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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6600
} | Medical Text: Admission Date: [**2162-8-17**] Discharge Date: [**2162-8-23**]
Date of Birth: [**2092-10-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
Bronchoscopy.
History of Present Illness:
This is a 70 year old woman with past medical history
significant for COPD (0.55 FEV1/FVC 38% of predicted on home
O2), status post left upper lobe endobronchial lung reduction,
CAD, CHF, PVD status post multiple bypass surgeries, on chronic
anticoagulation who presented with worsened dyspnea over the
past 4 weeks associated with hoarseness of voice since 2 weeks.
On admission, she was noted to have INR 8.1 in her PCP's office.
She was also found to have a CXR which showed left lung collapse
with tracheal deviation to the left, and was referred to our ED
for this, where she received a combivent nebulizer prior to
transfer. On presentation to the ED, the patient was complaining
of dyspnea and was tachypneic with respiratory rate to 25 with
O2 sat 95% on 5L. Otherwise, her systolic blood pressure was in
the 110 range and pulse in 80-90 range. Her admission labs were
remarkable for WBC of 22.7 and INR of 11.7. In the ED, she
received two combivent nebulizers and 10 mg SC vitamin K and was
then transferred to the MICU. There, she was given 60 mg
prednisone but she refused this citing history of steroid
induced psychosis; she is currently on a prednisone taper (20 mg
a day currently). She denies any recent chest pain, fever or
chills, abdominal pain, nausea or vomiting, headache, dysuria
and polyuria.
.
Since presenting to the MICU, she has undergone emergent rigid
bronchoscopy which demonstrated a mass in the left bronchus
which has subsequently been shown to be non small cell
carcinoma, likely squamous cell. Oncology is setting up a
complete outpatient workup for this patient, including Pet CT.
She was also seen by ENT for evaluation of hoarseness. She is on
aspiration precautions for a paralyzed vocal cord and will
follow up with Dr. [**Last Name (STitle) 33748**] as an outpatient. Two nights prior
to moving out of the MICU, the patient was found to be in
asymptomatic atrial fibrillation with RVR. She was started on an
amiodarone drip and converted back to sinus. Then, she had
another episode the night prior to transfer and converted on IV
amiodarone. She was switched from IV to PO amiodarone on [**8-21**]
and has been in sinus rhythm since the night prior to transfer.
.
At the present time, the patient feels at her baseline. She
denies any shortness of breath that is worse than her usual. She
denies any pain and states that she is "ready to get out" of the
hospital. She denies palpitations and chest pain.
Past Medical History:
1) COPD, FEV1 0.55, FEV1/FVC 38% of predicted
2) Status post LUL endobronchial lung reduction surgery [**12/2159**]
3) CAD status post remote MI (no history of cath)
4) CHF, previous EF 35% but most recent echo in [**2160**] with EF 55%
5) Mobile mass in mitral valve, unknown etiology
6) Peripheral vascular disease s/p multiple bypass surgeries
7) Prior history of DVT's
8) History of small bowel obstruction s/p exp. lap.
Social History:
Lives with husband who is health care proxy. 50 pk year history,
quit 5 years ago, rare alcohol use.
Family History:
Non-contributory.
Physical Exam:
T 97.9 BP 109/55 P 105 RR 24 O2 94 on 4L
Gen: Elderly thin female Caucasian, NAD, somewhat
anxious--speaking in full sentences, some accessory muscle use.
Eyes: PERRL, EOMi, sclerae anicteric
Mouth: MM somewhat dry, no bruising/bleeding
Neck: No bruits, supple, no LND
Chest: Decreased breath sounds in both fields, no wheezes
appreciated
Heart: Tachycardic regular distant heart sounds.
Abdomen: Flat, NT/ND, hypoactive bowel sounds.
Ext: Warm well perfused, weak pulses in feet, nl in hands.
Pertinent Results:
Admission Labs:
==============
[**2162-8-17**] 07:30PM WBC-22.7*# RBC-4.83# HGB-13.4 HCT-39.1 MCV-81
[**2162-8-17**] 07:30PM NEUTS-96.3* BANDS-0 LYMPHS-2.5* MONOS-1.0*
EOS-0.1
[**2162-8-17**] 07:30PM PT-87.1* PTT-44.0* INR(PT)-11.7*
[**2162-8-17**] 07:30PM TSH-0.47
[**2162-8-17**] 07:30PM ALBUMIN-3.6
[**2162-8-17**] 07:30PM ALT-19 AST-21 LD(LDH)-221 ALK PHOS-83 T
BILI-0.2
[**2162-8-17**] 07:30PM GLUCOSE-162* UREA N-15 CREAT-0.7 SODIUM-136
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15
.
RADIOLOGY:
=========
CXR [**2162-8-17**]-
1. Left lung atelectasis with associated leftward mediastinal
shift. CT scan can be performed for further evaluation to assess
etiology.
2. Emphysema.
.
CT [**2162-8-17**]-
Nearly complete collapse of the left lung, accelerated over
several hours. Heavy secretions throughout left bronchial tree,
could be disguising an endobronchial mass. Severe emphysema.
Ground glass peribronchial opacities in the right lung, likely
infectious, warranting CT. Mediastinal lymphadenopathy,
presumably reactive
.
CT [**2162-8-20**]-
1. Extensive intrathoracic malignancy, left lower lobe primary
mass with hilar adenopathy obstructing left upper lobe bronchus
and mediastinal extension crossing the midline in both the
subcarinal and lower paratracheal stations.
2. Severe emphysema. Endobronchial reduction valves, left upper
lobe. Left upper lobe fully collapsed.
3. Embolic occlusion proximal left subclavian artery, not due to
tumor invasion.
.
STUDIES:
=======
[**2162-8-18**] Bronchial washing:
ATYPICAL.
Rare atypical squamous cells.
Squamous cells, inflammatory cells and bacteria
.
PATHOLOGY-
SPECIMEN SUBMITTED: LEFT MAIN STEM TUMOR FOR F/S, LEFT MAIN STEM
TUMOR (RUSH). [**2162-8-19**]
DIAGNOSIS:
A). "Left main stem tumor biopsy for frozen":
Non-small cell carcinoma, favor squamous cell, focus suspecious
for lymphatic vascular invasion.
B)."Left main stem tumor (fresh)":
Non-small cell carcinoma, favor squamous cell
.
CXR ([**8-20**]): Left lower lobe has been substantially reexpanded.
Left upper lobe remains collapsed and left hilus enlarged. New
bronchial stent extends from the carina to just before the
anticipated location of the left upper lobe takeoff. Left
pleural thickening, unchanged. Leftward mediastinal shift
stable. Severe emphysema in the right lung, otherwise clear.
.
Labs at discharge:
Brief Hospital Course:
Mrs. [**Known lastname 47011**] is a 69 year old female with a history of COPD on
home oxygen (4L NC), status post left upper lobe reduction, CAD,
CHF, peripheral vascular disease on chronic anticoagulation who
presented with dyspnea secondary to left lung collapse and
associated tracheal deviation. On bronchoscopy, the patient had
a mass seen with biopsies taken which were consistent with
squamous cell lung cancer; a subsequent CT chest confirms
extensive intrathroacic malignancy.
.
#) Left lung collapse/atelectasis: On bronchoscopy, a mass was
seen with biopsies taken which were consistent with squamous
cell lung cancer. A subsequent CT chest confirms extensive
intrathroacic malignancy. The patient's left lung collapse
improved with stenting by IP. She has follow-up scheduled with
hematology/oncology and is scheduled for outpatient staging PET
scan. Oncology will call patient at home with appointments, PET
scan A social work consult for new diagnosis was obtained.
According to ENT & S&S recs, we will discharge patient home on
aspiration precautions with [**Hospital1 **] PPI, regular diet, medications
given in purees
.
#) Coagulalopathy: The patient did have a supratherapeutic INR
on admission on coumadin. At that time, her coumadin was held,
and her INR improved with vitamin K. Heparin was started for
bridge to coumadin prior to discharge, and transitioned to
lovenox 50mg [**Hospital1 **] until her INR becomes therapeutic. On day of
discharge, INR was 1.6 today, we therefore increased coumadin to
2mg po daily today, and discharged home on lovenox 50mg SC BID
(to treat embolic occlusion of left subclavian artery), while
waiting for INR to become therapeutic. Pt was aware, and
amenable to this plan. She will have home VNA check INR daily
and fax results to PCP ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) **], fax
[**Telephone/Fax (1) **]).
.
#) Hematocrit drop: The patient's drop in hematocrit was most
likely dilutional. She has no signs or symptoms of active
bleeding. Her hematocrit was otherwise stable throughout
admission.
.
#) Atrial fibrillation: Following her first episode of atrial
fibrillation, the patient was loaded with amiodarone IV with
conversion to normal sinus rhythm. She reverted back to atrial
fibrillation subsequently and was restarted on an amiodarone
drip. She was transitioned to PO amiodarone on [**8-21**] and will be
discharged on amiodarone 400 mg po daily. She will discharged
with anticoagulation as above (lovenox bridge to coumadin, f/u
with PCP for INR).
.
# CAD: On beta blocker, statin, ACEi. Will continue these
medications.
.
#) COPD: Prior to admission, the patient was on home O2 4L. Her
most recent PFTs demonstrate FEV1/FVC 38%. Therefore, her
underlying lung disease could be contributing to her dyspnea.
She was begun on prednisone for presumed COPD exacerbation, and
will be discharged home with a 3 day taper (2 more days on 20mg
then 3days on 10mg po qdaily).
.
#) Leukocytosis: This is perhaps secondary to steroids and the
stress of lung collapse. She is being treated for
post-obstructive pneumonia. Initially, she was trated with
vancomycin/ceftriaxone and then transitioned to PO levo/flagyl
to complete 7 day course. Cultures are all negative at time of
discharge, albeit contaminated. WBC was 12 on day of discharge,
felt [**12-31**] steroid use. Her antibiotic course was completed on
day of discharge.
.
#) Peripheral vascular disease - Pt was dicharged on aspirin and
pentoxyfilline.
.
#) Depression/anxiety--continued SSRI, PRN ativan for sleep per
home regimen. SW consulted for coping with new diagnoses of lung
ca.
.
# FEN: Regular diet with thin liquids and regular solids per
Speech & Swallow. The patient should take her pills with purees.
.
# Code status: Patient states that she does not want to have any
shocks or chest compressions. She does not object to intubation,
but would not want to be kept alive on ventilator for lengthy
period at the discretion of her husband (her healthcare proxy).
.
# Communication: Comm: [**Name (NI) 4906**], [**Name (NI) 382**] ([**Telephone/Fax (1) 47012**]
Medications on Admission:
1) Captopril 12.5 TID
2) Metoprolol 25 [**Hospital1 **]
3) Pentoxyfilline 400 TID
4) Lipitor 40 daily
5) ASA 81 daily
6) Advair 500/50 [**Hospital1 **]
7) Spiriva 1 puff daily
8) Ativan prn qHS
9) Warfarin 3mg qOD,4mg qOD
10) Oxazepam prn
11) Fluoxetine 20 mg daily
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
2. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed) as needed for throat pain.
Disp:*50 Lozenge(s)* Refills:*0*
12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day for 7
doses: please take 20 mg (two tablets) once daily x 2 days (last
day [**8-25**]) then take 10mg (1 tablet) once daily for 3 more days
(last day [**8-28**]). .
Disp:*8 Tablet(s)* Refills:*0*
15. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
please have INR checked by home VNA daily and sent to your PCP.
.
Disp:*28 Tablet(s)* Refills:*0*
16. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 7 days.
Disp:*14 injections* Refills:*0*
17. Outpatient Lab Work
please have home VNA draw labs DAILY to check INR and send the
results to your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3070**], fax
[**Telephone/Fax (1) **]).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Lung cancer, squamous cell
COPD
CAD
Peripheral vascular disease
Discharge Condition:
Hemodynamically stable and on 4L NC (home regimen)
Discharge Instructions:
Please take all medications as prescribed.
.
Please take lovenox injections twice daily until your INR is
between [**1-1**] (please ask home VNA draw labs DAILY to check INR
and send the results to your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 3070**], fax [**Telephone/Fax (1) **]). If your INR is not between [**1-1**]
within 7d please call your PCP to obtain refill of lovenox
perscription.
.
Please call your doctor or return to the emergency room should
you experience any of the following symptoms: chest pain,
increasing shortness of breath, fever or chills, easy bruising,
blood in your urine or stools, bleeding gums, increasing
hoarseness of voice, or any other concerns.
Followup Instructions:
The oncologists will call you with a follow up appointment as
well as a date/time for your PET scan.
Otherwise, please keep these already-scheduled appointments:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2162-9-2**] 1:40
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2162-9-2**] 2:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2162-9-2**] 2:00
ICD9 Codes: 496, 4280, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6601
} | Medical Text: Admission Date: [**2191-4-19**] Discharge Date: [**2191-4-21**]
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: The patient is an 85 year-old
male with a history of coronary artery disease and radiation
proctitis who presents with bright red blood per rectum on
the morning of admission. The patient had a bloody bowel
movement in his diaper at his nursing home and needed to be
changed four times since that morning. His blood pressure
was 110/60 and a heart rate of 70 in the field. The patient
was transferred to the [**Hospital1 69**]
for further evaluation. In the Emergency Department the
patient was given two large bore intravenouses and he was
given intravenous fluids. Gastrointestinal bleed scan was
attempted and there was no clear evidence of a
gastrointestinal bleed. Of note during the bleeding scan the
patient's blood pressure dropped to the 70s and 80s and the
patient was transferred back to the Emergency Department
before the scan could be officially completed. The patient
was asymptomatic throughout.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post anterior myocardial
infarction, status post coronary artery bypass graft in [**2182**],
status post percutaneous transluminal coronary angioplasty in
[**2186**].
2. Congestive heart failure with an EF of 25% according to a
[**2186**] echocardiogram with mild AS and aortic regurgitation and
moderate mitral regurgitation.
3. Prostate cancer status post radiation therapy in [**2183**],
complicated by radiation proctitis and bleeding.
4. Dementia secondary to Alzheimers.
5. Anemia.
ALLERGIES: Bee stings.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 q.d.
2. Sorbitol 30 q.d.
3. Ambien 5 q.d.
4. Hydrocortisone 1% to scalp.
SOCIAL HISTORY: The patient is a retired postal clerk. He
lives at [**Hospital 100**] Rehab Facility since [**2188**]. He is married
with three children. Health care proxy is [**Name (NI) **] [**Name (NI) 7692**].
PHYSICAL EXAMINATION: On examination the patient's
temperature is 96.9, pulse 82, blood pressure 126/38 that
fell to 88/60 over the course of the day. Respiratory rate
18. Satting 97% on room air. In general, he was an elderly
man sitting, awake, alert, but not oriented to person, place
or time. Head and neck examination extraocular movements
intact. Mucous membranes are moist. Conjunctiva were well
perfuse with no cervical lymphadenopathy. Cardiac
examination he had a 4 out of 6 systolic ejection murmur and
a 2 out of 6 diastolic murmur at the left upper sternal
border. His lung examination was limited due to lack of
cooperation, but it seemed that he had decreased breath
sounds at the bases. Abdomen was soft, nontender,
nondistended with normoactive bowel sounds. Extremities had
no clubbing, cyanosis or edema.
LABORATORY DATA: White blood cell count of 7.5 with a normal
differential. Hematocrit 34.0 and platelets 236. His chem 7
showed a sodium of 142, potassium 4.9, chloride 106, bicarb
30, BUN 28, creatinine 1.0, glucose 107. His PTT was 24.8,
INR 1.0, urinalysis negative. He had an electrocardiogram
that was done that showed Q waves in 2, 3, F and Qs in V1
through V6 with left bundle branch block and PR prolongation.
There was no substantial change from previous
electrocardiograms. Chest film was performed, which showed
no acute cardiopulmonary disease.
HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient's
gastrointestinal bleed was felt likely due to radiation
proctitis since the presentation was less consistent with
diverticular bleed or an AVM. The patient was admitted to
the Medical Intensive Care Unit for close hemodynamic
monitoring and serial hematocrits. The patient's hematocrit
did trend down over the course of the day and was given one
unit of packed red blood cells over the entire course of his
admission with an appropriate bump in his hematocrit and no
further bleeding. The patient had a sigmoidoscopy, which
showed an ulcer in the rectum, but was limited by poor prep.
The patient was kept overnight in the Intensive Care Unit and
was transferred out to the floor the following day without
complications. The patient denies any further evidence of
gastrointestinal bleeding. Follow up flexible sigmoidoscopy
showed the ulcer in the rectum, but was otherwise normal and
these were biopsied. This will be followed up as an
outpatient the differential being benign ulcers versus
malignancy.
2. Cardiac: The patient has a history of congestive heart
failure, but he tolerated the packed red blood cells and
fluid boluses well. His Atenolol was held out of concern for
hypotension. There were no ill effects from a congestive
heart failure standpoint. The patient remained satting well
on room air and he did not have any evidence for congestive
heart failure. In addition, the patient has a history of
coronary artery disease, however, there was no evidence of
ischemia on electrocardiogram.
3. Code: The patient is DNR/DNI.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital 100**] Rehab Facility.
DISCHARGE DIAGNOSES:
1. Rectal ulcer.
2. Lower gastrointestinal bleed.
3. Radiation proctitis.
DISCHARGE MEDICATIONS:
1. Sorbitol 30 q.d.
2. Ambien 5 q.h.s.
3. Hydrocortisone 1% to scalp.
4. Atenolol 25 q day, which should only be started once the
patient's blood pressure has normalized back to his baseline.
FOLLOW UP PLANS: The patient should follow up with his
primary care physician within one to two weeks. The biopsy
will be sent to his primary care physician and further
evaluation and treatment can be decided at that time.
[**Name6 (MD) 1592**] [**Name8 (MD) 1593**], M.D. [**MD Number(2) 1594**]
Dictated By:[**Last Name (NamePattern1) 7693**]
MEDQUIST36
D: [**2191-4-21**] 11:05
T: [**2191-4-21**] 11:08
JOB#: [**Job Number 7694**]
ICD9 Codes: 5789, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6602
} | Medical Text: Admission Date: [**2156-12-30**] Discharge Date: [**2157-1-7**]
Date of Birth: [**2086-3-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Actos
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
coronary artery bypass graft x3- LIMA-LAD, SVG to diagonal,
obtuse marginal, PDA
History of Present Illness:
This is a 70-year-old male who presented with
chest pain at rest. He has a stress test which was abnormal.
He underwent a cardiac catheterization and this demonstrated
3-vessel coronary artery disease with a totally occluded
right coronary artery. He had an echocardiogram performed
which showed that he had a left ventricular ejection fraction
of 30-40%. There was global left ventricular hypokinesis. It
was recommended he undergo coronary bypass grafting and after
the risks and benefits were explained to him he agreed to
proceed.
Past Medical History:
diabetes mellitus
hypertension
chronic kidney disease (Cr 1.5-1.7)
h/o inferior myocardial infarction with EF 40%
coronary artery disease- stent to cx [**2143**]
hyperlipidemia
Past Surgical History
right carotid endarterectomy
Social History:
Lives with wife
[**Name (NI) 595**] speaking
retired college professor
tobacco: quit 5 years ago; prior 2 cigarettes/day on and off for
20 years.
Family History:
non contributory
Physical Exam:
Pulse: 52 SR Resp: 12 O2 sat: 98%RA
B/P Right: Left: 145/54
Height: 5'6" Weight: 252lb
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] 1+edema b/l LEs, small varicosities bilaterally
Neuro: Grossly intact x
Pulses:
Femoral Right: cath site Left: 1+
DP Right: 1+ Left: 2+
PT [**Name (NI) 167**]: Left: not palpable
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 27594**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 27595**] (Complete)
Done [**2156-12-30**] at 9:31:09 AM PRELIMINARY
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildl-moderately dilated. There is mild
regional left ventricular systolic dysfunction with mild global
hypokinesis with more hypokinesis in the distal anterior and
anteroseptal walls.. Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POSTBYPASS
There is marginal improvement in LV systolic function. LVEF ~
50-55%. RV systolic function remains preserved. The study is
otherwise unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician
[**2157-1-7**] 05:45AM BLOOD WBC-13.0* RBC-3.75* Hgb-10.0* Hct-30.6*
MCV-82 MCH-26.6* MCHC-32.6 RDW-13.8 Plt Ct-561*
[**2157-1-7**] 05:45AM BLOOD PT-14.3* INR(PT)-1.2*
[**2157-1-6**] 06:05AM BLOOD PT-14.1* INR(PT)-1.2*
[**2157-1-6**] 06:05AM BLOOD Glucose-169* UreaN-34* Creat-1.6* Na-140
K-4.2 Cl-99 HCO3-31 AnGap-14
[**2157-1-7**] 05:45AM BLOOD UreaN-43* Creat-1.9* K-4.0
[**2157-1-7**] 05:45AM BLOOD Mg-2.3
Brief Hospital Course:
On [**2156-12-30**] Mr. [**Known firstname 1975**] [**Known lastname **] underwent a coronary artery bypass
grafting times four. This procedure was performed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
please see the operative note for details. He tolerated this
procedure well and was transferred in critical but stable
condition to the surgical intensive care unit. He was extubated
and weaned from his drips. He had atrial fibrillation which
resolved with amiodarone boluses and beta blockade. He was
transferred to the surgical step down floor and his chest tubes
were removed. [**Last Name (un) **] was asked to consult secondary to high
insulin requirements and a pre-operative HgbA1C of 7.8. He was
placed on U-500 concentrated insulin and an aggressive sliding
scale. His epicardial wires were removed. Keflex was initiated
for mediastinal incision erythema without drainage. A sleep
apnea consult was requested secondary to nocturnal desaturations
without bradycardia. Sleep study revealed a mixed sleep apnea.
Recommendation is to follow up as an outpatient, and use home
oxygen while sleeping in the meantime. Atrial
fibrillation/flutter returned. Cardizem was resumed and the
patient was started on coumadin. By the time of discharge on POD
8, the patient was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. He was discharged to
home in good condition with appropriate follow up instructions.
Medications on Admission:
cardizem cd 300 daily,tricor 145 daily,lasix 60 daily,imdur
60daily,humalog 20 before dinner,RISS,avapro 150 daily,lipitor
80daily,toprol xl 50 daily,NTG prn
plavix 75 daily,terazosin 2daily hs,dyazide 37.5/25 daily ,asa
81 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. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
3. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: sternal wound erythema.
Disp:*28 Capsule(s)* Refills:*2*
13. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day:
total of 60mg daily.
Disp:*90 Tablet(s)* Refills:*2*
14. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig:
Fifteen (15) units Injection three times daily with meals:
titrate up insulin dose every two days to a goal fasting blood
sugar of <120 and pre-meal blood sugar of <160 per instructions
of the [**Hospital **] clinic.
Disp:*qs * Refills:*2*
15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per
sliding scale Subcutaneous four times a day.
Disp:*qs * Refills:*2*
16. Cardizem CD 300 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose
will change daily for goal INR [**1-19**].
Disp:*30 Tablet(s)* Refills:*2*
18. Outpatient Lab Work
serial PT/INR
dx: atrial fibrillation
results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**]
19. home oxygen
oxygen 2Lpm continuous for portability
pulse dose system
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
diabetes mellitus
hypertension
chronic kidney disease (Cr 1.5-1.7)
h/o inferior myocardial infarction with EF 40%
coronary artery disease- stent to cx [**2143**]
hyperlipidemia
Past Surgical History
right carotid endarterectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Discharge Instructions: Please shower daily including washing
incisions gently with mild soap, no baths or swimming, and look
at your incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Recommended Follow-up:Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**1-26**] at 1:00 PM
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-18**] weeks [**Telephone/Fax (1) 250**]
Cardiologist Dr. [**Last Name (STitle) **] in [**12-18**] weeks [**Telephone/Fax (1) 62**]
***[**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 2716**], RN- will follow INR/Coumadin dosing for
Dr.[**Last Name (STitle) **], Please call daily for INR/Coumadin dosing
[**Hospital **] Clinic Dr. [**Last Name (STitle) 3617**] [**2157-3-4**] at 1:30 PM ([**Telephone/Fax (1) 20881**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Sleep Center: Thursday, [**2157-1-27**] 3pm, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 612**]
Completed by:[**2157-1-7**]
ICD9 Codes: 5119, 5180, 4240, 5859, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6603
} | Medical Text: Admission Date: [**2191-3-27**] Discharge Date: [**2191-3-30**]
Date of Birth: [**2131-6-20**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
cath lab for urgent intervention: stenting of OM1 with bare
metal stent
History of Present Illness:
Mr. [**Known lastname 101177**] is a 59M letter carrier who was working the night
shift when he had chest pressure, b/l jaw pain, diaphoresis, and
nausea. He went to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 101178**] where he had an EKG that
showed II>III STE. No RV or posterior leads were started. A
nitro gtt was briefly started but discontinued abruptly prior to
transfer at the reccomendations of our cardiology fellow. He was
given ASA, Plavix load, G32B inhibitor and heparin. He had some
bradycardia to the 30's. He was transferred to [**Hospital1 18**] cath lab
for urgent intervention.
.
He was found to have 100% occlusion of large OM1. A BMS was
deployed with some mild STE without chest pain felt to be
reperfusuion. He is currently CP free. He did get bivalirudin
during the case. On the CCU, he says he feels "great" and
denies CP, HA, SOB, abdom pain, chest pressure. At baseline, he
does cardio exercise 3-4x/wk doing stairmaster or spinning
Past Medical History:
??Inflammatory arthritis (lupus per pt)
[**Name (NI) 101179**]
Social History:
The patient works in the post office. No tobacco use since
early [**2158**]. No alcohol use.
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: still alive, no cardiac Hx
- Father: still alive at 83, had CABG in 60s
Physical Exam:
ADMISSION EXAM:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6-7cm. No carotid bruits.
CARDIAC: RR with occasional PVC, 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.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: AAOx3, CNII-XII intact
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
DISCHARGE EXAM:
98.2 105/62 62 18 99%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6-7cm. No carotid bruits.
CARDIAC: RR with occasional PVC, 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.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: AAOx3, CNII-XII intact
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2191-3-27**] 03:16PM BLOOD WBC-5.3 RBC-3.55* Hgb-12.2* Hct-36.2*
MCV-102* MCH-34.3* MCHC-33.7 RDW-13.2 Plt Ct-198
[**2191-3-27**] 03:16PM BLOOD PT-11.2 PTT-44.9* INR(PT)-1.0
[**2191-3-27**] 03:16PM BLOOD Glucose-98 UreaN-20 Creat-1.3* Na-136
K-4.3 Cl-102 HCO3-26 AnGap-12
[**2191-3-27**] 09:04PM BLOOD CK(CPK)-2123*
[**2191-3-27**] 09:04PM BLOOD CK-MB-GREATER TH cTropnT-8.00*
[**2191-3-28**] 05:55AM BLOOD CK-MB-244* MB Indx-18.4* cTropnT-4.74*
[**2191-3-28**] 05:55AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1 Cholest-220*
[**2191-3-28**] 05:55AM BLOOD Triglyc-107 HDL-68 CHOL/HD-3.2
LDLcalc-131* LDLmeas-148*
[**2191-3-28**] 05:55AM BLOOD %HbA1c-5.6 eAG-114
PERTINENT INTERVAL LABS:
[**2191-3-27**] 09:04PM BLOOD WBC-4.7 RBC-3.41* Hgb-11.4* Hct-35.2*
MCV-103* MCH-33.5* MCHC-32.5 RDW-13.5 Plt Ct-208
[**2191-3-28**] 05:55AM BLOOD WBC-3.8* RBC-3.52* Hgb-12.0* Hct-35.9*
MCV-102* MCH-34.1* MCHC-33.5 RDW-13.3 Plt Ct-199
[**2191-3-29**] 04:33AM BLOOD WBC-3.9* RBC-3.64* Hgb-12.2* Hct-37.3*
MCV-103* MCH-33.5* MCHC-32.7 RDW-13.1 Plt Ct-177
[**2191-3-30**] 04:27AM BLOOD WBC-3.6* RBC-3.90* Hgb-13.3* Hct-40.6
MCV-104* MCH-34.0* MCHC-32.7 RDW-13.2 Plt Ct-205
[**2191-3-28**] 05:55AM BLOOD PT-9.2* PTT-25.3 INR(PT)-0.8*
[**2191-3-27**] 09:04PM BLOOD Glucose-113* UreaN-20 Creat-1.4* Na-138
K-4.7 Cl-104 HCO3-26 AnGap-13
[**2191-3-28**] 05:55AM BLOOD Glucose-91 UreaN-17 Creat-1.2 Na-140
K-4.8 Cl-105 HCO3-25 AnGap-15
[**2191-3-29**] 04:33AM BLOOD Glucose-91 UreaN-19 Creat-1.2 Na-139
K-5.1 Cl-104 HCO3-24 AnGap-16
[**2191-3-30**] 04:27AM BLOOD Glucose-90 UreaN-21* Creat-1.7* Na-137
K-4.6 Cl-101 HCO3-25 AnGap-16
[**2191-3-28**] 05:55AM BLOOD CK(CPK)-1328*
[**2191-3-30**] 04:27AM BLOOD ALT-43* AST-79* LD(LDH)-533* AlkPhos-93
TotBili-0.9
[**2191-3-27**] 09:04PM BLOOD CK-MB-GREATER TH cTropnT-8.00*
[**2191-3-28**] 05:55AM BLOOD CK-MB-244* MB Indx-18.4* cTropnT-4.74*
[**2191-3-27**] 09:04PM BLOOD Calcium-8.8 Phos-3.8 Mg-2.3
[**2191-3-28**] 05:55AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1 Cholest-220*
[**2191-3-29**] 04:33AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7
[**2191-3-30**] 04:27AM BLOOD Albumin-4.4 Calcium-9.8 Phos-4.0 Mg-1.7
[**2191-3-27**] 03:16PM BLOOD TSH-4.0
[**2191-3-28**] 05:55AM BLOOD Triglyc-107 HDL-68 CHOL/HD-3.2
LDLcalc-131* LDLmeas-148*
[**2191-3-28**] 05:55AM BLOOD %HbA1c-5.6 eAG-114
STUDIES:
ECG [**2191-3-27**]: rate 62. Sinus rhythm with a ventricular premature
beat. Inferior ST segment elevation with Q waves suggesting an
inferior myocardial infarction which could be acute. RSR'
pattern in lead V1. Low QRS voltage in the precordial leads. No
previous tracing available for comparison. TRACING #1
Cardiac Catheterization [**2191-3-27**]:
COMMENTS:
1) Selective angiography of this right-dominant system
demonstrated
significant one-vessel coronary artery disease. The LMCA had no
angiographically-apparent flow-limiting stenoses. The LAD had a
50%
mid-vessel stenosis. The RCA had serial 70% mid- and
distal-vessel
stenoses. The LCx system had a totally-occluded large obtuse
marginal
branch.
2) Limited resting hemodynamics revealed systemic arterial
hypertension,
with a central aortic pressure of 172/90 mmHg.
ADDENDUM: INTERVENTION COMMENTS:
Initial angiography revealed an occlusion of OM which we planned
to
treat with PTCA and stenting. A 6 Fr XB 3.0 guiding catheter
provided
good support throughout the procedure. Bivalirudin bolus was
administered and infusion started. A Prowater wire was used to
successfully cross the occlusion and was positioned in the
distal
vessel. An Apex OTW 2.0 x 8 mm balloon was used to pre-dilate
the
lesion, restoring flow to the vessel. This was then stented
using an
Integrity 3.0 x 22 mm bare metal stent deployed at 18 atm. Final
angiography revealed an excellent result with 0% residual
stenosis in
the stented segment, TIMI 3 flow within the vessel and no
apparent
dissection. Hemostasis achieved at the right femoral arterial
access
site using Angioseal vascular closure device.
FINAL DIAGNOSIS:
1. Significant one-vessel coronary artery disease.
2. Primary PCI of obtuse marginal occlusion with bare metal
stent.
.
ECHO [**2191-3-28**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the basal half of the basal half of the inferior and
inferolateral walls. The remaining segments contract well (LVEF
50%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is an anterior fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional systolic dysfunction c/w CAD
(PDA distribution).
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
Mr. [**Known lastname 101177**] is a 59M h/o hypothyroidism and unspecified MSK
disease (per pt, is lupus), p/w classic ACS symptoms, found to
have a STEMI, s/p BMS to OM1.
ISSUES:
# STEMI: Patient presented with classic ACS symptoms, including
substernal chest pressure, arm and jaw pain. Patient had a
demonstrable STEMI, culprit lesion is OM1 s/p BMS PCI. He
remained hemodynamically stable throughout hospitalization. He
has had a few occasional runs of PVC's on telemetry, no other
complications. The patient was discharged on aspirin, plavix,
atorvastatin 80mg, metoprolol succinate 50mg qd. Lisinopril was
held because of [**Last Name (un) **]. The patient was discharged to home with
PCP [**Name9 (PRE) 702**] and cardiology follow-up, and was recommended to
pursue cardiac rehab.
# [**Last Name (un) **]: Admission Cr 1.3. Cr increased to 1.7 on [**2191-3-30**] (from
1.2), likely secondary to dye load from catheterization. The
patient was urged to drink plenty of fluids. The patient was
very anxious to be discharged, so we sent patient with a
prescription to have chem 7 checked tomorrow at his PCP's
office. We held his lisinopril in the setting of worsening
renal function.
.
# Hypothyroidism: continue home levothyroxine
.
# Unspecified MSK Dx (per pt, is lupus involving b/l hand
joints, and he has been taking 5mg prednisone qd-[**Hospital1 **] for 1 month
PTA). We held the patient's prednisone throughout his hospital
course.
.
TRANSITIONS OF CARE:
- repeat lipid panel as outpatient to ensure LDL at goal
- start lisinopril when Cr normalizes
Medications on Admission:
HOME MEDICATIONS:
Prednisone 10mg daily for past month
Levothyroxine, unknown dose
.
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Toprol XL 50 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*
6. Outpatient Lab Work
ICD-9 code: acute kidney injury
Check Chem 7 panel on [**2191-3-31**]
Please fax results: [**Last Name (LF) **],[**First Name3 (LF) **] B.
[**Hospital3 **] MEDICINE
Phone: [**Telephone/Fax (1) 4475**] / Fax: [**Telephone/Fax (1) 29683**]
Discharge Disposition:
Home
Discharge Diagnosis:
ST- elevated myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the [**Hospital1 18**] for chest pain. You were found
to have a heart attack. You had a bare metal stent placed in
one of your coronary arteries. It is very important for you to
follow up with your new cardiologist and your primary care
physician.
You also had some kidney injury while you were in the hospital.
It is very important that you drink plenty of water at home and
you need to have a laboratory test tomorrow to evaluate your
renal function.
If you have any chest pain, shortness of breath or any other
symptoms that worry you, you should call your PCP or present to
the emergency department as soon as possible.
Continue to take all of your medications as you previously had,
EXCEPT:
ADD aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) by mouth DAILY (Daily).
ADD clopidogrel 75 mg Tablet Sig: One (1) Tablet by mouth
once a day.
ADD atorvastatin 80 mg Tablet Sig: One (1) Tablet by mouth
DAILY (Daily).
ADD Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr by mouth once a day.
ADD levothyroxine 50 mcg Tablet Sig: One (1) Tablet by mouth
DAILY
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 101180**], MD
When: Wednesday [**4-6**] at 3:15pm
Location: [**Hospital3 **] INTERNAL MEDICINE
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Name: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Specialty: Cardiology
When: Thursday [**4-14**] at 1:45pm
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 4474**]
Phone: [**Telephone/Fax (1) 4475**]
ICD9 Codes: 5849, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6604
} | Medical Text: Admission Date: [**2120-2-3**] Discharge Date: [**2120-2-26**]
Date of Birth: [**2049-2-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old man with CLL, known lung masses and
recent brochial artery bleed, s/p embolization of LLL bronchial
artery [**1-17**], who presents with hemoptysis. He was recently
discharged from [**Hospital1 18**] to [**Hospital 100**] Rehab [**2-1**] after an extended
admission for hemoptysis during which he underwent rigid
broncoscopy demonstrating no endobronchial source followed by
angiography showing a bleeding LLL bronchial artery, which was
successfully embolized. He was also diagnosed with HAP during
that admission, and treatment with vanc/cefepime was begun [**1-28**].
Hemoptysis and infectious symptoms resolved, and he was
discharged to [**Hospital 100**] Rehab. The day of transfer, he again
developed hemoptysis of unclear volumes. EMS was activated.
.
On arrival of EMS, VS 98.2, HR 93, BP 140/90, RR 20, O2 93% on
RA. and he was intubated in the field by EMS, went to [**Hospital1 **].
From there he was transferred to [**Hospital1 18**] ED where BRB was still
coming from the ET tube. She was placed L side down. IP saw him
in the ED and felt that, given no visualization of endobronchial
source at the time of recent scope, it would be more useful to
go directly to IR for repeat guided embolization. They also
recommended advanced ET tube to R side to protect his lung,
which was done. He was reportedly hypotensive to 80/50, femoral
line was placed, and levophed gtt was started with improvement
in BP to systolic in the low 100s. He received 2 Units pRBC and
2L 2S. He was transferred to the MICU on AC at 100% FiO2, 20,
550, PEEP 5.
.
PAST MEDICAL HISTORY:
Past Medical History:
CLL x 20 yrs
-s/p fludarabine and Cytoxan ([**7-14**]) with good response
-auto-immune hemolytic anemia on chronic steroids
-mediastinal lymphadenopathy
-h/o bilat pleural effusions with + cytology ([**6-13**])
RCC s/p Left nephrectomy [**2106**]
CKD: prior baseline CR 1.5, most recently 1.1-1.2
BPH vs Prostate cancer
- h/o multiple prostate biopsies with only 1 c/w adenocarcinoma
([**Doctor Last Name **] 3+3)
GERD
Type II DM: -recently started insulin
R-sided Exotropia
Gallstone pancreatitis [**12-10**]; s/p lap chole
Hyperlipidemia
CAD s/p cath [**4-13**] with diffuse 2 vessel dz
- 70% RCA/PDA, 60%prox/mid LAD)
HTN
Hypogammaglobumenia, recurrent URI/PNA, on IVIG X 2years, good
response (last dose [**2118-11-11**])
Allergic rhinitis
Gilberts disease
Hypotesteronemia
R humeral fracture ([**12-16**])
Enlarged spleen secondary to CLL vs portal hypertension.
Social History:
Married, lives with wife [**Name (NI) **] in [**Location (un) **]. Is a retired
rabbi working in academics/think tank with 30 year history prior
to that of congregation work in [**State 760**]. They have two adult
children in [**Location (un) 9012**] and LA and three grandchildren. Life-time
[**Location (un) 24233**], rare EtOH, no illicit drug use.
Family History:
Father w/ [**Name2 (NI) 499**] cancer and coronary artery disease. Multiple
relatives with DM.
Physical Exam:
GEN: NAD, lying in bed, restrained
VS: T 100 axillary, BP 120/54, HR 114, RR 18, 100% RA
HEENT: PERRL, limited exam of oropharynx due to patient
sedation, but no signs of active hemoptysis, sclera anicteric
CV: tachycardic, regular rate, no m/g/r
PULM: decreased BS at left posterior lung base and right apice,
+occasional rhonchi in LLL, o/w CTAB. no wheezes.
ABD: soft, NT/ND, +BS, no guarding or rebound tenderness
LIMBS: no c/c/e, DP pulses palpable and equal bilaterally
NEURO: arousable, oriented x 1 (self), normal muscle tone,
spontaneously moves all extremities, follows simple commands
such as "open eyes",
Pertinent Results:
LABS ON ADMISSION:
[**2120-2-3**] 03:10AM BLOOD WBC-4.2# RBC-3.10* Hgb-8.5* Hct-24.8*
MCV-80* MCH-27.5 MCHC-34.3 RDW-16.6* Plt Ct-55*
[**2120-2-3**] 03:10AM BLOOD Neuts-86.6* Lymphs-7.0* Monos-4.7 Eos-1.4
Baso-0.2
[**2120-2-3**] 03:10AM BLOOD PT-16.7* PTT-29.0 INR(PT)-1.5*
[**2120-2-3**] 03:10AM BLOOD Glucose-204* UreaN-34* Creat-1.4* Na-136
K-4.5 Cl-105 HCO3-22 AnGap-14
[**2120-2-3**] 03:10AM BLOOD ALT-45* AST-35 CK(CPK)-76 AlkPhos-101
TotBili-0.8
[**2120-2-3**] 03:10AM BLOOD Lipase-47
[**2120-2-3**] 03:10AM BLOOD cTropnT-0.68*
[**2120-2-3**] 03:10AM BLOOD Albumin-2.9* Calcium-7.6* Phos-4.7*#
Mg-1.8
[**2120-2-3**] 07:34AM BLOOD Cortsol-18.3
[**2120-2-3**] 03:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2120-2-3**] 03:41AM BLOOD Type-ART Rates-20/ Tidal V-450 PEEP-5
FiO2-100 pO2-194* pCO2-44 pH-7.34* calTCO2-25 Base XS--2
AADO2-494 REQ O2-81 -ASSIST/CON Intubat-INTUBATED
STUDIES:
Chest X-ray [**2120-2-3**] - 1. Multiple masses, unchanged. 2. Small
left pleural effusion and increased atelectasis.
CT Head [**2120-2-9**] - There is no intracranial hemorrhage, edema,
shift of normally midline structures, or evidence of acute major
vascular territorial infarct. Ventricles and sulci are normal
in size and configuration, for the patient's age. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. The basilar cisterns are
symmetric. Paranasal sinuses and mastoid air cells are well
aerated.
CT Chest [**2120-2-9**] - Interval increase in bilateral pleural
effusions, small bilaterally, but left greater than right. New
heterogeneous opacities at the right lung base could represent
atelectasis or the sequela of aspiration. No lobar
consolidation. Unchanged appearance of large mediastinal and
perihilar masses bilaterally, with attenuation of the adjacent
airways. No new masses. Splenomegaly.
CT Head [**2120-2-17**] - This study is slightly limited due to
patient motion. There is no intracranial hemorrhage, edema, mass
effect, shift of normally midline structures, or acute major
vascular territorial infarction. The ventricles and sulci are
prominent, compatible with age-related volume loss. Visualized
paranasal sinuses are normally aerated. Inferior right mastoid
air cells are partially opacified. Mastoid air cells are
otherwise normally aerated. Osseous structures are
unremarkable.
2D ECHO [**2120-2-19**] - Compared with the prior study (images
reviewed) of [**2120-1-15**], LV systolic function is more impaired
(35-40%). There is global hypokinesis. The prior echo images
were also suboptimal - the ejection fraction may have been
OVERestimated on the prior study.
Brief Hospital Course:
70 year old male with known CLL presents with hemoptysis in
setting of known LLL mass; now s/p embolization of bronchial
artery with recurrent hemoptysis.
# Goals of Care - After prolonged hospitalization and no clear
clinical response to treatment, discussion of goals of care were
initiated with the family of Rabbi [**Known lastname **]. [**Name2 (NI) **] was initially
made DNR/DNI with no escalation of care, then placed on morphine
for comfort and control of his tachypnea, finally antibiotics
were discontinued. IV hydration and nutrition was continued
throughout admission until Rabbi [**Known lastname **] passed away on the
morning of [**2120-2-26**].
# Hemoptysis - Mr. [**Known lastname **] was admitted to the hospital for
hemoptysis noted while at [**Hospital 100**] Rehab facility. He was
intubated in the field by EMS. Due to hypotension, he was
started on pressors on arrival in the ED at [**Hospital1 18**]. He was
directly admitted to the ICU. While in the ICU, he underwent
flexible bronchoscopy that showed recurrent massive hemoptysis
from left lower lobe which had subsided with no signs of active
bleeding. Due to previous embolization, IR was contact[**Name (NI) **] and
felt that since hemostasis was alrady obtained, there was no
indication for IR intervention. He was extubated without event.
After completing stabilization in the ICU, he was transferred
to the BMT (bone marrow transplant/heme malignancy) unit for
further management. Rad-Onc was consulted and decision was made
to undergo radiation therapy to left lower lobe and mediastinal
masses for definitive treatment of hemoptysis. He underwent XRT
without complications. He had no repeat hemoptysis during his
admission.
# Acute Hypoxic Respiratory Failure (x 2): Patient was
transferred to the [**Hospital Unit Name 153**] on [**2120-2-14**] for respiratory failure.
Differential included flash pulmonary edema vs. acute
intrapulmonary hemorrhage vs compressive pathology of airways
from mediastinal lymphadenopathy/inflammation from XRT vs.
mucous plugging. HCT remained stable, no evidence of hemoptysis.
No evidence of worsening infection. PE less likely given rapid
response of 15 mins to mask ventilation. The patient was
diuresed, given pulmonary toilet with albuterol/ipratropium, and
was continued on vanc/zosyn. After transfer from ICU to BMT
service floor, Rabbi [**Known lastname **] had repeat episode of acute hypoxic
respiratory failure associated with SBP=200. He was transferred
to the unit with quick resolution of symptoms once placed on
BiPAP. He was monitored in the ICU prior to being transferred
back to the BMT floor.
# Altered Mental Status: Rabbi [**Known lastname **] was sedated in the ICU due
to being intubated. After discontinuation of all sedating
medications, he was noted to only be oriented to self,
intermittantly agitated as well as difficulty verbally
expressing himself. Initially felt to be delirium and drug side
effects, however altered mental status continued despite no
sedating medications. Neurology consult felt possible delirium
vs. intracranial process (mets, annoxic injury, infection,
seizure). MRI and LP were deferred out of request of family not
to use sedating medications. After initial hypoxic respiratory
failure prompting transfer to ICU, patient underwent EEG which
showed mild to moderate encephalopathy. CT head was negative
for acute intracranial process x 2. Prior to Rabbi [**Known lastname 24239**]
passing, there was no clear determination of the etiology of his
altered mental status.
# Tachypnea - Rabbi [**Known lastname **] started to have tachypnea
approximately 7-10 days into his hospitalization. ABG were
consistent with primary respiratory alkalosis. He was not
hypoxic, however tachypnea was in the 30-40 range at times.
Pulmonary consult was obtained out of concern for effusions as
etiology of tachypnea, however, felt more likely [**1-9**] CNS
etiology and deferred thoracentesis. Rabbi [**Known lastname 24239**] antibitoics
were continued until the day prior to his passing to treat any
residual pneumonia.
# CLL: After hemoptysis stopped and patient extubated, he a was
transferred to the BMT service for further treatment. Rabbi
[**Known lastname 24239**] CLL was not actively treated during admission, however,
he did recieve XRT for definitive treatment of his hemoptysis.
During these treatments, he had XRT to the large mediastinal CLL
mass as well. Neupogen was given on prn basis.
#CAD: ECG not significantly changed from prior. Metoprolol was
held during intial hypotensive episode. Metoprolol was
restarted on transfer to the floor and titrated as tolerated.
Mr. [**Known lastname **] was noted to have troponin leak during his initial
presentation as well as during his acute hypoxic respiratory
failure episodes. There was concern that he was volume
overloaded during his first hypoxic episode and was diuresed,
however on second hypoxic episode he had no sign of total body
volume overload. EKG remained unchanged. Echo was done and
showed .....
# Hypotension: He briefly required pressors. Hypotension was
likely due to a combination of positive pressure ventilation and
medication effect, less likely significant hemodynamic loss into
thorax or adrenal infufficiency given relatively low
(physiologic) home dose of prednisone. Random cortisol was
normal. Pressors were quickly weaned.
# Recent HAP: Vancomycin and cefepime were continued on
admission until [**2-5**] to complete antibiotic course for hospital
acquired pneumonia from previous admission.
# [**Last Name (un) **]: Cr elevated to 1.4 (baseline 1.0-1.2) on admission,
likely secondary to hypotension.
# Anemia: Patient has known AIHA related to CLL and HCT 25 from
baseline 28-30. Transfused 2 unit PRBCs in ED. Prednisone was
continued. Hct was subsequently stable.
# Diabetes Mellitus Type II - Mr. [**Known lastname **] was placed on QID
fingersticks and sliding scale insulin.
Medications on Admission:
Albuterol 90 mcg 2 puffs PRN
Allopurinol 100mg PO Daily
Folic Acid 2mg PO Daily
Insulin Lispro Protam & Lispro As Directed
Metoprolol Succinate 25mg PO BID
Nitroglycerin [NitroQuick] 0.3mg SL PRN
Prednisone 2mg PO daily
Rosuvastatin 5mg PO daily
Docusate Sodium [Colace] 100mg PO BID
Senna 8.6 PO BID PRN
Discharge Medications:
None - Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Massive Hemoptysis
2. Tachypnea
3. Altered Mental Status
4. Pneumonia
5. Acute hypoxic respiratory Failure
6. CLL
7. Anemia
8. Acute on Chronic renal Failure
Discharge Condition:
Expired
Discharge Instructions:
None.
Followup Instructions:
None.
ICD9 Codes: 5849, 5070, 2762, 5859, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6605
} | Medical Text: Admission Date: [**2158-6-7**] Discharge Date: [**2158-6-14**]
Service: CME
CHIEF COMPLAINT: Dyspnea and painful right foot.
HISTORY OF PRESENT ILLNESS: This is a 79-year old female
admitted to [**Hospital6 10353**] on [**5-26**] with a chief
complaint of dyspnea. The patient also complained of a
painful right foot. The patient stated that she had a one
week history of increased dyspnea.
At the outside hospital, she had a BNP of 1700. The patient was
felt to be in congestive heart failure. She was ruled out for a
myocardial infarction and was diuresed. The patient was started
on antibiotics for cellulitis. Her foot was debrided and grew
out Staphylococcus aureus as well as a group B Streptococcus.
The patient was treated with vancomycin and then a cephalosporin.
The patient was also maintained on Coreg and lisinopril as well
as intermittent Lasix.
An echocardiogram was performed which revealed LVH, akinesis
of the inferior and posterior walls, anterolateral wall
hypokinesis, with an ejection fraction of 30 percent, and
severe mitral regurgitation. The left atrium was moderately
dilated. The aortic valve was calcified with restricted
movement, peak and mean gradients of 80 and 40;
respectively. There was a valve area of 0.6 percent; felt to
be consistent with severe aortic stenosis. The patient also
had evidence of mild aortic insufficiency and moderate-to-
severe tricuspid regurgitation. The patient's pulmonary
artery systolic pressure was 63.
The patient was transferred to the Transitional Care Unit at
which time she developed oliguria with an increased
creatinine to 4.5. The patient was transferred to the
hospital again. She was found to be hypotensive as well as
in renal failure. An echocardiogram was repeated, and the
findings were similar to prior echocardiogram. The patient
was placed on dopamine and intravenous fluids. Her blood
pressure increased, and she also had increased urine output
with her creatinine decreasing from 4.5 to 1.3.
The patient was then transferred here for possible aortic
valve replacement, mitral valve replacement, and coronary
artery bypass grafting.
PAST MEDICAL HISTORY: Significant for type 2 diabetes
complicated by peripheral neuropathy.
Coronary artery disease.
Ventricular aneurysm in [**2150**]; status post surgical repair.
History of inferior posterior myocardial infarction 10 years
ago complicated by LV free wall rupture and pseudoanuerysm
repaired at [**Hospital1 18**].
History of hypertension.
History of myeloproliferative disorder.
History of anemia.
History of gout.
History of degenerative joint disease.
History of chronic renal insufficiency (with a baseline
creatinine of 1.3 to 1.7).
History of peripheral vascular disease.
Ischemia right medial hallux.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Hydrea.
2. Regular insulin sliding scale.
3. Lisinopril.
4. One-half normal saline with 40 of potassium chloride.
5. Vancomycin
REVIEW OF SYSTEMS: The patient's constitutional,
ophthalmologic, ear/nose/throat, gastrointestinal, endocrine,
hematologic, genitourinary, and musculoskeletal systems were
all within normal limits. On review of systems, the patient
had no chest pain. She did have dyspnea on exertion with
increasing lower extremity edema. No paroxysmal nocturnal
dyspnea. No orthopnea. Increased shortness of breath with
exertion. No palpitations, syncope, or presyncope.
SOCIAL HISTORY: The patient lives by herself in [**Hospital1 42377**]. She has a very supportive and close family and a son
that is very involved in her care. No tobacco. No ethanol.
No illicit substances.
PERTINENT LABORATORY VALUES ON PRESENTATION: Her temperature
was 97.5, her blood pressure was 119/70, her heart rate was
90, and the patient was saturating at 97 percent on 2 liters
by nasal cannula. Generally, the patient appeared her stated
age. She was sitting in bed. She appeared in no acute
distress. Head, eyes, ears, nose, and throat examination was
significant for normocephalic and atraumatic. The
extraocular movements were intact bilaterally. The sclerae
were anicteric. The oropharynx was clear with moist mucous
membranes. There was no evidence of thyromegaly on
examination. Heart was regular in rate and rhythm with a 3/6
systolic murmur at the left and right upper sternal borders
as well as the left lower sternal border with radiation to
the axilla. Jugular venous pressure was noted to be 9 cm.
The lungs were clear to auscultation with crackles at the
bases. No wheezes or rales were noted. The abdomen was
soft, nontender, and nondistended with normal active bowel
sounds. No evidence of hepatosplenomegaly. No masses were
palpated. Extremities were significant for no clubbing or
cyanosis but trace edema that was nonpitting. On the
patient's right foot there is an open wound adjacent to the
first big toe with no active drainage, no erythema, and no
edema. There was also a stage 1 decubitus ulceration on the
patient's coccyx. On neurologic examination, cranial nerves
II through XII were intact. Strength was [**5-31**] and symmetric.
The toes were downgoing. Pulses were dopplerable; that is,
both dorsalis pedis and posterior tibialis pulses
bilaterally. The patient's femoral pulses were palpable
bilaterally.
PERTINENT RADIOLOGY-IMAGING: On electrocardiogram, the
patient had evidence a right bundle branch block, a normal
sinus rhythm at a rate of 87. No acute ST changes. The
patient had T wave inversions in V1 through V4 as well as in
II and III.
On telemetry, the patient had evidence of a normal sinus
rhythm with no ectopy.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 26.2, her hematocrit was 34.8, and her
platelet count was 510. Differential with neutrophils of 90
percent, bands of 4 percent, lymphocytes of 4 percent, and
monocytes of 2 percent. Her prothrombin time was 19, her
partial thromboplastin time was 33.9, and her INR was 2.4.
Her fibrinogen was 343. D-dimer was 1040. Erythrocyte
sedimentation rate was 13. Sodium was 146, potassium was
4.3, chloride was 110, bicarbonate was 24, blood urea
nitrogen was 49, creatinine was 1.3, and her blood glucose
was 125. Her calcium was 8.6, her magnesium was 1.9, and her
phosphate was 2.7. Thyroid stimulating hormone was 2. High-
density lipoprotein was 23, her low-density lipoprotein was
58, and her triglycerides were 182. Her C-reactive protein
was 2.47. Urine culture was consistent with yeast.
Urinalysis was negative. Further data throughout her
admission revealed Gram stain of wound culture obtained on
[**2158-6-12**] revealed there were no microorganisms with only
2 plus polymorphonuclear neutrophils. Tissue no growth.
Aerobic culture was no growth. Wound culture from [**6-12**];
again, Gram stain was significant 1 plus polymorphonuclear
neutrophils and no microorganisms. Wound culture with no
growth. Aerobic culture with no growth. Blood cultures from
[**2158-6-10**] were no growth. Blood cultures from [**6-7**] were
no growth. The patient's peak creatine kinase was 54, and
her troponin was 0.43.
SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS: CONGESTIVE
HEART FAILURE ISSUES: The patient had a Swan-Ganz catheter
placed, and her central venous pressure transduced at 20 with
a pulmonary artery pressure of 66/32. The decision was made
that the patient should not initially be diuresed given that
she was preload dependent. Additionally, the patient was
stable on minimal oxygen to stable on room air. The patient
was maintained on her Coreg and lisinopril. Throughout her
hospitalization, the patient received as needed Lasix
intermittently. She had a good response to intravenous
Lasix, but diuresis was kept to a minimum given the patient's
aortic stenosis.
The patient had a transthoracic echocardiogram on [**2158-6-8**] which revealed long axis dimension at 5.9, a four
chamber length of 6.4, ejection fraction of 20 percent, a TR
gradient of 38 to 42, E:A ratio of 1.3, left atrium that was
moderately dilated, right atrium that was moderately dilated,
and moderate symmetric LVH. The left ventricular cavity was
mildly dilated. Overall left systolic ejection fraction was
severely depressed. The right ventricular cavity was
dilated. There was severe global right ventricular free wall
hypokinesis. The aortic root was normal in diameter. The
aortic valve leaflets were 3 and mildly thickened. There was
moderate aortic valve stenosis. There was 1 plus atrial
regurgitation was seen. The mitral valve leaflets were
thickened. Mild 1 plus mitral regurgitation was seen. The
mitral regurgitation is eccentric. The tricuspid valve
leaflets were normal. Moderate-to-severe 3 plus tricuspid
regurgitation was seen. Moderate pulmonary artery systolic
hypertension was seen. Physiologic pulmonary regurgitation
was seen. No pericardial effusion.
The patient underwent cardiac catheterization on [**2158-6-9**]
which revealed the following. Coronary angiography of a
right-dominant system revealed moderate two vessel disease.
The left main coronary artery was not obstructed. The left
anterior descending artery and its major branches had no
significant disease. The left circumflex had minimal distal
vessel 70 percent stenosis. The right coronary artery had
moderate luminal irregularities distally, up to 40 percent
stenosed. Resting hemodynamic measurements demonstrated
elevated right heart filling pressures. Right right atrial
mean was 29 mmHg. The right ventricular end-diastolic
pressure was 19 mmHg. Pulmonary arterial hypertension was
noted with pulmonary artery pressure of 16/14 mmHg with a
calculated peripheral vascular distance of 363 dynes seconds
per cm5, and mildly elevated left heart filling pressures,
with a mean capillary wedge pressure of 15 mmHg, and a left
ventricular end-diastolic pressure of 14 mmHg. There was
approximately 43 mmHg peak, and 36 mm mean gradient across
the aortic valve, and mildly diminished cardiac output, an
index of 3.9 liters per minute, and 2.4 liters per minute m2;
respectively, for a calculated valve area of approximately
0.6 cm2.
Left ventriculography revealed severe regional systolic
ventricular dysfunction. There was severe anterior and
apical hypokinesis and dyskinesis of the inferior wall with
prominent aneurysm of the inferior basal segment. There was
moderate 1 plus to 2 plus mitral regurgitation.
Final diagnoses included noncritical two vessel coronary
artery disease, severe aortic stenosis, moderate mitral
regurgitation, and severe regional systolic ventricular
dysfunction.
It was felt that given these findings that the patient would
be a candidate for aortic valve replacement. The case was
discussed with Cardiothoracic Surgery, and it was felt that
given the patient's active infection in the right foot that
aortic valve replacement should be deferred until a later
time after the patient has been on antibiotics for an
adequate amount of time.
CORONARY ARTERY DISEASE ISSUES: The patient was maintained
on aspirin.
INFECTIOUS DISEASE ISSUES: The patient was initially
maintained on vancomycin for a presumed right foot
osteomyelitis. The patient underwent x-rays of her right
foot which revealed no fracture, evidence of bony destruction
involving the head of the right first metatarsal consistent
with osteitis. There has been an amputation through the base
of the proximal phalanx of the second digit. No radiopaque
foreign bodies were seen. The left foot views revealed that
there was a hallux valgus deformity. There was resumption
involving the head of the second metatarsal with metatarsal
phalangeal subluxation at this location, and there could be
bony resorption of the head and the base of the proximal
phalanx of the second digit. No fracture. No radiopaque
foreign bodies noted.
Infectious Disease was consulted and they recommended
oxacillin intravenously for osteomyelitis. The length of
antibiotics was discussed with Infectious Disease, and it was
recommended that the patient would need at the very minimum
six weeks of intravenous antibiotics following right foot
debridement, and up to eight week total of intravenous oxacillin
depending upon how the patient's right foot looked at follow-up
appointments with both Podiatry and Infectious Disease.
Infectious Disease also stated that should an aortic valve
replacement be necessitated prior to six weeks of intravenous
antibiotics, at least two weeks of intravenous antibiotics are
recommended and that the ptient should have surveillance blood
cultures after this date, and if the patient's blood cultures are
negative that the patient could then proceed with aortic
valve replacement should it be necessitated before six weeks
of antibiotics could be completed.
Podiatry was also consulted, and they debrided the patient's
wounds. As stated above, the patient's wound cultures were
negative with no growth final.
PERIPHERAL VASCULAR DISEASE ISSUES: The patient also
underwent magnetic resonance imaging/magnetic resonance
angiography of her lower extremities to assess for peripheral
vascular disease and to see if she could possibly be a
candidate for stenting.
She had a magnetic resonance imaging/magnetic resonance
angiography performed on [**2158-6-9**] which revealed the
following. Mild atherosclerotic changes were present in the
infrarenal abdominal aorta without evidence of aneurysm or
dilatation. The assessment of the first station was limited
due to technical factors and venous contamination; however,
the iliac vessels appeared grossly normal to the level of the
femoral arteries with no hemodynamically significant
stenosis. The superficial femoral artery on the right leg
had minimal atherosclerotic changes at the adductor canal.
The right superficial femoral artery was of normal caliber
and provided adequate flow to the lower right leg. The right
profunda femoral appear appeared normal. The anterior tibial
artery appeared normal throughout its course and as it enters
the dorsalis pedis artery there was mild narrowing at the
tibiofemoral trunk. The posterior tibial artery appeared
normal at it enters the posterior foot. There was mild
proximal narrowing. The plantar arch appeared normal. In the
left leg, there was a surgical clip in the proximal superficial
femoral artery which obscured evaluation of a very focal region
of this area. The superficial femoral artery appeared normal.
The profunda artery was diffusely diseased. The popliteal artery
appeared normal. The anterior tibial artery had mild narrowing
in its distal third but remains normal in caliber as it enters a
normal-appearing dorsalis pedis. The tibiofemoral trunk
appeared normal. The posterior tibial artery becomes
diffusely atherosclerotic distally and was not identified at
the ankle. The proximal peroneal artery appeared normal with
diffuse disease distally. The plantar arch was not well
visualized.
The final impression was no significant aortoiliac disease,
mild narrowing at the right tibioperoneal trunk, and of the
distal peroneal artery, and diffuse disease of the left
profunda femoral artery, mild narrowing of the mid segment of
the anterior tibial artery, and diffuse disease of the distal
posterior tibial and peroneal arteries with apparent
occlusion of the these two vessels at the ankle. Given that
the patient had good distal arterial flow, it was felt that
the patient would not need stenting at this time.
CHRONIC RENAL INSUFFICIENCY ISSUES: The patient's creatinine
remained at her baseline. Her urine was sent, and urine
culture was negative. Additionally, the patient had no
evidence of urine eosinophils.
FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
maintained on a 2-gram cardiac diet as well as a diabetic
diet. Her electrolytes were followed and repleted as needed.
PROPHYLAXIS ISSUES: The patient was maintained on
subcutaneous heparin and a bowel regimen.
COMMUNICATION ISSUES: Communication was with her son
throughout. Additionally, the patient's primary care
physician was [**Name (NI) 653**] prior to the patient's discharge.
CODE STATUS ISSUES: The patient remained a full code.
MYELOPROLIFERATIVE DISORDER ISSUES: The patient was
maintained on her outpatient dose of Hydrea with a good
response. The patient did have elevated platelet counts in
the range of 500s; however, there was no evidence of thrombo
occlusive events.
Prior to discharge, the patient had a peripherally inserted
central catheter line placed for the purpose of extended
intravenous antibiotics. This occurred without event.
DISCHARGE INSTRUCTIONS: The patient was to take all
medications as prescribed.
The patient was to be weighed daily, and if greater than a 3-
pound weight gain, as needed Lasix was to be considered.
The patient also needs every 2-week liver function tests
given that she was on oxacillin. Her liver function tests at
the [**Hospital1 69**] were within normal
limits except a mildly elevated alkaline phosphatase at 130.
It was requested that the outside facility follow her liver
function tests while the patient was on oxacillin for right
osteomyelitis.
FINAL DISCHARGE DIAGNOSES: Severe aortic stenosis.
Congestive heart failure.
Chronic renal insufficiency.
Myeloproliferative disorder.
Diabetes.
Degenerative joint disease.
Peripheral vascular disease.
Hypertension.
DISCHARGE FOLLOW UP: [**Hospital **] Clinic on [**Last Name (LF) 2974**], [**2158-6-23**]
at 3 p.m. with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Infectious Disease by Dr. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3640**] at the [**Last Name (un) 2577**]
Building (telephone number [**Telephone/Fax (1) 457**]) on [**2158-7-17**] at
10:30 a.m.
Cardiothoracic Surgery with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] on [**2158-7-6**].
MAJOR SURGICAL-INVASIVE PROCEDURES PERFORMED: Status post
pulmonary catheter placement.
Status post cardiac catheterization.
Status post right foot debridement [**2158-6-11**].
CONDITION ON DISCHARGE: Stable. She was stable on room air.
She was mentating appropriately. Had no ectopy on telemetry.
No chest pain. She was not in congestive heart failure.
DISCHARGE STATUS: She was to be discharged to [**Hospital1 392**]
Transitional Care Unit.
MEDICATIONS ON DISCHARGE:
1. Regular insulin sliding scale.
2. Hydroxyurea.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD
[**MD Number(2) 15194**]
Dictated By:[**Last Name (NamePattern1) 18827**]
MEDQUIST36
D: [**2158-7-4**] 16:41:36
T: [**2158-7-4**] 18:58:31
Job#: [**Job Number 42378**]
ICD9 Codes: 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6606
} | Medical Text: Admission Date: [**2120-8-1**] Discharge Date: [**2120-8-9**]
Date of Birth: [**2040-6-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Perimesencephalic subarachnoid bleed after falling out of bed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78M s/p R CVA with trach who presented to outside hospital after
wife heard thump in his room and went in to find him on the
floor. Had left top of head laceration stapled at OSH. CT there
showed ICH. Transferred to [**Hospital1 18**] ED.
Past Medical History:
HTN
stomach CA
CVA 5 yr ago w/ trach
Social History:
no tob, no EtOH, lives with wife
Family History:
Non contributory
Physical Exam:
T: 100.1 BP:98 / 61 HR:103 R18 O2Sats100
Gen: WD/WN, comfortable, NAD, in hard collar, staples in left
top
of head with dried blood
HEENT: Pupils: 3mm ERRLA EOMs appear full but pt not
cooperative
Neck: in hard collar
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake not cooperative with exam
Orientation: nonverbal
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm bilaterally.
III, IV, VI: Extraocular movements appear intact bilaterally
without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing difficult to assess
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk bilaterally. Increased tone in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
abnormal
movements,
tremors. Strength: no obvious deficits throughout.
Reflexes: Pa Ac
Right 3 0
Left 2 0
Toes downgoing left, upgoing right
Pertinent Results:
[**2120-8-1**] 06:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2120-8-1**] 06:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2120-8-1**] 06:50AM FIBRINOGE-165
[**2120-8-1**] 06:50AM PT-12.1 PTT-23.3 INR(PT)-1.0
[**2120-8-1**] 06:50AM PLT COUNT-194
[**2120-8-1**] 06:50AM WBC-15.8* RBC-3.78* HGB-13.3* HCT-36.8*
MCV-97 MCH-35.3* MCHC-36.2* RDW-13.2
[**2120-8-1**] 06:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2120-8-5**] 06:15AM BLOOD WBC-8.9 RBC-4.04*# Hgb-13.8* Hct-39.7*#
MCV-98 MCH-34.0* MCHC-34.6 RDW-13.0 Plt Ct-228#
[**2120-8-4**] 03:40AM BLOOD WBC-8.0 RBC-3.16* Hgb-11.1* Hct-30.6*
MCV-97 MCH-35.0* MCHC-36.1* RDW-13.0 Plt Ct-148*
[**2120-8-5**] 06:15AM BLOOD Plt Ct-228#
[**2120-8-5**] 06:15AM BLOOD Glucose-119* UreaN-7 Creat-0.8 Na-139
K-3.9 Cl-99 HCO3-30 AnGap-14
Brief Hospital Course:
Mr [**Known lastname 12330**] was admitted to the ICU for close neurological and
hemodyamic monitoring given his obtunded exam initially on
arrival. He underwent a CTA of his brain to rule out source of
perimesencephalic bleed which was negative for any aneurysm or
AVM. He was seen by cardiology to rule out whether his fall was
related to a syncopal episode. They felt it may be related to
his afib/aflutter and his rate should be better controlled he
was placed on metropolol 25mg [**Hospital1 **].
Neurologically he became more arrousable on a daily basis. By
hospital day three he was following commands and moving all
extremities with full strenght. On hospital day number 4 he was
transferred to the surgical floor. On the evening of his
transfer he began to have episodes of agitation/sundowning. He
was started on a regiman of various atypical antipsychotics
finally finding Seroquel at 12.5mg HS worked well and had no
further episodes of agitation. Geriatrics consult service
helped us manage his behavioral issues.
Speech therapy saw the patient he was cleared to eat a regular
diet and recommended the following with regards to his speech:
. Speak VERY LOUD while looking directly at the patient
2. Help him depress the voicing button on the [**Doctor Last Name **]-[**Doctor Last Name **]
artificial larynx
3. Help him to place the intra-oral tube [**12-4**] way into his mouth
so that the sound can be shaped into audible/intelligible
speech and he can be understood
4. It is impossible to understand all the words produced with an
artificial larynx because it voices all sounds. (Many
sounds such as P, T, K, f, S, etc. are produced without
voice) So, it is easier to understand someone if:
A. You know the subject of conversation
B. He speaks in short phrases
(it can be harder to understand single words)
5. Watch his lips when he speaks, and if you don't understand,
A. Ask him to say it again more slowly
B. Put the tube further in his mouth
c. Clarify the topic
On discharge he was alert, orientated following commands with no
neurological deficits. His last CT was on [**8-2**] and it showed no
new blood.
Medications on Admission:
simvastatin, folic acid, plavix,
prozac, neurontin
Discharge Medications:
1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for scalp lac.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 245**] [**Hospital6 **], Satellite as [**Hospital1 **] Hospitals,
Hunt Center
Discharge Diagnosis:
Perimesencephalic SAH after fall
Discharge Condition:
Neurologically stable
Discharge Instructions:
Return to ER or call Dr[**Name (NI) 2845**] office if you develop any
neurologic changes such as headache, weakness or mental status
changes.
Followup Instructions:
Follow up in 6 weeks with Head CT in 6 weeks with Dr [**Last Name (STitle) 548**], call
for an appointment [**Telephone/Fax (1) 2992**]
Completed by:[**2120-8-9**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6607
} | Medical Text: Admission Date: [**2187-10-5**] Discharge Date: [**2187-10-9**]
Date of Birth: [**2120-3-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Hypotension
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67M s/p Whipple procedure [**2187-7-3**] for ampullary adenoma who was
readmitted post-op intra-abdominal fluid collections [**2187-7-25**],
and again on [**8-16**] for fevers and hypotension and E.Coli
bacteremia, who presents again after transfer from an outside
hospital with fevers and hypotension. Fevers at the OSH were
102.
The patient was discharged on his last admission with PO
antibiotics for 6 weeks (augmentin). His antibiotic course was
stopped just prior to this admission. Feeding as an outpatient
was continued with a dobhoff tube feeds. The patient was seen in
clinic 5 days prior to admission and reported good progress with
weight gain, and was afebrile since his last admission.
Past Medical History:
Past Medical History:
ampullary adenoma, likely diagnosis of familial adenomatous
polyposis, ypertension, coronary artery disease, chronic
obstructive pulmonary disease (COPD), arthritis and peripheral
vascular disease
PSH: Whipple procedure, coronary artery bypass graft (CABG) and
carotid endarterectomy, total abdominal colectomy and end
ileostomy, ex-lap's for SBO, EVAR
Social History:
His social history is significant for positive tobacco. He
smokes half pack per day, no alcohol and no IV drugs use, and no
intranasal cocaine use.
Family History:
Family History:
His family history is significant for his maternal grandfather
that was affected with colorectal cancer, mother that was
affected with polyposis, brother that was affected with
colorectal cancer, 2 daughters that are affected with polyposis,
a grandson that is affected with polyposis, a brother that was
lost to colorectal cancer and a son that is also affected with
polyposis.
Physical Exam:
Vitals- 97.4 97.4 75 100/52 15 97% 2L
Gen- NAD, alert
Head and neck- NC/AT, No JVD
Heart-RRR, SEM at LSB, II/VI
Lungs-clear bilaterally
Abd-soft, osteomy pink, dark green watery stool
Ext-no edema
Pertinent Results:
[**2187-10-6**] 12:12AM BLOOD WBC-7.7 RBC-3.43* Hgb-10.5* Hct-30.4*
MCV-89 MCH-30.6 MCHC-34.5 RDW-16.1* Plt Ct-146*
[**2187-10-7**] 01:12AM BLOOD WBC-5.0 RBC-3.38* Hgb-10.3* Hct-29.2*
MCV-86 MCH-30.5 MCHC-35.3* RDW-16.2* Plt Ct-145*
[**2187-10-7**] 01:12AM BLOOD Glucose-145* UreaN-9 Creat-0.5 Na-137
K-3.8 Cl-110* HCO3-21* AnGap-10
[**2187-10-8**] 06:00AM BLOOD ALT-55* AST-29 LD(LDH)-152 AlkPhos-157*
TotBili-0.4
[**2187-10-6**] 12:12AM BLOOD Lipase-61*
[**2187-10-7**] 01:12AM BLOOD Albumin-2.9* Calcium-7.8* Phos-2.1*
Mg-1.9
[**2187-10-8**] 06:00AM BLOOD Albumin-3.2* Mg-1.7
.
Blood Cultures OSH
E.coli pan-sensitive
.
Brief Hospital Course:
This is a 67 readmitted for hypotension, fevers, in the context
of
prior fluid collection, E.coli sepsis. He was sent from OSH for
1 day of rigors and malaise. Was reportedly hypotensive at OSH
ED, given 4 liters crystalloids w/ transient improvement. BP
90s/50-110/60s on arrival.
CT abdomen @ OSH - per ED report no free air or acute process.
It was reviewed by Gold surgery as having no acute issue/cause
for sepsis.
He was admitted to the SICU. He was Pan culture and started on
Vanc/zosyn.
He responded to IVF and his BP was stable.
Pain - minimal, continue to monitor
CARDIOVASCULAR: Hypotension - low CVP, most likely vasodilatory
[**1-6**] ?infection, given bolus to maintain SBP and responded well.
GI / ABD: He was restarted on PO's and tube feeds
HEMATOLOGY: Stable anemia, follow
ID: OSH blood cultures were pan-sensitive E.coli. He was
discharged home with 2 weeks of Levofloxacin
He was stable at time of discharge and will follow-up with Dr.
[**Last Name (STitle) 468**] in a few weeks.
Medications on Admission:
Simvastatin 10', Aspirin 325', Lopressor 50'', Omeprazole 20',
reglan 10"", dilaudid 1-2q4hp, colace 100"
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] visiting nurses
Discharge Diagnosis:
E.Coli bacteremia
hypotensive
febrile
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.
.
* Take all 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
* Continue with tubefeedings as directed
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2187-11-12**]
11:00
Completed by:[**2187-10-9**]
ICD9 Codes: 7907, 4589, 4019, 496, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6608
} | Medical Text: Admission Date: [**2153-4-19**] Discharge Date: [**2153-4-24**]
Service: NEUROLOGY
Allergies:
Penicillins / Codeine / Sulfonamides / Aspirin / Valium /
Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril
/ Egg / Oxycontin
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right sided weakness, speech difficulties-CODE STROKE
Major Surgical or Invasive Procedure:
tPA [**2153-4-19**]
History of Present Illness:
92W h/o afib not on AC presents as CODE STROKE after acute onset
of garbled speech, right sided weakness and left gaze
preference.
Last seen well @ 1:20pm by driver. Onset of symptoms @ 1:20pm
noted by driver that patient began to have garbled speech.
Driver subsequently called for an ambulance which brought pt to
[**Hospital1 18**] ED.
NIHSS
1a. alert 0
1b. LOC questions 2
1c. LOC commands 2
2. Gaze 1
3. Visual 0 (chronically blind)
4. Facial palsy 2
5. Motor L arm 0
5. Motor R arm 2
6. Motor L leg 0
6. Motor R leg 3
7. Limb ataxia 0
8. Sensory 0
9. Best language 2
10. Dysarthria 1
11. Extinction 2
NIHSS Total 17
Head and neck CTA showed ?LMCA distal division occlusion. Labs
INR 1.1, Cr 1.1 and FS 114.
Past Medical History:
-- CAD: s/p MI x2; s/p Cypher stent to RCA in [**2148**]; [**12-11**] P-MIBI:
Normal pharmacologic stress myocardial perfusion with normal
left
ventricular cavity size and wall motion.
-- Chronic diastolic CHF: Echo [**2151-3-4**] EF >55%, 1+MR, 1+ TR,
mild PA systolic
pressure
-- Hypertension
-- Diabetes mellitus
-- Atrial fibrillation - per history but currently in sinus. Not
on coumadin
-- Sjogren's syndrome / scleroderma.
-- squamous cell carcinoma
-- Interstitial lung disease
-- osteoporosis, with vertebral compression fractures.
-- GERD / esophageal dysmotility / peptic ulcer disease.
-- Macular degeneration
-- h/o DVT
-- s/p colectomy
-- s/p strokes x4
-- s/p TAH/RSO
-- s/p post appendectomy
-- h/o femoral hernia repair
-- Pancreatic lesion that needs follow up
-- influenza [**2-/2153**]
Reportedly no h/o seizures.
Social History:
Patient was a [**Hospital1 18**] employee x 36 years, widowed. She has 2
children, one in [**State **] and [**State 4565**]. Patient walks with a
cane. Patient lives in [**Location **] Place [**Hospital3 **]. Patient
reports she walks with cane assist only although she is legally
blind.
Tobacco: 15 pk-yr, quit 65 yrs ago
ETOH: None
Illicts: None
Son [**Name (NI) **] [**Name (NI) **] (HCP) [**Telephone/Fax (1) 96979**] in [**State **] but will be
coming
into town this weekend.
Family History:
One child died at age 60 of CAD/cancer
Father died at 52 of MI
Physical Exam:
T- 99.4 BP- 143/77 HR- 102 RR- 38 100 O2Sat NC FS 104
Gen: Lying in bed, tremulous and mild distress
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
CV: sinus tachycardia, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally but tachypneic
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert but not coherent. Rambling
speech
with incoherent content. Does not answer questions or follow
commands.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Left gaze preference but intact extraocular
movements with OCMs. R UMN facial droop. Palate elevation
symmetrical. Tongue midline, movements intact
Motor/Sensory:
Decr'd bulk throughout and tone decr'd on the right. Does not
cooperate with formal resistance testing but moves left arm
purposefully and leg spontaneously. Much fewer spontaneous
movement from the right side but will withdraw to noxious stim
bilaterally, again less on the right.
Reflexes: +2 symm throughout. Right toe upgoing and left toe
downgoing.
Coordination/Gait/Romberg: Unable.
