLESTEROLEMIA - Stable; Pt was continue on Lipitor.
Fasting lipids were drawn which were reasonable.
.
# HYPERTENSION - Stable; Pt was initiated on HCTZ, Cardia,
Lisinopril. Lisinopril was later held.
.
# TOBACCO ABUSE - offer nicotine patch prn
.
#.
# FEN: The patient was maintained on a regular - diabetic diet.
.
# PPX: SC hep
.
# CODE: FC
Medications on Admission:
Bupropion 100"
keflex, bactrim
insulin NPH
- 62u in AM, 52 in PM
HCTZ 50'
Cartia 180'
Lisinopril 40'
question other meds?
Discharge Medications:
1. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days: Last doses on [**3-1**].
Disp:*14 Tablet(s)* Refills:*0*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days: Last dose 4/12.
Disp:*4 Tablet(s)* Refills:*0*
7. Coumadin 3 mg Tablet Sig: Three (3) Tablet PO at bedtime:
Please take 3 mg daily, follow-up with your PCP on [**Month/Year (2) 3816**] for
dose adjustment. .
Disp:*5 Tablet(s)* Refills:*0*
8. Keflex 500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 7 days: Last doses on [**2187-3-3**].
Disp:*28 Tablet(s)* Refills:*0*
9. Please continue to take insulin as you were prior to
admission
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute respiratory failure - Possible Pulmonary Embolism/
pneumonia
Right Lower Extremity Cellulitis
Acute on Chronic Renal Failure
Secondary Diagnosis:
DM type II
Hypercholesterolemia
Hypertension
Obesity
Asthma
Discharge Condition:
Good. Ambulatory and no need for oxygen.
Discharge Instructions:
You were in the hospital for an infection in your right leg. We
also were unable to exclude a blood clot in your lungs, and are
treating you for this condition. You were given medicine to make
your blood thinner and antibiotics. It is ESSENTIAL that you see
your doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**] [**2-27**] at the latest as your blood can get
too thin and not thin enough and this can cause very serious
health problems.
You need to complete the course of antibiotics as prescribed.
Flagyl and Levofloxacin until [**3-1**], and Keflex until [**3-4**].
You need to use a CPAP machine at home for your obstructive
sleep apnea (breathing problems at home). You also need to
discuss this problem with your PCP during your next visit.
Please note that we have stopped hydrochlorothiazide, and
started a new blood pressure medication called Metoprolol.
Please take it as prescribed. Please note that we have also
stopped Lisinopril. Please discuss this with your PCP when you
see him on [**Month/Year (2) 3816**].
Followup Instructions:
With Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]. Please
call and schedule an appointment with him for Monday or [**Telephone/Fax (1) 3816**]
([**2-27**]) at the latest.
Should he not be available, please schedule an appointment with
a different provider in the clinic (episodic), but it is
ESSENTIAL that you be seen within the next two days.
ICD9 Codes: 5849, 486, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6592
} | Medical Text: Admission Date: [**2192-11-8**] Discharge Date: [**2192-11-11**]
Date of Birth: [**2151-4-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
EtOH Withdrawal
Abdominal pain
Major Surgical or Invasive Procedure:
Diagnostic paracentesis
History of Present Illness:
41yF with alcoholic cirrhosis who presented from OSH with 3d of
RUQ pain nausea/vomiting. Her abdominal pain was made worse with
eating or laying flat. She denies fevers/chills. RUQ US at OSH
demonstrates GB wall thickening 7mm without pericholecystic
fluid. Her wt ct was 16.7 at OSH with TBili 5. She was
transferred to [**Hospital1 18**] for management of putative acute
cholecystitis.
.
At [**Hospital1 **], pt started on unasyn, but U/S and CT [**Last Name (un) 103**] showed no
evidence of acute chole, but rather GB wall edema c/w cirrhosis.
Was admitted to SICU with plan for diagnostic para and HIDA
scan, but plan for HIDA was dropped. Meanwhile, patient was
feeling more agitated c/w previous <24 hour periods w/o EtOH.
Patient reported last EtOH intake on [**11-7**], with a decades-long
history of 1bottle of wine or vodka daily hx of EtOH use.
.
In the SICU, patient was thought to be showing some increased
signs of agitation, and so was transferred to the MICU for
possible EtOH w/d.
Past Medical History:
- Cirrhosis (dx day of admission)
- EtOH Abuse
- Bilateral carpal tunnel release 2y ago
- Breast augmentation 14 years ago
- C-section x 2
Social History:
Former dialysis RN. ETOH abuse x 20 years 6 cocktails/day. 1
bottle of wine/day. Prefers merlot and vodka. No IVDU or other
illicit drug use. Tobacco 1.5ppd x 30 years.
Family History:
father with stomach CA. Mother with HTN
Physical Exam:
Physical exam on discharge:
Vitals: T:97 BP:98/60 P:92 R: 18 O2:96% RA
General: Alert, anxious, NAD
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild abdominal tenderness, full belly, 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:
1. Labs on admission:
[**2192-11-7**] 09:30PM BLOOD WBC-13.6* RBC-2.26* Hgb-8.7* Hct-26.4*
MCV-117* MCH-38.6* MCHC-33.0 RDW-15.6* Plt Ct-212
[**2192-11-7**] 10:57PM BLOOD PT-16.4* PTT-30.6 INR(PT)-1.5*
[**2192-11-7**] 09:30PM BLOOD Glucose-115* UreaN-3* Creat-0.5 Na-139
K-2.6* Cl-100 HCO3-26 AnGap-16
[**2192-11-7**] 09:30PM BLOOD ALT-40 AST-177* AlkPhos-268* TotBili-4.7*
DirBili-3.4* IndBili-1.3
[**2192-11-7**] 09:30PM BLOOD Lipase-21
[**2192-11-7**] 09:30PM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.6*
Mg-1.2*
[**2192-11-7**] 09:59PM BLOOD K-2.4*
.
2. Labs on discharge;
[**2192-11-11**] 05:35AM BLOOD WBC-10.3 RBC-2.01* Hgb-7.7* Hct-24.4*
MCV-121* MCH-38.1* MCHC-31.5 RDW-15.7* Plt Ct-261
[**2192-11-11**] 05:35AM BLOOD PT-16.0* PTT-32.9 INR(PT)-1.4*
[**2192-11-11**] 05:35AM BLOOD Glucose-108* UreaN-5* Creat-0.4 Na-140
K-4.1 Cl-112* HCO3-20* AnGap-12
[**2192-11-11**] 05:35AM BLOOD ALT-38 AST-196* AlkPhos-221* TotBili-2.7*
[**2192-11-11**] 05:35AM BLOOD Calcium-7.7* Phos-2.2* Mg-1.9
[**2192-11-9**] 11:30AM BLOOD calTIBC-107* VitB12-741 Folate-11.8
Ferritn-782* TRF-82*
[**2192-11-8**] 10:27AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2192-11-9**] 11:30AM BLOOD IgG-952 IgA-253 IgM-134
[**2192-11-8**] 10:27AM BLOOD HCV Ab-NEGATIVE
[**2192-11-9**] 10:56AM BLOOD freeCa-0.96*
.
3. Imaging/diagnostics:
- CXR: Normal chest.
- Abdominal u/s: 1. Heterogeneous nodular echotexture of the
liver with increased echogenicity that is compatible with
provided history of cirrhosis. 2. Moderate amount of simple
intra-abdominal ascites. 3. Main portal vein is patent. 4.
Gallbladder sludge. No evidence of cholecystitis. 5. Mild
splenomegaly measuring up to 14.3 cm.
- CT abdomen/pelvis: 1. No evidence of acute cholecystitis.
Diffuse fatty liver infiltration/heterogeneity and a moderate
amount of abdominal and pelvic ascites and varices c/w
cirrhosis. 2. The patient has diverticulosis with colonic wall
hypertrophy; however, there are no surrounding changes to
suggest acute diverticulitis.
.
==================================================
Pending labs on discharge (to be followed up:
[**2192-11-9**] 09:30PM BLOOD AMA-PND Smooth-PND
[**2192-11-9**] 09:30PM BLOOD [**Doctor First Name **]-PND
[**2192-11-9**] 09:30PM BLOOD CERULOPLASMIN-PND
[**2192-11-9**] 09:30PM BLOOD ALPHA-1-ANTITRYPSIN-PND
===================================================
Brief Hospital Course:
41 yo F with history of alcohol abuse, initially admitted for
concern of acute cholecystitis and alcohol withdrawal, found to
have cirrhosis.
.
# EtOH Withdrawal: No prior history of DTs or active withdrawal
however concern given high daily EtOH intake. No hallucinations.
CIWA < 10 throughout hospitalization. Thiamine, folate,
multivitamins given and a social work consult was ordered.
Patient declined social work consult. Patient instructed to
attend AA meeting or join support group to help alcohol
cessation. Patient declined.
.
# Abdominal Pain/Nasea/Vomiting: Exam negative for acute
abdomen. Mild diffuse abdominal tenderness but non-localizable.
CT scan without evidence of acute process and RUQ US at OSH with
GB wall thickening 7mm but without pericholecystic fluid.
Transaminitis remained stable, likely chronic. Transitioned to
oral diet. Weaned off pain medication.
.
# Cirrhosis: New diagnosis on on transfer from OSH ([**2192-11-7**]).
Transaminitis and cholestatic picture noted on labs, unclear
past history but pt reports heavy drinking and AST/ALT ratio >
4, which remained stable. Viral hepatitis panel negative for
acute infection. Autoimmune panel and wilson's disease labs
pending at the time of discharge. Diagnostic paracentesis
negative for spontaneous bacterial peritonitis. Serum-ascites
albumin gradient 2.6, consistent with ascites due to portal
hypertension.
.
==================================================
Pending labs on discharge (to be followed up:
[**2192-11-9**] 09:30PM BLOOD AMA-PND Smooth-PND
[**2192-11-9**] 09:30PM BLOOD [**Doctor First Name **]-PND
[**2192-11-9**] 09:30PM BLOOD CERULOPLASMIN-PND
[**2192-11-9**] 09:30PM BLOOD ALPHA-1-ANTITRYPSIN-PND
===================================================
Medications on Admission:
None
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis
Transaminitis
Alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 5395**], you were admitted to [**Hospital1 1170**] ([**Hospital1 18**]) because you had abdominal pain. We found that you
have fibrosis of the liver called cirrhosis, most likely from
your alcohol use. Your liver enzymes were elevated but remained
stable. You had withdrawal from alcohol and we treated you for
that. We tapped the fluid in your abdomen which did not show an
infection.
.
It is VERY important that you call the liver clinic at [**Hospital1 18**] to
make a follow-up appointment on Monday [**2192-11-12**]. The phone
number is listed below. You should join a support group and stop
alcohol consumption to prevent progression of your liver
disease.
.
We made the following changes to your medications:
STARTED:
- Folic Acid 1 mg by mouth daily
- Thiamine 100 mg by mouth daily
- Multivitamins 1 tab by mouth daily
Followup Instructions:
Please call the Liver Center at [**Hospital1 1170**] at ([**Telephone/Fax (1) 1582**] on [**2192-11-12**] to schedule a follow-up
appointment within the next 2 weeks.
Completed by:[**2192-11-11**]
ICD9 Codes: 2768, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6593
} | Medical Text: Admission Date: [**2144-3-16**] Discharge Date: [**2144-3-17**]
Date of Birth: [**2097-12-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46 yo f with hx of EtOH abuse, who presented at ER after being
found down at a McDonald's appearing intoxicated. Pt was
unresponsive in [**Last Name (un) 8491**] and brought to ER. She had a bottle of
trazadone that was Rx early in [**Month (only) 404**] with the appropriate
amount of tabs remaining. Pt smelled of etoh. She does not
remember what happen today, but states she usually drinks about
a pint of vodka a day. She denies other drug use. She does
report a recent productive cough, but is unclear about the
details. She c/o chronic LBP. She denies CP, SOB, and GI sx.
.
On arrival to the ER pt VS were reported 96.7 90 89/63 12 94;
however [**Name8 (MD) **] MD pt was not hypotensive and BP was in 110s. Pt had
a CXR concerning for a RML infiltrate and was given levo 750mg,
and flagyl. Also given thiamine, folate, and MV. Pt started to
awake and was responsive to verbal stimuli. 3 liters of NS was
given including banana bag. Initially pt was low 90s% sats on
[**Last Name (LF) **], [**First Name3 (LF) **] a nasal trumpet was placed and pt was 100% on 4 liters.
Pt was admitted to MICU for observation and concern for
continued AMS. VS at transfer were 98.1 89 103/65 20 100% on 4
liters.
.
On the floor, pt is more awake but confused and a poor
historian.
Past Medical History:
-etoh use
-low back pain, s/p surgery
Social History:
Pt is homeless, lives at a shelter. Is single, reports a 12 yo
child, but unclear where the child is. Reports drinking a pint
of vodka a day. +tobacco use, but unclear on amount. Denies drug
use.
Family History:
NC
Physical Exam:
Vitals: 98.2 98 102/66 15 90% on RA
General: Alert, not oriented except to person and season
HEENT: Sclera anicteric, MMM, oropharynx with secretions
Neck: supple, no LAD
Lungs: diffuse rhonchi, + wheezes, bronchial breath sounds
CV: Regular rate and rhythm, no M, 2+ pulses
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley removed
Ext: warm, no edema, no clubbing
at time of leaving AMA, pt was orientated and had capacity
Pertinent Results:
[**2144-3-17**] 01:43AM BLOOD WBC-5.0 RBC-3.70* Hgb-12.0 Hct-37.7
MCV-102* MCH-32.5* MCHC-31.9 RDW-14.9 Plt Ct-460*
[**2144-3-16**] 07:50PM BLOOD WBC-6.7# RBC-3.82* Hgb-12.7 Hct-38.7
MCV-101* MCH-33.2* MCHC-32.8 RDW-14.7 Plt Ct-495*
[**2144-3-17**] 01:43AM BLOOD Neuts-56.1 Lymphs-39.3 Monos-3.8 Eos-0.4
Baso-0.3
[**2144-3-16**] 07:50PM BLOOD Neuts-52 Bands-2 Lymphs-36 Monos-7 Eos-0
Baso-0 Atyps-3* Metas-0 Myelos-0
[**2144-3-16**] 07:50PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Schisto-OCCASIONAL
Burr-OCCASIONAL
[**2144-3-17**] 01:43AM BLOOD Glucose-75 UreaN-6 Creat-0.5 Na-146*
K-3.8 Cl-115* HCO3-22 AnGap-13
[**2144-3-16**] 07:50PM BLOOD Glucose-97 UreaN-6 Creat-0.6 Na-143 K-4.0
Cl-110* HCO3-23 AnGap-14
[**2144-3-17**] 01:43AM BLOOD ALT-95* AST-172* LD(LDH)-236 AlkPhos-74
TotBili-0.2
[**2144-3-16**] 07:50PM BLOOD ALT-105* AST-172* AlkPhos-80 TotBili-0.2
[**2144-3-17**] 01:43AM BLOOD Calcium-6.9* Phos-3.1 Mg-1.6
[**2144-3-16**] 07:50PM BLOOD ASA-NEG Ethanol-568* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-3-16**] 07:56PM BLOOD Glucose-94 Lactate-2.2*
[**2144-3-16**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2144-3-16**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2144-3-16**] 08:00PM URINE Hours-RANDOM
[**2144-3-16**] 08:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2144-3-17**] 1:43 am SPUTUM Site: EXPECTORATED
**FINAL REPORT [**2144-3-17**]**
GRAM STAIN (Final [**2144-3-17**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2144-3-17**]):
TEST CANCELLED, PATIENT CREDITED.
cxr
AP UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: There is a hazy
opacity with a
central more dense consolidation in the right lower lobe. Linear
left lower lobe opacity is also present, the configuration of
the latter however favors atelectasis. There is no pleural
effusion or pneumothorax. There is no pulmonary edema. Heart
size is upper limits of normal. Hilar contours are unremarkable.
IMPRESSION: Right lower lobe opacity, could reflect pneumonia or
perhaps
aspiration. Differential considerations include atelectasis and
clinical
correlation is advised.
The study and the report were reviewed by the staff radiologist.
CT head
FINDINGS: There is no intra- or extra-axial hemorrhage, mass
effect, or shift of normally midline structures. The ventricles
and sulci are normal in size and configuration and the [**Doctor Last Name 352**] and
white matter differentiation is well preserved. There is no
acute major vascular territorial infarct. The basilar cisterns
appear preserved. There is no herniation. There is mucosal
thickening in bilateral ethmoid air cells and in the right
maxillary sinus. No acute fracture is seen.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
46 yo f with hx of etoh abuse, presented to ER after being found
unresponsive at a McDonald's, with suspected etoh intoxication.
# Etoh intoxication: pt has known hx of etoh use, on admission
alcohol level was 568. This is likely the cause of the pt's AMS,
since it improved after staying in the ICU overnight. Serum and
urine tox were only positive for etoh. Pt was given a banana bag
and 2 liters NS in ER. During the night pt became combative and
required a code purple while still intoxicated. She briefly was
in 4 point restraints since she still had an AMS. She was given
Ativan and improved. In the morning, pt did not want to go to a
detox center and once her MS had cleared she requested to leave
AMA. Pt was able to understand the risks and benefits of leaving
10:30AM.