Pertinent Results:
Trop-T: <0.01
138 102 19 114 AGap=18
-----------------
4.3 22 1.1
estGFR: 46/56 (click for details)
CK: 30 MB: Notdone
Ca: 9.6 Mg: 1.9 P: 2.6
ALT: 14 AP: 77 Tbili: 0.8 Alb:
AST: 23 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 42
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
MCV 93
7.6 D > 12.2 < 261 D
37.3
N:46.1 L:41.0 M:8.5 E:3.1 Bas:1.3
PT: 12.5 PTT: 25.6 INR: 1.1
UA neg
CT ABDOMEN/PELVIS [**4-19**]
CT OF THE ABDOMEN: Chronic interstitial lung changes at the
bases of the lungs bilaterally are again identified, similar in
appearance. Mild cardiomegaly is again identified. Coronary
artery calcifications are again identified. Extensive
calcification of the aorta and its branches is also noted. The
patency of these vessels cannot be evaluated due to lack of
contrast. However, within the limitations of a non- contrast
scan, the small bowel loops are unremarkable. There is no wall
thickening or bowel dilatation. The spleen is unremarkable.
Within the liver, multiple low- attenuation lesions (2, 24 and
2, 29) are identified and not completely evaluated on this
single phase study. Within the pancreas, there are two hypodense
lesions (2, 27 and 2, 29). These are incompletely characterized
on this non- contrast study. Multiple bilateral renal cysts are
again identified, most of which have increased in size when
compared to the prior exam. Contrast from prior CAT scan is seen
within the collecting system of the right kidney, however,
minimal contrast appears to fill the right ureter. There has
been interval development of right- sided hydronephrosis due to
a right- sided [**Month/Year (2) 96980**] obstruction. The left kidney demonstrates
normal excretion of contrast. Scattered mesenteric and
retroperitoneal lymph nodes are again identified, none of which
meet CT criteria for pathological enlargement. Patient is status
post right hemicolectomy. There is no free fluid or free air.
CT OF THE PELVIS: The rectum and sigmoid colon are unremarkable.
There is diverticulosis without evidence of diverticulitis.
There is a Foley catheter within the bladder. Contrast is seen
within the bladder lumen. There is no pelvic or inguinal
lymphadenopathy. Extensive diverticulosis without evidence of
diverticulitis is noted. Numerous phleboliths are seen within
the pelvis.
BONE WINDOWS: Multiple old right-sided rib fractures are
identified, with delayed/non-[**Hospital1 **] of right tenth rib. No
suspicious lytic or sclerotic lesions are noted.
IMPRESSION: Please note there is a change from the initial wet
read; the presence of right sided hydronephrosis is now added..
1. There has been interval development of right-sided
hydronephrosis and right- sided [**Hospital1 96980**] obstruction.
2. Interval increase in size of numerous bilateral renal cysts.
3. Multiple hepatic cysts.
4. Pancreatic hypodense lesions, incompletely characterized.
4. Extensive calcifications of the aorta and its branches.
5. Diverticulosis without evidence of diverticulitis.
6. Right-sided rib fractures with possible delayed/nonunion of
the right tenth rib (300B, 7).
ECHO:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%) No masses or thrombi are seen in
the left ventricle. The right ventricular cavity is moderately
dilated with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-6**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Dilated right ventricle with mild systolic
dysfunction. Preserved left ventricular systolic function.
Mild-moderate mitral regurgitation. Moderate-to-severe tricuspid
regurgitation. Moderate pulmonary hypertension.
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage,
edema, or major vascular territorial infarction evident on this
non-contrast head CT. No change since [**2153-2-3**]. Again seen
is prominence of the ventricles and sulci consistent with
age-related involutional changes. [**Doctor Last Name **]-white matter
differentiation is preserved. Again seen is chronic wall
thickening and atelectasis of the left maxillary sinus. The eyes
deviated leftward.
CTA OF THE HEAD AND NECK: The vertebral and carotid arteries are
seen from the origin, intracervical courses, with no significant
stenosis. The cavernous carotids are mildly calcified and
tortuous, nearly kissing at the center. The major vessels of the
circle of [**Location (un) 431**] and its major branches are patent, with no
flow-limiting stenosis or aneurysm detected. The vertebrobasilar
system is also patent, with no stenosis.
CT PERFUSION: There is an area of abnormal perfusion with
increased mean transit time and decreased cerebral blood flow
and blood volume, which is mild to moderate in extent, in the
left posterior cerebral artery circulation distribution,
concerning for an area of ischemia or infarction.
EKG: Sinus rhythm. Frequent atrial premature beats. Left axis
deviation. Probable old anteroseptal myocardial infarction.
Non-specific inferolateral ST-T wave changes. Compared to the
previous tracing of [**2153-4-19**] frequent atrial premature beats are
new. Left bundle-branch block has resolved. Clinical correlation
is suggested.
Brief Hospital Course:
A/P 92W h/o afib not on AC presents as CODE STROKE after onset
of garbled speech, right sided weakness and left gaze preference
and arrived to ED within 3 hours of time of onset and was given
TPA for NIHSS 17 and concern for left MCA occlusion on CTA head
nonreformatted. Rec'd TPA at 3:35pm and then admitted to
neuroICU. On Vanc, Aztreonam, Flagyl for fever 102 emp pulm
coverage d/t tachypnea on presentation.
NEURO:
Admitted to the ICU for close observation and post-tPA care.
Neurologically she fared well throughout the entire
hospitalization, with gradual near-full recovery. An EEG showed
only some mild diffuse intermittent theta-range slowing (formal
report pending at time of discharge). Since she's has such
remarkable recovery and the initial imaging studies, including
CT/CTA/perfusion did not reveal a LMCA stroke, and MRI was done
to assess for older strokes or signs of this recent stroke. It
revealed no DWI abnormalities, mild white matter
microangiopathic changes, and intact vessels intracranially
(formal read pending) . She was started on Plavix in lieu of
Aspirin [**1-6**] allergy. Given the previous admission where she had
altered mental status and speech resolved with resolution of the
fever, it is a possibility that she had the same issue now.
CARDIO
Recurrent episodes of CP reported upon Tx out of unit to floor.
Serial EKGs (3) and serial enzymes ruled out MI. Bloodpressure
was allowed to autoregulate. No further issues during
hospitalization. She was restarted on her home-meds gradually.
RESP
CXR as outlined under results, no PNA. No respiratory issues
during admission.
GI/ABD/UG
An abdominal scan was done for a high lactate and fever,
revealing no soource of infection but a it did reveal
right-sided hydronephrosis and right- sided [**Month/Day (2) 96980**] obstruction.
There also was extensive diverticulosis without evidence of
diverticulitis, multiple hepatic cysts, bilateral renal cysts
that had increased in number and hypodensities in the pancreas
that were anticipated. Urology was [**Month/Day (2) 653**] for the
hydronephrosis and [**Name (NI) 96980**] stenosis, and after reviewing the images
they said it was OK to follow it over time as long as she was
asymptomatic .
ID
High grade fever on admission, empirically treated with broad
spectrum ABx. D/C'd on day 3. No growth all cultures (urine,
blood), CXR negative).
ENT
She complained of a fullness of her L ear on day 3, on the
floor, and of earpain bilaterally on day 4, both self-resolved
with negative bedside otoscopy.
HEME/ONC The PCP was [**Name (NI) 653**] regarding the issues above, and
in his notes it is outlined that no further workup for her
pancreatic lesion was to be done. He is aware of the
hydrouretero-nephrosis. Also, Coumadin should be considered
given her atrial fibrillation.
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaled every 12 hours as
needed for shortness of breath
ATORVASTATIN - 10 mg Tablet - 1 once a day
CLONAZEPAM - 0.5 mg Tablet - [**12-6**] Tablet(s) by mouth twice a day
ESCITALOPRAM [LEXAPRO] - 10 mg Tablet - 1 Tablet(s) by mouth
once
a day
ISOSORBIDE MONONITRATE - 120 mg Tablet Sustained Release 24 hr -
1 Tablet(s) by mouth 1
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth four times a
day
as needed
METOPROLOL TARTRATE [LOPRESSOR] - 50 mg Tablet - [**12-8**] Tablet(s)
by
mouth twice a day
NITROGLYCERIN - 0.3MG Tablet, Sublingual - USE AS DIRECTED
RISEDRONATE [ACTONEL] - 35 mg Tablet - 1 Tablet(s) by mouth a
week
Medications - OTC
ASPIRIN [ASPIRIN EC] - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet, Delayed Release (E.C.)(s) by mouth once a day
CALCIUM - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth three times a day
OMEPRAZOLE - 20 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s)
by mouth once a day
ALL: Penicillins / Codeine / Sulfonamides / Aspirin / Valium /
Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril
/ Egg / Oxycontin
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every twelve (12) hours as needed for shortness of
breath or wheezing.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonazepam 0.5 mg Tablet Sig: half Tablet PO twice a day as
needed for anxiety.
5. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Nitroglycerin Oral
8. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Possible stroke
Discharge Condition:
Improved. No pronator drift, perhaps only mild 'cupping' of the
R hand but no paresis. Neurological exam has returned to
pre-admission baseline, no focal findings.
Discharge Instructions:
You have been admitted with an altered mental status and fever,
and there were signficant concerns for stroke. You have received
iv tPA, a strong medication that resolves clot. You have
recovered well with antibiotics as well.
You have also been started on Plavix. Please take all your
medications excactly as directed and please attend all your
follow-up appointments.
Please report to the nearest ER or call 911 or your PCP
immediately when you experience recurrence of weakness,
numbness, tingling, problems with speech, language, walking,
thinking, headache, or difficulties arousing, or any other signs
or symptoms of concern.
Followup Instructions:
1 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33176**], M.D. Phone:[**Telephone/Fax (1) 96976**]
Date/Time:[**2153-5-2**] 10:30
2 Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC Date/Time:[**2153-5-15**] 10:20
3 NEUROLOGY - Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2153-6-11**] 1:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2153-4-24**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6609
} | Medical Text: Admission Date: [**2144-9-10**] Discharge Date: [**2144-9-30**]
Date of Birth: [**2144-9-10**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Patient is a 34 and 6/7ths week
gestational age, 2475 gram male admitted from the Newborn
Nursery for respiratory distress at approximately four hours
of life.
G6, P2 now 3 mother. She is status post spontaneous abortion
times two, intrauterine fetal demise times one at 33 weeks
and also has two full term children.
MATERNAL PRENATAL SCREENS: O positive, antibody negative.
RPR nonreactive. Hepatitis surface antigen negative. GDS
unknown. Estimated date of consignment is [**2144-10-16**].
By report this has been an unremarkable pregnancy until the
mother experienced premature rupture of membranes at 8
o'clock the day prior to delivery. There was no fever.
There was no antibiotics until a dose of Clindamycin given at
the time of Cesarean section. The Cesarean section was
performed due to a history of previous Cesarean section.
DELIVERY HISTORY: Patient emerged vigorous. Apgar's were
[**8-10**]. He looked well and was transferred to the Newborn
Nursery. In the Newborn Nursery, the patient was noted to be
persistently grunting, flaring and retracting. He was
transferred to the NICU for further evaluation and
management.
PHYSICAL EXAMINATION: On admission birth weight is 2475
grams at 50th percentile. Length is 45.5 cm, 50th
percentile. Head circumference is 32 cm, 75th percentile.
The patient is an AGA male in moderate respiratory distress.
He has grunting, flaring and retraction. Respiratory rates
are in the 80s to 100s. Room air saturations are 90 to 92%.
Heart rate is 140s to 150s. The blood pressure ranged in the
mid 30s. His rectal temperature was 98.5 F.
Anterior fontanelle was soft, open and flat. He had
non-dysmorphic faces. The lungs were inconsistently well
aerated as there were intercostal and subcostal retractions.
Cardiovascular exam revealed regular rate, no murmurs.
Normal pulses. The abdomen had active bowel sounds and was
soft without masses. The GU exam was normal. Hips are
stable. The tone was somewhat decreased, but otherwise a
normal neurologic exam.
LABORATORY: Blood glucose on admission was 80. CBC and
blood culture was sent.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Patient's initial respiratory distress
actually resolved within several hours and he only briefly
required nasal cannula supplemental O2. By day of life #4,
he had weaned entirely to room air and has remained there.
2. CARDIOVASCULAR: Patient had normal cardiovascular exam
on admission and throughout his hospitalization. He did
develop apnea and bradycardia of premature at approximately
day of life #6. He had intermittent spells, but never
required caffeine. His last spell was on [**9-25**]. He
has no had no spells for over five days.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The patient's
briefly required intravenous fluids, but these were quickly
weaned as patient advanced on enteral feeds. He initially
required gavage feeding, but by approximately two weeks of
age, was taking full p.o. feeds and has continued to do so
with adequate weight gain. As mentioned his birth weight was
2475 and his discharged weight is 2695 grams.
4. GI: Patient tolerated enteral feeds without difficulty.
5. HEMATOLOGY: Patient's CBC on admission was as follows
with a white blood cell count of 14.3, 68 polys, 2 bands.
His hematocrit was 47 and platelet count was 285,000. He was
started on iron when he obtained full p.o. feeds. Also
from a hematological standpoint, the patient developed
physiological hyperbilirubinemia for which he received
further therapy for day of life #4 to 6. His peak bilirubin
was 14.
6. INFECTIOUS DISEASE: Patient, given his respiratory
distress, as initially started on ampicillin and gentamicin,
however given his benign CBC, quick resolution of his
respiratory distress and the fact that blood cultures
remained sterile after 48 hours, the antibiotics were
discontinued after 48 hours.
7. GU: Patient had a circumcision performed on [**2144-9-24**].
8. SENSORY: Audiology hearing screening was performed
through automated auditory brainstem responses and the
patient passed in both ears.
9. PSYCHOSOCIAL: A social worker was involved with the
family. The contact social worker can be reached at
[**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45058**] at [**Hospital **]
Pediatrics, [**Telephone/Fax (1) 45059**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge: Enfamil 20 and breast milk p.o. ad
lib.
2. Medications: Fer-In-[**Male First Name (un) **] 0.2 cc p.o. q.d.
3. Car seat position screening: Passed.
4. State newborn screening: Two week test sent and is
pending.
5. Immunizations: Hepatitis B vaccine given on [**2144-9-11**].
6. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
who meet any of the following criteria: 1) Born at less than
32 weeks; 2) born at 32 and 35 weeks with plans for DayCare
during RSV season with a smoker in the household or with
preschool siblings; and 3) with chronic lung disease. Baby
boy [**Known lastname 28708**] did receive Synagis on [**2144-9-25**].
FOLLOW UP APPOINTMENTS: Patient is to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45058**]
at the end of this week.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Transient tachypnea of a newborn.
3. Rule out sepsis.
4. Apnea and bradycardia of prematurity.
5. Status post circumcision.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 44694**]
MEDQUIST36
D: [**2144-9-30**] 11:07
T: [**2144-9-30**] 11:21
JOB#: [**Job Number 45060**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6610
} | Medical Text: Admission Date: [**2197-1-13**] Discharge Date: [**2197-2-3**]
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest discomfort and fatigue
Major Surgical or Invasive Procedure:
Aortic valve replacement (27mm [**Company 1543**] Mosaic),coronary artery
bypass x3(Lima-LAD,SVG-ramus, SVG-OM) and ligation of left
atrial appendage [**2197-1-17**]
History of Present Illness:
Mr. [**Known lastname 84178**] is an 86 year old man who has been experiencing
increasing episodes of chest discomfort and fatigue over the
past month. A recent echocardiogram revealed an EF of 45% with
modest aortic stenosis ([**Location (un) 109**] 1.2) and moderate
aortic regurgitation and 2+ mitral regurgitation and modest
tricuspid regurgitation. A subsequent cath revealed 90% LM and
RCA, LCX, and Ramus lesions. He is admitted for surgical
revasularization and aortic valve replacement.
Past Medical History:
Past Medical History: PAF, HTN, Meniere's, Aortic stenosis,
Aortic insufficiency, non-STEMI
[**12-14**], TIA (two episodes ten years ago), AFib
Social History:
Race:caucasian
Last Dental Exam:2 yrs ago
Lives with:alone
Occupation:retired
Tobacco:never
ETOH:never
Family History:
non contributory
Physical Exam:
Pulse: 77 Resp: 18 O2 sat: 100% RA
B/P 137/71
Height: 5'[**97**]" Weight:150 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur IV/Vi SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
superficial veins b/l None []
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right: Left: transmitted murmur
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84179**] (Complete)
Done [**2197-1-17**] at 1:08:20 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2110-1-20**]
Age (years): 86 M Hgt (in): 70
BP (mm Hg): 110/70 Wgt (lb): 150
HR (bpm): 50 BSA (m2): 1.85 m2
Indication: Coronary artery disease, aortic valve disease
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2197-1-17**] at 13:08 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - LVOT diam: 2.3 cm
Aortic Valve - Valve Area: *1.1 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Dilated LA. Moderate to severe spontaneous echo
contrast in the LAA. Depressed LAA emptying velocity (<0.2m/s)
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Focal calcifications in aortic arch. Simple atheroma
in descending aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
Moderate AS (area 1.0-1.2cm2) Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The rhythm appears to be atrial fibrillation.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
The left atrium is dilated. Moderate to severe spontaneous echo
contrast is present in the left atrial appendage. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
atrial septal defect is seen by 2D or color Doppler.
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are moderately thickened. There is
moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild
(1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on Mr.[**Known lastname 84178**]
before surgical incision.
Post_Bypass:
Normal RV systolic function.
LVEF 40%.
Intact thoracic aorta.
The bioprosthetic aortic valve is stable and functioning well.
NO periprosthetic leaks. Residual mean gradient is 4mm of Hg.
I certify that I was present for this procedure in compliance
with HCFA regulations.
.
Brief Hospital Course:
Mr. [**Known lastname 84178**] was admitted and taken tot he operating room for the
following:(see operative note for details)
1. Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic
ULTRA Bioprosthesis.
2. Coronary bypass grafting x3 with the left internal
mammary artery, left anterior descending coronary;
reversed after sustaining a single graft from the aorta
to ramus intermedius coronary artery; as well as reverse
saphenous vein single-graft from the aorta to the first
obtuse marginal coronary artery.
3. Resection of left atrial appendage.
4. Endoscopic left greater saphenous vein harvesting.
Post operatively he remained intubated and was admitted to the
CVICU for invasive hemodynamic monitoring and care. He awoke
neurologically intact and was weaned from the ventilator and
extubated without difficulty. Mr. [**Known lastname 84180**] chest tubes and
temporary pacing wires were removed per protocol. He was started
on betablockers, statins and diuresed toward his pre-operative
weight however he continues to have 2+ LE edema bilateral which
is being treated with IV lasix and zaroxyln. He remains in rate
controlled atrial fibrillation. Mr. [**Known lastname 84178**] was anticoagulated
with coumadin. He was evaluated and treated by physical therapy
for strength and conditioning. He was noted to have endo-vein
harvest site cellulitus on POD 8 and was placed on Vancomycin.
Leukocytosis was persistent, and ID was consulted and agreed
with vancomycin treatment. He developed loose stools and his
laxatives were tapered and C-diff toxin would return negative
twice. Cellulitis did improve on vancomycin.
Rehab was recommmended upon discharge. Mr. [**Known lastname 84178**] was
discharged to rehab on POD #17 after being cleared for discharge
by Dr. [**Last Name (STitle) 914**].
Medications on Admission:
ASA 81mg daily, plavix 75mg daily, lopressor 50mg [**Hospital1 **], zocor
20mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain. Tablet(s)
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take as directed for INR Goal 2-2.5
for afib.
13. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours): last dose pm on [**2197-2-9**].
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day:
while on lasix
check potassium daily.
17. Metolazone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): continue diuresis until lower extremity.
18. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
[**Hospital1 **] (2 times a day): until lower extremity edema resolves.
19. picc
picc line care and flushes per facility protocol
20. Outpatient Lab Work
check INR daily until stablizes and follow bun/creat and lytes
daily while on lasix and vanco
Discharge Disposition:
Extended Care
Facility:
[**Last Name (NamePattern1) **]Nursing Facility
Discharge Diagnosis:
post operative left lower extremity cellulitis from saphenous
vein graft site
Aortic stenosis
coronary artery disease
s/p aortic valve replacement, coronary artery bypass grafts and
ligation of left atrial appendage [**2197-1-17**]
Meniere's disease
hypertension
hyperlipidemia
paroxysmal atrial fibrillation
cerebrovascular disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol and ultram prn
Discharge Instructions:
Discharge Instructions: Please shower daily including washing
incisions gently with mild soap, no baths or swimming, and look
at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
When to Call Your Surgeon
Call your surgeon ([**Telephone/Fax (1) 1504**] (24 hours a day, seven days a
week) if any of the following occur:
* Your incision is warm, red or swollen or there is increased
tenderness or pain
* Any of your incisions have ANY fluid or drainage coming out
* You have a fever of 100.5 degrees Fahrenheit or higher
* Your weight has gone up more than two pounds in one day or
five pounds in a week
* You have severe pain or increased swelling in either leg
* You have palpitations
* You feel dizzy or weak (if severe, call 911)
* You notice any of the following, especially if you are on
warfarin (Coumadin)
o A lot of dark, large bruises
o Black or dark bowel movements
o Pain, discomfort or swelling in any area, especially after an
injury
o Severe or unusual headache (if symptoms are severe, please
call 911)
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) [**2197-2-28**] at 1pm
Dr. [**First Name11 (Name Pattern1) 2174**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 656**] (primary care) [**2-21**] at 130 pm
plaese call and schedule the following appointments:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] (cardiologist) in 2 weeks
Completed by:[**2197-2-3**]
ICD9 Codes: 4280, 4241, 4168, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6611
} | Medical Text: Admission Date: [**2172-1-31**] Discharge Date: [**2172-2-2**]
Date of Birth: [**2099-2-10**] Sex: M
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History obatined from NH notes, [**Name8 (MD) **] MD, and Patient. Patient is
poor historian.
The pt. is a 72 year-old male with PMH of SCC of the tongue s/p
XRT, and NSCLC of s/p RML and LUL resection, COPD on chronic O2
(2L NS), and current smoker, p/w 3 days of increased SOB with
productive cough from his NH (Bengamin Center [**Telephone/Fax (1) 110311**]). Has
been treated with nebs and levo for presumptive PNA over the
past 13 days. + Fevers at home, no shaking chills, no CP, N/V.
Is NPO [**2-20**] neck SCC but is able to swallow sercretion. No
odynophagia or dysphagia. Per NH records, patient was noted to
be 88% on usual 2l NC. On EMS arrival, 100% on NRB, tachypnic
26-28.
Per NH sheets, has refused pneumovax in the past.
He was admitted to the medical intensive care unit. In the MICU,
the patient was started on vanco/zosyn for presumed PNA. Was
maintained on oxygen mask with sating in the low 90's.
Past Medical History:
COPD on home O2 (2L)
Dementia
Squamous cell of the tongue s/p XRT
CHF with EF 20% 2/2 EtOH CM
PUD
NSCLC s/p RML,LUL resection; status post video
assisted left upper lobectomy in [**2159**] and laser ablation,
plus radiotherapy in '[**63**].
Peptic ulcer disease
Status post appendectomy.
History of alcohol (now sober per patient)
+++ tobacco use; 1-2ppd, currently [**Date range (1) 61126**] PPD
Social History:
Homeless, was transferred here from the [**Hospital **] Health Care
facility. He has a 40 pack/year history of smoking and continues
to smoke. He no longer uses alcohol. The patient was seen [**8-18**] status post a successful PEG placement with no
complications.
Family History:
Non-Contributory
Physical Exam:
Vitals: T:96 P:107 R:21 BP:116/76 SaO2:95
General: awake, nodding to questions
HEENT: PERRLA, EOMI without nystagmus, no scleral icterus noted,
mucous membranes very dry
Neck: no JVP or carotid bruits appreciated. XRT skin
hyperpigmentation. No tracheal deviation noted. no palpable
masses appreciated.
Pulmonary: Poor air movment throughout; prolonged exp phase with
end exp wheeze. + upper airway sounds
Cardiac: Tachy, regular, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. PEG site is c/d/i
Extremities: + clubbing; Atrophic limbs. DP and PT pulses b/l.
Pertinent Results:
EKG: ST 136, nl axis and intervals, PRWP, LAE, LVH by >35mm in
precordial leads. STD in V5/V6. c/w [**5-/2166**], PRWP is new and LVH is
more pronounced.
Radiologic Data: left shirt of mediastinum with tracheal
deviation. (unchanged from prior CXR), RUL and lLL new airspace
disease. Small left pleura effusions. on PTX.
Cultures:
[**2172-1-31**] Blood - pending
[**2172-1-31**] Urine - pending
Brief Hospital Course:
The patient was a 72 yo male with severe COPD, RML, LUL wedge
resection,and neck XRT presented with a 2 history of increased
SOB and cough. He had been on ceftriaxone from [**Date range (1) 90581**] and then
levofloxicin for 10 more days. The patient was at risk for
resistent organisms and also the risk of aspiration was great
and given neck XRT, impaired ciliary clearnance increases risk
of pseudomonas. On admission the patients ABG is remarkable for
PaCO2 of 90, but with a pH of 7.39; for chronic resp, acidosis,
expect his bicarb to be 39; thus he had a met alk as well.
Patient does not give any history of nausea/emesis(as one might
expect in Theoph toxicity). The patient had clearly documented
DNR/DNI status at the nursing home and his signed forms were
faxed over. The patient was initally admitted to the medical
intensive care unit. He was started on vanco and zosyn for
broad coverage and started on methylprednisolone q8 for
management of his COPD flare. It was unclear if there was a
superimposed PNA. The ICU team felt that BiPAP was not
indicated as it could serve only be a bridge to intubation and
intubation was against the patient's wishes. The patient was
maintained on NC and fasemask O2. He was transferred to the
medical floor there was no further intensive interventions. He
continued to be tachypnic and require increasing amounts of
oxygent to maintain O2>88%. He was given morphine for worsening
SOB. Multiple attempts were made to contact family members, but
none could be reached. The nursing home reported that the
patient had not had contact with any family member in over 1
year. The patient expired on [**2172-2-2**] at 4:55PM. Further
attempts were made to contact family members without success.
No autopsy was performed.
Medications on Admission:
TF Jevity Plus
Fluoxetine 20mg po qd
Protonix 40mg po qd
Prednisone 40mg po taper on [**1-19**] and completed this on the 11th;
now on baseline 10mg po qd
Trazodone 75mg po [**First Name9 (NamePattern2) 5910**]
[**Last Name (un) **]-24 300mg po BID
Lasix 40mg po BID
Clonazepam 1mg po bid
Percocet prn
combivent INH 3puffs qid prn
albuterol prn
colace/senna/fleets prn
Levo 500 from [**Date range (1) 35535**]
CTX on [**11-18**]
Allergies: LISINOPRIL WHICH CAUSES ANGIOEDEMA.
Discharge Medications:
Patient Expired on [**2172-2-2**] at 4:55 PM
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Lung cancer
Discharge Condition:
Expired [**2172-2-2**] at 4:55 PM
ICD9 Codes: 4280, 486, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6612
} | Medical Text: Admission Date: [**2171-4-2**] Discharge Date: [**2171-4-16**]
Service: CCU
CHIEF COMPLAINT: Dyspnea, fatigue, diaphoresis.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 104834**] is a 77-year-old male
with a history of hypertension, alcoholism, and tobacco abuse
who presented to the [**Hospital1 69**]
Emergency Department on the afternoon of admission
complaining of dyspnea earlier in the day. He had a feeling
of indigestion accompanied by diaphoresis, chills, and
nausea. He became progressively dyspneic throughout the
afternoon and presented to the Emergency Room.
In the Emergency Department, he was initially treated with
Lasix and antibiotics. Despite these measures he remained
tachypneic and was intubated for distress and worsening
hypoxia. He received 3 liters of fluid in the Emergency
Department over roughly six hours with no urine output. At
the time of intubation, his blood pressure had dropped to a
systolic of 80, and he was started on dopamine.
There was a report of weight loss over the past three months
along with malaise. There was no history of chest pain. No
recent history of gastrointestinal illnesses.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Depression.
3. Alcoholism.
4. Tobacco use of one pack per day times 50 years.
5. Gout.
6. Peripheral vascular disease.
7. Non-insulin-dependent diabetes mellitus.
8. Chronic obstructive pulmonary disease.
MEDICATIONS ON ADMISSION:
1. Micardis 20 mg p.o. q.d.
2. Lasix 20 mg p.o. q.d.
3. Effexor.
SOCIAL HISTORY: The patient is married and retired.
FAMILY HISTORY: Non-insulin-dependent diabetes in multiple
family members.
PHYSICAL EXAMINATION ON PRESENTATION: Admission physical
examination with vital signs which revealed a temperature
of 99.7, heart rate of 115, blood pressure of 96/41,
ventilator setting of FVC of 500 X 14, FIO2 of 50%, positive
end-expiratory pressure of 5. In general, intubated but
alert. Answered questions. Head, eyes, ears, nose, and
throat revealed pupils were equal, round, and reactive to
light. Extraocular movements were intact. Neck revealed
elevated jugular venous pressure. No bruits. Lungs revealed
rhonchorous breath sounds throughout. Scattered bibasilar
end-expiratory crackles. Abdomen was soft, nontender, and
nondistended. Normal active bowel sounds. Extremities were
thin, hairless, good pulses, no edema, cool. Skin revealed
no rash. Neurologically, moved all extremities.
PERTINENT LABORATORY DATA ON PRESENTATION: Admission
laboratories with a white blood cell count of 15.1
(85% neutrophils and no bands), hematocrit of 33.7, platelets
of 309, mean cell volume of 111. SMA-7 revealed a sodium
of 145, potassium of 5, chloride of 108, bicarbonate of 26,
blood urea nitrogen of 20, creatinine of 1.6, and glucose
of 259. Calcium of 8.5, phosphorous of 7.5, magnesium
of 2.1. Creatine kinase of 43, troponin of 2. Arterial
blood gas status post intubation was 7.23/56/238 on 50% FIO2
and 5 of positive end-expiratory pressure. Hepatic enzymes
revealed ALT of 17, AST of 42, alkaline phosphatase of 161,
total bilirubin of 0.4, amylase of 113.
RADIOLOGY/IMAGING: Chest x-ray revealed small right pleural
effusion, diffuse interstitial alveolar infiltrates
bilaterally (left greater than right); new compared to
[**2171-3-19**].
Electrocardiogram revealed sinus tachycardia with a rate into
the 120s, normal intervals, normal axis, Q waves in V2 and
V3, poor R wave progression, ST elevations in V2 to V4 noted
along with 1.5-mm ST depressions in V5 to V6. These changes
were new compared to [**2167-12-25**] electrocardiogram.
HOSPITAL COURSE: The patient was originally admitted to the
Medical Intensive Care Unit for management of respiratory
distress thought to be secondary to pneumonia.
Over the course of the first 24 hours the patient started
ruling in for a myocardial infarction, and he was emergently
transferred to the [**Hospital Ward Name 517**] to undergo cardiac
catheterization.
The patient did undergo cardiac catheterization which
revealed the following vascular abnormalities: The left main
was calcified but okay, the left anterior descending artery
had a 99% focal clot in the proximal region, and the left
circumflex had a 95% large second obtuse marginal and a 70%
distal circumflex lesion in the AV groove. The right
coronary artery had a 90% middle and a diffusely diseased
posterior descending artery. Stents were placed to the left
anterior descending artery and large second obtuse marginal.
The patient had elevations of his pulmonary capillary wedge
pressure, and pulmonary artery pressure, along with
borderline hypotension on high-dose Levophed; so an
intra-aortic balloon pump was placed. The patient was then
transferred to the Coronary Care Unit for further care.
At the time of presentation, the patient had also been anuric
for the first 24 hours of his admission.
Over the next 72 hours, the patient continued to have
progressive oliguria becoming increasingly refractory to
diuretics. His creatinine was rising, and he became fluid
overloaded. Though we were able to wean pressors and
intra-aortic balloon pump was off for cardiac support, the
fluid overload secondary to his worsening renal failure was
refractory to medical therapy.
Hemodialysis was initiated on [**2171-4-9**]. Prior to
hemodialysis, the patient had multiple weaning trials which
he had failed felt secondary to fluid overload in his lungs.
Despite several rounds of hemodialysis, which the patient
tolerated well, his weaning mechanics were still noted to be
quite poor. After 16 days of intubation, the goals of the
patient's care were revised and advance support was
withdrawn. The patient was extubated on [**2171-4-15**] after
getting his fourth round of dialysis; and over the next 18
hours, he was made comfortable as his cardiopulmonary
parameters decompensated.
The patient was pronounced dead at 6:20 a.m. on the morning
of [**2171-4-16**].
DIAGNOSIS AT DEATH:
1. Intraseptal myocardial infarction leading to cardiogenic
shock with subsequent multiorgan failure.
2. Inability to wean off ventilator despite successful
diuresis.
NOTE: The patient was notified of the patient's death, and
voluntary postmortem examination was refused, and funeral
home was to make arrangements.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2171-4-16**] 06:52
T: [**2171-4-16**] 13:10
JOB#: [**Job Number **]
ICD9 Codes: 5849, 486, 5990, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6613
} | Medical Text: Admission Date: [**2201-3-27**] Discharge Date: [**2201-4-1**]
Date of Birth: [**2137-3-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Byetta
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
64 yoM with known CAD complained of progressive angina, referred
for cardiac catheterization
Major Surgical or Invasive Procedure:
CABG [**3-28**]
Cardiac catheterization [**3-27**]
History of Present Illness:
64yo man with history of HTN,^chol,DM, and known CAD s/p PCI of
Cx(87) and RCA(99) free of angina after PCI know with recurrent
angina at rest and with minimal exertion for last several weeks.
EF by echo 60%
Past Medical History:
CAD s/p PCI(Cx and RCA), HTN, ^chol, DM2, BPH, Colon CA s/p
colonoscopy and chemo, Tonsillectomy, Depression
Social History:
Divorced, lives with friend. Owns [**Name2 (NI) 27234**] shop.
Occaisional ETOH, denies tobacco use
Family History:
non contributory
Physical Exam:
Admission:
VS T 98 HR 66 BP 113/60 RR 14 O2sat
Ht 5'7" Wt 165 lbs
Gen NAd
Neuro A&Ox3, nonfocal exam
Chest CTA-bilat, well healed Porta-cath site Rt chest wall
CV RRR no M/R/G
Abdm soft, NT/ND/NABS
Ext warm, well perfused. No edema. No varicosities
Discharge
Pertinent Results:
[**2201-3-27**] 11:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.000*
[**2201-3-27**] 09:00AM GLUCOSE-137* UREA N-21* CREAT-0.9 SODIUM-136
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-11
[**2201-3-27**] 09:00AM ALT(SGPT)-22 AST(SGOT)-20 CK(CPK)-172 ALK
PHOS-67 AMYLASE-72 TOT BILI-1.9* DIR BILI-0.3 INDIR BIL-1.6
[**2201-3-27**] 09:00AM ALBUMIN-4.1 CALCIUM-9.1 CHOLEST-139
[**2201-3-27**] 09:00AM %HbA1c-7.4* [Hgb]-DONE [A1c]-DONE
[**2201-3-27**] 09:00AM WBC-7.3 RBC-4.08* HGB-12.3*# HCT-34.5* MCV-85
MCH-30.1 MCHC-35.6* RDW-14.8
[**2201-3-27**] 09:00AM PT-11.5 PTT-26.4 INR(PT)-1.0
C.CATH Study Date of [**2201-3-27**]: 1. Selective coronary
angiography of this right dominant system demonstrated a three
vessel CAD. The LAD and LCx had a common ostium. The LAD had a
long proximal ulcerated lesion up to 90%. The LCx had a 70%
proximal stenosis and diffuse disease elsewhere. The RCA had a
70% ostial stenosis; previously placed stent was patent. 2.
Resting hemodynamics revealed a slightly elevated left sided
filling pressure with an LVEDP of 15 mm Hg. 3. Left
ventriclulography revealed no mitral regurgitation. The LVEF
was preserved and was calculated to be 60% with a normal wall
motion.
CXR [**2201-3-30**]: S/P CABG. Heart size is within normal limits.
There are small bilateral pleural effusions, left greater than
right, with linear atelectases in the left lower lobe. No
pneumothorax.
ECHO Study Date of [**2201-3-28**]: PRE-BYPASS: The left atrium is
normal in size. No spontaneous echo contrast or thrombus is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. The
right ventricular cavity is mildly dilated. Right ventricular
systolic function is normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3)appear
structurally normal with good leaflet excursion and no aortic
regurgitation. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Torn mitral chordae are present. Mild (1+)mitral
regurgitation is seen. There is no pericardial effusion. POST
CPB: Preserved biventricular systolic function. No change in
valve structuer or function.
Brief Hospital Course:
Pt with progressive angina referred for cardiac catheterization
which revealed native 3 vessel disease. Following
catheterization patient was referred to CT surgery for
consideration for CABG. Pt accepted for CABG and on [**3-28**] pt was
brought to operating room where he had CABGx4. Please see OR
report for details, in summary pt had LIMA-LAD, SVG-Diag,
SVG-OM, SVG-RCA. His bypass time was 120 minutes with X-clamp
time of 102 min. He did well in the immediate post-op period and
was extubated on the day of surgery. On POD1 he was transferred
to the step down floor. The remainder of his postop course was
uneventful. On POD2 his chest tubes were removed and physical
therapy was started. On POD3 his temporary pacing wires were
removed. PT continued to work with the patient until on POD4, he
was discharged home with VNA.
Medications on Admission:
ASA 81', Toprol XL 50", Lipitor 40', Altace 10', Lantus 17 QHS,
MVI, Coenzyme Q10
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q 3-4 hrs as
needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Insulin Glargine 100 unit/mL Solution Sig: Seventeen (17)
units Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x5 days then 400mg QD x 7 days then 200mg QD.
Disp:*70 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 2 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
CAD s/p CABGx4(LIMA-LAD, SVG-Diag, SVG-OM, SVG-RCA)[**3-28**]
PMH: CAD, Depression, HTN, ^chol, DM2, BPH, Colaon CA s/p
colectomy/chemo, tonsillectomy
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
[**Hospital 409**] clinic inn 2 weeks
Dr [**Last Name (STitle) **] in [**3-21**] weeks
Dr [**Last Name (STitle) 914**] in 4 weeks
Follow up with urologist
Completed by:[**2201-4-1**]
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6614
} | Medical Text: Admission Date: [**2166-4-28**] Discharge Date: [**2166-5-6**]
Date of Birth: [**2114-7-26**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worse headache
Major Surgical or Invasive Procedure:
[**2166-4-28**]: Diagnositic cerebral angiogram
History of Present Illness:
Mr. [**Known lastname 12967**] is a 51 y.o. RH male who presents to E.D. with
sudden onset of headache last Wednesday. He states that he was
using the bathroom and went to bed and felt sudden onset
headache. He tried Tylenol and ibuprofen without relief.
reports
pain in neck going up toward scalp initially and now has
progressed to global sharp headaches. He went to his PCP office
and was seen by [**Name8 (MD) **] NP who sent her to ED for evaluation.
Past Medical History:
PMHx: none
All: NKDA
Medications: None
Social History:
SOCIAL HISTORY: He is a nonsmoker. He does not drink alcohol
or
use illicit drugs. He lives with his wife and their one child
plus two [**Doctor Last Name **] children now. He denies having any criminal
record. He works with hazardous chemical and using respiratory
mask daily.
Family History:
Negative
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 1 GCS 15
O: AF bp 150/98, HR 98 RR 16 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: head: atraumatic, normocephalic, eyes clear, no
papilledema
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-1**] 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, 5to2
mm bilaterally. Visual fields are full to confrontation. no
papilledema
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
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.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-3**] throughout. No pronator drift
Upon discharge:
AOx3, PERRL, EOM intact, MAE [**5-3**], nonfocal exam
Pertinent Results:
CT/CTA Head and neck [**2166-4-28**]:
1. Normal intracranial vasculature without aneurysm.
2. Hyperdense lesion in the interpeduncular cistern extending
into the
prepontine cistern encases the distal basilar artery and may
represent
leptomeningeal disease such as lymphoma, primitive
neuroectodermal tumor,
metastatic disease or sarcoid. Followup MRI with and without
contrast is
recommended for further characterization.
3. Severe stenosis at the origin of the right vertebral artery.
4. Non-calcified atheroma of the left carotid bulb with 40%
stenosis.
Cerebral angiogram [**2166-4-28**]:
FINDINGS:
1. Right internal carotid artery fills well along the cervical,
petrous,
cavernous and supraclinoid portions with brisk filling of the
anterior and
middle cerebral artery and normal distal runoff. There is no
evidence of
stenosis, occlusion, aneurysm or arteriovenous malformation.
2. Right external carotid artery and its branches are well
outlined. There
is no evidence of an arteriovenous malformation.
3. Right vertebral artery angiogram shows brisk filling of the
right
vertebral artery with reflux of contrast into the left vertebral
artery. The basilar artery is well outlined and appears normal
in caliber. There is no evidence of stenosis, occlusion,
aneurysm or arteriovenous malformation in the posterior
circulation. Dedicated angiographic images of the right and left
vertebral angiograms for evaluation of intraspinal vessels in
the cervical spine showed no evidence of a spinal arteriovenous
fistula or vascular malformation. The anterior spinal artery was
well outlined and appeared normal in caliber.
4. The right subclavian artery and its branches are well
outlined. There is no evidence of an arteriovenous malformation.
5. Left subclavian artery and its branches are well outlined.
There is no
evidence of an arteriovenous malformation.
6. The left vertebral artery angiogram also shows brisk filling
of the left vertebral artery with no evidence of stenosis,
occlusion, aneurysm or
arteriovenous malformation. Basilar artery is well outlined and
appears
normal. There is no evidence of any abnormal arteriovenous
communication in the cervical spinal canal arising from the left
vertebral artery.
7. Left internal carotid artery fills well along the cervical,
petrous,
cavernous and supraclinoid portions with brisk filling of the
anterior and
middle cerebral artery and normal distal runoff. There is no
evidence of
stenosis, occlusion, aneurysm or arteriovenous malformation.
8. Left external carotid artery and its branches are well
outlined. There is no evidence of an arteriovenous malformation.
9. Right common femoral artery angiogram shows normal caliber of
the right
common femoral artery with good flow of contrast distal to the
sheath.
IMPRESSION: Mr. [**Known firstname 34077**] [**Known lastname 12967**] underwent diagnostic cerebral
angiography
which was unremarkable. There is no aneurysm or vascular
malformation in the intracranial circulation or in the cervical
spinal canal as described above.
MRI Brain [**2166-5-5**]:
IMPRESSION:
1. Small T1 and T2 hyperintense extra-axial lesion in the left
side of the
interpeduncular cistern. This has decreased in size since the
prior study and likely represents an evolving hematoma. Non
contrast CT head is advised to see for interval change. MRI head
is advised after few weeks to confirm resolution.
2. Hypoenhancing lesion in the inferior aspect of the pituitary
gland. This likely represents a pituitary adenoma. Dedicated
pituitary imaging and correlation with laboratory values is
advised.
Head CT [**2166-5-6**]:
IMPRESSION:
1. Resolved focus of subarachnoid hemorrhage in the
interpeduncular cistern from prior CT of [**2166-4-28**]. No new
intracranial hemorrhage.
2. Sinus disease as detailed above.
Brief Hospital Course:
Mr. [**Known lastname 12967**] was admitted to the neurosurgery service for
intracranial hemorrhage. He underwent a Cerebral angiogram
which was negative for an aneurysm. He remained in the ICU
overnight for continued neurochecks and SBP control. His
neurologic exam remained stable. His groin had no hematoma and
he had good distal pulses. He was transferred to the SDU on [**4-29**]
in stable condition. His SBP goals were liberalized to less than
160 and he was kept on nimodipine 60mg q4 hours. On [**4-30**], he
reported headache which was treated adequately with pain
medication. He was transferred to the floor and awaiting repeat
angiogram. From [**5-1**] to [**5-5**], there were no changes to his exam.
He was being prepped for his repeat Angiogram and prior imaging
was being reviewed. Dr. [**First Name (STitle) **] thought this brain lesion could
be a tumor and MRI was doen on [**2166-5-5**].
The MRI showed interval improvement in the hypodense lesion
which correlates with a bleed vs. mass. There was also question
of a pituitary macroadenoma, although a incidental finding, labs
were sent for baseline measurement.
A repeat head CT on [**5-6**] showed resolution of the bleed and he
was discharged home.
Medications on Admission:
None
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for HA.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for HA.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Perimesencephalic SAH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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, you may
safely resume taking this when cleared by Neurosurgery.
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a MRI/MRA brain.
Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Completed by:[**2166-5-6**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6615
} | Medical Text: Admission Date: [**2201-4-20**] Discharge Date: [**2201-5-21**]
Date of Birth: [**2201-4-20**] Sex: M
Service: NB
ADDENDUM: Discharge interim summary date of [**2201-5-19**].
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 61655**] is a 2150-gram
product of a 33 and [**5-26**] week gestation born to a 34-year-old
gravida 3/para 2 (now 3) mother. Maternal history is notable
for celiac disease. Prenatal screens with blood type A
negative, antibody screen negative, hepatitis B surface
antigen negative, RPR nonreactive, GBS negative. She
developed preterm labor at 32 and 5/7 weeks and completed a
course with betamethasone. The infant was delivered by
spontaneous vaginal delivery. There was meconium at delivery.
The infant emerged vigorous with a good cry. Apgar's were 9
and 9. He was admitted to the NICU for prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Anterior fontanel open
and flat. Palate and clavicles intact. Clear breath sounds
with good aeration. A regular rate and rhythm. No murmur.
Good femoral pulses. The abdomen was soft. No
hepatosplenomegaly. He was pink and well perfused. He was a
normal male with a patent anus. A small sacral dimple at the
base visualized, and he moved all extremities well.
HOSPITAL COURSE BY SYSTEM THROUGHOUT THIS INTERIM SUMMARY:
1. RESPIRATORY: He was on room air throughout his entire
stay. He began having apneic and bradycardic spells all
around feeding which resolved with mild-to-moderate
stimulation. At the time of this dictation he is currently
on day 3 of 5 of a spell countdown prior to his being able
to be discharged home.
1. CARDIOVASCULAR: He has been cardiovascularly stable
throughout his stay with no murmurs. His blood pressures
have been normal, and he has had normal perfusion.
1. FLUIDS, ELECTROLYTES, AND NUTRITION: He was initially on
IV fluids for the first 24 hours of his life with normal
electrolytes, urine output, and glucoses. Enteral feedings
were initiated on day of life 2 and slowly advanced. By
day of life 4, he was breast feeding and taking at least a
minimum of 80 cc/kg per day. His most recent weight is
2950 grams. He is on vitamins and iron.
1. GI: He had a bilirubin on day of life 4 that was 4.3. He
was never on phototherapy.
1. HEMATOLOGY: His admission hematocrit was 46%, white blood
cell count was 6.7, and platelets were 327,000 (with 50
polys and no bands).
1. INFECTIOUS DISEASE: He was placed on ampicillin and
gentamicin for 48 hours after his delivery. These were
discontinued when his blood culture was negative at 48
hours.
1. SENSORY: He passed his hearing screening on day of life
18. He did not meet criteria for a screening head
ultrasound or screening for retinopathy of prematurity. He
received his hepatitis B vaccination. He was also
circumcised on day of life 8.
CONDITION ON DISCHARGE: Good.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 38676**], [**First Name3 (LF) **]
[**Hospital **] Pediatrics.
FEEDINGS AT TIME OF INTERIM SUMMARY: Maternal breast milk or
Similac 24 calories ad lib plus breast feeding.
DISCHARGE DIAGNOSES: Prematurity at 33 and 6/7 weeks,
hyperbilirubinemia, physiologic apnea and bradycardia of
prematurity.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2201-5-19**] 16:37:26
T: [**2201-5-19**] 17:43:57
Job#: [**Job Number 61656**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6616
} | Medical Text: Admission Date: [**2115-10-22**] Discharge Date: [**2115-10-24**]
Date of Birth: [**2055-5-29**] Sex: F
Service:
CHIEF COMPLAINT: Malaise, nausea and vomiting.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 34331**] is a 60-year-old
woman with a prior medical history of end stage renal disease
secondary to polycystic kidney disease on hemodialysis with
multiple graft clot and revisions secondary to non compliance
with Coumadin, also with hypertension and chronic obstructive
pulmonary disease, discharged from vascular surgery service
yesterday after having been unable to underlie hemodialysis
secondary to a thrombosed graft. The patient missed several
Coumadin doses prior to the graft thrombosing. Subsequently
she missed hemodialysis. On [**7-8**] she had a thrombectomy and
she was discharged. She went to have hemodialysis on [**7-10**]
but was unable to dialyze again as access was not obtained.
She was readmitted to [**Hospital1 69**]
for thrombectomy which was performed on [**2115-7-10**] and is now
being transferred to medicine for complaint of malaise,
nausea, vomiting, diarrhea. The patient is a poor historian
but he reports 2-3 weeks of intermittent vomiting and nausea
with subsequent decreased po intake, including her
medications. She denies any abdominal pain, fever, chills,
hematemesis, coffee ground or change in symptoms with food.
She complains of diarrhea of loose brown stool, no melena, no
blood or mucus. Stools are not clearly related to eating and
she can have [**5-31**] bowel movements per day which vary in size.
No recent history of travel, no sick contacts at home, no
weight loss. The patient also complains of chronic cough
which has been increased recently. She denies any shortness
of breath, chest pain, changes in sputum color or hemoptysis.
She uses inhalers more than usual but denies any wheezes or
other upper respiratory infection symptoms.
PAST MEDICAL HISTORY: Significant for end stage renal
disease on hemodialysis secondary to polycystic kidney
disease with multiple clotted graft followed by revision.
Hypertension, depression, chronic obstructive pulmonary
disease.
ALLERGIES: Penicillin per patient report.
MEDICATIONS: RenaGel 800 mg tid, Nephrocaps one q d,
Albuterol as needed, Atrovent as needed, Coumadin.
SOCIAL HISTORY: Lives with her husband and daughter. She
has a positive tobacco history which consisted of two packs
per day for 30 years. She quit one year ago, denies any
alcohol use and reports that her family helps her with her
medications.
PHYSICAL EXAMINATION: Temperature 96.4, heart rate 92, blood
pressure 115/50, respiratory rate 16 with an oxygen
saturation of 98% on room air. General appearance, sleeping
but arousable, in no acute distress with occasional
congestive cough. HEENT: Anicteric, pupils are equal,
round, and reactive to light, oropharynx clear. Neck supple
without JVD. Chest, positive mild inspiratory plus
expiratory wheezes with decreased air movement throughout, no
rales. Heart, regular rate and rhythm, no murmurs, rubs or
gallops. Abdomen soft, nontender, nondistended with positive
bowel sounds, no right upper quadrant tenderness to
palpation, no mass. Extremities, no clubbing, cyanosis or
edema, Pneumo boots on. Neuro, alert and oriented times
three, cranial nerves II through XII intact. Strength
extremities not tested secondary to surgery today [**4-26**], left
upper extremity and bilateral lower extremities. Babinski
downgoing.
LABORATORY DATA: WBC 8.8, hematocrit 34.4, platelet count
184,000, PT 13, PTT 27, INR 1.2, sodium 136, potassium 5.2,
chloride 95, CO2 24, BUN 58, creatinine 9.2, glucose 82.
Albumin 3.7, ALT 11, AST 15, alkaline phosphatase 117, total
bilirubin 0.5, amylase 61, lipase 47. EKG on [**7-10**], sinus
tachycardia at 105, no acute ST or T wave changes. C. diff
negative. Radiology data: KUB, nonspecific bowel gas
pattern, no dilated loops. Chest x-ray, hyperinflated lungs,
no evidence of pneumonia or congestive heart failure.
Urinalysis on [**10-6**] cloudy, large blood, positive nitrites and
leukoesterase, 100 protein, PH 9.0, more than 50 RBC and WBC
and many bacteria.
HOSPITAL COURSE: Mrs. [**Known lastname 34331**] is a 60-year-old woman with end
stage renal disease secondary to polycystic kidney disease on
hemodialysis and also with chronic obstructive pulmonary
disease, presenting with a few weeks of intermittent nausea
and vomiting, diarrhea and decreased po intake.
GI: Etiology of nausea and vomiting and diarrhea is unclear;
could be related to renal function as the patient has missed
dialysis sessions during the past weeks and her BUN and
creatinine have been elevated. During her hospital course
she also related that the nausea, vomiting and diarrhea had
been occurring the past when she missed hemodialysis or her
BUN and creatinine were particularly elevated. The nausea
and vomiting resolved throughout her hospital stay right
after she underwent dialysis but continued to appear in a
milder form in between dialysis sessions.
Renal failure: The patient requires hemodialysis. The
patient presented to medicine status post AV graft
thrombectomy with primary graft repair. Not withstanding the
thrombectomy and despite the heparin drip, the graft remained
non palpable but positive to Doppler. Heparin was increased
to achieve a PTT between 60 and 90 and Coumadin was started.
A Perma-cath was placed on [**2115-7-11**] to be used for dialysis
until the graft would be cleared by vascular surgery. The
patient received dialysis through the Perma-cath on [**2115-7-12**].
Meanwhile, the rate of the heparin drip had to be increased
as the patient had difficulty in achieving PTT therapeutic
range of 60-90. An arteriographic exploration of the graft
was planned while the patient remained on heparin and
Coumadin was titrated to achieve the therapeutic INR between
2.5 and 3.5. As arteriography could not be easily scheduled
during the [**Hospital 228**] hospital stay, the procedure was
scheduled as an outpatient for one week later. The patient
continued to remain in hospital until [**2115-7-17**] in the attempt
to achieve a therapeutic INR so that she could be discharged
on Coumadin only. However, as this did not happen by [**7-17**]
and the patient was eager to go home, she was discharged on
Lovenox. Teaching was performed by a teaching nurse and her
daughter appeared to be able to inject the patient with
Lovenox. She was instructed to have her daughter inject her
with Lovenox and have her INR checked at the local clinic
where she had been going before. She would be returning to
the hospital for an outpatient revision of the graft.
[**Doctor First Name 4623**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4624**], MD [**MD Number(2) 4625**]
Dictated By:[**Last Name (NamePattern1) 6831**]
MEDQUIST36
D: [**2115-10-30**] 18:53
T: [**2115-11-4**] 19:30
JOB#: [**Job Number **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6617
} | Medical Text: Admission Date: [**2200-8-3**] Discharge Date: [**2200-8-16**]
Date of Birth: [**2169-3-15**] Sex: M
Service: BLUE GENERAL SURGERY
Attending:[**Last Name (NamePattern4) **]
HISTORY OF PRESENT ILLNESS: The patient is a 31 year old
male recently diagnosed with hepatocellular carcinoma and
hepatitis B in [**2200-7-5**]. He presented to the Emergency
sweats, headache and worsening right upper quadrant abdominal
pain. It was unclear how high the patient's temperature was
as he did not take his temperature at home. The patient
denied nausea, vomiting, diarrhea or cough or cold symptoms.
The patient denied having any sick contacts. Furthermore,
the patient complains of new right lower quadrant abdominal
pain at times radiating to his flank. He also complains of
his abdominal pain. The patient also had a poor appetite.
PAST MEDICAL HISTORY:
1. Hepatitis B.
2. Hepatocellular carcinoma diagnosed [**2200-7-5**].
PAST SURGICAL HISTORY: Status post appendectomy in [**2194**].
ALLERGIES: Optiray 320, CT scan intravenous contrast causes
rash, itching. Levaquin causes itching and redness.
MEDICATIONS ON ADMISSION:
1. Epivir HBV 100 mg once daily.
2. Famotidine 20 mg q.h.s.
3. Percocet q4-6hours p.r.n. for pain.
SOCIAL HISTORY: The patient lives with his girlfriend in
[**Name (NI) 1474**], [**State 350**]. He works as a custodian in a
nursing home. He denied a history of tobacco, intravenous
drug use and recreational drug use. He drinks alcohol
socially.
PHYSICAL EXAMINATION: On admission, the patient is a healthy
appearing pleasant gentleman, appropriate for his stated age,
in no apparent distress, laying on a stretcher. The head and
neck examination showed extraocular movements are intact.
The pupils are equal, round, and reactive to light and
accommodation. He has oral thrush and cervical
lymphadenopathy. There is no thyromegaly. His chest
examination revealed bilaterally clear to auscultation. His
heart has a regular rate and rhythm, normal heart sounds, no
murmurs. His abdomen was soft, nondistended, right upper
quadrant/epigastric/right lower quadrant abdominal
tenderness. Bowel sounds active. Surgical scar from
previous appendectomy. Burn scar infraumbilically. Rectal
examination showed no masses with guaiac negative stools. He
has no peripheral edema. His extremities were warm and well
perfused. His neurologic examination was grossly intact.
LABORATORY DATA: Pertinent laboratory results revealed a
white count of 8.0, hematocrit 37.8, platelet count 150,000.
His blood electrolytes were within normal limits. His liver
function tests revealed AST of 155, ALT 226, alkaline
phosphatase 167, total bilirubin 1.0, amylase 78 and lipase
of 15.
RADIOLOGIC STUDIES: Chest x-ray revealed clear lungs, no
effusions. CT scan with p.o. contrast revealed large mass in
the left hepatic lobe. In comparison to [**2200-7-18**], the mass
was larger. No lesions in the right lobe. No biliary
dilatation. Right upper quadrant ultrasound showed extension
of portal venous clot to include the entire main portal vein
to the level of the pancreatic head. The right portal vein
remains preserved. There was a known 6.0 centimeter hepatic
lobe mass consistent with hepatocellular carcinoma.
HOSPITAL COURSE: The patient was admitted for scheduled
hepatic lobectomy, cholecystectomy and removal of portal vein
thrombosis. At the time of presentation, he noted to have
two day history of fever and was found to have a temperature
of 102.8. Blood culture was sent and failed to identify
organism. A chest x-ray was negative. The patient was
started on Ampicillin, Gentamicin and Flagyl for empiric
treatment. A heparin drip was initiated in attempt to prevent
further extension of the thrombus in the portal vein.
Fever was thought to be of tumor origin and the patient was
brought to the operating room on [**2200-8-8**]. He underwent a
left hepatic lobectomy, cholecystectomy and removal of portal
vein clot with placement of two [**Location (un) 1661**]-[**Location (un) 1662**] drains.
Pathology report confirmed hepatocellular carcinoma with
tumor thrombosis in the portal vein. Surgical margins were
positive at the junction of the left portal vein and main portal
vein. Because this was viewed as a palliative resection we did
not consider resection of the entire portal vein with
interposition graft. He received 18 units of packed red blood
cells, three units of platelets and 11 units of fresh frozen
plasma intraoperatively and postoperatively.
The patient remained intubated postoperatively and was
transferred to the Surgical Intensive Care Unit in stable
condition with epidural in place for pain control. He
required Propofol to maintain systolic blood pressure less
than 180. The patient was weaned from Propofol and extubated
postoperative day number one and transferred to the floor on
postoperative day number two.
The patient continued to spike fevers postoperatively despite
antibiotic treatment. Blood, urine and sputum cultures were
obtained on postoperative day number two. Sputum cultures
were positive for pansensitive Klebsiella. Chest x-ray
showed possible right middle lobe pneumonia. Gentamicin was
discontinued when the patient began to experience ringing in
his ears. Ampicillin and Flagyl were replaced with
Ceftriaxone. Fevers resolved.
The patient was discharged with one [**Location (un) 1661**]-[**Location (un) 1662**] drain in
place. He was given a prescription for two weeks of Bactrim
and instructed to follow-up with Dr. [**Last Name (STitle) **] within one week.
MEDICATIONS ON DISCHARGE:
1. Bactrim DS one tablet p.o. twice a day times ten days.
2. Epivir HBV 100 mg p.o. once daily.
3. Percocet 5/325 one to two tablets p.o. q4-6hours p.r.n.
for pain.
4. Famotidine 20 mg p.o. q.h.s.
5. Colace 100 mg p.o. twice a day.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home without services.
DISCHARGE DIAGNOSIS: Hepatocellular carcinoma, status post
left hepatic lobectomy and portal vein thrombectomy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 27821**]
MEDQUIST36
D: [**2200-8-16**] 19:13
T: [**2200-8-19**] 19:49
JOB#: [**Job Number 42713**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6618
} | Medical Text: Admission Date: [**2181-6-12**] Discharge Date: [**2181-6-26**]
Date of Birth: [**2155-4-14**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 76273**]
Chief Complaint:
left lower quadrant pain
Major Surgical or Invasive Procedure:
cesarean section
hysterectomy
History of Present Illness:
Patient is a 26y/o G4P2012 at 34+4 weeks gestation with [**Last Name (un) **]
[**2181-7-20**] by 6wk U/S. She presents to labor and delivery from the
office with severe left lower quadrant pain. Pt reports pain
[**7-17**] and describes it as sharp, localized to LLQ, and does not
radiate. She was seen [**2181-6-7**] with similar complaints and had an
evaluation including pelvic ultrasound. No acute process noted
and she was discharged home on percocet. States she has been
taking percocet but feels that it is not helping the pain. She
denies any vaginal bleeding, leaking of fluid, fevers, chills,
contractions.
Patient has a known placenta accreta and a history of two prior
c/s. She is scheduled for c-hyst on [**2181-6-22**].
Past Medical History:
PRENATAL COURSE
(1)EDC [**2181-7-20**] by LMP c/w first trimester U/S
(2)Labs O pos, Ab neg,
(3)U/S nl FFS, previa, cannot r/o accreta
(4)Screening: Quad neg
Issues
* T2DM - poor control ([**5-14**]) EFW 2347g (>90%)
was discharged NPH 28 qam, 38 qhs
Humalog 34/30/36/-
* Placenta previa/accreta - last vaginal bleed in
[**Month (only) 404**] (slight spotting), stable; f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13675**]
- ([**5-24**]) MRI neg for percreta, myometrium not clearly
visualized
* Short cervix - [**Doctor Last Name **] cerclage placed ([**2-13**])
* Asthma - albuterol prn, with hospitalization from [**3-14**]-
[**3-16**] with steroid treatment
PAST OBSTETRIC HISTORY G4P2012
- '[**75**] LTCS for suspected macrosomia, boy 9#8oz
- '[**77**] rpt LTCS, boy 8#2oz, had cerclage
- SAB 10wks
- present, with cerclage
PAST GYNECOLOGIC HISTORY
- h/o abnl pap -> nl on rpt and since
denies STIs
PMH:
- asthma
- albuterol prn
- migraine
- T2DM, insulin
PAST SURGICAL HISTORY
- LTCS x2
- cerclage x2
Social History:
married, lives in [**Location 669**] with husband, children and in-laws
currently not working
denies tobacco, alcohol, illicit drug use
Family History:
noncontributory
Physical Exam:
GENERAL: A&O x 3, NAD
VITALS: T 97.2, BP 112/60, HR 98
LUNGS: CTAB
HEART: RRR
ABDOMEN: soft, tenderness with palpation
no guarding or rebound, +BS
EXTREMITIES: trace edema
FHT: 130-140s and reactive
TOCO: no contractions
SVE: closed/50%
Pertinent Results:
[**2181-6-12**] FIBRINOGE-549 PT-12.1 PTT-30.5 INR-1.0
[**2181-6-12**] WBC-5.9 RBC-3.96 HGB-9.2 HCT-27.7 MCV-70 PLT-193
[**2181-6-12**] PELVIC MRI
Low anterior placenta with findings concerning for placenta
percreta with involvement of the anterior abdominal wall at the
level of the lower uterine segment, and with unchanged
questionable involvement of the bladder wall, but no definite
evidence of mucosal penetration. Ultrasound could possibly be
helpful in the evaluation of the anterior abdominal wall,
particularly for planning of the surgical approach. For
evaluation of the bladder, cystoscopy may be helpful as
previously suggested.
[**2181-6-20**] CT HEAD
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Slight asymmetry of the frontal horns of the lateral
ventricles, however no definite mass lesions identified. If
clinical suspicion remains high, an MR may be helpful.
[**2181-6-19**]
CT CHEST WITH INTRAVENOUS CONTRAST:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Multifocal pneumonia, bilateral pleural effusions with
atelectasis.
[**2181-6-22**]
CTA CHEST
IMPRESSION:
1. Multiloculated pelvic fluid collection is likely
hemoperitoneum in resolution, though superinfection is possible.
The collection is amenable to percutaneous drainage.
2. Acute pulmonary embolus to apical segmental branch of right
upper lobe pulmonary artery.
3. Worsening of multifocal pneumonia and bilateral now moderate
pleural effusions.
4. Generalized anasarca.
Brief Hospital Course:
26y/o G4P2012 with known placenta acreta admitted at 34+4 weeks
with lower abdominal pain.
.
Mrs [**Known lastname 3095**] was admitted for close observation and bedrest.
Fetal testing was reassuring. [**Last Name (un) **] followed her to assist in
management of her diabetes. A repeat MRI on the day of admission
revealed findings concerning for placenta percreta with
involvement of the anterior abdominal wall at the level of the
lower uterine segment, and with unchanged questionable
involvement of the bladder wall, but no definite evidence of
mucosal penetration. Due to the findings concerning for placenta
percreta, in addition to her left lower quadrant tenderness, the
decision was made to move up her delivery date to [**2181-6-15**]. Please
see the operative report for further details. Briefly, her
cesarean delivery was complicated by excessive hemorrhage
requiring supracervical hysterectomy and abdominal packing.
During this operation the patient received 15 units of packed
red blood cells, 10 units of fresh frozen plasma, 1 unit of
cryoprecipitate, 3 units of platelets. The patient was then
taken to the operating room on [**2181-6-18**] for exploratory
laparotomy, removal of pelvic packing, cystoscopy, removal of
cerclage.
.
Patient was in the ICU from [**2181-6-15**] through [**2181-6-22**]. She was
briefly called out to the floor on the evening of [**2181-6-22**] but
returned to the ICU for respiratory distress in the setting of
tachycardia and fever. Patient was transferred back to the floor
on [**2181-6-25**].
Brief hospital course by organ system:
*) NEURO:
- Patient underwent CT head on [**2181-6-20**] for delirium and
disconjugate gaze on exam, which was negative. Patient's pain
was controlled with IV Toradol, oxycodone, and ibuprofen. The
day prior to discharge, the patient expressed significant
anxiety and urgency regarding going home. She was started on
Lorazepam, and was seen by social worker.
*) CARDIOVASCULAR:
- Patient had persistent tachycardia immediately post
operatively which was most pronounced with activity. Patient
underwent two CTA chest studies. Initial study was negative for
PE but showed multifocal pneumonia. The second study showed
worsening multifocal, small segmental branch pulmonary embolism,
and worsening pulmonary effusions with generalized anasarca. The
patient was started on antibiotics and received diuresis. Her
tachycardia resolved.
*) RESPIRATORY:
- Please see CV above
- Briefly, the patient remained intubated post operatively, but
was extubated without problems on [**2181-6-19**]. [**Name2 (NI) **] was
persistently tachycardic and underwent CTA chest which revealed
multifocal pneumonia. The patient initially received a 7 day
course of Cipro/Vanco/Flagyl. However, the patient was noted to
be febrile, with worsening respiratory status requiring transfer
back to the ICU. Repeat CTA chest revealed worsening PNA and the
patient was started on Cipro/Miropenem/Vanco after she underwent
a miropenem desensitization protocol. The patient was also noted
to have a pulmonary embolus and she was started on
anticoagulation. Her respiratory status improved greatly. Upon
discharge, she was treated with lovenox 90mg [**Hospital1 **].
*) HEME:
- Throughout the hospitalization the patient received a total of
22u pRBC, 12u FFP, 2 units of cryo, and 4 units of platelets. At
the time of discharge, patient's hematocrit and coags were WNL
*) FEN/GI:
- The patient was noted to have generalized anasarca and
underwent diuresis both throughout the ICU stay as well as on
the floor with IV lasix.
- Patient was started on TPN briefly while awaiting return of
her bowel function.
- Patient's diet was slowly advanced.
*) ID:
- Please see CV / Resp above, but briefly, the patient was
initially received a 7 day course of Cipro / Vanc / Flagyl for
multifocal pneumonia, but continued spiking temperatures. An ID
consultation was obtained and the patient's antibiotics were
changed to Vancomycin, Ciprofloxacin, and Miropenem for 3 days.
At the time of the discharge, multiple blood cultures are
pending. Patient was also noted to have multiple loose bowel
movements per day and C. diff was negative x 2. The patient was
discharged home on Levo/Flagyl as she refused any further IV
antibiotics.
- Patient was noted to have a multiloculated pelvic fluid
collection on CT abdomen and underwent an uncomplicated CT
guided drainage on [**2181-6-22**]. At the time of discharge the
culture of the pelvic fluid is pending.
*) ENDOCRINE:
- The patient has type II Dibetes mellitus. She was followed by
[**Last Name (un) **] throughout her hospitalization. The patient was initially
receiving insulin drip, but was transitioned to sliding scale.
*) RENAL:
- The patient received diurses with IV lasix and was euvolemic
at the time of discharge.
*) PPX:
- The patient was receiving venodynes, heparin, and famotidine
for prophylaxis
Medications on Admission:
insulin
percocet
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
Disp:*1 * Refills:*5*
2. Metronidazole 250 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 14days days.
Disp:*180 Tablet(s)* Refills:*0*
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety / nausea.
Disp:*30 Tablet(s)* Refills:*0*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
5. Enoxaparin 100 mg/mL Syringe Sig: One (1) 90mg Subcutaneous
Q12H (every 12 hours): Use as directed.
Disp:*60 90mg * Refills:*2*
6. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10u
Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*2*
7. Insulin Lispro 100 unit/mL Solution Sig: Three (3) units
Subcutaneous w/ breakfast, lunch and dinner: see sliding scale
for additional insulin.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
placenta eccreta
pneumonia
pulmonary embolus
diabetes
asthma
Discharge Condition:
stable
Discharge Instructions:
call for fever >100.5, vaginal bleeding, abdominal pain,
nausea/vomiting, respiratory Symptoms, any questions or
concerns.
Followup Instructions:
2 days with Dr [**First Name (STitle) **]
Completed by:[**2181-7-5**]
ICD9 Codes: 2851, 5185, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6619
} | Medical Text: Admission Date: [**2118-6-17**] Discharge Date: [**2118-6-20**]
Date of Birth: [**2065-12-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**6-17**] cath lab: ballon angioplasty in his right coronary artery
History of Present Illness:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M.
.
CHIEF COMPLAINT: chest pain
.
.
HISTORY OF PRESENTING ILLNESS:
52 yo male with h/o poorly controlled hypertension and tobacco
abuse presented to his PCP's office today with chest pain, seen
in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], and now transferred to [**Hospital1 18**] for STEMI.
Patient reports he felt like he had an "attack" on Sunday (5
days PTA) while taking a shower, felt like his "whole lungs"
hurt. Also had diaphoresis and dizziness at the time. Since then
had been feeling short of breath and having chest pain. Finally
presented to his PCP's office today for a medication refill and
mentioned his pain. Pain at that time [**1-29**], ECG reportedly
concerning for MI. He presented by car then to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
(refused ambulance), where troponin I was 5.72 and EKG showed
1-[**Street Address(2) 1766**] elevations in inferior limb leads with reciprocal
changes in lateral chest leads. Started on heparin gtt, loaded
with 600mg [**Street Address(2) 4532**], given metoprolol and aspirin 325mg and
transferred urgently to the cath.
In the cath lab, he was found to have subtotal occlusion of RCA,
50-60% lesion in mid/prox LAD and 40-50% in LCx. RCA was a
small [**Last Name (LF) 12425**], [**First Name3 (LF) **] lesion was POBA'd with good flow. He was
started on integrillin with plan to continue this for 18 hours
in the CCU.
On arrival to the CCU, patient is chest pain free and
comfortable.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, 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 presence of chest pain,
dyspnea, diaphoresis.
No orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
Hypertension (poorly controlled)
Depression
Tobacco abuse
?Iron overload (pt reports needed therapeutic phlebotomy)
COPD
H/o asbestos exposure
MEDICATIONS:
Ibuprofen 800mg [**Hospital1 **]
ALLERGIES: NKDA
Social History:
Works part-time as a mechanic. Lives alone, unmarried.
-Tobacco history: 1ppd x 35 years
-ETOH: ~18 beers per week (6 beers in one sitting)
-Illicit drugs: denies
Family History:
Brother with CAD (s/p 5 stents)
Physical Exam:
VS: T=98.4 BP=141/68 HR=72 RR=18 O2 sat= 94% RA
GENERAL: Obese middle aged male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, elevated JVP
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. Bibasilar crackles, no
wheezes or rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness.
EXTREMITIES: 2+ pitting edema of bilateral LEs, TR band in place
over radial site.
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:
[**2118-6-17**] 10:30PM SODIUM-140 POTASSIUM-4.0 CHLORIDE-105
[**2118-6-17**] 10:30PM CK-MB-5
[**2118-6-17**] 10:30PM PLT COUNT-171
EKG:
NSR @72 bpm, NA/[**Last Name (LF) **], [**First Name3 (LF) **]-elevations in II,III,aVF and V1-V3, TWIs
in V4-V6
CARDIAC CATH:
LMCA: patent
LAD: diffusely diseased, long mid 50-60% lesion
LCx: large [**First Name3 (LF) 12425**] giving large OM, distal AV groove has a 40-50%
lesion and OM has diffuse luminal irregularities
RCA: totally occluded proximally just past the conus origin
LVEDP 26
1. Successful POBA of totally occluded RCA
2. Moderate disease in the LAD and LCx system
Brief Hospital Course:
52 yo M with history of poorly controlled hypertension and
tobacco abuse who presented with chest pain, found to have
STEMI, now s/p POBA of RCA.
ACUTE ISSUES:
# STEMI: s/p balloon angioplasty to the RCA. Troponin I 5.72 at
OSH, however MB here is 5 (no MB at OSH). Event likely occurred
5 days prior to admission when he had severe pain, and he
arrived to the [**Hospital1 18**] chest pain free. Echo showed likely
preserved EF at >50% with no obvious wall motion abnormalities
(however poor windows). He was started on [**Last Name (LF) 4532**], [**First Name3 (LF) **],
atorvastatin, ACE-i. Beta blocker was also started at lower dose
due to episodes of bradycardia (see below). We also encouraged
smoking cessation and dietary changes
# Bradycardia: Patient had several episodes of bradycardia with
pauses lasting at longest 6.5 seconds. This was mainly at night
and was asymptomatic. Episodes possibly a complication of his
inferior MI with resultant ischemia to conduction system,
however more likely they are vagal in nature. Beta blocker dose
was decreased and he had no further episodes on telemetry.
# Acute diastolic congestive heart failure: LVEDP elevated at 26
in the cath lab, volume overloaded on exam. EF found to be
preserved at >50%, likely had diastolic dysfunction in setting
of acute MI. Volume status mproved with IV lasix diuresis.
CHRONIC ISSUES:
# COPD: albuterol PRN
# Tobacco abuse: He was given nicotine 21mcg patch We
encouraged smoking cessation
# Possible hemochromatosis: report h/o therapeutic phlebotomy.
Hct and ferritin elevated, however no sign of cardiac
involvement.
TRANSITIONAL ISSUES:
# Bradycardia: will follow up with cardiologist, will continue
low dose metoprolol
#STEMI: Will follow up with Dr. [**First Name (STitle) **] on [**2118-7-21**].
Discharged on metoprolol, lisinopril, aspirin, [**Date Range 4532**], and
atorvastatin.
#Hemochromatosis: follow up with heme/onc
Medications on Admission:
Ibuprofen 800mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP<100, HR<50
RX *metoprolol succinate 25 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/[**Street Address(2) **] one patch on arm daily Disp
#*30 Transdermal Patch Refills:*2
7. TraMADOL (Ultram) 50 mg PO BID back pain
RX *tramadol 50 mg one tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
Take 1 tab under tongue, wait 5 min, then take up to 1 more tab.
Call 911 if you still have chest pain after 2 tabs.
RX *nitroglycerin 0.4 mg one tablet sublingually as directed
Disp #*25 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
ST elevation myocardial infarction
Hypertension
Acute systolic dysfunction
Hemochromatosis
Chronic Obstructive pulmonary disease
Tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 112375**] because you were
having a heart attack. The cardiac catheterization showed
blockages in several arteries but the blockage that was causing
the heart attack was opened with a balloon procedure. You have
been started on new medicines to help your heart recover from
the heart attack and to prevent another heart attack. You will
see Dr. [**First Name (STitle) **] in about a month to discuss your heart
disease further.
It is very important that you take all of your medicines and
quit smoking, this is crucial to prevent further health
problems.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: COMMUNITY PHYSICIANS ASSOCIATES
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 70678**]
Phone: [**Telephone/Fax (1) 40833**]
Appt: [**6-23**] at 12:15pm
Department: CARDIAC SERVICES
When: THURSDAY [**2118-7-21**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4280, 496, 311, 3051, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6620
} | Medical Text: Admission Date: [**2116-4-17**] Discharge Date: [**2116-4-19**]
Date of Birth: [**2062-10-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
PVI
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
Pericardial drain placement
History of Present Illness:
Mr. [**Known lastname **] is a 53 yo otherwise healthy man with lone atrial
fibrillation who presented for elective pulmonary vein
isolation. Following isolation of the first pulmonary vein, the
pt became hypotensive and tachycardic. Echocardiography
demonstrated evidence of a moderate pericardial effusion and
evidence of earely tamponade physiology (RV diastolic collapse),
and the pt underwent urgent pericardiocentesis with drainage of
approximately 400 cc of blood. As he was anticoagulated with
warfarin and heparin, he received protamine, Vitamin K and FFP.
He was transiently on neosynephrine. A pericardial drain remains
and continues to drain about 10 cc/hr. He was also DC
cardioverted into junctional rhythm. Repeat echocardiogram
demonstrated no pericardial effusion.
.
In the CCU, pt is hemodynamically stable, awake, and
comfortable. He denies dizziness, lightheadedness, chest pain,
palpitations or shortness of breath. He also denies nausea,
abdominal pain, extremity pain, numbness or weakness
Past Medical History:
Atrial fibrillation - Diagnosed [**2116-11-15**], after a road
bike competition in which he had become uncharacteristically
short of breath. Pt was placed on warfarin and elected to
attempt this definitive procedure given his active lifestyle and
the associated risk of bleeding on anticoagulation therapy. He
has previously defered antiarrhythmic medications due to
concerns over long term side effects.
.
CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension
.
Social History:
Denies tobacco, EtOH or illicit drug use. Pt is an avid and
competitive runner and biker (55 marathons, 3 triathalons)
Family History:
No family history of early MI, otherwise non-contributory
Physical Exam:
VS: HR 81 BP 99/62 RR 25 SpO2 100
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
light pink, pallor of the oral mucosa is present. No
xanthalesma.