# Aspiration PNA: on exam had diffuse rhonchi and some wheezing.
Pt was producing thick white sputum. CXR was concerning for
aspiration, which pt is at risk for due to intoxication. She
was given levo and Flagyl while admitted. She refused to stay
for further tx. She stated she would go to her homeless clinic
today. At time of leaving the sputum cx was contaminated and the
blood cx were pending. She remained afebrile and no longer was
hypoxic.
# Transaminitis: Mild elevation, likely [**3-10**] to etoh
# Bandemia: 2% bands, concerning for infection. Pt likely has a
PNA. UA was negative. This may also explain mild elevation of
lactate. However, pt also had some atypical cells initially.
However on repeat labs and bands and atypical cells were not
seen.
Attending and fellow were notified that pt left.
Medications on Admission:
trazadone
tramadol (currently off)
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
left AMA
Discharge Condition:
left AMA
Discharge Instructions:
left AMA
Followup Instructions:
left AMA
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2144-3-17**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6594
} | Medical Text: Admission Date: [**2167-6-2**] Discharge Date: [**2167-6-10**]
Date of Birth: [**2116-3-29**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Confusion, head trauma, unsteady gait, multiple hemorrhagic
lesions on head CT
Major Surgical or Invasive Procedure:
MR HEAD W & W/O CONTRAS
CHEST (PORTABLE AP)
CT CHEST W/CONTRAST
CT ABD W&W/O C
CT PELVIS W/CONTRAST
MRA BRAIN W/O CONTRAST
MR HEAD W/O CONTRAST
Cardiology ECHO
Neurophysiology EEG
Cardiology ECG
CHEST (PA & LAT)
CT HEAD W/O CONTRAST
CT C-SPINE W/O CONTRAST
History of Present Illness:
Pt is a 51 yo with h.o HTN, hyperlipidemia, anxiety, and
alcoholism who is sent in from his PCP after being brought there
by his father for confusion, head trauma, and gait problems.
The history is sparse as the pt is unable to relate one and his
father is currently unreachable. From talking to his PCP and
the records, it appears that his father was unable to contact
him for several days this week so he finally went to his house
to check on him. It is unclear if this was yesterday or today.
He found his house to be disheveled and many things
broken/dirty. The pt was confused and apparently was having
trouble walking. He would not eat unless food was brought to
him. He was disoriented. His father thought he has had nothing
to drink since Friday, but unclear how he knows this. Also
reportedly he has not taken his meds for 1 week(again not sure
how we know this). He was taken to his PCP who agreed he was
confused and thought he had some possible right sided weakness.
He was sent here. A head CT here shows ~8 hemorrhagic lesions
in his cerebral hemispheres with some edema, but no mass effect
or shift. No blockage of CSF flow is obviously seen.
When asked why he is here the pt says he needed to get his BP
checked and that he is otherwise ok. He has clear evidence of
head trauma on exam though. He is unable to give any more
substantial history and on ROS, changes his answers to the same
questions if he answers them at all.
ROS: Patient denies any HA, diplopia(although holds 1 eye shut
constantly), fevers, weakness, numbness, or tingling.
Past Medical History:
hypertension
hyperlipidemia
anxiety
alcoholism
h/o MVA with possible TBI
Social History:
Lives alone but father checks in on him. He is an alcoholic.
He smokes.
Family History:
Unknown
Physical Exam:
Vitals:98.5, 80, 143/87, 16, 97% on RA
Gen:NAD. Holds eyes closed
HEENT:MMM. Sclera clear. OP clear. Brusing over his face and
head as well as laceration of his forehead.
Neck: C-collar in place
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
Neurologic examination:
Mental status: Awake and alert but holds eyes closed, moderately
cooperative with exam
Orientation: Oriented to person. Thinks he is in LA. Then says
he is at [**Hospital **] Clinic. Year is variably "[**2062**] or [**2166**]". Says
it is "harvest time". Knows father lives in JP. Says he
personally lives "1 house from here".
Attention: Unable to do DOWF or B
Registration: Not tested
Language: Fluent with moderate comprehension and normal
repetition. Naming impaired to low freq objects. No dysarthria
or paraphasic errors
No apraxia, no neglect or ext to DSS.
[**Location (un) **] intact with slight trouble.
Calculation intact to simple addition. can't do quarters in
1.75.
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 4 to 3mm
bilaterally. Visual fields are full to confrontation grossly.
Fundi normal bilaterally.
III, IV, VI: Extraocular movements hard to assess as he is
poorly cooperative, but ? limitation of upgaze and possible
decrease in right eye abduction.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk and tone bilaterally
No tremor
Full strength throughout
No pronator drift
Sensation: Intact to light touch, pinprick, temperature (cold)
throughout all extremities, although MS makes this unreliable.
Reflexes: B T Br Pa Ankle
Right 2 t t 1 0
Left 1 t t 1 0
Toes were up on right and mute to up on left.
Coordination: Significant ataxia/dysmetria on left and less
severe, but still present on right. Fairly good with FFM and
[**Doctor First Name **].
Gait: Unable as C-spine not cleared
Pertinent Results:
WBC-8.7# RBC-5.11# Hgb-16.8# Hct-49.7# MCV-97 MCH-32.9*
MCHC-33.8 RDW-13.2 Plt Ct-303# Neuts-70.7* Lymphs-20.6 Monos-6.6
Eos-0.5 Baso-1.6
PT-12.5 PTT-26.9 INR(PT)-1.1
Glucose-107* UreaN-24* Creat-0.9 Na-141 K-4.2 Cl-102 HCO3-25
AnGap-18 Calcium-9.8 Phos-3.8 Mg-2.8*
ALT-29 AST-24 AlkPhos-78 TotBili-0.9 Lipase-32 Albumin-4.2
Lactate-2.1*
[**2167-6-2**] 01:30PM BLOOD CK(CPK)-89 CK-MB-NotDone cTropnT-<0.01
TSH-1.0
BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.024 Blood-NEG
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-SM
Urobiln-4* pH-7.0 Leuks-NEG bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Bld cxs [**Date range (1) 14706**] x6 NGTD
[**6-2**] UCx neg
[**2167-6-7**] 11:30 am URINE Source: CVS.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
[**2167-6-2**] CT C-SPINE W/O CONTRAST: No evidence of acute fracture
or dislocation.
[**2167-6-2**] CT HEAD W/O CONTRAST: Multiple hemorrhages in the
cerebral hemispheres, with questionable intraventricular v.
subepndymal extension.
[**2167-6-2**] CHEST (PA & LAT): 1) No acute cardiopulmonary process.
2) Elevation of the left hemidiaphragm. Correlation with old
films is recommended to document stability.
[**2167-6-2**] Cardiology ECG:
Sinus rhythm. Findings are within normal limits. Compared to the
previous
tracing of [**2166-6-3**] no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 166 80 396/429 59 45 67
[**2167-6-3**] Neurophysiology EEG: Largely normal EEG for drowsiness.
There were no areas of prominent focal slowing, and there were
no epileptiform features.
[**2167-6-3**] Cardiology ECHO: There is symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is mildly depressed. 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 leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is no pericardial effusion. No LV thrombus
visualized (cannot exclude). No vegetation seen (cannot
definitively exclude).
[**2167-6-4**] MRI AND MRA OF THE BRAIN: Multiple T1 bright lesions in
the cerebrum, vermis, possibly an intraventicular lesion, and a
scalp lesion.
[**2167-6-4**] Radiology MR HEAD W & W/O CONTRAST: There are multiple
bilateral hemorrhagic lesions within the cerebral hemispheres as
previously demonstrated on CT and MRI. These lesions are
markedly T1 hyperintense before contrast administration, making
it difficult to assess if there is any enhancement, as these
lesions appear similar on the pre- and post- contrast images. No
other enhancing lesions are visualized on the post- contrast
images that were not already T1 hyperintense on the pre-
contrast images. There is no evidence of intraventricular
extension of lesions, as was questioned on the prior CT.
Gradient echo sequences do demonstrate many other smaller
punctate areas of susceptibility artifact concerning for smaller
lesions which do not enhance demonstrably on the gadolinium
sequences. In addition to the larger lesions previously
described on prior studies, there are many smaller lesions which
appear to involve the cerebellar vermis on the right. The
diffusion-weighted images demonstrate no restriction outside of
the previously described lesions to suggest acute infarction.
Surgical hardware in the posterior elements of the upper
cervical spine obscures evaluation of the cervical cord and
marrow of the upper cervical spine.
[**2167-6-7**] CHEST (PORTABLE AP): IMPRESSION: Subsegmental
atelectasis, left base.
Brief Hospital Course:
51 yo with h.o HTN, hyperlipidemia, anxiety, and alcoholism who
is sent in from his PCP after being brought there by his father
for confusion, head trauma, and gait problems. His exam is
significant for disorientation, inattention, frontal
dysfunction, possible eye movement abnormalities (denies
diplopia, but holds one eye shut constantly. He also has
possible upgoing toes and incoordination L>R.
NEURO: Patient was admitted to the ICU for close neuro
monitoring. CT C-spine was negative for fracture and patient
was clinically cleared in the ED. MRI/A of the head with and
without gado showed numerous T1 bright lesions involving both
frontal, parietal, and right temporal, and left occipital
regions, as well as the vermis on the right, normal intracranial
vessels and no arteriovenous malformations.
Patient was loaded on Dilantin and maintained on maintenance to
achieve a therapeutic level of Dilantin between [**10-10**]. EEG
showed irregular heart rate, mostly sleepy, no
focal/epileptiform features.
Paient was called out to the floor on [**6-4**], screened by physical
therapy and then discharged to rehab. The cause for his
presentation is not clear as patient lives alone and cannot
recall the events surrounding his presentation. He clearly had
external head trauma and either fell multiple times or was
perhaps assaulted. Blood cultures and echocardiogram were
performed to exclude endocarditis and a possible etiology of
septic emboli. Torso CT was also performed to exclude a primary
malignancy and etiology of metastatic lesions that bled in the
brain. It was thought most likely etiology of intracranial
hemorrhages were from trauma.
With regards to patient's confusion possibilities included
seizures causing post-event confusion, infection, EtOH
withdrawal, or Wernicke's encephalopathy. It was thought to be
most consistent with the latter given the associated findings of
confabulation, gait problems and ophthalmoplegia that improved
with IV thiamine and folate repletion. Patient will follow-up
in [**Hospital 4038**] Clinic as an outpatient and have a repeat MRI brain
with contrast at that time to assess for interval change.
CV: Surface echocardiogram was negative for apical hypokinesis
or low EF, ASD/PFO, clot or valvular vegetations. Continued
Lisinopril, Lovastatin and Zetia. Resumed Lisinopril and
Hydrochlorothiazide. Held Atenolol which can be resumed as
tolerated as an outpatient. Continued Lovastatin and Zetia.
PULM: Continued Fluticasone-Salmeterol INH.
GI: Heart healthy diet. PPI.
END: Multivitamin, thiamine, folate. Covered with insulin
sliding scale.
ID: Ciprofloxacin
PPX: Alcohol withdrawal prophylaxis with PRN Ativan for CIWA>10
per protocol every 4 hours. H2B, Tylenol PRN for fevers or
pain.
Medications on Admission:
(unclear compliance, but he is prescribed the following):
Lovastatin 40 daily
Atenolol 100 daily
HCTZ 25 daily
Lisinopril 5 daily
Zetia 10 daily
Advair 100-50 daily
Neurontin 300 [**Hospital1 **]
Valium 2 prn
Ultram 50 prn
Discharge Medications:
1. Lovastatin 20 mg Tablet Sig: Two (2) Tablet PO daily ().
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Phenytoin Sodium Extended 100 mg Capsule Sig: [**12-23**] Capsules PO
three times a day for 1 weeks: Take 1 cap (100mg) QAM and QNOON.
Take 2 caps (200mg) QPM. Start [**6-10**]. Discontinue on [**6-19**].
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO three times a day for 1 weeks: Start on [**6-19**].
Discontinue on [**6-26**].
11. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO twice a day: Starting [**6-26**]. Discontinue [**7-3**].
12. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO once a day: Start [**7-3**]. Discontinue on [**7-10**].
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: Dc on [**6-14**].
14. Folic Acid 5 mg/mL Solution Sig: One (1) mg Injection DAILY
(Daily).
15. Thiamine HCl 100 mg/mL Solution Sig: One Hundred (100) mg
Injection DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
primary diagnosis:
Hemorrhagic brain lesions bilaterally
E. coli urinary tract infection
secondary diagnosis:
Hypertension
Hyperlipidemia
Anxiety
Alcoholism
h/o MVA with possible TBI
Discharge Condition:
Awake alert oriented only to self. Speech is clear but
confabulates when he does not know the answer to questions.
Incomplete adduction of left eye and dysconjugate gaze.
Discharge Instructions:
You have bled into your brain. You will need to follow-up with
a stroke neurologist. You will need a repeat MRI brain with
contrast in month's time.
Please use an eye patch while awake alternating eyes every 4
hours to help with your diplopia.
Please take medications as prescribed and keep your follow-up
appointments.
Do not take motrin or aspirin.
Followup Instructions:
Neurologist: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone: [**Telephone/Fax (1) 2574**] Date/Time:
[**2167-8-18**] 9:00am
MRI with contrast: Friday [**2167-7-10**] 2:25pm Phone: [**Telephone/Fax (1) 327**]
Location: [**Hospital Ward Name 23**] [**Location (un) 861**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2167-6-10**]
ICD9 Codes: 5990, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6595
} | Medical Text: Admission Date: [**2160-11-12**] Discharge Date: [**2160-11-16**]
Date of Birth: [**2081-5-5**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79yo RH M h/o DM2, hyperlipidemia who went to bed in USOH
neurologically normal and awoke so at 6:30am and went to the
bathroom. he was standing at the sink when he "lost coordination
and lost balance" and he slumped to the ground, feeling woozy.
He
denied weakness, vertigo or light-headedness at this time and
pulled himself up, walked downstairs, and told his wife what
happened. His speech was clear and without errors at this time.
He did not have a headache. He complained, though, of right hand
numbness and EMS was called. By the time of their arrival, he
was
neurologically normal. However, at 9:50am, he became acutely
dysarthric and was seen by neurology at the OSH, with his NIHSS
of 4, presumably due to a right facial droop, which is still
present. CT revealed no bleed and the patient was given tPA at
11:40am. He is transferred here for post-tPA care.
He denies blurry vision, diplopia, problems with understanding
or
communicating language aside from dysarthria. No hoarseness. No
headache. No weakness or numbness in his limbs. No
incoordination
or trouble walking.
Past Medical History:
DM2
Hyperlipidemia
Glaucoma
s/p b/l knee replacement
BPH with recent UTI/sepsis
L rotator cuff injury (limits pronation/supination)
Social History:
SH: lives at home with his wife, independent with ADLs. Retired
insurance worker. No etoh, drugs. Quit smoking 35yrs ago.
Family History:
FH: negative for HTN, strokes, DM
Physical Exam:
98.4 96 150/88 12 99%
Gen lying in bed in NAD
HEENT Neck supple
CV rrr
pulm ctab
Abd soft nt/nd +BS
Ext no edema
NEURO
NIH SS:
1a. Level of Consciousness: 0
1b. LOC questions: 0
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 0
4. Facial palsy: 2, right lower face
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb ataxia: 0
8. Sensory: 0
9. Best language: 0
10. Dysarthria: 2
11. Extinction and inattention: 0
MS: awake and alert, fully oriented. Recites [**Doctor Last Name 1841**] backwards.
Speech dysarthric, esp for labials but also somewhat for
dentals,
linguals and guttarals. Otherwise, speech is fluent with intact
comprehension, [**Location (un) 1131**] and naming. No neglect to cookie jar. No
apraxia.
CN VFF without extinction. Acuity normal. Pupils 4->2 b/l. EOM
full no diplopia or nystagmus, in all directions. Facial
sensation intact to LT, PP. Upper facial strength full, lower
face droops on attempted smile on the right, the right NLF is
decreased and the cheek puffs out on attempted closure. Hearing
intact b/l. Palate rises symmetrically. Shrug [**6-13**]. Tongue
midline.
Motor: normal bulk and tone throughout. No pronator drift (L arm
does not suppinate fully due to rotator cuff injury)
D B T WE FE FF FAbd IP Q H DF PF TE TF
Sensory: intact to LT, PP, JPS, vibration throughout, no
extinction.
Coord: FTN, HTS intact b/l. RAMs equal and rhythmic.
Reflexes: 2+ throughout, toes down b/l
Gait: deferred
Brief Hospital Course:
The patient was transferred here after receiving tPA and
admitted to the ICU for post-tPA care. He sustained no
complications from tPA and MRI/A one day after receiving it
showed a left corona radiata stroke. He was transferred to the
floor and started on aggrenox. He should have fasting lipid
panel and hemoglobin A1c drawn by his primary care physician, [**Name10 (NameIs) **]
minimize stroke risk factors, as well as for blood pressure
control.