NECK: Supple with JVP of [**6-21**] cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rate, S3 and S4 present. No m/r/g. No thrills,
lifts.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Lab results:
[**2116-4-17**] 06:45AM BLOOD WBC-3.4* RBC-4.63 Hgb-14.0 Hct-39.9*
MCV-86 MCH-30.2 MCHC-35.0 RDW-13.6 Plt Ct-205
[**2116-4-18**] 06:33AM BLOOD WBC-5.9# RBC-3.54* Hgb-11.0* Hct-31.0*
MCV-88 MCH-31.0 MCHC-35.5* RDW-13.9 Plt Ct-156
[**2116-4-19**] 02:53AM BLOOD WBC-5.5 RBC-3.51* Hgb-11.0* Hct-30.0*
MCV-85 MCH-31.3 MCHC-36.7* RDW-13.8 Plt Ct-168
[**2116-4-17**] 06:45AM BLOOD Neuts-54.2 Lymphs-33.9 Monos-6.8 Eos-4.3*
Baso-0.9
[**2116-4-17**] 06:45AM BLOOD PT-23.0* INR(PT)-2.2*
[**2116-4-17**] 07:40PM BLOOD PT-19.9* PTT-28.3 INR(PT)-1.9*
[**2116-4-18**] 06:33AM BLOOD PT-20.5* PTT-29.1 INR(PT)-1.9*
[**2116-4-19**] 02:53AM BLOOD PT-16.9* PTT-26.9 INR(PT)-1.5*
[**2116-4-17**] 06:45AM BLOOD Glucose-80 UreaN-16 Creat-1.0 Na-142
K-4.2 Cl-106 HCO3-28 AnGap-12
[**2116-4-18**] 06:33AM BLOOD Glucose-105 UreaN-13 Creat-0.9 Na-139
K-3.9 Cl-104 HCO3-29 AnGap-10
[**2116-4-19**] 02:53AM BLOOD Glucose-102 UreaN-13 Creat-0.9 Na-135
K-3.9 Cl-102 HCO3-27 AnGap-10
[**2116-4-18**] 06:33AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.0
[**2116-4-19**] 02:53AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.9
.
TTE: [**2116-4-18**] The left atrium is elongated. The right atrium is
moderately dilated. 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%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2116-4-17**], no
change.
Brief Hospital Course:
# Cardiac tamponade: [**2-17**] perforation of either pulmonary vein
or right atrium. Patient remained stable in the ICU and
pericardial drain output diminshed significantly. The tube was
pulled the next day. Anticoagulation had been reversed during
procedure but was restarted on discharge. Transient pressor
requirement was weaned and patient remained hemodynamically
stable on the floor. He was sent home with indomethacin for 5
days and coumadin and will follow up with his cardiologist
regarding his atrial fibrillation.
# Anemia: Baseline HCT of 39 now down to 29, likely secondary to
acute blood loss. Hcts remained stable. He did not require a
transfusion.
# Atrial fibrillation: Not in sinus rhythm. Had only one PVI,
and was in NSR s/p DC cardioversion upon arrival to the CCU.
Initially all anticoagulants were held overnight given concern
for bleeding and then restarted upon discharge. Pt continues to
defer antiarrythmic medications, will readdress this issue if he
reverts to atrial fibrillation while in the hospital. He will
follow up with his outpatient cardiologist to address his
options for treatment of AF.
Medications on Admission:
Warfarin (since [**2116-11-15**])
Magnesium
MVI
Discharge Medications:
1. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
3. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Atrial fibrillation
Cardiac tamponade, secondary to pericardial bleed during
pulmonary vein isolation
Discharge Condition:
The patient is hemodynamically stable, with no evidence of
cardiac tamponade on exam.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for an elective procedure of
pulmonary vein isolation for attempted ablation of your atrial
fibrillation. You had a complication during the procedure which
caused a small bleed into the pericardial space, the space
around your heart. You had a drain placed to remove the fluid
around your heart. Your symptoms improved, and it appears that
the bleed has stopped. You should follow up with your
cardiologist regarding this procedure and your atrial
fibrillation.
.
You should restart coumadin 5mg to be taken every day. Please
follow up in the coumadin clinic in 5 days for an INR check.
.
You will be given a prescription for a medication, Indomethacin,
to help the pain from the procedure, to be taken for 5 days.
.
If you experience worsening chest pain, shortness of breath,
lightheadedness, loss of consciousness, dizziness, fever, chills
or any other worrisome symptoms please seek medical attention.
Followup Instructions:
Please follow up with your primary cardiologist regarding
further therapy and possible repeat procedure.
.
Please follow up with the coumadin clinic in 5 days for an INR
check.
.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1193**]
[**Last Name (NamePattern1) 35663**], in the next 2-3 weeks to discuss your recent
hospitalization. The phone number to the office is [**Telephone/Fax (1) 80692**]
Completed by:[**2116-4-19**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6621
} | Medical Text: Admission Date: [**2131-8-10**] Discharge Date: [**2131-8-15**]
Date of Birth: [**2058-6-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
[**8-10**] CABG x 5 (LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **], RCA, PLV)
History of Present Illness:
73 yo chinese woman with history of MI referreed for surgical
revasculization
Past Medical History:
HTN
hyperlipidemia
Mi ([**6-28**])
Bilat cataract surgery
"brain embolism"
Social History:
no tob
no etoh
lives with son and daughter in law
Family History:
sister with cad age 70
Physical Exam:
NAD
CV RRR
Lungs CTAB
Abd Benign
Extrem no edema
MSI healing well
Pertinent Results:
[**2131-8-14**] 06:35AM BLOOD WBC-8.3 RBC-3.46* Hgb-10.8* Hct-30.3*
MCV-88 MCH-31.2 MCHC-35.5* RDW-14.9 Plt Ct-169
[**2131-8-14**] 06:35AM BLOOD Plt Ct-169
[**2131-8-15**] 06:55AM BLOOD Creat-0.4 K-4.1
[**2131-8-14**] 06:35AM BLOOD Glucose-106* UreaN-12 Creat-0.5 Na-143
K-3.5 Cl-104 HCO3-29 AnGap-14
Brief Hospital Course:
Ms. [**Known lastname 1256**] was taken to the operating room on [**2131-8-10**] where she
underwent a CABG x 5. She was transferred to the SICU in
critical but stable condition on phenylephrine and propofol. She
was extubated later that same day. He neo was weaned to off on
POD #2, after she received 2 units of PRBCs for an HCT of 21.She
was transferred to the floor on POD #3. She did well
postoperatively, she had no problems with atrial fibrillation
and was very easily diuresed. She was ready for discharge on POD
#5.
Medications on Admission:
lopressor, fosinopril, zocor, norvasc, asa, indur
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 3
days.
Disp:*12 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
CAD
PMH: CAD s/p MI, HTN, ^chol, s/p b/l cataracts, ? brain embolism
that resolved with Chinese medicine
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 9183**] 2 weeks
Dr. [**First Name (STitle) 1075**] 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2131-8-15**]
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6622
} | Medical Text: Admission Date: [**2201-5-11**] Discharge Date: [**2201-5-26**]
Service: MEDICINE
Allergies:
Morphine Sulfate / Ciprofloxacin / Demerol
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hip fracture
Major Surgical or Invasive Procedure:
OR [**5-14**]-- L hemi
History of Present Illness:
89yoM with h/o CAD s/p 4vCABG, COPD on 2L home O2, CHF (EF 35%),
Afib on coumadin, Parkinson's disease, myelodysplastic syndrome
with anemia and thrombocytopenia, transferred from OSH with left
hip fracture. History obtained from the patient and his
daughter. The patient lives alone in an apartment downstairs
from his daugther who helps with all ADLs. He walks with a
walker. While alone in his apartment, he fell while walking
backward from the kitchen with his walker. He called lifeline
and was brought to [**Hospital3 1196**]. He reports hitting
his head but no LOC. Head CT negative for hemorrhage at
[**Hospital1 **]. C-spine cleared.
.
Per the patient's daughter, over the past week he has been
somewhat short of breath. His weight was 170lbs, up from his dry
weight of 160lbs. He normally does not wear his home O2
frequently but did so this past week. He was also found to be in
ARF with creatinine elevated at 2.8 last week. His lasix dose
was increased, and at the OSH today his creatinine was 2.5
(baseline 1.5-1.7). He sleeps with his head elevated in a
hospital bed; denies PND.
.
Pt underwent L hemiarthoplasty of the hip for a L femoral head
fx. Pt unable to wean from vent in PACU. Admitted to MICU for
VAP, hypotension (briefly on levophed) and ATN thought to be [**3-12**]
hypotension. Pt placed on lasix gtt with good u/o to this. Now
continues to have altered MS but improved improved creat and
treatment of presumed infection.
Past Medical History:
PMH
Myelodysplasia - dx'd 2 [**2-9**] yrs ago
Atrial fibrillation
CAD s/p CABG/quadruple '[**89**], CHF-EF 40% in [**2198**]
AI s/p valvuloplasty
Aortic stenosis
Melanoma or basal cell ca? - face, dx in '70s s/p radiation
Acute pancreatitis -
Cholelithiasis
"Mild Parkinson's"
Internal Hemorrhoids
GERD
Dyplastic polyps on colonscopy
Social History:
Lives in the same house as his adult daugher who appears
supportive and actively involved in this care. He occupies the
apt below hers and uses a baby [**Name (NI) **]-[**Name2 (NI) 18065**] to stay in constant
communication with him. Uses a walker to ambulate at home.
Family History:
Family Hx: Daughter, Crohn's Disease
Physical Exam:
Pt died 1832 on [**5-26**]
Pertinent Results:
[**2201-5-11**] 11:00PM GLUCOSE-130* UREA N-57* CREAT-2.7* SODIUM-143
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-21* ANION GAP-20
[**2201-5-11**] 11:00PM CALCIUM-10.2 PHOSPHATE-3.5 MAGNESIUM-2.3
[**2201-5-11**] 11:00PM WBC-7.5 RBC-3.00* HGB-10.7* HCT-33.1*
MCV-111*# MCH-35.8*# MCHC-32.4 RDW-18.5*
[**2201-5-11**] 11:00PM NEUTS-80.7* LYMPHS-14.1* MONOS-4.8 EOS-0.3
BASOS-0.1
[**2201-5-11**] 11:00PM HYPOCHROM-2+ ANISOCYT-2+ MACROCYT-3+
[**2201-5-11**] 11:00PM PLT COUNT-58* LPLT-2+
[**2201-5-11**] 11:00PM PT-22.8* PTT-32.9 INR(PT)-2.2*
Brief Hospital Course:
A/P: 89 yo M with h/o CAD s/p CABG, AS s/p valvuloplasty, CHF EF
35%, COPD, AF, CRI, Parkinson's Disease presenting with failure
to extubate secondary to poor mental status after left hip
hemiarthroplasty transferred to the MICU with hypoxic
respiratory failure, hypotension.
.
# Respiratory/PEA arrest: Pt self-extubated [**5-23**]. CXR with mild
vascular congestion, LLL collapse. s/p treatment w/ 8 day course
of Vanco/Zosyn for VAP completed on [**5-22**]. Lasix gtt d/c'd [**5-24**]
d/t hypotension. US did not show a large enough LLL effusion to
tap. After transferred to the medical floor on [**5-26**], pt
complained of acute shortness of breath. He became hypoxic and
then had a PEA arrest. He was resuscitated with EPI and
atropine. He was shocked x 3 for probable VT and bolused with
amiodarone 300 mg IV x 1. On tranfer to the MICU, again had a
PEA arrest with bradycardic rhythm x 2 unresponsive to multiple
doses of Epi, atropine, bicarbonate, calcium chloride,
transcutaneous pacing and maximum pressor support on Levophed,
Dopamine and Neosynephrine. Laboratory results were significant
for severe metabolic lactic acidosis. Discussions were made with
the family regarding pt's poor prognosis despite maximal medical
efforts. Time of death was 1832 on [**5-26**]. Possible etiology may
have been acute PE, though patient had been anticoagulated x 2
weeks for his atrial fibrillation. CXR did not show signs of
fluid overload/PNA/PTX. Pt's family declined a post-mortem.
.
# ID: Pt treated for VAP s/p 8 day Vanco and 7 day Zosyn on
[**5-22**], MRSA in sputum.
.
# Acute on Chronic renal failure: Cr elevated from baseline of
1.5, peaked at 4.1, trending down to 2.9 likely from ATN. Renal
had been following, HD had not been started.
.
# CV:
> CAD: increased enzymes earlier in admission were c/w demand
ischemia [**3-12**] hypotension. Was on ASA, statin, BB
> Rhythm: atrial fibrillation- rate controlled, anticoagulated
on heparin gtt.
.
# Anemia: s/p 1u PRBC [**5-17**]. Hct remained stable.
.
# Mental Status: Initial somnolence likely secondary to
narcotics administered in the PACU. Slow improvement in MS
likely from uremia.
.
# s/p Left hip hemiarthroplasty: Ortho had been following along
with PT for mobilization.
.
# MDS: Anemia/thrombocytopenia at baseline. Had been on
EPO/Iron.
.
# Parkinson's Disease: was on Sinemet
.
# Conjunctivitis: was on erythromycin ointment
Medications on Admission:
Outpt meds:
Epogen 20,000/ml 1 ml SQ qwk
Sinemet 25/100 1 tab [**Hospital1 **]
Lasix 40mg 2 tabs qd
Aldactone 25mg 1 tab qd
Toprol XL 50mg tab qd
Protonix 40mg 1 tab qd
Lipitor 10mg 1 tab qd
Paxil CR 12.5 mg qd
Pepcid AC 10mg 2 tabs qd
Coumadin 1.0 mg qd
Alphagan 10ml one drop to left eye [**Hospital1 **]
Xalatan 0.005% one frop to left eye qhs
IC Erythromycin ointment tid prn
Discharge Medications:
Pt died [**5-26**] at 1832
Discharge Disposition:
Expired
Discharge Diagnosis:
Time of death 1832, [**2200-5-26**]
Discharge Condition:
death
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2201-5-27**]
ICD9 Codes: 5185, 0389, 5849, 5859, 4280, 496, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6623
} | Medical Text: Admission Date: [**2157-5-26**] Discharge Date: [**2157-6-6**]
Date of Birth: [**2084-11-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization ([**5-27**]), Interventional Cardiology
[**2157-6-1**]: Coronary artery bypass grafting x3, left internal
mammary artery graft to left anterior descending, reverse
saphenous vein up to the marginal branch and the posterior
descending artery.
History of Present Illness:
72yo man with HTN and DM who
presented to ER with chest pain that occurred at rest. chest
pain
was associated with diaphoresis and mild shortness of breath.
In the ED, patient's initial VS were 97.4 84 220/96 20 94% on
Bipap. The patient was started on Bipap and was given NTG SL x 3
and started on NTG gtt. The patient was also given Lasix 20mg IV
x 1. The patient's ECG was in NSR and showed diffuse ST
depression with elevation in AVR. Patient was started on Hep gtt
and plavix loaded.
Past Medical History:
coronary artery disease, Diabetes, Dyslipidemia, Hypertension,
CRI(1.7), rt arm atrophy
Social History:
He smokes occasional cigars and does drink alcohol. Patient
enjoys fishing
Family History:
Mother: DM
Father: Died of unknown causes
Physical Exam:
VS: 112/63, 67, 20, 97RA
Height: 5ft6in Weight:175lbs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] rales bases bilat
Heart: RRR [x] Irregular [] Murmur-no
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, nonfocal exam
Pulses:
Femoral Right:2+(cath)Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right: no Left: no
Pertinent Results:
Labs on Admission:
[**2157-5-25**] WBC-8.7 RBC-4.60 Hgb-13.8* Hct-42.8 MCV-93 Plt Ct-192
[**2157-5-25**] Neuts-54.5 Lymphs-39.4 Monos-4.3 Eos-1.3 Baso-0.6
[**2157-5-25**] PT-11.7 PTT-25.4 INR(PT)-1.0
[**2157-5-25**] Glucose-410* UreaN-20 Creat-1.7* Na-137 K-4.0 Cl-98
HCO3-30
[**2157-5-26**] CK(CPK)-408*
[**2157-5-26**] %HbA1c-9.9* eAG-237*
[**2157-5-25**] cTropnT-0.04*
[**2157-5-26**] proBNP-424*
[**2157-5-26**] cTropnT-0.04*
[**2157-5-26**] CK-MB-39* MB Indx-9.6* cTropnT-0.97*
[**2157-5-26**] CK(CPK)-408*[**2157-6-5**] 09:11AM BLOOD Hct-31.5*
[**2157-6-4**] 04:46AM BLOOD WBC-13.4* RBC-3.63* Hgb-11.0* Hct-32.4*
MCV-90 MCH-30.4 MCHC-34.0 RDW-14.7 Plt Ct-148*
[**2157-6-5**] 09:11AM BLOOD Glucose-205* UreaN-21* Creat-1.0 Na-134
K-4.2 Cl-97 HCO3-32 AnGap-9
[**2157-6-6**] 04:56AM BLOOD UreaN-18 Creat-1.0 K-3.8
Reports:
Cardiac Catheterization:
1. Coronary angiography in this right-dominant system
demonstrated
three-vessel disease. The LMCA had a 30% distal stenosis. The
mid-LAD
had serial 90% stenoses. The LCx was patent, but a large first
obtuse
marginal branch had serial 90% stenoses. The RCA had serial 90%
stenoses
in its proximal and middle portion.
2. Limited resting hemodynamics revealed normal systemic
arterial blood
pressure.
FINAL DIAGNOSIS:
1. Three-vessel coronary artery disease.
.
CXR PA/LAT: Diffuse perihilar opacities and vascular congestion
have resolved. The cardiomediastinal silhouette is normal. There
are no
pleural effusions. Chronic elevation of the right hemidiaphragm
is stable
since [**2148**].
.
ECHO: Overall left ventricular ejection fraction is normal (LVEF
65%). However, the basal segment of the inferior wall and the
apex are hypokinetic. Right ventricular chamber size and free
wall motion are normal. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
Intra-op echo [**2157-6-1**]:
Prebypass
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results on [**2157-6-1**] at 1030am.
Post bypass
Patient is on phenylephrine and is AV paced. Biventricular
systolic function is unchanged. Mild mitral regurgitation
present. Aorta is intact post decannulation.
Brief Hospital Course:
The patient is a 72yo gentleman who presented to the ED with a
hypertensive emergency and ruled in for NSTEMI by EKG and
enzymes. Cardiac cath revealed multi-vessel disease and cardiac
surgery consultation was requested. The patient underwent the
routine preoperative workup. He was taken to the operating room
on [**2157-6-1**] where he underwent coronary artery bypass x3
LIMA-LAD, SVG to Oobtuse marginal and SVG to PDA. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Vancomycin was used for surgical
antibiotic prophylaxis. POD 1 found the patient extubated,
alert and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. He was restarted on his preoperative medication
Lisinopril but at a lower dose given marginal systolic blood
pressure in the 80's.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility.
[**Last Name (un) **] was consulted for blood sugar management and his insulin
regimen was changed to Lantus. He is to follow up Dr. [**Last Name (STitle) 57318**] as
an outpatient for further adjustments in insulin.
By the time of discharge on POD #5 the patient was ambulating
with assistance, the wound was healing and pain was controlled
with oral analgesics. The patient was cleared for discharge to
[**Hospital3 **] rehab in good condition with appropriate follow
up instructions.
Medications on Admission:
Atenolol 100mg daily
Lipitor 40mg daily
HCTZ 25mg Twice Weekly
Isosorbide 15mg daily
Lisinopril 40mg daily
Metformin ER 1000mg Once Daily
Aspirin 81mg daily
Novolog (70-30) 33/17
Discharge Medications:
1. Metformin 1,000 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
5. 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*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24)
hours for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 20 units
Subcutaneous Q AM.
Disp:*QS 1 month * Refills:*0*
11. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10 units
Subcutaneous Q BEDTIME.
Disp:*QS 1 month * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
PMH:
Diabetes, Dyslipidemia, Hypertension, CRI(1.7), right arm
atrophy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
sternal incision clean and dry
Left leg harvest site clean and dry with intact steri strips.
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 cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2157-6-30**] 1:15pm
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 132**] C. [**Telephone/Fax (1) 133**] in [**2-12**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-12**] weeks
Endocrinologist at [**Last Name (un) **] Dr [**Last Name (STitle) 57318**] Wed [**6-8**] at 11:00 AM
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2157-6-6**]
ICD9 Codes: 5119, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6624
} | Medical Text: Admission Date: [**2120-9-26**] Discharge Date: [**2120-10-9**]
Date of Birth: [**2080-8-6**] Sex: M
Service: Plastic Surgery
REASON FOR ADMISSION: The patient was transferred from [**Hospital3 418**] Hospital via med-flight, status post [**2080**]5 feet
out of a tree with extensive facial fractures.
HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old
gentleman who fell 25 feet four hours prior to arrival at
[**Hospital1 69**] after an intermediate
stop at an outside Emergency Department ([**Hospital3 417**]
Hospital) who intubated the patient for airway protection and
life-flighted him to the trauma unit here.
PAST MEDICAL HISTORY: The patient's past medical history on
presentation was negative (per report). The patient was
intubated.
REVIEW OF SYSTEMS: Review of systems was negative.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's blood
pressure on arrival was 137/81. His heart rate was in the
80s. He was intubated at 99%. His pupils were equal, round,
and reactive to light and accommodation. There was blood in
his nares. A mobile hard palate was appreciated, and he had
three lacerations on the left cheek. His tympanic membranes
were clear. He had a chin laceration as well. He was placed
in a cervical collar. No obvious deformity was appreciated.
His lungs were clear to auscultation bilaterally. His
abdomen was soft, nontender, and nondistended. A left upper
quadrant abrasion was noted. His peritoneum was
guaiac-negative. His prostate was okay. His extremities
revealed a left shoulder contusion. Pulses were found in all
distal extremities and in all upper extremities. He moved
all extremities spontaneously. His back and spine revealed
there was no deformity. He was on a back board on
presentation. His [**Location (un) 2611**] Coma Scale on presentation was 7.
PAST MEDICAL HISTORY: Further information was obtained from
the family regarding the patient's past medical history of
hypertension, high cholesterol, and gastroesophageal reflux
disease.
MEDICATIONS ON DISCHARGE: His medications were [**Doctor First Name **] and
Lipitor.
ALLERGIES: He had an allergy to PROTONIX (from which he got
a rash).
SOCIAL HISTORY: Occasional alcohol. A nonsmoker.
PERTINENT LABORATORY VALUES ON PRESENTATION: His
laboratories on presentation revealed his white blood cell
count was 13.8, his hematocrit was 37.7, and his platelets
were 245. His sodium was 144, potassium was 4.2, chloride
was 108, bicarbonate was 24, blood urea nitrogen was 19,
creatinine was 0.8, and blood glucose was 155. His amylase
was 59. His prothrombin time was 12.7, partial
thromboplastin time was 18.4, and his INR was 1.1.
Toxicology screen was negative. Gas was 7.34/45/92/28 with a
base deficit of -1. The patient was on synchronized
intermittent mandatory ventilation at 700, 50% FIO2, and a
positive end-expiratory pressure of 5.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was negative.
A pelvic x-ray was negative.
A computed tomography of the abdomen and pelvis was negative.
CONCISE SUMMARY OF HOSPITAL COURSE: The diagnosis at the
time of presentation was loss of consciousness and maxillary
fracture. The patient was admitted to the Trauma Surgical
Intensive Care Unit. Cervical spine films, cervical collar,
ACT, tetanus, antibiotics, and a Plastic Surgery was
initiated.
Plastic Surgery saw the patient the same evening. They
arrived to find the patient sedated. The patient was
intubated and sedated. Facial laceration of 5 cm and a chin
laceration were sutured. Open mandible fracture, midline and
open palate, and ecchymosis of the left eye. Tympanic
membranes were clear bilaterally. No septal hematoma was
appreciated. Facial bones were palpated. Stepoff was noted
at palate.
At this juncture, two coronal computed tomography scans were
initiated for evaluation of facial fractures. Oral and
Maxillofacial Surgery was initiated. An Ophthalmology
consultation was initiated. The patient was placed on
clindamycin and sutures of laceration for repair.
On postoperative day one, the patient continued to be
hemodynamically stable. His respiratory system was clear.
His abdomen was soft with positive bowel sounds. Socially,
his wife was updated on his status, as an Intensive Care Unit
resident, and the patient was stable.
On hospital day two, officially the cervical spine was
cleared. The patient was evaluated by the Plastics
attending. Le Fort I and Le Forte II palatal fracture. The
plan was for open reduction/internal fixation of facial
fractures after cervical spine clearance.
On hospital day two, Ophthalmology came by. On computed
tomography, there was already apparent, with a lateral
orbital fracture nondisplaced with no evidence of globe
rupture. The left lateral orbital wall fracture. Consensual
pupil reflexes were intact.
On hospital day three, the patient continued to be stable.
He did spike a temperature with a temperature maximum of 101
degrees Fahrenheit. Urine cultures were initiated which
turned out to be negative.
On hospital day four, tube feeds were started. The patient's
temperature maximum was 101.2 degrees Fahrenheit. The
patient remained stable and intubated.
On hospital day five, the patient continued to be stable. No
events of significance. The patient was made nothing by
mouth at midnight with a plan to take the patient to the
operating room on hospital day six.
The patient was taken to the operating room for open
reduction/internal fixation of multiple facial fractures.
Please see the Operative Report. The patient tolerated the
procedure well. The patient was stable postoperatively with
a patent airway and was kept intubated overnight. His head
was elevated. The patient was placed in a maxillary
mandibular fixation.
On postoperative day one, hospital day seven, the patient
continued to do well. The patient did spike a temperature to
103.1 degrees Fahrenheit. In addition to clindamycin, the
patient was placed on levofloxacin.
On hospital day seven, postoperative two, the patient
continued to be intubated secondary to facial edema. A
Dobbhoff tube was placed, and tube feeds were once again
started. Maxillary computed tomography scan was taken again,
and with input of Oral and Maxillofacial Surgery, the
condylar displacement was once again evaluated and judged to
be stable. Further evaluation will be determined through
Oral and Maxillofacial Surgery. The patient's hematocrit, on
hospital day seven, required a transfusion of 2 units of
packed red blood cells with further hematocrit levels being
ascertained. Input was once again given by Oral and
Maxillofacial Surgery. All fractures were reduced. The
patient was stable from a Plastic Surgery perspective;
however, he remained intubated due to facial edema. Tube
feeds were advanced.
On [**2120-10-5**] there was decreasing facial edema. The
sutures in the cheek were removed. The sutures under the
chin were removed subsequently. The patient was in an
extubation trial. The patient was appropriate and followed
commands. The patient was extubated on hospital day ten,
postoperative day four. The patient continued to do well.
He was transferred to the floor. The facial swelling was
decreasing. As the patient was transferred to the floor, he
continued to improve. However, there was some question as to
when the patient was out of bed and was evaluated by Physical
Therapy; there was some question as to some unsteadiness on
his feet. His Romberg sign was negative; however, that
coupled with his mechanism injury prompted a head computed
tomography which was negative for mass effect or for any old
or new bleeds. The patient continued to improve.
On hospital day 12, the patient was given a Panorex. His
Foley catheter was discontinued. On hospital day 13, the
patient was evaluated by Nutrition and given instructions on
what kilocalories were needed to meet the patient's needs.
The patient would need 9 cans to 10 cans of Boost per day.
The patient continued to do well and was cleared by Neurology
as to a normal neurologic examination. The patient was
cleared by Physical Therapy to be able to go home with a cane
for assistance until he regained stability in ambulation.
Occupational Therapy cleared the patient from a neurologic
perspective as well.
DISCHARGE DISPOSITION: It was deemed that the patient would
be appropriate to go home on [**2120-10-9**] after his
continued improvement.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Oral and
Maxillofacial Surgery regarding maxillomandibular fixation.
2. The patient was instructed to follow up with Plastic
Surgery regarding his facial fractures.
CONDITION AT DISCHARGE: The patient was discharged on
[**2120-10-9**] in stable condition.
MEDICATIONS ON DISCHARGE: Discharge medications included
resuming his home medications.
DISCHARGE DIAGNOSES:
1. Complicated facial fractures (Le Forte I and Le Forte
II).
2. Mandibular fracture.
3. Lateral and orbital wall fracture.
4. Status post open reduction/internal fixation of facial
fractures.
5. Status post fall from a height of 20 feet.
[**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], M.D. [**MD Number(2) 2613**]
Dictated By:[**Name8 (MD) 2614**]
MEDQUIST36
D: [**2120-10-8**] 19:52
T: [**2120-10-9**] 08:28
JOB#: [**Job Number 2615**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6625
} | Medical Text: Admission Date: [**2106-4-5**] Discharge Date: [**2106-4-8**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Lumbar laminectomy L3-S1
History of Present Illness:
Mr. [**Known lastname 34210**] has a long history of back and leg pain. He has
attempted conservative therapy including physical therapy and
has failed. He now presents for surgical intervention.
Past Medical History:
DM
CRI
CVA 3 years ago w/residual right sided weakness
?CAD
Spinal stenosis
Lower back pain and hip pain
Social History:
Lives with daughter and wife. Wife has stage IV breast cancer.
Family History:
Not obtained
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics on the
left, decreased on the right 3-4/5; sensation intact in all
dermatomes; reflexes intact at biceps, triceps and
brachioradialis
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL on the left, decreased
on the right [**3-22**]; sensation intact distally
Pertinent Results:
[**2106-4-8**] 06:25AM BLOOD WBC-17.4* RBC-3.84* Hgb-11.3* Hct-34.2*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.7 Plt Ct-154
[**2106-4-7**] 09:30AM BLOOD Hct-36.0*#
[**2106-4-7**] 12:46AM BLOOD WBC-14.2* RBC-3.16* Hgb-9.5* Hct-27.9*
MCV-88 MCH-30.1 MCHC-34.1 RDW-13.7 Plt Ct-146*
[**2106-4-6**] 02:12PM BLOOD WBC-12.1*# RBC-3.20* Hgb-9.6* Hct-28.3*
MCV-89 MCH-29.9 MCHC-33.8 RDW-13.8 Plt Ct-167
[**2106-4-8**] 06:25AM BLOOD Glucose-98 UreaN-22* Creat-1.2 Na-137
K-4.4 Cl-99 HCO3-24 AnGap-18
[**2106-4-7**] 12:46AM BLOOD Glucose-105 UreaN-20 Creat-1.2 Na-137
K-4.3 Cl-105 HCO3-25 AnGap-11
[**2106-4-6**] 02:12PM BLOOD Glucose-123* UreaN-22* Creat-1.3* Na-139
K-4.4 Cl-105 HCO3-27 AnGap-11
[**2106-4-7**] 12:46AM BLOOD CK-MB-6 cTropnT-<0.01
[**2106-4-6**] 07:49PM BLOOD CK-MB-6 cTropnT-<0.01
[**2106-4-6**] 02:12PM BLOOD CK-MB-7 cTropnT-<0.01
Brief Hospital Course:
Mr. [**Name14 (STitle) 41743**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]
for a laminctomy at L3-S1. He was informed and consented for
the procedure and elected to proceed. Please see Operative Note
for procedure in detail.
Post-operatively he was administered antibiotics and pain
medication. POD1 his blood pressure was noticed to be low and
he was given 2 liters of fluid in addition to 1 unit of packed
red blood cells. A medicine consult was obtained to evaulate
the continue hypotension and it was recommended that he be
transferred to the MICU. He was medically managed and given an
additional 2 units of PRBCs with good effect on his blood
pressure. He was transferred out to the floor when stable and
was able to work with physical therapy.
His incisions were clean and dry upon discharge. He was passing
flatus but had not had a bowel movement. He was dischargeed
from the hospital to an acute care facility where ther will
monitor his bowel regimen. He was discharged in good condition.
Medications on Admission:
Cymbalta
Simvastatin
Lisinopril
Glipizide
Glargine
Novalog
Oxydodone
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
10. glargine Sig: Fourteen (14) units Subcutaneous qAM.
11. Novalog Sig: Eight (8) units Subcutaneous qPM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Lumbar stenosis L3-S1
Post-operative anemia
Post-operative hypotension
Discharge Condition:
Good
Discharge Instructions:
Please be sure to call your primary care physician to discuss
the need for an outpatient colonoscopy to be sure you have no
bleeding from your colon to explain your anemia.
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Activity as tolerated
Lumbar corset for ambulation
Treatments Frequency:
Please continue to change the dressings daily with dry, sterile
gauze.
Followup Instructions:
Please follow up in the Orthopedic Spine clinic during your
previously scheduled appointments.
Completed by:[**2106-4-8**]
ICD9 Codes: 5859, 5180, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6626
} | Medical Text: Admission Date: [**2119-6-11**] Discharge Date: [**2119-6-22**]
Service: MEDICINE
Allergies:
amiodarone
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
elective corevalve
Major Surgical or Invasive Procedure:
Percutaneous aortic valve replacement
Endotracheal intubation
Central line
History of Present Illness:
86 year old woman with severe AS (valve area = 0.4, peak
gradient 100), LVEF 55%, PAF, Amiodarone lung toxicity,
pulmonary fibrosis, pacemaker for tachybrady syndrome,
scleroderma/CREST syndrome and severe pulmonary hypertension.
Patient was ADL independent at home untill her most recent
admission to [**Hospital1 18**] in [**4-/2119**] with small bowel obstruction and
pneumonia compicated by left basilic vein DVT from a PICC line
which was replaced prior to her discharge on [**2119-5-25**]. She was
started on Vanco + Cefepim [**5-21**], she had negative blood cultures
and sputum grew MRSA, Cefepim was given for 5 days and Vanco
for 10 days (last dose 5/11). Patient was worked up during her
admission for aortic valve procedure to treat her critical AS.
She is now readmited electively from rehab for the procedure.
Antibiotics for pneumonia have been completed and patient is
afebrile. Bowel obstruction has since resolved and patient is
tolerating soft diet. Coumadin was discontinued on [**2119-6-7**] and
switrched to fundaparinaux. She does report frequent loose
stools, repeated assays for C. diff have been negative.
.
Untill her recent admission patient had been ADL independent and
taking care of her demented [**Age over 90 **] year old husband at home. She
dressed, cooked and shopped on her own and got cleaning help
once weekly. She did have base-line DOE and was not able to walk
more than 20 paces without stopping. She has had significant
unintentional weight loss over the past 4-5 years. She was on
oxygen at home for hypoxia attributed to her chronic pulmonary
fibrosis. She has chronically low systolic blood pressure,
running 70-90's. She had intermittent dizziness upon standing.
She had orthopnea X 1 pillow. Nocturia X2. She denies leg
swelling. At rehab she was able to walk upto 10 paces with
walker and had to stop d/t SOB. She reports an episode of
epigastic/lower anterior chest pain yesterday after a meal which
she attributes to her scleroderma related GERD. Pain was
continous for 2 hours and resolved with analgesia. ECG was
checked and was reportedly unchanged. She denies any chronic
angina.
GU: voiding spontaneously, occasional inconteince.
.
Hct on [**6-8**] --27.7 . No evidence of bleeding. Hct initally was
around 33 at rehab, but has trended down to 27-28 and has
remained stable since [**6-1**].
.
On review of systems, she denies prior history of stroke, TIA,
pulmonary embolism, bleeding at the time of surgery, cough,
hemoptysis, black stools or red stools. Denies recent fevers,
chills or rigors.
.
Cardiac review of systems - notable for absence of paroxysmal
nocturnal dyspnea, ankle edema, palpitations, syncope or
presyncope
Past Medical History:
1. Aortic stenosis (valve are = 0.8)
2. Left ventricular systolic dysfunction with ejection fraction
of 45-55%.
3. Paroxysmal atrial fibrillation.
4. Amiodarone lung toxicity.
5. Pulmonary fibrosis, on home oxygen. PHTN (PAP = 80)
6. Tachybrady syndrome, status post permanent pacemaker.
7. History of breast cancer.
8. Gastroesophageal reflux disease.
9. Scoliosis.
10. Diverticulosis.
11. Hypothyroidism.
12. Basal cell carcinoma.
13. Left rotator cuff tendinitis and partial tear in [**2119**].
14. Scleroderma with GI manifestations and lung manifestations,
but without renal manifestations.
15. Severe pulmonary hypertension.
16. left basilic vein thrombosis, PICC induced [**5-/2119**]: Left
basilic vein thrombosis: PICC induced during previous admission
[**5-31**], considered superficial thrombosis. PICC on left pulled and
no anticoagulation was indicated
17. s/p left shoulder injury with rotator cuff tear [**2119**]
18. partial SBO [**4-/2119**]
Social History:
Retired, a registered nurse [**First Name (Titles) **] [**Last Name (Titles) 88870**]. Until her previous
admission in [**4-/2119**] patient reports she had been ADL independent
and taking care of her demented [**Age over 90 **] year old husband at home. She
dressed, cooked and shopped on her own and got cleaning help
once weekly. She did have base-line DOE and was not able to walk
more than 20 paces without stopping. She has been in rehab since
her discharge on [**2119-5-25**], There she was able to walk up to 10
paces with walker.
.
Her 4 kids live in the area. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20246**] (daughter) is her HCP
(tel: [**Telephone/Fax (1) 88871**]).
.
.
-Tobacco history: ~ 50 pack years, stopped in
-ETOH: untill recently used to drink one vodka-[**Doctor Last Name 6654**] with
olive per evening.
-Illicit drugs: none
Family History:
Mother with breast CA.
Physical Exam:
On Admission:
VS: T= 95.6...BP=109/49...HR=69...RR=20...O2 sat= 97%
GENERAL: cachectic, frail appearing woman, NAD, tachypneic to 25
with speech dyspnea, A+OX3. Appropriate affect.
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no carotid bruits, JVD to the
angle of the Jaw.
HEART: Irregularly irregular, 3/6 SEM max at LUSB with out
radiation to the carotids. no RG.
LUNGS: faint crackles to the scapulas bilaterally, rare
scattered exp wheezes.
ABDOMEN: normal bowel sounds, Soft/NT/ND, no masses or HSM, no
rebound/guarding mid lower abdomen, left knee, right sholder
Skin: surgical scars
EXTREMITIES: WWP, trace pre-tibial edema, no c/c, vertical
surgical scar over left knee
NEURO: Awake, A&Ox3, CNs II-XII grossly intact. motor 4-5/5
throughout, sensory intact except for loss of proprioception in
3rd through 5th toes of right foot.
Lines: PICC right arm - no erythema, tenderness, discharge or
swelling.
Pulses r/l: radial -/-; brachial ++/+; TP +/+; DP -/-
.
On discharge:
expired
Pertinent Results:
On admission:
[**2119-6-11**] 04:40PM BLOOD WBC-5.7 RBC-3.05* Hgb-9.7* Hct-30.7*
MCV-101* MCH-31.9 MCHC-31.8 RDW-15.5 Plt Ct-334
[**2119-6-11**] 04:40PM BLOOD PT-14.8* PTT-29.7 INR(PT)-1.3*
[**2119-6-11**] 04:40PM BLOOD Glucose-100 UreaN-15 Creat-0.7 Na-141
K-5.2* Cl-106 HCO3-28 AnGap-12
[**2119-6-11**] 04:40PM BLOOD ALT-13 AST-14 LD(LDH)-230 AlkPhos-91
TotBili-0.4
[**2119-6-14**] 03:07AM BLOOD Lipase-28
[**2119-6-11**] 04:40PM BLOOD CK-MB-3 proBNP-[**Numeric Identifier 88872**]*
[**2119-6-11**] 04:40PM BLOOD Albumin-3.0* Calcium-8.5 Phos-4.2 Mg-2.2
Iron-23*
.
[**6-14**] TTE: FOCUSED STUDY. Overall left ventricular systolic
function is normal (LVEF>55%). An aortic CoreValve prosthesis is
present. Mild (1+) aortic regurgitation is seen. There is no
pericardial effusion.
.
[**6-20**] TTE:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). The right ventricular cavity is markedly dilated
with moderate global free wall hypokinesis. An aortic CoreValve
prosthesis is present. The prosthetic aortic valve leaflets
appear normal The transaortic gradient is normal for this
prosthesis. A mild (1+) anterior paravalvular aortic valve leak
is present. The mitral valve leaflets are mildly thickened.
Moderate (2+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normally-functioniong CoreValve aortic prosthesis
with mild paravalvular regurgitation. Normal global and regional
left ventricular systolic function. Severe pulmonary
hypertension with dilated right ventricle with moderate global
systolic dysfunction. Moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2119-6-15**],
estimated PA pressures are higher still and RV appears slightly
more dilated. The other findings are similar.
.
On [**2119-6-22**]
[**2119-6-22**] 03:33AM BLOOD WBC-17.5* RBC-2.68* Hgb-8.3* Hct-25.5*
MCV-95 MCH-30.8 MCHC-32.3 RDW-21.0* Plt Ct-89*
[**2119-6-22**] 02:06AM BLOOD PT-20.1* PTT-90.9* INR(PT)-1.8*
[**2119-6-22**] 03:33AM BLOOD Glucose-178* UreaN-94* Creat-4.8* Na-142
K-4.8 Cl-108 HCO3-14* AnGap-25*
[**2119-6-22**] 02:06AM BLOOD ALT-62* AST-132* AlkPhos-109*
Amylase-610* TotBili-0.5
[**2119-6-22**] 02:06AM BLOOD Lipase-1540*
[**2119-6-20**] 04:16AM BLOOD proBNP-[**Numeric Identifier 4732**]*
[**2119-6-22**] 06:14AM BLOOD Type-ART Temp-37.8 pO2-103 pCO2-34*
pH-7.30* calTCO2-17* Base XS--8 Comment-AXILLARY T
[**2119-6-22**] 06:14AM BLOOD Lactate-6.7*
Brief Hospital Course:
86 year old woman with severe AS (valve area = 0.4, peak
gradient 100), LVEF 55%, PAF, Amiodarone lung toxicity,
pulmonary fibrosis, pacemaker for tachybrady syndrome,
scleroderma/CREST syndrome and severe pulmonary hypertension who
was admitted electively for core-valve placement, expired on
[**2119-6-22**].
.
# Critical AS: valve area = 0.4, peak gradient 100. Patient not
deemed a surgical candidate for surgery due to her
co-morbidities therefore scheduled for core-valve on [**6-13**].
Patient with uneventful pre-operative course. Intra-procedure
patient plavix loaded. Procedure complicated by inability to
pull right groin shealth necessitating open closure per
vasculature. Patient extubated and transferred to the CCU.
Follow-up TTE demonstrated stable, properly placed corevalve.
.
# PUMP: CHF, EF 45% per OSH. TTE prior to procedure 55%.
Post-procedure, TTE demonstrated overall normal left ventricular
systolic function, (LVEF>55%). An aortic CoreValve prosthesis is
present. Mild (1+) aortic regurgitation is seen. There is no
pericardial effusion. Patient was continued on metoprolol,
digoxin.
.
#. ATRIAL FIBRILLATION: Pre-opertively patient had been on
coumadin which had been transitioned to lovenox and subsequently
switched to fondaparinaux.
-- RATE CONTROL:
Patient rate controlled with digoxin and metoprolol.
-- ANTICOAGULATION:
Pre-opertively patient had been on coumadin which had been
transitioned to lovenox and subsequently switched to
fondaparinaux
Patient initially anticoagulated post-procedure with heparin IV
however due to concern for HIT, heparin was stopped and
argatroban started. HIT antibody returned negative and patient
restarted on heparin gtt on [**6-20**].
.
# Hypotension. Post-procedure patient noted to be hypotension
with MAPS in 50s and SBPs in 80s necessitating pressure support.
Initial hypotension attributed to fluid shifts s/p core valve
and blood pressure augmented with neo. Neo resulted in
pronounced peripheral vasoconstriction with resulting left
extremity cyanosis. However patient persistently hypotension
thought secondary to probable sepsis. Patient started on broad
spectrum antibiotics and decision made to aggressively hydrate
with IVF and transition pressure support to levophed and
vasopression. On [**6-21**], the patient became increasingly
hypotensive requiring pressor support with levophed,
vasopressin, and dopamine. Despite pressors, lactate continued
to climb into the 7 range until aggressive measures were
withdrawn.
.
# Thrombocytopenia. Platlets with precipitous drop while
hospitalized; ~300 pre-procedure with nadir in the 60s.
Differential diagnosis at that time included sepsis, DIC
medication side effect and HIT. DIC labs negative. Patients 4 T
score ~6 (especially after UE US with evidence of new left
brancial thrombosis). Concern for HIT prompted transition to
argatroban and send out of the HIT antibody. On [**6-20**] HIT
returned negative and patient transitioned back to IV heparin.
Likely drop reflective of underlying infectious process as HIT
ruled out and DIC labs negative.
.
# Acute Kidney Injury. Patient with elevation in creatinine and
decrease in urine production post-corevalve. CT with evidence of
renal infarct thought to have occurred intra-procedure. Etiology
to [**Last Name (un) **] likely multifactorial in setting of renal infarct as well
as hypovolemia in setting of hypotension. Patients kidney
function was monitored daily, medications were renally dosed.
The patient remained oliguric for several days and became net +
13L. Cr stabilized around 4.8 and urine output improved
transiently on a lasix gtt before the patient began to
deteriorate and urine output again declined.
.
# Peripheral vasoconstriction/left hand cyanosis. Post-procedure
patient with complaints of numbness and tingling in left hand.
Decision made to pull left axillary arterial line after which
symptoms subsided. Patient with hypotension s/p procedure
necessitating augmented pressure support with neo. Additional
vasoconstriction in setting of neo in a patient with scleroderma
likely resulted in aggravated peripheral vasoconstriction of
left hand. Pressors transitioned from neo to vasopression with
some improvement in perfusion.
.
# Elevated LFTS. Likely secondary to shocked liver in the
setting of hypotension and sepsis. LFTs stabilized and began to
slowly trend down after initiation of broad spectrum antibiotics
and normalization of blood pressure.
.
#. CAD. Left cath undertaken in [**4-/2119**] as part of work-up for
core-valve demonstarted left dominant system with singel vessel
disease: ~50-70% lesion in OM1. Patient without complaints of
chest pain in house. Continued on ASA 81 as well as BB.
.
# Lung disease. Pateint with history of extensive interstitial
pulmonary fibrosis secondary to to amiodarone exposure vs
scleroderma vs radiation injury (got radiation for breast cancer
in the past. Per chart biopsy, baseline home oxygen 2-3L.
Pre-procedure chest CT and severe pulmonary HTN on RHC which
showed PA systolic pressure of 80mmHg in the presence of nopmal
wedge pressure (16mmHg). Post-extubation patient continued on
home nebulizer treatments. On [**6-21**], the patient acute desaturated
to the 80s. She was deep suctioned with improvement in her sats.
There was concern that the patient was not protecting her airway
because of altered mental status and she was again intubated on
[**6-21**].
.
# Provoked Left basilic vein thrombosis. PICC induced during
previous admission [**5-31**], considered superficial thrombosis.
Monitored clinically in house
.
# Scleroderma: Clinically suspected on past admission on the
basis of her ILD and chronic GERD complaints. Rheumatology were
consulted and serology showed positive [**Doctor First Name **] + Anticentromere ab
with neg SCL70, RNA ab and B2 glycoprotein. Impression was of
CREST syndrome. No systemic therapy was started. Patient
continued on PPI for treatment of GERD
.
# Nutrition. Post-procedure course complicated by extubation
necessitating intubation. Of note patient is significantlly
cachectic with hypoalbuminemia (Alb = 2.7 [**2119-5-21**]) likely [**2-22**]
to her various chronic diseases and poor PO intake. There was
concern for mesenteric ischemia post-procedure because of
complaints of abdominal pain, and TPN was started.
.
# Hypothyroidism: TSH [**4-/2119**] = 2.6. Patient continued on home
[**Year (4 digits) **] 75mcg
.
On [**6-22**], the patient was re-intubated for altered mental status
and inability to protect her airway. The patient was noted to
have oliguria, worsening lactic acidosis, evidence of
pancreatitis and persistent respiratory failure. Discussions
about goals of care were held with the patient's family -
including her daughter who served as her HCP. The decision was
made to transition the patient to comfort measures only. She
passed away shortly after pressors were discontinued on the
morning of [**2119-6-22**].
Medications on Admission:
digoxin 125 mcg Tablet 1 Tablet(s) by mouth once a day
levalbuterol HCl [Xopenex] 0.63 mg/3 mL Solution for
Nebulization
inh four times a day
levothyroxine 75 mcg Tablet 1 Tablet(s) by mouth once a day
metoprolol tartrate 25 mg Tablet 1 Tablet(s) by mouth q8hrs
omeprazole 20 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by
mouth twice a day
potassium chloride 10 mEq Capsule, Extended Release 1 Capsule(s)
by mouth once a day
aspirin 81 mg Tablet, Delayed Release (E.C.)
1 Tablet(s) by mouth once a day
cholecalciferol (vitamin D3) 2,000 unit Tablet
1 Tablet(s) by mouth once a day
Arixtra SQ 2.5 mg QD
Lidoqain patch was started in rehab on [**6-10**]
Sucralfat 1g QID
in rehab also got: Zolpidem, guiafenasine, maalox, glycolax,
ondasternon
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
Severe aortic stenosis s/p percutaneous aortic valve replacement
Atrial fibrillation
Pulmonary fibrosis
Tachybrady syndrome
Hypothyroidism
Scleroderma
Pulmonary hypertension
Discharge Condition:
Expired
Discharge Instructions:
Patient made comfort measures only on [**2119-6-22**] after developing
cardiogenic shock and multi-system organ failure. This was in
the setting of having received a percutaneous aortic valve
replacement on [**2119-6-13**].
Followup Instructions:
None
ICD9 Codes: 4241, 0389, 5845, 4280, 2762, 5119, 2449, 4168, 2875, 496, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6627
} | Medical Text: Admission Date: [**2198-1-13**] Discharge Date: [**2198-1-29**]
Date of Birth: [**2129-7-30**] Sex: F
Service: CARD. [**Doctor First Name 147**]
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 45419**] is a 68-year-old
female with cardiac risk factors including
non-insulin-dependent diabetes mellitus, hypertension,
hypercholesterolemia, and tobacco use, who was in her usual
state of health until [**2198-1-10**], when she noted an
acute onset of substernal chest pain while cooking which was
associated with shortness of breath. This chest pain and
shortness of breath lasted for approximately five to ten
minutes and resolved with rest. She did not seek medical
attention at that time. On [**2198-1-11**], she again had
another episode of chest pain and shortness of breath while
at rest, which was relieved with a baby aspirin. On [**2198-1-12**], she again noted acute onset of shortness of breath
without chest pain while at rest and, upon informing her
family, she was taken by ambulance to an outside hospital.
It was noted that her shortness of breath was not positional
or related to exertion. On the day of admission to the
outside hospital she had sharp upper back pain between her
shoulder blades which was relieved with Motrin. She at that
time denied any other symptoms. She denied nausea, vomiting,
chest pain, abdominal pain, lower extremity swelling,
palpitations, paroxysmal nocturnal dyspnea, lightheadedness,
dizziness, melena, diarrhea or constipation. Upon arrival to
the outside hospital, she was found to be hypoxic to 92% on
oxygen saturation on room air and was started on oxygen by
nasal cannula which relieved her shortness of breath. She
was also given 10 mg of Lasix intravenously as her chest
x-ray at the time showed pulmonary edema. An EKG done at the
outside hospital showed ST depressions in the lateral leads,
and her initial cardiac enzymes were found to have a CK of
151 with an MB fraction of 10.5 and a troponin of 3.4. She
was started on a nitroglycerin drip and subcutaneous Lovenox
injections and was transferred to [**Hospital1 190**] for further management and evaluation. Upon
arrival at the Emergency Department at [**Hospital1 190**] she was given 25 mg of Lopressor for
hypertension, and admitted to the Cardiology service for
treatment of acute coronary syndrome.
PAST MEDICAL HISTORY:
1. Non-insulin-dependent diabetes mellitus for approximately
two years.
2. Borderline hypertension.
3. Borderline hypercholesterolemia.
4. Melanoma status post resection from the chin times two.
MEDICATIONS AT THE TIME OF ADMISSION:
1. Metformin 500 mg once per day.
2. She was also on a nitroglycerin drip from the outside
hospital.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient states that she smoked one-half
pack per day for 20 years but had quit 15 years previously.
She lives with her husband and has three healthy children.
FAMILY HISTORY: There is no family history of coronary
artery disease or cerebrovascular disease. There is an
extensive history of cancer. Father died of prostate cancer
at age 79, mother died of multiple myeloma at age 80.
PHYSICAL EXAMINATION ON ADMISSION: The patient was found to
have a temperature of 97.4, heart rate of 86 in sinus rhythm,
blood pressure of 164/90 with an oxygen saturation of 96% on
two liters nasal cannula. In general, she was an elderly
female in no apparent distress. Her pupils were equally
reactive to light and accommodation with extraocular muscles
intact and anicteric sclerae. Her mucus membranes were dry.
Her neck was supple with jugular venous pressure estimated at
8 cm, 2+ palpable carotid pulses, with a question of carotid
bruit versus radiation of cardiac murmur. Her lung
examination demonstrated rales up to one-third of her lung
fields bilaterally with no wheezes. There was some left lung
dullness, but no egophony or accessory muscle use. Her heart
showed a regular rate and rhythm with normal S1, S2, and a
grade [**2-22**] mid to late peaking crescendo-decrescendo systolic
murmur heard best at the left upper sternal border and
radiating to the carotids. She was found to have no rubs or
gallops. Her abdomen was obese, soft, non-tender,
non-distended, with no hepatosplenomegaly and no palpable
masses. There were no periumbilical or femoral bruits. Her
extremities showed [**1-18**]+ edema bilaterally up to the mid shin
in the lower extremities. She had 1+ palpable dorsalis pedis
and posterior tibial pulses bilaterally. On neurological
examination, she was alert and oriented times three, with
cranial nerves II through XII intact and no focal motor or
sensory deficits.
LABORATORIES ON ADMISSION: Showed a white count of 11.7 with
hematocrit of 31.3 and platelet count of 267,000. Chem-7
showed a sodium of 135, potassium 4, chloride 102,
bicarbonate of 20, BUN and creatinine of 15 and 0.5 and a
blood glucose of 234. Her CK at this hospital was 117 with
an MB fraction of 11.
ELECTROCARDIOGRAM: EKG done at the time showed sinus rhythm
at 68 beats per minute with T-wave inversions in leads V5,
V6, 1 and aVL, as well as in 2, 3 and aVF. It was found to
have poor R-wave progression. There were no ST elevations or
depressions noted. In comparison with the EKG from the
outside hospital, the ST depressions noted in the lateral
leads had resolved.
RADIOLOGY: On chest x-ray she was found to have bilateral
effusions with interstitial edema and borderline
cardiomegaly. There were no infiltrates noted. CT of the
chest, abdomen and pelvis was also done which showed no
dissection, no pericardial effusion, bilateral mild pleural
effusions and bilateral increased septal thickening. The
abdomen and pelvis were found to be unremarkable.
HOSPITAL COURSE: Ms. [**Known lastname 45419**] was admitted to the hospital
through the Emergency Department to the Cardiology service
and was monitored for a period. During the next couple days
she continued to have episodes of shortness of breath and
chest pain, and a troponin which was continually monitored
peaked at 21. Due to her continuing instability, she was
taken to the Cardiac Catheterization Suite on hospital day
three, and was found to have severe left main, left
circumflex, and right coronary artery disease. She was also
found to have mild left ventricular dysfunction, marked left
ventricular diastolic dysfunction, moderate mitral
regurgitation, and moderate pulmonary hypertension. Due to
her catheterization results and continued instability and
symptomatology, the patient was taken to the Operating Room
on [**2198-1-16**], where she underwent coronary artery
bypass graft times four. Please refer to the dictated
operative note for full details of this procedure. She
tolerated the procedure well and was transferred
postoperatively to the Cardiac Surgical Intensive Care Unit.
At the time of transfer, she was on a propofol drip at 10
mcg/kg/min. She was also on Neo-Synephrine and nitroglycerin
drip to maintain her systolic blood pressure in an acceptable
range. She was A-paced at 88 beats per minute and no ectopy
was noted, with an underlying rhythm of 47 beats per minute.
She was weaned from the ventilator and extubated late on the
day of surgery which she tolerated well. On postoperative
day one she continued to be A-paced at 88 beats per minute as
her underlying rhythm was sinus bradycardia in the 40's. She
was also continuing to require Neo-Synephrine drip to
maintain her systolic blood pressure in the 130 to 140 range
which was necessary due to her carotid artery disease. On
postoperative day two, the patient was transfused one unit of
packed red blood cells due to a hematocrit of 24.9 with a
repeat hematocrit of 28.1. Her Neo-Synephrine drip was also
weaned to off, as her systolic blood pressure remained in the
120 to 140 range without need for the drip. She did,
however, remained A-paced, as her underlying rhythm ranged
between 40 and 60 beats per minute. On postoperative day
three, she was noted to have some low urine output for
approximately two to three hours, at which time Lasix was
started. She also demonstrated some lability of blood
pressure, requiring Neo-Synephrine drip from time to time to
maintain her systolic blood pressure greater than 110. She
did also remain A-paced at this time. Though early in the
day she was tolerating fluids by mouth, later in the day she
began to have episodes of nausea and vomiting, which were
treated using Reglan and Zofran as well as Phenergan. She
continued to have a poor appetite and was unable to eat
without vomiting. On postoperative day four she was actually
found to be hypertensive with elevation as high as the 180 to
200 range of systolic blood pressure when in episodes of pain
or retching associated with her nausea and vomiting. She was
no longer needing to be A-paced, as her underlying rhythm was
now in the 70's with normal sinus rhythm and no ectopy. Her
Foley catheter was discontinued on postoperative day four as
well. The patient continued to have active bowel sounds and
was passing flatus on postoperative day five, however, she
did continue to have severe episodes of vomiting and nausea.
These episodes were associated with hypertension with
systolic blood pressure as high as 200, and were very
difficult to control. She was given intravenous labetalol
and intravenous Haldol to help with her increasing agitation,
which helped to improve her blood pressure. She at this time
refused nasogastric tube placement despite continued
vomiting. The nasogastric tube was finally placed on
postoperative day five, and a Gastroenterology consult was
obtained. Possibilities for her etiology of nausea and
vomiting were thought to be gastritis with gastric outlet
obstruction as opposed to gastroparesis or medication effect.
It was recommended by the Gastroenterology service that she
undergo examination by esophagogastroduodenoscopy. On
postoperative day eight, the patient underwent EGD, which
showed a normal esophagus and duodenum, with two
benign-appearing linear ulcers without visible vessels,
approximately 4 and 3 cm long respectively and 8 mm wide in
the body of the stomach. It was felt by the Gastroenterology
service that these ulcers likely represented the etiology of
the patient's nausea and vomiting. The patient was
continually treated on an oral proton pump inhibitor and on
postoperative day eight, her nasogastric tube was clamped.
She subsequently tolerated this well, and on postoperative
day nine, the nasogastric tube was discontinued. In
addition, on postoperative day nine, the patient on
respiratory examination demonstrated decreased breath sounds
at both bases, left greater than right. Chest x-ray done at
the time showed a large sized pleural effusion on the left,
and the patient underwent sterile insertion of a left-sided
chest tube with 400 cc of serous drainage. The patient's
nausea slowly began to improve on postoperative day ten, and
she began to tolerate solid food for the first time. At this
time, there was also some question of suicidal ideation on
the part of the patient and a Psychiatry consult was
obtained. At the time of the Psychiatric consultation, the
patient denied any suicidal ideation, and it was felt by the
psychiatric service that she was not a risk for self harm.
Late on postoperative day ten, the patient was finally deemed
ready and stable for transfer from the Intensive Care Unit to
the regular patient floor. The patient had progressive
improvement in her ability to tolerate oral foods, and
decreases in her nausea and vomiting. She also showed
improvement in her level of anxiety and expressed no further
suicidal ideation. By postoperative day 13, she was
tolerating p.o.'s easily, and showed a much improved mental
state. At this time it was deemed that she was stable and
ready for discharge home with visiting nurses to continue to
do wound checks, blood pressure checks and to ensure that she
was tolerating a regular diet. Her chest tube had been
discontinued the day before without incident, and she
reported no shortness of breath. At the time of discharge,
the patient was afebrile with heart rate of 56 in sinus
rhythm, and a blood pressure of 130/80. She did have a
slightly unsteady gait, but she was cleared by the Physical
Therapy service for discharge home with use of a cane.
PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: Showed a
regular rate and rhythm with a normal S1, S2 and 2/6 systolic
murmur. Her lungs were clear to auscultation bilaterally.
Her abdomen was soft, non-tender, non-distended with no
hepatosplenomegaly. Her sternal incision was healing nicely.
She had minimal lower extremity edema.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg twice per day times seven days.
2. Potassium chloride 20 mEq twice per day times seven days.
3. Enteric coated aspirin 325 mg once per day.
4. Percocet one to two tablets every four to six hours as
needed for pain.
5. Lopressor 50 mg twice per day.
6. Captopril 75 mg three times per day.
7. Protonix 40 mg by mouth twice per day.
8. Metformin 500 mg once per day.
9. Ascorbic acid 500 mg twice per day.
10. Iron sulfate 325 mg once per day.
11. Colace 100 mg twice per day.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post myocardial
infarction.
2. Status post coronary artery bypass graft times four.
3. Gastric ulcers times two.
4. Gastroesophageal reflux disease.
5. Non-insulin-dependent diabetes mellitus.
6. Hypertension.
7. Hypercholesterolemia.
8. Melanoma status post resection times two.
FOLLOW UP: Follow up scheduled in the [**Hospital 409**] Clinic on
_______ in two weeks' time. It was told to the patient that
she should follow up with her cardiologist and primary care
physician within the next one to two weeks. A follow-up
appointment was scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in
approximately four weeks' time.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name (STitle) 47509**]
MEDQUIST36
D: [**2198-3-28**] 16:25
T: [**2198-3-28**] 17:52
JOB#: [**Job Number 47510**]
ICD9 Codes: 4280, 4240, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6628
} | Medical Text: Admission Date: [**2112-2-7**] Discharge Date: [**2112-2-12**]
Date of Birth: [**2057-8-11**] Sex: M
Service: [**Hospital1 **] Medicine
HISTORY OF PRESENT ILLNESS: On presentation the patient is a
54 year old man with a history of hepatitis C, insulin
dependent diabetes mellitus, osteomyelitis, status post
recent surgery of his toe and a lengthy rehabilitation stay
who eloped from rehabilitation and went home the day before
admission to the Medicine Intensive Care Unit. The patient
was relatively stable per family with talking, walking well
at around 5 PM and the family then noticed that around 6 PM
the patient was unresponsive and sleeping on the floor. The
family called emergency medical services at that point and
the patient was noted to be unresponsive with a fingerstick
of 16. The patient was given 2 amps of D50 and Narcan 1 mg
times two.
The patient was then noticed to have agonal breathing with
respiratory rates 4 to 6 and was intubated for that reason on
the field and was brought into the Emergency Department for
evaluation.
The patient was started on low dose Propofol for sedation as
the patient appeared agitation on the ventilator. He was
moving all extremities but not responding to commands.
Per the family, the patient had a recent problem with low
fingersticks in the 50s. The patient usually takes care of
his own medications and his family is unsure of his
medication regimen. Per the family the patient did not have
any fevers, chills, upper respiratory infection symptoms or
gastrointestinal symptoms prior to admission.
PAST MEDICAL HISTORY:
1. Hepatitis C.
2. Diabetes type 2 which is now insulin dependent.
3. History of endocarditis in the [**2068**].
4. History of intravenous drug abuse which is current.
5. Hypertension.
6. Osteoarthritis.
7. Increased PSA.
8. Osteomyelitis.
9. Thyroid nodule.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Univasc, Ciprofloxacin, Percocet,
Atenolol, Cimetidine, Oxazepam, Folic acid, Cyclobenzaprine,
Clindamycin, Fluoxetine, Indomethacin and Novolin.
SOCIAL HISTORY: History of intravenous drug abuse.
Currently he uses cocaine. Smokes one pack per day of
cigarettes. Alcohol, he drinks regularly.
PHYSICAL EXAMINATION: Physical examination on admission, the
patient's temperature was 95.3,blood pressure 102/82,
heart rate 70s, respiratory rate 16, 100% on SIMV.
General: Unresponsive, thin man intubated and sedated.
Head, eyes, ears, nose and throat: Pupils were minimally
reactive, no doll's eyes.
Cardiovascular: Regular rate, no murmurs.
Chest: Clear to auscultation bilaterally with equal breath
sounds.
Abdomen: Soft, nontender, nondistended, positive bowel
sounds.
Extremities: No cyanosis, clubbing or edema. 1+ bilateral
pulses.
LABORATORY DATA: Pertinent laboratory data on admission
revealed lactate 7.9.
Chest x-ray was significant for metal fragments in his right
upper chest.
Electrocardiogram with normal sinus rhythm at 80 with a
normal axis.
Head computerized tomography scan was negative for any masses
or bleeds.
Toxicology screen was positive for cocaine and
Benzodiazepines.
HOSPITAL COURSE: 1. Hypoglycemia - Most likely a fasting
sugar of 15 was due to patient overdosing him on himself of
his usual dose of Novolin. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained
during this admission. See medication list for [**Last Name (un) **]
recommendations.
2. Unresponsiveness - The patient had a neurology consult
during this admission and workup included
electroencephalogram which showed mild encephalopathy but no
seizures. An magnetic resonance imaging scan showed enlarged
lateral ventricles which are old, otherwise no bleeds or
masses. However, neurocognitive testing revealed that the
patient was incompetent to care for himself. Testing showed
that he had significant cognitive impairment, that interferes
with the ability to care for himself with deficits in memory,
planning and sustaining a task. The patient was maintained
on a CIWA scale with prn Valium. However, the patient did
not require any Valium. The CIWA was 1 to 2 during this
admission. The patient was maintained on a 1:1 sitter
because of his history of elopement and inability to care for
himself.
3. Respiratory failure - The patient was intubated secondary
to mental status and extubated one day after intubation. The
patient has since then had good oxygen saturations with no
problems in terms of respiratory status.
3. Hypertension - The patient in the Intensive Care Unit was
started on a beta blocker and Hydralazine. On reaching the
medical floor on the [**Hospital1 **] Team this regimen was changed
to Captopril and Metoprolol which was titrated upwards for
goal blood pressure of systolic around 130s.
4. Code status - The patient remained full code throughout
this admission.
5. Smoking history - The patient was kept on a nicotine
patch while in-house and was stopped on the nicotine patch on
discharge.
DISPOSITION: The patient was discharged to a rehabilitation
institution.
CONDITION ON DISCHARGE: Mentally incompetent to care for
himself, however, medically was stable with good blood
pressures and good fingersticks, all within the normal range
36 hours before discharge.
DISCHARGE DIAGNOSIS:
1. Hypoglycemia.
2. Diabetes Type 2 which is now insulin dependent.
3. Hypertension.
4. Osteoarthritis.
5. History of intravenous drug abuse.
6. History of recent osteomyelitis.
7. Dementia.
DISCHARGE MEDICATIONS:
1. Ranitidine 150 mg p.o. b.i.d.
2. Multivitamin one capsule p.o. q.d.
3. Thiamine one tablet p.o. q. day
4. Folic acid 1 tablet p.o. q. day
5. Docusate 100 mg p.o. b.i.d.
6. Reglan insulin sliding scale. See addendum for full
insulin regimen.
7. Captopril 25 p.o. t.i.d.
8. Metoprolol 77.5 p.o. b.i.d.
FOLLOW UP PLANS: The patient is to follow up with his
primary care physician as appropriate from discharge.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-735
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2112-2-11**] 15:51
T: [**2112-2-11**] 16:39
JOB#: [**Job Number 23265**]
ICD9 Codes: 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6629
} | Medical Text: Admission Date: [**2109-12-25**] Discharge Date: [**2109-12-26**]
Date of Birth: [**2078-6-19**] Sex: M
Service: EMERGENCY
Allergies:
Doxorubicin Hcl Liposomal
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Anaphylaxis to liposomal doxorubicin
Major Surgical or Invasive Procedure:
None
History of Present Illness:
31M with history of cutaneous T cell lymphoma who had
anaphylaxis to his first infusion of liposomal doxorubicin
(around 5ml). He was seen by his oncologist in clinic this AM
and then arranged to get first dose of lip dox. Few minutes into
his infusion, patient developed shortness of breath and became
stridorous with progressive facial swelling. He got benadryl 50,
pepcid, sq epi 0.4, decadron 10 mg and nebulized epi. He was
hemodynamically stable with O2 sat at 100% on NRB. He was
transferred from to [**Hospital Unit Name 153**] for monitoring.
Past Medical History:
Cutaneous T-cell lymphoma
RSV pneumonia- [**11-20**]
Social History:
Denied tobacco and illicit drug use. He drinks alcohol
occasionally. He works for a financial company. He is married
with 3 children.
Family History:
Denies family history of coronary artery disease, hypertension,
diabetes or cancer
Physical Exam:
97, 98, 144/73, 23, 100%/15L cool neb
GEN: comfortable, NAD
SKIN: diffuse hperpgmentation with multiple CTCL lesions,
ulcerations from the lympoma
NECK: occipital ulceration from CTCL, no supraclavicular or
cervical lymphadenopathy,
RESP: CTA b/l with good air movement throughout, no stridor
CV: RR, S1 and S2 wnl, 1/6 systolic mumrur at LSB
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
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
Pertinent Results:
[**2109-12-25**] 08:10AM GLUCOSE-104 UREA N-16 CREAT-1.4* SODIUM-137
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13
[**2109-12-25**] 08:10AM estGFR-Using this
[**2109-12-25**] 08:10AM ALT(SGPT)-22 AST(SGOT)-20 LD(LDH)-338* ALK
PHOS-95 TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2
[**2109-12-25**] 08:10AM TOT PROT-7.8 ALBUMIN-3.9 GLOBULIN-3.9
CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-2.2 URIC ACID-2.9*
CHOLEST-143
[**2109-12-25**] 08:10AM WBC-6.3# RBC-4.06* HGB-13.2* HCT-39.9*
MCV-99* MCH-32.4* MCHC-33.0 RDW-12.9
[**2109-12-25**] 08:10AM NEUTS-52 BANDS-0 LYMPHS-14* MONOS-3 EOS-30*
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2109-12-25**] 08:10AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2109-12-25**] 08:10AM PLT SMR-NORMAL PLT COUNT-250
Brief Hospital Course:
31M with history of cutaneous T cell lymphoma who had
anaphylaxis to his first infusion of liposomal doxorubicin.
.
# Anaphylaxis: Patient recieved IM epinephrine, diphenhydramine,
ranitidine, and inhaled epinephrine for immediate treatment of
his anaphylaxis reaction. Patient transiently developed stridor
but never had desaturations and was never intubated.
Patient was monitored overnight with stable vital signs, good
oxygen saturations on room air, normal phonation, and tolerating
po. A prednisone taper was initiated for 7 days. Standing
benadryl and ranitidine were continued on discharge.
.
# Cutaneous T cell lymphoma: stable; discussed with Dr. [**Last Name (STitle) **],
holding any further treatment for now. Patient to followup as
scheduled with Dr. [**Last Name (STitle) **].
.
# Acute Renal Failure: baseline around 1.2; increased to 1.4 on
admission to the ICU, resolved with rehydration.
.
# F/E/N: IVF with NPO. Repleted lytes PRN.
.
# PPx: Ambulatory after initial treatment.
.
# Access: PIV
.
# Dispo: to Home
.
# Code Status: Full
.
# Communication: HCP Wife [**Name (NI) **] [**Name (NI) 1005**] (Phone: [**Telephone/Fax (1) 52195**])
Medications on Admission:
Clobetasol 0.05 %--Apply to affected areas twice daily.
TRIAMCINOLONE ACETONIDE 0.1 %--apply to affected areas [**Hospital1 **]
BACTROBAN 2 %--Apply to wound twice daily [**Hospital1 **]
Discharge Medications:
1. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular PRN as needed for allergic reaction: GO TO THE
EMERGENCY ROOM IMMEDIATELY UPIN USING THIS MEDICATION.
Disp:*2 pens* Refills:*5*
2. Prednisone 5 mg Tablet Sig: 8,8,4,4,2,2,1,1 Tablets PO once a
day for 8 days: Please take 8 pills on the first day, then 8
pills, then 4 pills for 2 days, then 2 pills for 2 days, then 1
pill for 2 days until you complete this course.
Disp:*30 Tablet(s)* Refills:*0*
3. Diphenhydramine HCl 25 mg Tablet Sig: Two (2) Tablet PO every
six (6) hours for 7 days.
Disp:*56 Tablet(s)* Refills:*0*
4. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Anaphylaxis
Cutaneous T Cell Lymphoma
Discharge Condition:
Stable
Discharge Instructions:
During this admission you were treated for an allergic reaction.
Please continue to take all medications as prescribed. Please
come to the Emergency Department immediately if you develop any
recurrent symptoms.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/CUT. ONC. DERM. Phone:[**Telephone/Fax (1) 46583**]
Date/Time:[**2110-1-8**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2110-1-8**] 10:00
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6630
} | Medical Text: Admission Date: [**2106-3-1**] Discharge Date: [**2106-3-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Status-post arrest
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 724**] is a [**Age over 90 **] year male with past medical history of a
traumatic subdural hematoma s/p craniectomy, HTN, and afib.
Today while at his nursing home, he was noted to have
tonic-clonic movements, then collapsed on the floor. Per report
from the nursing home, no pulse was appreciated at that time.
CPR was started, and portable defibrillator pads were placed,
which advised no shock. He was reported to be asystolic. EMS
arrived approximately 3 minutes later. Intravenous access was
established and he was given 1 mg of epinephrine. The EMS team
attempted to intubated the patient, at which time zucchini was
noted in the airway above the vocal cords. This was removed and
he was intubated. CPR was continued and he was transported to
[**Hospital1 18**]. On route, he was noted to have return of spontaneous
circulation, with atrial fibrillation at a rate of 140 was
noted, with systolic blood pressure of 90.
.
Upon arrival to the ED, he was intubated, with a heart rate of
140 in atrial fibrillation and systolic blood pressure of 80.
Levophed was started. He converted into sinus before he was able
to be cardioverted, with improvement in his blood pressure. EKGs
demonstrated left axis deviation, RBBB, and ST depressions in
leads V3-V6. A right IJ was placed. He underwent a head CT which
demonstrated bilateral small collections, with possible acute
component. No trauma was apparent on examination. Neurosurgery
evaluated the patient in the ED and concluded no surgical
intervention was necessary. A chest x-ray was unremarkable and
revealed appropriate CVL and ETT placement.
.
He was started on the Arctic Sun protocol 90 minutes after
arrival and reached goal temp of 34C 150 minutes after arrival.
His granddaughter arrived to the emergency room. He was
transferred to the ICU for management.
.
Upon arrival to the ICU the patient is intubated, unresponsive,
and cooled to 34C. Fentanyl, versed, and norephinepherine drips
are running.
Past Medical History:
- Receives medical care at [**Hospital 3278**] Medical Center
- Traumatic subdural hematoma s/p 3 drainage procedures ~18
months ago
- Parkinsons Disease
- HTN
- Atrial fibrillation
- Hyperlipidemia
- Dysphagia
- Worsening gait
- Incontinence
Social History:
From [**Country 651**], has lived in the USA for >75 years. Lived
independently until 18 months ago. Had a fall with subdural
hematoma s/p 3 drainage procedures. Has since lived in a [**Hospital1 1501**] at
[**Hospital6 **]. At baseline good mental status with "only
a little" memory impairment. He walks with a walker, and
requires help often with eating, hygeine and other ADLs and
IADLs. Does not use tobacco, EtOH or other substances.
Granddaughter [**Name (NI) **] is his health care proxy.
Family History:
Noncontributory. Parents lived into their 100s.
Physical Exam:
VS: T=33.8C (bladder), HR=57, BP=106/64,
Intubated A/C 50% O2, 5 PEEP, 500cc Tv, 16 RR, 100% saturation.
Gen: Appears younger than given age. Intubated, arctic sun
cooling device in place, lying unresponsive.
Neuro: Does not respond to voice. Does not withdraw to painful
stimuli. R pupil unresponsive, L pupil 3->2.5mm sluggish
response to light without apparent consensual R pupil reflex. No
vestibuloocular reflex. Unable to access remaining cranial
nerves. Limbs are atonic. Reflexes absent throughout, toes
unresponsive on Babinski.
HEENT: Head without any lesions. Moist occular mucosa, sclera
noninjected, nonicteric. Nasogastric tube in place. Nasopharynx
without exudate. Oropharynx difficult to access with
endotrachael tube in place. No apparent lesions. Moist mucosa.
Neck: Supple. No lymphadenopathy. No thyromegaly. R IJ in place,
clean.
CV: JVD not elevated. PMI in the midclavicular line. Heart
sounds are soft. Regular rate. Preserved S1 and S2. No murmurs.
No gallop.
Pulm: Limited exam. Clear anteriorly and laterally with good air
movement bilaterally.
Abd: Exam limited by circumfirential cooling device. +BS. Soft.
No masses appreciated. 60cc dark urine in foley.
Ext: Cool. Present radial pulses. No pedal pulses. Good
capillary refill. No edema. No cyanosis.