Carotid U/S was normal. Echo showed no source of emboulus, PFO
or ASD.
He will be seen in neurology stroke clinic for follow-up. At
discharge, his speech had improved and he only had a mild drift
of the right arm. He had good strength in the legs.
Medications on Admission:
Glipizide 5mg po BID
Lipitor 40mg po daily
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
Disp:*60 Cap(s)* Refills:*2*
3. Outpatient Physical Therapy
Home safety evaluation. Gait training.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left corona radiata stroke
Discharge Condition:
Improved
Discharge Instructions:
Please continue to take all medications as prescribed. Return to
ER with any new neurologic symptoms
Followup Instructions:
Please call ([**Telephone/Fax (1) 7394**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], to schedule an
outpatient neurology appointment.
Completed by:[**2160-11-16**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6596
} | Medical Text: Admission Date: [**2146-7-21**] Discharge Date: [**2146-7-26**]
Date of Birth: [**2071-5-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
severe aortic stenosis
Major Surgical or Invasive Procedure:
redo sternotomy/AVR(#23mm St.[**Male First Name (un) 923**] porcine) on [**2146-7-22**]
History of Present Illness:
76yo well developed male with history of Parkinson's disease
seeking deep brain stimulator device. Elective procedure on hold
due to severe aortic stenosis elevating risk. Past medical
history of CAD s/pCABG x 3 ([**2137**]), hyperlipidedmia. Patient
admits to noticing increasing fatigue over the last year, now
requiring daily naps. Reports lightheadedness when getting out
of
bed in the morning, and dizziness after 2-3 minutes of pulling
weeds. He can climb a flight of stairs but must pace himself,
ambulates 2 blocks before needing to stop due to shortness of
breath. He denies chest pain or syncope. Echocardiogram reveals
aortic valve area 0.8cm2, peak gradient 66mmhg, EF>60%.
NYHA Class: II
Past Medical History:
-aortic stenosis
-CAD, s/p CABG x 3 ([**2137**])
-hyperlipidemia
-sick sinus syndrome
-Parkinson's (rt hand tremors, RLE weakness, speech hesitancy)
-[**Year (4 digits) 499**] Ca s/p [**Year (4 digits) 499**] resection
- exlap for twisted bowel
-vein ligation
-vertebral fracture T5-6-7 secondary to fall, s/p fusion
-right arm fracture
-tonsillectomy
-left ankle fracture
-varicella zoster rt torso [**6-2**]
Previous Cardiac Surgery: [**2137**] CAGGx3- LIMA-LAD, SV-PDA,SV-OM1
Social History:
Retired to [**State 1727**]. Supportive friends. Usually walks the
neighbors labrador several times a week, none recent.
contact: [**Name (NI) **] [**Name (NI) 91288**] (brother) [**Telephone/Fax (1) 91289**]
Family History:
Father deceased age 70's, stomach Ca. Mother deceased age [**Age over 90 **],
CAD/CVA. Two brothers deceased, [**Name2 (NI) 499**] Ca.
Brother 82yo alive. Widowed, 3 adopted children.
Physical Exam:
Physical Exam on Admission
Pulse:68 Resp:14 O2 sat:96% on RA
B/P Right:128/56 Left:
General:well appearing 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] Irregular [] Murmur [x] grade _4/6_____
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [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: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right: radiating murmur Left: radiating
murmur
Discharge Exam:
VS 99.1 73 106/54 18 97%-RA
Gen: NAD
Neuro: A&O x3, MAE-nonfocal exam
CV: RRR no murmur. Sternum stable-incision CDI
Pulm: clear-slightly diminished in bases bilat
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused. trace pedal edema bilat
Pertinent Results:
Admission labs:
[**2146-7-21**] 08:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2146-7-21**] 08:53PM PT-11.4 PTT-31.9 INR(PT)-1.1
[**2146-7-21**] 08:53PM PLT COUNT-245
[**2146-7-21**] 08:53PM WBC-7.5 RBC-4.33* HGB-14.6 HCT-42.7 MCV-99*
MCH-33.8* MCHC-34.3 RDW-12.9
[**2146-7-21**] 08:53PM ALBUMIN-4.5
[**2146-7-21**] 08:53PM proBNP-303
[**2146-7-21**] 08:53PM ALT(SGPT)-6 AST(SGOT)-25 CK(CPK)-141 ALK
PHOS-64 TOT BILI-0.9
[**2146-7-21**] 08:53PM GLUCOSE-124* UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-23 ANION GAP-12
Discharge labs:
[**2146-7-26**] 05:55AM BLOOD WBC-11.0 RBC-2.87* Hgb-9.1* Hct-27.8*
MCV-97 MCH-31.7 MCHC-32.7 RDW-14.2 Plt Ct-196
[**2146-7-26**] 05:55AM BLOOD Plt Ct-196
[**2146-7-24**] 02:32AM BLOOD PT-13.6* PTT-30.2 INR(PT)-1.3*
[**2146-7-26**] 05:55AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-135
K-3.5 Cl-102 HCO3-26 AnGap-11
[**2146-7-26**] 05:55AM BLOOD Mg-2.0
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 99 ml/beat
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *3.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *50 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 33 mm Hg
Aortic Valve - LVOT pk vel: 0.[**Age over 90 **] m/sec
Aortic Valve - LVOT VTI: 26
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Normal regional LV systolic function. Overall normal
LVEF (>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**11-22**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: Informed consent was obtained. 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. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**11-22**]+) mitral regurgitation is seen.
POSTBYPASS
There is preserved biventricular systolic function. There is a
well seated, well functioning bioprosthesis in the aortic
position. No perivalvular AI is visualized. The MR is now trace.
The study is otherwise unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2146-7-22**] 12:38
Radiology Report CHEST (PORTABLE AP) Study Date of [**2146-7-25**] 8:59
AM
Final Report: There is no evident pneumothorax. Moderate
cardiomegaly is stable. Widened mediastinum is unchanged.
Pulmonary edema has improved, now mild. Bibasilar atelectases
have markedly improved. If any, there is a small left pleural
effusion. Sternal wires are aligned.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
.
[**2146-7-26**] 05:55AM BLOOD WBC-11.0 RBC-2.87* Hgb-9.1* Hct-27.8*
MCV-97 MCH-31.7 MCHC-32.7 RDW-14.2 Plt Ct-196
[**2146-7-25**] 06:05AM BLOOD WBC-10.2 RBC-2.89* Hgb-9.3* Hct-27.8*
MCV-96 MCH-32.2* MCHC-33.5 RDW-14.2 Plt Ct-138*
[**2146-7-26**] 05:55AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-135
K-3.5 Cl-102 HCO3-26 AnGap-11
[**2146-7-25**] 06:05AM BLOOD Glucose-100 UreaN-16 Creat-0.7 Na-137
K-3.7 Cl-104 HCO3-26 AnGap-11
[**2146-7-26**] 05:55AM BLOOD Mg-2.0
Brief Hospital Course:
On [**2146-7-22**] Mr. [**Known lastname 69467**] was taken to the operating room and
underwent a redo sternotomy/Aortic Valve Replacement (#23mm
St.[**Male First Name (un) 923**] Porcine) with Dr.[**Last Name (STitle) **]. Please see opeartive report
for further details. He tolerated the procedure well and was
transferred to the CVICU for invasive monitoring in critical but
stable condition. He awoke neurologically intact and extubated
on the day of surgery. He weaned off pressor support on POD1.
All lines and drains were removed per cardiac surgery protocol
withoout complication. No Beta-blocker were initiated due his
history of sick sinus syndrome and postoperative accelerated
junctional rhythm. Statin/ASA/and diuresis were intiated along
with resuming preoperative meds before transfer from ICU on
POD#1. Physical Therapy was consulted to work on stregnth and
mobility. The remainder of his postop course was essentially
uneventful. He continued to progress and was ready for discharge
to rehabilitation at Clipper [**Hospital1 **] Health in [**Location (un) 12017**], NH on
POD 4.
At the time of discharge he was ambulating with assistance,
incisions are healing well. All follow up appointments were
advised.
Medications on Admission:
CARBIDOPA-LEVODOPA - 25 mg-100 mg tablet - two Tablet(s) by
mouth
4 times per day
CITALOPRAM - 20 mg tablet - one Tablet(s) by mouth once at night
RAMIPRIL [ALTACE] - (Prescribed by Other Provider) - Dosage
uncertain
SIMVASTATIN - (Prescribed by Other Provider) - Dosage uncertain
TAMSULOSIN - 0.4 mg capsule,extended release 24hr - one
Capsule(s) by mouth once per day
ZONISAMIDE - 25 mg capsule - 1 Capsule(s) by mouth twice a day
ZONISAMIDE - 50 mg capsule - 1 Capsule(s) by mouth twice per day
increase to twice a day after 1 week
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - Dosage uncertain
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Carbidopa-Levodopa (25-100) 2 TAB PO QID
3. Citalopram 20 mg PO DAILY
4. Simvastatin 40 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Zonisamide 100 mg PO DAILY
7. Acetaminophen 650 mg PO Q4H:PRN fever, pain
8. Docusate Sodium 100 mg PO BID
9. Milk of Magnesia 30 ml PO HS:PRN constipation
10. Oxycodone-Acetaminophen (5mg-325mg) [**11-22**] TAB PO Q4H:PRN pain
11. Ranitidine 150 mg PO BID Duration: 1 Months
12. Furosemide 40 mg PO DAILY Duration: 10 Days
13. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
Discharge Disposition:
Extended Care
Facility:
clipper [**Hospital1 **] of [**Location (un) **] care and rehabilitation center
Discharge Diagnosis:
aortic stenosis
-redo sternotomy/AVR(#23mm St.[**Male First Name (un) 923**] porcine) on [**2146-7-22**]
-CAD, s/p CABG x 3 ([**2137**])
-hyperlipidemia
-sick sinus syndrome
-Parkinson's (rt hand tremors, RLE weakness, speech hesitancy)
-[**Year (4 digits) 499**] Ca s/p [**Year (4 digits) 499**] resection
- exlap for twisted bowel
-vein ligation
-vertebral fracture T5-6-7 secondary to fall, s/p fusion
-right arm fracture
-tonsillectomy
-left ankle fracture
-varicella zoster rt torso [**6-2**]
Previous Cardiac Surgery?: [**2137**] CAGGx3- LIMA-LAD, SV-PDA,SV-OM1
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema -trace bilat LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 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**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Last Name (LF) **], [**First Name3 (LF) **] [**Telephone/Fax (1) 1504**] on [**8-17**] @1:30PM
Cardiologist: [**Last Name (LF) **], [**Name8 (MD) **] MD ([**Location (un) 34004**] cardiology, ME)on [**9-30**]
@11:20AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 35326**] in [**11-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2146-7-26**]
ICD9 Codes: 4241, 2762, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6597
} | Medical Text: Admission Date: [**2117-12-30**] Discharge Date: [**2118-1-4**]
Date of Birth: [**2054-1-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Neurogenic claudication
Major Surgical or Invasive Procedure:
[**2117-12-30**] PLIF L4-5
History of Present Illness:
63-year-old woman who complains of bilateral lower extremity
symptoms that are exacerbated by walking. She receives some
amelioration with rest. She denies difficulty with bowel or
bladder function.
Past Medical History:
HTN
Diabetes
Angina
Social History:
NC
Family History:
NC
Physical Exam:
Pre-Op on clinic visit:
On examination, her motor strength was [**3-30**] in hip flexion,
extension, quadriceps, hamstrings, dorsiflexion, and plantar
flexion bilaterally. Her sensory examination was intact with
respect to the modality of light touch. Her reflexes were
normal
and symmetric in the patellar and absent in the Achilles
bilaterally. Her pulses were palpable bilaterally. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
sign was positive on the left and not on the right, but weekly
so.
Upon Discharge:
A&OX3
PERRL
EOMs: intact
Motor: IP [**Initials (NamePattern5) 12643**] [**Last Name (NamePattern5) **] AT [**Last Name (un) 938**]
R 5 5 5 5 4 4
L 5 5 5 5 5 5
Incision: c/d/i- STAPLES
Pertinent Results:
CT L-SPINE W/O CONTRAST [**2118-1-1**]
1. Postoperative changes in the lumbar spine including posterior
fusion of
L4-L5. Grade 1 anterolisthesis of L4 on L5.
2. Drain is identified within the postoperative bed. No evidence
of
immediate hardware complication.
LUMBO-SACRAL SPINE (AP & LAT) [**2118-1-1**]
Status post L4-L5 stabilization. The stabilization material is
in
correct position. No evidence of complications.
Brief Hospital Course:
[**2117-12-30**] s/p PLIF L4-5 with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**]. Surgery was
uneventful and immediately post-operatively she remained stable.
POD 1 [**12-31**] she had an episode of stridor and feeling like she
could not breath, desat to 84-86% - she received an albuterol
and racemic neb with good effect, CXR was negative. Later that
morning she experienced a second episode of stridor and feeling
like she could not breath but OS sat was 100% and was
transferred to the ICU for observation. Etiology is unclear but
appeared to be upper respiratory. SQ Heparin was started on
[**2117-12-31**].
On [**1-1**] she was transferred to the floor and her JP drain was
discontinued. On [**1-3**], patient complained of pain in her back
that radiated down both legs. Her R IP and [**Last Name (un) 938**] were both [**2-28**] on
exam. She was started on neurontin and a medrol dose pack to
help alleviate pain. PT is working with patient to determine if
she needs to go to a rehab facility.
On [**1-4**], patient reported that her pain was much more controlled.
Her exam is improved with her R IP [**3-30**], but [**Last Name (un) 938**] is [**2-28**]. Patient
will be discharged to [**Location (un) 86**] Center for rehabilitation.
Medications on Admission:
Atenolol
Metformin
Lisinopril
Nortriptyline
Hydroxychloroquine [Plaquenil]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever > 100.4, pain.
2. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain.
6. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO
breakfast/lunch/dinner () for 1 days.
15. Methylprednisolone 8 mg Tablet Sig: Two (2) Tablet PO
bedtime () for 1 days.
16. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) for 1 days: start on [**2118-1-5**].
17. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 1 days: start on [**2118-1-6**].
18. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days: start on [**2118-1-7**].
19. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO QD ()
for 1 days: start on [**2118-1-8**].
20. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
22. Magnesium Citrate 1.745 g/30mL Solution Sig: Three Hundred
(300) ML PO ONCE (Once) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Lumbar Spondylolisthesis
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:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2118-1-3**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed
at your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN [**6-4**] DAYS FOR REMOVAL OF YOUR
STAPLES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2118-1-4**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6598
} | Medical Text: Admission Date: [**2106-6-26**] Discharge Date: [**2106-7-11**]
Date of Birth: [**2039-6-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Ventricular peritoneal shunt placement [**2106-6-28**]
History of Present Illness:
Pt is a 66 yo male w/ PMHx sig for who was recently
admitted to [**Hospital1 18**] from [**5-18**] - [**6-9**] for hospitalization related to
a non-aneurysmal SAH with complicated hospital course now
readmitted for altered mental status and CT scan from [**6-24**] that
showed marked hydrocephalus.
The patient initially presented to [**Hospital1 18**] on [**5-18**] for altered
mental status and gait difficulties. CTA of the end showed
SAH in the basilar cisterns, with no evidence of aneurysm by CT
and conventional angiogram. The patient's initial CT scan from
[**5-18**] showed evidence of hydrocephalus that resolved on the
following CT from [**5-19**]. The patients hospital course was
complicated respiratory distress requiring intubation,
pneumonia,
and fluctuating mental status. Neurology saw the patient and
felt that b/l SDH could be causing the impaired mental status.
The patient then went for b/l frontal burr holes. Eventually he
was transferred to step down and eventually to a rehab unit. At
rehab, the patient continued to have difficulty with attention
and orientation. He had a head CT on [**6-24**] that showed marked
hydrocephalus. As a result, he was transferred back to [**Hospital1 18**]
for
planned VP shunt.
Past Medical History:
DIABETES MELLITUS [**2053**]
COLONIC POLYPS [**2099**]
CORONARY ARTERY DISEASE [**2093**]
HYPERTENSION
UMBILICAL HERNIA
ELEVATED PSA [**12/2103**]
Social History:
He lives alone and has sister who lives in [**Name (NI) 108**].
Family History:
3 brothers died of MIs, father died of MI, no history of
aneurysms.
Physical Exam:
Vitals: T 98.1; BP 137/76; P 89; RR 18; O2 sat 97% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA but shallow breaths
Cardiac: regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: Lethargic but opens eyes to stimulation. States
name. Shows thumb, raises arms. Year - [**2103**], month - [**Month (only) **]
hospital - [**Hospital1 18**]. Fluent speech with no paraphasic or phonemic
errors. Drifts off without repeated stimulation.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI.
V, VII: facial sensation intact, facial strength symm.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-5**]
XII: Tongue midline without fasciculations.