Pertinent Results:
[**2106-3-1**] 01:06PM FIBRINOGE-73*
[**2106-3-1**] 01:06PM PT-28.8* PTT-117.3* INR(PT)-2.9*
[**2106-3-1**] 01:06PM PLT SMR-VERY LOW PLT COUNT-42*
[**2106-3-1**] 01:06PM WBC-2.2* RBC-0.84* HGB-2.7* HCT-9.0* MCV-106*
MCH-31.7 MCHC-29.9* RDW-14.1
[**2106-3-1**] 01:06PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2106-3-1**] 01:06PM LIPASE-16
[**2106-3-1**] 01:06PM estGFR-Using this
[**2106-3-1**] 01:06PM UREA N-17 CREAT-0.6
[**2106-3-1**] 01:19PM GLUCOSE-84 LACTATE-4.0* NA+-146 K+-1.2*
CL--137* TCO2-6*
[**2106-3-1**] 01:19PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TUBE
[**2106-3-1**] 01:34PM FIBRINOGE-263#
[**2106-3-1**] 01:34PM PT-16.4* PTT-45.7* INR(PT)-1.5*
[**2106-3-1**] 01:34PM PLT COUNT-165
[**2106-3-1**] 01:34PM WBC-13.5*# RBC-3.17*# HGB-10.5*# HCT-31.8*#
MCV-100* MCH-33.2* MCHC-33.1# RDW-13.1
[**2106-3-1**] 01:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2106-3-1**] 01:34PM ALBUMIN-3.4 CALCIUM-8.0* PHOSPHATE-7.4*
MAGNESIUM-2.5
[**2106-3-1**] 01:34PM CK-MB-NotDone
[**2106-3-1**] 01:34PM cTropnT-0.01
[**2106-3-1**] 01:34PM ALT(SGPT)-40 AST(SGOT)-203* LD(LDH)-357*
CK(CPK)-74 ALK PHOS-77 AMYLASE-251* TOT BILI-0.3
[**2106-3-1**] 01:34PM GLUCOSE-217* UREA N-42* CREAT-1.9*#
SODIUM-144 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-12* ANION
GAP-26*
[**2106-3-1**] 01:41PM K+-4.3
[**2106-3-1**] 01:41PM PO2-494* PCO2-37 PH-7.10* TOTAL CO2-12* BASE
XS--17
[**2106-3-1**] 01:52PM GLUCOSE-200* LACTATE-9.1* NA+-145 K+-4.5
CL--113* TCO2-12*
[**2106-3-1**] 05:12PM PT-14.9* PTT-33.7 INR(PT)-1.3*
[**2106-3-1**] 05:12PM PLT COUNT-137*
[**2106-3-1**] 05:12PM WBC-12.0* RBC-3.38* HGB-11.0* HCT-33.4*
MCV-99* MCH-32.4* MCHC-32.8 RDW-13.0
[**2106-3-1**] 05:12PM ALBUMIN-3.4 CALCIUM-6.8* PHOSPHATE-3.8#
MAGNESIUM-2.2
[**2106-3-1**] 05:12PM CK-MB-4 cTropnT-0.04*
[**2106-3-1**] 05:12PM ALT(SGPT)-54* AST(SGOT)-255* LD(LDH)-437*
CK(CPK)-102 ALK PHOS-73 TOT BILI-0.4
[**2106-3-1**] 05:12PM GLUCOSE-202* UREA N-42* CREAT-1.6* SODIUM-144
POTASSIUM-4.5 CHLORIDE-117* TOTAL CO2-17* ANION GAP-15
[**2106-3-1**] 05:48PM HGB-11.5* calcHCT-35
[**2106-3-1**] 05:48PM GLUCOSE-183* LACTATE-3.0* NA+-142 K+-4.6
CL--115*
[**2106-3-1**] 05:48PM TYPE-ART PO2-129* PCO2-37 PH-7.24* TOTAL
CO2-17* BASE XS--10
[**2106-3-1**] 10:45PM freeCa-1.22
[**2106-3-1**] 10:45PM HGB-12.8* calcHCT-38
[**2106-3-1**] 10:45PM GLUCOSE-121* LACTATE-3.0* NA+-143 K+-4.8
CL--115*
[**2106-3-1**] 10:45PM TYPE-ART TEMP-34 PO2-141* PCO2-36 PH-7.23*
TOTAL CO2-16* BASE XS--11 INTUBATED-INTUBATED
[**2106-3-1**] 11:14PM URINE URIC ACID-RARE
[**2106-3-1**] 11:14PM URINE GRANULAR-7*
[**2106-3-1**] 11:14PM URINE RBC-52* WBC-6* BACTERIA-FEW YEAST-NONE
EPI-0
[**2106-3-1**] 11:14PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2106-3-1**] 11:14PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2106-3-1**] 11:14PM URINE OSMOLAL-528
[**2106-3-1**] 11:14PM URINE HOURS-RANDOM UREA N-500 CREAT-114
SODIUM-32
CT head [**3-1**]:
IMPRESSION:
1. Small mixed density bifrontal subdural collections, likely
acute on
chronic.
2. Bilateral ethmoidal mucosal thickening, left maxillary
mucosal thickening
and aerosolized secretions in the nasal cavity. Clinical
correlation
recommended.
Echo [**3-2**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is small.
Left ventricular systolic function is hyperdynamic (EF 70-80%).
There is no ventricular septal defect. The right ventricular
cavity is dilated with borderline normal free wall function. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: dilated, borderline hypocontractile right ventricle;
small, hyperdynamic left ventricle
CT head [**3-3**]:
CONCLUSION: Negligible interval change from prior study.
Brief Hospital Course:
[**Age over 90 **]yo M with chronic subdural hematoma, Parkinsons, and [**Hospital1 1501**]
dependant at baseline who presented after cardiac arrest. The
patient suffered severe anoxic brain injury and was made CMO by
his family on the evening of [**3-9**] with plan for hospice care.
The patient is to not receive IV fluids, any antibiotics,
feeding tubes or dobhoffs nor is he to be rehospitalized for any
reason. The patient is to be full hospice care.
#) Arrest: Pt suspicious for asphyxiation leading to
cardiopulmonary arrest with asystole given that he was found to
have food at the vocal cords and he had an "non shockable"
rhythm. His history does not support other common causes of
PEA/asystole, and his lab abnormalities are likely a result and
not cause of arrest. Pt did not have circulation for a total of
10min. He was started on the arctic sun cooling protocol w/ goal
34C. Pt remained on artic sun for 24h then rewarmed,
electrolytes were monitered closely during rewarming. Pt did not
have any hemodynamic compromise after this.
#) Anoxic brain injury / AMS: Patient's neurologic exam is
concerning for significant impairment secondary to
cardiopulmonary arrest leading to anoxic brain injury. Neurology
was consulted. Initially sz activity was also on the
differential, but the EEG showed no epileptiform activity and
no lateralizing areas. His myoclonic jerks were attributed to
his anoxic brain injury. Pt did have intact pupillary reflex and
weak OCR, but absent corneal reflex, and stereotypic posturing
to pain in all extremities. His prognosis is very poor w/ little
chance of meaningful recovery and very likely to stay in
vegetative state. Family meeting was held and decided to attempt
extubation, and not reintubate if pt declines. Family was
against the idea of a trach/PEG, but are willing to have NG tube
- for food/meds. TF started. Palliative care consulted.
#) Respiratory Failure: There was no evidence on exam or CXR of
respiratory failure or significant gas exchange abnormality and
no evidence of further aspiration. Maintained on mandatory
ventilation while cooling. Wean O2 as tolerated. His peak airway
pressures have been in the 30s. This may be due to some
obstructive airway disease at baseline/ elevated lung volumes.
Pt was kept on vent because of his poor MS and inability to
protect airway, at least until a decision was made on pt's goals
of care. Pt was extubated and tolerated extubation well.
#) Aspiration Pneumonitis: His CXR was concerning for aspiration
PNA the next day and pt was started on Vanc/Zosyn. Pt's sputum
and blood cx remained negative for G(+) and Vanc was d/c. Pt
continues to have significant secretions even after extubation.
Pt was continued on an 8 day course of Zosyn, currently on day
[**6-23**].
#) Anion Gap: Patient has an anion gap with an elevated lactate,
both of which are improving with IV fluids and improved
hemodynamic status. This is secondary to cardiac arrest and
resultant poor perfusion.
#) Bifrontal subdural fluid collections - Patient with known
chronic subdural hematomas. CT concerning for possible new acute
progression in left frontal area. Seen by neurosurgery. No need
for acute intervention. Reimaging did now show any chagnes.
#) Acute Kidney Injury - Patient has an elevated creatinine
likely due to prerenal azotemia. This could be strictly prerenal
or may have progressed to ATN. It is reassuring that his
creatinine is now trending down. Rhabdomyolsis is unlikely given
the normal CK. Pt's prerenal failure resolveed.
#) ST depressions - EKG shows precordial ST depressions and
Troponin is elevated. This is likely secondary to arrest and CPR
leading to cardiac myocyte damage. ACS is unlikely by history.
Pt [**Name (NI) **].
Medications on Admission:
Atenolol 25mg PO daily
Lisinopril 2.5mg PO daily
Prilosec 20mg PO daily
Carbidopa/Levodopa 25/100 mg PO daily
Colace 100mg PO BID
Ipratropium-Albuterol neb QID PRN dyspnea
Mirapex 0.125mg qac
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-18**]
Drops Ophthalmic PRN (as needed).
2. Morphine Concentrate 20 mg/mL Solution Sig: 5-15 mg PO Q2H
(every 2 hours) as needed.
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
4. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H
(every 6 hours) as needed for fever.
5. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed.
6. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Center
Discharge Diagnosis:
Anoxic Brain Injury
Cardiopulmonary arrest
Acute Renal Failure
Elevated LFTs
Atrial fibrillation
Discharge Condition:
Comfort Meausures Only.
DNR/DNI, do not rehospitalize. No IVF, antibiotics. The goal of
care is comfort.
Discharge Instructions:
The patient has been made CMO. DNR/DNI, do not rehospitalize.
No IVF, antibiotics. The goal of care is comfort.
Followup Instructions:
Patient is CMO. Care at [**Hospital1 1501**].
ICD9 Codes: 4275, 5070, 5849, 496, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6631
} | Medical Text: Admission Date: [**2160-1-17**] Discharge Date: [**2160-1-23**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 82 year old
man with end stage renal disease on peritoneal dialysis with
a history of coronary artery disease, who presented with
worsening shortness of breath. The patient was in his usual
state of health until a few days prior to admission when he
began to experience worsening shortness of breath, more than
his baseline. He had experienced paroxysmal nocturnal
dyspnea for some time but more frequently and progressively
worse. At 4:00 a.m. the morning of admission, he awoke with
extreme shortness of breath which improved when he sat up.
He also reported dyspnea on exertion and occasional chest
discomfort with exertion over the six months prior to
admission, much worse over the week prior to admission. He
reports that his chest pain improved with rest. The patient
denied diaphoresis, nausea and vomiting. He reported that he
could only walk down a [**Doctor Last Name **] until he experienced shortness of
breath and needed to rest.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post percutaneous
transluminal coronary angioplasty to the D1 and right
coronary artery.
2. End stage renal disease secondary to focal segmental
glomerulosclerosis. The patient has been on chronic
ambulatory peritoneal dialysis for two and one half years and
has had two episodes of supraventricular tachycardia.
3. Chronic leukocytosis.
4. History of pulmonary embolus.
5. Chronic obstructive pulmonary disease.
6. Hypertension.
7. Hypercholesterolemia.
8. Congestive heart failure.
9. Gout.
10. Status post total hip replacement.
11. Status post right knee replacement.
12. Prostate cancer.
13. Status post cataract surgery.
14. History of adenomatous polyps.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.125 mg p.o. q.o.d.
2. PhosLo 2 mg p.o. three times a day.
3. Renagel 1500 mg p.o. three times a day.
4. Simvastatin 40 mg p.o. once daily.
5. Aspirin 81 mg p.o. once daily.
6. Lactulose 15 to 30 mg p.o. three times a day.
7. Metoprolol 2.5 mg p.o. once daily.
ALLERGIES: Motrin.
SOCIAL HISTORY: The patient quit smoking fifty years ago.
He denies alcohol use. His primary cardiologist is Dr. [**Last Name (STitle) 121**].
PHYSICAL EXAMINATION: Vital signs revealed temperature 96.3,
heart rate 89, blood pressure 134/72, oxygen saturation 99%
on two liters, weight 200 pounds. Cardiovascular - The
patient had distant heart sounds with a regular S1 and S2 and
faint S3. Pulmonary - He had faint bibasilar crackles.
Abdomen was obese, distended to percussion and nontender to
palpation. Extremities showed no edema, palpable posterior
tibial pulses and no femoral bruit. Neurologic examination
was intact.
LABORATORY DATA: On admission, white blood cell count was
14.7. Potassium 3.3. Blood urea nitrogen 33, creatinine
10.9. Liver function tests were normal. Digoxin level 0.88.
HOSPITAL COURSE: The patient was admitted and initially was
believed to rule in for myocardial infarction with a troponin
of 5.0. Maximal CK was 157 with a MG of 13 and a positive MB
index of 9.1. The patient was subsequently taken for cardiac
catheterization where coronary angiography of the right
dominant circulation revealed branch vessel coronary artery
disease. Left main coronary artery had no significant
stenoses. The left anterior descending had mild luminal
irregularities. D1 totally occluded distally at the site of
prior stenting. D2 no lesions. Left circumflex had mild
luminal irregularities. Three OM branches free of disease.
The right coronary artery was widely patent at the sites of
prior stenting and otherwise free of significant stenoses.
The right coronary artery supplied the posterior descending
artery and PLV. Resting hemodynamics were measured at
baseline and revealed a markedly impaired cardiac output of
3.6 liters per minute and a moderately elevated left
ventricular filling pressures with a left ventricular end
diastolic pressure of 25 mmHg. At rest, the gradient across
the aortic valve was 21 mmHg with a calculated valve area of
0.97 square centimeters. Dobutamine was infused up to 10
mcg/kg/minute. The patient's systolic blood pressure fell to
a level of 70 mmHg. During this time, the patient's cardiac
output rose to 5.9 liters per minute. Aortic valve
calculations revealed peak gradient of 34 mmHg and a valve
area of 1.02 square centimeters. The patient was then
started on Dopamine with no effect on the systemic arterial
pressure. For this reason, an intra-aortic balloon pump was
inserted with subsequent return of blood pressure to baseline
and a cardiac output of 7.1 liters per minute.
The patient was transferred to the Cardiac Care Unit where he
was weaned off the balloon pump and Dopamine without
difficulty. Electrophysiology service was consulted and
evaluated the patient for biventricular pacemaker which was
placed in addition to an ICD. The patient's symptoms of
shortness of breath improved markedly after the biventricular
pacer placement. He was transferred to the Cardiac Medicine
floor for an additional day of monitoring. He had one
episode of systolic blood pressure in the high 70s but
otherwise was stable through the remainder of his hospital
course.
Renal - The patient was continued on his chronic ambulatory
peritoneal dialysis throughout his hospital stay. He was
closely followed by his primary nephrologist as well as the
renal team. The patient's persistent leukocytosis was not
felt to be a change, however, a sample of a diasolate was
sent for culture with no growth by the time of discharge.
Gram stain was negative. Per the renal team, the patient was
instructed to continue his outpatient antihypertensive
regimen with further fine tuning of his blood pressure
through dialysis.
DISCHARGE DIAGNOSES:
1. Status post biventricular pacer.
2. Congestive heart failure.
MEDICATIONS ON DISCHARGE:
1. Digoxin 0.125 mg p.o. q.o.d.
2. PhosLo 2 mg p.o. three times a day.
3. Renagel 1500 mg p.o. three times a day.
4. Simvastatin 40 mg p.o. once daily.
5. Aspirin 81 mg p.o. once daily.
6. Lactulose 15 to 30 mg p.o. three times a day.
7. Metoprolol 2.5 mg p.o. once daily.
FOLLOW-UP: Device Clinic [**2160-1-29**], at 1:00 p.m., Dr. [**Last Name (STitle) 121**] in
two weeks after discharge, Dr. [**Last Name (STitle) 174**] as needed.
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2160-1-23**] 20:36
T: [**2160-1-27**] 11:34
JOB#: [**Job Number 21536**]
ICD9 Codes: 4241, 496, 4254, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6632
} | Medical Text: Admission Date: [**2174-11-28**] Discharge Date: [**2174-12-1**]
Date of Birth: [**2094-6-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Dyspnea (although patient non-verbal)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 YO nonverbal M with end-stage Alzheimer's and a
well-documented h/o chronic aspiration p/w increased breath
sounds. The patient's CC from the ED was initially dyspnea, but,
per MICU resident discussions with the family, they were
concerned about increased airway sounds described as "gurgling."
The patient has failed a s/s eval in the past with frank
aspiration. The family decided not to pursue a g-tube in the
past despite documented aspiration given lack of likely benefit
for the patient. The family normally will feed him yougerts at
home and reports that he coughs with all PO intake. As the
patient is non-verbal and only tracks to voice, please refer to
the MICU history obtained from the family.
.
The patient was briefly admitted to the MICU due to persistent
tachycardia despite having been given 3L of fluids in the ED.
Upon review of prior EKGs, it appears the patient has been
persistently tachycardic. A d-dimer was checked and was elevated
so a CTA was ordered; the read is pending at this time. He has
not been noted to be hypoxic while awake although sats did drop
to the high 80s while sleeping. He did respond to 1L NC. In
addition, the patient was reportedly suctioned by MICU nursing
staff who produced whole pieces of food from his airways.
Past Medical History:
Recent hospitalization ([**Date range (2) 43948**]) with resp failure and
resultant intubation requiring intubation
Alzheimer's dementia- nonverbal at baseline
h/o pneumonia requiring intubation 2 years ago
h/o SBO [**1-29**]
HTN
Social History:
Lives at home with wife and son. [**Name (NI) **] is his primary caregiver.
[**Name (NI) **] is dependent for all ADLs. Pt is originally from [**Country 3587**].
He lived in [**Country 6257**] for 40 years, moved to US in [**2151**]. Formerly
worked in construction, building maintenance. History of
sniffing tobacco, but none for greater than 10 years. No history
of smoking or EtOH use.
Family History:
non-contributory
Physical Exam:
Vitals - T: afebrile BP: 105/65 HR: 116 (low 100s to 120s) RR:
22 02: 93% on 1L while sleeping
GENERAL: opens eyes, non verbal, tracks
HEENT: NCAT, edentulous, PERRL
CARDIAC: tachy, no MRG
LUNG: diffuse rhonchi
ABDOMEN: soft, NT/ND, NBS
EXT: no CCE
Pertinent Results:
[**2174-11-28**] 07:40AM WBC-9.3 RBC-5.49 HGB-17.0 HCT-53.7*# MCV-98
MCH-30.9 MCHC-31.6# RDW-12.7
[**2174-11-28**] 07:40AM NEUTS-74* BANDS-2 LYMPHS-10* MONOS-7 EOS-0
BASOS-0 ATYPS-7* METAS-0 MYELOS-0
[**2174-11-28**] 07:40AM PLT SMR-NORMAL PLT COUNT-320
[**2174-11-28**] 07:40AM GLUCOSE-187* UREA N-15 CREAT-1.0 SODIUM-145
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-25 ANION GAP-16
[**2174-11-28**] 07:40AM ALT(SGPT)-19 AST(SGOT)-17 LD(LDH)-209
CK(CPK)-64 ALK PHOS-70 TOT BILI-0.9
[**2174-11-28**] 07:40AM LIPASE-17
[**2174-11-28**] 07:40AM cTropnT-<0.01
[**2174-11-28**] 07:40AM CK-MB-NotDone
[**2174-11-28**] 07:40AM ALBUMIN-4.1
CXR [**2174-11-28**]:
1. Decrease mild vascular congestion. Cleared pneumonia.
2. Mild right lower lobe atelectasis, unchanged.
Chest CTA [**2174-11-28**]:
1. No evidence of central pulmonary embolism.
2. Findings most consistent with chronic or recurrent
aspiration, including dependent bibasilar airspace opacities,
peribronchiolar consolidation, and mild cylindrical
bronchiectasis.
3. Possible tracheomalacia. If clinically indicated, further
evaluation
could be performed with dedicated CT airway study when the
patient is
clinically able.
Brief Hospital Course:
80-year-old non-verbal man with end-stage Alzheimer's and
chronic aspiration presented with increased airway secretions
and tachycardia, concerning for aspiration pneumonia.
# Aspiration pneumonia: patient has a long history of chronic
aspiration, and his family was fully aware of the risks of PO
intake. Even though he had no fever, his history of aspiration,
his tachycardia and oxygen requirement on admission were
concerning for aspiration pneumonia. Therefore, he was treated
with clindamycin and levofloxacin and was discharged on these
antibiotics to finish a 5-day course. By discharge, patient was
breathing comfortably on room air.
# Dysphagia: was seen by speech and swallow again during this
admission, who recommended pureed diet.
# Hematuria: seen on urinarlysis. Should be followed up as
outpatient.
# CODE: FULL
Medications on Admission:
Viatmin E 800units [**Hospital1 **]
Albuter MDI 2 puffs PRN
Zocor 20mg daily
Ambien 5mg HS PRN
Bisacodyl PR PRN
Discharge Medications:
1. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
2. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**11-26**] inh Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
4. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis: aspiration pneumonia
Secondary diagnoses: Alzheimer's dementia, hypertension
Discharge Condition:
Stable. O2 saturation 97 on room air, not tachycardic or
tachypneic.
Discharge Instructions:
You presented to [**Hospital1 69**] with
increased gurgling. You were found to have a possible aspiration
pneumonia and were started on antibiotics. By discharge, your
respiratory status was stable, and you did not need supplemental
oxygen. Please take these antibiotics, along with the rest of
your medications, as instructed.
Followup Instructions:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: [**Last Name (LF) 766**], [**12-5**] at 11:30am
Location: [**Location **], [**Hospital1 **],
[**Location (un) **],[**Numeric Identifier 12201**]
Phone number: [**Telephone/Fax (1) 7976**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
ICD9 Codes: 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6633
} | Medical Text: Admission Date: [**2119-7-4**] Discharge Date: [**2119-7-8**]
Date of Birth: [**2037-1-20**] Sex: M
Service: MEDICINE
Allergies:
Phenytoin / Cefazolin
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Hypotension, fever, hypoxia
Major Surgical or Invasive Procedure:
[**2119-7-4**] s/p Left Knee Aspiration
.
[has Single lumen PICC, Right AC, placed [**2119-6-27**] @ [**Hospital1 2025**],
placement confirmed by CXR @ [**Hospital1 18**]]
History of Present Illness:
HPI: This is a 82 year-old M with a history of rheumatoid
arthritis S/P bilateral total knee replacements and recent
admission to [**Hospital1 2025**] for left septic knee ([**Date range (2) 94427**],
7/22-29/08)(Coagulase negative Staph) who presents from rehab
with episodes of "staring and unresponsiveness." After
completing a physical therapy session on the day prior to
admission, patient was noted by his wife to be unresponsive
while lying in bed, with a gaze fixed to the left. She denied
witnessing any myoclonic jerks, but does think he may have had
urinary incontinence, without fecal incontinence.
.
Patient was transferred by EMS to [**Hospital3 417**] ED. On arrival
to ED, he was noted to have fever to 103, BP 93/57, HR 98, RR
40, Sat 96% on 2L and he received 750 mg IV levofloxacin. Course
was notable for frequent emesis, subsequent respiratory
distress, and hypotension to 78/57 unresponsive to fluids, so he
was started on Levophed gtt. He was transferred to [**Hospital1 18**] for
further evaluation and management.
.
Of note, patient has had recurrent infectious complications
related to knee hardware, and was most recently discharged on
Vancomycin/Rifampin suppressive therapy, per ID recommendations.
He also had recent episodes of diarrhea, but has been rule-out
for C. difficile at [**Hospital1 2025**], and empiric metronidazole was
discontinued.
Past Medical History:
#. Bilateral hip and knee replacements
-L knee replaced [**2099**] c/b hardware dislocation and infection
?[**2113**], cultures grew coag negative staph and p. acnes, treated
with vancomycin x6weeks followed by levofloxacin/rifampin
suppressive therapy subsequently changed to doxycycline
#. Septic L knee [**5-7**]
- Arthrocentesis showed >35k WBC with 98% polys, s/p I+D and
linear replacement but retained hardware
- Culture grew Staph lugdunesis (Tet R, Ox/Vanc/Clinda/Bactrim
S)
- Initially treated with nafcillin/rifampin
- Represented with diarrhea on [**6-4**] (workup negative), knee said
to have some surround erythema, underwent repeat tap WBC 9700
72%
polys.
- Nafcillin changed to vancomycin [**6-21**] due to concern for ?naf
related AIN
#. Rheumatoid arthritis and OA
#. Hypertension
#. Hypercholesterolemia
#. Prostate cancer s/p prostatectomy
#. Spinal stenosis s/p laminectomy
#. s/p wrist surgery, plate
#. Polyneuropathy
#. s/p TURP
Social History:
The patient is retired and usually lives with his wife although
more recently in rehab. He is now retired, but previously worked
in insurance
Tobacco: None
ETOH: None
Illicits: None
Family History:
Noncontributory
Physical Exam:
D/C Physical Exam:
=================
.
T 98.2, P 72 BP 138/87 RR 18 O2 97% on RA
General: elderly man sitting in [**Female First Name (un) 1634**] chair, alert, flat affect,
somewhat lethargic
HEENT: PERRL, EOMI, sclera white, conjunctiva pale, MMM
Pulm: Bibasilar/posterior fine crackles which do not clear w/
DB&C.
CV: RRR, s1 s2, 2/6 SEM RUSB
Abd: Soft nontender +bowel sounds, no masses or organomegaly
Extremities: bilat LE - warm, slight pitting ~[**11-30**] to knees L>R,
hemesidern noted, DP 2+, cap refill ~ 3 secs, CSM intact,
blanching erythema bilat heels.
L knee with midline well approximatedly surgical wound,
non-tender& non-erythemic but slightly warm to touch, more
swollen compared to the right.
Neuro: Alert, oriented to self (name & DOB), month "[**Month (only) 216**]",
year "08", president "[**Last Name (un) 2450**]"; day "6" (is 9th), location "rehab",
when corrected to hospital, can not say which one. Face
symmetrical @ rest & with movement, tongue midline, resonds
appropriately to requests.
Derm: Erythemic rash in bilat buttocks region, hyperkeratosis
noted bilat feet, skin tear left anterior upper chest w/ dsg
D&I. Bruising noted right lateral flank just superior to illiac
crest.
Access: single lumen PICC, right AC.98.2
Pertinent Results:
ADMISSION LABS:
===============
[**7-4**]: Joint Aspirate ??????left knee ?????? WBC 8000, RBC [**Numeric Identifier 92903**], PMNs 77%,
Lymph 2%, Mono 20%, Eos 0% -c/w inflammatory background but
unlikely septic
[**7-4**]: Gram stain joint fluid prelim ?????? 2+ PMNs, no microorganisms
to date
[**7-4**]: joint crystal analysis pending
[**2119-7-4**] 05:16AM URINE RBC-2 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0
[**2119-7-4**] 05:16AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
[**2119-7-4**] 05:16AM PT-15.0* PTT-33.7 INR(PT)-1.3*
[**2119-7-4**] 05:16AM GLUCOSE-158* UREA N-23* CREAT-1.7* SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
[**2119-7-4**] 05:16AM ALT(SGPT)-11 AST(SGOT)-18 LD(LDH)-165 ALK
PHOS-125* TOT BILI-0.5
[**2119-7-4**] 05:16AM proBNP-264
[**2119-7-4**] 05:16AM ALBUMIN-2.7* CALCIUM-9.6 PHOSPHATE-3.8
MAGNESIUM-1.6
[**2119-7-4**] 05:16AM WBC-18.8* RBC-2.91* HGB-8.7* HCT-25.8* MCV-89
MCH-29.9 MCHC-33.8 RDW-15.3
[**2119-7-4**] 05:16AM NEUTS-78.8* BANDS-0 LYMPHS-16.9* MONOS-3.7
EOS-0.3 BASOS-0.3
.
IMAGING:
=======
[**2119-7-5**] PELVIS (AP ONLY) PORT - FINDINGS: The patient is status
post bilateral total hip arthroplasty with revision prosthesis
on the right. There is no major hardware complication seen on
the radiograph. Comparison with prior study will be helpful.
There is severe osteoarthritic changes in the lower lumbar
spine. IMPRESSION: No major hardware complication. Recommend
comparison with prior study.
[**2119-7-5**] CHEST (PORTABLE AP) - Since yesterday, lung volumes
improved and bibasilar atelectasis slightly decreased. Left
lower lobe alveolar opacity also slightly decreased but persists
associated with unchanged patchy alveolar opacity in the right
mid lung, worrisome for multifocal pneumonia which should be
followed up. There is no vascular congestion. Heart size is top
normal and the aorta is moderately tortuous. Right PICC line is
in SVC in unchanged position. Blunting of the left
costodiaphragmatic angle is unchanged.
[**2119-7-4**] KNEE (AP, LAT & OBLIQUE - IMPRESSION: 1) Tibiofemoral
prosthesis;
2) Small lucency in the medial tibial plateau suspicious for
fracture,
comparison to old films would be very useful; 3) Absence of the
patella with dystrophic calcifications seen anteriorly; 4) Large
joint effusion. Joint aspiration would be required if there is
concern for septic joint.
[**2119-7-4**] CHEST (PORTABLE AP) - IMPRESSION: 1. Left lower lobe
pneumonia;
2. Mild pulmonary edema.
.
EEG:
===
[**2119-7-4**] - BACKGROUND: Somewhat unevenly modulated [**8-9**] Hz
posterior background with occasional slower alpha was seen
throughout the later portions of the record with the patient
fully awake. The anterior-posterior voltage gradient was
preserved. No focal, lateralized, or discharging abnormalities
were noted in waking. HYPERVENTILATION: Not performed.
INTERMITTENT PHOTIC STIMULATION: Not performed. SLEEP: The
patient began the tracing in stage II sleep and only gradually,
over time, was able to be aroused to full wakefulness, after
which the patient maintained full wakefulness for the second
half of the record. No abnormalities were noted in stage II
sleep. CARDIAC MONITOR: No arrhythmias noted. IMPRESSION:
Borderline EEG due to some uneven voltage modulation but without
any marked or undue slowing or discharging features. The
clinical significance of the uneven voltage modulation is
uncertain and is of a lesser clinical significance.
.
EEG:
===
[**2119-7-4**] - IMPRESSION: Borderline EEG due to some uneven voltage
modulation but without any marked or undue slowing or
discharging features. The clinical significance of the uneven
voltage modulation is uncertain and is of a lesser clinical
significance.
.
MICROBIOLOGY:
============
[**2119-7-8**] STOOL - CLOSTRIDIUM DIFFICILE TOXIN A & B TEST
(Pending):
[**2119-7-8**] STOOL - OVA + PARASITES (Pending)
[**2119-7-5**] BLOOD CULTURE (Source: Line-PICC) - Pending
[**2119-7-4**] URINE C&S (Catheter) - NO GROWTH
[**2119-7-4**] Blood Cultures x's 3 - pending
[**2119-7-4**] JOINT FLUID (Knee) - GRAM STAIN (Final [**2119-7-4**]): 2+
(1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES; NO
MICROORGANISMS SEEN. FLUID CULTURE (Final [**2119-7-7**]): NO GROWTH.
.
DISCHARGE LABS:
===============
[**2119-7-7**] STOOL - FECAL CULTURE (Pending); CAMPYLOBACTER CULTURE
(Pending); OVA + PARASITES (Pending); CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST (Final [**2119-7-8**]): Feces negative for
C.difficile toxin A & B by EIA.
[**2119-7-7**] 04:59AM BLOOD Vanco-27.9*
[**2119-7-8**] 05:03AM BLOOD WBC-8.1 RBC-3.07* Hgb-9.4* Hct-27.5*
MCV-89 MCH-30.4 MCHC-34.0 RDW-16.6* Plt Ct-297
[**2119-7-8**] 05:03AM BLOOD Neuts-58.7 Lymphs-30.1 Monos-7.1 Eos-3.3
Baso-0.8
[**2119-7-8**] 05:03AM BLOOD Glucose-89 UreaN-14 Creat-1.4* Na-139
K-3.6 Cl-108 HCO3-24 AnGap-11
[**2119-7-8**] 05:03AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.7
Brief Hospital Course:
82 year old male with h/o RA on chronic prednisone, multiple
joint replacements with h/o recent L knee septic joint [**5-7**] on
Vanc/rifampin admitted [**7-4**] with hypotension/hypoxia/MS
changes/fevers/possible seizures. Found to have severe sepsis
[**12-31**] PNA (HAP), placed on zosyn with improvement in above and
admitted to ICU. Transfered to Gen Med [**7-5**] for further
management.
.
Hospital/healthcare Aquired Pneumonia - admitted with fevers,
leukocytosis, MS changes, cough/hypoxia--> severe sepsis/septic
shock (pressors), which has resolved. Patient with LLL and RML
PNA on imaging, ?HAP vs aspiration pneumonitis.
Improved clinical status on Zosyn (10 day course, Day 1 =
[**2119-7-4**], last day = [**2119-7-13**], d/c on [**2119-7-14**]) and Vanc 750mg
q24h (until [**7-11**] for septic joint), currently on RA. Of note,
Vancomycin dose decreased from 1 g -> 750 mg for a Vancomycin
level of 27.9 on [**2119-7-7**] at 0500H.
.
Diarrhea: per wife, this was a [**Last Name 16423**] problem when previously on
nafcilin in [**5-7**], then switched to vanc and placed on imodium
with some improvement but still persistant diarrhea 2-3X/day.
Now, over past day back to having frequent loose stools (not
able to provide more info). No feves, white count is stable. of
note, has also been off imodium while here. not associated with
meals, thus secretory (not osmotic). Stool for C diff negative
x's one & second pending. Given past h/o diarrhea, ID
reccomended NOT starting c. diff rx empirically. Some perirectal
skin rash [**12-31**] stool incot, & need to monitor I/O's & lytes.
.
Acute on chronic renal failure, resolved. Per chart review,
baseline creatinine appears to be around 1.2-1.4. Has improved
with IVF, creatinine 1.4 on [**2119-7-8**]. Would monitor closely given
multiple antibiotics & potential for electrolyte imbalance with
diarrhea.
.
Chronic Septic Arthritis, seen by ID here. Left knee tap this
admission negative cx (inflamm effusion). Continue Vancomycin
and Rifampin (plan to Rx until 8/12 per notes, then bactrim
suppression). Follow up by [**Hospital1 2025**] Ortho and ID clinics: has Ortho
appointment but NEEDS APPOINTMENT WITH [**Hospital1 2025**] ID.
.
Anemia NOS: normocytic, no evidence of bleeding, Fe studies not
suggesting Fe def, T.bili normal so no hemolysis. Most likely
ACD given chronic septic joint. Received 2U PRBC on [**2119-7-6**]. Hct
27.5 on D/C.
.
Altered Mental Status/delirium - multifactorial, but mostly
likely brewing PNA. CT head negative. MS now back to baseline. ?
staring episode concerning for seizure, EEG unremarkable, but
does not rule out (nonepileptiform). [**Month (only) 116**] have been related to
hypotension/[**Month (only) **] cerebral perfusion. Neuro exam nonfocal. If
concern or repeat ? sz like activity, MRI as outpt, but none
indicated currently.
.
Rheumatoid arthritis ?????? chronic prednisone, was placed on stress
dose steroids in ICU X2days, then prednisone X50mg X2doses, then
switched to Prednisone 5mg [**Hospital1 **] and now on Prednisone 5 mg qd.
.
Hyperlipidemia ?????? continue Atorvastatin 20 mg PO QD
.
Hypertension - normotensive currently, re-started on Metoprolol
Tartrate 25 mg PO BID.
.
Decreased appetite & ? Depression - started on Mirtazapine 15 mg
PO QHS on [**2119-7-7**].
.
PPx: Heparin 5000 units SQ TID; Protonix 40 mg po QD
.
Dispo/Code: DNR but not DNI, confirmed with patient.
Medications on Admission:
Rifampin 300 mg [**Hospital1 **]
Bactrim 1 tab daily
Vancomycin 1 gm IV Q 24 hrs
Prednisone 5 mg daily
Omeprazole 20 mg daily
Loperamide 2 mg [**Hospital1 **] PRN
Tylenol 650 mg Q 6 hrs PRN
Oxycodone 5 mg Q 6 hrs PRN
Calcium carbonate 1 tab daily
Lactobacillis 1 packet [**Hospital1 **]
Ferrous sulfate 324 mg daily.
Lovenox 40 mg sub Q daily
Simvastatin 10 mg daily
Multivitamins with minerals 1 tab daily
Lopressor 25 mg [**Hospital1 **]
Nexium 40 mg PO daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. 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.
10. Piperacillin-Tazobactam Na 2.25 g IV Q6H x's 10days, Day
1=[**2119-7-4**], last day = [**2119-7-13**], d/c on [**2119-7-14**]
11. Vancomycin 750 mg IV Q 24H, last day = [**2119-7-11**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
=================
Hospital Aquired Pneumonia, Sepsis
Altered Mental Status
Acute Renal Failure
.
Secondary Diagnosis:
===================
#. s/p Bilateral hip and knee replacements, L knee replacement
([**2099**]) c/b hardware dislocation and infection in ?[**2113**], cultures
grew coag negative staph and p. acnes.
#. Septic L knee [**5-7**], arthrocentesis showed >35k WBC with 98%
polys, s/p I+D and linear replacement but retained hardware,
culture grew Staph lugdunesis (Tet R, Ox/Vanc/Clinda/Bactrim S),
associated diarrhea on [**6-4**] (workup negative)
#. Rheumatoid arthritis and OA
#. Hypertension
#. Hypercholesterolemia
#. Anemia
#. Prostate cancer s/p prostatectomy
#. Spinal stenosis s/p laminectomy
#. s/p wrist surgery, plate
#. Polyneuropathy
#. s/p TURP
Discharge Condition:
Stable: o2 sat 97% RA, no longer hypotensive, taking & retaining
PO's, continues incot loose/liquid brown stools.
Discharge Instructions:
You were admitted to the hospital after experiencing a change in
mental status, low blood pressure, and vomitting. You also
developed a high fever and trouble breathing. Initially you were
sent from Rehab ([**Hospital1 **]) to a local hospital (Caritas
Good Saamaritan)and then transfered to [**Hospital1 **].
You were found to have Pneumonia in several places in your
lungs, probably from aspiration. An aspiration of the fluid in
your left knee did not reveal any bacteria or fungus. Your
breathing and blood pressure has gotten better, so we are
transferring you back to your rehabilitation site.
.
It is important that you take all of your medications as
prescribed and also to follow the instructions of the therapists
at rehabilitation.
.
A new antibiotic called Zosyn was started. You will need to
complete a ten day course of this medication. Your Rifamoin was
continued as was your Vancomycin (but at a lower dose). Your
Bactrim was discontinued.
.
Please let your care givers know if you have any of the
following:
changes in mental status, fever or shaking chills, uncontrolled
vomiting, any blood or "coffee grounds" in any vomit, chest
pain/pressure, trouble breathing, pain in your throat or
abdomen, increased difficulty walking, feel dizzy or
light-headed, blood in your stools, black stools, pain not
adequately controled by medications or other health-related
concerns.
.
Please make and keep all of your follow-up apointments. You
should follow-up with your Primary Care Provider when you are
discharged from the rehabilitation setting.
Followup Instructions:
Please make & keep your follow-up appointments.
.
[**Hospital1 2025**] Orthopaedic Surgery: Dr. [**First Name11 (Name Pattern1) 3613**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 23001**], MD, [**Telephone/Fax (1) 94428**],
for [**2119-8-14**]: 7:30 AM x-rays & 8:00 AM with Otho Fellow and Dr.
[**Last Name (STitle) 23001**].
.
Please call Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 94429**], MD, Infectious Disease at [**Hospital1 2025**],
([**Telephone/Fax (1) 94430**] to schedule a follow-up appointment.
Completed by:[**2119-7-8**]
ICD9 Codes: 0389, 5070, 5849, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6634
} | Medical Text: Admission Date: [**2146-11-21**] Discharge Date: [**2146-11-28**]
Date of Birth: [**2066-7-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfasalazine / Morphine / Nsaids / Fosamax
Attending:[**First Name3 (LF) 10682**]
Chief Complaint:
Fever and Vomiting
Major Surgical or Invasive Procedure:
A line [**2146-11-21**]
Central venous line, RIJ, [**2146-11-21**]
History of Present Illness:
80F with RA on prednisone and chronic diastolic CHF admitted
with hypotension and tachycardia. Presented to PCP's office on
the day of admission with headache and rhinitis beginning 3 days
prior. Symptoms followed with anorexia and nonbloody, nonbilious
vomiting. Reports fever as high as 103.4, dysuria, and
epigastric pain which she attributes to dry heaving. Reports
[**7-9**] constant nonradiating nonpositional substernal chest
pressure beginning earlier this evening, without associated
lightheadedness, diaphoresis, palpitations, nausea, dyspnea, or
edema. Reports that her weight is stable. Never experienced
chest pressure before. Had a flu vaccine earlier this season. On
exam in clinic T 99 O2sat 96%RA BP 86/60 HR 120 while standing
and 90/60 HR 120 while supine. EKG showed newly discovered AFib
with RVR. Referred to ED. Triage V/S 98.0 120 119/81 14 95% 3L
NC. Rectal temp 102 BP 86/51 normal mentation guaiac negative.
Labs notable for lactate 0.7 (after 3L NS) WBC# 16.3 (86.5%
PMN), BNP 7980, trop 0.09, U/A+. CXR showed cardiomegaly but no
acute process. Persistently hypotensive (MAP 50s) despite 3L NS
- right IJ was placed. Started levophed gtt. Given vancomycin 1
g IV, zosyn 4.5 g IV, ASA 325, acetaminophen 1 g, 3L NS. V/S
prior to transfer 118 93/52 (levophed 0.04 mcg/kg/min) 29 96%2L.
Past Medical History:
RA
Chronic diastolic CHF
Hyperparathyroidism
Hyperlipidemia
Shingles
Osteoporosis
DJD
Adenomatous/hyperplastic polyps
Internal & external hemorrhoids
s/p R THR ([**2135**]), bilat TKR
Social History:
[**Hospital 8735**] home health aide. Lives with her husband in [**Name (NI) 2312**].
Former smoker, quit ~20 years ago.
Family History:
Two sisters have had "heart attacks" but are alive and well in
their 80s.
Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 153**]:
V/S: T 98.3 BP 126/65 HR 133 RR 17 O2sat 98%2LNC.
GEN: Appears well, respirations nonlabored
HEENT: OP clear dry MM
NECK: R IJ site c/d/i flat neck veins
RESP: bibasilar rhonchi clear with coughing no wheeze
CV: irreg irreg tachy nl S1S2 no m/r/g
ABD: soft NTND normoactive BS
EXT: warm, dry tr pitting edema to mid-calves bilat no leg
swelling
SKIN: no rash
NEURO: AAOx3
Pertinent Results:
Admission labs:
[**2146-11-21**] 02:15PM BLOOD WBC-16.3* RBC-4.21 Hgb-13.4 Hct-38.7
MCV-92 MCH-31.8 MCHC-34.5 RDW-13.8 Plt Ct-280
[**2146-11-21**] 02:15PM BLOOD Neuts-86.5* Lymphs-9.7* Monos-3.4 Eos-0.1
Baso-0.4
[**2146-11-21**] 02:15PM BLOOD PT-14.8* PTT-28.0 INR(PT)-1.3*
[**2146-11-21**] 02:15PM BLOOD Glucose-87 UreaN-21* Creat-1.1 Na-134
K-4.0 Cl-94* HCO3-27 AnGap-17
[**2146-11-21**] 02:15PM BLOOD ALT-16 AST-31 LD(LDH)-245 AlkPhos-91
TotBili-0.7
[**2146-11-21**] 02:15PM BLOOD proBNP-7980*
[**2146-11-21**] 02:15PM BLOOD cTropnT-0.09*
[**2146-11-22**] 02:40AM BLOOD cTropnT-0.09*
[**2146-11-22**] 12:54PM BLOOD CK-MB-7 cTropnT-0.05*
[**2146-11-21**] 02:15PM BLOOD Albumin-3.4* Calcium-8.7 Mg-1.8
[**2146-11-22**] 02:40AM BLOOD Iron-12*
[**2146-11-22**] 02:40AM BLOOD calTIBC-215* Hapto-295* Ferritn-284*
TRF-165*
[**2146-11-21**] 06:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2146-11-21**] 06:00PM URINE Blood-TR Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-MOD
[**2146-11-21**] 06:00PM URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE
Epi-0
[**2146-11-21**] 6:00 pm URINE Site: CATHETER
Discharge labs:
[**2146-11-28**] 06:00AM BLOOD WBC-11.3* RBC-3.93* Hgb-11.8* Hct-37.3
MCV-95 MCH-30.1 MCHC-31.7 RDW-14.9 Plt Ct-361
[**2146-11-28**] 06:00AM BLOOD Glucose-80 UreaN-22* Creat-0.9 Na-143
K-3.9 Cl-107 HCO3-31 AnGap-9
[**2146-11-28**] 06:00AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.8
[**2146-11-24**] 06:55AM BLOOD CK(CPK)-66
[**2146-11-24**] 06:55AM BLOOD CK-MB-6 cTropnT-0.03*
[**2146-11-28**] 06:00AM BLOOD PT-27.2* PTT-34.3 INR(PT)-2.7*
[**2146-11-24**] 10:28AM BLOOD %HbA1c-6.4* eAG-137*
[**2146-11-24**] 06:55AM BLOOD Triglyc-88 HDL-36 CHOL/HD-3.1 LDLcalc-59
[**2146-11-24**] 06:55AM BLOOD calTIBC-234* Ferritn-229* TRF-180*
**FINAL REPORT [**2146-11-23**]**
URINE CULTURE (Final [**2146-11-23**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2146-11-21**]
ECG
Atrial fibrillation, average ventricular rate 123. Early
transition. Diffuse non-specific T wave changes. No previous
tracing available for comparison.
[**2146-11-21**]
CXR:
PA and lateral views of the chest are obtained. The heart is
moderately enlarged. Mild interstitial prominence within the
lungs could indicate chronic lung disease and clinical
correlation is advised. No gross CHF. No pleural effusion or
pneumothorax. Aorta is unfolded. Bony structures appear grossly
intact.
IMPRESSION: Cardiomegaly. Prominence of the interstitial
markings could
reflect interstitial lung disease for which clinical correlation
is advised.
ECHO [**11-25**]-The left atrium is mildly dilated. The right atrium
is moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 10-20mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). There is no ventricular septal defect. Right
ventricular chamber size is normal. with borderline normal free
wall function. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**1-1**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Brief Hospital Course:
A/P: 80F with RA on prednisone and chronic diastolic CHF
admitted with shock and afib with RVR.
#Sepsis from urinary tract infection. Patient presented with
fever, dysuria, and positive UA on the background of hypovolemia
[**2-1**] poor oral intake and vomiting, complicated by rate-related
hypotension from poor distolic filling time in the setting of
rapid AF. She required phenylepherine the night of ICU
admission. Her initial antibiotics were vancomycin and zosyn,
but vancomycin was discontinued as E coli was growing out on
[**2146-11-22**]. She was switched from Zosyn to ceftriaxone as the
E. coli turned out to be pan-sensitive on [**2146-11-23**]. This was
changed to PO cipro on the medical floor. She will need 2 weeks
of antibiotics for acute complicated urinary tract infection.
She also received stress dose steroids given that she is on
chronic steroids as an outpatient. This was weaned down to
prednisone 20 mg with instructions to further wean to home dose.
#Atrial fibrillation with RVR: Upon further review, pt states
that this not new and she was told she had afib during an OR
procedure in the past. Current afib with RVR likely promoted by
increased sympathetic drive in the setting of septic shock and
baseline chronic diastolic CHF. Pt had an echo showing mild-mod
dilation of the L and R atria, mild symmetric LVH, EF 50-55%,
mild to moderate [**1-1**]+MR and mild pulmonary artery hypertension.
Her rate improved with antibiotics treatment for the underlying
urosepsis. Pressor was weaned and she was able to restart
metoprolol. This dose was uptitrated to toprol xl 75 mg daily
She continued with aspirin and was transitioned to coumadin with
a heparin/lovenox bridge for CHADS2 score of 2. She will need
to have her INR monitored in the outpatient setting with
adjustment of coumadin as pt is taking cipro.
#Elevated troponin (0.09 on admit, decreased to 0.03): This was
thought to be related to demand from AF with RVR and sepsis.
Cardiac enzymes trended down. Aspirin was continued, BB was
uptitrated. Simvastatin continued.
#Chest pain: Pt reported chest pressure at home with some DOE
on occasion, relieved by rest. Patient had 1 episode this
admission. EKG was unchanged. Cardiac enzymes x2 were flat;
these troponins had trended down from admission troponins. CP
occurred in the setting of HR ~150 afib. DDX includes angina
from CAD vs. poor rate control. BB was uptitrated. Pt remained
on asa. Lipid panel ordered showing LDL of 59, AIC of 6.4%.
Informed pt's PCP of the above. Pt will be scheduled for an
outpatient stress test for further evaluation. Pt did not have
any additonal episodes as an inpatient.
#chronic diastolic CHF: Patient had elevated BNP upon admission
to the hospital. ECHO as above showing EF 50-55%. Pt's lasix
dose was held while in the ICU and initially on the medical
floor. However, given development of crackles on exam, this was
resumed on [**11-26**] at a dose of 20mg daily, then titrated to 40 mg
daily. (reported home dose 60mg daily). This can be uptitrated
as needed and followed as an outpatient.
#Chest xray showing mild interstitial prominence within the
lungs: This was read as "could indicate chronic lung disease and
clinical correlation is advised". Pt denies smoking. This may or
may not be related to her underlying rheumatoid arthritis. Pt
did not have any respiratory difficulty and had good room air
sats. This can be further worked up as an outpatient if
indicated.
#Rheumatoid arthritis: Pt continued on plaquenil. She got home
dose prednisone which was later switched to stress dose steroid
given hypotension from septic shock while in the ICU. Her
steroid dose was changed to PO on the floor and tapered down to
prednsione 20mg upon discharge, which she was instructed to
taper to her home dose of 5mg [**Hospital1 **] after 1 week.
#Comm: [**Name (NI) **] [**Name (NI) 43429**], husband, [**Telephone/Fax (1) 43430**].
Medications on Admission:
Medications at home (per Atrius records)
Prednisone 5 mg [**Hospital1 **]
Plaquenil 200 mg [**Hospital1 **]
Simvastatin 20 mg daily
Alendronate 70 mg weekly
Furosemide 60 mg daily
Metoprolol 25 mg QAM, 37.5 mg QPM
Omeprazole 20 mg daily
Caltrate+D 600 mg-400 IU 1 tab [**Hospital1 **]
Discharge Medications:
1. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
6. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days: last dose [**2146-12-5**]. 2 week course.
Disp:*16 Tablet(s)* Refills:*0*
8. Outpatient [**Name (NI) **] Work
PT/INR. Please have this checked in 2 days after discharge
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) **]
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 43431**]
Fax: [**Telephone/Fax (1) 6808**]
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
12. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 6 days: Then change to 5 mg twice a day.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Americare VNA
Discharge Diagnosis:
Major:
Sepsis due to urinary tract infection
Atrial fibrillation with rapid ventricular rate
Minor:
relative adrenal insufficiency
chronic diastolic heart failure
rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 43429**],
It was pleasure taking care of you. You were initially admitted
to the ICU with sepsis related to a urinary tract infection. You
also were found to have atrial fibrillation with a rapid heart
rate. For your infection you were given antibiotics with good
effect. Your symptoms have improved. For your atrial
fibrillation, you were given increased doses of metoprolol to
better control your heart rate. You were started on blood
thinning medication called coumadin to decrease your risk of
stroke. You will need your INR closely followed as an
outpatient.
You also reported chest pressure when your heart rate was fast.
You will need to undergo a stress test soon to evaluate for
possible disease in your heart's blood vessels. Please discuss
scheduling this test with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 36055**].
You were also given increased steriods due to your current
illness and this will need to be slowly decreased.
Medication changes:
1.coumadin 2mg daily
2.Toprol XL 150mg daily
3.Aspirin 81mg daily
4.Prednisone 20 mg daily for 1 week, then 5 mg twice a day.
5.Ciprofloxacin 250 mg twice a day until [**12-5**].
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) **]
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 43431**]
*Someone from Dr. [**Last Name (STitle) 43432**] office will contact you to book an
appointment. You should follow up with the doctor within a week.
If you dont hear from the office in 2 business days, please call
the number above.
Please also follow up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Hospital1 **] within 2 weeks. Her clinic number is
[**Telephone/Fax (1) 38275**].
ICD9 Codes: 5990, 2762, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6635
} | Medical Text: Admission Date: [**2147-7-25**] Discharge Date: [**2147-7-28**]
Date of Birth: [**2102-4-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 25876**]
Chief Complaint:
increased SOB and abdominal girth over the past 3 days with
subjective fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient presented to ED with increased SOB and abdominal girth
over the past 3 days with subjective fevers. She reports
increased nausea with poor po intake but no diarrhea, melena or
hematochezia. She also reports cough productive of bloody sputum
for the last two days. She dnies any dysuria, hematuria,
frequency or urgency.
In the ED she was febrile and hypotensive and was given 4L NS
with improved hypotension but developed respiratory distress.
CXR was c/w PNA with superimposed CHF so she was given 20mg IV
lasix X 2 with good effect. She was transferred to the [**Hospital Unit Name 153**] for
further management.
Pt initially hypotensive in [**Hospital Unit Name 153**], receiving stress dose steroids
until home doses were available. No documented fevers. Pt states
her breathing is now improved.
Past Medical History:
Onc hx:
Initially presented with mole at her left flank which grew and
turned black. She underwent a resection of a 12.5-mm thick
ulcerated melanoma from her left abdominal wall in [**Month (only) 958**] of
[**2145**]. She underwent wide local excision and sentinel node
biopsy, with melanoma present in one of four inguinal sentinel
lymph nodes. On [**2146-5-11**], she underwent complete left inguinal
node dissection, with no melanoma in three remaining lymph
nodes. She was enrolled in intergroup protocol S0008 and was
randomized to the biochemotherapy arm. She received three cycles
of biochemotherapy initiated on [**2146-7-11**]. Following that
therapy, she developed a psychotic depression, which fully
resolved on antidepressant therapy. CT scans in [**Month (only) 116**] showed
possible bilateral pulmonary nodules. PET scans in [**Month (only) **]
confirmed metastatic disease in the lungs, liver, and bone and a
head MRI showed multiple small CNS metastases. Upon
documentation of this CNS metastases, she was referred to
Neuro-Oncology for evaluation. She underwent an LP, which
disclosed no evidence of leptomeningeal disease. Because of
multiple CNS lesions and skull metastasis, she was started on
whole brain radiation in early [**Month (only) 205**]. She completed her treatment
last Wednesday.
Social History:
originally from [**Country 38213**], moved to US with family 2 1/2 years
ago. Worked as cashier. 2 daughters in college and husband.
[**Name (NI) **] [**Name2 (NI) **]/EtOH or drugs.
Family History:
no melanoma
Physical Exam:
T 97.8 HR 120 BP 120/80 RR 18 O2sat 94% on 2L NC
HEENT: PERRL, EOMI O/P clear
CVS: tachycardic, regular, S1, S2
lungs: crackles on L base, fair air entry
Abd: tense, mild diffuse tenderness, no rebound or guarding,
significant ascites present
Extrem: 2+ radial and DP pulses
Neuro: grossly intact
Pertinent Results:
[**2147-7-24**] 11:45PM URINE RBC-<1 WBC-<1 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2147-7-24**] 11:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2147-7-24**] 11:45PM PLT SMR-VERY LOW PLT COUNT-57*#
[**2147-7-24**] 11:45PM WBC-5.8 RBC-2.85*# HGB-8.6*# HCT-24.4*#
MCV-86 MCH-30.4 MCHC-35.5* RDW-14.0
[**2147-7-24**] 11:45PM NEUTS-69 BANDS-4 LYMPHS-10* MONOS-10 EOS-1
BASOS-0 ATYPS-0 METAS-3* MYELOS-3*
[**2147-7-24**] 11:45PM GLUCOSE-110* UREA N-21* CREAT-0.6 SODIUM-136
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-28 ANION GAP-15
[**2147-7-24**] 11:45PM ALT(SGPT)-87* AST(SGOT)-54* ALK PHOS-198*
AMYLASE-72 TOT BILI-0.4
[**2147-7-24**] 11:56PM LACTATE-3.2*
[**2147-7-25**] 07:42PM WBC-6.4 RBC-3.20* HGB-9.3* HCT-27.0* MCV-85
MCH-29.1 MCHC-34.4 RDW-14.9
CT: Marked interval progression of metastatic disease -
innumerable new liver mets with hepatomegaly, new adrenal mets,
splenic mets, intraperitoneal seeding with ascites, breast
nodules, lungs mets, diffuse alveloar opacities likely
represents lymphatic spread of tumor with interstitial edema, no
obstruction, focal consolidation in right lower lobe.
Brief Hospital Course:
Hypotension - resolved following initial hydration with 4L IVF
in ED. No further episodes of hypotension. Pt initially on
stress dose steroids, later switched to home dose of decadron
2mg [**Hospital1 **].
Respiratory distress - initial shortness of breath worsened
after IVF but improved after some lasix. CXR consistent with
pneumonia given hx of fevers and cough, but metastatic spread
also possible. Pt remained afebrile in hospital. Started on
levo/flagyl. Pt was chronically oxygen dependent, stable on 4L
per nasal cannula
Ascites - pt tolerating discomfort, does not want therapeutic
tap at this time, likely would reccur quickly.
Anemia: some vague hx of vaginal bleeding. No other known
bleeding. Received 2 units pRBC during hospitalization. No
bleeding noted in hospital.
Depression: Continued on home Zoloft and Risperidone.
Metastatic Melanoma - prognosis dire, after discussion between
hematology/oncology and pt and her family, it was decided that
pt would go home with hospice care.
Contact: daughters [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 56508**] [**Doctor First Name 56509**]
[**Telephone/Fax (1) 56510**]
Discharge Medications:
1. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
Disp:*33 Tablet(s)* Refills:*0*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Metastatic Melanoma
Pneumonia
Discharge Condition:
guarded
Discharge Instructions:
Please follow-up with your oncology physician as desired.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 24699**] office as needed with questions.
Completed by:[**2147-7-28**]
ICD9 Codes: 486, 4280, 2851, 2875, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6636
} | Medical Text: Admission Date: [**2193-2-4**] Discharge Date: [**2193-2-19**]
Service:
HISTORY OF PRESENT ILLNESS: This is a 79-year-old female
with a past medical history significant for increased
cholesterol who presented to our hospital who presented for
several days of malaise, nausea, vomiting, weakness, and
dizziness. The patient was OB+. She had a Hartmann in her
40's and was found to be hypotensive. She denies any chest
pain or shortness of breath. Electrocardiogram showed [**Street Address(2) 11741**] depression in V2 and V4 and ST elevations in 2, 3, and AvF
as well as complete heart block. The patient was started on
IV heparin and then became apneic and hypotensive in the
emergency room. This required intubation and administration
of dopamine. She was transferred to the [**Hospital1 18**] for cardiac
catheterization, but has now become hypotensive on admission
and still in complete heart block. She had a left heart
catheterization which revealed 95% of left anterior
descending stenosis and 100% occluded left circumflex which
was stented. She was also found to have a small RC not
supplying a large part of myocardium. After this cardiac
catheterization, the patient has hypotension with an episode
of supraventricular tachycardia. All of these stopped with
the initiation of intra-aortic balloon pump. In addition on
doing cardiac catheterization, the saturations in the left
and right side of the heart suggested presence of
atrioventricular septal defect.
PAST MEDICAL HISTORY: Unremarkable.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: She is widowed and lives alone. No smoking
or alcohol.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature is 98.7, heart rate of
105, blood pressure was 126/50. Respiratory rate is 20,
oxygen saturation is 98. The patient is intubated and was
generally nonreactive to stimuli. Head, ears, eyes, nose and
throat: Pupils are small, but equal and reactive to light.
Mucus membranes are dry. Neck: Difficult to appreciate
jugular venous distention. No lymphadenopathy is palpable.
Cardiovascular: Tachycardic, obscured heart sounds. Chest:
Good breath sounds bilaterally. Abdomen: Soft and nontender
and normal active bowel sounds. Extremities: No edema. Good
bilateral pulses.
LABORATORY DATA: Significant for CK of 159, MB of 15, index
of 10 and troponin of 1.9.
HOSPITAL COURSE:
1. Cardiovascular: The patient was admitted to the Coronary
Care Unit for close observation monitoring. Immediately upon
admission, she had a TU which revealed anteroseptal defect.
The initial impression was to try to close this with a clam
shell procedure which is going to offer her best chances of
stabilizing a hemodynamics given that she became to be very
hypotensive.
However, discussion with the family, they decided that they
did not want any procedures done. The patient's blood
pressure remained extremely labile requiring a few pressors
in the beginning with fair satisfactory result. Initial
subsequent echocardiogram revealed that she had global left
ventricular hypokinesis. She was started on aspirin, Plavix
and maintained on IV heparin. She was also started on
Lipitor. Initially, we could not start a beta-blocker given
her complete heart block and hypotension. However, this
subsequently improved. This was added to her regimen. To
further improve her hemodynamics upon arrival to the CCU she
received large amounts of fluid and became about 15 liters
positive. However, this increased preload and had
significant improvement in her hemodynamics and initially was
tolerated. After while she became volume overloaded without
evidence of compromising her oxygenation. This volume
overload was gradually improved with gentle diuresis and
sometimes with autodiuresis. Once the condition improved,
she was started on Captopril which she tolerated a small
dose. The balloon pump was stopped and had no significant
effect on her hemodynamics.
On hospital day #4 and #5, it became apparent that the
patient was aseptic which is the cause of her continued
hypotension. She required pressors for about 10 consecutive
days, but eventually was able to be weaned off completely and
maintained good blood pressure. In terms of rhythm, the
patient remained most of the time in first degree AV block
and notable in complete heart block with tachycardia in the
unit. However, she did have one episode of atrial
fibrillation in the context of ventilatory weaning. Because
of this, she was started on amiodarone 400 mg p.o. q. day.
She had no further episodes of atrial fibrillation. She is
also being anticoagulated for atrial fibrillation and for low
ejection fraction with akinetic ventricle.
2. Infectious disease: There were multiple consults
involving infectious disease. The patient was probably
aspirated during episodes of nausea and vomiting in the
outside hospital and particularly given the findings on
x-ray. Sputum showed multiple organisms including gram
positive cocci and gram negative rods, but none of these were
grown. She received a 14 day course of levofloxacin and
Flagyl with marked improvement in her symptoms.
Additionally, the patient had 2 out of 4 blood cultures
positive for staph. Both local lines were stopped and she
received a 14 day course of IV vancomycin. Upon discharge,
all of her infectious disease issues has been resolved and
she has no evidence of being infected at this point.
3. Renal: Upon admission, the patient may be in very mild
acidosis which could have an myocardial infarction. This
improved. She was being diuresed while in the hospital
course. She had a mild increase of creatinine and this is
probably normal and to be expected.
4. Endocrine: The patient initially had very labile blood
sugars in the 300 to 500 range. She required initiation of
IV insulin drip and this was continued for at least 4 days.
This patient was getting better and was changed to a standing
NPH insulin. It is quite likely that she has unrecognized
underlying diabetes mellitus that has not been treated. She
will probably require further follow up for this condition.
5. Pulmonary: The patient was initially intubated for
protection. She had a very prolonged and complicated course
including inability to wean over a week, pneumonia and fluid
overload. On hospital day #10, the final attempts to
extubate the patient was successful and she remained very
stable from respiratory standpoint and positioned to room air
shortly thereafter. She has no acquired pneumonia and was
able to breathe comfortably on room air at this point.
6. Gastrointestinal: The patient had some episodes of
bleeding from the oropharyngeal tract, but this is believed
more to be due to injury from the TE and intubation rather
than any gastrointestinal bleed. Consultation of ENT was
obtained. There is no continued gastrointestinal bleeding
from the gastrointestinal tract.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE MEDICATIONS:
1. Plavix 75 p.o. q. day indefinitely.
2. Aspirin 325 p.o. indefinitely.
3. Amiodarone 400 mg p.o. q. day to be switched to 200 mg
p.o. q. day in about 3 to 4 weeks.
4. Lisinopril 5 mg p.o. q. day.
5. Lipitor 10 mg p.o. q. day, this may need to be readjusted
for proper INR.
6. NPH 60 units in the morning, 10 units at night.
7. Lopressor 12.5 b.i.d.
DISCHARGE DIAGNOSIS:
1. Acute myocardial infarction.
2. Status post catheterization.
3. Diabetes mellitus.
4. Atrial fibrillation.
5. Sepsis.
6. Aspiration pneumonia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 251**] 12-191
Dictated By:[**Name8 (MD) 5094**]
MEDQUIST36
D: [**2193-2-18**] 10:59
T: [**2193-2-19**] 05:54
JOB#: [**Job Number 45730**]
ICD9 Codes: 5070, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6637
} | Medical Text: Admission Date: [**2114-7-2**] Discharge Date: [**2114-7-5**]
Date of Birth: [**2062-8-21**] Sex: M
Service: NEUROLOGY
Allergies:
Morphine / Erythromycin Base / Valium / Robaxin / Penicillins /
Felbatol / Phenobarbital / Thorazine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
confusion, spell in ER
Major Surgical or Invasive Procedure:
Intubation [**7-2**]
Extubated [**7-3**]
History of Present Illness:
51 year old man with history of temporal lobe epilepsy as well
as a history of nonepileptic spells that resemble seizures, as
well as a psychotic disorder who presented on [**7-2**] for feelings
of confusion while sitting at a cafe, which he described as
"feeling seizurey," and a spell he had in the ER for which he
was intubated. He is followed by Dr. [**Last Name (STitle) **], and had earlier in
the day told Dr. [**Last Name (STitle) **] that he had been hearing voices. The
patient also reports feelings of "uncontrollable crying in the
absense of emotion," which he also refers to as "brain tears"
while sitting in a cafe [**Location (un) 1131**] a book. This sensation lasted
two hours, and then his right eye closed; he at that point felt
"seizurey," and he called an ambulance because he felt as if he
were about to have a seizure. He was brought to [**Hospital1 18**] where in
the ER he had a witnessed spell which was observed by Dr. [**First Name (STitle) **]
and Dr. [**First Name (STitle) **] of the neurology service. Dr.[**Name (NI) 104030**] description
is as follows:
"When I went to evaluate patient, I noted the his head was
extended back, eyes fixed upwards, eye lids fluttering
repetitively. The rate and frequency of the fluttering was not
regular. It would cease if you held the patient's eye lids open.
It would stop if you held up eyes to blink to threat or to test
corneal reflex. At that same time, both of his arms were flexed
in and rigid. Patient would actively resist movement of the
arms.
Legs were extended and rigid. When noxious stimuli was used,
rate
of patient's eye lid fluttering would change. There was a brief
withdrawal of the bilateral lower extremities.
ED completed Dilantin 1 gram. Patient then began to have
convulsive activity. Head was extended and jerking. Arms were
flexed in and stiff. Resisted opening. Legs were shaking
symmetrically but shaking was dysrhytmic. If you held one of the
legs, shaking could be stopped and would start up again at a
faster frequency when you let leg go. Babinski testing made
shaking stop. ED gave him another 2 mg of Ativan. Several
minutes
after that, shaking stopped.
About one hour after patients arrival, called emergently to room
as "actively seizing". Dr. [**First Name (STitle) **] (Chief Resident) and I went to
evaluate patient. ED staff had given another 4 mg of Ativan.
Arms
again in and stiff, actively resisting opening. Legs shaking,
both frequency and amplitude of movement varying. Would blink to
threat and stop eye lid fluttering with confrontation. Patient
moved to Red Zone for possible intubation. However, maintaining
O2 sats in high 90s with nonrebreather. Dr. [**First Name (STitle) **] and I arranged
for emergent EEG to assess if activity had electrographic
correlate. While being manipulated by ED staff for IVs, patient
would cry out, spit, puff cheeks.
While tech putting on leads, patient had generalized shaking. No
electrical correlate [**Doctor Last Name **] seen by myself nor by EEG Fellow.
During remainder of EEG, patient was calm but not yet oriented
or
alert.
Shortly before 8pm, ED docs called to patient's room again for
recurrent convulsions. I was at bedside. Patient was
tachycardic,
but with respiratory rate in 20s, Oxygen saturation in high 90s
on the non-rebreather. ED staff planning to intubate patient. I
argued that seizures were not clinically consistent with
epileptic seizures, that EEG did not show ongoing epileptiform
activity, and that patient was protecting airway at that time."
The ER attending Dr. [**Last Name (STitle) 6633**] was worried about the patient's
risk of aspirating and despite neurology input that this was not
in fact a seizure, the patient was intubated and transferred to
the neuro ICU after receiving more ativan. The following day,
he was extubated and transferred to the floor. Per Dr. [**First Name (STitle) **],
the spell had lasted over twenty minutes.
Interview at that time reveals recent psychosocial stressors
including being evicted from his apartment.
Past Medical History:
-Pt has extensive psych history-please see d/c summary from
[**10/2111**] for excellent summary, including complex social history.
-Temporal lobe epilepsy from OMR diagnosed in [**2087**] by Dr.
[**Last Name (STitle) 104031**]. See d/c summary from [**2101**].
-multiple admissions for seizures from [**2103**]-[**2107**] with no
electrographic correlate.
-syphilis in late [**2078**]'s
Social History:
Patient lives in [**Hospital1 8**], desribes himself as writer. He does
not report any recent Etoh, tobacco, or drug use.
Family History:
No known history of seizures
Physical Exam:
ADMISSION PHYSICAL EXAM BY DR. [**First Name (STitle) **]:
PHYSICAL EXAM:
Most recent vitals post intubation:
Tc: Still awaiting rectal temp by ED nurse
BP: 81/30 after intubation meds and propofol
HR: 89
RR: 14
O2Sat: 100% on vent
Rest of exam is pre intubation:
Gen: WD/WN,uncomfortable, diaphoretic.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Eyes open at times, but eyelids fluttering. Will
not alert to examiner. Not following commands. No verbal output.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Blinks to threat bilaterally.
III, IV, VI: +Oculocephalic reflex bilaterally.
V, VII: Facies symmetric.
VIII: Unable to assess.
IX, X: +Gag.
[**Doctor First Name 81**]: Unable to assess.
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Tone in arms and legs mostly rigid, with
patient actively resisting limb movements. Grimaced and had
increased respiratory rate in upper extremities after noxious
stimuli. Withdrew to noxious in the lower extremities
bilaterally.
Sensation: Grimaced and had increased respiratory rate in upper
extremities after noxious stimuli. Withdrew in lower extremities
to noxious.
Reflexes: Patient's arms and legs both rigid; unable to elicit
reflexes.
Toes downgoing bilaterally.
Coordination: Unable to assess.
Gait: Unable to assess.
WHEN EVALUATED ON THE FLOOR:
General: Awake, alert, and cooperative with exam in no acute
distress.
HEENT: Normocephalic, no scleral icterus noted, clear oropharynx
with moist mucus membranes
Neck: supple, with no JVD or carotid bruits appreciated
Pulmonary: Lungs clear to auscultation bilaterally without
wheezes, rhonchi or rales
Cardiac: regular rate and rhythm, with no murmurs
Abdomen: soft, nontender, with normoactive bowel sounds, no
masses or organomegaly noted.
Extremities: Warm with no edema and good pulses throughout
Skin: no rashes or lesions noted.
Neurologic:
Mental status: The patient is awake, alert, and oriented x 3.
Able to relate history without difficulty. Language is fluent
with intact repetition and comprehension, and speech is normal
rate, tone and volume. Patient was able to register 3 objects
and recall [**2-15**] at 30 seconds and at 5 minutes. The patient had
good knowledge of current events. There was no apraxia.
Cranial Nerves: Olfaction not tested. Pupils equal, round and
reactive to light bilaterally, and visual fields intact to
confrontation bilaterally with no hemineglect. No ptosis is
noted, and fundoscopic exam revealed sharp discs and venous
pulsations. Extra-ocular muscles were intact without nystagmus.
Sensation was intact to light touch over face. No facial
asymmetry was noted, and hearing was intact to finger-rub
bilaterally. Palate and uvula elevate at midline. There is [**4-19**]
strength in trapezii and sternocleidomastoids bilaterally.
Tongue protrudes in midline, with no fasciculations.
Motor: normal bulk, tone throughout. No tremor, asterixis or
drift.
Delt Bic Tri WrF WrE FFl FE IO IP Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 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
Sensory: No deficits to light touch, pinprick, vibratory sense,
proprioception throughout. No extinction to DSS.
Coordination: Normal finger to nose and heel to shin, with no
dysmetria. No dysdiadochokinesia noted on rapid alternating
hand movements or finger tapping.
Reflexes: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. The patient had downgoing toes on
plantar response bilaterally.
Gait: Normally based, with normal arm swing. Able to walk in
tandem without difficulty. Romberg absent.
Pertinent Results:
[**2114-7-2**] 04:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2114-7-2**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2114-7-2**] 03:58PM ALT(SGPT)-36 AST(SGOT)-25 LD(LDH)-164 ALK
PHOS-84 TOT BILI-0.4
[**2114-7-2**] 03:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2114-7-2**] 03:58PM WBC-8.6 RBC-4.71 HGB-14.9 HCT-39.7* MCV-84
MCH-31.6 MCHC-37.5* RDW-13.1
[**2114-7-2**] 03:58PM PLT COUNT-206
EEG DURING SPELL:
FINDINGS:
NOTE: At the beginning of the record, the patient presented in
the
video for less than five seconds clonic flexion of both arms
synchronously with fast breathing. During this episode there
were no
EEG correlations except movement artifact noted.
BACKGROUND: Is a low voltage [**9-25**] Hz alpha frequency rhythm
with
normal anterior-posterior voltage gradient. There is a
superimposed
beta frequency activity seen throughout the record.
HYPERVENTILATION: Could not be performed due to the patient's
clinical
condition.
INTERMITTENT PHOTIC STIMULATION: Could not be performed because
this
was a portable study.
SLEEP: Normal transitions of the sleep architecture were not
seen.
CARDIAC MONITOR: A sinus tachycardia with a rate between 100 and
120
were seen.
IMPRESSION: This is a normal portable EEG. There were no clear
epileptiform activities recorded, especially no epileptiform
features
during the clinical presentation of clonic flexion of both arms.
Beta
frequency activity was seen and this is likely a medication
effect. A
sinus tachycardia was noted.
Brief Hospital Course:
The patient was admitted initially to the ICU and soon
afterwards extubated and transferred to the floor the following
evening. His spell was proven by EEG to have been nonepileptic,
and despite the fact that this patient has known epilepsy, his
recent spell was considered to be psychiatric in nature,
possibly in response to recent stressors in his life. Physical
therapy was consulted to help him out of bed, as he reported
feeling "unsteady" on his feet after his brief ICU stay. His
medications were not adjusted, and he was monitored clinically
for further spells. Physical therapy felt that his difficulty
with walking was not physiologic, and the primary team felt that
as his anxiety improves, his walking will likely improve. Of
note, he takes a total of 8 mg ativan each day at home; Dr.
[**Last Name (STitle) **] prescribes him for 6 mg per day (split dosing). He has
follow up with Dr. [**Last Name (STitle) **] in the near future and should keep his
appointment. He was seizure-free on the day of discharge and
his physical exam was completely unchanged from the previous
day.
Medications on Admission:
Medications prior to admission:
1. Trileptal [**Telephone/Fax (3) 104032**]. Ativan 2 mg po tid
3. Seroquel 100 mg po qid
4. Effexor XR 150 mg po bid
5. Zantac 300 mg po qHS
Discharge Medications:
1. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
2. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO QAFTERNOON
().
3. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Quetiapine Fumarate 300 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
8. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): or as directed.
Discharge Disposition:
Home
Discharge Diagnosis:
Nonepileptic spell
Temporal Lobe Epilepsy
Nonepileptic Spell
Complex Partial Seizure disorder
Discharge Condition:
no signs of seizure
good
Followup Instructions:
F/u with PMD as previously scheduled; follow up with Dr. [**Last Name (STitle) **]
in [**1-19**] weeks
Provider: [**Name10 (NameIs) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6929**], MD Where: KS [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) BEHAVIORAL NEUROLOGY UNIT
Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2114-7-19**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **]
COMPLEX) NEUROLOGY/[**Hospital Ward Name **] 503 Phone:[**Telephone/Fax (1) 5285**]
Date/Time:[**2114-7-27**] 3:00
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 32084**] Date/Time:[**2114-8-31**] 11:00
Completed by:[**2114-7-5**]
ICD9 Codes: 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6638
} | Medical Text: Admission Date: [**2117-9-29**] Discharge Date: [**2117-10-5**]
Service: CARDIOTHORACIC
Allergies:
aspirin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2117-9-29**] Aortic valve replacement with a 29-mm [**Company 1543**] Mosaic
Ultra bioprosthesis. Replacement of ascending aorta with a 30-mm
Dacron tube graft using deep hypothermic circulatory arrest
which included hemi-arch replacement.
History of Present Illness:
[**Age over 90 **] year old male known to our service (see previous notes) who
has a history of severe AS ([**Location (un) 109**] 0.8cm2), HTN, chronic GI
bleeding ([**1-6**] AVMs, UC) requiring frequent transfusion,
myelodysplastic syndrome s/p recent chemotherapy. He has been
undergoing work-up for potential aortic valve replacement and
asc. aorta repl. He first needed neuro clearance after new left
foot drop. Neuro decided foot drop is related to peroneal nerve
lesion. Given his complex GI history, he was also waiting GI
clearance and to make sure that his colitis was in control and
hopefully off steroids. Following cardiac surgery, it was
recommended that he have a colectomy because of the ulcerative
colitis and a large polyp that is almost to the anal verge.
There are multiple other polyps that are also adenomas. He now
presents again in clinic for further discussion of surgery.
Past Medical History:
- Severe aortic stenosis
- Hypertension
- Hyperlipidemia
- Systolic congestive heart failure
- Benign Prostatic Hypertrophy
- Ulcerative colitis with recurrent GI bleeding on sulfasalazine
- Gastric AVMs s/p GI bleed, admitted on [**2117-7-26**] to [**2117-7-28**]
- Myelodysplastic syndrome, tx with Vidaza [**Date range (1) 32684**]
- Prostate Cancer in [**2095**]'s
- Left foot drop - common peroneal nerve lesion, likely at the
fibular head. Wears foot orthosis and foot drop splint.
- s/p b/l cataract extraction and lens implants
Social History:
Race: Caucasain
Last Dental Exam: edentulous
Lives with: Wife
Occupation: Retired carpenter
Cigarettes: Smoked no [] yes [X] Hx:quit smoking 50 years ago
and smoked for 20 years
Other Tobacco use: Denies
ETOH: < 1 drink/week [X] [**1-11**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
Daughter - breast ca
Father - died at age 72 prostate Ca
Physical Exam:
Pulse: 85 Resp: 16 O2 sat: 99/RA
B/P 99/56
Height: 5'5" Weight: 75 kgs
General: Well-developed elderly male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [Xx] Irregular [] 3/6 systolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema Trace
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit Right/Left: systolic murmur radiating
Pertinent Results:
Echo [**2117-9-29**]: PRE-BYPASS: No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
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%). Doppler parameters are most
consistent with Grade II (moderate) left ventricular diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results at time of surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Biventricular function is unchanged. There is a
well-seated, well-functioning bioprosthetic valve in the aortic
position. No aortic regurgitation is seen. No paravalvular leak
is seen. There is a mean gradient of 7 mmHg across the aortic
valve at a cardiac index of 2.1. Mitral regurgitation is trace.
Tricuspid regurgitation is unchanged. The aorta is intact.
[**2117-10-4**] 05:45AM BLOOD WBC-4.3 RBC-2.85* Hgb-8.6* Hct-27.9*
MCV-98 MCH-30.2 MCHC-30.9* RDW-18.0* Plt Ct-219
[**2117-9-30**] 03:18AM BLOOD PT-14.4* PTT-33.3 INR(PT)-1.2*
[**2117-10-4**] 05:45AM BLOOD Glucose-100 UreaN-34* Creat-1.4* Na-140
K-4.3 Cl-104 HCO3-30 AnGap-10
[**2117-10-4**] 05:45AM BLOOD Mg-2.1
[**2117-10-5**] 06:05AM BLOOD UreaN-37* Creat-1.3* Na-142 K-4.4 Cl-105
[**2117-10-5**] 06:05AM BLOOD Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 14218**] was a same day admit after undergoing pre-operative
work-up prior to admission. On [**2117-9-29**] he was brought to the
operating room where he underwent an aortic valve replacement
and ascending aorta replacement. Please see operative report for
surgical details. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 2 the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. He was
seen by speech and swallow for a bedside evaluation and was
cleared for a regular diet. His rhythym was initially asystole
and then became nodal and eventually he was in a sinus rhythm in
the 60's. EP service was consulted. Low dose beta blocker was
initiated and titrated up and the patient tolerated this well.