Motor/[**Last Name (un) **]: Normal bulk. Normal tone. Does not comply with
formal
strength testing but moves arms purposefully and withdraws in
all
four extremities to painful stimuli.
Sensation: intact to pinprick, light touch, vibration, and
position sense. Does not extinguish to double simultaneous
stimulation
Reflexes: Bic T Br Pa Ac
Right 2 2 2 0 0
Left 2 2 2 0 0
Toes downgoing bilaterally.
Pertinent Results:
CT HEAD W/O CONTRAST [**2106-6-28**]
1. Interval right frontal ventriculostomy catheter with
persistent unchanged moderately severe hydrocephalus.
2. Minimally larger right frontal subdural collection measuring
up to 10 mm compared to prior 9 mm. Unchanged left frontal
subdural collection.
BILAT LOWER EXT VEINS [**2106-6-29**]
No evidence of deep vein thrombosis in either leg
NECK,SOFT TISSUE US [**2106-6-26**]
Small hypoechoic nodules as described above within the right and
left lobes of thyroid without aggressive features. No definitive
mass seen in the midline region of the neck, underlying region
of palpable concern. If clinical concern persists, recommend CT
of the neck for further evaluation.
Series of CT HEAD w/o contrast:
[**7-2**] IMPRESSION:
1. Increased hypodense bilateral frontal subdural collections,
more prominent on the right with new small amount of blood
layering along the right frontal convexity. These findings could
be related to marked decrease in ventricular size and
re-expansion of bilateral subdural spaces. Close followup is
recommended.
2. Right frontal ventriculostomy catheter in the right lateral
ventricle is unchanged .
[**7-6**] IMPRESSION:
1. Marked interval increase in ventriculomegaly compared to [**7-2**], with
unchanged configuration of the VP shunt catheter in the right
lateral
ventricle.
2. Stable bilateral subdural collection, without evidence of new
bleeding.
[**7-7**] IMPRESSION:
1. Persistent ventriculomegaly with right frontal VP shunt in
unchanged
configuration, compared to [**7-6**], but overall worsened compared
to [**7-2**]. Some narrowing of the suprasellar cistern due to
enlargement of the third ventricle is also unchanged.
2. Stable bilateral subdural collections.
3. No new intracranial hemorrhage.
[**7-9**] IMPRESSION:
1. No interval change since yesterday's exam, with persistent
ventriculomegaly and stable bilateral subdural collections.
2. Unchanged scattered mastoid air cell opacification.
CT CHEST [**7-6**]:
Slightly suboptimal bolus timing. Bilateral small segmental PE,
non
occlusive, predominantly in the left and right lower lobe and in
the right
upper lobe. Mild right pleural effusion, bilateral atelectasis.
No evidence of right heart strain.
No other lung parenchymal changes.
Brief Hospital Course:
67M s/p nonaneurysmal SAH and external hydrocephalus presented
from rehab with altered mental status. Outpatient head CT showed
an increase in hydrocephalus and the patient was admitted to the
neurosurgical service for VP shunt placement. VP shunt was
placed without complication on [**6-28**]. Patient was transferred to
the MICU on HD#4 for respiratory distress due to aspiration
pneumonitis. The patient was stable for transfer to the medical
floor on HD#6. Additional hospital course was complicated by
aspiration pneumonia treated with broad-spectrum antibiotics.
Nasogastric tube feeding was initiated. Frequent adjustments to
the VP shunt were made by the neurosurgery team. Heparin IV was
started to treat pulmonary emboli diagnosed on [**7-6**] after
discussing the risks and benefits of anticoagulation with the
neurosurgery team. On [**7-9**] a meeting was held with the primary
medical team, palliative care team (Dr. [**First Name (STitle) 9305**] [**Name (STitle) 4261**] and
[**First Name4 (NamePattern1) 501**] [**Last Name (NamePattern1) 23636**], NP), the patient's sister (and healthcare proxy)
and the patient's brother-in-law. We discussed Mr. [**Known lastname 23637**]
strong religious beliefs and advanced directives about
end-of-life care. These preferences were reinforced via
communication with his primary care physician who had spoken
openly with the patient about his beliefs on a prior occasion.
Despite an unclear prognosis, the patient's sister stated
clearly that Mr. [**Known lastname **] would not favor having a gastrostomy
tube placed for a more permanent means of delivering nutrition,
nor would he favor transfer to a rehabilitation facility. His
family stated unequivocally that Mr. [**Known lastname 23637**] preference would
be a comfort-based approach to his care. Comfort measures only
were instituted that day and he was transferred to inpatient
hospice on [**7-10**]. He passed away at 12:24 AM on [**2106-7-11**].
Medications on Admission:
Keppra 500 mg [**Hospital1 **]
Colace 200 mg [**Hospital1 **]
Amantadine HCL 50 mg q day
Glimepiride 2 mg
Metoclopramide 5 mg tid
Metformin 500 mg q 8
Lisinopril 10 mg daily
Lactulose 30 ml [**Hospital1 **]
Atenolol 25 mg daily
MVI
Trazadone 25 mg qhs
Omeprazole 40 mg qhs
Insulin Glargine 44 units qhs
Folate
Lipitor 80 mg q day
Insulin Regular
Heparin 5000 sc tid
Ipatropium
Albuterol
Discharge Medications:
none.
Discharge Disposition:
Expired
Discharge Diagnosis:
External Hydrocephalus
Hyperkalemia
Resp alkalosis
Hyperglycemia
Acute Gastritis with hematemesis
Tachypnea
Submandibular mass
Chemical pneumonitis from aspiration
Hypocarbia
Acute renal failure
Dehydration
Hypertension
Leukocytosis
Pulmonary emboli
Subdural fluid collections
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2106-7-14**]
ICD9 Codes: 5070, 5849, 4019, 2859, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6599
} | Medical Text: Admission Date: [**2105-1-26**] Discharge Date: [**2105-2-4**]
Date of Birth: [**2047-2-3**] Sex: F
Service: MEDICINE
Allergies:
Ambien / Percocet
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
admitted for pre-op cath
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
57 y/o F w/CAD s/p CABG [**2098**] (at [**Hospital1 112**], LIMA->LAD, SVG->RCA,
SVG->OM3), CHF [**1-28**] diastolic dysfxn w/EF 50%, and aortic
stenosis, admitted today for pre-op cath, prior to possible redo
CABG and possible AVR. She was noted to have aortic stenosis on
a TTE from an OSH in [**7-30**], with a valve area 1.0 cm2, peak
gradient 59 mm Hg, 1+ MR, and mod pulm htn. Her most recent adm
to the [**Hospital1 **] was [**8-30**], when she presented w/resting CP. EKG at
that time demonstrated old lat TWI. She underwent cath which
revealed patent LIMA->LAD, 80% mid LAD, 80% OM1, and 100% OM3
occlusions. Her EF was noted to be 55%. She had a PTCA of
OM1, c/b dissection with resulting overlying cypher stents
placed.
Since that intervention, she has noted no improvement in her
anginal symptoms, and has been having 3-6 episodes of angina
daily both at rest and with exertion (episodes resolve w/nitro
spray). She also c/o orthopnea and increasing LE edema, but no
PND.
Prior to her cath today, she became hypotensive in the holding
area (72/41, pulse 61). She received 2 L NS, 1 mg atropine,
with a pressure that responded to 108/52. She was also somewhat
hypotensive during her cath, systolics 80s. Today, she
underwent a cath which revealed patent LIMA->LAD, totally
occluded RCA/SVGs, 3+MR, posterobasal/inferior akinesis, and EF
40%. Her CO was 6.3, CI 3.2, PA 44/20, wedge 23, and RA mean 30.
Aortic valve area 1.1 cm2, peak gradient 40 mm Hg (mean 28 mm
Hg). She also had posterobasal and inferior akinesis on left
ventriculography.
Past Medical History:
1. CAD
2. Mitral regurg
3. Aortic stenosis
4. rheumatoid arthritis
5. osteoarthritis
6. fibromyalgia
7. hypothyroidism
8. htn
9. hypercholesterolemia
10. depression
11. iron def. anemia
12. s/p appy
13. s/p TAH
Social History:
single, has daughter, denies EtOH or tobacco
Family History:
Mother had CABG at age 48, died of CAD at age 68
Father had DM, CAD, died of MI
Physical Exam:
T: 97.2 P: 67 BP: 127/53 RR: 12 O2 sat: 97%
Gen: alert & oriented anxious female, in NAD
HEENT: NCAT. no conjunct. pallor. MMM.