He was gently diuresed toward his preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
(patient was in sinus rhythm in the 80's) after third dose of
beta blocker without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 6 the patient was
ambulating with assistance, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged to
[**Hospital 88006**] [**Hospital **] Rehab in [**Location (un) 38**] in good condition with
appropriate follow up instructions.
Medications on Admission:
AZACITIDINE [VIDAZA] - (Prescribed by Other Provider) - Dosage
uncertain
EPOETIN ALFA [PROCRIT] - (Prescribed by Other Provider) - 20,000
unit/mL Solution - 60,000 units twice a week
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 40 mg
Tablet - 0.5 (One half) Tablet(s) by mouth once a day
MESALAMINE [CANASA] - 1,000 mg Suppository - 1 Suppository(s)
rectally at bedtime
PREDNISONE - 7.5 mg Tablet - 1 Tablet(s) by mouth once a day as
directed
SULFASALAZINE [SULFAZINE] - 500 mg Tablet - 2 Tablet(s) by mouth
twice a day
TERAZOSIN - (Prescribed by Other Provider) - 2 mg Capsule - 1
Capsule(s) by mouth once a day
Medications - OTC
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider) - 1,000 mcg Tablet - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or fever.
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. mesalamine 1,000 mg Suppository Sig: One (1) Suppository
Rectal HS (at bedtime).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP <100 or HR <60.
11. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
14. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 10 days.
Discharge Disposition:
Extended Care
Facility:
tbd
Discharge Diagnosis:
Severe aortic stenosis s/p Aortic valve replacement
Dilated ascending aorta s/p Ascending aorta replacement
Past medical history:
- Hypertension
- Hyperlipidemia
- Systolic congestive heart failure
- Benign Prostatic Hypertrophy
- Ulcerative colitis with recurrent GI bleeding on sulfasalazine
- Gastric AVMs s/p GI bleed, admitted on [**2117-7-26**] to [**2117-7-28**]
- Myelodysplastic syndrome, tx with Vidaza [**Date range (1) 32684**]
- Prostate Cancer in [**2095**]'s
- Left foot drop - common peroneal nerve lesion, likely at the
fibular head. Wears foot orthosis and foot drop splint.
- s/p b/l cataract extraction and lens implants
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema - 2+ bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on on [**11-8**] at 1:00pm
Cardiologist: Dr. [**Last Name (STitle) **] on [**10-15**] at 9:45a
Please call to schedule appointments with your
Primary Care Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 25693**] in [**3-9**] weeks [**Telephone/Fax (1) 25694**]
**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:[**2117-10-5**]
ICD9 Codes: 4241, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6639
} | Medical Text: Unit No: [**Numeric Identifier 73151**]
Admission Date: [**2105-5-29**]
Discharge Date: [**2105-6-2**]
Date of Birth: [**2105-5-29**]
Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 73152**] was the 3.1 kg product born to a
33-year-old, G2, P1 mother. Prenatal screens: A positive,
antibody negative, hepatitis surface antigen negative, RPR
nonreactive, rubella immune, GBS positive. EDC of [**2105-6-12**]. Benign prenatal course. Normal first trimester nuchal
translucency. Maternal history noncontributory. Family
history: A 2-1/2-year-old, well. Infant born by precipitous
vaginal delivery with cord cut on perineum, brought to warmer
and noted to have respiratory distress. Infant brought to the
newborn intensive care unit with CPAP for further evaluation.
Mother was GBS positive. Temp was 99.1. Rupture of membranes
a half hour prior to delivery. Antepartum antibiotics a half
hour prior to delivery. Due to infant's severe respiratory
distress and need for 100% positive pressure ventilation,
infant intubated. Transillumination and chest x-ray
consistent with right pneumothorax. Additionally, infant with
decreased perfusion and received 20 cc/kg of normal saline
bolus.
PHYSICAL EXAM ON DISCHARGE: Anterior fontanel open and flat.
Palate intact. Breath sounds clear and equal bilaterally.
Regular rate and rhythm. Normal S1, S2. No audible murmur.
Pulses 2+ x4. Abdomen: Nontender, nondistended abdomen,
active bowel sounds, no hepatosplenomegaly. Normal external
male genitalia with testes descended bilaterally. Hips:
Stable. Patent anus. Spine: Intact. Infant active and alert
with exam.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname 916**] was
admitted to the newborn intensive care unit and intubated,
received 1 dose of surfactant and was weaned to nasal cannula
O2. He also received a thoracentesis on the right side for a
right pneumothoraces which resolved with needle aspiration.
He is currently in room air without cardiorespiratory
compromise.
CARDIOVASCULAR: On admission received a total of 30 cc/kg of
normal saline. He is currently cardiovascular stable with
heart rates 90s-120s, blood pressure 77/47 with a mean of 57.
FLUIDS, ELECTROLYTES AND NUTRITION: He was initially started
on 60 cc/kg/D of D10W. Enteral feedings were initiated on day
of life #1. Infant is currently ad lib feeding breast milk or
Similac 20 calorie, taking in adequate amounts. His weight at
the time of transfer was 3055 grams.
GI: Peak bilirubin was on day of life #3 of 9.8/0.6. Most
recent bilirubin is on [**2105-6-2**] of 8.8/0.7. Infant has
not required intervention.
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC on admission had an ANC of 198, white count
was 2.2, platelets 253, 1 poly, 6 bands, 1 meta, 1 myelo.
Follow-up CBC at 24 hours had an ANC of 8618. Because of his
abnormal chest xray and shifted cbc, he was diagnosed with
pneumonia. Infant is going to receive a total of 10 days of
ampicillin and gentamicin. Gentamicin levels on day of life #2:
Pre was 0.5, post was 8.3. Infant also had a lumbar puncture
performed, and lumbar puncture was within normal limits.
HEMATOLOGY: Hematocrit on admission was 42.3 He has not
required any blood transfusions. His most recent cbc was wbc 13.9
hct 42.7 and plt 283 on [**2105-5-30**].
NEURO: Infant has been appropriate for gestational age.
SENSORY: Hearing screen has not been performed but should be
done prior to discharge.
DISCHARGE DISPOSITION: To newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66546**], telephone
number [**Telephone/Fax (1) 43701**].
CARE RECOMMENDATIONS:
1. Continue ad lib feedings, Similac or breast milk 20
calorie.
2. Medications: Continue ampicillin and gentamicin for a
total of 10 days, [**6-2**] being day 5 of 10.
3. State newborn screen was sent on day of life #3 and is
pending.
4. Infant has not received any immunizations to date.
DISCHARGE DIAGNOSES: Term infant, pneumonia treated with
antibiotics for a total of 10 days, right pneumothoraces,
respiratory distress syndrome, hypovolemia, presumed sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2105-6-2**] 07:06:21
T: [**2105-6-2**] 07:28:19
Job#: [**Job Number 73153**]
ICD9 Codes: 486, 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6640
} | Medical Text: Admission Date: [**2119-4-18**] Discharge Date: [**2119-4-24**]
Date of Birth: [**2056-4-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
"My VNA found me at 65%"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 63 yo male with severe COPD on home oxygen, s/p
recent PEA arrest, referred to the ED by his VNA. Per his
report, his visiting nurse found him satting 65% on his
supplemental O2. He states that his sat rose to 81% with "some
exercises." He states that he felt extremely short of breath at
the time but is unable to identify any precipitating event. He
states that he felt sluggish that morning and had returned to
bed, but was up out of bed by the time his VNA arrived. He
denies any fever or chills or rigors. He has had a productive
cough for several months, which he distinguishes from his
baseline "smokers cough." He reports that it is occasionally
productive of deep green sputum. He states that his coughing has
been limited by chest wall pain since he underwent CPR 2 weeks
ago. He was recently seen by the NP[**Company 2316**] on [**4-13**] and was
prescribed a steroid taper for a COPD flare at that visit; he
states that he did not take this taper as prescribed. He
continues to smoke [**4-18**] cigarettes per day.
In the ED, he received combivent nebs x3, azithromycin 500 mg
PO, ceftriaxone 1 g IV, ASA 325 mg, and prednisone 60 mg PO.
Past Medical History:
1. COPD- on home O2 (3L), FEV1 22% predicted, FEV1/FVC
ratio 43% predicted, last intubated 3 years ago. followed by
Pulm
2. Tobacco Abuse
3. DM II
4. Diverticulosis
5. h/o SBO
6. C6-C7 HERNITATION
7. B12 Deficiency- on monthly injections
8. Obesity
Social History:
Pt is married and lives with wife and 2 of his children. He is
currently umemployed- former restaurant manager
Tob: smokes [**6-20**] cigs/day, used to smoke 5PPD for 50 years, cut
down 3 years ago
EtOH: last drink over [**Holiday 944**], used to drink heavily
Drugs: no IV drug use, no other illicits
Family History:
Mother and Father died of lung cancer in their 60s, sister just
recently died at age 50s from lung CA, daughter with cystic
fibrosis
Pertinent Results:
[**2119-4-18**] 11:00AM WBC-9.3 RBC-4.59* HGB-13.4* HCT-42.3 MCV-92
MCH-29.2 MCHC-31.7 RDW-14.1
[**2119-4-18**] 11:00AM NEUTS-75.4* LYMPHS-15.1* MONOS-6.7 EOS-2.5
BASOS-0.3
[**2119-4-18**] 11:00AM CK-MB-NotDone
[**2119-4-18**] 11:00AM cTropnT-0.02*
[**2119-4-18**] 11:00AM CK(CPK)-53
[**2119-4-18**] 11:00AM GLUCOSE-128* UREA N-22* CREAT-0.8 SODIUM-148*
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-37* ANION GAP-10
[**2119-4-18**] 11:00AM PLT COUNT-199
[**2119-4-18**] 11:00AM PT-11.9 PTT-22.1 INR(PT)-1.0
Brief Hospital Course:
A/P: Mr. [**Known lastname **] is a 63 yo male with severe COPD who presents
with hypoxia
.
1) COPD flare: No clear infectious trigger identified with a
clear CXR, normal WBC, negative ROS. Treated with steroids, IV
then to prednisone with slow taper. Plan to see NP[**Company 2316**] in
week and determine whether can taper to off.
2) Diastolic heart failure: Continue lasix 40 mg daily
3) Hypertension: Continue Norvasc, Lisinopril
4) Chest wall pain, s/p chest compressions: Ibuprofen PRN
5) DM2: Glyburide, Glucophage at home. Required insulin while
on higher doses of steroids, but fsbg better controlled as
glucophsge restarted and prednisone tapered down. Pt told to
check fsbg at home and report to his primary nurse practitioner.
6)Pneumonia: CXR c/w pneumonia, sputum with MRSA. Double
coverage with Bactrim and Levofloxacin.
Medications on Admission:
Prednisone 10 mg QOD
Albuterol MDI 2 puffs 4x/day
Aledronate 70 mg PO qMonday
Norvasc 5 mg daily
ASA 325 mg daily
Calcium + Vit D [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Senna 2 tabs qHS
Combivent QID
Flonase 50 mcg 2 sprays daily
Metformin 100 mg [**Hospital1 **]
Glyburide 2.5 mg QOD
Lasix 40 mg daily
Prilosec 20 mg [**Hospital1 **]
Ranitidine 300 mg qHS
Ferrous sulfate 325 mg daily
Advair 250/50 [**Hospital1 **]
Ibuprofen 600 mg TID:PRN
Lisinopril 20 mg daily
Lumigan OU daily
Vitamin B12 1000 mcg qmonth
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID W/ MEALS ().
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
14. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
16. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
18. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
19. Prednisone 10 mg Tablet Sig: 1-3 Tablets PO once a day: Take
30 mg [**4-25**], then Prednisone 20 mg per day until you see
your nurse [**5-2**].
Disp:*30 Tablet(s)* Refills:*0*
20. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
21. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhalation
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
COPD flare
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please continue your steroids (prednisone) until you see your
nurse at [**Hospital6 733**]. She will let you know how much
longer you need to take the prednisone. Please continue the
antibiotics until completed. Call your PCP with increased
shortness of breath.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2119-5-2**] 10:00
Provider: [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2119-5-29**] 2:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2119-4-28**]
ICD9 Codes: 4280, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6641
} | Medical Text: Admission Date: [**2110-7-9**] Discharge Date: [**2110-7-14**]
Date of Birth: [**2057-7-18**] Sex: M
Service: CARDIOTHOR
REASON FOR ADMISSION: Mitral valve repair.
HISTORY OF PRESENT ILLNESS: The patient is a 52 year old
Mandarin speaking gentleman with a history of severe mitral
regurgitation. For the past several years, the patient has
continued to have significant exercise intolerance which has
limited his ability to work. He reports severe dyspnea on
exertion.
The patient had a recent admission earlier in the month and
he was discharged on [**2110-7-3**], after undergoing cardiac
catheterization. This was significant for demonstrating no
flow-limited disease in the coronaries but several fistulae
from the left anterior descending to the PA. Several of
these were coil embolized during this admission. He
tolerated this well, was sent home, and now returns for his
mitral valve repair.
PAST MEDICAL HISTORY:
1. Mitral valve regurgitation.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg p.o. q. day.
2. Enteric-coated aspirin 325 mg p.o. q. day.
3. Nitroglycerin sublingual p.r.n.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is currently on Disability and
lives at home with his wife. [**Name (NI) **] was born in [**Country 651**]. He
denies any ETOH or tobacco use.
FAMILY HISTORY: Negative.
PHYSICAL EXAMINATION: The patient is in no acute distress.
Temperature is 98.3 F.; pulse is 76; blood pressure 113/52;
breathing 18; 98% on room air. HEENT: The patient is
missing many teeth. Oropharynx is clear. There is no
cervical lymphadenopathy. Supple neck. Heart is regular
rate and rhythm with a III/VI systolic ejection murmur. His
lungs are clear to auscultation bilaterally. Abdomen is soft
and nontender. The patient has no cyanosis, clubbing or
edema in extremities.
LABORATORY: On admission include a white blood cell count of
5.6, hematocrit of 32.5, platelets of 202. Sodium of 140,
potassium of 3.5, BUN of 4, creatinine of 0.6, glucose of
137.
Chest x-ray shows no infiltrate or pneumothorax.
Cardiac catheterization demonstrates no significant disease
in the coronary arteries. Two branches of an left anterior
descending to PA fistula which was successfully coiled.
There is a persistent flow through an inferior branch of the
left anterior descending to PA fistula and a persistent
branch of the circumflex to PA branch fistula which
anatomically were not suitable for coil embolization.
Ejection fraction was 60%.
HOSPITAL COURSE: On the day of admission, the patient went
to the Operating Room and underwent a minimally invasive
mitral valve repair. He tolerated this procedure well. The
patient was brought to the cardiothoracic Intensive Care Unit
in stable condition on minimal pressor support. He was
successfully weaned off this support. The patient was fully
weaned from ventilatory support secondary to a persistent
acidemia. This was treated with sodium bicarbonate and a
Swan-Ganz was placed to provide close hemodynamic monitoring.
The patient was found to have stable hemodynamics with
appropriate mixed venous saturations in the 70% range. The
patient was corrected to a normal pH of 7.41 by the first
postoperative night and remained stable.
He was then weaned off of ventilatory support and was
successfully extubated. The patient did have a slight bit of
confusion early in post-extubation course which cleared.
This was also compounded by a language barrier since the
patient cannot speak English.
In addition, the patient's early postoperative course had a
tremendous urine output. It was equally up to 700 cc. an
hour and a renal consultation was obtained. He underwent a
head CT scan to rule out intracranial pathology leading to
diabetes insipidus. This was negative. The patient's serum
and urine electrolytes indicated that this diuresis was
appropriate. The patient's urine output has decreased and
his BUN and creatinine remained normal.
The patient's Foley was discontinued. He had developed some
hematuria which has resolved. The patient has remained
stable and is now ready for discharge to home with follow-up
in approximately four weeks.
DISCHARGE DIAGNOSES:
1. Mitral regurgitation status post minimally invasive
mitral valve repair.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg p.o. twice a day.
2. Colace 100 mg p.o. twice a day.
3. Percocet one to two p.o. q. four hours p.r.n.
4. Aspirin 325 mg p.o. q. day.
CONDITION ON DISCHARGE: Stable.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS:
1. The patient will follow-up with Dr. [**Last Name (Prefixes) **] in four
weeks.
2. He will follow-up with his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 25213**], in two weeks.
3. The patient will call for any fevers or difficulties with
the wound care, and will be instructed with an interpreter
present.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2110-7-14**] 08:34
T: [**2110-7-19**] 15:44
JOB#: [**Job Number 25214**]
ICD9 Codes: 4240, 4280, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6642
} | Medical Text: Admission Date: [**2107-1-28**] Discharge Date: [**2107-2-14**]
Date of Birth: [**2032-5-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Azithromycin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2107-2-4**]
Off-pump coronary bypass grafting x1 with the left internal
mammary artery to left anterior descending artery
History of Present Illness:
74M p/t OSH w chest pain, exertional dyspnea. Ruled in for
NSTEMI. Echo revealed decline in EF to 10% (from 30% in [**2099**])
and AS with [**Location (un) 109**] 0.8cm2. He has a h/o 2vessel CAD on cath in
[**2099**]. Cardiac cath will be performed on Monday, [**2107-1-31**].
Cardiac surgery is asked to evaluate for AVR, CABG.
Past Medical History:
Past Medical History:
CAD
chronic systolic heart failure
DM
CRI (baseline Cr 1.9)
^lipids
htn
right foot w diabetic ulcer
PVD
Depression
Past Surgical History
Left CEA
Right fem-[**Doctor Last Name **] bypass [**2-/2106**]
Prostatectomy
Partial colectomy for adenoma [**2104**]
Social History:
Race: Caucasian
Last Dental Exam: 50 yrs. ago
Lives with: wife
Occupation: retired, sales
Tobacco: 60 pack yrs, quit 2 weeks ago
ETOH: denies
Family History:
Family History:
Father, CHF, d. age 54 pneumonia
Mother DM, d. age [**Age over 90 **] myocardial infarction
Brother CA unknown
Brother Bladder ca
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death
Physical Exam:
Pulse: 63 Resp: 18 O2 sat: 98%RA
B/P Right: Left: 90/50
Height: Weight: 79kg
General: NAD, appears stated age
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: 1+pedal edema bilaterally
Varicosities: None [x]
well healed incision of RLE fem-[**Doctor Last Name **] bypass
right lateral foot w 3mm round ulcer- no erythema, minimal
drainage on dressing, does not appear infected
Neuro: Grossly intact x
Pulses:
Femoral Right: Left:
DP Right: NP Left: NP
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 1+ Left: 1+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2107-2-4**]
Introp TEE
Pre-Procedure:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is severely depressed
(LVEF= 10 - 15 %). with moderate global free wall hypokinesis.
There is significant calcification of the ascending aorta. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen.
There is no pericardial effusion.
The patient was started on NTG and his PA pressures came down
from 70/35 to 55/30 with modest improvement of RV fxn. LV
remained severely depressed.
Based on the epi-aortic scan and the surgeon's assessment of the
ascending aorta, the procedure was changed to an off-pump LIMA -
LAD CABG only. The plan was to refer the patient for a
trans-vascular aortic valve replacement.
Post-procedure::
The patient is on low-dose phenylephrine.
RV systolic fxn remains mildly depressed.
LV systolic fxn is severly depressed.
AI remains trace.
MR is trace.
[**2107-2-10**] 04:27AM BLOOD WBC-13.6* RBC-3.18* Hgb-10.0* Hct-29.3*
MCV-92 MCH-31.5 MCHC-34.2 RDW-14.1 Plt Ct-496*
[**2107-2-10**] 08:15AM BLOOD PT-45.0* PTT-37.4* INR(PT)-4.8*
[**2107-2-10**] 04:27AM BLOOD Glucose-82 UreaN-25* Creat-1.5* Na-135
K-4.5 Cl-100 HCO3-27 AnGap-13
[**2107-2-13**] 05:08AM BLOOD WBC-11.5* RBC-3.05* Hgb-9.5* Hct-28.3*
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.9 Plt Ct-615*
[**2107-2-14**] 05:24AM BLOOD PT-22.2* INR(PT)-2.1*
[**2107-2-14**] 05:24AM BLOOD UreaN-24* Creat-1.3* Na-134 K-4.8 Cl-99
Brief Hospital Course:
This is a 74-year-old male who presented to an outside hospital
with chest pain, exertional dyspnea, and ruled in for
non-ST-elevated myocardial infarction. He had an echocardiogram
that revealed a decline in his ejection fraction to 10% from 30%
in [**2099**]. He also had aortic stenosis with an aortic valve area
of 0.8 cm2. Cardiac catheterization demonstrated 3-vessel
coronary artery disease with 60% left anterior descending artery
stenosis, 70-95% left circumflex artery stenosis, an occluded
right coronary artery with poor left-to-right collaterals. He
was taken to the operating room on [**2107-2-4**] and underwent an
off-pump coronary bypass grafting x1 with the left internal
mammary artery to left anterior descending artery. The aorta
was palpated and found to be heavily calcified throughout the
entire ascending aorta all the way down to the annulus.
Intraoperatively Dr. [**Last Name (STitle) **] was asked to evaluate the level of
calcific anatomy, and confirmed Dr[**Doctor Last Name **] findings. A discussion
was carried out as to what options the patient had. It was felt
that it would be a prohibitively high risk to replace the aortic
valve, since there was no safe place to clamp on the aorta. At
this point, it was elected to do the left internal mammary
artery to left anterior superior descending artery bypass off
pump. See operative note for full details. Post operatively he
was extubated and epinephrine was slowly weaned. He went into
rapid atrial fibrillation on POD#1 and dropped his systolic
blood pressure into the 70's. He was cardioverted x 3 with
200/360/360 Joules and converted to sinus rhythm. He was weaned
from all vasoactive medications over the next 3 days and was
hemodynamically stable in sinus rhythm. He did have post
operative acute renal failure with a peak creatinine of 2.0 and
this was decreasing at the time of discharge. He was started on
Coumadin for paroxysmal atrial fibrillation and received 2 doses
of 5 mg and INR went to 4.8. He was resumed with Coumadin at a
lower dose and INR was therapurtic at the time of discharge. He
was evaluated by physical therapy for strength and mobility and
cleared for home. He was transferred to the step down floor on
post operative day 5. Chest tubes and pacing wires were removed
per cardiac surgery protocol. He was tolerating a full oral
diet, ambulating with assistance and his wounds were healing
well. It was felt that he was safe for discharge home with
services on POD # 8. The patient will be advised to follow up
with Dr [**Last Name (STitle) **] in 3 weeks and at that time discuss Corevalve
options for aortic stenosis. All follow up appointments were
advised.
Medications on Admission:
Aspirin 325mg daily
Atenolol 50mg Daily
Glyburide 5mg daily
Lovastatin 40mg daily
Metformin
Lisinopril
Discharge Medications:
1. amiodarone 200 mg [**Last Name (STitle) 8426**] Sig: Two (2) [**Last Name (STitle) 8426**] PO BID (2 times
a day): x 3 days, then decrease to 1 tab twice daily x 7 days,
then dcrease to 1 tab daily .
Disp:*120 [**Last Name (STitle) 8426**](s)* Refills:*2*
2. atorvastatin 80 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY
(Daily).
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
3. glyburide 2.5 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO BID (2 times a
day).
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
4. aspirin 81 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Last Name (STitle) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. furosemide 20 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO BID (2 times a
day) for 14 days.
Disp:*28 [**Last Name (STitle) 8426**](s)* Refills:*0*
7. potassium chloride 10 mEq [**Last Name (STitle) 8426**] Extended Release Sig: Two
(2) [**Last Name (STitle) 8426**] Extended Release PO Q12H (every 12 hours) for 14
days.
Disp:*56 [**Last Name (STitle) 8426**] Extended Release(s)* Refills:*0*
8. warfarin 1 mg [**Last Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM: INR goal=[**12-30**] for Atrial Fibrillation.
Disp:*150 [**Month/Day (3) 8426**](s)* Refills:*2*
9. carvedilol 3.125 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO BID (2
times a day).
Disp:*60 [**Month/Day (3) 8426**](s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
1. Coronary artery disease.
2. Aortic valve stenosis.
3. Calcified ascending aorta.
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 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:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2107-3-9**]
1:30
Cardiologist: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2107-3-21**] 8:00
Please Draw INR for Coumadin dosing to be called into Dr.
[**Last Name (STitle) **] #[**Telephone/Fax (1) 55136**], Fax # [**Telephone/Fax (1) 55139**]
Coumadin indication:postoperative Atrial Fibrillation
INR goal=[**12-30**]
1st INR draw on [**2107-2-15**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**3-1**] weeks [**Telephone/Fax (1) 55136**]
**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:[**2107-2-14**]
ICD9 Codes: 5849, 5990, 2761, 4280, 4241, 5859, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6643
} | Medical Text: Admission Date: [**2152-12-5**] Discharge Date: [**2152-12-11**]
Date of Birth: [**2152-12-5**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] was the 1895
gram product of a 37 and [**11-26**] week gestation, born to a 29
year-old, Gravida 2, Para 1 now 2 mother. Prenatal screen:
A positive, antibody negative, hepatitis surface antigen
negative, RPR nonreactive, GBS positive. This pregnancy was
notable for intrauterine growth restriction. Mother received
several doses of intrapartum antibiotics. Infant was
delivered by Cesarean section due to non reassuring fetal
tracing. Apgars were 8 and 9. Infant was admitted to the
newborn intensive care unit for hypoglycemia and hypothermia
and was then readmitted 24 hours later for hypothermia.
PHYSICAL EXAMINATION: On admission, weight was 1885 grams.
Length 17.5 cm. Head circumference 31.5 cm. Anterior
fontanel open and flat. Regular rate and rhythm. Clear
breath sounds with good aeration. No retractions. No murmur.
Good femoral pulses. Abdomen soft, nondistended. Positive
bowel sounds. No hepatosplenomegaly. Pink and well perfused.
Moves all extremities with good tone. Normal male. Active
and alert.
HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname **] has been
stable in room air since admission to the Neonatal Intensive
Care Unit.
Cardiovascular: No issues.
Fluids, electrolytes and nutrition: Birth weight was 1895
grams. Infant has been ad lib breast feeding with
supplementation of NeoSure 22 calories, taking in good
amounts. Discharge weight is [**2080**] grams .
Gastrointestinal: Bilirubin on [**12-8**] was 7.4 over 0.3.
Hematology: Hematocrit on admission was 40.7. Infant has not
required any blood transfusions.
Infectious disease: CBC and blood culture on admission were
within normal limits with a white count of 19.2. Platelet
count of 415. 62 polys, 0 bands. Blood cultures remained
negative at 48 hours. Infant did not require antibiotics. A
urine CMV culture was sent to evaluate the patient's growth
retsriction. It is no growth to date.
Neurologic: The infant has had some temperature instability
which has resolved over time. He has been stable in an open
crib, swaddled for the past 48 hours.
Audiology: Hearing screen was performed with automated
auditory brain stem responses and the infant passed both
ears.
A care est test was passed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 17563**] [**Last Name (NamePattern1) **],
telephone number [**Telephone/Fax (1) 71413**].
CARE RECOMMENDATIONS: Feeds at discharge: Continue ad lib
breast feeding or supplementing with NeoSure 22 calories.
MEDICATIONS: Not applicable.
Car seat position screening was performed and the infant .
Infant received hepatitis B vaccine on [**2152-12-10**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks; (2) Born between 32 weeks and 35 weeks with two of
the following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSES:
1. Term infant, small for gestational age.
2. Rule out sepsis.
3. Hypothermia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2152-12-10**] 23:34:19
T: [**2152-12-11**] 04:55:46
Job#: [**Job Number 71414**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6644
} | Medical Text: Admission Date: [**2113-5-19**] Discharge Date: [**2113-5-31**]
Date of Birth: [**2036-2-4**] Sex: M
Service: MEDICINE
Allergies:
olanzapine
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Chest pain --> bradycardia
Major Surgical or Invasive Procedure:
Intubation and extubation
Central line placement and removal
History of Present Illness:
76 yo man with DM, HTN, HL, (possibly CHF, CAD) who presented to
OSH today after several days of worsening CP and apparently self
titrating up of his home medical regimen (see below: digoxin,
BB, amlodipine) who was found to be bradycardic to 20s (? BP)
and was electively intubated (difficult intubation) and was
externally paced. While at OSH, he received 1mg of atropine,
digibind (1 vial), calcium gluconate (10g), glucagon (4mg). He
was also started on Dopamine and propofol. Transferred to [**Hospital1 18**]
for further evaluation.
.
On arrival to OSH his BP was 100/40 and in ventricular escape.
with rate in 20s. His BP trended upward to 229/112 prior to
transfer to [**Hospital1 18**]. In the [**Last Name (LF) **], [**First Name3 (LF) **] attempt to place an internal
pacer (now at R atrium vs. vent. wall) was made, however there
was no capture. He required continued external pacing
throughout as apparently w/o this he had no intrinsic rhythm.
He received 4 vials of dibibond, 4mg glucagon, 2mg of calcium
gluconate. The patient spontaneously converted to slow afib
with LBBB.
.
Unable to obtain ROS given intubation.
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:
- Atrial Fibrillation, likely permanent - managed with
Metoprolol and Digoxin, previously anticoagulated.
- CKD, likely Cr 1.4 baseline.
Social History:
- Tobacco history: Quit smoking 15 years ago
- ETOH: Noted in [**Hospital1 6136**] notes that he drinks 2-3
beers/daily
- Illicit drugs: None noted in OSH records
Family History:
Noncontributory.
Physical Exam:
On admission:
GENERAL: Sedated, intubated
HEENT: NCAT. Sclera anicteric. PERRL, although small.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP of 7cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. [**Last Name (un) **], normal S1, S2. II/VI HSM at apex. No thrills, lifts.
No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, distended. Hypoactive BS. No rebound or
guarding.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT dopplerable
On discharge: ____________
Pertinent Results:
On admission:
[**2113-5-19**] 06:00AM BLOOD WBC-9.7 RBC-3.76* Hgb-12.1* Hct-36.7*
MCV-97 MCH-32.1* MCHC-33.0 RDW-14.3 Plt Ct-203
[**2113-5-19**] 06:00AM BLOOD Neuts-78.0* Lymphs-18.4 Monos-2.8 Eos-0.3
Baso-0.4
[**2113-5-19**] 06:00AM BLOOD PT-16.4* PTT-31.5 INR(PT)-1.4*
[**2113-5-19**] 06:00AM BLOOD Fibrino-416*
[**2113-5-19**] 06:00AM BLOOD UreaN-53* Creat-2.9* Na-139 K-6.3*
Cl-109* HCO3-22 AnGap-14
[**2113-5-19**] 06:00AM BLOOD ALT-27 AST-38 AlkPhos-42 TotBili-0.6
[**2113-5-19**] 10:30AM BLOOD LD(LDH)-314*
[**2113-5-19**] 06:00AM BLOOD Lipase-72*
[**2113-5-19**] 06:00AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.2 Mg-2.3
[**2113-5-19**] 10:30AM BLOOD %HbA1c-6.1* eAG-128*
[**2113-5-19**] 10:30AM BLOOD TSH-1.1
[**2113-5-19**] 10:30AM BLOOD Digoxin-6.8*
[**2113-5-19**] 06:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2113-5-19**] 07:49AM BLOOD Type-ART FiO2-100 pO2-107* pCO2-60*
pH-7.16* calTCO2-23 Base XS--8 AADO2-553 REQ O2-91
Intubat-INTUBATED
Creatinine
[**2113-5-19**] 06:00AM BLOOD Creat-2.9*
[**2113-5-19**] 06:07PM BLOOD Creat-2.7*
[**2113-5-20**] 04:09AM BLOOD Creat-3.0*
[**2113-5-21**] 02:49PM BLOOD Creat-2.4*
[**2113-5-23**] 04:57AM BLOOD Creat-1.7*
[**2113-5-25**] 02:23PM BLOOD Creat-1.9*
[**2113-5-27**] 07:16AM BLOOD Creat-1.8*
MICROBIOLOGY:
Joint fluid:
WBC-135 RBC-195* Polys-15 Lymphs-5 Monos-9 Mesothe-11* Macro-60
GRAM STAIN (Final [**2113-5-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
Sputum cx:
GRAM STAIN (Final [**2113-5-20**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2113-5-26**]):
MODERATE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS SPECIES NOT INFLUENZAE. HEAVY GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
HAEMOPHILUS SPECIES NOT INFLUENZAE. MODERATE GROWTH.
2ND MORPHOLOGY.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Stool: CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
IMAGING:
TTE (on admission): The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
TEE: 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 intracardiac shunt seen
at rest (with agitated saline). No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. No thoracic aortic dissection is seen. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-5**]+) mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: No spontaneous echo contrast or thrombus in the
atria/ atrial appendages. No intracardiac shunt. No thoracic
aortic dissection. Normal global [**Hospital1 **]-ventricular systolic
function. Mild to moderate mitral regurgitation.
EKG: Atrial fibrillation. Left bundle-branch block. Since the
previous tracing of [**2113-3-27**] no significant change.
CT head: IMPRESSION:
1. No evidence of hemorrhage or recent infarction.
2. Moderate-to-severe small vessel ischemic changes.
CT chest/abd/pelvis: IMPRESSION:
1. Bibasilar consolidative opacities, likely atelectasis.
Superimposed
pneumonia however is not excluded and may account for the
enlarged subcarinal lymph nodes. Small focus of hyperdense
material at the right base could suggest aspiration.
2. CBD dilation without intrahepatic duct dilation. No definite
mass or
stone. A non-emergent MRCP could be used to further evaluate.
Probable
gallbladder sludge. Changes from initial wet read were discussed
via phone with Dr. [**Last Name (STitle) 10755**] at 9:20pm on [**2113-5-19**].
3. Left adrenal nodule, indeterminate for an adenoma. If
clinically warranted, recommend dedicated adrenal cross
sectional imaging.
Abdominal U/S:
IMPRESSION: Dilated common bile duct measuring 1.9 cm
proximally, tapering
down to 0.8 cm but not completely visualized along its entire
length. No
cause for dilation identified. Further evaluation with an MRCP
is
recommended.
Brief Hospital Course:
76 yo man with DM, HTN, HL, ?CHF who presented to OSH with
complete heart block needing transcutaneous pacing possibly
secondary to B-blocker or Digoxin toxicity, intubated with
hypoxemic respiratory failure with PNA/parapneumonic effusion
and extubated on [**5-24**]. Hospital course complicated by poor rate
control with atrial fibrillation, acute on chronic renal
failure, non-typeable Haemophilus pneumonia, C. difficile
diarrhea, and resolving toxic-metabolic encephalopathy with
labile blood pressures.
# Complete Heart Block ?????? He arrived in complete heart block,
potentially secondary to digitalis and beta-blocker toxicity,
s/p glucagon and repeated administrations of digibind. There
was increased concern for B-blocker toxicity given his initial
hypoglycemia and hyperkalemia, both of which seem to have
resolved. His digoxin and metoprolol were held and his baseline
heart rate of atrial fibrillation with left bundle branch block
with heart rates 80s-110s returned. We started a low-dose
B-blocker (lower than home dose) with good control of HR,
without deficits in blood pressure.
# Acute Hypoxemic Respiratory Failure with Severe Hypoxemia [**3-8**]
Pneumonia with ?parapneumonic effusions: PaO2/FiO2 ratio was
initially 185, so it was presumed that he developed ARDS. On
review of his echocardiogram, his LVEF was preserved and his RV
was normal, without evidence of strain. TEE with Bubble Study
was negative for shunt. Given his ETOH history, it is possible
the patient could have aspirated. The patient did have a
retrocardiac opacity and bibasilar atelectasis as well as
bilateral pleural effusions. He continued to have copious
secretions and a worsening leukocytosis, for which he was
started on broad-spectrum antibiotics. ?VAP vs. aspiration PNA.
His sputum showed GPCs and GNRs on Gram stain, but only
non-typeable haemophilus grew out in culture. He was quite
difficult to extubate, secondary to agitation and hypertension,
but was eventually extubated on [**5-24**]. He was kept NPO due to
inability for the Speech and Swallow service to clear him
secondary to delirium. Once he was cleared, he resumed a normal
diet. His vancomycin ([**5-20**]- [**5-24**]) and pip/tazo ([**5-20**] ??????
[**5-25**]) was narrowed to ceftriaxone to cover these GPCs and
Haemophilus for a total 8-day antibiotic course, ending on
[**2113-5-27**].
# Hypertension: He developed hypertensive urgency with systolic
BPs reaching >200s, felt to be secondary to volume overload and
known essential hypertension. Multiple anti-hypertensive agents
were tried, but only a nitroglycerin gtt with PRN IV
hydralazine, and uptitrated doses of captopril TID were able to
keep his blood pressure under control. Given persistent HTN
despite multiple agents, we also considered secondary causes of
hypertension such as renovascular or endocrine disease, but
these were not evident. He was weaned off a nitro gtt and he was
started back on the majority of his home anti-hypertensives:
amlodipine, captopril TID (instead of lisinopril), and labetalol
[**Hospital1 **] (instead of metoprolol). If his blood pressure continues to
be difficult to control, we would recommend an outpatient
work-up for secondary causes of hypertension.
On the floor his catpropril was changed to lisinopril and his
labetalol was uptitrated. His home imdur was added back and his
hydralazine was changed to [**Hospital1 **] dosing.
# Atrial Fibrillation: Patient in Afib with LBBB, at baseline,
anticoagulated with Coumadin. While he was being treated with
antibiotics, we adjusted his Coumadin dosing as needed. He was
rate controlled with increasing doses of metoprolol, which was
eventually changed over to labetalol for both blood pressures
and rate control.
Digoxin was discontinued and should not be restarted as an
outpatient.
# C. Diff: Patient noted to be C. Diff positive, likely in the
setting of recent hospitalization and antibiotic use. Abdominal
exam without peritoneal signs, but patient did eventually
develop an ileus. Tube feeding had been started given the
patient's relatively long period of intubation, but was held.
An aggressive bowel regimen caused copious stool output,
prompting placement of a flexiseal. He was initially started on
PO vancomycin and IV metronidazole for severe C. diff (elevated
creatinine, leukocytosis, and fevers). IV metronidazole was
discontinued when his leukocytosis and creatinine began to
resolve. He should be continued on PO vancomycin for 14 days
after completing his PNA antibiotics ([**5-28**] ?????? [**6-11**] for 14-day
course - see below).
# Toxic-metabolic encephalopathy: Patient with underlying
infection, s/p extubation, unfamiliar environment with confusion
and agitation likely consistent with delirium. He was given
seroquel 25 mg prn and standing QHS for agitation. He is also
quite hard of hearing, so reorientation was difficult, but his
delirium mostly resolved prior to transfer from the ICU and
seemed to resolve on the floor.
# Acute on chronic renal failure with hyperkalemia ?????? The initial
hyperkalemia was likely caused by beta-blocker toxicity although
it can also be seen with digitalis toxicity. He has underlying
CKD (stage III per note) likely worsened in setting of reduced
perfusion and diuresis. Cr 2.9 on admission. His baseline
nephropathy is likely secondary to HTN and DM, but this acute
kidney injury may have been secondary to hypovolemia vs. ATN for
hypotension secondary to bradycardia.
# Normocytic Anemia - His admission Hct 36.7 trended down to 28,
without active signs/symptoms of acute blood loss. While it
stabilized now in high 20s, iron studies were unrevealing. We
did not uncover a cause of this anemia, though his initial
hematocrits may have been due to hemoconcentration.
# Right knee effusion: His right knee was noted to be quite
enlarged with a large effusion. There was no evidence of
crystals or septic arthritis on joint aspiration. Per family, he
has had swelling in the past, possibly related to underlying OA.
Joint aspirate had no growth on culture. There was not any
further erythema or warmth throughout the hospitalization
# DM II: He is on Glipizide at home and his HbA1c was 6.1 on
admission, indicating good control. He was maintained on SSI
while in house.
# Hyperlipidemia: He was continued on simvastatin.
# CODE: Full code
# CONTACT: Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1004**] [**Telephone/Fax (1) 90116**] (HCP)
Medications on Admission:
- Lisinopril 10mg daily
- ASA 81mg daily
- Digoxin 125mcg daily
- Glipizide 5mg daily
- Simvastatin 40mg daily
- Warfarin 5mg daily
- Furosemide 40mg daily
- Metoprolol Tartrate 200mg [**Hospital1 **]
- Spironolactone 25mg daily
- Imdur 60mg daily
- Ativan 1mg daily
- ? Amlodipine 5mg daily (per OSH records, but no medication
bottle)
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
7. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please check the INR on [**2113-5-30**] and fax to Dr. [**Last Name (STitle) 90117**]. Fax:
[**Telephone/Fax (1) 78086**]
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please start this medication AFTER your BP has been checked at
your appointment this Friday, [**2113-6-2**].
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Digoxin toxicity
Heamophilus pneumonia
Clostridium difficle diarrhea
Hypertension
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 due to a slow heart rate due
to one of your medications (dignoxin). Due to your instability
with the slow heart rate, you were intubated (a breathing tube
was placed) This medication was stopped and your heart rate was
treated and improved.
You were also found to have a pnuemonia and were treated with an
antibiotic with improvement. Additionally you developed
diarrhea caused by a bacteria called Clostridium difficile. You
will need to complete an antibiotic course for this infection.
You blood pressure was also very elevated and multiple
medication changes were made.
Medication changes:
RESTART lisinopril 10 mg daily after your follow-up appointment
Friday
STOP spironolactone
STOP digoxin
STOP ativan
DECREASE metoprolol to 100 mg twice daily
START vancomycin 125 mg every 6 hours until the last dose on [**6-10**]
CHANGE warfarin to 3mg daily
Otherwise continue your outpatient medications as prescribed.
Followup Instructions:
Primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] Practitioner
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Address: 237A [**Street Address(1) **] ROUTE 6, [**Location **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 9674**]
Fax: [**Telephone/Fax (1) 78086**]
FRIDAY [**2113-6-2**] 1:15 PM
You will need to have your INR checked within the next 72hours
because the level was slightly lower today after you received a
slightly higher dose of your coumadin yesterday.
Completed by:[**2113-6-2**]
ICD9 Codes: 0389, 5070, 5849, 2930, 4280, 2724, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6645
} | Medical Text: Admission Date: [**2195-4-21**] Discharge Date: [**2195-4-27**]
Date of Birth: [**2126-6-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Burning
Major Surgical or Invasive Procedure:
[**2195-4-21**] Coronary Artery Bypass Graft Surgery with Left internal
mammory artery -> Left anterior descending artery, Reverse
saphenous vein graft --> obtuse marginal and Reverse saphenous
vein graft to right coronary artery
History of Present Illness:
68 year old female with symptoms of exertional chest burning and
shortness of breath. She had + stress test and was referred for
cardiac catheterization to further evaluate which showed
coronary artery disease.
Past Medical History:
Hypertension
Dyslipidemia
Diabetes Mellitus
thyroid nodule- last u/s- size stable
polpyectomy during colonoscopy- benign
Past Surgical History:
s/p tonisillectomy
Social History:
Lives with:husband
Occupation:retired
Tobacco: quit 3 years ago, [**7-23**] cigs/day x 45 years
ETOH: denies
Recreational drugs: denies
Family History:
Father died of MI age 71, Mother with heart problems, 2 sisters
s/p MI, brother s/p stent
Physical Exam:
Pulse:51 Resp:16 O2 sat:96%RA
B/P Right:167/63 Left: 165/
Height:4'[**96**]" Weight:64.9kg (143 lbs)
General:
Skin: Dry [x] intact [x] 5mm raised erythematous papule with
crust on bilateral cheeks
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur II/VI SEM LUSB, III/VI HSM
RUSB
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2195-4-27**] 05:10AM BLOOD Hct-32.1*
[**2195-4-26**] 05:45AM BLOOD WBC-9.6 RBC-3.98* Hgb-11.3* Hct-33.9*
MCV-85 MCH-28.5 MCHC-33.4 RDW-14.0 Plt Ct-402
[**2195-4-21**] 01:20PM BLOOD WBC-20.0*# RBC-3.87*# Hgb-11.2*#
Hct-32.0*# MCV-83 MCH-29.0 MCHC-35.1* RDW-13.7 Plt Ct-310
[**2195-4-21**] 12:24PM BLOOD WBC-12.2*# RBC-2.77*# Hgb-7.9*#
Hct-23.1*# MCV-83 MCH-28.5 MCHC-34.2 RDW-13.7 Plt Ct-222
[**2195-4-26**] 05:45AM BLOOD Plt Ct-402
[**2195-4-21**] 01:20PM BLOOD PT-13.1 PTT-26.9 INR(PT)-1.1
[**2195-4-27**] 05:10AM BLOOD Glucose-119* UreaN-18 Creat-0.6 Na-136
K-4.8 Cl-101 HCO3-27 AnGap-13
[**2195-4-21**] 01:20PM BLOOD UreaN-12 Creat-0.5 Cl-117* HCO3-25
[**2195-4-27**] 05:10AM BLOOD Mg-2.2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
A-Paced, low dose Neo.
Normal biventricular systolic fxn.
Trace MR, no AI. Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2195-4-21**] 12:22
Sinus rhythm. Consider inferior myocardial infarction of
indeterminate age
but baseline artifact in the inferior leads makes assessment
difficult.
Low precordial lead QRS voltage is non-specific. Lateral
precordial lead
ST-T wave changes are non-specific. Clinical correlation is
suggested.
Since the previous tracing of [**2195-4-15**] sinus bradycardia is
absent and
lateral precordial lead ST-T wave changes are seen but baseline
artifact
in the inferior leads makes comparison of these leads difficult.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 172 92 380/429 48 -1 -41
Brief Hospital Course:
Admitted same day surgery and underwent coronary artery bypass
graft surgery. See operative report for full details. She
received cefazolin for perioperative antibiotics. Post
operatively she was transferred to the intensive care unit for
management. In the first twenty four hours she was weaned from
sedation, awoke neurologically intact and was extubated without
complications. She remained in the intensive care unit post
operative day one due hypotension and was started on vasoactive
medications. She was transfused 2 units of packed red blood
cells for a hematocrit of 24 and low blood pressure on
postoperative day 2 and improved. She was transferred to the
floor later on post operative day 2. Physicial therapy worked
with her on strength and mobility. She continued to progress
and was ready for discharge home with services on post operative
day six.
Medications on Admission:
Atenolol 25mg po daily
Lisinopril 5mg po daily
Metformin 500mg po daily
Simvastatin 20mg po daily
ASA 81 mg po daily
Calcium Carbonate-Vit D 1 tab po daily
Ergocalciferol-400 unit capsule po daily
Glucosamine chondroitin 1 capsule po daily
MVI 1 tab po daily
Omega-3 fatty acids 1 cap po 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Hypertension
Dyslipidemia
Diabetes Mellitus type 2
thyroid nodule
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Ultram prn
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] [**5-26**] at 1:30 PM
Primary Care Dr [**Last Name (STitle) 54049**] [**Name (STitle) **] in [**1-17**] weeks
Cardiologist Dr [**First Name8 (NamePattern2) 19118**] [**Last Name (NamePattern1) 23705**] in [**1-17**] weeks
Completed by:[**2195-4-27**]
ICD9 Codes: 5180, 5990, 2859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6646
} | Medical Text: Admission Date: [**2134-4-6**] Discharge Date: [**2134-4-22**]
Date of Birth: [**2066-3-29**] Sex: F
Service: MEDICINE
Allergies:
Latex / Keflex / Codeine / Statins-Hmg-Coa Reductase Inhibitors
/ Ace Inhibitors / Ciprofloxacin / adhesive tape / Angiotensin
Receptor Antagonist / Tomato / morphine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Left Carotid Endarterectomy
Diagnostic Cardiac Catheterization
History of Present Illness:
68 y/o F with hx of DMII, HTN, PVD, admitted for CEA of left now
POD #2 with SOB and EKG changes. Pt was dx with critical carotid
stensois >80 L and R, [**1-1**] at [**Hospital1 2177**] and was admitted for CEA of
left. Post op she was hypotensive and given IVF. She has been
having increased O2 needs since, now on face tent + NC 5 liters
and nitro gtt. Her wt increased from 90.7 on admission to 98kg.
CXR with pulm edema and BNP elevated to [**Numeric Identifier **]. Post op, she also
developed EKG changes with STD in lateral leads and CE are
elevated with MB peaked at 24 and Trop 0.67. She has worsened
renal function since admission, with Cr now 2.7. She was given
lasix 60mg IV last night and 20mg IV and 60mg IV today. Heparin
is being started at time of transfer without a bolus. [**Name (NI) 94597**]
pt is SOB with +orthopnea, with some CP with coughing in center
of chest. Cough is nonproductive. No fever, no n/v. No BM since
surgery, but passing flatus. No HA or vision changes. Pt has
chronic neuropathy in feet and leg claudication.
Past Medical History:
1. CARDIAC RISK FACTORS:
-Diabetes, on insulin and actos, with peripherial neuropathy
-Dyslipidemia, intolearant of statins due to severe cramps,
failed lipitor and pravastatin
-Hypertension, higher BP in left arm
2. CARDIAC HISTORY:
-Inferior MI seen on stress test, with EF 40% on stress echo
[**4-1**] with apical inferior and inferior lateral hypokinesis
-Heart murmur per pt
3. OTHER PAST MEDICAL HISTORY:
-CRF, stage II
-right and left internal carotid stenosis, >80%, dx [**2134-1-5**],
now s/p CEE on left
-GERD
-Osteo arthritis
-Asthma
-PVD with hx of thrombophlebitis
-Hypotension with anesthesia
-Epistaxis on left
-Endometeriosis
-Nephrolithiasis x 2
-UTIs
-Anemia
-Hyperplastic cells in right breast bx, ductal cyst removed [**7-1**]
rt; star angioma rmoved from right breast
-bilateral cataracts s/p surgery
-s/p chole [**2101**]
-s/p appy [**2121**]
-s/p removal of abscess in right groin [**2075**]
-hx of assault from pts including facial assault and back/rib
cage injury
-s/p right retinal laser surgery in [**2131**]
Social History:
No children, lives alone with cat. Semi-retired psych RN. Uses a
cane when there is ice.
- Tobacco history: former heavy smoker ([**3-26**] ppd), from age 20-35
- ETOH: social
- Illicit drugs: none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: mesothelioma
- Father: unknown
- GF: asthma
- [**1-24**] Sister: breast CA in situ, HTN
- GM: [**Month/Day (2) 1106**] disease
Physical Exam:
Admission Exam:
VS: 99.8 144/64 100 26 93-97% 5L NC +face tent, I/O- yest
1800/[**2038**]; today 130/805
GENERAL: anxious. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP elevated at mid neck with sitting at 45
degrees, wound on left neck healing well
CARDIAC: RRR, No M, +2 radial pulses, 1+ DP pulses
LUNGS: Crackles bilaterally, [**2-25**] of the way up
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c, trace edema
.
Discharge Exam:
GENERAL: anxious. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP elevated at mid neck with sitting at 45
degrees, wound on left neck healing well
CARDIAC: RRR, No M, +2 radial pulses, 1+ DP pulses
LUNGS: Crackles bilaterally, [**2-25**] of the way up
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c, trace edema
Pertinent Results:
Admission Labs ([**4-6**]):
WBC-8.4 RBC-3.48* Hgb-10.2* Hct-30.7* MCV-88 MCH-29.2 MCHC-33.2
RDW-14.6 Plt Ct-200
Glucose-154* UreaN-40* Creat-1.7* Na-145 K-3.9 Cl-111* HCO3-25
AnGap-13
CK-MB-3 cTropnT-<0.01
CK(CPK)-88
Calcium-8.4 Phos-3.7 Mg-1.7
Type-ART pO2-186* pCO2-39 pH-7.43 calTCO2-27 Base XS-2
Intubat-INTUBATED
freeCa-1.16
.
Cardiac Enzyme Trend:
[**2134-4-6**] 02:21PM BLOOD CK-MB-3 cTropnT-<0.01
[**2134-4-6**] 09:57PM BLOOD CK-MB-3 cTropnT-<0.01
[**2134-4-7**] 04:04AM BLOOD CK-MB-8 cTropnT-0.09*
[**2134-4-7**] 04:20PM BLOOD CK-MB-24* MB Indx-7.6* cTropnT-0.44*
proBNP-[**Numeric Identifier **]*
[**2134-4-7**] 10:17PM BLOOD CK-MB-24* MB Indx-6.8* cTropnT-0.55*
[**2134-4-8**] 03:57AM BLOOD CK-MB-21* cTropnT-0.67*
[**2134-4-8**] 01:55PM BLOOD CK-MB-15* MB Indx-4.9 cTropnT-0.83*
.
Imaging:
ECHO ([**2134-4-7**]):
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-15mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
infero-lateral akinesis (EF 45%). No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. An eccentric, posteriorly directed jet of
moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
ECHO ([**2134-4-21**]):
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe hypokisis of the basal and mid inferior and inferolateral
walls. The remaining segments contract normally (LVEF = 45 %).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-24**]+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD. Mild-moderate mitral
regurgitation. Dilated aortic root. Compared with the prior
study (images reviewed) of [**2134-4-15**], the findings are similar.
.
CXR ([**2134-4-16**]):
IMPRESSION:
1. Significant interval improvement in severity of pulmonary
edema.
2. New mild lingular atelectasis.
Brief Hospital Course:
CCU Course:
68 yo female with hx of inferior MI, PVD, DMII, now s/p CEA on
left on [**2134-4-6**] transferred to the CCU on [**2134-4-8**] with s/s of
CHF secondary to iv fluid administration and new mitral
regurgitation.
# PUMP: Patient was admitted to the CCU with signs and symptoms
of CHF. Her echo on [**4-7**] showed EF 45% along with severe mitral
regurgitation. She also had an elevated BNP and CXR that showed
pulm edema. On admission to the CCU, her weight was up 8 kg from
admission. This weight gain was likely caused by IVF given for
hypotension post op. She was started on diuresis with iv lasix,
lasix drip and diuril with limited effect. Her diuresis was
improved when she was wearing her BIPAP mask but she had
difficulty tolerating this mask. Her severe mitral regurgitation
likely contributed to the difficulty with diuresis as she had
limited forward flow. She was intubated on [**2134-4-11**] for
persistent hypoxia, difficulty tolerating BIPAP mask. She was
also started on CVVH on [**2134-4-12**]. She became 6-7 liters negative
over 48 hours. Her oxygenation was improved and her CXR was much
improved. She was extubated and transitioned to 50% shovel mask
with good O2 saturations. Her weight also returned to baseline.
She was started on torsemide iv boluses with the goal to make
her fluid even. She had a repeat echo which showed improved [**1-24**]+
mitral regurgitation and resolution of pulmonary hypertension.
She was seen by CT surgery for evaluation of her mitral
regurgitation and they recommended she follow-up with them as an
outpatient. She has been intolerant of an ACE-I/[**Last Name (un) **] in the past.
She was started on imdur and hydralazine for afterload
reduction, but was founf to have orthostatic hypotension and so
it the hydralazine was discontinued and the Imdur was initially
lowered to 30mg PO Daily and then eventually discontinued. She
continued to be orthostatic with physical therapy, but her
symptoms of dizziness and nausea resolved. She will be
discharged to Rehab with a prescription for torsemide 5mg to be
given if Ms [**Known lastname **] is noted to be gaining weight on a daily
basis. However at this time, we held off on starting afterload
reducing agents given her orthostasis.
# CAD: Pt has a hx of a inferior MI seen on stress test last
fall and she was admitted to the CCU with new CE elevations and
lateral STD in post op setting, concerning to ACS vs demand
ischmia. Stress echo prior to surgery did not show ischemic
changes, but was at subopitimal exercise <4.5 METs. Pt was also
not on a BB perioperatively. She has not tolearted statins,
ACE-I or ARBs in the past. Also pt had hypotension post
operatively, which may have worsened any ischemia. Echo [**4-7**]
with new presumed MR, which may be from ischemia. She was
initially treated with heparin drip, plavix (loaded with 600 mg
po x1 then maintained on 75 mg po daily), metoprolol, nitro
drip, aspirin 325 mg po daily. She had a cardiac catheterization
on [**2134-4-12**] which showed diffuse coronary disease but did not
show any intervenable lesions. Her plavix was stoppped on [**4-12**]
given that she may need mitral valve surgery.
# Acute on Chronic Renal Failure: Patient has underlying CKD,
with creatinine of 1.8 on admission. She developed acute renal
failure in the setting of aggressive diuresis, cath and her
creatinine became elevated to a max of 4.0. This may also be
related to the poor forward flow from her severe mitral
regurgitation. She required CVVH for fluid removal. She was
treated with mucomyst prior to cath. Her creatinine eventually
began trending down and on discharge was 2.1. She will need
follow up labs to monitor whether she returns to baseline or
whether she will be at a new baseline of her kidney function
given this recent injury.
# RHYTHM: patient was in sinus rhythm. She developed bradycardia
along with hypotension after a femoral groin line was placed,
though to be a vagal response. Her metoprolol was stopped and
her bradycardia improved when the groin line was pulled on
[**2134-4-15**]. Her metoprolol was eventually restarted and she
tolerated it well. She will be discharged on metoprolol XL 50mg
PO Daily. She will continued to be monitored by her
cardiologist.
# HTN: Patient has hypertension and all blood pressures were
monitored on the left arm. Her right arm shows falsely low blood
pressure related to right sided subclavian stenosis. She was
initially managed on amlodipine, metoprolol, nitro gtt for goal
SBP 100-140. She was then transitioned to imdur and hydralazine
for afterload reduction. On hospital day 13, pt was orthostatic
lying BP 138/61 HR 88 to standing BP 80/48 HR 92. She was a
little dizzy and nuaseaus. Her Imdur and Hydralazine were held
and no diuretics started. She continued to be orthostatic, but
less symptomatic. Her orthostasis likely has some autonomic
component given her prolonged hospital stay and bedrest. She
will be discharged to rehab where she will likely improve. She
will be given a prescription for torsemide in the event that she
gains some weight and needs a diuretic, but her afterload
reducers are being held at this time.
# HLD: Patient has failed atrovastatin and pravastatin as an
outpatient due to severe cramps and she was resistant to retry a
statin. Her lipid panel was not at goal, but not severely
elevated- LDL 109, HDL 45, total cholesterol 175. Her fish oil
was held during her hospital stay but was restarted the day
prior to discharge. She was also started on Crestor 5mg PO
Daily. She will continue to be monitored in the outpatient
setting.
# Anemia: Iron studies are consistent with anemia of chronic
disease and may also be related to anemia [**2-24**] CKD. She required
1 unit of PRBC for HCT of 22.4 with an appropriate response. Her
HCT then remained stable in high 20s, low 30s.
.
# Carotid stenosis: stable, healing well s/p left CEA. She will
likely need a future procedure for right sided stenosis.
.
# DMII: Patient was treated with lantus 28 hs and humalog
sliding scale. Her A1c was 7.2. Her actos was held and was not
restarted as it may contribute to worsened CHF.
# Hypothyroidism: TSH within normal limits. She was continued on
her home dose of levothyroxine.
# Asthma: ? asthma vs COPD vs cardiac asthma due to heavy prior
tobacco use. She was continued on Albuteral nebs and Advair.
.
# Anxiety: patient has significant underlying anxiety and
becomes more anxious when she does not know her plan of care.
She was treated with lorazepam 1 mg iv prn.
#Code: FULL CODE (confirmed with patient)
Medications on Admission:
-Actos (pioglitazone) 45mg qday
-Levoxyl 150mcg qday
-Amlodipine 10mg qday
-Xalantan 1 drop each eye HS
-Alprazolam 0.25mg 1-2 tabs prn, none for last 4 months
-Humalog, 2 units for BS >250
-Lantus 28 units HS
-Protonix 40mg
-Lasix 10mg PO qday
-MV qday
-ASA 81mg qday
-Calcitrol 0.25mcg qday
-fluticasone-salmeterol 250 mcg-50 mcg/Dose 1 puff IH [**Hospital1 **]
-Montelukast 10 mg qday
-Calcium carbonate 600 mg
-Coenzyme Q10 100 mg
-Omega-3 fatty acids 1,200 mg-144 mg qd
-Salmon oil 1000mg qday
-Pen VK 500mg prn tooth infection
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. alprazolam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for sleep.
6. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous at bedtime.
7. insulin lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous four times a day: per sliding scale.
8. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID (3 times a day).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. hydrocortisone acetate 25 mg Suppository Sig: One (1)
Suppository Rectal DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
15. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
16. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. omega-3 fatty acids Capsule Sig: One (1) Capsule PO TID
(3 times a day).
18. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
20. Calcitrate 200 mg (950 mg) Tablet Sig: One (1) Tablet PO
twice a day.
21. torsemide 5 mg Tablet Sig: One (1) Tablet PO once a day.
22. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
23. Xalatan 0.005 % Drops Sig: One (1) gtt Ophthalmic at
bedtime: each eye.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6594**] Rehabilitation & Nursing Center
Discharge Diagnosis:
Status-post Left Carotid Endarterectomy
Myocardial Infaction
Acute Systolic Congestive Heart Failure: allergy to ACEi and [**Last Name (un) **]
Mitral Regurgitation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital for surgery of your left
carotid artery. Following your surgery, you developed a low
blood pressure with difficulty breathing and your lab tests and
EKG changes were concerning for a heart attack. You were
transfered to the cardiac intensive care unit where you were
evaluated and treated by the cardiology service. You were found
to have a significant excess of fluid throughout your body and
improtantly in your lungs that made it difficult for you to
breathe. You received medication to help your kidneys remove the
excess fluid, but your breathing continued to be difficult and
you required intubation and assistance from a breathing machine.
You also required temporary dialysis because your kidneys were
not able to remove enough fluid. Careful use of dialysis allowed
enough fluid to be removed and you were extubated with improved
breathing. You also received a cardiac catheterization that
revealed your known coronary disease but did not require
intervention. While your fluid volume was very high, you were
noted to have worsened heart valve disease (mitral
regurgitation) that improved after removing a large amount of
fluid. You will need to follow up with your outpatient doctors.
Please take your medications as prescribed and keep your
outpatient appointments.
The following changes have been made to your home medications:
1. Stop taking Actos, amlodipine, furosemide and co-enzyme Q10
2. Start Torsemide to prevent fluid buildup
3. Increase aspirin to 325 mg daily for one month
4. STart Tucks and hydrocortisone suppositories for your
hemmorrhoids
5. STart colace and senna to prevent constipation
6. STart metoprolol succincate to slow your heart rate and
improve your heart function
7. STart trazadone to help you sleep
8. STart crestor and zetia to lower your cholesterol. Please
talk to Dr. [**Last Name (STitle) 1836**] is you get leg cramps again
9. Start Plavix to prevent blood clots in your carotid artery
.
Please check your weight daily before breakfast. Call Dr. [**Last Name (STitle) **] if
your weight increases more than 3 pounds in 1 day or 5 pounds in
3 days.
Followup Instructions:
Department: [**Last Name (STitle) **] SURGERY
When: THURSDAY [**2134-5-6**] at 2:00 PM [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2134-5-6**] 2:00
Department: [**Month/Day/Year **] SURGERY
When: THURSDAY [**2134-5-6**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: Cardiology
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
**Please contact Dr. [**Last Name (STitle) **] office on [**Last Name (LF) 766**], [**4-26**] to book a
follow up appointment. You will need to be seen by Dr. [**Last Name (STitle) **]
within 2-4 weeks of your discharge from the hospital.**
Name: [**Last Name (LF) 94598**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital3 **] CTR
Address: [**Location (un) **], 7TH FL, STE#7A
Phone: [**Telephone/Fax (1) 94599**]
Appointment: Tuesday [**5-18**] at 11:30AM
ICD9 Codes: 9971, 5849, 4280, 3572, 4240, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6647
} | Medical Text: Admission Date: [**2185-7-24**] Discharge Date: [**2185-7-27**]
Date of Birth: [**2142-6-2**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
43 y/oF with polysubstance abuse and hepatitis who presented to
ED with altered mental status. According to patient, she used
heroine along with 2 beers and 1 "shot" of rum earlier yesterday
and was then found unresponsive by family members who then
called EMS. Upon initial assessment, patient was given narcan
with improvement of mental status. Patient was then brought to
ED for further evaluation.
.
In ED, patient's initial VS were 97.8 86 130/99 14 100% RA. On
initial evaluation patient appeared tired however did not
require any further narcan and eventually was more interactive.
She apparently vomitted approximately 350cc of coffee ground
emesis. NG tube was placed and revealed more coffee grounds with
active bleeding. Hct was 39 which was thought to be
hemoconcentrated however repeat Hct was not drawn. GI was
consulted who recommended admission to MICU for EGD. She
remained hemodynamically stable.
.
Also while in ED, patient was noted to have a lactic acidosis to
4.4 with anion gap of 18. She was also hypernatremic to 149 and
had a Cr of 2.5. Patietn was given a total of 2000cc of NS and
1000cc of D5 1/2 NS. Repeat lactate was 2.4. Patients serum ETOH
level was 98 on admission and utox/serum tox were positive for
opioids and cocaine.
.
Prior to transfer, patients VS were HR 86 BP 138/91 RR 18 SpO2
100%RA
.
In the MICU, patient was resting comfortably however complaining
of thirst.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
- hepatitis C
- depression
- polysubstance abuse
- hypertension.
- tubal ligation at the age of 27
- right hand surgery to remove an abscess at the age of 30.
Social History:
- Lives with [**Location (un) 686**]
- Has 4 children ages 20, 19, 17 and 14.
- currently on [**Social Security Number 93147**]Social Security disability
- tobacco: never
- illicits: current heroine/cocaine, occ marijuana
- ETOH: 6pack of beer + liquor 3-4times per week.
Family History:
- mother passed away at age 50 from gastric cancer also with
hypertension, and had polysubstance abuser
- father is an alcoholic.
Physical Exam:
Vitals: 98 143/90 77 95%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: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength, tremulous
Discharge Exam:
VItals, afebrile, VSS
Gen: AxO x3, comfortable
CV: RRR, no murmurs
RESP: CTAB
ABD: soft, NT/ND
Ext: warm, no LE edema
Pertinent Results:
ADMISSION LABS
[**2185-7-24**] 01:30AM BLOOD WBC-5.1 RBC-3.59* Hgb-12.7 Hct-37.3
MCV-104*# MCH-35.3* MCHC-34.0 RDW-12.9 Plt Ct-248
[**2185-7-24**] 01:30AM BLOOD Neuts-88.1* Lymphs-7.8* Monos-3.6 Eos-0.1
Baso-0.3
[**2185-7-24**] 01:30AM BLOOD PT-11.3 PTT-26.5 INR(PT)-0.9
[**2185-7-24**] 01:30AM BLOOD Glucose-93 UreaN-15 Creat-2.5*# Na-149*
K-4.1 Cl-103 HCO3-28 AnGap-22*
[**2185-7-24**] 01:30AM BLOOD ALT-33 AST-110* AlkPhos-77 TotBili-0.3
[**2185-7-24**] 01:30AM BLOOD Albumin-4.8
[**2185-7-24**] 06:13AM BLOOD Calcium-7.6* Phos-5.0* Mg-2.3
[**2185-7-24**] 09:50AM BLOOD D-Dimer-360
[**2185-7-24**] 01:30AM BLOOD ASA-NEG Ethanol-98* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2185-7-25**] 04:21AM BLOOD Type-[**Last Name (un) **] pH-7.37 Comment-GREEN TOP
[**2185-7-24**] 02:41AM BLOOD Lactate-4.4*
[**2185-7-24**] 05:20AM BLOOD Lactate-2.4*
[**2185-7-24**] 01:15AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
[**2185-7-24**] 01:15AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2185-7-26**] 06:20AM BLOOD VitB12-1326* Folate-13.0
EKG ADMISSION: Sinus rhythm. Prolonged Q-T interval. Poor R wave
progression in the
anterior precordial leads. Inferior and anterior T wave changes
suggest
myocardial ischemia. No previous tracing available for
comparison.
TTE: IMPRESSION: Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation with normal valve morphology.
EGD: normal esophagus, stomach, duodenum
DISCHARGE LABS
[**2185-7-27**] 06:10AM BLOOD WBC-4.6 RBC-3.85* Hgb-13.3 Hct-38.0
MCV-99* MCH-34.7* MCHC-35.1* RDW-12.5 Plt Ct-229
[**2185-7-27**] 06:10AM BLOOD Glucose-86 UreaN-9 Creat-1.2* Na-139
K-4.2 Cl-95* HCO3-34* AnGap-14
[**2185-7-26**] 06:20AM BLOOD ALT-45* AST-86* AlkPhos-69
[**2185-7-27**] 06:10AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.1
Brief Hospital Course:
43 y/o F with history of hepatitis C and polysubstance abuse who
presents with altered mental status in setting of opioid
intoxication found to have coffee ground emesis concerning for
upper GI bleed.
.
ACTIVE ISSUES:
1. GI Bleed: Patient presented with coffee ground emesis c/w
upper GI source, however NG lavage did not show active bleed. Pt
was admitted to MICU and serial Hct's were stable. She had no
further melena or hematemesis. Pt was given IV PPI [**Hospital1 **]. GI was
consulted and deferred EGD while in the unit given that pt
appeared tremulous and was possibly withdrawing from EtOH. When
the patient was transferred to the floor, GI performed an EGD
which showed a normal esophagus, stomach and duodenum. There was
no evidence of varices. Her bleeding was thought to be secondary
to gastritis or from trauma due to retching. No further
interventions needed.
2. Overdose/Polysubstance abuse/Altered Mental Status: Patient
apparently used cocaine and heroin prior to arrival to ED which
caused somnolence. She responded to narcan and was mentating
well on arrival to MICU. Last drink was day before admission and
pt with unclear h/o withdrawal but appeared tremulous on MICU
admission. She was kept on CIWA scale, SW was consulted, and she
was given a banana bag. Patient was stable but somnolent on
transfer to the floor. While on the floor she required no Valium
for CIWA scale. Social work offered patient substance abuse
treatment resources and information but patient declined. She
plans to return to AA and to see her psychiatrist.
3. Acute renal failure: Likely pre-renal. She was given 3L IVF's
in the ED and Cr quickly trended down to normal.
.
# transaminitis - likely secondary to ETOH and chronic Hep C -
trended down during admission
.
# macrocytic anemia - likely vitamin B12, folate deficiency from
ETOH
- HCTs stable during admission
.
# Hypernatremia: Initially 149 with free water deficit of 0.9L.
Received a total 2L of NS and 1L D5 1/2NS. Responded to fluids
and now resolved.
.
# Depression
- continue Celexa, trazodone, risperdone, depakote
TRANSITIONAL ISSUES
Antihypertensive regimen was adjusted while in the hospital.
This will likely need further titration after discharge.
Medications on Admission:
medications confirmed, doses however not
- Citalopram 20 mg tablet, 1 tablet by mouth daily.
- Divalproex 250 mg tablet delayed release, 1 tablet by mouth 3
times daily.
- Risperidone 2 mg tablet, 1 tablet by mouth daily.
- Trazodone 150 mg tablet, 1 tablet by mouth at bedtime.
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. citalopram Oral
3. Depakote Oral
4. risperidone Oral
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. trazodone Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Upper gastrointestinal bleed
Secondary diagnosis: polysubstance abuse, hepatitis C,
depression, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 9513**],
It was a pleasure caring for you while you were in the hospital.
You were admitted for altered mental status due to drug and
alcohol use and concern for blood in your vomit. You were
treated for alcohol withdrawal. The gastroenterology team also
followed you while you were in the hospital. They performed an
esophagogastroduodenoscopy which showed normal GI tract. After
discharge you should continue to avoid drugs and alcohol. You
should follow up with your primary providers at [**Hospital1 778**] health.
The following medication changes have been made.
You should START taking:
amlodipine
You should STOP taking:
hydrochlorathiazide
Followup Instructions:
[**Hospital1 778**] Health ([**Telephone/Fax (1) 2776**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] NP
Thursday [**2185-8-4**] at 11:00 am
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
Completed by:[**2185-8-1**]
ICD9 Codes: 5789, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6648
} | Medical Text: Admission Date: [**2158-4-28**] Discharge Date: [**2158-5-2**]
Date of Birth: [**2091-3-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Fenofibrate / STEROIDS / Wellbutrin / lobsters /
crabs
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
confusion, altered mental status
Major Surgical or Invasive Procedure:
none this hospitalization
History of Present Illness:
67 yo M with widely metastatic lung cancer since [**6-/2157**]
including brain mets found [**2158-4-8**] presents today with increased
confusion x 1 day. Patient was scheduled to receive final
fraction of course of Whole Brain Radiation Therapy today. On
Monday [**2158-4-24**] was started on a steroid taper-dose was decreased
from Dexamethasone 4 MG PO twice a day down to once a day.
Yesterday received first cycle of Pemetrexed. Wife states as
part of chemo regimen on day before chemo (Wed); day of (Thurs)
and plan is for today (Fri) was to take 4 MG PO Dexamethasone PO
twice each day. States was instructed to resume Dexamethasone
4MG PO once a day tomorrow. Was noted in pre-treatment labs to
have a lower Na level of 121 with Cl of 86 and decreased the
amount of iv fluids that he received with chemo and advised
fluid restriction to [**Telephone/Fax (1) 20571**] ml per day. He and his wife report
that the headaches are improving, and that his gait originally
improved, but is now worse again since yesterday. Wife reports
that he was repeating routines and forgetful of habitual
activities last night such as [**Location (un) 1131**] the psalm and seen trying
to take his medications twice. She performed a minimental at
home yesterday and he scored very poorly but now he is improved.
They phoned his outpt provider who recommended [**Name9 (PRE) **] evaluation. Of
note, pt has hx of hyponatremia attributed to SIADH from [**7-/2157**]
resulting in discontinuation of diuretics.
.
ED course: initial vitals 98.8 71 164/85 14 100%. No fluids
given in ED. Initial labs showed WBC 7.7, Hct 37.4, plt 149,
coag wnl, Na 119, lactate 0.7. Blood cultures sent. Neuro exam
felt to be non-focal. Pt admitted to [**Hospital Unit Name 153**] for management of
hyponatremia. Outpt oncologist/[**Doctor Last Name 3274**] was emailed.
.
On arrival to the ICU pt is [**Name (NI) **]3 and feels well. He denies
nausea/vomiting, anorexia, fever/chills or urinary complaints.
Had headache and visual changes for the last few weeks with
intermittent confusion per wife. Confusion was worse over last
couple days. Pt reduced fluid consumption after chemo appt
yesterday. Currently wife and pt feel he is at baseline.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Stage IV Adenocarcinoma lung (KRAS wild-type;EGFR negative; ALK
rearrangement unknown)
Oncologic history:
- [**6-/2157**] - Imaging of the back for severe back pain revealed
metastatic vertebral lesions
- [**7-/2157**] - Biopsy of L2 lesion consistent with metastatic
carcinoma positive for CK7 and TTF-1.
- Staging scans revealed primary lesion in the right lower lobe
and right hilum with mediastinal lymphadenopathy, lung lesion in
the left lower lobe, liver lesion, left adrenal lesion, and
multiple bone lesions. No brain lesions.
- [**2157-8-11**] - Carboplatin (6 AUC)/Paclitaxel (200
mg/m2)/Bevacizumab (15 mg/kg) initiated (C1D1)
- [**2157-9-1**] - C2D1 [**Doctor Last Name **]/Taxol/Bevacizumab
- [**2157-9-16**] - Palliative radiotherapy to lumbosacral vertebrae.
- [**2157-9-22**] - C3D1 [**Doctor Last Name **]/Taxol (Bevacizumab held as patient
receiving radiation treatment)
- [**2157-10-13**] - C4D1 [**Doctor Last Name **]/Taxol/Bevacizumab
- [**2157-11-3**] - C5D1 [**Doctor Last Name **]/Taxol/Bevacizumab
- [**2157-11-24**] - [**2158-3-9**] C1-6 Maintenance Bevacizumab (15 mg/kg)
- [**4-/2158**] - MRI brain revealed metastatic lesions to the brain.
Presented with gait changes and headaches.
- [**2158-4-13**] - whole brain radiation, completed 10 cycles. Also with
dexamethasone PO
.
Other medical history:
1) Hypertension
2) Hyperlipidemia
3) Vitamin D deficiency
4) Bronchial asthma
5) Allergic rhinitis/sinusitis
6) Monoclonal gammopathy
Social History:
Social History: He has a 15 pack year smoking history and
currently smokes 6 cig/day. He usually drinks [**2-13**] glasses of
wine with dinner. He has 2 grown sons who live in [**Name (NI) 583**]. He
is widowed and remarried 3 years ago. He works as a plasma
physicist.
Family History:
Family History: His mother died at the age of eight nine of
unknown causes. His father died at the age of 81 of emphysema.
He has a sister who is 57 years old and is well.
Physical Exam:
Admission Physical Exam:
.
Vitals 97.1 138/86 73 13 98/RA
General: Alert, oriented, elderly male in no acute distress
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, strength intact b/l, reflexes 2+ b/l upper/lower
ext, downgoing plantar reflexes, gait deferred, CN II-XII
grossly intact, finger to nose intact
.
Discharge Exam:
Vitals: T 96.7 BP 110s-130s/60s-80s HR 60s-80s RR 18 O2 sat 97%
RA
General: Alert, oriented, elderly male in no acute distress
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3 CN II-XII intact, 5/5 strength, intact finger to
nose, gait deferred
Pertinent Results:
ADMISSION LABS:
.
[**2158-4-27**] 08:50AM BLOOD WBC-10.3 RBC-4.13* Hgb-13.3* Hct-39.7*
MCV-96 MCH-32.2* MCHC-33.5 RDW-13.5 Plt Ct-183
[**2158-4-27**] 08:50AM BLOOD Neuts-84.3* Lymphs-8.5* Monos-6.2 Eos-0.7
Baso-0.2
[**2158-4-28**] 11:00AM BLOOD PT-9.7 PTT-27.7 INR(PT)-0.9
[**2158-4-27**] 08:50AM BLOOD UreaN-13 Creat-0.6 Na-121* K-4.3 Cl-86*
HCO3-29 AnGap-10
[**2158-4-27**] 08:50AM BLOOD ALT-36 AST-26 AlkPhos-49 TotBili-0.5
[**2158-4-27**] 08:50AM BLOOD TotProt-6.4 Albumin-4.3 Globuln-2.1
Calcium-9.1 Phos-2.8 Mg-2.1
[**2158-4-28**] 11:00AM BLOOD Osmolal-249*
[**2158-4-28**] 03:21PM BLOOD TSH-0.67
[**2158-4-27**] 08:50AM BLOOD CEA-3.2
[**2158-4-28**] 11:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2158-4-28**] 11:12AM BLOOD Lactate-0.7
.
DISCHARGE LABS:
[**2158-5-2**] 06:25AM BLOOD Glucose-102* UreaN-16 Creat-0.6 Na-130*
K-4.8 Cl-97 HCO3-27 AnGap-11
[**2158-5-2**] 06:25AM BLOOD WBC-7.3 RBC-4.00* Hgb-12.4* Hct-38.3*
MCV-96 MCH-30.9 MCHC-32.4 RDW-13.5 Plt Ct-140*
.
MICROBIOLOGIC DATA:
.
[**2158-4-27**] Monospot testing - negative
[**2158-4-28**] MRSA screen - pending
[**2158-4-28**] Blood culture - pending
[**2158-4-28**] Urine legionella - negative
[**2158-4-28**] Influenza culture - pending
[**2158-4-28**] Respiratory viral culture - pending
[**2158-4-28**] Sputum culture - contaminated; PCP immunostain [**Name Initial (PRE) **] pending
[**2158-4-28**] Urine culture - negative
[**2158-4-29**] HIV viral load PCR - pending
.
[**2158-4-28**] 2D-ECHO - The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal. The
main pulmonary artery is dilated. There is no pericardial
effusion.
.
[**2158-4-28**] CHEST (PORTABLE AP) - As compared to the previous
radiograph, there is no relevant change. No evidence of
pneumonia. No pulmonary edema. No pleural effusions. Normal size
of the cardiac silhouette.
CT HEAD W/O CONTRAST Study Date of [**2158-4-28**] 11:41 AM
IMPRESSION: Extensive metastatic disease without evidence of
acute
hemorrhage, edema, or mass effect.
Brief Hospital Course:
67y M w h/o metastatic lung ca s/p 9/10 sessions total brain
irradiation presenting with acute confusion/MS changes and
hyponatremia.
.
# Hyponatremia: Given acute MS changes would presume acute Na
decrease from baseline however on arrival to ICU pt and wife
confirmed return to baseline wo intervention. He had started
fluid restricting the day prior after his clinic appt. Serum Osm
249. Likely SIADH related to brain mets given hyponatremia and
hypochloremia but differential would include hypervolemic and
hypovolemic states but exam is not clinically consistent with
either. Low suspicion for adrenal insufficiency given normal
adrenal findings 1 year ago on CT and normotensive. FeNA 1.7%.
TSH was wnl. He was monitored overnight in the ICU and remained
clinically stable. Serial Na levels showed improvement with
fluid restriction to 1000cc daily and the addition of salt tabs
twice per day. At time of discharge his sodium level was 130.
.
# Mental status changes: He presented with 2 days of
waxing/[**Doctor Last Name 688**] quality of mental status. CT head negative for
findings to explain MS changes. Chest xray and cultures were
NGTD as part of infectious etiology for confusion. Neurology
exams remained nonfocal. His mental status improved as his
sodium levels improved as well.
.
# Brain metastases: Has been on outpt course of TBI for recently
diagnosed mets 02/[**2158**]. CT head on presentation negative for
edema or midline shifts. He was continued on dexamethasone 4mg
daily per outpt plan. He completed his last dose of whole brain
radiation during this hospitalization.
.
# Lung ca: Dx'd [**6-/2157**] s/p most recent chemo treatment with
Pemetrexed on [**2158-4-27**]. He follows up with Dr. [**Last Name (STitle) 3274**] as an out
patient.
.
# HTN: continued home dose amlodipine and ASA.
# HL: continued home dose rosuvastatin
.
TRANSITION OF CARE ISSUES:
1. Pt has a follow up appointment with Dr. [**Last Name (STitle) 3274**] two days
post discharge. His sodium level should be repeated at that
time. The pt should also be given further guidance about whether
to continue the salt tabs at that time as well.
Medications on Admission:
AMLODIPINE 5 mg daily
CLONAZEPAM 1-2 mg qhs
DEXAMETHASONE 4 mg [**Hospital1 **] (will change to daily [**2158-4-24**])
FLUTICASONE nasal spray [**Hospital1 **]
HYDROMORPHONE 2 mg po q4h prn
IPRATROPIUM-ALBUTEROL nebs prn
OMEPRAZOLE 20 mg daily
PROCHLORPERAZINE 190 mg q6h
ROSUVASTATIN 40 mg qhs
SILDENAFIL prn
ACETAMINOPHEN prn
ASCORBIC ACID 500 mg [**Hospital1 **]
ASPIRIN 81 mg daily
CHOLECALCIFEROL 8000 u daily
loratidine
NICOTINE patch
OMEGA-3
miralax prn
SENNOSIDES 1-2 tabs qhs
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clonazepam 1 mg Tablet Sig: 1-2 Tablets PO QHS (once a day
(at bedtime)) as needed for anxiety.
3. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) nebulizer Inhalation every [**5-19**]
hours as needed for shortness of breath or wheezing.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. sildenafil 50 mg Tablet Sig: One (1) Tablet PO as needed :
take 1 hr before sexual activity.
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO four times a day.
15. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
16. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
17. Omega 3 350-400 mg Capsule Sig: One (1) Capsule PO once a
day.
18. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
19. senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for Constipation.
20. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Stage IV Adenocarcinoma lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 103023**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with low blood
sodium levels. We restricted your fluid intake and supplemented
your diet with salt. These treatments have caused your sodium
level to rise. It is important that you continue to restrict
your fluid intake to no more than 1.5L per day until instructed
by your doctor not to do so.
The following changes have been made to your medications:
START:
Sodium Chloride Tabs twice per day until instructed by a
physician to stop
Please see below for follow up appointments that have been made
for you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2158-5-4**] at 10:00 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2158-5-4**] at 10:00 AM
With: DR. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2158-5-18**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21833**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2930, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6649
} | Medical Text: Admission Date: [**2189-8-31**] Discharge Date: [**2189-10-23**]
Date of Birth: [**2150-9-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
s/p fall ~ 30 feet
Major Surgical or Invasive Procedure:
T5-T11 posterior fusion with CSF leak repair
Lumbar drain
History of Present Illness:
38 year old male portugese speaking s/p fall ~30 feet landed on
stomach. No LOC at scene- Unable to move feet, loss of LE
sensation/+step-offs.
Past Medical History:
None
Social History:
Nonsmoker, family lives in [**Location 4194**]
Family History:
None
Physical Exam:
PHYSICAL EXAM upon admission:
Gen: AOx3, NAD
HEENT: multiple facial lacerations, right periorbital ecchymosis
Pupils: 3>2 bilateral EOMs full and intact
Neck: in cervical collar
Lungs: not examined
Cardiac: not examined
Abd: not examined
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 0 0 0 0 0 0
L 5 5 5 5 5 0 0 0 0 0 0
Sensation: Intact to light touch in upper extremities and on
trunk superior to xiphoid process bilaterally, no sensation to
light touch on trunk distal to xiphoid process and in lower
extremities bilaterally.
Rectal Tone: reported intact by General Surgery Trauma service
on
their exam
Reflexes: B T Br Pa Ac
Right 1+ 1+ 1+ absent
Left 1+ 1+ 1+ absent
Toes neutral on Babinski, no clonus
Exam upon discharge:
[**6-2**] UE
0/5 LE
no sensation T8 distal
wound well healed
Pertinent Results:
[**2189-8-31**] 08:59AM WBC-9.2 RBC-5.26 HGB-15.4 HCT-43.8 MCV-83
MCH-29.3 MCHC-35.1* RDW-14.5
[**2189-8-31**] 08:59AM PLT COUNT-236
[**2189-8-31**] 08:59AM PT-13.2 PTT-21.2* INR(PT)-1.1
[**2189-8-31**] 08:59AM FIBRINOGE-378
[**2189-8-31**] 08:59AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-8-31**] 09:14AM GLUCOSE-147* LACTATE-3.0* NA+-142 K+-3.6
CL--100 TCO2-25
[**2189-8-31**] 09:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2189-8-31**] 09:25AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
CT C-spine [**8-31**]:
IMPRESSION:
1. No acute fracture or malalignment involving the cervical
spine.
2. Old T1 spinous process.
3. Biapical lung scarring, likely sequelae of prior
TB/granulomatous
exposure.
CT CAP [**8-31**]:
IMPRESSION:
1. Comminuted vertebral fracture at T8 with retropulsion of
multiple bony
fragments into the central spinal canal concerning for
transection. There is associated paravertebral hematoma.
2. Posterior mediastinal hematoma adjacent to the distal
esophagus and
descending aorta which may reflect tracking of hematoma from
paraspinal hematoma. Howevre, esophageal injury cannot be
entirely excluded.
Recommend correlation with esophagram if needed. No definite
evidence for
aortic injury, though follow-up recommended if there is clinical
concern
given the hematoma adjacent to the descending thoracic aorta at
the level of the spinal fractures.
3. Retrosternal hematoma along the anterior aspect of the heart
without
identifiable sternal fracture. Findings may be secondary to
blunt trauma and cardiac contusion cannot be excluded. Clinical
correlation is advised.
4. Biapical lung scarring suggestive of prior TB with areas of
ground-glass
opacity in the peripheral aspect of the right middle lobe,
unclear etiology, may reflect chronic interstitial lung disease,
less likely contusion.
5. Multiple rib fractures, multiple transverse process
fractures.
CT sinus/mandible [**8-31**]:
IMPRESSION:
1. Right lamina papyracea fracture with small extraconal
hematoma and air
locules in the medial right orbit.
2. Right nasal bone fracture.
3. Pansinus mucosal thickening.
4. No other fractures identified.
5. Mucosal thickening involving the paranasal sinuses. Recommend
clinical
correlation for sinusitis.
MRI T-spine [**2189-8-31**]:
IMPRESSION:
1. Acute compression fracture of the T8 vertebral body with
Grade II
anterolisthesis of T7 on T8 and retropulsion of fracture
fragments posteriorly and superiorly causing severe spinal cord
compression and possible spinal cord transection. Additional
punctate T2 hyperintense focus within the spinal cord at T10 may
represent a small post traumatic syrinx.
2. Large prevertebral soft tissue hematoma.
3. Large bilateral pleural effusions with a probable right
hemothorax.
Cardiology Report ECG [**2189-9-1**] 10:59:58 AM
Sinus rhythm. No diagnostic abnormalities. No previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
97 116 80 [**Telephone/Fax (2) 82810**] 44
[**9-6**] CXR:
FINDINGS: Interval surgery for thoracic spine fracture with
[**Location (un) 931**] rods
in place. Cardiomediastinal contours are within normal limits.
Moderate
layering right pleural effusion with adjacent retrocardiac
opacity, probably atelectasis, although infection is not
excluded. Nonspecific fibronodular opacities at the lung apices,
potentially due to scarring, although active disease is not
excluded without older studies for comparison. Several rib
fractures are demonstrated and seen to better detail on recent
CT of [**2189-8-31**].
LENI [**9-7**]
IMPRESSION: No evidence of deep vein thrombosis of the right or
left lower
extremity.
thoracic spine xrays [**9-8**]:
FINDINGS: There is again seen a burst fracture involving the T8
vertebral
body with loss of approximately 40% of the anterior height.
There is again
seen anterolisthesis of T7 over T8, but the alignment is
improved since the initial study. There is a posterior
stabilizing hardware spanning T5 to T12 with pedicle screws
within the T5, T7, T10, T11, and T12. There are no signs of
hardware-related complications.
Abdominal US [**9-8**]
IMPRESSION: Sludge in gallbladder without other signs of
cholecystitis.
[**Doctor Last Name 515**] sign is negative. No specific US signs of acute
cholecystitis.
CXR [**9-8**]
IMPRESSION:
AP chest compared to [**9-6**]:
Lateral aspect of the right lower chest is excluded from the
examination. The imaged pleural surfaces are normal. The region
of chronic right lower costal pleural thickening is not
examined. Lungs are grossly clear. Heart size normal. Spinal
stabilization device and skin staples project over the
thoracic and upper lumbar spine. Stomach is at least moderately
distended
with air.
Abdomen [**9-9**]
No evidence of ileus, obstruction or fecal impaction seen.
R wrist [**9-9**]
IMPRESSION: No evidence of fracture. Normal right wrist.
Brief Hospital Course:
Patient is a 38 year old Protugese speaking male s/p fall ~30
feet landed on stomach. No LOC noted at sceen. Patient was
found to have comminuted vertebral fracture at T8 with
retropulsion of multiple bony fragments into the central spinal
canal with cord transection demonstrated. Neurosurgery was
consulted in the trauma unit. The patient was admitted to the
TICU and stabilized. Upon clearance of the C-spine the patients
c-collar was removed. The patient was then transfered to the
floor and on [**9-2**] the patient was taken to the operating room
with Neurosurgery for repair of his injuries and was transfered
to the Neurosurgery service for continued care.He underwent
posterior instrumented fusion T5-11 with repair of dura, right
iliac crest bone harvest and placement of lumbar drain all done
under general anesthesia. There was estimated 1 liter of blood
loss during the procedure and the patient recieved 2 units of
packed red blood cells in the OR. He tolerated this proceure
well, was extubated in TICU. Lumbar drain was functioning and
drained 5-10cc/hr. Diet was advanced, medication changed to PO.
He was transferred to the floor on [**9-3**]. His activity was
advanced with help of PT and [**Doctor Last Name 2598**] lift, he tolerated being
upright. The patient had fevers beginning on [**9-3**] and again on
[**9-6**] with workup all being negative(CXR, cultures,abdominal
US,LENIs) though this was during time he was being covered with
ancef while lumbar drain was in place. The lumbar drain was
clamped on [**9-7**]. Lumbar drain was removed [**9-8**] with wound being
dry. Good placement of operative hardware noted on thoracic
Xray. ID consult was obtained but pt remained afebrile after
lumbar drain removed and ancef stopped. He was also begun on
bowel regimen and remained with foley. Urine cultures showed
no growth. Blood and CSF cultures were all negative.Wound was
clean and dry. He required enemas and suppositories for bowels,
had foley for bladder. On [**9-9**], the patient developed right
wrist pain. The wrist xray was negative for fracture. He
experienced reported chest pain and his EKG was negative. His
abdomen was distended and a KUB xray was performed which showed
no ileus or obstruction or fecal impaction. [**9-10**] stool was sent
for C-Diff which was negative. The patient continues to be seen
by Rehab medicine during his hospital stay.
On [**9-17**] he had some mild dehiscence of the upper 1/3rd of his
incision. There was scant drainage. Wound care consult was
requested. The wound adequately healed in time. On [**9-18**] he was
instructed how to straight cath himself. On [**9-19**] he was found to
have mild diabetes, diet controlled and also started on emycin
for conjuctivitis. On [**9-24**] he received wrist brace for transfer.
On [**2189-10-19**] he was found to have foul smelling urine with
negative urinalysis but culture showing MSSA and he was started
on 7d course of cipro on [**2189-10-22**].
Weekly case management meetings have been taking place with the
patient, his pastor, friends, the neurosurgery team, case
management, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and nursing throughout his prolonged
hospital stay. The meetings have explored all options of rehab
(he is unable to go to due to no insurance), medical shelters
(denied due to no longer follow term care), going back to [**Country 4194**]
and apartments in the local area. Dr [**Last Name (STitle) **] has set up free care
at [**Hospital6 **] with a spinal cord specialist. Free
medications have been set up through our free care pharmacy. A
reconditioned wheelchair was obtain, a commode and a slider
board, and cath equipment were all given to the patient. The
patient is now proficient in self cath and bowel care. His PPD
was read as negative for tuberculosis. He was discharged to
apartment with community support on [**2189-10-23**].
Medications on Admission:
None
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 2 weeks.
Disp:*28 * Refills:*3*
2. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
3. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 months.
Disp:*90 Tablet(s)* Refills:*0*
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QAM (once a day (in the morning)).
Disp:*60 Suppository(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*120 Tablet(s)* Refills:*2*
6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever,pain.
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*120 Capsule(s)* Refills:*2*
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
9. Outpatient Physical Therapy
s/p thoracic instrumented fusion
please treat and evaluate
Discharge Disposition:
Home
Discharge Diagnosis:
spinal cord injury
abdominal distention
fever of unknown origin
conjuctivitis
Discharge Condition:
stable,paraplegic
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
* Do not smoke
* Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
* Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. until after [**12-1**].
* Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
* The following places are where you can get urinary
catheters:
[**Hospital 43292**] Medical Supply [**Telephone/Fax (1) 51271**] and [**Hospital3 **] Medical Supply
[**Telephone/Fax (1) 82811**]
CALL IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
*The following clinic services free care patients. Please call
and arrange for appointment to establish a primary care
physician for general care: [**Location (un) 3786**] Family Medicine Center (part
of the [**Hospital6 12736**]) [**Street Address(2) 82812**], [**Location (un) 3786**] MA
[**Telephone/Fax (1) 25050**].
*Please follow up with Spinal Cord Injury Specialist [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 805**], MD, [**Telephone/Fax (1) 82813**], [**Last Name (NamePattern1) **] [**Location (un) 442**] [**Location (un) 20473**]
Family Building at [**Hospital6 **] on [**10-30**] at 1:30
PM.
*Follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks, you will need xrays at
this appt. Please call [**Telephone/Fax (1) 2992**] to schedule.
Completed by:[**2189-10-23**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6650
} | Medical Text: Admission Date: [**2158-10-22**] Discharge Date: [**2158-10-28**]
Date of Birth: [**2089-11-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Central line placement and removal
History of Present Illness:
The patient is a 68 year-old female with history of bilateral
breast cancer and metastatic kidney cancer, with extensive
osseous and pulmonary metastases, who was discharged to NH from
[**Hospital1 18**] on [**2158-10-19**] after an admission during which she was
diagnosed with extensive bony metastasis, and was treated with
T9-L1 posterior fusion for unstable T11 metastasis. Reportedly,
she developed fever and was found to have decreased oxygen
saturation to 80s at room air at the NH and some confusion and
was transferred to the ED at [**Hospital1 18**]. She had denied chest pain,
and reported mild sob. Denied abdominal pain, diarrhea, or
dysuria. Denied calf pain. She had been minimally mobile at NH
and was taking heparin SQ TID for DVT prophylaxis.
Her VS in the ED were: 99.6 (Tm:101),124/91, 20, 96% 4L Nasal
Cannula. A UA was abnormal. And she had an elevated WBC to 15.
She had a head CT that did not show evidence of acute CVA.
Unfortunately due to IV access issues (it could not be
determined whether she had a power port), she could not obtain a
CT chest with contrast to evaluate for PE. But was empirically
treated with therapeutic dose of lovenox after a D-dimer was
found to be mildly elevated. A chest CXR showed worsening pul
edema, but given extensive lung mets, a consolidative process
could not be ruled out. She was empirically started on
vancomycin and cefepime for UTI as well as possible pneumonia,
and admitted to the floor.
Review of Systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies blurry vision, diplopia, loss of vision, photophobia.
Denies sinus tenderness, rhinorrhea or congestion. Denies chest
pain or tightness, palpitations, lower extremity edema. Denies
cough, or wheezes. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, hematemesis, hematochezia.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
[**2142-6-26**]: left nephrectomy for 11 cm clear cell renal cell
carcinoma
[**2155-3-15**]: diagnosted with bilateral breast cancer
(node-positive on left, ER/PR positive, HER-2 negative). Treated
with neoadjuvant dose-dense AC and weekly taxol ending [**2155-10-3**],
bilateral mastectomy [**2155-12-25**] (after lumpectomy with positive
margins), radiation ending [**3-22**]. On arimidex since completion of
chemotherapy.
[**2156-7-14**]: CT torso (done because of elevated alk phos) showed
1.5 and 0.6 cm left upper lobe nodules.
[**2156-8-26**]: Left upper lobectomy showed two foci of clear cell
renal cell carcinoma.
[**2157-5-4**]: MRI of T/L spine with disease at T10, T11 vertebral
bodies, soft tissues T10-T12, and L3 body. CT-guided biopsy
consistent with renal cell carcinoma. Bone scan [**2157-4-18**] also
showed involvement of several left ribs. Subsequently received
XRT to thoracic spine.
[**5-/2157**]: Began sunitinib; dose reduced over time to 25 mg because
of toxicities. Sutent ended in [**2158-1-14**] because of disease
progression.
[**2158-2-7**]: MRI L-spine with T11 disease with persistent mass
effect
on thecal sac but no significant cord compression, and T9 and
T10
disease, all likely unchanged. New T12 compression fracture.
Significant progression of L3 vertebral body lesion with
pathologic fracture and retropulsion of posterior cortex.
[**2158-2-13**]: CT torso with interval marked progression of
innumerable
pulmonary mets since [**2157-8-2**]. Destructive lytic lesion within
left femoral head.
[**2158-2-14**]: XRT to lumbar spine
[**2158-4-12**]: signed consent for 08-184 trial of avastin and
temsirolimus. CT torso showed osseous mets in spine and left
ibs, with interva lincrease in size in soft tissue component at
T11 encasing thecal sac, invading cord, and invading more than
50% of the spinal canal. At L3, compression fracture with soft
tissue component extending into spinal canal. Increase in number
and size of numerous pulmonary mets bilaterally. Destructive
lytic lesion within left femoral head.
[**2158-4-19**]: C1D1 08-184 (avastin/temsirolimus)
[**2158-6-7**]: CT torso with significant decrease in size of bilateral
pulmonary lesions and stable osseous disease with decrease in
soft tissue mass at T11
- [**Date range (3) 10263**]: admitted for PNA, mental status changes, found
to have frontal CVA, taken off study
- [**2158-8-9**] CT TORSO: stable disease
Other Past Med Hx:
- Hypertension
- Breast Cancer s/p resection
- gout
Social History:
She lives with her 3 sons who assist with her medical care. She
used to work at [**Hospital3 2568**] in the GI division. She is a
non-smoker, no alcohol or other drugs.
Family History:
Father had esophageal cancer. Her maternal grandmother had
breast cancer in her
70s.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 100.4 BP: 132/81 P: 111 R: 28 O2: 100% on 4L NC
General: Drowsy, confused but orientable, mild respiratory
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, exam limited by body
habitus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, mildly decreased air entry.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, +Obesity, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place, draining yellow urine.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
Vitals: 96.0 100-140/70-90 90-100 18-22 93-96%RA, requiring some
O2 at night
General: Awake and oriented but anxious appearing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to interpret, no LAD, exam limited
by body habitus
Lungs: Clear to auscultation bilaterally except for mild
anterior wheezes (unable to get full posterior lung exam due to
pain) and some bibasilar crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: Foley in place, draining yellow urine
Ext: Warm, well perfused with 2+ nonpitting edema on all four
extremities, LUE>RUE
Pertinent Results:
ADMISSION LABS
[**2158-10-22**] 05:05PM WBC-15.7*# RBC-3.09* HGB-9.2* HCT-28.1*
MCV-91 MCH-29.8 MCHC-32.9 RDW-16.6*
[**2158-10-22**] 05:05PM NEUTS-96.5* LYMPHS-1.6* MONOS-1.5* EOS-0.3
BASOS-0.1
[**2158-10-22**] 05:05PM PLT COUNT-263
[**2158-10-22**] 05:05PM PT-15.0* PTT-50.1* INR(PT)-1.3*
[**2158-10-22**] 05:05PM GLUCOSE-100 UREA N-12 CREAT-0.9 SODIUM-136
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14
[**2158-10-22**] 05:38PM LACTATE-2.0
[**2158-10-22**] 08:43PM D-DIMER-2523*
[**2158-10-22**] 06:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-5.5 LEUK-LG
[**2158-10-22**] 06:15PM URINE RBC-14* WBC-173* BACTERIA-MOD YEAST-NONE
EPI-2 TRANS EPI-1
[**2158-10-22**] 06:15PM URINE COLOR-AMBER APPEAR-Hazy SP [**Last Name (un) 155**]-1.030
DISCHARGE AND OTHER PERTINENT LABS:
[**2158-10-25**] 04:34AM BLOOD WBC-8.6 RBC-2.94* Hgb-8.7* Hct-27.1*
MCV-92 MCH-29.6 MCHC-32.1 RDW-16.5* Plt Ct-281
[**2158-10-25**] 04:34AM BLOOD PT-14.7* PTT-38.7* INR(PT)-1.3*
[**2158-10-24**] 12:29PM BLOOD ESR-81*
[**2158-10-24**] 04:09AM BLOOD Ret Aut-2.3
[**2158-10-25**] 04:34AM BLOOD Glucose-94 UreaN-14 Creat-0.7 Na-136
K-4.0 Cl-105 HCO3-21* AnGap-14
[**2158-10-24**] 04:09AM BLOOD LD(LDH)-226 TotBili-0.5
[**2158-10-25**] 04:34AM BLOOD TotProt-PND Calcium-7.0* Phos-2.0* Mg-2.0
[**2158-10-24**] 04:09AM BLOOD Hapto-348*
[**2158-10-25**] 04:34AM BLOOD TSH-PND
[**2158-10-24**] 04:09AM BLOOD Cortsol-19.5
[**2158-10-24**] 04:09AM BLOOD CRP-GREATER TH
[**2158-10-23**] 08:41AM BLOOD Lactate-1.4
[**2158-10-22**] CXR: UPRIGHT FRONTAL CHEST RADIOGRAPH: A right-sided
catheter terminates within the right atrium. Spinal fusion
hardware in the mid thoracic region is unchanged in position.
Multiple left upper quadrant surgical clips are present. Again
seen are innumerable pulmonary nodules, compatible with known
history of metastatic disease. Since the [**2158-10-13**]
examination, there has been interval increase in pulmonary
vascular congestion and mild underlying pulmonary edema is
present. Small bilateral pleural effusions are present. There is
no pneumothorax.
[**2158-10-22**] CT Head w/o contrast: No acute intracranial process or
evidence. No evidence of metastatic disease, though please note
MRI is more sensitive.
[**2158-10-23**] CTA Chest: 1. No pulmonary embolism or acute aortic
pathology. 2. Ground-glass opacification in the right middle
lobe likely reflects infectious process with new right greater
than left small-to-moderate pleural effusions. 3. Innumerable
pulmonary metastases, many of which are increased in size.
Unchanged left sixth rib, left pectoral and T11 vertebral body
metastases with interval vertebral fusion, which is incompletely
characterized.
[**2158-10-23**] LLE US: 1. No left lower extremity DVT above the knee.
2. Diffuse subcutaneous edema.
[**2158-10-23**] LUE US: 1. No left upper extremity DVT. 2. Diffuse
subcutaneous edema.
[**2158-10-24**] TTE: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. An eccentric,
laterally directed jet of at least mild to moderate ([**1-15**]+)
mitral regurgitation is seen (likely moderate 2+). The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2158-10-24**]: MRI T/L spine: Metastatic disease to L3 vertebral body
is again identified and unchanged. Indentation on the thecal sac
and moderate spinal stenosis is also seen at this level. Fluid
collection is identified in the upper lumbar posterior soft
tissues at L1 level measuring 3 x 2.5 cm which likely is
postoperative in nature, but MRI appearances alone cannot help
in excluding infection in this postoperative collection and
clinical correlation is recommended.
[**2158-10-26**]: CT T/L spine:
1. No evidence of retroperitoneal fluid collection, however, a
large fluid
collection in the subcutaneous fat posterior to the paraspinal
region
extending from L2-T10, larger than on MR from 2 days prior. In
order to
visualize if this is a CSF leak, a CT myelogram would be a more
appropriate study. 2. L3 compression fracture secondary to
metastatic disease. Lytic lesion within the posterior rib at the
T8 vertebral level.
3. Multiple pulmonary metastatic nodules. Bilateral pleural
fluid, right
greater left. 4. Cholelithiasis. 5. Possible kink in the
centralv enous catheter on the scout, unchanged from prior CTA
Chest - d/w RN taking care of pt by Dr.[**Last Name (STitle) **] on [**2158-10-27**].
PENDING STUDIES:
- Pleural fluid cytology
- TSH
- Pleural fluid beta2-transferrin and protein electropheresis
- [**10-22**] Blood cultures pending, no growth to date
- [**10-26**] Pleural fluid culture, no growth to date
Brief Hospital Course:
68 year-old female with history of bilateral breast cancer and
metastatic kidney cancer with extensive osseous and pulmonary
metastases who was discharged to NH from [**Hospital1 18**] on [**2158-10-19**] after
an admission during which she was diagnosed with extensive bony
metastasis, and was treated with T9-L1 posterior fusion for
unstable T11 metastasis. On this admission, she presented with
fevers, confusion, hypoxia and felt to have sepsis due to UTI.
#. Hypotension: She was admitted with hypotension that was fluid
responsive. It was ultimately felt to be sepsis due to UTI.
She did not require pressors. She was ruled out for PE. AM
cortisol was 19.5. TTE was unremarkable. She was initially
treated with vancomycin and cefepime which was narrowed to cipro
and then changed to bactrim.
#. Hypoxia: She has extensive pulmonary disease as evidenced by
her CXR and CTA. No evidence of PE as above. She had the new
development of pleural effusions felt to be either related to
her spinal wound drainage or the fluid resuscitation in the ICU.
She responded well to one dose of lasix but further doses were
deferred as she was on room air most of the time and refused
further labs draws. She also responded to nebulizers at times.
# Urinary tract infection: Admission UA was consistent with
infection. Urine culture grew E Coli and Klebsiella both
sensitive to cipro and Bactrim. She was initially on broad
spectrum antibiotics and then narrowed to cipro. There was some
concern for delirium induced by cipro and her antibiotics were
changed to bactrim. She is being discharged with a chronic
foley.
#. Wound drainage s/p Spinal Fusion: She recently had spinal
fusion on [**2158-10-11**] and her wound drained a large amount of serous
fluid during her admission. Her orthopedics team followed her
wound and consulted neurosurgery. She had multiple imaging
studies that showed a fluid collection around the wound. There
was concern that her new pleural effusions may be related to
leakage of CSF. Therefore, she underwent thoracentesis to
sample the fluid. Beta2 transferrin and PEP are pending at the
time of discharge, which will help determine if the pleural
fluid is CSF. The neurosurgery team will follow-up these
studies as an outpatient and decide if a lumbar drain is needed.
She has follow-up scheduled with neurosurgery.
#. Metastatic renal cancer with mets: Patient was recently
found to have extensive bony mets and has reportedly had
difficulties controlling pain. Palliative care follwed during
this admission for titration of pain control meds.
#. Anemia: Likely anemia of chronic disease secondary to
underlying cancer. Received 1 unit pRBC on [**2158-10-24**] with good
response. Hemolysis labs were unremarkable.
# HTN: Valsartan was held given episode of hypotension that
responded well to fluid boluses. It can be restarted after
discharge.
#. Port-a-cath blockage: She had difficulty with blood return
from her port. She refused a chest film to confirm patency of
indwelling chest port. There was also some concern that the
line was kinked on her CT chest. Her line was given TPA in an
attempt to clog it. Blood return was achieved and line was
patent on DC.
#. Delirium/Anxiety: She was mildly delirious during her
admission with difficulty with attention. This is likely
related to her ongoing medical issues, as well as pain. She
responded well to olanzapine 2.5mg po at night, and also was
written for Ativan as needed. She continued to be anxious,
requiring frequent reminders of her medical plan.
#. Goals of care: The patient was refusing multiple procedures
and studies during this admission. She was following by primary
care and her primary oncologist. She expressed a desire to
focus on comfort, but a full discussion of hospice was deferred
until her delirium improves. She refused all labs and xrays
over the last 1-2 days of her admission.
TRANSITIONAL ISSUES:
- Pending studies: TSH, blood culture, pleural fluid culture,
cytology, beta2 transferrin and PEP
- Needs neurosurgical/ortho-spine followup for her wound in 2
weeks. It has continued to drain serous fluid requiring
multiple changes per day.
Medications on Admission:
- anastrozole 1 mg Tablet 1 Tablet(s) by mouth once a day (Not
Taking as Prescribed: no prescription now so not taking)
- levothyroxine 50 mcg Tablet 1 Tablet(s) by mouth once a day
- lorazepam [Ativan] 0.5 mg Tablet [**1-15**] Tablet(s) by mouth three
times a day as needed for anxiety
- ondansetron 4 mg Tablet, Rapid Dissolve 1 Tablet(s) by mouth
every 8 hours as needed for nausea
- oxycodone 5 mg Tablet 1 Tablet(s) by mouth every 4 hours as
needed for pain
- oxycodone [OxyContin] 10 mg Tablet Extended Release 12 hr 2
Tablet(s) by mouth twice a day
- prochlorperazine maleate 10 mg Tablet 1 Tablet(s) by mouth
every six (6) hours as needed for nausea/vomiting
- simvastatin 10 mg Tablet 1 Tablet(s) by mouth once a day
- valsartan [Diovan] 160 mg Tablet 1 Tablet(s) by mouth once a
day hold for bp < 110
- acetaminophen 325 mg Tablet 1 Tablet(s) by mouth every 6 hours
(OTC) prn
- aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth daily
- docusate sodium 100 mg Capsule 1 Capsule(s) by mouth
Discharge Medications:
1. anastrozole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for anxiety.
4. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
5. oxycodone 60 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
6. hydromorphone 2 mg Tablet Sig: 3-5 Tablets PO Q3H (every 3
hours) as needed for pain.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
8. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day): Hold for loose stool.
14. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia: Patient may refuse.
15. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours): For prophylaxis.
16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
17. ipratropium bromide 0.02 % Solution Sig: One (1)
nebulization Inhalation Q6H (every 6 hours) as needed for
wheeze.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) 10264**] Rehab
Discharge Diagnosis:
Primary Diagnosis:
Urinary tract infection
Pleural effusions
Wound fluid collections
Metastatic renal cell carcinoma
Secondary Diagnosis:
Hypertension
Gout
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to the hospital due to fevers, confusion and
low blood pressures felt to be related to an urinary tract
infection (UTI). You were admitted to the ICU and were given
antibiotics for your UTI and your symptoms improved.
Your oxygen level was also low on admission, but improved prior
to discharge. It was felt to be due to some fluid around your
lungs, as well as the cancer in your lungs. You had a procedure
where fluid was removed around your lungs.
You were also evaluated by the orthopedic surgeons and
neurosurgeons due to concern about leakage from your wound. It
is still leaking significantly and you have labs that are
pending to determine the source of leakage. Your neurosurgery
team will follow-up on these studies.
CHANGES TO YOUR MEDICATIONS:
ADD Bactrim 1 DS tab by mouth twice daily for 5 more days
INCREASED oxyCONTIN to 60mg by mouth every 8 hours
ADD olazapine 2.5mg by mouth at bedtime as needed
ADD enoxaparin 30 mg SC every 12 hours for prophylaxis
Followup Instructions:
You have the following appointments scheduled:
Department: SPINE CENTER
When: FRIDAY [**2158-11-10**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*You should discuss with him if you need a separate appointment
with Dr. [**Last Name (STitle) **]*
ICD9 Codes: 0389, 5119, 2930, 5990, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6651
} | Medical Text: Admission Date: [**2133-5-26**] Discharge Date: [**2133-6-4**]
Date of Birth: [**2068-9-24**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 64 year old gentleman
who has a recent significant history for excision of
malignant melanoma in [**2133-3-19**], with bilateral groin lymph
node dissection with positive groin lymph nodes, had been
recovering well until one week prior to admission when he
developed increasing shortness of breath and decreased
exercise tolerance, positive orthopnea, paroxysmal nocturnal
dyspnea, and left sided chest discomfort with exertion. The
patient presented to outside radiation technologist to
receive radiation therapy to his groin, where upon discovery
of symptoms, the patient was referred to the Emergency
Department for further evaluation.
PAST MEDICAL HISTORY: Type 2 diabetes mellitus.
Hypertension.
Hypercholesterolemia.
History of malignant melanoma as previously described.
Status post ventral hernia repair.
MEDICATIONS ON ADMISSION:
1. Glucophage 500 mg p.o. twice a day.
2. Glipizide 1.25 mg p.o. once daily.
3. Hydrochlorothiazide 25 mg p.o. once daily.
4. Lisinopril 40 mg p.o. once daily.
5. Verapamil XR 240 mg p.o. once daily.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] where he was noted to have
congestive heart failure by chest x-ray, was started on
Heparin drip, Lasix for diuresis and he subsequently
improved. The patient was taken for cardiac catheterization
on [**2133-5-27**], which showed pulmonary artery pressure of 59/32
with a wedge of 32, 100 percent mid right coronary artery
lesion, 100 percent mid left anterior descending coronary
artery lesion, 90 percent first diagonal lesion, 100 percent
obtuse marginal lesion. During the cardiac catheterization,
the patient developed worsening pulmonary edema and
subsequent respiratory failure and required emergent
intubation for this. The patient had an intra-aortic balloon
pump placed in the cardiac catheterization laboratory and the
patient was taken to the operating room by Dr. [**Last Name (STitle) 70**]
emergently for a coronary artery bypass graft and a mitral
valve repair. The patient's ejection fraction had previously
been determined on echocardiogram to be 25 percent with three
plus mitral regurgitation.
In the operating room upon performing sternotomy, it was
noted the patient had a fair number of darkly colored nodules
as well as a dark rubbery spot on the heart. These tissues
were sent to the pathology department with the subsequent
frozen section coming back positive for melanoma. In the
operating room, the patient [**Last Name (STitle) 1834**] a coronary artery
bypass graft times two, saphenous vein graft to left anterior
descending coronary artery, saphenous vein graft to obtuse
marginal, as well as a mitral valve repair. Postoperatively,
the patient was transported to the Intensive Care Unit in
stable condition with an intra-aortic balloon pump which had
been placed in the cardiac catheterization laboratory on a
Milrinone infusion, Levophed infusion, Epinephrine infusion.
Please see operative note for full details.
The patient remained intubated on his first postoperative
night with good hemodynamics. The Milrinone was weaned down.
Intra-aortic balloon pump was removed on postoperative day
number one. The patient was weaned and extubated from
mechanical ventilation on postoperative day number two. On
postoperative day number two after the patient developed
atrial fibrillation, the patient was started on Amiodarone
and Lopressor after the pressors and inotropes had been
weaned off. The pulmonary artery catheter was removed as the
patient continued to have good hemodynamics in spite of the
atrial fibrillation. Chest tubes were removed without
incident. On postoperative day number three, the patient
began working with physical therapy. On postoperative day
number four, the patient was transferred from the Intensive
Care Unit to the regular part of the hospital. By that time,
he had converted into sinus rhythm. He had no further atrial
fibrillation. The patient's pacing wires were removed on
postoperative day number five.
At that time, he was noted to have a moderate amount of
serosanguinous drainage from his sternal incision. The
patient was started on Keflex. The amount of drainage
decreased over the next several days and had completely
disappeared by postoperative day number seven. By
postoperative day number six, the patient had completed a
level V with physical therapy and was able to ambulate 500
feet and climb one flight of stairs without difficulty and at
that time had been cleared for discharge to home by physical
therapy; however, due to the patient's drainage from his
sternal incision, the patient remained in the hospital until
postoperative day number eight at which time he was cleared
from a cardiac surgery standpoint.
CONDITION ON DISCHARGE: Temperature maximum 98.8, pulse 93,
sinus rhythm, blood pressure 123/79, respiratory rate 16,
oxygen saturation in room air 94 percent. Laboratory date
showed white blood cell count 12.9, hematocrit 31.4, platelet
count 337,000. Sodium 137, potassium 4.6, chloride 100,
bicarbonate 26, blood urea nitrogen 27, creatinine 1.0. The
patient's weight on [**2133-6-4**], is 126 kilograms. The patient
weighed 120 kilograms preoperatively. Neurologically, the
patient is awake, alert and oriented times three.
Examination is nonfocal. Heart is regular rate and rhythm
without rub or murmur. Respiratory - breath sounds are
decreased at bilateral bases. Gastrointestinal - The abdomen
is obese, positive bowel sounds, nontender, nondistended.
Sternal incision is clean and dry. There is a small amount,
less than one half centimeter, of erythema at the distal
portion of the incision. The sternum is stable. Bilateral
lower extremities have two to three plus pitting edema. The
left lower extremity vein harvest site has a small amount of
serous drainage, no erythema and no pain on palpation.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg p.o. twice a day times ten days.
2. Potassium Chloride 20 mEq p.o. twice a day times ten days.
3. Colace 100 mg p.o. twice a day.
4. Zantac 150 mg p.o. twice a day.
5. Enteric Coated Aspirin 325 mg p.o. once daily.
6. Plavix 75 mg p.o. once daily.
7. Lopressor 25 mg p.o. twice a day.
8. Keflex 500 mg p.o. once daily times seven days.
9. Glucophage 500 mg p.o. twice a day.
10. Glipizide 1.25 mg p.o. once daily.
DISCHARGE STATUS: The patient is to be discharged to home in
stable condition.
DISCHARGE DIAGNOSES: Coronary artery disease.
Status post emergent coronary artery bypass graft and mitral
valve repair.
Malignant melanoma.
Postoperative sternal drainage.
FOLLOW UP: The patient has an appointment with Dr. [**Last Name (STitle) 70**]
on [**2133-7-1**], at 1:15 p.m. and the patient has an appointment
with Dr. [**Last Name (STitle) 6530**], his oncologist, on [**2133-7-8**], at 9:15 a.m. The
patient is to follow-up with his primary care physician in
one to two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2133-6-5**] 18:57:06
T: [**2133-6-6**] 10:27:34
Job#: [**Job Number 11886**]
ICD9 Codes: 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6652
} | Medical Text: Admission Date: [**2179-11-10**] Discharge Date: [**2179-11-17**]
Date of Birth: [**2108-11-8**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
SDH
Major Surgical or Invasive Procedure:
RIGHT CRANIOTOMY FOR SDH EVACUATION
History of Present Illness:
HPI:71 y.o. F. who has complained of a headache for the past
three weeks according to family. She had a negative MRI at
[**Hospital **] hospital three weeks ago. Family reports frequent falls
due to drinking. Found trying to unlock her neighbor's house,
confused, with a bruise over L thigh. She was transported to an
outside hospital, where a head CT showed a sdh with uncal
herniation, which prompted [**Hospital1 18**] transfer. She was intubated for
the transfer, and received Mannitol 40 gm, and dilantin 750 mg
bolus.
Past Medical History:
PMHx:
low platelet count;
alcoholic
HTN
Hypothyroidism
Hearing loss
Depression
Social History:
Social Hx: alcoholic, binges daily, family thinks last drink 4
days ago, lives alone, smoke pack year history 106. She has six
children, and her healthcare proxy is [**Name (NI) **] [**Name (NI) 11135**].
Family History:
Family Hx:unknown
Physical Exam:
ON ARRIVAL
PHYSICAL EXAM:
O: BP: 116/78 HR:58 R 15 O2Sats 100% intubated, FiO2 100%, PeeP
5
HEENT: Pupils: unreactive EOMs unable to assess
Extrem: Warm appears malnourished, multiple scratches on legs.
Neuro:
Mental status: Intubated
Orientation: does not follow commands.
Cranial Nerves:
II: Pupils equally round non-reactive to light, 1.5
mm bilaterally.
Motor: Localizes to noxious stimuli with bilateral upper
extremities, withdraws bilateral lower extremities to noxious
stimuli, tows up-going.
Pertinent Results:
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2179-11-15**] 11:28 AM
CHEST (PORTABLE AP)
Reason: r/o pneumonia
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with s/p SDH, large smoking history, desating
REASON FOR THIS EXAMINATION:
r/o pneumonia
HISTORY: Status post subdural hematoma, desaturation, evaluate
for pneumonia.
COMPARISONS: [**2179-11-10**].
FINDINGS: Single semi-upright portable chest radiograph
performed at 11:45 a.m. demonstrates interval removal of
endotracheal tube. Lungs are clear. There is no pneumothorax or
pleural effusions. Cardiomediastinal silhouette is normal and
unchanged. Left clavicular fracture is unchanged. Healing right
posterior lower rib fracture seen.
IMPRESSION: No acute cardiopulmonary process.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2179-11-12**] 8:37 AM
CT HEAD W/O CONTRAST
Reason: assess for interval change
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with SDH, uncal herniation s/p evacuation
REASON FOR THIS EXAMINATION:
assess for interval change
CONTRAINDICATIONS for IV CONTRAST: None.
COMPARISON: [**2179-11-10**].
NON-CONTRAST HEAD CT: There is a large right frontal, parietal,
and temporal subdural hematoma with mixed acute and chronic
components that has decreased in size and now measures
approximately 1 cm from the skull base. Decreased associated
pneumocephalus is noted. There is an approximately 3 mm midline
shift, and there is no evidence of subfalcine or uncal
herniation. The mastoid air cells are well aerated. There are
air-fluid levels within the right and left maxillary sinus and
opacification of the anterior ethmoid air cells, unchanged.
IMPRESSION:
1. Improved appearance of large right acute on chronic subdural
hematoma with markedly decreased midline shift and no evidence
of subfalcine or uncal herniation.
2. Multiple air-fluid levels in the maxillary and sphenoid
sinuses with near complete opacifications of air cells may
represent sinusitis, although not significantly changed from
prior exam. Recommend clinical correlation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94**]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: SUN [**11-14**],
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2179-11-10**] 8:55 PM
CT HEAD W/O CONTRAST
Reason: FOUND DOWN
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with SDH and ?herniation
REASON FOR THIS EXAMINATION:
eval ich
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Subdural hematoma. Evaluate for herniation.
No priors are available.
NON-CONTRAST HEAD CT:
FINDINGS: There is a large right frontal, parietal and temporal
subdural hematoma with mixed acute and chronic components
causing extensive effacement of the adjacent sulci, severe
subfalcine herniation of approximately 17 mm, and mild uncal
herniation causing mass effect on the brainstem and effacement
of the ambient cistern. There is prominence to the left
occipital/temporal horns, likely related to mass effect on the
third ventricle. The fourth ventricle also appears slightly
prominent. There is no evidence of intraparenchymal hemorrhage
with periventricular hypoattenuation likely related to chronic
small vessel disease. Soft tissues appear unremarkable with
mastoid air cells appearing well aerated. There are air-fluid
levels noted within the right and left maxillary sinus and right
sphenoid sinus with near-complete opacification of the majority
of the anterior middle ethmoid air cells. Mild mucosal
thickening is noted within the frontal sinuses. Large amount of
secretions is noted within the oropharynx consistent with the
patient's intubation.
IMPRESSION:
1. Large right acute on chronic subdural hematoma causing
significant subfalcine herniation and mild-to-moderate uncal
herniation. Prominence to the left occipital and temporal horns
along with effacement of the third ventricle is suggestive of
hydrocephalus/outflow obstruction.
2. Multiple air-fluid levels within the maxillary sinus and
sphenoid sinus with near-complete opacification of ethmoid air
cells in this intubated patient. Findings are worrisome for
developing sinusitis. Please correlate clinically.
RADIOLOGY Final Report
CT C-SPINE W/O CONTRAST [**2179-11-10**] 8:55 PM
CT C-SPINE W/O CONTRAST
Reason: FOUND DOWN
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with SDH and ?herniation
REASON FOR THIS EXAMINATION:
eval fx
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Known subdural hematoma. Evaluate for acute fracture.
No prior comparison exams are available.
CT OF THE CERVICAL SPINE WITH CORONAL AND SAGITTAL REFORMATIONS:
IMPRESSION:
No evidence of acute fracture or malalignment. Vertebral body
heights appear well preserved. Small ossific fragment anterior
to C4-C5 is likely degenerative in nature, and there is mild
multilevel degenerative joint and disc disease. Visualized
contents of the intrathecal sac appear unremarkable; however,
MRI is more sensitive for evaluation of spinal cord injury.
There is no prevertebral soft tissue swelling. Pooled secretions
are noted within the oropharynx consistent with patient's
intubation. Please refer to dedicated CT head for better
description of sinus findings. The soft tissues display atrophic
or absent right thyroid gland with multiple calcifications noted
within the left thyroid gland. There is biapical pleural
scarring and areas of linear atelectasis along with mild
centrilobular emphysema.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2179-11-14**] 08:00AM 7.3 2.88* 9.7* 30.3* 105* 33.8* 32.1 15.5
253
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2179-11-10**] 08:45PM 70.3* 24.4 3.3 1.6 0.5
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2179-11-14**] 08:00AM 253
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2179-11-14**] 08:00AM 85 2* 0.4 141 3.8 105 30 10
Brief Hospital Course:
Pt was seen and admitted through the emergency department on
[**2179-11-10**] for complaint of a headache for the past three weeks
according to family. She had a negative MRI at [**Hospital **] hospital
three weeks ago. Family reports frequent falls due to drinking.
Found trying to unlock her neighbor's house, confused, with a
bruise over L thigh. She was transported to an outside hospital,
where a head CT showed a sdh with uncal herniation, which
prompted [**Hospital1 18**] transfer. She was intubated for the transfer, and
received Mannitol 40 gm, and dilantin 750 mg bolus. Pt was
brought to OR emergently for evacuation of R SDH. Pt underwent
the procedure and awoke from anesthesia without complication.
She was extubated in SICU the following morning. Her exam
improved and she was following commands. Her post-op CT scan
was stable. Diet and acitivity were advanced. She was seen by
PT/OT/ST for eval. She passed swallow eval and was recommended
for rehab from PT/OT perspective. Foley was d/c'd and pt is
voiding. She will require follow up in [**4-23**] weeks with CT scan of
brain - dilanitin should continue unitl that time and be managed
by PCP.
Upon discharge, she is neurologically stable, she is oriented
x3; following commands; no focal deficit found on her neuro
exam.
Medications on Admission:
family usure, knows of antihypertensives and hypothyroid drugs
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
4. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for dose per CIWA scale: Please dose according to CIWA
scale. .
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day): Patient should continue taking this
medication at least until seen in [**Hospital 4695**] clinic. .
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
13. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN
14. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
RIGHT SUBDURAL HEMATOMA
Discharge Condition:
NEUROLOGICALLY STABLE
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Check your incision daily for signs of infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE HAVE THE REHAB FACILITY REMOVE THE STAPLES ON [**11-23**]
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN [**4-23**] WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
YOU SHOULD FOLLOW UP WITH YOUR PCP REGARDING YOUR
HOSPITALIZATION - IT IS BEST TO BE SEEN WITHIN 2 WEEKS / Your
PCP will manage your dilantin levels.
Completed by:[**2179-11-17**]
ICD9 Codes: 3051, 2875, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6653
} | Medical Text: Admission Date: [**2143-6-28**] Discharge Date: [**2143-7-4**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 14961**]
Chief Complaint:
CC - MS changes
Major Surgical or Invasive Procedure:
Intubation [**2143-6-28**], extubation [**2143-6-29**]
History of Present Illness:
HPI - This is a 89 y/o male with h/o demetia, depression, SI in
past requiring inpt psych hospitalization 2 months ago, CAD, HL,
orthostatic hypotension, ITP, p/w MS changes on [**2143-6-28**]. Per pt's
wife, pt found around 12:30 am at home on [**2143-6-28**] sitting, but
unresponsive and unable to speak. Pt taken to ED, code stroke
was called. Pt was admitted to the Neuro ICU, and MRI depicted
two small foci likely representing small infarcts in right
periventricular matter. During this time the pt was intubated
for airway protection as he had been vomiting; extubated
successfully this AM. However, it was felt by the Neuro team
that these small changes were unlikely to cause his MS changes.
A metabolic w/u showed elevated LFTs and a serum tylenol level
of 165 on [**2143-6-28**] at 2pm, drawn approximately 12-16 hrs after
presentation. Pt was not given any NAC until [**2143-6-29**] at 3pm (24
hrs after level was drawn). Upon further questioning with pt, he
confessed to taking to tylenol for a suicide attempt and did not
want his family to know. Upon detailed coversation with his
family and HCP, we were told the patient has done this in the
past requiring inpt psychiatric hospitalization 2-3 months ago.
Per his son, he has not seemed more depressed or expressed any
suicidal ideations.
.
Currently, pt has no complaints except for the bruising on his
arms. Patient does have active SI and says "I didn't take enough
tylenol"
Past Medical History:
1. Dementia - sees Dr. [**Last Name (STitle) **]
2. Depression, ?prior SI/attempts - sees Dr. [**Last Name (STitle) **]
3. s/p MVA earlier this year
4. CAD s/p CABG x 3v
5. HL
6. Orthostatic hypotension
7. h/o ARF resulting in MS changes
8. thrombocytopenia, h/o ITP - sees Dr. [**First Name (STitle) **]
Social History:
SH - Lives at home with his wife. [**Name (NI) **], [**Name (NI) **] [**Name (NI) 17931**], is HCP
([**Telephone/Fax (1) 106034**]). Former tobacco h/o (>130 pk/yr), no EtOH or
illicits.
Family History:
FH - Sister died of cancer. Father had GI cancer.
Physical Exam:
VS - T 96.5, BP 135/95, HR 78, RR 20, SaO2 100%/2LNC, I/O =
1475/950
General - Pleasant, AO x 3 though conversation rambling. In NAD.
HEENT - NC/AT, PERRL/EOMI. MM dry, OP clear.
Neck - supple, no JVD
Chest - bibasilar crackles, otherwise clear
CV - RRR s1 s2 nl, 2/6 SEM at LSB
Abd - soft, NT/ND, NABS
Ext - no c/c/e, pulses 2+ b/l
Neuro - AO x 3, conversant though rambling. Moving all four
extremities equally. CN II-XII intact grossly
Psych - +SI
Pertinent Results:
[**2143-7-1**] 05:45AM BLOOD Plt Ct-48*
[**2143-7-1**] 11:00AM BLOOD Plt Ct-37*
[**2143-7-2**] 05:55AM BLOOD PT-15.6* PTT-26.0 INR(PT)-1.4*
[**2143-7-2**] 05:55AM BLOOD Plt Ct-49*
[**2143-7-3**] 06:55AM BLOOD PT-13.0 PTT-24.6 INR(PT)-1.1
[**2143-7-3**] 06:55AM BLOOD Plt Ct-36*
[**2143-6-29**] 02:45AM BLOOD ALT-237* AST-292* AlkPhos-56 TotBili-0.6
[**2143-6-29**] 02:14PM BLOOD ALT-1156* AST-1416* AlkPhos-62
TotBili-1.0
[**2143-6-30**] 04:33AM BLOOD ALT-[**2105**]* AST-[**2153**]* LD(LDH)-1131*
AlkPhos-61 TotBili-1.1
[**2143-7-1**] 05:45AM BLOOD ALT-2651* AST-2197* LD(LDH)-1093*
AlkPhos-67 TotBili-1.0
[**2143-7-2**] 05:55AM BLOOD ALT-1621* AST-706* LD(LDH)-295*
CK(CPK)-135 AlkPhos-68 TotBili-1.5
[**2143-7-3**] 06:55AM BLOOD ALT-1106* AST-278* LD(LDH)-256*
AlkPhos-79 TotBili-0.9
[**2143-6-28**] 02:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-165.5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2143-6-29**] 02:14PM BLOOD Acetmnp-11.9
TTE [**6-28**] -
The left atrium is normal in size. No atrial septal defect or
patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF 60-70%).
Tissue velocity imaging demonstrates an e' of <0.08m/s c/w an
elevated left
ventricular filling pressure (>12mmHg). No masses or thrombi are
seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The left
ventricular inflow pattern suggests impaired relaxation. There
is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
EEG [**6-28**] - IMPRESSION: This is an abnormal portable EEG due to
the presence of
slow and disorganized background rhythms with superimposed fast
activity. This finding suggests an encephalopathy. Medications,
infection, or metabolic disturbances are among the most common
causes.
There were no clear focal abnormalities recorded.
CT head [**6-28**] - IMPRESSION: Limited study due to motion. No
evidence of hemorrhage. If there is a further concern for
stroke, please perform further evaluation by MRI. The
information was discussed with the referring physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
in person at the completion of the study.
MRI/MRA of head [**6-28**] - IMPRESSION: Small foci of restricted
diffusion seen in the left frontal and right frontal lobes,
likely representing small distal infarcts.
MRA: Major branches of the Circle of [**Location (un) 431**] appear patent. There
is no evidence of significant stenosis. The vertebral arteries
and basilar artery appear unremarkable with normal appearing
flow. Incidentally noted is a 3mm right carotid cavernous
aneurysm.
IMPRESSION: Vertebral arteries and basilar arteries appear
unremarkable. Incidental note of a 2 mm right carotid cavernous
aneurysm.
Brief Hospital Course:
This is an 89 y/o male with depression, h/o SI, CAD, dementia,
ITP, who initially presented with mental status changes,
initially thought to be [**2-28**] CVA and admitted to the Neuro ICU
service. He was intubated on arrival for airway protection as he
was vomiting and to be able to accurate scans. An MRI/MRA of the
head demonstrated two small ischemic foci in the right and left
frontal lobes, likely [**2-28**] old infarcts. Based on these findings,
it was felt that the etiology of the MS changes was not
secondary to an acute CVA. He had a stroke w/u, including a TTE
and carotid u/s which was unremarkable. He was not started on
any anti-platelet regimen due to his thrombocytopenia [**2-28**] ITP.
An EEG showed diffuse slowing c/w toxic/metabolic process.
During the w/u, the patient was noted to have elevated LFTs
(transaminases in the 200-300's) on [**2143-6-28**]. A serum tylenol
level was checked approximately 12-16 hrs after admission and
was elevated in the hepatotoxic range of 165 on [**2143-6-28**]. Once the
patient was extubated, it was elicited from the patient that he
had taken too much tylenol to "call it quits." It was also
further elicited from the patient's family that the patient has
a history of suicidal attempts, requiring a recent inpt
psychiatric hospitalization 2-3 months ago in [**Hospital 17065**]
hospital. The patient was transferred to the Medicine service
for further management on [**2143-6-29**]. Psychiatry and Hematology were
involved during his course.
.
1. Tylenol toxicity - Toxic/metabolic w/u revealed elevated LFTs
and a serum tylenol level of 165 on [**6-28**] (12-16 hrs after pt
presented, no level checked on admission). Pt not given any
mucomyst (NAC) until [**6-29**] for unclear reasons and was started on
NAC continuous gtt 18 mg/kg/hr per in-house toxicologist. The
patient's LFTs continued to trend upward as well as his INR
(indicative of synthetic function) and finally peaked on [**2143-7-1**].
His enzymes then began trending down, with return of his INR to
1.1 (normal) on [**2143-7-3**]. The NAC gtt was d/c'd on [**2143-7-2**] as it
was clear the patient's liver was recovering - this was
confirmed with in-house toxicology. During his course, he did
not demonstrate any signs of encephalopathy or other end-organ
damage. Medications metabolized through the liver, including
aricept, risperdal, zocor, and effexor were held during the
active hepatitis. They may be restarted once his LFTs are back
to baseline. LFTs should be checked every day or every other day
until they normalize. His synthetic function is preserved,
indicated by his INR of 1.1 (normal). Given this was a suicide
attempt, 1:1 sitter was always present and psych was consulted
(see below).
.
2. Dementia - per family, pt at baseline. Aricept was held given
acute hepatic injury, could be restarted once LFTs completely
back to baseline.
.
3. Depression, NOS - follows with psych as outpt, h/o
SI/attempts in past. Psych was consulted during this admission
and recommended geriatric psych placement given patient is not
safe at home. Family was agreeable to this plan. His risperdal
and effexor was d/c'd during this course given acute hepatic
injury - may be restarted once LFTs back to baseline and
depending on psych's preferences. Patient is a section 12 and
continues to be actively suicidal. He has not been agitated at
all and not required any prn anti-psychotics.
.
4. Thrombocytopenia - pt w/history of ITP, unresponsive to
steroids but given Rhogam in past for plts<40 (last dose per OMR
[**3-31**]). Likely his thrombocytopenia is [**2-28**] ITP, although
risperdal is associated with thrombocytopenia and was recently
started in [**6-1**]. Another concern is his thrombocytopenia could
have been worsened acutely from hepatic injury. Hematology was
consulted in-house and recommened one dose of Rhogam (250
units/kg) for plts<40 as patient was having an episode of nose
bleed. This was given w/o complication on [**2143-7-1**]. Rhogam works
to hemolyze the RBCs through the spleen, saving the platelets
from being destroyed instead. His platelets are currently stable
and there are no signs of bleeding. If patient becomes more
thrombocytopenic or begins to bleed, hematology should be
consulted as the patient may need additional doses of Rhogam. To
monitor his platelets, his Hct, platelets, and coags need to be
checked weekly to ensure stability.
.
5. Orthostatic hypotension - continue fludrocort and midodrine
.
6. HL - held zocor given hepatic injury, may be restarted once
LFTs back to baseline
.
7. F/E/N - regular diet, IVF
.
8. PPx - PPI, pneumoboots
.
9. Code - FULL (confirm each situation w/HCP son [**Name (NI) **] [**Name (NI) 17931**]
[**Telephone/Fax (1) 106034**]; h [**Telephone/Fax (1) 106035**])
.
10. Dispo - medically stable to be transferred to [**Female First Name (un) **]-psych
facility. Liver function has returned to [**Location 213**] and
thrombocytopenia has stabilized.
Medications on Admission:
MEDS (home) -
1. Aricept 5 mg qd
2. Effexor SR 75 mg q24
3. Fludrocort 0.1 mg [**Hospital1 **]
4. Midodrine 10 mg tid
5. Zocor 40 mg qd
6. Risperdal 0.5 mg qd
Discharge Medications:
1. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Primary - hepatotoxicity [**2-28**] tylenol overdose
Secondary - depression, suicidal ideations, dementia, ITP, HL,
orthostatic hypotension
Discharge Condition:
Medically stable, liver synthetic function at baseline
Discharge Instructions:
-continue medications as prescribed
-anti-depressants and anti-psychotic medications were stopped
given pt's hepatotoxicity; once liver enzymes return to baseline
can likely restart medications
-please follow-up with appts below
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8753**], MD Phone:[**Telephone/Fax (1) 1682**] Date/Time:[**2143-7-31**]
12:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2143-8-8**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2143-8-27**] 11:30
Completed by:[**2143-7-4**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6654
} | Medical Text: Admission Date: [**2171-4-15**] Discharge Date: [**2171-4-23**]
Service: CCU
CHIEF COMPLAINT: The patient was transferred to the
Coronary Care Unit from Catheterization Laboratory status
post myocardial infarction, status post intra-aortic balloon
pump placement.
HISTORY OF PRESENT ILLNESS: The patient is an 82 year old
female with no known prior history of coronary artery
disease, with a history of lung, breast and colon carcinoma,
who presented to [**Hospital 26200**] Hospital with a CK of
3,243. The patient was in her usual state of health prior to
her presentation to that hospital until three days prior when
she developed dyspnea on exertion. Her symptoms developed
into dyspnea at rest, and she was noted to have an O2
saturation of 83%. The patient denied any chest pain at that
time.
At the outside hospital, her EKG showed ST elevations in V2
through V6, with Q waves present. She was transferred to
[**Hospital1 69**] at which time she had a
heart rate of 87, a blood pressure of 128/80 and an O2
saturation of 97 on five liters. She got aspirin,
nitro paste, Lopressor intravenously, intravenous Lasix, and
a heparin drip. She was then taken to the Catheterization
Laboratory on arrival at [**Hospital1 69**]
which showed a total occlusion of her proximal left anterior
descending, total occlusion of her left circumflex, 60%
proximal right coronary artery and a 30% obtuse marginal
coronary artery. She had minimal right to left collaterals
and left to left collaterals.
Her right heart catheterization showed a wedge pressure of 27
and a PA-saturation of 49%. Her ejection fraction was 15%
with anterior and inferior septal akinesis with an apical
thrombus present. An intra-aortic balloon pump was placed
secondary to cardiogenic shock. She was going to be
evaluated by Cardiothoracic Surgery for whether she is an
operable candidate.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Osteoporosis.
3. Colon carcinoma status post partial colectomy in 11/98.
4. Lung carcinoma.
5. Status post left upper lobe lobectomy in [**2167**].
6. Breast carcinoma.
7. Peripheral vascular disease.
8. Irritable bowel syndrome.
9. Chronic obstructive pulmonary disease.
10. Spinal stenosis.
11. History of transient ischemic attack.
12. Depression.
MEDICATIONS:
1. Imipramine 25 q. day.
2. Oxybutynin 5 q. day.
3. Aricept 10 q. day.
4. Zestril 20 q. day.
5. Tylenol 650 three times a day.
6. Lomotil 2 tablets q. day.
7. Aspirin 325 q. day.
ALLERGIES: Aricept causes nausea and the patient is
allergic to penicillin.
SOCIAL HISTORY: The patient lives with her husband in a
senior living complex. She has a remote smoking history.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission, vital signs are
temperature 98.9 F.; heart rate 85; blood pressure 127/68; O2
saturation 97%; respiratory rate 24. In general, the patient
is mildly agitated, answering questions appropriately, in no
acute distress. HEENT: Pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
intact. Tongue midline; moist mucous membranes. Neck: No
bruits. Jugular venous distention above clavicle with
minimal head elevation. Heart is regular rate and rhythm
with normal S1 and S2, positive S3. No murmurs, rubs or
gallops. Lungs are clear to auscultation anteriorly.
Abdomen with positive bowel sounds, soft, nontender,
nondistended. Guaiac negative on presentation at outside
hospital. Extremities with palpable dorsalis pedis pulses
bilaterally, trace lower extremity edema. Left groin sheath
without hematoma. Neurological: Cranial nerves II through
XII intact. Moving all extremities.
LABORATORY: On arrival, white blood cell count 17.9;
hematocrit 41.9, platelets 226; 85% neutrophils, 11 lymphs, 3
monocytes. PT 14.8, PTT 150 and INR 1.5. Sodium 149,
potassium 4.5, chloride 113, bicarbonate 20, BUN 23,
creatinine 1.1 and glucose 146.
CK 3294, up from 3243 at the outside hospital.
Arterial blood gas was 7.48, 29 and 94.
EKG after catheterization showed ST elevation as well as Q
waves in V2 through V6, with Q's in II and AVL.
Chest x-ray showed congestive heart failure with a left sided
effusion.
HOSPITAL COURSE:
1. Cardiovascular: 1) Ischemia - the patient who presented
with acute ST elevation myocardial infarction. She had
cardiac catheterization with a total occluded proximal left
anterior descending, totally occlusion in the left circumflex
and 60% proximal right coronary artery. The patient had
three-vessel disease. Also noted on catheterization was
severe systolic dysfunction and elevated filling pressures
with cardiogenic shock. She had an intra-aortic balloon pump
placed.
She was continued on heparin and aspirin. The patient was
found not to be a surgical candidate. She was eventually
started on an ACE inhibitor and beta blocker after her blood
pressure had stabilized when she was out of the Intensive
Care Unit and continued on aspirin. The patient was also
sent home on Coumadin given her low ejection fraction.
2) Pump - the patient was found to be in cardiogenic shock
and had an intra-aortic balloon pump placed during cardiac
catheterization. She developed some hypotension on the
following day and the patient was started on Dobutamine. The
patient also was put on Nipride.
She had an echocardiogram that was done on [**2171-4-17**], which
showed [**Doctor First Name **] ejection fraction of 20 to 25% and severe left
global hypokinesis and severe pulmonary artery hypertension.
The patient was then weaned off the intra-aortic balloon pump
on the 2nd and pressors were eventually weaned off. She was
started on ACE inhibitor and beta blocker. Given her poor
ejection fraction, she was continued on heparin and started
on Coumadin. She was discharged home on Coumadin.
The patient was also started on low-dose Lasix and eventually
sent home on 20 q. day.
DISCHARGE DIAGNOSES:
1. Acute myocardial infarction.
2. Cardiogenic shock.
3. Hypertension.
4. Osteoporosis.
5. Colon carcinoma.
6 Lung carcinoma.
7. Breast carcinoma.
8. Peripheral vascular disease.
9. Irritable bowel syndrome.
10. Chronic obstructive pulmonary disease.
11. Spinal stenosis.
12. History of transient ischemic attack.
13. Depression.
14. Severe systolic dysfunction with an ejection fraction of
20%.
DISCHARGE MEDICATIONS:
1. Imipramine 25 q. day.
2. Oxybutynin 5 q. day.
3. Aricept 10 q. day.
4. Zestril 10 q. day.
5. Tylenol 650 three times a day.
6. Lomotil 2 tablets q. day.
7. Aspirin 325 q. day.
8. Lopressor 12.5 twice a day.
9. Lasix 20 q. day.
DISCHARGE INSTRUCTIONS:
1. The patient is going to follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 121**] of
Cardiology at [**Hospital3 4527**], whose phone number is
[**Telephone/Fax (1) 4105**].
2. The patient will follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27226**].
DISPOSITION: The patient will be discharged home to
[**Hospital3 **] with 24-hour care, Visiting Nurses
Association and Physical Therapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2171-6-27**] 11:15
T: [**2171-6-29**] 16:14
JOB#: [**Job Number 27227**]
ICD9 Codes: 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6655
} | Medical Text: Admission Date: [**2163-10-5**] Discharge Date: [**2163-10-14**]
Date of Birth: [**2108-8-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin / Compazine / Bactrim Ds / Sulfa
(Sulfonamides) / Dapsone / Levaquin / Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 55 year old woman with h/o NHL (27 years ago),
complicated by lung toxicity [**1-25**] to Bleomycin treatment,
sarcoidosis, Factor V Leiden, systolic CHF (EF 30%, adriamycin
toxicity), CKD, recently discharged to rehab after a complicated
hospital course for respiratory distress, requiring trach and
PEG placement, s/p treatment for PNA, currently being treated
for Cdiff colitis, now presents with fever.
Patient was recently admitted [**Date range (1) 107084**] for respiratory
failure, requiring intubation. The patient was unable to be
weaned from the [**Last Name (LF) **], [**First Name3 (LF) **] trach and PEG were placed. During this
hospitalization, the patient was persistently febrile, despite
treatment with Abx. She was treated for an 9d course of
Vanc/Cefepime for presumed HAP. Given an Abx holiday for 48-72
hrs given concern for drug fevers, but fevers persisted. She was
restarted on Vanc/Cefepime with addition of IV Flagyl and PO
Vanc for positive Cdiff. Prior to d/c, sputum culture grew gram
negative rods, so IV Vanc was d/c'd and Cefepime was changed to
Meropenem. Meropenem was continued until [**2163-9-29**] at rehab. The
patient is currently still on PO Vanc and PO Flagyl for Cdiff
treatment.
The patient was noted to have low grade fevers for the past week
at rehab. She was restarted on Vanc and Meropenem. Temp was up
to 102.6 today, so she was transferred to the ED for further
care. The patient currently feels well. She notes some R wrist
pain/tendinitis. There have been no changes in her [**Month/Day/Year **]
settings. She is currently on Flagyl and PO Vanc for Cdiff
colitis. She continues to have loose stools, although improved
from when she intially went to rehab. No chills, sweats,
increased cough, worsening shortness of breath, chest pain,
abdominal pain, nausea, vomiting.
In the ED, initial vs were: T 102.2 P 119 BP 143/83 RR 43 O2 sat
100% [**Month/Day/Year **]. The patient was tachycardic to 110, but BP remained
stable. CXR unchanged from prior. UA unremarkable. Patient was
given Tylenol, Vancomycin, and Meropenem. Vitals on transfer: P
97 BP 108/54 RR 30 O2sat 100% [**Month/Day/Year **].
On the floor, the patient remains comfortable. She notes R wrist
pain, but otherwise has no complaints.
Past Medical History:
- s/p trach/PEG [**9-2**]
-Sarcoidosis: treatment History: methotrexate [**12-31**], stopped [**1-31**]
due to reaction, prednisone 10-20-10-7.5mg [**Date range (1) 107077**] stopped due
to Cushingoid side effects in [**11-1**].
- Non-Hodgkin's lymphoma (27 years ago) s/p chemotherapy c/b
bleo lung tox, autologous BMT, and high-dose myeloablative total
body irradiation.
- Pulmonary embolism with Factor-5 Leiden- long term coumadin
goal INR [**1-26**] therapy
- Status post CVA with memory deficit.
- Stage III-IV chronic kidney disease.
- Systolic CHF- [**1-25**] adriamycin from large cell lymphoma several
years ago. Recent Echo 30%.
- Hypertension.
- Hyperlipidemia
- Mild sleep apnea.
- Anxiety
- Gout.
- Anemia - on Aranesp
- Iron overload.
- Multiple environmental allergies
Social History:
Currently living at [**Hospital 100**] Rehab x2 weeks. She has been on
disability for the past 15 years, but used to work in a hotel as
a reservations consultant.
- Tobacco: None
- Alcohol: None
- Illicits: None
Family History:
- Maternal: clots, PE, TIA, Factor V Leiden, dementia at 92
- Paternal: CAD, pancreatic CA
- Siblings: sister died [**2162-12-24**] from complications of DM,
another sister with thyroid problems and high cholesterol
- Children: one healthy daughter without [**Name2 (NI) **] V Leiden
- Uncle: colon cancer
Physical Exam:
Vitals: T 100.1 P 96 BP 102/60 RR 22 O2sat 98%
General: Alert, oriented, no acute distress, trach in place,
mechanically ventilated
HEENT: Sclera anicteric, dry MM, oral thrush
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds bilaterally anteriorly
CV: tachycardic, S1 + S2, no murmurs, rubs, gallops appreciated
given coarse breath sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, PEG site
c/d/i - no erythema/induration/pus
GU: foley
Skin: redness in groin area, lower back/buttocks, under breasts
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no calf tenderness, RUE PICC c/d/i - no erythema,
induration, pus
Pertinent Results:
ADMISSION LABS:
[**2163-10-5**] 12:40PM BLOOD WBC-16.7*# RBC-2.73* Hgb-8.4* Hct-24.9*
MCV-91 MCH-30.7 MCHC-33.6 RDW-15.7* Plt Ct-430
[**2163-10-5**] 12:40PM BLOOD Neuts-81.5* Lymphs-11.9* Monos-5.5
Eos-0.7 Baso-0.3
[**2163-10-5**] 12:40PM BLOOD PT-27.8* PTT-30.5 INR(PT)-2.7*
[**2163-10-5**] 12:40PM BLOOD Glucose-110* UreaN-55* Creat-1.5* Na-125*
K-4.3 Cl-86* HCO3-29 AnGap-14
[**2163-10-5**] 12:40PM BLOOD ALT-19 AST-27 AlkPhos-143* TotBili-0.2
[**2163-10-5**] 12:40PM BLOOD Albumin-3.2* Phos-4.3 Mg-2.8*
[**2163-10-5**] 12:54PM BLOOD Glucose-118* Lactate-0.8
[**2163-10-5**] 12:40PM BLOOD Lipase-66*
OTHER PERTINENT LABS:
[**2163-10-6**] 05:00PM BLOOD Ret Aut-1.1*
[**2163-10-6**] 05:00PM BLOOD LD(LDH)-161 TotBili-0.2
[**2163-10-6**] 05:00PM BLOOD Hapto-521*
URINE:
[**2163-10-5**] 12:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006
[**2163-10-5**] 12:40PM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2163-10-5**] 12:40PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2163-10-5**] 04:20PM URINE Hours-RANDOM UreaN-296 Creat-24 Na-10
K-12 Cl-<10
[**2163-10-5**] 04:20PM URINE Osmolal-177
MICRO:
[**10-5**] BCx: negative
[**10-5**] UCx: negative
[**10-5**] SputumCx: sparse yeast, GNR
[**10-5**] PICC catheter tip Cx: negative
[**10-12**] Feces negative for C.difficile toxin A & B by EIA.
IMAGING:
[**10-5**] CXR:
Low lung volumes and overall stable interstitial opacities.
Given differences in technique and patient position, left
pleural effusion is likely without significant change.
[**10-12**] CXR:
In comparison with the study of [**10-10**], there is still diffuse
bilateral pulmonary opacifications bilaterally in a patient with
known sarcoidosis. No definite evidence of acute focal
pneumonia. Tracheostomy device remains in place.
[**10-10**] Upper Extremity Doppler:
Deep venous thrombosis involving the right subclavian and
axillary veins, with extension into one of two brachial veins.
The internal jugular, basilic and cephalic veins remain patent.
[**10-6**] CT abd/pelvis:
1. No acute intra-abdominal or pelvic process.
2. Redemonstration of interstitial and peribronchial thickening
consistent
with the patient's history of sarcoidosis with new areas of
ground-glass
opacity within the medial lower lobes bilaterally. While this
could be related to sarcoidosis, superimposed infection or
aspiration cannot be excluded and clinical correlation is
recommended
3. Small bilateral pleural effusions
4. Hyperenhancing 1.8 mm region within segment VIII of the liver
peripherally, which likely represents a benign perfusion
abnormality.
5. Hypodensities within the kidneys bilaterally, which are
incompletely
characterized, but likely represent renal cysts, some of which
were present on the prior non-contrast study.
DISCHARGE LABS:
[**2163-10-14**] 03:25AM BLOOD WBC-7.3 RBC-2.78* Hgb-8.5* Hct-25.6*
MCV-92 MCH-30.4 MCHC-33.0 RDW-15.9* Plt Ct-487*
[**2163-10-14**] 03:25AM BLOOD Glucose-106* UreaN-24* Creat-0.8 Na-136
K-4.2 Cl-102 HCO3-27 AnGap-11
[**2163-10-14**] 03:25AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname **] is a 55 year old woman with h/o restrictive lung
disease (bleomycin toxicity), sarcoidosis, systolic CHF (EF 30%,
adriamycin toxicity), Factor V Leiden, s/p trach and PEG
placement, here with recurrent fevers.
#. Fever: Patient was admitted with fever and leukocytosis.
Infectious considerations initially included VAP vs line
infection vs UTI vs Cdiff. On admission PICC line was removed
and foley was replaced. Patient was transiently on Meropenem and
IV Vanco however was discontinued on [**10-10**], as there was low
suspicion for active infection. Sputum cultures grew gram
negative rods (ACHROMOBACTER DENTRIFICANS) which was though to
be a colonizer. Patient remained on PO vanco throughout stay and
will continue on it until [**10-21**]. Rheumatology and ID were
consulted however no source for the fever could be found. She
had a DVT in her right upper extremity that may be causing her
fevers. She was started on enoxaparin for DVT therapy, as she
developed a clot despite Coumadin therapy. This should be
continued at therapeutic dose lifelong, given the patient's h/o
Factor V Leiden.
# Upper Extremity DVT: Pt with new RUE DVT seen on U/S at the
site of her PICC. She developed this despite being therapeutic
on Coumadin. She was started on Lovenox, which should be
continued lifelong as above.
# Transient hypotension: SBP transiently dropped to 80s,
typically while she was sleeping. Responded to IVF boluses. No
other intervention was necessary.
# Diarrhea: Had C. diff infection since late [**9-2**] and was being
treated with PO Vanco. Patient will remain on PO Vanco until
[**10-21**]. Last C. diff toxin in stool was negative. Patient
was started on banana flakes to bulk stool which seemed to help
stool output.
# Hyponatremia: On admission hyponatremia was considered likely
secondary to hypovolemia. It resolved in 12 hours of admission.
# Skin rash: Pt presented with fungal rash under breasts, groin,
and lower back/buttocks. She was treated w/miconazole powder and
PO diflucan.
# Thrush: Pt noted to have oral thrush on exam. She was treated
with PO diflucan.
# Respiratory failure: Secondary to bleomycin toxicity. Pt
arrived trached and on [**Month (only) **]. Weaning process was started during
this hospitalization. Pt tolerated several hours a day on trach
mask. Does get anxious when on the trach mask - Ativan is
effective for relief.
# CHF: [**Last Name **] problem. [**Name (NI) **] interventions were necessary.
# CKD: [**Last Name **] problem. [**Name (NI) **] interventions were necessary.
# Factor V Leiden: H/o Factor V Leiden. Pt was on Coumadin for
life-long anticoagulation. Coumadin was discontinued given that
patient developed a DVT on coumadin. Pt should continue on
therapeutic dose of Lovenox lifelong.