Lungs: CTA bilaterally
CV: RRR, III/VI mid-peaking systolic murmur heard throughout,
radiating to carotids
Abd: obese, nontender, nondistended. normoactive bowel sounds.
Ext: no edema. 1+ dorsalis pedis pulses bilaterally.
Pertinent Results:
Admit ECG: NSR, q waves in II, III, avF, and TWI in V4-6.
Cardiac Cath:
COMMENTS: 1. Selective coronary angiography demonstrated
native
three vessel coronary artery disease in this right dominant
circulation.
The LMCA was a short vessel without flow limiting disease. The
LAD was
totally occluded after the first septal branch. The distal LAD
filled
via a patent LIMA graft. The LCX had a 50% tubular proximal
stenosis.
The OM2 had a 70% ostial stenosis and was a large vessel. A
patent stent
was seen between OM2 and OM3. OM3 was a large vessel without
flow
limiting disease. The RCA was totally occluded in the proximal
vessel
with left to right collaterals seen filling the distal vessel.
2. Graft angiography demonstrated a widely patent LIMA-LAD. The
SVG-RCA
and SVG-OM3 were known to be occluded and not engaged.
3. Resting hemodynamics from right and left heart
catheterization
revealed markedly elevated right and left sided filling
pressures
(RVEDP=28mmHg and LVEDP=26mmHg). Cardiac output and index were
preserved
at 6.3L/min and 3.2L/min/m2. There was a 40mmHg peak gradient
and 28mmHg
mean gradient across the aortic valve with calculated aortic
valve area
of 1.1cm2. Moderate pulmonary systolic pressures was seen.
4. Left ventriculography demonstrated posterobasal and inferior
akineses
with LVEF of 40%. 3+ mitral regurgitation was seen.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease. Patent LIMA-LAD.
2. Moderate aortic stenosis.
3. Moderate to severe mitral regurgitation.
4. Focal LV systolic dysfunction.
5. Severe biventricular diastolic dysfunction.
TTE [**2105-1-29**]:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size
is normal. Overall left ventricular systolic function is mildly
depressed
(ejection fraction 40-50 percent) secondary to hypokinesis of
the inferior
free wall. No masses or thrombi are seen in the left ventricle.
There is no
ventricular septal defect. The aortic valve is bicuspid. There
is moderate
aortic valve stenosis, with mild aortic regurgitation. The
mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. At least
mild mitral regurgitation is seen. There is no pericardial
effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2105-1-27**], the transaortic valvular gradient is somewhat lower;
however, moderate
aortic stenosis is still present; otherwise no major change is
evident
(inferior hypokinesis present on prior study).
Pertinent lab results:
[**2105-1-26**] 01:45PM BLOOD WBC-3.1* RBC-3.70* Hgb-7.9* Hct-25.9*
MCV-70* MCH-21.4* MCHC-30.5* RDW-13.8 Plt Ct-215
[**2105-1-26**] 06:43PM BLOOD Hct-27.1*
[**2105-1-27**] 05:05AM BLOOD WBC-4.5 RBC-3.85* Hgb-8.1* Hct-27.2*
MCV-71* MCH-21.1* MCHC-29.9* RDW-14.2 Plt Ct-231
[**2105-1-28**] 06:02AM BLOOD WBC-5.7 RBC-3.81* Hgb-8.3* Hct-26.8*
MCV-70* MCH-21.8* MCHC-31.0 RDW-14.1 Plt Ct-211
[**2105-1-29**] 06:30AM BLOOD WBC-4.9 RBC-4.32 Hgb-9.6* Hct-30.6*
MCV-71* MCH-22.3* MCHC-31.4 RDW-15.3 Plt Ct-209
[**2105-1-30**] 06:10AM BLOOD Hct-29.2*
[**2105-1-31**] 06:50AM BLOOD Hct-29.7*
[**2105-2-1**] 06:40AM BLOOD Hct-30.8*
[**2105-2-2**] 07:00AM BLOOD Hct-30.8*
[**2105-1-26**] 01:45PM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-140
K-4.5 Cl-111* HCO3-25 AnGap-9
[**2105-1-26**] 06:43PM BLOOD Glucose-143* UreaN-15 Creat-0.8 Na-141
K-4.4 Cl-111* HCO3-26 AnGap-8
[**2105-1-27**] 05:05AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-138
K-4.4 Cl-107 HCO3-24 AnGap-11
[**2105-1-28**] 06:02AM BLOOD Glucose-87 UreaN-15 Creat-0.9 Na-139
K-4.3 Cl-108 HCO3-23 AnGap-12
[**2105-1-29**] 06:30AM BLOOD Glucose-78 UreaN-15 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-26 AnGap-15
[**2105-1-26**] 01:45PM BLOOD ALT-22 AST-22 AlkPhos-108 TotBili-0.3
[**2105-1-29**] 06:30AM BLOOD Mg-1.7 Cholest-232*
[**2105-1-29**] 02:02PM BLOOD %HbA1c-6.4*
[**2105-1-28**] 06:02AM BLOOD TSH-1.5
Brief Hospital Course:
1. Cardiac:
-coronaries: She was continued on ASA, plavix, statin. She was
evaluated by the CT surgery team regarding the possibility of
CABG/valve replacement, and they felt she could follow-up with
them as an outpatient. It was not felt to be an urgent
inpatient matter and f/u was arranged with Dr. [**Last Name (STitle) **].
Throughout her stay, she had numerous episodes of chest pain
which she states were the typical chest pain she has at home
that wake her up at night. EKGs were done for all of these
episodes, and never showed any signs of ischemia. The pain
would resolve on its own or with sublingual nitroglycerin. It
was unclear whether this pain represented angina or not, however
given the lack of EKG changes it seemed unlikely to be angina.
-pump: She has an EF of 40%. Because of her AS, she is
preload-dependent and so was not aggressively diuresed. Her bp
was difficult to control and several medication adjustments were
made throughout her admission. She was eventually discharged on
lisinopril, toprol, isosorbide mononitrate, and HCTZ.
-rhythm: remained in sinus throughout.
2. Hypotension: She was admitted to the CCU for post-cath
hypotension, which resolved by the night of admission. This was
felt to be most likely related to medications, as the patient
was given her meds on a different schedule than her home regimen
(she usually only takes her meds at night).
2. Heme: She has a hx of iron-def anemia and was kept on her
iron supplementation. She was transfused to a hematocrit of 30
given her CAD.
3. Hypothyroidism: continued on levoxyl.
4. Fibromyalgia/Osteoarthritis: She was continued on her home
pain regimen (duragesic, hydrocodone, nambutone). She was also
given prn percocet. However, this was attempted to be limited,
as the pt often appeared to be overly medicated on narcotics
(falling asleep during conversations, etc.)
5. PT: The patient had difficulty ambulating secondary to her
chronic back/leg pain. She was evaluated by PT, who felt she
was safe to go home w/home PT, which was arranged.
Medications on Admission:
crestor 10 mg po daily
nambutone 500 mg po bid
levoxyl 150 mcg po daily
imdur 120 mg po daily
norvasc 50 mg po tid
plavix 75 mg po daily
lopid 600 mg po daily
toprol XL 100 mg po daily
lisinopril 40 mg po daily
effexor XR 150 mg po daily
hydrocodone 7.5-750 2 tabs q4-6 hrs prn
duragesic patch 125 mcg q48hrs
trazodone 150-200mg po qhs
nitro sublingual prn
ASA 325 po daily
iron 325 mg po tid
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
3. Nabumetone 500 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)).
6. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: Two
(2) Capsule, Sust. Release 24HR PO QHS (once a day (at
bedtime)).
8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
10. Trazodone HCl 50 mg Tablet Sig: 1-3 Tablets PO HS (at
bedtime) as needed.
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 48HR
Transdermal Q48HRS ().
14. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 48HR
Transdermal Q48HRS ().
15. Rosuvastatin Calcium 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
16. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
18. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease
Aortic Stenosis
Mitral Regurgitation
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or return to the emergency room for
worsening chest pain, chest pain that does not resolve with 5
minutes, shortness of breath, nausea, vomiting, abdominal pain,
lightheadedness, or any other concerns.
Please take all of your medications as prescribed. If some of
your medications are supposed to be taken at intervals during
the day, it is important that you take them at those times. Do
not just take all of your daily dose at night for medications
that are dosed more than once per day.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Last Name (Prefixes) 413**] CARDIAC SURGERY LMOB 2A Where: CARDIAC
SURGERY LMOB 2A Date/Time:[**2105-2-5**] 1:00
f/u with your PCP within one week
You have anemia, which we discussed. You should talk with your
primary care physician about pursuing an upper endoscopy and a
colonoscopy.
ICD9 Codes: 2449, 4019 |
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