# HTN: Prior h/o hypertension, although had hypotension during
last admission. Coreg was held given normal blood pressures.
Meds should be restarted upon outpatient assessment and
uptitrated as necessary.
#. Psych: continued Ativan prn for agitation/anxiety
#. Anemia: HCT was as low as 21 and received 2 unit pRBC. No
clear source of bleeding and patient's hct remained stable.
Receives Aranesp as an outpatient.
#. Sarcoidosis: Followed by Dr. [**Last Name (STitle) 575**]. Stable on this
admission. Ventilation requirements should be weaned as
tolerated.
Medications on Admission:
Meropenem 500mg IV q8h x7days - completed [**2163-9-29**], restarted
[**10-5**]
Vancomycin 1000mg IV q24h - restarted [**10-4**]
Vancomycin 125mg PO q6h x21 days
Flagyl 500mg PO q8h x21days
Warfarin 5mg PO daily
Coreg 12.5mg PO BID
White Petrolatum-Mineral Oil Ophthalmic TID prn redness
Bisacodyl 10mg PO daily prn
Maalox PO QID prn
Miconzaole powder [**Hospital1 **] prn
Tylenol solution 650mg PO q6h prn
Chlorhexidine 1mL [**Hospital1 **]
Famotidine 20mg PO q24h
Heparin 5000units SC TID
Discharge Medications:
1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 9 days.
2. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
9. famotidine 40 mg/5 mL Suspension Sig: One (1) PO once a day.
10. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: One (1)
PO four times a day as needed for indigestion.
11. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
12. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q4H (every 4 hours) as needed for Wheezing.
14. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
15. darbepoetin alfa in polysorbat 25 mcg/mL Solution Sig:
Twenty Five (25) mcg Injection once a week: last received
[**2163-10-5**] at prior rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Upper Extremity Deep Venous Thrombosis
Chronic respiratory failure
Upper Extremity Deep Venous Thrombosis
Chronic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted because you were having fevers. After
extensive work-up, we do not believe you were having an active
infection causing the fever. You will remain on the Vancomycin
for your prior C. difficile infection. You had a clot in your
right arm vein. You were started on a new blood thinner called
Lovenox. Many changes were made to your medications; please see
attached list.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2722**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2163-10-28**] 1:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2163-11-22**] 11:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2163-11-22**] 11:30
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2163-10-14**]
ICD9 Codes: 4280, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6656
} | Medical Text: Admission Date: [**2188-8-21**] Discharge Date: [**2188-9-8**]
Date of Birth: [**2111-12-1**] Sex: M
Service: MEDICINE
Allergies:
Phenytoin / Decadron
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
Meningioma
Major Surgical or Invasive Procedure:
[**2188-8-20**]: Left Craniotomy for Meningioma with reconstruction
[**2188-8-31**]: G-tube placement
History of Present Illness:
76-year-old male with history of recurrent meningioma s/p
bifrontal craniotomy with cranioplasty and bone flap [**2188-8-21**],
transferred from TICU for further management of post-operative
atrial fibrillation. Patient has baseline sinus bradycardia and
underwent ablation after presentation with tachyarrythmia on
[**2188-7-16**]. Patient unable to give history.
Past Medical History:
1. Atypical Reccurent Right Frontal Meningioma: Symptoms began
in [**2180-6-22**] per [**First Name8 (NamePattern2) 38984**] [**Last Name (NamePattern1) **] "when he became forgetful and
sluggish. Initially he was treated for depression. A head MRI
showed a large dura-based mass in the right frontal brain. A
resection was done by [**Name6 (MD) 1528**] Cares, MD [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital1 38994**]. Pathology was atypical meningioma. He did well until
[**10-22**] when the mass recurred. He had a second resection on
[**2182-1-9**] by Dr. [**Last Name (STitle) 38985**]. This was followed with involved-field
cranial irradiation by [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 38986**], MD [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital1 **]
from [**Month (only) **] to [**2182-3-22**] to 5760 cGy. A follow up MRI on [**2183-6-26**]
showed a 0.5-mm dural based nodular enhancement and he was
referred here for SRS. Surveillance MRI on [**2184-12-8**] revealed
growth of the meningioma in the superior margin of the surgical
cavity invading the skull. He underwent craniectomy on [**2185-1-26**]
by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) 38987**]. There had been invasion
into the inner and outer tables of the skull. A piece of Duagen
dural substitute was placed over the dural defect and then
Methyl Methacrylate cranioplasty was placed over the skull
defect. Pathology revealed atypical meningioma." Underwent
cyberknife therapy in [**2-27**]. He has been maintained on temodar
(chemo) 25mg/m2.
2. Atrial fibrillation: Known to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and followed
by Dr. [**Last Name (STitle) 16958**].
3. GERD
4. OA of knee
5. Hypothyroid
Social History:
Married with two children. Used to smoke a pack a day but quit
in [**2151**]. Used to drink beer but stopped when he was put on
Coumadin. Mother died at 80 from stroke. Father died at 60's,
unclear cause. Bother died 60 from lung cancer.
Family History:
Non-contributory
Physical Exam:
Gen: elderly male in NAD. Oriented x 1. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
CV: Regular rate, normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. Poor air
flow bases bilateral. No wheezes or crackles.
Abd: Soft, NTND. PEG tube inplace. No HSM or tenderness.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars.
Pertinent Results:
[**2188-8-22**] Echocardiogram: The left atrium is mildly dilated. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Overall left ventricular
systolic function is normal (LVEF 60%). The right ventricular
cavity is dilated with depressed free wall contractility. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The estimated pulmonary artery systolic pressure is
normal. There is a small pericardial effusion. There is an
anterior space which most likely represents a fat pad. There are
no echocardiographic signs of tamponade.
.
Compared with the findings of the prior study (images reviewed)
of [**2188-7-15**], the findings are similar.
.
Head CT [**2188-8-31**]: Multifocal intraparenchymal hemorrhage
centered within the right frontal lobe with surrounding edema is
relatively unchanged when compared to prior exam. A small amount
of extra-axial hemorrhage along the right frontal craniotomy is
stable in appearance as well. Areas of pneumocephalus near the
right frontal craniotomy mesh is persistent. There is no shift
of normally midline structures. The ventricle configuration is
unchanged. Hypodensity in the periventricular and subcortical
white matter reflects chronic microvascular and vascular
ischemic changes. Secretions in the right frontal sinus is
unchanged.
.
MRI [**2188-8-22**]: Status post interval resection of right frontal
scalp mass and the contiguous extra-axial enhancing lesions.
There is stable enhancing heterogeneous tissue in the inferior
right frontal lobe. There are findings suggestive of ischemia in
the right frontal lobe which is new compared to the prior study
of [**2188-8-21**]. There is a new mesh cranioplasty in the right
frontal region.
.
Labs on Admission:
[**2188-8-21**] 11:30AM BLOOD WBC-2.5* RBC-3.39* Hgb-11.0* Hct-29.7*
MCV-87 MCH-32.5* MCHC-37.1* RDW-14.1 Plt Ct-202
[**2188-8-21**] 08:20AM BLOOD PT-23.0* PTT-33.7 INR(PT)-2.2*
[**2188-8-21**] 05:45PM BLOOD Glucose-196* UreaN-15 Creat-1.2 Na-142
K-3.9 Cl-105 HCO3-26 AnGap-15
[**2188-8-21**] 05:45PM BLOOD Calcium-10.0 Phos-3.3 Mg-2.5
.
Labs on Discharge:
Brief Hospital Course:
Patient was electively admitted on [**8-21**] for a planned surgical
resection and esthetic reconstruction of his left cranium for
recurrent meningioma. On admission, his coagulation studies
were elevated, requiring the use of FFP infusion and vitamin K
infusion to correct prior to surgery. This was done
uneventfully, and surgery proceded. Intraoperatively, he had
several episodes of atrial fibrillation with rapid ventricular
response, which was refractory to cardioversion. He also
underwent an intraoperative TEE for further interrogation of
this process. Post-operatively, he was admitted to the ICU for
this reason, and cardiology consulted for control of his atrial
fibrillation he was started on an Amiodarone drip and Diltiazem
drips which eventually converted him. He remained abulic,
followed commands inconsistently and answered in one word
answers.
.
# Atrial Fibrillation: On [**8-27**] he was transferred to the step
down unit. On [**8-27**]: Back into afib on Esmolol. On [**8-29**]: amio 200
[**Hospital1 **], LFTs wnl; back in afib. Lopressor 37.5mg PO BID. On [**2188-8-29**],
patient was transferred from trauma SICU to medicine cardiology
service. On arrival, he was in atrial fibrillation with RVR. Per
cardiology recs, he was given acebutolol 200mg via the NG tube.
Overnight, patient pulled out his NG tube. Given that he had
failed swallow studies twice in the previous week, he was not
able to take any medications by mouth. Plan was to give patient
IV beta-blockers as needed until a PEG tube was placed. On the
morning of [**2188-8-30**], patient was given metoprolol IV 5mg x1 for
atrial flutter with heart rate in 130s. Patient converted back
to sinus rhythm. On [**2188-9-1**] patient re-entered A Fib with RVR.
Patient was started on Acebutolol, Amiodarone 100mg qd and
digoxin 0.125mg. Metoprolol was not started as patient become
bradycardiac last time he converted. However, patient did not
convert with Acebutolol titrated up to 400mg [**Hospital1 **] consequently we
started Metoprolol. Patient converted on [**2188-9-6**] when titrated
to Metoprolol 100mg [**Hospital1 **]. No significant pauses or brady on
conversion. Patient recently had ablation in [**6-29**]. Pacemaker
placement not an ideal option as patient will require multiple
MRI for meningioma resection follow-up.
- Discharge on the following medications for rate control:
Metroprolol 75mg po BID, Amiodarone 100mg po qd, Digoxin
0.125mcg po every other day.
- Started Aspirin 81 mg, Neurosurgery stated this was ok.
**** Per neurosurgery, need to wait 1 month before
anticoagulation can be started due to recent craniotomy. Patient
is a candidate for anti-coagulation, was in A Fib with AVR
during hospitliazation. In 1 month need to discuss with
Neurosurgery and Cardiology re-starting anti-coagulation ****
.
# s/p frontal craniotomy: Of note, on [**2188-8-30**] plastic surgery
noted fluid build up at the incision site on frontal region.
Fluid was cultured and final report was no growth. Patient
received vancomycin for a 5 day course given that infection to
that area could be devastating. Kept head of bed elevated.
Continued Keppra for seizure prophylaxis. Patient has follow-up
appointments with Neurosurgery and Plastic surgery (will be
removing sutures).
.
# FEN: Patient has failed swallow study twice. Patient pulled
out NG tube night of [**2188-8-29**]. G tube placed [**2188-8-31**]. On tube
feeds with banana flakes secondary to bowel incontinence.
- Diet order per nutrition in page 1
- discontinue banana flakes if patient becomes constipated
- peg site needs to changed daily with dry dressing
.
# Hypothyroidism: Repeat TSH 1.3, however free T4 remained
elevated at 1.9. Decreased Levothyroxine from 50mcg to 37.5 mcg.
- Recheck TSH and free T4 in 1 month
.
# Hematuria: Urine culture negative. Repeat Ua no RBC. Hematuria
most likely secondary to trauma from patient pulling at foley.
Condom cath did not work, patient currently incontinent.
Discharge on foley. When patient becomes more oriented can d/c
foley
- recheck Ua for hematuria in [**1-23**] months
.
# DM: Morning NPH units increased to 14 from 12 as blood sugars
slightly elevated.Can adjust sliding scale at rehab as
appropriate.
.
#. Hypertension: Well-controlled throughout admission. Continued
lisinopril 10mg PO daily, for rate control patient on Metoprolol
75 mg [**Hospital1 **] with hold parameters.
.
# Code Status: Full, confirmed with wife
Medications on Admission:
1. Amiodorone (200 mg daily)
2. Coumadin [Warfarin] (stopped [**2188-8-17**])
3. Levoxyl (50mcg daily)
4. Lisinopril [Prinivil, Zestril] (10 mg daily)
5. Metoprolol succinate [Toprol XL] (25 mg daily)
6. Neurontin (Gabapentin)(400 mg [**Hospital1 **])
7. Sanctura 20 mg [**Hospital1 **])
8. Pepcid (Famotidine)(20 mg daily)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
Meningioma
Atrial fibrillation with RVR
.
Secondary Diagnosis:
Hypothyroidism
Diabetes
GERD
Discharge Condition:
Vitals stable, sinus rythm.
Discharge Instructions:
You were admitted on [**2188-8-21**] for removal of a meningioma. During
the hospital course you were transferred to the cardiology
service for further management of a fast heart rhythm. You
eventually converted to sinus rythym.
.
We have made changes to your medications please take them as
directed.
.
Please attend your follow-up appointments as listed:
1) You have an appointment with Plastic Surgery Clinic on
[**2188-9-12**] 01:30p [**Hospital6 29**], [**Location (un) **]. They will be
removing your sutures.
2) You have an appointment with Radiology on [**2188-10-7**] 08:30a XCT
[**Apartment Address(1) 9394**] [**Hospital Ward Name **] CC CLINICAL CENTER, [**Location (un) **] RADIOLOGY to
have a CT head. Immediately following you have an appointment
with Neurosurgery on [**2188-10-7**] 9:30 am with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]
M. LM [**Hospital Unit Name **], [**Location (un) **] NEUROSURGERY WEST. You will not
need an MRI of the brain, as this was done during your hospital
stay. If you have any questions there number is [**Telephone/Fax (1) 1669**].
3) Follow-up with your Cardiologist, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] on
[**10-16**] at 10:20am. His office is at [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY
4) Follow with primary care doctor Mr. [**Name13 (STitle) **] in [**2-25**] weeks.
Have [**Hospital **] rehab call [**Telephone/Fax (1) 38995**] to make an appointment.
.
Call your primary care doctor or go to the ER if you experience
rapid heart rate, feeling dizzy, pass out, chest pain, shortness
of breath or any other symptoms.
.
The following discharge Instructions have been provided by
Neurosurgery regarding your surgery:
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen
etc.
- If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
- Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
- New onset of tremors or seizures.
- Any confusion or change in mental status.
- Any numbness, tingling, weakness in your extremities.
- Pain or headache that is continually increasing, or not
relieved by pain medication.
- Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
- Fever greater than or equal to 101?????? F.
Followup Instructions:
1) You have an appointment with Plastic Surgery Clinic on [**8-23**] 1:30pm at [**Hospital Ward Name 23**] Building [**Location (un) 470**]. They will be removing
your sutures.
.
2) You have an appointment with Radiology on [**2188-10-7**] 08:30a XCT
[**Apartment Address(1) 9394**] [**Hospital Ward Name **] CC CLINICAL CENTER, [**Location (un) **] RADIOLOGY to
have a CT head. Immediately following you have an appointment
with Neurosurgery on [**2188-10-7**] 9:30 am with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]
M. LM [**Hospital Unit Name **], [**Location (un) **] NEUROSURGERY WEST. You will not
need an MRI of the brain, as this was done during your hospital
stay. If you have any questions there number is [**Telephone/Fax (1) 1669**].
.
3) Follow-up with your Cardiologist, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] on
[**10-16**] at 10:20am. His office is at [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY
.
4) Follow with primary care doctor Mr. [**Name13 (STitle) **] in [**2-25**] weeks.
Have rehab call [**Telephone/Fax (1) 38995**] to make an appointment.
Completed by:[**2188-9-8**]
ICD9 Codes: 2760, 4280, 4019, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6657
} | Medical Text: Admission Date: [**2174-9-5**] Discharge Date: [**2174-10-4**]
Date of Birth: [**2121-3-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
Hispanic female was last admitted on [**2174-3-31**] with
chest pain and shortness of breath. She ruled out for a
myocardial infarction and had a normal exercise MIBI. She
had medical management and has had intermittent substernal
chest pain with exertion since that time. Her pain radiates
to the right arm and can last for one hour. She is now
admitted for chest pain lasting more than one hour on [**9-5**]. She also has a history of nephrotic syndrome with an
increased creatinine, and cardiac catheterization was trying
to be avoided.
An echocardiogram on [**9-8**] revealed an ejection fraction
of 60%, mild left ventricular hypertrophy, 1 to 2+ mitral
regurgitation, and 1+ tricuspid regurgitation. A
catheterization on [**9-8**] revealed the left anterior
descending artery had a 70% mid stenosis and a 70% first
diagonal stenosis. The left circumflex had a 90% small
obtuse marginal stenosis. The right coronary artery had an
80% stenosis at the origin, 80% proximal stenosis, and 90%
distal stenosis.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. History of angina.
2. History of hypertension.
3. History of nephrotic syndrome with a baseline creatinine
of 1.9.
4. History of hypercholesterolemia.
5. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
6. Status post appendectomy.
MEDICATIONS ON ADMISSION:
1. Lopressor 75 mg by mouth twice per day.
2. Hydrochlorothiazide 50 mg by mouth once per day.
3. Lipitor 20 mg by mouth once per day.
4. Norvasc 5 mg by mouth once per day.
5. Lisinopril 40 mg by mouth once per day.
6. Glipizide 10 mg by mouth once per day.
7. Nitroglycerin as needed.
8. Ciprofloxacin 250 mg by mouth twice per day (started on
[**9-8**]).
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: She does not smoke cigarettes. She does not
drink alcohol.
FAMILY HISTORY: Family history is significant for diabetes.
REVIEW OF SYSTEMS: Review of systems was unremarkable.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient was a well-developed Hispanic female
in no apparent distress. Vital signs were stable. The
patient was afebrile. Head, eyes, ears, nose, and throat
examination revealed normocephalic and atraumatic.
Extraocular movements were intact. Pupils were equal, round,
and reactive to light and accommodation. The oropharynx was
benign. The neck was supple. Full range of motion. No
lymphadenopathy or thyromegaly. Carotids were 1+ in the
ankles bilaterally and without bruits. The lungs were clear
to auscultation and percussion. Cardiovascular examination
revealed a regular rate and rhythm. No murmurs, rubs, or
gallops. The abdomen was soft and nontender. Positive bowel
sounds. No masses or hepatosplenomegaly. Extremity
examination revealed no clubbing, cyanosis, or edema. Pulses
were 2+ and equal bilaterally except for the bilateral
posterior tibialis pulses which were 1+. Neurologic
examination was nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION:
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was seen by Dr. [**Last Name (STitle) 1537**], and she had an elevated
creatinine following catheterization, so her coronary artery
bypass graft was delayed. She continued to have chest pain
while in the hospital. Her creatinine went up to 2.8
following the catheterization and then eventually came back
down to 2.4.
On [**9-15**], she underwent a coronary artery bypass graft
times two with left internal mammary artery to the left
anterior descending artery and saphenous vein graft to
posterior descending artery.
The patient tolerated the procedure well and was transferred
to the Cardiothoracic Surgery Recovery Unit in stable
condition. She was extubated. Her creatinine did continue
to rise postoperatively; up to 3.3. She still continued to
be diuresed with Lasix. Her chest tubes were discontinued on
postoperative day one. Her creatinine continued to rise and
3.9 and then went to as high as 5.4 on [**9-19**], and then
she eventually started to trend down to her baseline. She
did have hemodialysis on [**9-19**] and tolerated this well.
On [**9-19**], she had a left effusion, and she had a
pleurocentesis from which 400 cc of serosanguineous fluid was
obtained. She was then started on continuous venovenous
hemofiltration and tolerated this well and then went back to
hemodialysis.
On [**9-23**], the patient was transferred to [**Hospital Ward Name 121**] Two. She
did not require dialysis at that point anymore. She
continued to improve. She had her epicardial pacing wires
discontinued.
On [**9-26**], she was noted to have a large left pleural
effusion which had reaccumulated. She underwent a
pleurocentesis again, and 800 cc of serosanguineous fluid was
obtained, and the patient had been oxygen dependent and after
that was not oxygen dependent and had symptomatic relief.
She continued to have a sizeable left effusion at that point.
On [**9-28**], she had a chest tube placed, and 700 cc of
serosanguineous fluid was obtained.
On [**9-29**], the chest tube was discontinued, and she had a
small pneumothorax following that. She had another chest
tube placed that had a slight air leak and still had a
pneumothorax following this placement. She also underwent a
bronchoscopy which did not reveal anything.
She had the chest tube discontinued on [**10-3**]. There
was a small bilateral pleural effusion on the final x-ray,
slightly elevated hemidiaphragm, and a small left apical
pneumothorax.
She also had an issue urinary retention. She had a Foley
catheter in for several days. Eventually, this was
discontinued. Then she had to have it put back in again
three days prior to discharge. She had it discontinued on
the night prior to discharge and voided well following that.
DISCHARGE DISPOSITION: On postoperative day 19, she was
discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
PERTINENT LABORATORY VALUES ON DISCHARGE: Her laboratories
on discharge revealed her white blood cell count was 6800,
her hematocrit was 31.3, and her platelets were 502,000. Her
sodium was 130, potassium was 4.7, chloride was 97,
bicarbonate was 16, blood urea nitrogen was 27, creatinine
was 2.1, and her blood glucose was 203.
MEDICATIONS ON DISCHARGE: (Her medications on discharge
were)
1. Colace 100 mg by mouth twice per day.
2. Glipizide 10 mg by mouth twice per day.
3. Atenolol 50 mg by mouth twice per day.
4. Ecotrin 325 mg by mouth once per day.
5. Protonix 40 mg by mouth once per day.
6. Norvasc 10 mg by mouth once per day.
7. Lasix 20 mg by mouth once per day.
8. Vioxx 25 mg by mouth once per day.
9. Tylenol No. 3 one to two tablets by mouth q.4-6h. as
needed (for pain).
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**Last Name (STitle) 33950**] in one to two weeks and by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2174-10-4**] 17:00
T: [**2174-10-4**] 17:02
JOB#: [**Job Number 33951**]
ICD9 Codes: 4111, 5849, 5990, 5119, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6658
} | Medical Text: Admission Date: [**2178-6-21**] Discharge Date: [**2178-6-26**]
Date of Birth: [**2111-11-10**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Effexor
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization, no intervention
History of Present Illness:
66-year-old man with CAD s/p LAD PCI, right SFA/peroneal bypass
and angioplasty, asymptomatic right subclavian and carotid
disease,
brittle diabetes on insulin pump, hyperlipidemia, and
hypertension, who was POD#3 s/p Right total knee replacement at
the [**Hospital1 **] who developed chest pain with BP in the 180s, and
EKG changes infero-laterally with ST depressions similar to EKG
changes during stress test before surgery and concern for V1-3
STe, which was unchanged from EKG at [**Hospital1 18**] 1mo ago. Given the
EKG changes (not aware of baseline EKG at [**Hospital1 18**]) and CP, he was
started on heparin gtt, and he was transferred to [**Hospital1 18**] for
emergent catheterization, which revealed no changes from c.cath
1mo ago.
.
On arrival to cath lab, he was hypertensive and required a nitro
gtt to maintain SBPs < 160, he was given full dose ASA and 600mg
of Plavix. Upon completion of cath, was transferred to the
floor, hypoxemic on 10 L facemask and tachypneic. Nitro gtt was
discontinued. At ~ 1600, had an acute episode of SOB,
desaturations to 92 on max NC, thus requiring NRB to maintain
sats > 96%, BP at the time was 144/65. He was given IV lasix for
suspected pulmonary edema and haldol for agitation. UOP from
lasix was 1L in one hour and his RR improved to low 20s, though
he remained confused. CTA chest was peformed which preliminarily
showed no PE and a ? RUL consolidation with mild pulmonary
edema. He was briefly transferred to the MICU for continued SOB,
hypoxemia and nursing care. During his MICU course he was given
80 mg IV lasix and put out nearly 1.8 L of urine. He was also
quite agitated and delerious (which has been ongoing) and
received 20 mg olanzapine which calmed him down. He is
transferred to the CCU for further management.
.
Notably, most recent cath findings as follows: SBPs 160s - 180s.
60% LAD, MR, right dominant system with 70% 1st diag, 60% 2nd
diagnoal, moderate LCX disease and 60% small PDA. Per discussion
with cards fellow, it was felt that EKG changes constituted
demand ischemia in setting of acute drop in hematocrit from 35
to 26 and was consistent with prior stress test. Of note, [**5-22**]
cath showed diffuse CAD, EF > 60%, there was no intervention and
findings were similar to above. Also of note, upon transfer to
[**Hospital1 18**], he was given 1 unit pRBC for anemia.
.
At OSH, Labs were notable for HCT 35->26 post op, WBC 4.7->9.5
admission to [**6-21**] with left shift, CO2 31, Cr. 0.7 and
CK/CKMB/Trop 503/6.1/0.26 (high/high/nl(< 0.4)). BNP was 311.
.
Per review of OSH nursing notes, pt has been confused since at
least [**6-19**], has been receving dilaudid for pain. On [**6-20**] AM was
noted to be somnolent and resonded to narcan.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope
Past Medical History:
DM1 (dx'ed in late 20s) c/b triopathy
CAD s/p PTCA/stent to LAD in [**2-5**]
PVD s/p fem/tib bypass
Enviromental allergies
Non-healing R foot ulcer s/p R first toe amputaton ([**2173-2-11**])
Orthostatic hypotension
Hyperlipidemia
HTN
Depression
[**12-6**]+MR (by echo [**4-8**])
moderate pulm HTN
Social History:
Works as administrator at [**Hospital1 498**] [**Location (un) 5169**]
Smoked pipe for several years in 20s
h/o EtOH abuse ([**7-14**] drinks/day x 10 years) now sober
Family History:
[**Name (NI) 61930**] pt is adopted.
Physical Exam:
Admission PE:
VS: T=98.7 BP=144/46 HR=96 RR= 24 O2 sat= 93% 6 Liters
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of at clavicle.
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.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2178-6-21**] 01:44PM BLOOD WBC-15.5*# RBC-3.09*# Hgb-9.6*#
Hct-28.0*# MCV-91 MCH-31.0 MCHC-34.2 RDW-13.7 Plt Ct-209
[**2178-6-22**] 05:11AM BLOOD WBC-9.8 RBC-3.09* Hgb-9.5* Hct-27.6*
MCV-89 MCH-30.7 MCHC-34.4 RDW-13.9 Plt Ct-182
[**2178-6-25**] 07:15AM BLOOD WBC-6.4 RBC-3.53* Hgb-10.5* Hct-31.7*
MCV-90 MCH-29.8 MCHC-33.2 RDW-15.1 Plt Ct-300
[**2178-6-21**] 01:44PM BLOOD PT-13.5* PTT-39.0* INR(PT)-1.2*
[**2178-6-24**] 04:43AM BLOOD PT-12.3 PTT-29.2 INR(PT)-1.0
[**2178-6-21**] 01:44PM BLOOD Glucose-220* UreaN-12 Creat-0.6 Na-133
K-3.9 Cl-97 HCO3-29 AnGap-11
[**2178-6-25**] 07:15AM BLOOD Glucose-120* UreaN-10 Creat-0.6 Na-140
K-3.8 Cl-102 HCO3-33* AnGap-9
[**2178-6-21**] 01:44PM BLOOD LD(LDH)-273* TotBili-1.7*
[**2178-6-22**] 05:11AM BLOOD ALT-24 AST-55* CK(CPK)-754* AlkPhos-67
Amylase-12 TotBili-1.1
[**2178-6-22**] 05:11AM BLOOD Lipase-9
[**2178-6-21**] 08:37PM BLOOD cTropnT-0.24*
[**2178-6-22**] 05:11AM BLOOD CK-MB-9 cTropnT-0.21*
[**2178-6-21**] 01:44PM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9
[**2178-6-25**] 07:15AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.2
[**2178-6-21**] 01:44PM BLOOD Hapto-96
[**2178-6-23**] 09:19AM BLOOD Ammonia-19
.
Discharge Labs
Microbiology:
[**2178-6-21**] 6:46 pm URINE Source: Catheter.
**FINAL REPORT [**2178-6-22**]**
URINE CULTURE (Final [**2178-6-22**]): NO GROWTH.
[**2178-6-21**]: BCx2 pending
Radiology:
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2178-6-21**] 3:50 PM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 53630**] [**2178-6-21**] 3:50 PM
CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 61931**]
Reason: POD # 2 s/p kmee surgery, chest pain, clean cath Note:
recei
Contrast: OPTIRAY Amt: 100
HISTORY: 66-year-old male, with two-vessel coronary artery
disease and LVEF
on LV gram 60%. Now two days status post knee surgery. Presents
with
shortness of breath.
Chest pain. Evaluate for pulmonary embolism or acute aortic
pathology.
COMPARISON: Limited comparison from prior chest radiograph on
[**2173-4-30**].
TECHNIQUE: MDCT images were acquired from the thoracic inlet to
the lung
bases before and after administration of IV contrast.
Multiplanar reformatted
images were obtained for evaluation.
CTA CHEST: The pulmonary arterial vasculature is normally
opacified to the
subsegmental level without filling defect to suggest acute
pulmonary embolism.
There is an aorta arch with bovine variant, but the aorta is
otherwise normal
in course and caliber without acute pathology. Scattered
vascular
calcifications are noted along the aortic arch. The remaining
great
mediastinal vessels are normal. Moderate coronary calcifications
are noted.
The heart is normal in size without pericardial effusions.
There are bilateral pleural effusions, small on the right and
tiny on the
left. There are mild adjacent bilateral atelectasis. Increased
septal lines
are compatible with mild pulmonary edema. In the upper lobes,
there are hazy
patchy opacities, right greater than left. While this could
represent the
underlying pulmonary edema, early infectious process cannot be
excluded.
There is no pneumothorax. No mediastinal, hilar or axillary
lymphadenopathy
is noted.
The study is not designed for subdiaphragmatic diagnosis but no
gross
abnormalities are noted.
BONE WINDOW: Multilevel degenerative changes are
mild-to-moderate, with
subchondral cysts and Schmorl's node formation. No suspicious
lytic or
sclerotic lesions are noted.
IMPRESSION:
1. No pulmonary embolism or acute aortic pathology.
2. Mild pulmonary edema. Patchy opacities in the upper lobes,
right greater
than left, cannot rule out early infectious process.
3. Bilateral pleural effusions with dependent atelectasis.
4. Coronary artery disease.
Dr. [**First Name8 (NamePattern2) 5586**] [**Last Name (NamePattern1) **] has discussed the findings with the primary team,
Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at 4:33 p.m. shortly after the preliminary interpretation
of the exam.
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: SUN [**2178-6-21**] 7:05 PM
CXR:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2178-6-22**] 8:20
AM
FINDINGS:
The pulmonary vasculature is prominent and there are bilateral
pleural
effusions, consistent with congestive heart failure. There are
also foci of
hazy opacities at the right upper and right lower lobe,
consistent with
infection. No pneumothorax. The cardiomediastinal silhouette
remains
unchanged.
IMPRESSION:
Multifocal infection and increased pulmonary venous pressure.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 251**] [**Name (STitle) 8580**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
CXR:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2178-6-23**] 7:48
AM
FINDINGS: As compared to the previous radiograph, the
pre-existing
parenchymal opacities show improvement.
No other changes, constant size of the cardiac silhouette, no
evidence of
pleural effusions.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Arterial duplex scan:
Radiology Report ART DUP EXT LO UNI;F/U RIGHT Study Date of
[**2178-6-23**] 2:01 PM
STUDY: Lower extremity arterial duplex.
REASON: Decreased pulse post-total knee replacement.
FINDINGS: Duplex evaluation was performed of the right lower
extremity
bypass. Peak velocities in centimeters per second from
proximal-to-distal are
as follows: Common femoral 115, profunda 142, SFA 150, 91, 94;
proximal
anastomosis 138, vein graft 110,89, 59; distal anastomosis 157,
outflow 105.
IMPRESSION: Patent right lower extremity bypass with no evidence
of stenosis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Carotis U/S:
Radiology Report CAROTID SERIES COMPLETE Study Date of [**2178-6-24**]
10:11 AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 61932**] [**2178-6-24**] 10:11 AM
CAROTID SERIES COMPLETE Clip # [**Clip Number (Radiology) 61933**]
Reason: pre-op for CABG, assess stenosis
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with CAD, multivessel disease requiring CABG.
REASON FOR THIS EXAMINATION:
pre-op for CABG, assess stenosis
Final Report
STUDY: Carotid series complete.
REASON: Preop CABG.
FINDINGS: Duplex evaluation was performed of bilateral carotid
arteries.
There is heterogeneous plaque seen bilaterally.
On the right, peak velocities are 94, 107, and 183 in the ICA,
CCA, and ECA
respectively. This is consistent with less than 40% stenosis.
On the left, ICA velocity is 184/50, CCA is 93, the ECA is 210.
The ICA/CCA
ratio is 2.0. This is consistent with 60-69% stenosis.
There is antegrade vertebral flow bilaterally. The right
vertebral waveform
is notched suggesting possible subclavian stenosis. There is a
normal right
CCA waveform.
IMPRESSION: Right ICA less than 40% stenosis. Left ICA 60-69%
stenosis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Venous duplex scan:
Radiology Report UNILAT LOWER EXT VEINS RIGHT Study Date of
[**2178-6-25**] 4:01 PM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 53630**] [**2178-6-25**] 4:01 PM
UNILAT LOWER EXT VEINS RIGHT Clip # [**Clip Number (Radiology) 61934**]
Reason: SWELLING PAIN RULE OUT DVT ON RIGHT
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with recent knee surgery and more swelling on
right.
REASON FOR THIS EXAMINATION:
rule out dvt on right
Wet Read: [**First Name9 (NamePattern2) 20005**] [**Doctor First Name **] [**2178-6-25**] 4:23 PM
No DVT right lower extremity.
Preliminary Report
No DVT right lower extremity.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Cardiology results:
Cardiology Report ECG Study Date of [**2178-6-21**] 11:39:18 AM
Sinus rhythm. A-V conduction delay. Left atrial abnormality.
Cannot exclude
prior anterior wall myocardial infarction. Left ventricular
hypertrophy.
Secondary repolarization abnormalities most prominent in the
lateral leads.
Compared to the previous tracing of [**2178-5-22**] the lateral ST
segment depressions,
which are new, raise concern for concomitant myocardial
ischemia. Clinical
correlation is suggested.
Cardiac catheterisation:
Cardiology Report Cardiac Cath Study Date of [**2178-6-21**]
1. Selective coronary angiography in this right dominant system
demonstrated two vessel coronary artery disease. The LMCA had
mild
disease. The LAD had diffuse calcific disease, and the
previously
placed stent(s) was patent. There was 60% stenosis in the
proximal
vessel. There was 70% stenosis of the first diagonal and 60%
stenosis
of the second diagonal. The LCx had moderate, diffuse disease
in a
small vessel. The RCA had a 60% stenosis in a small PDA. The
anatomy
appeared stable when compared to the recent cath of [**2178-5-23**].
2. Limited resting hemodynamics revealed moderate systemic
arterial
systolic hypertension SBP 167mmHg.
3. Left ventriculography was deferred.
4. Hemostasis of the left femoral arteriotomy site was
successfully
achieved with a 6 French Angioseal device.
FINAL DIAGNOSIS:
1. Unchanged two vessel coronary artery disease.
2. Moderate systemic arterial systolic hypertension.
3. Successful angioseal deployment.
Brief Hospital Course:
66-year-old man with CAD s/p LAD PCI, right SFA/peroneal bypass
and angioplasty, asymptomatic right subclavian and carotid
disease, brittle diabetes on insulin pump, hyperlipidemia, and
hypertension, who was POD#3 s/p Right total knee replacement at
the [**Hospital1 **] who developed chest pain with BP in the 180s, and
EKG changes infero-laterally with ST depressions similar to EKG
changes during stress test before surgery and concern for V1-3
STe, which was unchanged from EKG at [**Hospital1 18**] 1mo ago. He was
started on heparin gtt and transferred to [**Hospital1 18**] for emergent
catheterization, which revealed no changes from cardiac cath 1
month ago.
.
On arrival to cath lab, he was hypertensive and required a nitro
gtt to maintain SBPs < 160, he was given full dose ASA and 600mg
of Plavix. Upon completion of cath, was transferred to the
floor, hypoxemic on 10 L facemask and tachypneic. Nitro gtt was
discontinued. He was transitioned to nasal cannula but then had
an acute episode of SOB, desaturations to 92 on max NC,
requiring NRB to maintain sats > 96%. BP at the time was
144/65. He was given IV lasix for suspected pulmonary edema and
haldol for agitation. CTA chest was peformed which showed no PE
and a ? RUL consolidation with mild pulmonary edema. He was
briefly transferred to the MICU for continued SOB, hypoxemia and
nursing care. During his MICU course he was given 80 mg IV lasix
and put out nearly 1.8 L of urine. He was also quite agitated
and delerious, and received 20 mg olanzapine which calmed him
down. He is transferred to the CCU for further management.
.
Cath findings as follows: SBPs 160s - 180s. 60% LAD, MR, right
dominant system with 70% 1st diag, 60% 2nd diagnoal, moderate
LCX disease and 60% small PDA. Per discussion with cards fellow,
it was felt that EKG changes constituted demand ischemia in
setting of acute drop in hematocrit from 35 to 26 and was
consistent with prior stress test. Of note, [**5-22**] cath showed
diffuse CAD, EF > 60%, there was no intervention and findings
were similar to above. Also of note, upon transfer to [**Hospital1 18**], he
was given 1 unit pRBC for anemia.
.
CCU Course:
# NSTEMI: Felt to be secondary to demand in setting of decrease
in Hct from 35 -> 26 causing enzyme elevations and ST
depressions in lateral leads. Initial concern for STEMI as STE
seen in V1-V3, however this was unchanged from old EKG. No
intervention performed during cardiac cath, and patient was
chest pain free on transfer to CCU. Troponin peaked at 0.24 and
was trending down. He was continued on aspirin, Plavix,
atorvastatin, atenolol and an ACE inhibitor. His lisinopril was
stopped on [**2178-6-23**] in setting of fluctuating blood pressures.
He was monitored on telemetry. His HCT was trended given
concern for ischemia. He was transfused an additional unit of
PRBCs on [**2178-6-23**]. Carotid U/S revealed a right ICA less than
40% stenosis and a left ICA 60-69% stenosis. He will follow up
with CT surgery as an outpatient, plan for CABG.
.
# Diastolic Heart Failure: The patient was breathing comfortably
with sats in the mid-90s on supplemental oxygen at time of CCU
tranfer. His fluid balance was monitored with a goal of net
even to negative 500cc per day. He was continued on a beta
blocker. His lisinopril was stopped on [**2178-6-23**] in setting of
varying blood pressures.
.
# Hypoxemic resp. failure: Respiratory status improved with
diuresis. Respiratory decline most likely due to flash pulmonary
edema, in setting of hypertension, and volume overload (likely
received fluid in OR), 1U PRBCs, as well as adrenergic drive in
setting of CP. CTA revealed mild pulmonary edema and patchy
opacities in the upper lobes, right greater than left, which
could represent an early infectious process. Echo [**2178-6-22**] showed
1+ MR [**First Name (Titles) 151**] [**Last Name (Titles) 61935**] EF (65-70%) and elevated filling pressures
consistent with diastolic dysfunction which could support flash
pulmonary edema etiology. CTA did not reveal any evidence of PE.
PNA seemed less likely based on the location (RUL), however the
patient was febrile and aspiration PNA/HAP remained on
differential. He was continued on empiric antibiotic coverage
with vanc/cefepime/flagyl. CXR on [**2178-6-23**] showed improvment in
previously seen opacities. Patient's antibiotics were stopped,
as it was felt he did not have PNA. His O2 was titrated to keep
his sats above 92%.
.
# Delirium. Slowly improved with holding additional pain
medications. Per OSH records, he had been confused and agitated
since TKR. Confusion thought to be multifactorial, and related
to post-op course, opioids, fever, and hypoxemia. He was given
Zyprexa prn agitation, and also ordered for haldol prn
agitation. His home anxiolytics were held, but sertraline and
buproprion were continued. He was started on vicodin prn pain
after his delerium had resolved, and was tolerating the
medication well at time of discharge.
.
# Fever: Tmax 100.8F over 24 hours prior to CCU transfer.
Source of fever was unknown, but DDx included PNA, possible
wound infection, or post-op fever. His WBC was trended, and he
was initially continued on empiric antibiotics until it was felt
he did not have any clincial signs of PNA. His antibiotics were
then discontinued. His WBC normalized and he was afebrile at
time of discharge with no sign of active infection.
.
# PVD: He was continued on plavix, aspirin, and a statin. His
extremities were warm, and well-perfused during the admission.
An arterial duplex study of his right lower extremity on [**2178-6-23**]
revealed a patent right lower extremity bypass with no evidence
of stenosis. He will be followed up in teh community by vascular
surgery.
.
# s/p R TKR: Patient in soft cast at time of admission, and knee
was not tender to palpation. Dr. [**Last Name (STitle) 61936**] (ortho) was aware of
patient's admission. Ortho team followed patient during his
hospital course. He was continued on partial weight bearing and
continuous power machine. PT was also consulted for
recommendations. He developed increased pain in the knee, for
which he received vicodin prn pain. Dr. [**Last Name (STitle) **] from
Orthopedics called to consult about right knee erythema around
suture site which was felt likely to be inflammation as opposed
to any soft tissue infection, and recommended 10 days of
Cephalexin which was given to pt at discharge. A right lower
extremity ultrasound did not reveal any evidence of DVT.
.
# DM: Patient has h/o brittle diabetes, with A1C 7.9% 1.5 months
ago. He was placed on Lantus 18 plus an insulin sliding scale.
His blood glucose levels were difficult to control during the
admission, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes Center consult was called. He
was restarted on his home insulin pump regimen, with minor
adjustments made after the [**Last Name (un) **] consult.
.
# Autonomic and Peripheral Neuropathy: Patient had orthostatic
hypotension and a very labile BP during admission, which has
been chronic issue. His postural BP as monitored, and his
atenolol and lisinopril were held in setting of fluctuating BPs.
The patient was continued on fludrocortisone.
.
#) Anxiety: On transfer to CCU, patient was agitated and
encephalopathic. He was continued on sertraline and bupropion,
but other anxiolytics were initially held.
.
#) Neuropathy: His gabapentin was initially held.
.
#) OSA: He was continued on Bipap, 15/8 as per home regimen.
.
#) Prophylaxis: He was initially on SC heparin, then switched to
Lovenox for DVT prophylaxis.
Medications on Admission:
Afrin prn
ambien 10 mg prn
aspirin 81 daily
Atenolol 25 daily
Fludrocortisone 0.05 mg q pm
Gabapentin 200 [**Hospital1 **]
Lipitor 40 daily
Lisinopril 10 mg AM and 5 mg PM
Novolog pump
Percocet prn
plavix 75 daily
wellbutrin 200 daily
zoloft 25 daily
viagra 100 prn
vicodin prn
xanax 0.5-1.0 mg q pm prn
vitamins plus b complex q AM
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Bupropion HCl 200 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain. Tablet(s)
9. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
HS (at bedtime) as needed for Nasal congestion.
10. Ambien 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous ASDIR (AS DIRECTED).
12. Xanax 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime.
13. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a
day.
14. Viagra Oral
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Fludrocortisone 0.1 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Location (un) 260**]
Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Diabetes Type 1 on insulin pump
Coronary Artery Disease
Peripheral Vascular Disease
Autonomic Dysfunction
Hypertension
Hyperlipidemia
Acute on Chronic Diastolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had some chest pain and changes on your alectrocardiogram at
the [**Hospital **] hospital after your knee operation. You were
transferred to [**Hospital1 18**] for a cardiac catheterization that showed
no change in the blockages in your coronary arteries from
previously. You had a small heart attack but your echocardiogram
was unchanged. The pressures inside of your heart has been high
and you received some diuretics to lower the pressures. You had
some delirium, confusion that is common in the hospital, this
has now improved greatly. You will return in [**Month (only) 216**] to talk to
Dr. [**Last Name (STitle) **] about bypass surgery.
WE made the following changes to your medicine.
1. Increase Aspirin to 325 mg daily
2. Decrease Lisinopril to 5mg twice daily
3. Continue on home insulin pump
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Department: CARDIAC SURGERY
When: THURSDAY [**2178-7-30**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2178-10-8**] at 1:45 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PODIATRY
When: THURSDAY [**2178-7-30**] at 10:45 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: Cardiology
Who: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
When: The office of Dr. [**Last Name (STitle) **] will be calling you regarding the
date of your upcoming appointment within 1 month of your
discharge. Please call the office in 2 business days if you have
not heard from the office.
Where: [**Last Name (NamePattern1) 14648**], [**Location (un) 86**], MA
[**Doctor Last Name 3649**] Building [**Apartment Address(1) 40601**]
Phone: ([**Telephone/Fax (1) 32215**]
Department: Orthopaedics
Who: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 61936**]
When: The office of Dr. [**Last Name (STitle) 61936**] will be calling you regarding
the date of your upcoming appointment within 1 month of your
discharge. Please call the office in 2 business days if you have
not heard from the office.
Where: [**Last Name (NamePattern1) 14648**], [**Location (un) 86**], MA
[**Hospital1 756**] 5, [**Apartment Address(1) 61937**]
Phone: ([**Telephone/Fax (1) 61938**]
ICD9 Codes: 4280, 3572, 4168, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6659
} | Medical Text: Admission Date: [**2169-9-23**] Discharge Date:
Date of Birth: [**2117-12-21**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: This 51-year-old man with a
newly diagnosed GBM status post resection on [**2169-9-8**] with
residual right hemiparesis was discharged to rehabilitation
but was noted to have increased word finding difficulties on
[**2169-9-23**]. He had been at [**Hospital6 310**]
from [**2169-9-12**] until [**2169-9-23**]. Per his wife, she first
noticed increased word finding difficulties on the Saturday
prior to admission. On Sunday, the day of admission, he was
unable to articulate three word sentences which was his
baseline at [**Hospital1 **].
PAST MEDICAL HISTORY: Significant for GBM diagnosed in
[**9-/2169**], resected on [**2169-9-8**], with a plan to have
radiation therapy done. History of inflammatory bowel disease
status post resection with ileostomy in [**2143**]. Hyperlipidemia,
gastroesophageal reflux disease and steroid-induced diabetes
mellitus.
MEDICATIONS ON ADMISSION:
1. Decadron 2 mg p.o. b.i.d.
2. Hydrochlorothiazide 25 mg q day.
3. Lopressor 12.5 mg b.i.d.
4. Lipitor 10 mg q day.
5. Insulin.
6. Tylenol.
SOCIAL HISTORY: He transferred from [**Hospital3 7**]. No
tobacco. No ETOH. Married. Works as a consultant. Has two
children.
FAMILY HISTORY: Significant for breast cancer for mother and
father with coronary artery disease.
PHYSICAL EXAMINATION: On admission, vital signs:
Temperature 100.0, blood pressure 157/77, heart rate 82,
respirations 18, O2 is 95 percent. General: He was agitated.
HEENT: Ruddy complexion baseline per wife, pupils equal,
round and reactive to light and accommodation, extraocular
movements were full. Cardiac: Regular rate and rhythm. Lungs
are clear bilaterally. Abdomen: Soft, nontender,
nondistended. Extremities: No edema. He was awake, alert and
completely aphasic but able to follow commands such as "close
your eyes" and able to repeat "no ifs, ands or buts about
it". Cranial nerves II-XII are grossly intact except for a
right facial droop with decreased labial fold and tongue
deviation to the right. Strength was five out of five on the
left. Unable to assist on the right due to neglect. Reflexes
were three plus on the right and two plus on the left.
LABORATORY DATA: White blood cell count 18.7, hematocrit
37.7, platelets 226, sodium 133, potassium 4.6, 93/25 and 29
for BUN, 0.8 for creatinine, 234 for glucose, calcium 8.9,
alkaline phosphatase 4.6, magnesium 2.1. Urinalysis was
within normal limits. ALT was noted to be at 131. AST was 26.
LDH 243, lipase 224, CK were within normal limits. Head CT
showed air and blood products in the subdural space along the
left convexity and surgical resection site and in the left
cortex/basal ganglia with surrounding hypo-attenuation into
the left caudate nucleus and internal capsule and thalamus.
Normal ventricles. No midline shift. Chest x-ray showed a
retrocardiac opacity in the left lower lobe likely
atelectasis. Electrocardiogram showed atrial bigeminy at a
rate of 78. Blood cultures on [**2169-9-23**] on both anaerobic
and aerobic were positive for GPC pairs and clusters.
HOSPITAL COURSE: The patient was admitted to the Oncology
service where he underwent a fever workup. He had reported
fevers at [**Hospital1 **]. Also is part of the fever workup they
obtained lower extremity Dopplers, which showed a clot in his
left peroneal vein. He also was started on Dilantin to rule
out seizures given his change in mental status and he was
given a dose of 10 mg intravenous and changed to 6 mg q six
hours. It was noted that his incision site on his head from
his previous surgery was fluctuant with what was felt to be a
fluid collection underneath. Blood cultures from [**2169-9-23**] and
[**2169-9-24**] showed
coag positive staphylococcus aureus methicillin
sensitive. The blood culture results were indicative of high-
grade MSSA bacteremia. An Infectious Disease consultation was
obtained and the patient was started on oxacillin 2 gm
intravenously q four hours with a recommendation for six
weeks. For empiric coverage prior to starting the oxacillin,
he was started on vancomycin and cefepime. Those were
discontinued on [**2169-9-26**] and as mentioned he was started on
the oxacillin. Infectious Disease also recommended an
echocardiogram be done to rule out endocarditis. No
vegetation was seen via echocardiogram that was completed on
[**2169-9-26**].
On [**2169-9-25**], [**Name6 (MD) **] [**Name8 (MD) 739**], M.D. aspirated 80 cc
of purulent fluid from his wound site which showed Gram
positive cocci in pairs and clusters and grew out
staphylococcus aureus coagulopathy positive. Regarding the
patient's deep venous thrombosis, Dr. [**Last Name (STitle) 739**] did not
want to anticoagulate but follow with serial ultrasounds to
see if the clot propagated. On [**2169-9-25**], the patient
underwent a left-sided craniotomy for wound debridement and
evacuation of subdural intracranial empyema. On [**2169-9-25**],
the patient had an upper extremity ultrasound to rule out a
deep venous thrombosis in his right arm and that was negative
for any deep venous thrombosis. Postoperatively, he was sent
to the Intensive Care Unit where he was monitored with close
neurological checks. He was awake and alert and aphasic with
right-sided hemiplegia. While in the Intensive Care Unit, it
was noted that his platelets dropped to as low as 85. His
subcutaneous heparin was discontinued and a heparin panel was
sent off. Also, his sodium at that time started to fall to
the 133 range. He was started on sodium p.o. The HIT panel
was positive for heparin-induced thrombocytopenia. His liver
function tests were monitored closely while continuing to
receive oxacillin.
He was transferred to the surgical floor on [**2169-9-27**] where
he remained awake, alert and aphasic. The patient expressed
extreme need to be discharged home along with his wife. They
did not want to go back to any rehabilitation facility and
were adamant that he be discharged home as soon as possible.
The discharge planning process was begun. Home physical
therapy, occupational therapy, necessary medical equipment
were ordered. Also, home visiting nurse service was set up
due to the fact that he would need continuous infusion of
oxacillin.
On [**2169-9-28**], a repeat ultrasound was performed of the
patient's right lower extremity which showed propagation of
deep venous thrombosis to the popliteal vein and distal
superficial femoral vein. Given that new finding,
Interventional Radiology was contact[**Name (NI) **] and an inferior vena
cava filter was placed. The patient had no complications from
his inferior vena cava filter placement. On [**2169-9-29**], a
PICC line was inserted into the patient's left median vein
without complication. Also, a psychiatry consultation was
obtained also on [**2169-9-29**] given the patient's depression,
periods of confusion, agitation and then occasional treatment
opposition. Their recommendation was to avoid benzodiazapine,
use Haldol for acute agitation and have psychiatric follow-up
as needed at home. Social Work also saw the family and
offered services as needed. On [**2169-9-30**], it was noted that
the patient's HIT panel was positive. At that time,
Hematology/Oncology was consulted who recommended starting
argatroban. They recommended avoiding all heparin and
continuing argatroban only until it is clear that the
platelets had normalized. Further recommendations on
[**2169-10-2**] from Hematology/Oncology was to discontinue the
argatroban and to start a fondaparinux 7.5 mg subcutaneously
q day and introduce Coumadin in the next 4-5 days continuing
on the fondaparinux until his INR level was at 2.0, and he
should continue on Coumadin therapy for four weeks.
On [**2169-10-3**], the day of discharge, it was noted that his
hematocrit was 26.8. Dr. [**Last Name (STitle) 739**] recommended
transfusing one unit of packed red blood cells and starting
on iron. Also, on [**2169-10-3**], his platelet count had
recovered to 245. His sodium had recovered to 137. At this
time, the patient and his family again expressed a profound
interest to be discharged home. They are acutely aware of the
amount of services that will be needed at home and the 24
hour supervision that the patient's care will entail. They
once again were offered the option of
DICTATION ENDED
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2169-10-3**] 14:39:58
T: [**2169-10-3**] 15:20:54
Job#: [**Job Number 58060**]
ICD9 Codes: 7907, 2761, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6660
} | Medical Text: Admission Date: [**2108-6-15**] Discharge Date: [**2108-6-19**]
Date of Birth: [**2048-1-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Ciprofloxacin
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
RLE cellulitis and concern for endocarditis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 60 year old male with PMH of HIV/AIDS (CD4 nadir < 100,
recent CD4 562), s/p mechanical AVR (Cardiomedics mechanical
valve) following episode of strep pneumo endocarditis ([**2100**]),
and hypertension, now presenting with redness and swelling of
the right ankle shortly after dental work without prophylaxis.
.
Patient states that he noted swelling inferior to the right
ankle on Monday, [**6-11**]. This area became more painful and swollen
over the course of the week. He also noted subjective fevers
with chills. He took ibuprofen for the pain with some relief. He
became more concerned on Thursday so presented to the ED.
.
He states that he had a dental cleaning last Thursday but did
not take antibiotics at the same time per his usual routine. He
denies any falls at home but is using a cane due to the
increased pain in the right foot with walking.
.
In the ED, intitial vitals were: T 98.7 HR 80 BP 148/72 RR 16
98% on RA. The patient had an ultrasound which showed small
fluid collections in the right leg but no DVT. He was treated
with vancomycin 1 g IV X 1 and gentamycin 80 mg IV X 1 and
received a total 2 L NS.
.
ROS: No nausea, vomiting, constipation, diarrhea, melena, BRBPR,
chest pain (pleuritic or otherwise), palpitations, dizziness or
lightheadedness change in vision, hearing, hematuria, dysuria,
numbness, tingling, weakness, joint pain, myalgias. Had a slight
headache this morning which resolved with ibuprofen. Has lost
about 10 pounds in the past few months, ascribes this to eating
less junk food. Had a high INR lately so stopped his coumadin
last weekend; resumed on Monday at 5 mg daily. Reports no recent
travel and no sick contacts.
.
Past Medical History:
Past medical history:
* HIV/AIDS: diagnosed [**2091**], CD4 nadir < 100; h/o PCP & HSV; Last
CD4 562 in [**3-29**]
* Strep pneumoniae bactermia/endocarditis/empyema ([**2100**])
resulting in mechanical aortic valve replacement
* h/o seizure disorder in setting of heavy alcohol use in past
* s/p partial splenectomy [**2081**]
* hypertension
* hyperlipidemia
* h/o polyneuropathy
* h/o asthma (not using inhalers currently)
* s/p incisional hernia repair with mesh
Social History:
Social history: Lives with partner, [**Name (NI) **]. Does not work but
previously worked in general labor. Prior smoking history but
quit 25 years ago. Drinks [**12-23**] alcoholic beverages in moderation
most days per week but not all. Smokes marijuana daily. No
injection drug use.
Family History:
Family history: Mother with DM and colon cancer. Father with
prostate cancer.
Physical Exam:
VS: T=99.4 BP=150/91 HR=66-71 RR=16 O2 sat= 96% on RA
GENERAL: NAD, AOx3, somewhat flat affect
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: No LAD, supple
CARDIAC: RRR, + mechanical S2, III/VI WEM, loudest at LUSB but
heard throughout, no audible S3
LUNGS:CTAB
ABDOMEN: Soft, NT/ND, NABS
Extremities: Erythema, swelling and warmth of lateral aspect of
right ankle surrounding medial malleolus and anterior surface of
foot, slightly TTP, no open wound. Ankle dorsiflexion &
plantarflexion both active & passive do not elicit more pain
bilaterally. DP & PT pulses 2+ BL. No other edema.
Pertinent Results:
[**2108-6-15**] 09:38PM PT-20.0* PTT-68.0* INR(PT)-1.8*
[**2108-6-15**] 06:05AM WBC-11.9* RBC-4.71 HGB-15.7 HCT-45.8 MCV-97
MCH-33.4* MCHC-34.3 RDW-15.2
[**2108-6-15**] 06:05AM GLUCOSE-79 UREA N-18 CREAT-1.0 SODIUM-140
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
[**2108-6-14**] 10:23PM WBC-12.5* RBC-5.01 HGB-16.8 HCT-48.9 MCV-98
MCH-33.5* MCHC-34.3 RDW-14.7
Brief Hospital Course:
60 y/o man with HIV/AIDS, hypertension, and prior mechanical
AVR, originally admitted with right leg pain and swelling and
new murmur shortly after having dental work without antiobitc
prophylaxis.
.
1. Right Leg Cellulitis: Patient presented with a 10cm by 15cm
erythematous region which was tender to touch and palpation on
his right lower leg, surrounding his ankle, which was felt to be
consistent with a cellulitis. He remained afebrile and his WBC
was not elevated from his baseline. Fluid collections were seen
on ultrasound and confirmed with MR. [**Name13 (STitle) **] was examined by
ortho and it was agreed there was no evidence of a septic joint.
He was started on Doxycycline and Cephalexin. The appearance of
his leg improved significantly each day of his admission, and by
the third day he had only a trace of edema and erythema. His WBC
rose on day 3, however, to > 13 (from 11) and this raised
concern about an underlying infection. Given patient??????s history
of HIV and prosthetic aortic valve, it was felt that any
underlying fluid collection could serve as a reservoir for
infection and may pose a risk to this patient. Accordingly, the
fluid collection was drained under ultrasound on the third day
of hospitalization. The procedure was tolerated well. The
patient??????s WBC count returned to baseline the day after the
drainage. He was discharged with a home course of the same
antibiotics (Cefalexin and Doxy) and scheduled for follow up at
the [**Hospital 778**] clinic shortly after discharge.
2. New SEM Murmur: On admission the patient was found to have a
III/VI SEM which was not documented in his most recent physical
exam. Accordingly, this was felt to be a new murmur, and in the
setting of a patient with a mechanical aortic valve with a
recent history of dental work without prophylactic antibiotics
the concern for endocarditis was very high. An initial TTE was
inconclusive, but showed elevated gradient across the valve.
Given the concern, arrangements were made for a TEE, which due
to the weekend schedule involved the patient being transferred
overnight to the CCU (note that the patient was stable
throughout his hospitalization, and was not transferred to the
CCU due to clinical instability). The TEE was negative. Given
the high risk of the patient, however, it was felt that after
the current course and antibiotics are resolved, a surveillance
set of blood cultures should be performed on an outpatient
basis.
3. Anticoagulation for Prosthetic Aortic Valve: The patient was
admitted with a subtherapeutic INR after recent changes to his
daily Coumadin dose. A heparin drip was started and titrated to
ensure adequate anticoagulation. Coumadin was held pending the
patient??????s TEE, and then restarted at 3mg the night after the
procedure, and raised to his regular home dose of 5mg the day
after that. The patient??????s Coumadin was continued at 5mg but his
ritonavir, which had inadvertently been held on admission, was
restarted with the expectation that it likely boosts warfarin
effects. The patient??????s INR was 2.0 on the day of discharge,
which was considered therapeutic for his valve (therapeutic
range of 2.0 to 3.0 for newer valves, per cardiology
recommendations).
4. HIV/AIDS: CD4 Nadir < 100, most recent > 400. The patient was
continued on his ARV regimen across his hospitalization, with
the exception of his ritonavir, which was inadvertently held on
admission and then restarted on day #3. He was likely
approximately 2 days without ritonavir to boost his primary
protease inhibitor. He will continued to be followed closely as
an outpatient for his HIV care.
5. Hyperlipidemia: His outpatient statin was continued.
6. Hypertension: We continued beta blockade and the patient
remained stable and in good blood pressure control across
hospitalization.
Medications on Admission:
Medications (Reconciled with Patient)
* Metoprolol 50 mg [**Hospital1 **]
* Coumadin 5 mg daily, INR checked at [**Hospital 778**] clinic q few weeks
* Emtricitabine/Tenofovir (Truvada) 200/300 mg 1 daily
* Lipitor 10 mg daily (recently decreased from 20mg daily)
* Fosamprenavir 700 mg q12h
* Ritonavir 100 mg q12h
* Amoxicillin prn dental work - ordered but not filled this past
time
* Abacavir (Ziagen) 300 mg po q12h
* depo-testosterone IM q2weeks
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for insomnia/agitation.
Disp:*15 Tablet(s)* Refills:*0*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
8. Fosamprenavir 700 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
9. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
Disp:*12 Capsule(s)* Refills:*0*
11. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. Cellulitis, RLE
SECONDARY:
1. HIV/AIDS
2. Mechanical Aortic Valve
3. Hypertension
4. Hyperlipidemia
Discharge Condition:
Improved. Vital signs stable and patient ambulating well
Discharge Instructions:
You were admitted for cellulitis of your right lower leg as well
as concern for endocarditis. A transesophageal echocardiograph,
which is an ultrasound that can look closely at your heart,
determined that you did not have endocarditis. Your cellulitis
was treated with two antibiotics: Cephalexin and Doxycyclin. You
should continue both of these medications after you are
discharged. Please take 1 tab of the Cephalexin every 6 hours
for 6 more days (until [**2108-6-25**]). Please take the 1 tablet
of the Doxycycline (100mg) twice every day for 6 more days
(until [**2108-6-25**]).
During your stay we stopped your Coumadin temporarily and used
other medications to thin your blood. We started you back on
Coumadin before you were discharged, and you should continue to
take your regular dose of 5mg every day until you see your
primary care physician. [**Name10 (NameIs) **] should resume all of the other
medications you were on before coming to the hospital.
We have arranged for you to see Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 103217**] at the [**Hospital 778**]
Clinic on the day after discharge, Wednesday, [**6-20**] at 11:20am.
He should examine your foot and check your white blood cell
count as well as your INR. He may want to adjust your Coumadin
dose.
Please call your physician or return to the emergency department
if you experience any of the following: increased pain, swelling
or warmth in your right lower leg; fevers above 100.4; shortness
of breath, chest pain; nausea, vomiting or diarrhea, or any
bloody stool; bleeding from the site on your right leg where
fluid was withdrawn; increased weakness, light-headedness, or
any loss of consciousness; or any other concerning symptoms.
Followup Instructions:
We have made a follow up appointment for you to see your
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 103217**], at the [**Hospital 778**] Clinic, on Wednesday
[**2108-6-20**] at 11:20 AM. His office is located at the [**Hospital1 9060**] Center, [**Street Address(2) 6421**], [**Location (un) 86**], MA, and
his office can be reached at [**Telephone/Fax (1) 798**].
In addition, we have made a follow up appointment for you with
your cardiologist, Dr. [**Last Name (STitle) **], for Tuesday, [**7-3**], at
1:45PM.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6661
} | Medical Text: Admission Date: [**2189-12-29**] Discharge Date: [**2190-1-26**]
Date of Birth: [**2142-10-18**] Sex: F
Service:
CHIEF COMPLAINT: Respiratory distress
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
female with human immunodeficiency virus with a CD4 nadir of
150 and a CD4 count of 443 and a viral load of less than 50
in [**2189-9-17**], as well as history of intravenous drug
use, chronic obstructive pulmonary disease and bipolar
disorder who presented on [**10-13**] to an outside
hospital with several weeks of cough, was treated for primary
care physician without response and transferred to [**Hospital6 1760**] for further evaluation and
treatment.
The patient had presented with several weeks of increased
cough, green sputum, low grade fever, low back pain,
weakness, bilateral hand swelling and non bloody diarrhea.
The patient had bilateral crackles on exam at the outside
hospital with a white blood cell count of 10.5. The patient
was treated for Pneumocystis carinii pneumonia, despite
having a CD4 count greater than 200 and being on Bactrim
prophylaxis. The patient's course was complicated by acute
renal failure, thought to be secondary to a combination of
ACE inhibitor and NSAIDS.
The patient was treated with Bactrim, prednisone, intravenous
fluids and Levaquin. A CT scan was done at the outside
hospital which revealed severe diffuse bilateral fibrosis
with honeycombing, no lymphadenopathy and no effusion.
Echocardiogram was performed which revealed ejection fraction
of 45% to 50%, concentric left ventricular hypertrophy by
atrial enlargement and pulmonary artery pressures in the 50s.
Cocaine was positive on the admission toxicology screen. The
patient was bronchoscoped in early [**Month (only) 956**] at the outside
hospital revealing rare white blood cells and rare gram
positive cocci with negative stains for fungi acid fast
bacteria and PCP. [**Name10 (NameIs) 3754**] was concern for cocaine associated
BOOP. The patient also ruled in for a non Q-wave myocardial
infarction. Her course was complicated by atrial
fibrillation with rapid ventricular response. Over the
course of the few days prior to transfer, the patient
developed increasing O2 requirement and was intubated. She
was finally transferred to [**Hospital6 2018**].
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus complicated by cryptococcal
meningitis, spinal abscess, thrush, [**Female First Name (un) 564**] esophagitis. The
patient had most recent labs in [**2189-9-17**] with a viral
load of less than 50 and a CD4 count of 443.
2. Myocarditis
3. Cervical cancer, status post total abdominal
hysterectomy/bilateral salpingo-oophorectomy
4. Recurrent pneumonia
5. Gastroesophageal reflux disease
6. Hypertension
7. Bipolar disorder
8. Chronic obstructive pulmonary disease
9. History of duodenal tumor
10. History of ruptured ectopic
MEDICATIONS FROM OUTSIDE HOSPITAL:
1. Levofloxacin 500 mg po q day
2. Bactrim Double Strength
3. Dyazide 1 po q day
4. Diflucan 200 mg po q day
5. Celexa 30 mg po q day
6. Prevacid 30 mg po q day
7. Zocor 20 mg po q day
8. Sustiva 600 mg q hs
9. Guaifenesin 1 mg po q hs
10. Premarin 0.25 mg po q day
11. Neurontin 300 mg po tid
12. Remeron 20 mg po q hs
13. Prednisone 40 mg po bid
14. Atenolol 100 mg po q day
15. Norvasc 10 mg po q day
16. Klonopin 0.5 mg po tid
17. Combivir
ALLERGIES: PENICILLIN
SOCIAL HISTORY: The patient works as a community health
educator. She lives alone. She has one daughter. Mother
lives in the area. The patient smoked one pack per day for
17 years. The patient has a history of alcohol and
polysubstance abuse. The patient uses heroin and cocaine.
FAMILY HISTORY: Breast cancer, congestive heart failure,
father with history of pulmonary fibrosis.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient had a blood pressure of 90/44,
pulse of 51 and oxygen saturation of 95%. The patient was on
ventilatory support with pressure support of 20, PEEP of 5
and FIO2 of 100%. The patient had a respiratory rate of 20.
GENERAL: The patient was intubated, sedated and in no
apparent distress.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light. Extraocular movements intact. Oropharynx
clear.
NECK: Supple with no lymphadenopathy.
CARDIOVASCULAR: Regular bradycardia, normal S1, S2 and a 1/6
systolic murmur at the left lower sternal border and patient
had jugular venous distention to 8 cm.
PULMONARY: Bilateral inspiratory rales.
ABDOMEN: Belly that was soft, nontender and nondistended
with normal bowel sounds and no hepatosplenomegaly.
EXTREMITIES: No edema.
NEUROLOGIC: Withdrawal to pain, moving all four extremities
and 3+ deep tendon reflexes with downgoing plantar reflexes.
SKIN: No rash. There was presence of needle tracks on the
forearms.
IMAGING: Chest x-ray revealed diffuse bilateral nodular
interstitial infiltrates. Chest CT from the outside hospital
revealed diffuse bilateral interstitial infiltrates with
slightly geographic distribution, mild honeycombing. These
were most prominent at the bases.
PERTINENT LABORATORY FINDINGS: The patient had arterial
blood gases with a pH of 7.35, PCO2 of 35 and P02 of 110 on
100% FIO2. The patient's white blood cell count was 7.9 with
a hematocrit of 3.4 and platelets of 132. The patient's
sodium was 138 with a potassium of 5.2, chloride of 110,
bicarbonate of 20, BUN of 71, creatinine of 1.6 and glucose
of 94. Albumin was 2.5. Calcium 8.1, magnesium 2.1, CK 55
and troponin 4.6. The patient had an LDH of 665.
SUMMARY OF HOSPITAL COURSE: On [**12-31**], the patient
underwent open lung biopsy which revealed pathology
consistent with BOOP. The patient was continued on
ventilatory support, given steroid therapy and nebulizer
treatments, as well as antibiotics. The patient continued to
have atrial fibrillation with rapid ventricular response.
The patient's course was complicated by thrombocytopenia and
anemia. The patient was taken off heparin prophylaxis and
Zantac. Low extremity ultrasounds were negative and a hit
antibody was negative.
On [**1-6**], electrophysiology was consulted and they
recommended starting the patient on a heparin infusion as
well as sotalol 80 mg po tid and Lopressor. On the 21st, the
patient was found to have low grade DIC based on labs. On
[**1-9**], the patient had a febrile episode with
hypotension. The patient had atrial fibrillation with rapid
ventricular response and was cardioverted. There was
question of ventilator associated pneumonia and the patient
was started on clindamycin.
On [**1-14**], the patient was gradually weaned to
pressure support ventilation. Steroids and sedation were
gradually weaned. On the [**12-22**], the patient underwent
PEG placement and tracheostomy. She experienced marked
agitation which was thought to be secondary to withdrawal
from tapering of the patient's sedation. The patient's
sedation was tapered more slowly and a head CT was done which
revealed no signs of intracranial hemorrhage or mass effect.
The patient's mental status gradually improved. The patient
was eventually weaned off of mechanical ventilation and
converted to trach mask. Neurology was contact[**Name (NI) **] regarding
the patient's mental status and they felt that the picture
was most consistent with benzodiazepine withdrawal.
Infectious disease was also contact[**Name (NI) **] in order to facilitate
on the patient's human immunodeficiency virus care, as she
moved to the outpatient setting. The patient was continued
on Bactrim with fluconazole. The patient had daily QTCs
monitored secondary to occasional administration of Haldol
with the patient being on sotalol.
Case management and social work followed the patient in
hospital. The patient had culture results with no growth at
the time of this dictation. Vitamin B12, TSH and cortisol
were normal during the hospitalization.
DISCHARGE CONDITION: Stable
The remainder of this dictation will be dictated as the
[**Hospital 228**] hospital course continues.
[**Last Name (LF) **],[**First Name3 (LF) **] N. M.D. [**MD Number(1) 39096**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2190-1-26**] 08:15
T: [**2190-1-26**] 08:49
JOB#: [**Job Number 39097**]
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6662
} | Medical Text: Admission Date: [**2180-5-3**] Discharge Date: [**2180-5-24**]
Date of Birth: [**2110-6-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
alcohol intoxication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 69yo M with hitory of extensive alcohol abuse(refused
detox), extensive smoking(2-3ppd) who was found down and brought
to the ED by EMS. HE was unable to relate the incidenve prior to
the event. IN thet ED, he was initially placed in observation
with hydration but developed guiac positive dark stool. He was
hemodynamically stable with stable hematocrit. He was admiited
for withdrawal and GIB. Patient refused NGT, colonoscope,
endoscopy and blood produst(patient was oriented and cognitively
appropriate)
In the ED, he was given banana bag, valium, head CT was negative
and protonix
Past Medical History:
hypertension
GERD
alcohol abuse with multiple admissin for withdrawal
Social History:
Lives in a senior communityHeavy Drinker for >40 yearsTob
2ppdformer mailman.No familyFriend [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 96052**] takes care of
his cats[**Telephone/Fax (1) 99557**]
Family History:
NC
Physical Exam:
GEn-A+O x3, lethargic, smells of ETOH, tremulous
HEENT-poor dentition
CV-tachycardic, no r/m/g
resp-course breath sounds, decreased BS bilaterally
[**Last Name (un) 103**]-thin,soft, NT/ND, small liver, no splenomelagy
ext-palmar erhythema,
neuro-tremulous, A+O x3, moves all feet
Brief Hospital Course:
69 yo M with extensive alcohol abuse admitted yet [**Last Name (un) 7162**] for
alcohol intoxication and now has guiac positive stool and
hemodynamically stable. He had a witnessed aspiration on the
floor and then was transferred to the MICU for resp failure.
.
# Resp failrue: the aptient has a large aspiration PNA while on
the floor during a period of decreased MS. [**Name13 (STitle) **] was initially on 3
days of decadron for airway edema. He was covered with clinda
and Ceftazidime (since his sputum grew pseudomonas). He has
completed a 14 day course. He was very difficult to wean from
the vent intially mainly because of agitation and copious
secretions. He was extubated on [**5-15**] following which he had a
strong cough to clear secretions and only required 2 L NC. On
[**5-18**] pt was called out to the floor from the MICU in stable
condition after extubation, but was returned to the MICU 18
hours later and reintubated for emergent bronchoscopy due to a
collapsed right lung from a right mainstem bronchus mucus plug.
The plug was removed and the pt was extubated the following day.
He had aggressive chest PT and was stable from a respiratory
standpoint from that time until discharge.
.
# alcohol intoxication - He is no longer withdrawing. He was
placed on Valuim for agitation initially while intubated which
should be decreased and/or stopped before discharge.
.
#GIB: one episode of melena; likely from upper(varices, [**Doctor First Name 329**]
[**Doctor Last Name **], gastritis etc due to alcohol). patient refused
scopes/blood product/lavage. HCT stable since admission and
increased today. Continue aggressive nutrition, consider
checking Fe studies.
.
# hypertension: on ACE-inhibitors, Lopressor as an outpt.
Continuing outpt meds.
.
# No active family or healch care proxy
Medications on Admission:
accupril
ranitidine
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale units Injection ASDIR (AS DIRECTED).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation Q4H (every 4 hours) as needed.
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Eight (8)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous Q8H (every 8 hours) for 6 days: Until
[**5-24**].
11. Quinapril HCl 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
alcohol withdrawal
aspiration pneumonia
hypertension
Discharge Condition:
stable, afebrile
Discharge Instructions:
Please seek medical attention for fevers>101.4, or for anything
else medically concerning.
Please stop drinking alcohol.
Please take your medications as directed.
Followup Instructions:
please see your pcp [**Last Name (NamePattern4) **] [**1-9**] weeks for follow-up
ICD9 Codes: 5070, 5789, 5180, 2765, 496, 2859, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6663
} | Medical Text: Admission Date: [**2116-8-10**] Discharge Date: [**2116-8-19**]
Date of Birth: [**2048-2-1**] Sex: M
Service:
CHIEF COMPLAINT: Sigmoid perforation.
HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old
male brought to [**Hospital1 69**] by
[**Location (un) **] for sigmoid perforation. The patient has no
pneumoperitoneum. The patient has had pain in the morning in
his lower abdomen. The patient has also had fever and
chills. The patient went to [**Hospital3 22439**], where a CT
was performed, which showed 6 cm x 6 cm mass with air next to
the sigmoid colon. The patient was medflighted to the
[**Hospital3 22439**] to [**Hospital1 69**].
On the way, NG tube was placed due to vomiting.
PAST MEDICAL HISTORY: The patient has a history of
diverticular disease and hypertension.
MEDICATIONS ON ADMISSION: The patient is on the following
medications at home:
1. Cardura.
2. Toprol XL.
3. Protonix.
4. Paxil.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature 101. Heart rate 112. Blood pressure 171/80.
Respirations: 28, 99% on nonrebreather mask. GENERAL: The
patient appears to be in mild distress. HEENT:
Normocephalic, atraumatic, pupils equal, round, and reactive
to light. Extraocular muscles are intact. Oropharynx clear.
Neck was supple. There was no lymphadenopathy. Chest was
clear to auscultation bilaterally, no wheezes, rhonchi, or
crackles. CARDIOVASCULAR: The patient is tachycardiac; no
murmurs; normal S1 and S2, no S3 or S4. ABDOMEN: The
patient is diffusely tender in the lower quadrants, more so
than in the upper quadrants. The patient displays rebound
tenderness and guarding. EXTREMITIES: Symmetrical. No
clubbing, cyanosis or edema. SKIN: Warm and moist.
NEUROLOGICAL: The patient is alert and oriented times three.
Otherwise, the neurological system is intact.
EKG was performed. The patient was in sinus rhythm with no
ischemic changes. Chest x-ray showed no free air in the
abdomen. A new CT was performed because the CT from
[**Hospital3 22439**] did not have the correct name. The name
on the film was [**First Name8 (NamePattern2) **] [**Known lastname 986**], as opposed to
[**Known firstname 3065**] [**Known lastname 986**]. New CT indicated a sigmoid perforation.
The patient was admitted and immediately sent to the
operating room, where a partial colectomy and colostomy with
Hartmann pouch was performed. The patient was placed on IV
antibiotics including Ampicillin, Gentamicin, and Flagyl.
After the surgery was complete, the patient was transferred to
the Surgical Intensive Care Unit having had no apparent
complications from the operating room. The patient was
immediately extubated and placed on nasal cannula. While
in the ICU, the patient experienced a decrease in the urine
output for which he received multiple IV fluid boluses, which
resolved the urine outpatient problems. The patient's
hypertension was controlled with Lopressor. As the patient
had quite a bit of pain, he was controlled with a morphine
PCA, which had the side effect of causing him to be somewhat
confused and caused visual hallucinations. The patient was
also treated with subcutaneous heparin, having had a history
of DVT. The patient was transferred to the floor on
postoperative day #4, where he was left on telemetry to
monitor the cardiac function. While on the floor, he
developed periodic visual hallucinations associated
with his pain medications. This resolved with d/c of narcotis.
While on the floor, he slowly began to improve. He started to
put out gas and stool through his ostomy and the patient was
placed on clears and then a regular diet, which he tolerated
well. Urine output continued to be maintained adequately.
The patient was also placed on some Lasix to try to decrease
edema caused by the earlier fluid boluses that he had
received.
The patient was also visited on a number of occasions by an
ostomy nurse who was pleased with the patient's ability to
care for his ostomy. The ostomy remained pink and
healthy-appearing with only a minimal amount of necrotic
tissue, which was actively sloughing. The patient was also
seen by the Department of Physical Therapy on a number of
occasions, who were pleased with his physical ability and
ability to ambulate comfortably. The patient has also been
seen by the Department of Nutrition who has indicated to him
that it would be alright for him to enjoy a regular diet.
The patient was changed from antibiotic therapy of Ampicillin,
Gentamicin, and Flagyl to PO Levaquin and Flagyl. The patient
will be discharged on [**2116-8-19**]. The patient is in stable
condition. He and his wife strongly preferred the patient's
recuperation in [**State 531**] where they live. He will be driven
home by his wife. The patient and his wife have made
follow-up appointments with the VNA for ostomy care, his
PCP and [**Name Initial (PRE) **] surgeon where he will have his colostomy taken down
sometime in the future.
The patient will be discharged on the following medications:
DISCHARGE MEDICATIONS:
1. PO Levaquin.
2. PO Flagyl.
The patient will also be sent with copies of his records and
CT scan to aid in his follow up care in [**State 531**].
FINAL DIAGNOSIS: Sigmoid perforation of diverticulum status
post partial colectomy with colostomy and Hartmann pouch.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Last Name (NamePattern1) 44041**]
MEDQUIST36
D: [**2116-8-18**] 11:20
T: [**2116-8-18**] 11:27
JOB#: [**Job Number 44042**]
ICD9 Codes: 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6664
} | Medical Text: Admission Date: [**2156-8-23**] Discharge Date: [**2156-8-26**]
Date of Birth: [**2087-10-23**] Sex: M
Service: [**Hospital 11212**] [**Hospital6 733**] Firm
HISTORY OF PRESENT ILLNESS: The patient was a 68-year-old
gentleman with a history of stage IV colon cancer metastatic
[**Known firstname **] lung and liver who was transferred from a nursing home
status post developing tachypnea, hypoxia [**Known firstname **] 80% on room air,
and a change in mental status.
The patient was seen in the Emergency Department and was
hypotensive with blood pressures of 80/47 and a respiratory
rate in the 30s. The patient was in moderate respiratory
distress, and chest x-ray showed a retrocardiac density. The
patient was persistently hypotensive despite multiple fluid
boluses. Antibiotics were started. The patient was started
on pressors and intubated with an arterial blood gas on room
air of a pH of 7.21, a PCO2 of 60, and a PO2 of 86.
The patient's oncologist (Dr. [**First Name (STitle) **] from [**Hospital 10908**] was contact[**Name (NI) **] in order [**Known firstname **] gain more information on the
patient's stage IV colon cancer. Apparently, the patient
refused any further treatment about six months ago and
desired [**Known firstname **] be do not resuscitate/do not intubate. The
patient's course was also discussed with the family, and it
was decided [**Known firstname **] make the patient comfort measures only. The
patient was subsequently extubated on [**2156-8-25**].
Pressors were weaned off, and morphine drip was started. The
patient remained comfortable and in no apparent distress and
was transferred out of the Intensive Care Unit [**Known firstname **] the general
medical floor.
PAST MEDICAL HISTORY:
1. Stage IV colon cancer widely metastatic [**Known firstname **] lung and
liver. A computerized axial tomography on [**2156-8-5**]
showed a left pleural effusion, bilateral lung nodules, and
liver enlargement with increasing new liver masses, left
adrenal nodule, left moderate-[**Known firstname **]-severe hydronephrosis
secondary [**Known firstname **] retroperitoneal lymph nodes. The patient is
status post gastrojejunostomy tube placement secondary [**Known firstname **]
dysphagia and failure [**Known firstname **] thrive.
2. Hypertension.
3. Hypercholesterolemia.
4. Right cerebrovascular accident.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient's temperature was 96.9 degrees
Fahrenheit, his blood pressure was 70s [**Known firstname **] 80s/30s [**Known firstname **] 40s, his
heart rate was 60s [**Known firstname **] 70s, and his oxygen saturation was 96%
on room air. In general, the patient was not arousable. Not
responsive [**Known firstname **] pain, but he appeared comfortable. Head, eyes,
ears, nose, and throat examination revealed nonreactive
pupils but equal. The mucous membranes were dry. Neck
examination revealed no jugular venous distention. Pulmonary
examination revealed coarse rhonchi throughout the lung
fields. Cardiovascular examination revealed a regular rate
and rhythm. Normal first heart sounds and second heart
sounds. No murmurs, rubs, or gallops. The abdomen was
distended, notable bowel sounds, and jejunostomy tube in
place. Extremity examination revealed 3+ pitting edema [**Known firstname **]
the lower extremities. Neurologic examination revealed
pupils were nonreactive. Positive corneal reflexes.
Negative doll's eyes. The patient did not withdraw [**Known firstname **] pain.
Negative Babinski.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was a
68-year-old gentleman with metastatic stage IV colon cancer
admitted with respiratory distress, hypotension, hypoxia,
acute renal failure, and unresponsiveness.
The patient was made comfort measures only; per family's
wishes. The patient was extubated. Pressors were withdrawn.
A morphine drip was started. The patient was comfortable and
in no apparent distress.
The patient expired on [**2156-8-26**] with the time of death
being approximately 11:15 in the evening. The patient was
examined by night float resident. The patient's family
friend [**First Name8 (NamePattern2) **] [**Name (NI) 724**]) was notified of the patient's death. She
helped [**Known firstname **] interpret this information [**Known firstname **] the patient's son who
was [**Name (NI) 46396**] only. The patient's attending was
contact[**Name (NI) **]. The patient's family declined autopsy.
The immediate cause of death was cardiopulmonary arrest
secondary [**Known firstname **] stage IV metastatic colon cancer.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 4937**]
MEDQUIST36
D: [**2156-9-3**] 15:12
T: [**2156-9-6**] 09:30
JOB#: [**Job Number 50099**]
ICD9 Codes: 5070, 5849, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6665
} | Medical Text: Admission Date: [**2163-3-24**] Discharge Date: [**2163-3-26**]
Service: MEDICINE
Allergies:
Pneumovax 23
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
88yo F Russian speaking woman with dCHF, s/p AVR 3 years ago,
SSS with baseline HR in the 40s, feeling week and tired today
with heart rates in the 30s. Patient has had "good days" and
"bad days" with some days feeling very tired and fatigued and
other days feeling more energetic. Today, patient felt
especially tired. Noted dyspnea on exertion and some accompanied
chest pressure with exertion and nausea. No dizziness,
diaphoresis, syncope, blurred vision. Patient called Dr [**Last Name (STitle) 171**]
and he requested direct admission from home. Denies any fevers
or chills but does endorse ~5lbs weight loss over the past
several months and decreased appetite.
.
On arrival to the floor, patient felt tired. Denied any current
nausea, SOB, or CP. However systolic BP was 90-100. Her HR was
20-30 bpm. On going to the bathroom she described chest pain,
[**5-26**], mild substernal with no radiation, that is not positonal
and is new for her. She complained of some mild headache and
continued to have some baseline orthopnea. Labs were drawn and
she was admitted to the CCU to be started on a low dose dopamine
infusion and is due for PPM implantation in the AM.
.
REVIEW OF SYSTEMS
As above, also denies abdominal pain, diarrhea, urinary
frequency, dysuria, lower extremity edema, cough.
.
Past Medical History:
1. CARDIAC RISK FACTORS: DM, hyperlipidemia, HTN
2. CARDIAC HISTORY:
-Aortic stenosis s/p bioAVR [**2-24**]
-Diastolic Heart Failure (EF >75%)
-CABG: CAD s/p single-vessel CABG [**2-24**] (SVG-PDA)
3. OTHER PAST MEDICAL HISTORY:
NASH
GERD
Reducible umbilical hernia
Social History:
Widowed, lives in [**Location 86**] with family nearby. Has VNA 3x/wk.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
Family hx of heart disease in many members, unable to specify
what kind, otherwise non-contributory.
Physical Exam:
ADMISSION exam:
VS: T=94.5 BP=117/44 HR=34 RR=16 O2 sat=98%RA
GENERAL: WDWN woman in NAD.
HEENT: MMM. PERRL, EOMI.
NECK: No JVD
CARDIAC: Bradycardic with 3/6 harsh systolic murmur heard
throughout precordium, nl S1 S2, no S3 or S4
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM
EXTREMITIES: No c/c/e. 2+DP b/l
DISCHARGE EXAM:
P62 98% 120/87
GENERAL: WDWN woman in NAD.
HEENT: MMM. PERRL, EOMI.
NECK: No JVD
CARDIAC: Bradycardic with 3/6 harsh systolic murmur heard
throughout precordium, nl S1 S2, no S3 or S4
LUNGS: CTAB, no crackles, wheezes or rhonchi. CDI PM dressing
over left anterior chest wall.
ABDOMEN: Soft, NTND. No HSM
EXTREMITIES: No c/c/e. 2+DP b/l
Pertinent Results:
ADMISSION LABS:
[**2163-3-24**] 10:13PM BLOOD WBC-6.5 RBC-2.60* Hgb-8.4* Hct-23.5*#
MCV-91 MCH-32.2* MCHC-35.6*# RDW-13.4 Plt Ct-185
[**2163-3-24**] 10:13PM BLOOD PT-10.9 PTT-32.1 INR(PT)-1.0
[**2163-3-24**] 10:13PM BLOOD Glucose-124* UreaN-83* Creat-2.7*#
Na-129* K-6.6* Cl-99 HCO3-20* AnGap-17
[**2163-3-24**] 10:13PM BLOOD CK-MB-3 cTropnT-0.02*
[**2163-3-24**] 10:13PM BLOOD Calcium-7.9* Phos-5.9*# Mg-2.6
DISCHARGE LABS:
[**2163-3-26**] 07:36AM BLOOD WBC-5.5 RBC-2.71* Hgb-8.9* Hct-24.2*
MCV-90 MCH-32.9* MCHC-36.7* RDW-13.0 Plt Ct-213
[**2163-3-26**] 07:36AM BLOOD Glucose-125* UreaN-44* Creat-1.6* Na-141
K-4.6 Cl-106 HCO3-27 AnGap-13
[**2163-3-26**] 07:36AM BLOOD Calcium-8.3* Phos-4.5 Mg-2.3
ECG
On admission the ECG showed extreme sinus bradycardia, with a
junctional or fascicular escape rhythm (rate 30-40 bpm)having a
RBBB, left axis deviation. This represented a marked change
from previous ECGs that showed NSR or sinus bradycardia with
short-normal PR interval, and minor, nonspecific
intraventricular conduction delay, with QRS duration 110-120
msec.
TTE [**2163-3-24**]:
The left atrium is elongated. The right atrium is moderately
dilated. The estimated right atrial pressure is at least 15
mmHg. The left ventricular cavity is unusually small. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). There is a mild resting left ventricular
outflow tract obstruction. A mid-cavitary gradient is
identified. The right ventricular cavity is mildly dilated with
normal free wall contractility. The aortic valve is not well
seen. A bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. No aortic regurgitation is seen. Mild to moderate
([**1-17**]+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2162-12-8**],
the aortic valve gradient and max TR gradeint are higher however
they were probably underestimated on the prior study.
CXR [**2163-3-26**]:
There has been placement of new left-sided pacemaker with the
distal lead tips in the right atrium, right ventricle and
appropriately sited. Median
sternotomy wires are again seen. There are low lung volumes with
crowding of the pulmonary vascular markings. There is mild
pulmonary vascular congestion. Heart size is enlarged but
stable. No large areas of consolidation are seen. There are no
pneumothoraces.
Brief Hospital Course:
HOSPITAL COURSE: 88yoF, Russian speaking, dCHF (preserved EF),
s/p AVR 3 years ago, presenting with symptomatic bradycardia and
some CP on ambulation. Transferred to CCU for dopamine infusion
and PPM placement, tolerated the procedure well and was
discharged home.
.
# Syptomatic bradycardia: Pt with hx of SSS w/o pacemaker as she
had previously been asymptomatic, now with fatigue, DOE and HR
in the 30s. SBPs were in 90s and the pt had CP but she was alert
and interactive. However, EKG and troponins did not suggest any
ischemia and the patient went for ppm placement. Patient
tolerated procedure well with improvement in her HR and systolic
pressures, she had resolution of symptoms with pacer placement.
Post procedural CXR demonstrated no effusions or pneumothroax
and correct placment of leads.
.
# Hypotension: Patient had episode of hypotension to the 90s and
concurrent chest pain. There were no other symptoms or
laboratory abnormalities. Amlodipine, enalapril were transiently
held and started her on dopamine infusion at 5/hr and gave
250+500cc of IV NS. This was felt to be related to her
bradycardia and improved after placer placement.
# Chronic Diastolic Heart Failure: Patient had no symptoms or
exam findings suggestive of an acute exacerbation though did
have pulmonary edema noted on CXR and hyperkalemia. She was
given IV lasix dose x1.
.
# [**Last Name (un) **]: patient presented with a Cr of 2.7, with a K of 6.6 and
Na of 129. Felt to be prerenal in the setting of poor forward
flow and kidney hypoperfusion. Hyperkalemia was treated with
calcium gluconate, kayexcelate, insulin and fluids. Cr improved
to 2.4 in after pacer placement.
# CAD: pt had CP but cardiac enzymes and EKG were negative for
signs of ischemia. We continued ASA 81 and atorvastatin
# DM: stable. Last Hba1c 6.5, Oral antihyperglycemics were held
on admission and patient was discharged on home metformin and
glipizide.
# Dementia: stable. We continued donepezil 10mg
# GERD: stable. We continued omeprazole
.
TRANSITIONAL ISSUES:
-patient is a full code, this should be readressed.
Medications on Admission:
Amlodipine 5mg daily
Aspirin 81 mg/day
glipizide 2.5 mg/day
metformin
atorvastatin 20 mg/day
donepezil 10 mg/day
enalapril 15 mg/day
furosemide 30 mg/day
esomeprazole
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*64 Tablet(s)* Refills:*0*
4. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 2 days.
Disp:*6 Capsule(s)* Refills:*0*
5. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
6. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
7. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. esomeprazole magnesium Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Symptomatic bradycardia due to sinus node dysfunction (normal AV
conduction). Treated with implantation of permanent pacemaker.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms [**Known lastname **],
You were admitted to [**Hospital1 18**] for a slow heart beat. A pacemaker
was placed that will help keep your heart beating at an
acceptable rate. You will need to take antibiotics until Sunday
[**2163-3-28**]. A prescription is below.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
While you were here we made the following changes to your
medications:
We STARTED you on Keflex (antibiotic)
We STARTED Acetaminophen (as needed for pain)
.
We STOPPED Your amlodipine
We STOPPED Your enalapril
We STOPPED Your furosemide
.
.
We made no other changes to your medications.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2163-3-31**] at 9:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2163-4-14**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2163-6-7**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4280, 2767, 2724, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6666
} | Medical Text: Admission Date: [**2147-12-8**] Discharge Date: [**2148-1-2**]
Date of Birth: [**2114-10-13**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p MVC with injuries
Major Surgical or Invasive Procedure:
[**2147-12-9**]: Traction pin to LLE
[**2147-12-9**]: 1.IM nail right femur, 2.Closed reduction right pilon
fracture, 3.Application multiplanar external fixator,
4.Operative treatment of left subtrochanteric femur fracture
with intramedullary nail, 5.Washout and debridement, left open
femur fracture wound, 6.Treatment of left femoral shaft fracture
with IM implant.
[**2147-12-12**]: IVC filter placement, I&D Left open femur fx
[**2147-12-22**]: ORIF Right pilon fx
History of Present Illness:
Mr. [**Name13 (STitle) 27294**] is a 33 year old man who was invoved in a high speed
rollover motor vehicle crash on [**2147-12-8**]. He was trapped under
his car for 30 minutes with a GCS of 3 He was taken by
[**Location (un) **] to [**Hospital1 18**] for further care and treatment.
Past Medical History:
denies
Social History:
Works as a forklift operator
Lives with wife
Family History:
n/a
Physical Exam:
Upon admission
Intubated
Cardiac: Regular rate rhythm
Chest: No crepitus, equal but decreased breath sounds
Abdomen: Soft nontender nondistended
Extremities: In cervical collar
Left arm, large laeration over dorsum of left hand
Bilateral LE: Thighs grossly swollen, L lateral thigh with open
laceration around 2 cm in lenght, Right lower extremity
externall rotated to 90 degrees, Right ankle grossly unstable,
RLE pappable DP, Doppler PT weak, LLE no DP doppler PT
Pertinent Results:
[**2147-12-25**] 10:35AM [**Month/Day/Year 3143**] WBC-8.3 RBC-3.25* Hgb-9.6* Hct-28.3*
MCV-87 MCH-29.6 MCHC-33.9 RDW-14.2 Plt Ct-666*
[**2147-12-23**] 10:31AM [**Month/Day/Year 3143**] WBC-12.1* RBC-3.37* Hgb-10.1* Hct-29.4*
MCV-87 MCH-30.0 MCHC-34.4 RDW-14.5 Plt Ct-677*
[**2147-12-19**] 06:07AM [**Month/Day/Year 3143**] WBC-12.4*# RBC-3.14* Hgb-9.8* Hct-27.4*
MCV-87 MCH-31.2 MCHC-35.7* RDW-15.0 Plt Ct-610*#
[**2147-12-13**] 06:37AM [**Month/Day/Year 3143**] WBC-7.6 RBC-3.03*# Hgb-9.0*# Hct-26.7*#
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.4 Plt Ct-206
[**2147-12-12**] 06:50AM [**Month/Day/Year 3143**] WBC-7.9 RBC-2.26* Hgb-7.1* Hct-19.5*
MCV-86 MCH-31.4 MCHC-36.4* RDW-14.2 Plt Ct-149*
[**2147-12-11**] 05:45PM [**Month/Day/Year 3143**] Hct-21.2*
[**2147-12-11**] 01:30PM [**Month/Day/Year 3143**] Hct-20.8*
[**2147-12-11**] 07:57AM [**Month/Day/Year 3143**] WBC-8.9 RBC-2.63* Hgb-8.0* Hct-22.6*
MCV-86 MCH-30.5 MCHC-35.6* RDW-13.9 Plt Ct-134*
[**2147-12-11**] 05:00AM [**Month/Day/Year 3143**] WBC-9.3 RBC-2.32* Hgb-7.2* Hct-20.0*
MCV-86 MCH-30.9 MCHC-36.0* RDW-14.2 Plt Ct-135*
[**2147-12-10**] 01:15PM [**Month/Day/Year 3143**] WBC-9.0 RBC-2.35* Hgb-7.5* Hct-20.5*
MCV-87 MCH-31.9 MCHC-36.7* RDW-13.4 Plt Ct-143*
[**2147-12-10**] 03:13AM [**Month/Day/Year 3143**] WBC-8.4 RBC-2.61* Hgb-8.1* Hct-22.9*
MCV-88 MCH-31.2 MCHC-35.5* RDW-13.5 Plt Ct-154
[**2147-12-9**] 02:28PM [**Month/Day/Year 3143**] WBC-9.1 RBC-3.38* Hgb-10.5* Hct-29.4*
MCV-87 MCH-31.0 MCHC-35.6* RDW-13.5 Plt Ct-213
[**2147-12-9**] 04:54AM [**Month/Day/Year 3143**] WBC-8.0 RBC-3.96* Hgb-12.0* Hct-34.8*
MCV-88 MCH-30.4 MCHC-34.6 RDW-13.5 Plt Ct-214
[**2147-12-9**] 01:11AM [**Month/Day/Year 3143**] WBC-11.6* RBC-3.93* Hgb-12.1* Hct-34.3*
MCV-87 MCH-30.9 MCHC-35.4* RDW-13.5 Plt Ct-216
[**2147-12-11**] 07:57AM [**Month/Day/Year 3143**] Neuts-75.7* Lymphs-13.4* Monos-5.9
Eos-4.9* Baso-0.2
[**2147-12-23**] 10:31AM [**Month/Day/Year 3143**] Glucose-133* UreaN-7 Creat-0.7 Na-130*
K-4.2 Cl-94* HCO3-25 AnGap-15
[**2147-12-19**] 06:07AM [**Month/Day/Year 3143**] Glucose-102 UreaN-12 Creat-0.7 Na-133
K-4.4 Cl-97 HCO3-26 AnGap-14
[**2147-12-12**] 06:50AM [**Month/Day/Year 3143**] Glucose-104 UreaN-8 Creat-0.7 Na-138
K-3.5 Cl-103 HCO3-28 AnGap-11
[**2147-12-11**] 05:00AM [**Month/Day/Year 3143**] Glucose-109* UreaN-8 Creat-0.8 Na-136
K-3.7 Cl-102 HCO3-29 AnGap-9
[**2147-12-10**] 01:15PM [**Month/Day/Year 3143**] Glucose-138* UreaN-12 Creat-0.9 Na-129*
K-4.2 Cl-99 HCO3-26 AnGap-8
[**2147-12-10**] 03:13AM [**Month/Day/Year 3143**] Glucose-148* UreaN-13 Creat-0.8 Na-134
K-4.2 Cl-103 HCO3-26 AnGap-9
[**2147-12-9**] 02:28PM [**Month/Day/Year 3143**] Glucose-150* UreaN-9 Creat-0.7 Na-139
K-4.3 Cl-108 HCO3-23 AnGap-12
[**2147-12-9**] 04:54AM [**Month/Day/Year 3143**] Glucose-113* UreaN-10 Creat-0.8 Na-143
K-3.5 Cl-108 HCO3-21* AnGap-18
Brief Hospital Course:
Mr. [**Name13 (STitle) 27294**] presented to [**Hospital1 18**] via [**Location (un) **] on [**2147-12-8**] after a
motor vehicle crash in which he was ejected and pinned under the
car. He was intubated at the scene. He was seen by the trauma
surgery service and was consulted on by orthopaedics and plastic
surgery.
Injuries:1. Left open femur fx, 2. Right femur fx, 3. Avulsion
of left hand with extension tendon exposure. 4. Right pilon fx.
He was admitted to the trauma intensive care unit for further
monitoring. On [**2147-12-9**] a traction pin was placed on his LLE
which resulted in return of DP/PT doppler pulses. Later that
day he was consented and prepped for surgery, he was taken to
the operating room for a IM nail right femur, Closed reduction
right pilon fracture, Application multiplanar external fixator,
Operative treatment of left subtrochanteric femur, fracture with
intramedullary nail, Washout and debridement, left open femur
fracture wound, Treatment of left femoral shaft fracture with IM
implant. He tolerated the procedure well and was taken back to
the trauma intensive care unit for recovery. He was later
extubated without difficulty. He remained hemodynamically
stable and was able to be transferred out of the trauma
intensive care unit to the floor on [**2147-12-10**]. He returned to the
operating room on [**2147-12-12**] for a washout and debridement of the
Left open femur fracture. During that procedure an IVC filter
was placed by Dr. [**Last Name (STitle) **] of trauma surgery. He tolerated the
procedure well without difficulty. He was also transfused with
2 units of packed red [**Last Name (STitle) **] cells for post-operative anemia. On
[**2147-12-15**] Mr. [**First Name (Titles) 27294**] [**Last Name (Titles) **] pressure was noted consistently high,
with his pain controlled and was started on 12.5mg daily of
lopressor, with noted effect. On [**2147-12-22**] he was taken to the
operating room for removal of the right leg ex-fix with ORIF of
ther fibula and tibia. He remained hemodynamically stable and
tolerated the procedure well. He continued to work with
physical therapy to improve his strenght and mobility.
Throughout his stay his pain was controled and his vital signs
remained within normal limits. He was discharged in stable
condition with instructions for follow up care.
Medications on Admission:
denies
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily): Hold for SBP less than 120.
7. Oxycodone 5 mg Tablet Sig: 1-4 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg syringe
Subcutaneous Q12H (every 12 hours) for 4 weeks.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Multi-trauma
Post operative anemia
Discharge Condition:
Stable
Discharge Instructions:
If you develop any swelling, redness, or drainage from your
incision, or if you have a temperature greater than 101.5 or if
you become short of breath please call the office or come to the
emergency department.
Continue to be nonweight bearing on your right leg and weight
bearings as tolerated on your left leg.
Continue your lovenox injestions as directed
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Non weight bearing
Treatment Frequency:
You may apply a dry sterile dressing to draining right ex-fix
areas.
Your staples on your right pilon fx can be removed in 4 days (14
days after surgery)
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in clinic in 2 weeks, please
call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Completed by:[**2148-1-2**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6667
} | Medical Text: Admission Date: [**2103-7-29**] Discharge Date: [**2103-8-2**]
Date of Birth: [**2046-3-31**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Hemetemesis
Major Surgical or Invasive Procedure:
endoscopy s/p banding
History of Present Illness:
57F H/O ETOH cirrhosis with known varices admitted [**2103-7-29**] with
hematemesis x3 on the prior night. +nausea during the day, then
~9pm she vomited several mouthfuls of bright red blood. She then
had an episodes of coffee ground emesis around midnight, thus
came to ED.
.
Per the patient and her husband, she tends to be chronically
hyponatremic with a Na ~130 at baseline. She also tends to have
a low BP, with SBP 80-90 when in the hospital and 95-110 out of
the hospital.
.
In the ED, her vitals were T 100.6 103 84/56 20 100%2L. she was
given 2 L NS, octreotide 50mg IV once, protonix IV once, zofran
4mg iv and ativan 1mg iv. The patient had one more episode of
hematemesis in the ED. The patient refused NG lavage.
.
Per ICU note, on arrival to the floor she was hypotensive with
sbps in the 80s. Hepatology saw her and scoped her emergently in
the CCU. Upon arrival to the MICU VS= 99.6 92/42 88 16 100%RA.
EGD revealed 4 cords of varices without active bleeding. Banding
was performed.
.
She received a total of 2U PRBCs since admission (last [**2103-7-29**]
5am), her HCT improved from 20->27->26->26->24 over 24hrs. She
is being called out to the medical floor for further management
of presumed GIB, hyponatremia and etoh cirhosis.
Past Medical History:
- ETOH cirrhosis with known varices - The patient lives in
[**State 108**] and was diagnosed with ETOH cirrhosis around 1 year ago.
She had an EGD several weeks ago that showed evidence of
esophageal varices, was tried on trial of beta blocker, but
failed secondary to hypotension. She has had 2 paracenteses in
the past and denies history of SBP, though has been on cipro in
past per her husband. She is not currently on the transplant
list. The patient reports that her last drink was when she found
out that she had liver disease.
.
denies CAD/HTN/DM/PE/DVT/cancer, beleives she had a stroke,
though not diagnosed by MD.
Social History:
Social History: Pt. lives in [**State 108**] and is here visiting her
ill mother. [**Name (NI) **] reports drinknig [**1-24**] glasses of wine a
night for years, and then for the last 4 years drinking about 3
cocktails a night. She reports not drinking since learning of
her diagnosis [**5-30**], per son prior to that was drinking 0.5
bottles wine/day x 5 yrs.
Family History:
Family history: denies family history of liver disease, DM.
Family history of CA.
Physical Exam:
Vitals: 99.3 84 94/50 24 100%RA
Gen: no acute distress
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR. NL S1, S2. 3/6 SEM loudest @ apex (first heard here)
LUNGS: crackles @ bilateral bases
ABD: Soft, distended, mild diffuse TTP, no rebound or gaurding.
negative fluid wave.
EXT: No edema. 2+ DP pulses BL
SKIN: spider hemangeomas, diffuse
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-24**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred. faint
axterixis
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
WBC-17.1* Hgb-8.6* Hct-25.7* MCV-92 Plt Ct-267
Neuts-66 Bands-5 Lymphs-23 Monos-3 Eos-1 Baso-0 Atyps-2* Metas-0
Myelos-0
Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+
Microcy-NORMAL Polychr-1+ Stipple-1+
PT-16.3* PTT-36.2* INR(PT)-1.5*
Glucose-94 UreaN-31* Creat-1.2* Na-123* K-5.5* Cl-88* HCO3-27
ALT-33 AST-53* LD(LDH)-255* AlkPhos-99 TotBili-2.0*
.
Discharge Labs:
WBC-6.3 Hgb-8.2* Hct-24.6* MCV-91 MCH-30.6 Plt Ct-148*
Glucose-84 UreaN-7 Creat-0.9 Na-133 K-3.3 Cl-100 HCO3-25
Calcium-8.0* Phos-3.2 Mg-1.3*
.
Studies:
[**2103-7-29**] EGD:
Findings: Esophagus:
Lumen: A medium size hiatal hernia was seen.
Protruding Lesions 4 cords of grade II varices were seen in the
lower third of the esophagus. The varices were not bleeding.
Stomach:
Mucosa: Diffuse continuous congestion, erythema, friability and
mosaic appearance of the mucosa with contact bleeding were noted
in the antrum, stomach body and fundus. These findings are
compatible with portal hypertensive gastroapthy.
Other procedures: 4 bands were successfully placed in the lower
third of the esophagus.
Impression: Varices at the lower third of the esophagus
Medium hiatal hernia
Congestion, erythema, friability and mosaic appearance in the
antrum, stomach body and fundus compatible with portal
hypertensive gastroapthy
(ligation)
Otherwise normal EGD to second part of the duodenum
[**2103-7-30**] CXR:
The cardiomediastinal silhouette is stable. There is increase in
distention of the azygos vein which might represent volume
overload. There is no evidence of pulmonary edema. The new
opacity in the right lower lung most likely consistent with the
right middle lobe atelectasis. There is no evidence of pleural
effusion. Rib fractures partially healed on the left are again
noted.
.
[**2103-7-30**] RUQ U/S:
No portal vein thrombosis.
1. Minimal free fluid noted in the perihepatic space not
sufficient for diagnostic or therapeutic paracentesis.
.
2. Please note the gallbladder was not visualized. In the
absence of history of cholecystectomy, this could reflect a
collapsed gallbladder obscured by overlying bowel gas. Otherwise
unremarkable abdominal ultrasound.
.
[**2103-7-31**] Liver U/S with doppler IMPRESSION:
1. 3.9 cm solid right hepatic mass. A multiphasic CT or MRI is
recommended
for further characterization.
2. Patent hepatic vasculature.
3. Trace of ascites.
4. Splenomegaly.
.
Brief Hospital Course:
57 year old female with a history of alcoholic cirrhosis with
known varices presenting with likely variceal bleed.
.
1. Upper GI Bleed: The patient has known esophageal varices.
She was initially admitted to the MICU and GI was consulted for
bleeding and an EGD was performed. Banding was done by
hepatology with no evidence of active bleeding. Her hematocrit
dropped from 25.7 to 20.8 between 11am [**7-28**] and 3am [**7-29**]. The
patient was transfused 2 units PRBC on the morning of [**7-29**] with
an increase in Hct to 27.8 A repeat Hct later in the day on [**7-29**]
was 26.2. Hct the morning of [**7-30**] was stable at 26.1. The
patient was maintained on protonix IV BID, octreotide gtt, and
sucralfate PO. She received ceftriaxone 1g QD X5 days ([**7-29**] -
[**8-2**]) for prophylaxis in the setting of a GI bleed. On the
evening of [**7-30**] the patient was transferred to the hepatology
service. Her hematocrit remained stable and she was switched to
PO protonix. On discharge she was adivsed to follow-up with a
repeat EGD in 2 weeks time, either with Dr. [**Last Name (STitle) 10285**] in [**Location (un) 86**], or
with her gastroenterologist in [**State 108**] with whom she already has
an appointment.
.
2. EtOH Cirrhosis: The patient's home rifaximin and lactulose
were held at presentation as the patient was NPO. There was no
evidence of ascites on clinical exam. Ultrasound of the liver
showed trace ascites, though not enough to be tapped. Lactulose
and rifaximin were restarted on [**7-30**]; lasix and aldactone were
initially held and restarted on [**7-31**] as the patient had developed
worsening ascities. The ascities decreased somewhat for the
remainder of her hospital stay after the diuretics were
restarted. LFTs, INR, and Tbili were monitored and decreased
from presentation to [**7-30**]. Doppler of the portal vein showed
patent hepatic vasculature.
.
3. Hyponatremia: The patient had hyponatremia at presentation
which was thought to be related to diuretic use as the patient
was on lasix QD and aldactone TID at home. This could have also
been related to dehydration as patient got several liters of NS
in the ED. There was also likely a component of
hypotonic/hypervolemic hyponatremia secondary to the patient's
known cirrhosis. The sodium increased to 129 on the morning of
[**7-30**] and further increased to 133 on the day of discharge.
.
4. Leukocytosis: The patient had a WBC of 17 on the day of
admission ([**7-29**]). There was no clear source as there were no
localizing symptoms, the patient was afebrile and CXR was
negative for any acute processes. Blood cultures were negative.
Admission urine culture grew out 3000 probable Enterococcus.
The WBC decreased to 8 on the morning of [**7-30**]. Ceftriaxone was
continued in the setting of the GI bleed. A second urine
culture collected on [**8-1**] grew out only skin flora.
.
5. Pain: The patient has a high opiate use at home (Percocet)
and repeatedly complained of pain during her MICU stay, most
often in the area of the esophagus after her EGD. She was put
on morphine 2mg IV Q3h PRN and ativan 1-2mg Q4h PRN. She also
received trazodone 50mg on the night of [**7-28**] for help with
anxiety and sleeping, and was noted by nursing to also take some
of her home pills "from her purse" which helped her to sleep.
When she was tranferred to the floor, her home medications were
held by nursing and she received oxycodone 5mg Q6H PRN and
ativan.
.
6. Chest pain: The patient reported pain in the area of the
esophagus after the EGD procedure. Her EKG was negative and it
was felt that the pain was unlikely to be related to an MI given
its longevity and initiation around time of EGD. She likely had
pain associated with the EGD and anxiety. The patient also
likely has a low pain tolerance, but high opiate requirement,
given her pain medication usage at home. There was no crepitus
on exam. Her pain regimen was continued as per above. CXR on
the morning of [**7-30**] showed no evidence of free air.
.
7. Depression: Stable during the hospital course, though likely
above her baseline given that she was in the city visiting her
ill mother before her episodes of hematemesis. Home wellbutrin
was held while she was NPO. Wellbutrin was restarted on the
afternoon of [**7-30**] when she was taking PO.
.
8. FEN: She was kept NPO for her GI bleed 24 hours after EGD and
restarted on a liquid diet on [**7-30**]. She was advanced to a
regular diet as tolerated.
.
9. Prophylaxis: DVT prophylaxis with pneumoboots
.
10. CODE: DNR/DNI
Medications on Admission:
Centrum silver
Lasix 40 mg QD
Aldactone 100mg TID
Wellbutrin 150 mg [**Hospital1 **]
Lactulose 45 mL QID
Xifaxan 400 mg TID
Milk thistle 175 mg QD
Restoril 30 mg QHS
Dulcolax
Oxycodone and ativan prn Q6H
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO QID
(4 times a day).
Disp:*5400 ML(s)* Refills:*2*
6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
11. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
end stage liver disease
cirrhosis
esophageal varices and upper GI bleed
Secondary:
Depression
Discharge Condition:
stable, pain free, hematocrit
Discharge Instructions:
You had an upper GI bleed to to a bleeding esophageal varices
from your liver cirrhosis. These were banded and you should have
a repeat endoscopy in a few weeks to evaluate the varices.
Please take all medications as directed.
Please stop taking your restoril and ativan as it may cause
excessive somnolence.
Please attend your follow-up appointments. You have an
appointment with Dr. [**Last Name (STitle) **] on [**2103-8-15**].
PLease call your doctor if you have any nausea, vomiting,
abdominal pain, fevers, bloody vomit, black or tarry stools,
bloody stools, or any other concerning symptoms.
Followup Instructions:
Please call [**Telephone/Fax (1) 463**] if you need to reschedule.
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2103-8-15**] 10:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2103-8-15**] 10:30
ICD9 Codes: 2851, 2761, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6668
} | Medical Text: Admission Date: [**2189-8-3**] Discharge Date: [**2189-8-5**]
Date of Birth: [**2149-8-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
39 year old male with DM1, h/o depression and polysubstance
abuse, Hep C who presents with lethargy and polydipsia after not
taking his insulin for 2 days. He reports that his lost his
glucometer and insulin. Over the past 2 days he developed nausea
and lethargy and polydipsia. He felt warm to the touch per his
girlfriend, but [**Name2 (NI) 15598**]'t take his temperature. He also was more
confused the evening prior to admission. He additionally
complined of [**5-21**] chest pressure, non-radiating which lasted [**2-11**]
hours. No associated SOB, cough, or urinary symptoms.
.
In the ED, T 97.6 HR 110 , BP 137/64 R 16 O2 sats 96 % on RA. K
7.0 with AG of 25, and pH 7.22 pCO2 27 pO2 103 and glucose above
the dectable range on fingerstick with a serum glucose of 753
and peaked T waves, on ECG he receieved calcium gluconate 1 amp
x1, 3 L NS, insulin 10 unit IVx1 and insulin drip at 10 units
per hour, ASA 325 mg po x1. On arrival to the ICU he reported
feeling better. Denies CP or SOB.
Past Medical History:
Past Psych History:
-Patient's Psychiatrist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78730**] at [**Hospital1 **], whom the
patient has been seeing for the past 2 years for
psychopharmacology.
-Therapist: No present therapist. Pt had been seeing [**First Name4 (NamePattern1) 1060**]
[**Last Name (NamePattern1) **] for 2 years but stopped seeing her.
-inpatient hospitalizations including [**Hospital1 **], [**Hospital1 18**],
FH. Last hospitalization [**9-15**] at [**Hospital1 18**]. Second to last
hospitalization was at Bayridge last
year- around [**9-13**]. He reports that his presentation has been
similar with each presentation with depression, SI and PSA.
-Although patient denies history of [**Last Name (LF) **], [**First Name3 (LF) **] [**First Name3 (LF) **], he has history
of multiple suicide attempts. During a past admission, he
reported cutting his wrists at 18yo, and h/o multiple o/d
attempts with most recent [**3-15**] requiring ICU stay at FH. He
reports h/o attempted asphyxiation.
-Per [**Name (NI) **], pt reports a prior diagnosis of BPAD- he denies manic
sxs, stating that he predominantly presents with "depression and
anger".
-Per [**Name (NI) **], h/o assaultive behaviors with h/o jail time for
assault and battery. He reports that his last jail sentence was
3 years ago. He denied present legal issues, stating that his
parole ended [**12-14**].
Past Medical History:
DM type 1 (poorly controlled)
Hepatitis C
Polysubstance abuse
Social History:
Currently lives with his daughter and is a plumber. Has been
sober from EtOH and substances for the last 3 years until
relapsing a few days ago with EtOH and cocaine. Former heroine
user. Quit smoking 3 yrs ago.
Family History:
Mother, Father, one brother with ETOH dependence
Physical Exam:
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender:
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**2189-8-5**] 04:28AM BLOOD WBC-4.9# RBC-4.11* Hgb-12.0* Hct-35.8*
MCV-87 MCH-29.3 MCHC-33.7 RDW-13.6 Plt Ct-163
[**2189-8-5**] 04:28AM BLOOD Glucose-187* UreaN-12 Creat-1.0 Na-137
K-4.3 Cl-112* HCO3-17* AnGap-12
[**2189-8-5**] 04:28AM BLOOD Calcium-7.3* Phos-1.8* Mg-1.5*
[**2189-8-3**] 08:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
DKA - Upon admission to the [**Hospital Unit Name 153**], the patient's diabetic
ketoacidosis was treated with IV fluids and an insulin drip.
During the course of his first 12 hours of admission, his
hyperglycemia decreased from 436 to a goal of between 100-200
with 25 units/hours insulin drip. The patient had an anion gap
of 21 in the ICU, which closed by the morning of admission. He
also received 8 liters NS IVF. After his serum glucose was
stabilized and his anion gap closed, he was converted back to
his home lantus, but at a reduced dose of 20 units SQ QHS, which
was increased to 30 units SQ QHS the morning of discharge. He
was also placed on a insulin glargine sliding scale, as
recommended by endocrinology.
Hyperkalemia - The patient had an elevated potassium up to 6.8
with ECG changes, specifically peaked T waves. He was given 1
gram of calcium gluconate and his potassium stabilized and on
the morning of discharge was 4.3.
Chest discomfort - The patient reported chest discomfort
described as pressure for 1 hour the day of admission. The pain
resolved prior to admission, and during the length of his
hospital stay he reported no similar symptoms or chest pain.
His ECG did not demonstrate any changes and his cardiac enzymes
were negative x2.
CAD - Received 81 mg ASA PO daily.
Polysubstance abuse - Urine tox screen was negative.
Depression - Received home dose of wellbutrin SR.
Hepatitis C - Stable during admission.
Medications on Admission:
Bupropion SR 150 mg 1 tab po daily
Insulin lantus 30 units SQ QHS
Insulin lispro at sliding scale dose
OTC
ASA 81 mg po daily
Multivitamin 1 tab daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
3. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
Disp:*900 units* Refills:*2*
4. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day.
Disp:*1000 units* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Diabetic ketoacidosis
Secondary
1. Hepatitis C
Discharge Condition:
good
Discharge Instructions:
You were admitted for diabetic ketoacidosis. This was due to not
taking your insulin. It is very important that you follow your
diabetic regimen including measuring your blood glucose at least
4 times a day and taking appropriate insulin.
Please return to the ED if you develop symptoms including
nausea, vomiting, or abnormally high blood glucose levels.
Please take all of your medications as directed.
Please keep all of your follow up appointments.
Followup Instructions:
You have an appointment today, [**2189-8-5**], at 2pm at the [**Hospital **]
Clinic with [**First Name9 (NamePattern2) 32887**] [**Doctor Last Name 1726**]. At that time, you will get a new
glucometer.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2189-11-13**] 11:20
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-11-2**] 4:20
Completed by:[**2189-8-5**]
ICD9 Codes: 5849, 2767, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6669
} | Medical Text: Admission Date: [**2132-1-30**] Discharge Date: [**2132-2-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12658**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 21214**] is a [**Age over 90 **]F with recent confusion and URI found to
have PE on CT in ED. Pt was seen by her PCP today for followup
of her recent hyponatremia. Pt's chronic venous stasis and leg
ulcerations were thought to look worse and possibly be infected,
so she was sent to the ED for further evaluation. There, her O2
sat dropped into 60s during her stay. A CXR was performed,
which showed RLL collapse, and a CTA showed 2 large PEs in the R
main pulmonary artery.
.
Pt denies SOB or chest pain. She states she is feeling
comfortable. She does not remember being in the ED earlier
today. She does not believe she is in [**Location (un) 86**].
.
On further questioning of pt's son, he states that she had a
recent URI, as did her husband. [**Name (NI) **] states that pt has been
talking to herself more frequently at night over the last [**3-16**]
days and has been more confused. She is usually oriented and
sharp, and she has been confused and rambling. Her PCP notes
this from their visit today, as well. [**Name (NI) 1094**] son does not recall
pt complaining of SOB or chest pain.
.
In the [**Name (NI) **], pt rec'd D50 and insulin, 2 amps bicarb, Kayexalate,
and Unasyn 3g x1. Heparin gtt started after CT angio results
returned.
Past Medical History:
Hypertension
s/p CVA [**2130**]
Atrial fibrillation
Macular degeneration
h/o Breast cancer
Social History:
Lives with husband. They have nursing care 12 hours/day.
Family History:
Non-contributory
Physical Exam:
VS: 97.7 100 126/88 20 98% NRB
Gen: cachectic, not oriented to place or person, kyphotic, no
respiratory distress
CV: tachycardic, irregularly irregular, nl S1, loud P2
Pulm: decreased breath sounds bilaterally, scattered wheezes at
LUL, no crackles
Abd: soft, distended, + BS, no masses
Ext: cold to touch; [**2-16**]+ pitting edema in lower extremities to
knees with skin changes c/w venous stasis; also with multiple
areas of ulcerated lesions, weeping sanguinous and in certain
places more purulent material; sensation intact to light touch
Pertinent Results:
131 91 41
------------< 227
5.9 30 1.2
12.2 > 15.2 < 397
45.3
N:90.4 Band:0 L:6.7 M:2.7 E:0.1 Bas:0
PT: 18.0 PTT: 31.9 INR: 1.7
EKG: 83bpm, v paced; TWI in aVL, no TWI in precordials, no
S1Q3T3
.
STUDIES:
CTA Chest: Two large acute PEs in R main pulm A; filling defect
in RLL bronchus - mucous plug vs mass; near total collapse of
RLL [**2-15**] bronchial filling defect; bilateral large pleural
effusions
.
CT head: no intracranial hemorrhage; high density air-fluid
level in L maxillary sinus, lucency in posterior wall and focal
indentation of anterior wall suspicious for fx
.
CXR: worsening bibasilar atelectasis/consolidation, with likely
complete collapse of RLL, poss PNA
.
RUE US: No DVT identified
.
UE ARTERIAL STUDY: Essentially normal arterial inflow to the
hands bilaterally.
.
RENAL U/S: Unremarkable renal ultrasound.
Brief Hospital Course:
A/P: Ms. [**Known lastname 21214**] is a [**Age over 90 **] year old female with a h/o afib
admitted for PE and RLL PNA.
# PE: She had been on coumadin chronically but became
supertherapeutic so her coumadin was held. On admission her INR
was 1.7 and CTA showed large acute pulmonary emboli in her right
main pulmonary artery. She was initially transferred to the
MICU and put on a heparin gtt. Her respiratory status remained
stable and then trasferred to Medicine for futher care. She was
transitioned to coumadin with a 2 day overlap with heparin when
the INR was therapeutic between 2 and 3. She is discharged with
coumadin 2mg daily, and she should have her INR monitored
frequently and coumadin adjusted accordingly. She did not
develop any bleeding complications.
.
# PNA: CXR showed RLL collapse, suggestive of a post-obstructive
PNA. In the MICU,s he was covered emperically with ceftriaxone,
azithromycin, and unasyn. Then her antibiotic regimen was later
changed to azithromycin (for CAP) and Zosyn (for coverage of
aspiration pneumonia). Her respiratory status was stable on
nasal cannula. She completed a 5 day course of azithromycin.
She will complete a 14 day course of zosyn upon discharge, last
date [**2132-2-15**]. Vancomycin was added to cover for potential MRSA,
and she will complete a 10 day course also on [**2132-2-15**]. She has a
PICC line in for access. For her Vanc, she is dosed 1000mg q48
hours based on her renal function at this time. She should have
her dose adjusted while in rehab. She was given xopenex for
bronchodilation; albuterol should be avoided as she is
tachycardic. Atrovent was avoided because of anticholinergic
effects, which may cause some mental status change.
.
# DELIRIUM: Likely secondary to infectious process (PNA) and
hospitalization in the elderly. She is not on any medication
that would incite mental status decline. She is not hypoxic,
and had an unremarkable ABG here. She had head CT that was
negative for bleed. Her mental status improved over her
hospital course. She should avoid narcotics and sedative
including sleeping aids at night.
.
# ABD XRAY: She had a KUB that showed possible ileus. However,
she was eating without symptoms and she had loose stools. She
should have a follow up KUB to assess if this has resolved. Her
loose stools were negative for cdiff x 2. She was on flagyl
emperically briefly but this was discontinued since she has 2
sets negative.
.
# AFIB: She is rate controlled with metoprolol 50mg tid. She is
on coumadin for anticoagulation.
.
# VENOUS STASIS ULCERS: She initially presented from PCP's
office because her venous ulcers look infected. These improved
on both legs with wound care consult. She should have dry guage
changes [**Hospital1 **], wrapped with kerlex. Of note, she looses
significant fluids from these ulcers so she might need fluid
replacement.
.
# ELBOW ULCER: She has a pressure ulcer on her right elbow that
does not look infected. This should be treated with guage and
kerlex.
.
# ARF: She does not have baseline renal disease. Urine lytes
and FENA suggested a prerenal picture. Her lisinopril was held
in this setting. She was given gentle IVF's but she still has
some renal insufficiency. She will continue to need IVF at
rehab. Renal ultrasound was unremarkable.
.
# CYANOTIC RIGHT HAND: Arterial study was normal arterial blood
flow and and ultrasound did not show DVT in her right arm.
.
# NUTRITION: She tolerates a regular cardiac diet with
supplemental Ensure TID. Her albumin is 2.2 so she is has
severe malnutrition. Would continue to enourage PO intake.
.
# CODE: DNR/DNI as discussed with pt's PCP
Medications on Admission:
lisinopril 5mg [**Hospital1 **]
atenolol 75mg daily
calcium citrate 2 tabs [**Hospital1 **]
MVI
spironolactone 25mg daily
lipitor 10mg daily
timoptic drops OU
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: Three (3) ML
Inhalation q6H PRN ().
5. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 8 days: last day
[**2132-2-15**].
6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q48H (every 48 hours) for 8 days: last day [**2132-2-15**].
7. Timoptic 0.25 % Drops Sig: One (1) drop Ophthalmic once a
day: each eye.
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY
PE
PNA
Mental status change
SECONDARY
1. Atrial fib- Patient is normally anticoagulated on coumadin.
It had been held prior to admission secondary to an elevated
INR.
2. S/P CVA one year ago in the right perisylvian region
3. Chronic venous stasis with leg ulcerations
4. Hyperlipidemia
5. S/P pacemaker placement
6. H/O breast cancer s/p mastectomy in [**2089**]
7. Macular degeneration
8. Syncopal episodes
9. S/P hip fracture with pinning [**6-/2131**]
Discharge Condition:
hemodynamically stable, afebrile
Discharge Instructions:
Please take all medication as prescribed. Keep all appointments
listed below. If you have chest pain or shortness of breath,
seek medical attention immediately. If you have any medical
questions or concerns, please call your doctor or go to the
emergency room.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] 1 week:
[**Last Name (LF) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 719**]
------------------
OTHER APPOINTMENTS:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 6197**]
Date/Time:[**2132-6-17**] 2:20
Completed by:[**2132-2-6**]
ICD9 Codes: 2767, 5849, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6670
} | Medical Text: Admission Date: [**2104-12-8**] Discharge Date: [**2104-12-18**]
Date of Birth: [**2026-12-30**] Sex: F
Service: Vascular surgery #58
This is a stat ADDENDUM to the discharge summary dictated on
[**2104-12-15**].
The patient complained of hoarseness postoperatively. She was
seen by Ear, Nose and Throat specialist on [**2104-12-16**], who felt
that there was no vocal cord paralysis. If the hoarseness
persisted more than one week, then a fiberoptic examination
was recommended.
The patient had small amounts of drainage from her groin
incision sites. She was started on Kefzol. She was screened
and accepted by [**Hospital **] Rehabilitation on [**2104-12-18**]. She was
discharged on Keflex until she followed up with Dr.
[**Last Name (STitle) **] in the office in two weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2105-1-5**] 11:55
T: [**2105-1-6**] 04:51
JOB#: [**Job Number 27198**]
ICD9 Codes: 4275, 4241, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6671
} | Medical Text: Admission Date: [**2199-11-22**] Discharge Date: [**2199-12-6**]
Service: MEDICINE
Allergies:
Captopril / Erythromycin Base / Ampicillin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
PEG tube placement
NG tube placement
History of Present Illness:
Patient is a 84 yo female with h/o diastolic CHF who presents
with dyspnea and lower extremity edema. The patient states that
she has been having increasing lower extremity edema for the
past 3 weeks. Last night, she woke up in the middle of the
night to go to the bathroom and experienced abdominal cramping.
She called the nurse [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab, who evaluated the patient
and found her to be dyspneic and satting 94% on room air. Ms.
[**Known lastname 94752**] denies orthopnea, as she states she now always sleeps on
an incline because of her C2-C4 fusion in [**Month (only) 359**]. The patient
also denies PND and states that she never felt subjectively
dyspneic. Of note, the patient states that she takes Lasix 40
mg daily and has been compliant with her medications. She also
denies eating many salty foods, but admits to frequent
consumption of soups.
.
In the ED, the patient's VS were BP 189/86, P 76, R 20, O2 74%
on 4L. She was placed on Bipap and received Lasix 80 mg IV, ASA
325 mg, was placed on a nitro gtt. An ECG demonstrated that the
patient is in AFib, which is altered from her previous baseline.
The patient diuresed 1.1L and her O2 requirement decreased to
2L. She was then admitted to [**Hospital Ward Name 121**] 3 for further workup and
evaluation.
.
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. He denies exertional buttock or calf pain. All of the
other review of systems were negative. Cardiac review of
systems is notable for absence of chest pain, dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
HTN
Diastolic CHF
Gout
Barrets
Polymyositis
Bell's Palsy (Rt)
Massive PE s/p Trendy procedure, IVC filter placement
TAH
Appendectomy
T4, T8 vertebroplasty [**2196-10-11**]
C4-C5 disectomy and hardware placement
3.9 cm infrarenal AAA
Recent BM biopsy from iliac crest
Social History:
40 pack year hx of tobacco, quit over 20 years ago, no
etoh/illict drug use; was living independently until recently;
now in [**Hospital 100**] Rehab after recent surgery; does not have much
family - is close with friends; good friend [**Name (NI) 2184**] [**Name (NI) 951**] is her
HCP
Family History:
mom with osteoporosis and heart disease, died at age 79; no
other history of heart disease
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.8, BP 160/80, P 57, R 22, O2 94% on 2L
Gen: Elderly woman, pleasant, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: R sided facial droop and ptosis. PERRL, Sclera
anicteric. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
Neck: Supple with JVD to base of ear.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. 2/6 systolic murmur best heard at L lower
sternal border. No thrills, lifts. No S3 or S4.
Chest: Kyphosis. Resp were unlabored, no accessory muscle use.
Diffuse crackles to mid-lung bilaterally
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: 3+ pedal edema bilaterally. Skin darkening in lower
extremities bilaterally. No femoral bruits.
Skin: + stasis dermatitis, no ulcers, scars, or xanthomas.
.
Pulses:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2199-11-22**] 05:20AM BLOOD WBC-12.7* RBC-3.61* Hgb-10.1* Hct-31.8*
MCV-88 MCH-28.1 MCHC-31.9 RDW-15.7* Plt Ct-456*
[**2199-11-22**] 05:20AM BLOOD Neuts-82.8* Lymphs-12.3* Monos-2.9
Eos-1.9 Baso-0.2
[**2199-11-22**] 05:20AM BLOOD PT-31.2* PTT-26.3 INR(PT)-3.2*
[**2199-11-22**] 05:20AM BLOOD Glucose-85 UreaN-28* Creat-1.5* Na-143
K-4.6 Cl-105 HCO3-30 AnGap-13
[**2199-11-22**] 05:20AM BLOOD CK(CPK)-32
[**2199-11-22**] 05:20AM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-9136*
[**2199-11-22**] 02:43PM BLOOD cTropnT-0.03*
[**2199-11-23**] 07:38AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
[**2199-11-26**] 09:44PM BLOOD Lactate-1.9
.
[**2199-12-2**] EKG - Sinus bradycardia. Left axis deviation likely due
to left anterior fascicular block. Lateral ST-T wave changes are
non-specific. Compared to the previous tracing of [**2199-11-29**] the
findings are similar.
.
[**2199-12-2**] echo - The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: No intracardiac shunt identified. Mild aortic valve
stenosis. Mild mitral regurgitation. Mild pulmonary artery
systolic hypertension.
.
[**12-1**] - echo - IMPRESSION: No hydronephrosis. Bilateral simple
renal cysts.
.
[**12-1**] PA/Lateral chest x-ray - FINDINGS: Comparison is made to
prior study of [**2199-11-27**]. There is again seen bibasilar
atelectasis and small pleural effusions. There are no signs of
overt pulmonary edema. No focal consolidation is seen. The
filter and spinal fixation hardware is again seen.
.
[**2199-11-24**] - CT chest - IMPRESSION:
1. New centrilobular "tree-in-[**Male First Name (un) 239**]" and nodular opacities in the
lower lobes and right middle lobe consistent with infection or
aspiration.
2. Moderate centrilobular upper lobe predominant emphysema.
3. Extensive moderate aortic valve calcifications of uncertain
physiologic
significance.
.
[**12-2**] - echo with bubble study - IMPRESSION: No intracardiac
shunt identified. Mild aortic valve stenosis. Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
Brief Hospital Course:
#. Hypoxia: With pulmoary engorment on CXR and elevated BNP of
9000 and new AF, the etiology of the patient's hypoxia was felt
to be acute exacerbation of diastolic dysfunction. Over the
course of her 4 day admission, the patient had been diureesed
with IV lasix with removal of 6 liters. The patient had
continued to be hypoxic during the hospitalization, and a chest
CT was obtained, showing a question of right middle and lower
lobe infitrate vs. aspiration. The patinet was started on
levofloxacin/vanc/flagyl to treat a potential pneumonia. The
patiet triggered after being noted to be hypoxic at 76% on 4L
NC, 82% on 6L NRB despite the aggressive diuresis. The patient
was transfered to the CCU for futher care.
Differential for patient's hypoxia included blossoming PNA
vs. aspiration pneumonitis vs. flash pulmonary edema with dCHF
and AF vs. PE. The patient had been significantly diureesed
during the course of the hospitalization, and on exam appeared
euvolemic to dry. Patient was not acutly hypertensive during
inciting event. Chest XR was without evidence of acute
pulmonary edema. The patient was being treated for pneumonia
and had been afebrile. Chest CT showed dependent area of
nodular opacities which could be consistent with likely
aspiration pneumonia. Patient has a history of severe
aspiration on swallow study, and felt that this would be most
likely explanation of patinet's hypoxia. PE seems less likely
given supratherapeutic INR throughout hospitalization and IVC
filter in place.
The patient's O2 requirement improved over three days. She
was given supportive nebs and a course of solumendral given
wheezes on physical exam. With high O2 requirement, pulmonary
was consulted, who agreed that aspiration pneumonitis likely
etiology to patient's hypoxia with element of chronic bronchitis
from aspiration. At the time of transfer from the unit, the
patient's antibiotics were reduced to levofloxacin/flagyl with
negative cultures, to complete a 5 day course. Her prednisone
was increased to 60 mg daily every other day.
On the floor patient was made NPO given her severe aspiration.
She completed a total of 10 day course of antibiotics for
aspiration pneumonia/pneumonitis. She underwent a PEG tube
placement to reduce the risk of aspiration which was
uncomplicated. In addition, her steroids are being decreased
back to her home dose. Patient underwent an echo with bubble
that showed no evidence of intracardiac shunt. Of discharge
patietn saturatin 94% on 4L. Goal O2 sats are 90-92% and oxygen
should continued to be adjusted to meet this goal.
.
# Coronaries: The patient has no history of coronary artery
disease, and last PMIBI without any defects. No complaints if
chest pain and no iscemic changes on EKG.
.
# Diastolic Congestive Heart: The patient presented with
elevated BNP, hypoxia, and lower extremity edema. Patient
initially was diagnosed over 6L, with continued hypoxia thought
to be secondary to aspiration as described above. Patient came
in with new atrial fibrillation possibly secondary to worsening
heart failure, with possible insufficient lasix dose or poor
dietary compliance. [**Last Name (un) **] being held in the setting of elevated
Cr. Patient was started on a CCB to help supress ionotropic
activity. Her beta blocker was continued and titrated up as
tolerated. Patient underwent a TTE with a bubble study to
evaluate for left to right shunt which was negative.
.
#. Atrial Fibrillation: The patient's ECG on admission
demonstrates atrial fibrillation, which is a new diagnosis. She
has been in and out of AF since admission, and is currently in
sinus. Likely contributing to element of acute diastolic heart
failure. She was continued on metoprolol and diltiazem was
started, both were titrated up to improve blood pressure
control. She is already anticoagulated for PEs. Coumadin was
continued with goal INR [**1-20**]. Coumadin was held in the setting of
needing to get PEG placed, however patient was transitioned with
IV heparin drip and will go back to [**Hospital1 100**] with IV heparin
bridge until INR is therapeutic again for 48 hours.
.
#. Hypertension: The patient has a history hypertension and had
BP 189/86 on admission. She was continued on metoprolol. Her
home amlodpine was held, and diltiazem was started as described
above. Her [**Last Name (un) **] was being held in the setting of ARF.
.
# Acute Renal Failure: Patient with Cr of 1.2 on admission, and
had risen to 2.1 after aggressive diuresis. Cr on day of
discharge was 1.4. Renal ultrasound demonstrated no evidence of
hydronephrosis. [**Last Name (un) **] was held secondary to rising Cr. Would
continue to hold Losartan until she follows up with her primary
care provider.
.
#. Polymyositis: The patient has a history polymyositis, for
which she takes 20 mg prednisone every other day. Her
prednisone had been increased to treat concern for COPD
exacerbation in the setting of chronic fibrotic changes
secondary to chronic aspiration after treatment with IV
solumedrol. She is being weaned back to home dose on discharge.
Currently patient recieving 40 mg PO QOD. In addition, she is on
bactrim for PCP [**Name Initial (PRE) 1102**].
.
# Hypercholesterolemia:
Continued simvastatin 10mg daily
. .
#. Aspiration. The patient is a known sevear aspirater, and has
failed passed swallow studies. The patient had been
non-compliant with restricted diet in [**Hospital **] rehab. The patient
had declined PEG in the past, but agreed on this admission given
the severity of her aspiration. Patient had PEG placed [**2199-12-5**]
with interventional radiology. Patient will continue to be NPO
on discharge with tube feeding and free water flushes through
her PEG to maintain her free water needs.
.
#. PPx: DVT: IV heparin drip until INR therapeutic for 48
hours. Goal INR [**1-20**]. If INR > 3 please hold coumadin and lower
dose by 0.5 mg. If INR between [**1-20**] do not change dosing. If INR
is < 2 for 2 days would increase dose by 0.5 mg. Continue PPi.
Colace and senna.
.
#. Code: Full Code
Medications on Admission:
Acetaminophen 325-650 mg
Simvastatin 10 mg daily
Folic Acid 1 mg daily
Calcium Carbonate 500 mg [**Hospital1 **]
Losartan 25 mg TID
Metoprolol Tartrate 50 mg TID
Furosemide 40 mg daily
Multivitamin daily
Fluoxetine 10 mg daily
Pyridoxine 50 mg daily
Prednisone 20 mg qod
Oxycodone 5-10 mg q3h prn for pain
Vitamin D 400 unit daily
Cortisone 1 % Cream TID prn
Warfarin 2 mg daily
Ipratropium Bromide INH q6h prn
Docusate Sodium 50 mg [**Hospital1 **] (liquid)
Fluticasone 110 mcg 2 puffs [**Hospital1 **]
Lidocaine 5 %(700 mg/patch) Adhesive Patch, daily
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-19**]
Drops Ophthalmic Q8H (every 8 hours) as needed.
Albuterol nebulization q6h prn
Senna 8.6 mg [**Hospital1 **]
Benzonatate 100 mg TID
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
please hold for BP < 100 HR < 55.
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for dyspnea.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
9. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain, headache, fever.
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day: please hold
for BP < 100, HR < 55.
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 days: please give 40 mg dose, only [**12-8**].
13. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER
DAY (Every Other Day): please start patient on this dose at
[**12-10**].
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day:
please hold for BP < 100 HR < 55.
15. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane TID (3 times a day).
16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: for
goal INR [**1-20**].
17. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for 3 days.
18. 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.
19. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Ativan 0.5 mg Tablet Sig: 0.5 Tablet PO three times a day as
needed for anxiety, insomnia: please hold for sedation or RR <
12.
21. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
22. Heparin (Porcine) Injection
23. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**3-24**]
hours as needed for pain: please hold for sedation or RR < 12.
24. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO three times a day.
25. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
26. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day.
27. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Hypoxia secondary to aspiration pneumonia, diastolic
heart failure
Secondary:
gout
Bell's palsy
polymyositis
massive PE and IVC filter placement
3.9 infrarenal AAA in [**2197**]
Discharge Condition:
afebrile, vital signs stable, saturing 94% on 4L
Discharge Instructions:
You were admitted to the hospital with worsening hypoxia and
lower extremity swelling. You were diagnosed with aspiration
pneumonia and treated with IV antibiotics. You were evaluated
by speech and swallow who felt that you were extremely high
aspiration risk. Given this you had a PEG tube inserted in
order to feed you more safely. While you were eating nothing by
mouth you were kept on IV fluids for maintence. You will be
able to start using your new PEG tube tonight and we have
consulted nutrition for tube feeding reccomendations for you in
the meantim. We are going to reccomend that you keep your ins
and out roughly even and adjust your lasix dose as needed to do
this. We are currently holding one of your medications which
can worsen renal function. We would reccomend that you continue
to hold this medication until you see your primary care doctor.
For your safety, we reccomend that you take NOTHING BY MOUTH as
you are at high risk to put this into your lungs. You can use
oral swabs if your mouth feels dry however you will get all of
your fluids/water through your feeding tube.
.
You should continue on the IV heparin drip until your INR > 2
for at least 48 hours. We have increased your lasix dose in
order to help maintain your urine output. This lasix dose can be
adjusted while you are at [**Hospital 100**] Rehab in order to meet goals
ins and outs even. You need to continue oxygen, and will likely
need oxygen on discharge home from rehab. Currently you are on
4L of NC. Our goal oxygen saturation for you in between 90-92%
so your oxygen can be adjusted down accordingly.
.
IV heparin drip until INR therapeutic for 48 hours. Goal INR
[**1-20**]. If INR > 3 please hold coumadin and lower dose by 0.5 mg.
If INR between [**1-20**] do not change dosing. If INR is < 2 for 2
days would increase dose by 0.5 mg.
Followup Instructions:
You should follow up with your primary care provider as
previously scheduled on discharge from [**Hospital 100**] Rehab. You should
regardless have an appointment within one month. Your PCP
number Dr. [**Last Name (STitle) 2204**], [**First Name3 (LF) **] ([**Telephone/Fax (1) 2941**].
.
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2200-6-30**] 10:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2200-6-30**] 11:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2199-12-6**]
ICD9 Codes: 5070, 5849, 5990, 4280, 5859, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6672
} | Medical Text: Admission Date: [**2166-3-3**] Discharge Date: [**2166-3-4**]
Date of Birth: [**2166-3-3**] Sex: M
Service: [**Hospital 59074**] transfer to Newborn Nursery
The patient is being transferred to the Newborn Nursery on
[**2166-3-4**].
HISTORY OF PRESENT ILLNESS: The infant is a full term, 4250
gram male infant born on [**2166-3-3**], to a 36 year old gravida
III, para II, mother. Prenatal screens were remarkable for
blood type O positive, antibody unknown, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, and GBS
negative. There was a maternal history of depression for
which mother was on Zoloft. Mother has had one previous
child who is healthy and had no issues of thrombocytopenia.
This pregnancy was reportedly uncomplicated.
Neonatal Intensive Care Unit was called to assess the patient
when the infant was noted to have bruising on the thorax and
was subsequently found to be thrombocytopenic. Mother's
platelet count was normal at 274,000.
There were no prenatal risk factors. Mother was GBS
negative. There was no maternal fever and rupture of
membranes was less than 24 hours. Maternal anesthesia was
via epidural/spinal. The infant was delivered by repeat
cesarean section with Apgar of eight and nine.
Neonatal nurse practitioner was asked to see the infant in
the Newborn Nursery for petechiae and bruising. A complete
blood count was drawn at that time, and platelet count was
reported at 5000. A repeat level was sent and returned at
8000. At that point, the infant was transferred to the
Neonatal Intensive Care Unit for further management.
PHYSICAL EXAMINATION: On admission, weight is 4250 grams
(LGA). In general, a comfortable appearing newborn in no
acute distress, nondysmorphic. Anterior fontanelle open and
flat. Red reflex times two. Positive suck. Normally placed
ears. Intact clavicles with supple neck. Lungs were clear
to auscultation bilaterally and equal. Examination of the
heart revealed regular rate and rhythm with no murmurs.
There were normal femoral pulses. The abdomen was soft with
bowel sounds. Examination of genitourinary revealed normal
male phallus with testes descended bilaterally. Patent anus.
There were no sacral abnormalities noted. The hips were
stable. The infant was pink and well perfused with some
acrocyanosis. Examination of the skin revealed diffuse
petechiae over the trunk, abdomen and groin areas of the
extremities. The face and back were relatively spared.
There was also some larger bruising over the chest and groin.
No joint swelling or effusions. Neurologic examination
revealed a normal alert infant and effective tone and
strength.
HOSPITAL COURSE: Respiratory - The patient was stable in
room air throughout his admission.
Cardiovascular - The patient was hemodynamically stable
throughout his admission in the Neonatal Intensive Care Unit.
Fluids, electrolytes and nutrition - The patient was allowed
to breast feed and bottle feed Similac 20 with good p.o.
intake during his admission.
Hematology - Initial platelet count of 5,000 with follow-up
of 8,000. The remainder of the complete blood count was
unremarkable with a white blood cell count of 11.4 and
hematocrit of 48.1. The patient was transfused with 15 cc/kg
of platelets. Platelet count one hour after transfusion was
145,000. Platelet count four hours after transfusion was
139,000 and approximately ten hours after transfusion, the
platelet count remained stable at 138,000. Maternal platelet
count as reported earlier was normal. Maternal laboratories
have been sent including a PLA-1 antibody.
Infectious disease - Given the thrombocytopenia, complete
blood count and blood culture were obtained as well as the
baby being started on Ampicillin and Gentamicin. Blood
cultures are no growth to date. The baby remains on
Ampicillin and Gentamicin for a full 48 hour rule out.
Neurology - Given the initial platelet count of 5,000, a head
ultrasound was performed on [**2166-3-4**], which was reported as
within normal limits.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To normal Newborn Nursery.
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Doctor Last Name 59075**], [**Location (un) 2274**] in
[**Location (un) 8985**].
CARE/RECOMMENDATIONS:
1. Continue p.o. ad lib feedings.
2. Continue Ampicillin and Gentamicin for full 48 hour rule
out.
3. Repeat platelet count in a.m. to assure that platelet
count has stabilized and follow-up on maternal
laboratories sent.
DISCHARGE DIAGNOSES:
1. Thrombocytopenia, likely alloimmune.
2. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 58671**]
MEDQUIST36
D: [**2166-3-4**] 15:45:44
T: [**2166-3-4**] 18:12:40
Job#: [**Job Number 59076**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6673
} | Medical Text: Admission Date: [**2102-12-31**] Discharge Date: [**2103-1-11**]
Date of Birth: [**2102-12-31**] Sex: F
Service: NEONATOLOG
HISTORY OF PRESENT ILLNESS: Initially, this is a 29 [**12-19**] week
gestation, mono-mono twin #1, delivered preterm by C section
due to premature rupture of membrane. Mother was a 28 year
old gravida 2, para 0 to 2, female with an unremarkable
prenatal screen. The GBS was unknown. There was a mono-mono
diabetes treated with Insulin. The mother did note
epigastric pain prior to delivery which prompted her to come
to the hospital for evaluation. Ultrasound was reassuring
with biophysical profile of 8 and 8. She was treated with
betamethasone and that was completed on [**2102-12-21**]. She was,
also at the time noted to be hypertensive and started on
Labetalol.
She remained in house; then on the morning of delivery,
spontaneous rupture of membranes occurred and there was
therefore delivery by C section because of concern regarding
a cord accident in the setting of a monoamnion. This twin
emerged with spontaneous cry requiring facial CPAP and
routine care in the Delivery Room. Apgars were 8 and 8 and
the baby was transferred to the NICU on CPAP for further
evaluation and management of prematurity.
PHYSICAL EXAMINATION: On admission, the weight was 1,540
grams (90th percentile); length was 40 cm (60th percentile)
and head circumference was 27.25 cm (55th percentile).
Overall appearance was appropriate for age. The baby's
physical examination was remarkable for mild intercostal and
substernal retraction with excellent air entry. There was a
three vessel cord. Abdominal examination was benign. There
was no murmurs and normal female external genitalia for
gestational age was noted. There was some bruising in the
right groin, otherwise, well perfused and vigorous. The baby
was admitted for continued management for prematurity and
rule out sepsis and respiratory distress.
HOSPITAL COURSE:
1. Respiratory - The baby was continued on CPAP but had
increased respiratory rate and work. This prompted
intubation followed by administration of Surfactant with good
clinical response. The baby was extubated shortly thereafter
and placed on a nasopharyngeal CPAP at FIO2 of 30 to 36
percent. She had only received one dose of Surfactant. The
baby was loaded with caffeine prior to extubation as
prophylaxis of apnea with prematurity. The baby did have
some occasional desats as well at the time.
On CPAP the baby did well from a respiratory standpoint and
was weaned off to nasal cannula in the ensuing days. There
was no evidence of PDA from her echocardiogram. She remained
cardiovascularly stable.
2. Cardiovascular - From a cardiovascular standpoint, the
baby was hemodynamically stable with no signs of a PDA
throughout her entire NICU stay.
3. Fluids, Ellectrolytes and Nutrition: From a FEN
standpoint, the baby was started on a [**Name (NI) **] with total fluids
of 80 cc per kilo per day. This was quickly advanced and by
the time of the baby's extubation, the baby was increasing
slowly with enteral feeds. The baby's goal is total fluid to
150 cc per kilo per day with full enteral feeds at adequate
calories. The baby's electrolytes were within
normal limits. The baby had tolerated parenteral nutrition
earlier on in her life without any incidents.
4. Gastrointestinal - From a gastrointestinal standpoint,
the baby did have increased aspirates in the early part of
the enteral feedings. Therefore the enteral feedings were at
one point held and restarted following a normal KUB. After a
few days of slow feeding with occasional intolerance,
most likely secondary to low motility of prematurity, the
baby's feeds were advanced without any further complications
and by the time of this discharge was at full volume feeds,
increasing in caloric content.
5. From a hematological standpoint, the baby continued to do
well with satisfactory hematocrits. The baby did have
hyperbilirubinemia which was treated satisfactorily with
phototherapy. This was felt to be most likely secondary to
physiologic jaundice.
6. From an Infectious Disease standpoint, the baby received
48 hours of antibiotics (Ampicillin and Gentamicin). She did
not have any further infectious disease issues.
At the time of this discharge, she continued to do well
without any incidents.
Due to her relatively well clinical
course, as well as for familial convenience, there was
discussion of transferring her and her sibling to a closer
hospital at a level II. At the time of this dictation, the
discussion issue is ongoing with a strong possibility of the
transfer.
TRANSFER MEDICATIONS:
1. Caffeine.
The baby did receive Vitamin K and has not received the
Recombivax vaccine as of this dictation. The baby is
currently on a 26 calorie formula with a goal of going to a
28 calorie formula tomorrow.
DR.[**Last Name (STitle) **],[**Doctor Last Name **] 50-470
Dictated By:[**First Name3 (LF) 40504**]
MEDQUIST36
D: [**2103-1-11**] 14:38
T: [**2103-1-11**] 15:55
JOB#: [**Job Number 45701**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6674
} | Medical Text: Admission Date: [**2175-1-30**] Discharge Date: [**2175-2-9**]
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 6994**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
-Triple lumen placed on [**2175-1-31**].
-Intubation.
History of Present Illness:
Patient is an 82 year old female with ESRD on hemodialysis MWF,
mild dementia, hypertension, CAD statsu post CABG in [**2162**], who
presented with two days of confusion and mental status changes
at her nursing home. [**Name (NI) **] son reports that he saw her [**2-4**]
days prior to admission and she was her usual
self--conversational, alert, oriented, and with mild memory
difficulties. [**Name (NI) **] son went to see her on the morning of
[**1-30**] and noted that she was writhing, lying in the fetal
position and noticed shallow breathing. He could not elicit more
detailed complaints out of her as she was not verbal on the day
of admission.
.
Per the nursing home reports, she was hypoxic to the 70s on the
morning of admission. It increased to the 90s% on 2-4L NC.
Vomited x1 on morning of admission. Emesis was nonbilious and
nonbloody. She was incontinent of stool x4, when she is
typically continent. Last hemodialysis was on Friday (is on MWF
schedule). Has had increasing confusion over the last few days.
.
In the ED, she was febrile to 101.4 and was cultured. She was
hypertensive to 160s-190s systolic. CXR demonstrated fluid
overload, with a question of pneumonia. A blood gas revealed an
ABG 7.46/27/183. Initial lactate was 2.6. She was placed on
BiPAP and as she could not be weaned from BiPAP, was admitted to
MICU. She initially received one gram of vanco, 1g of ceftaz,
80mg of gentamicin. He received one dose of ASA 600mg PR.
.
In the MICU, patient was getting dialyzed and was found to be
more unresponsive, cyanotic, not at all moaning or responding to
sternal rub. She was intubated for airway protection,
tachypneic, appeared moribund. L subclavian triple lumen placed,
as well. HD was discontinued and 1L NS was run in through the HD
catheter wide open. At that point, patient appeared somewhat
more responsive.
Past Medical History:
-ESRD on HD (m/w/f)
-Status post right hip repair in [**2174-8-2**] which has prompted
prolonged nursing home stay
-Hypertension
-CABG x3 in [**2172**] at [**Hospital1 2025**] (found to have 3VD on cath)
-Arthritis
-Neuropathy
-Laparscopic cholecystectomy in summer [**2174**]
-Left temporal CVA [**11-7**]
-Pneumothorax after line placement in [**2174-12-2**] status post
chest tube
-Herpes zoster right t3/t4 in [**2174-11-2**]
Social History:
Widowed, resides at [**Location (un) **] [**Hospital1 **] NH, four children, no
tobacco, no ETOH. Generally pleasant but tends to isolate. Her
four children visit her but she does not speak with them very
often.
Family History:
Mother had coronary artery disease.
Physical Exam:
Physical Exam (on admission to MICU):
VS: 101.8 165/82 99 28 88% (bad pleth) on BiPAP 10/5
Gen: moaning, does not respond verbally to questions, not
responding to commands
HEENT: mask interfering with exam
Neck: JVD to 10cm
CV: RRR, nl S1/S2, no m/r/g
Chest: R tunneled s/c dialysis catheter - no surrounding
erythema
Pulm: CTAB anteriorly
Abd: soft, NT/ND, +BS, no masses
Ext: no c/c/e; onychomycosis
Neuro: delirium, cannot answer questions
.
Physical Exam on admission to floor:
T:97.9 BP:140/80 HR:80 RR:20 O2saturation: 100% on room air,
blood sugar 41.
Gen: Laying in bed. Minimally responding. Knew year and city,
but assumed in nursing home. Elderly woman, in no apparent
distress.
HEENT: Slight conjunctival pallor. No icterus. Slightly dry
mucous membranes. NGT in place.
NECK: No cervical or supraclavicular lymphadenopathy. No JVD. No
thyromegaly. Hemodialysis catheter in left upper chest.
CV: RRR. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**]
appreciated.
LUNGS: Clear to auscultation bilaterally. Decreased breath
sounds in lower lung fields, bilaterally. Slight crackles
appreciated, bilaterally.
ABD: Normal active bowel sounds in all four quadrants. Soft.
Nontender and nondistended. No guarding or rebound. Liver edge
not palpated. No splenomegaly appreciated. No abdominal aortic
bruit.
EXT: Distal extremities cool and cyanotic. No lower extremity
edema, bilaterally. 2+ radial pulses, bilaterally.
SKIN: Several ecchymoses.
Pertinent Results:
Images:
AV fistulogram ([**2175-2-8**]): Left AV fistulogram demonstrates good
flow in the anterior side of the fistula to the cephalic vein.
Also there is patent subclavian, and SVC veins.
.
EKG ([**2175-1-30**]): 97bpm, NSR, LAFB, TWI in V2 (old)
.
Chest Xray Portable ([**2175-2-3**]): Perhaps slight improvement in
pulmonary edema. Persistent left lower lobe atelectasis or
consolidation.
.
Chest xray ([**2175-2-2**]): Left subclavian vein catheter tip is in
the lower SVC. Right subclavian catheter tip is in the right
atrium. Left lower lobe collapse is persistent. Small right
pleural effusion is stable. NG tube tip is in the stomach.
There is no pneumothorax. Mild cardiomegaly is stable.
.
CXR ([**2175-1-30**]): 1. Pulmonary edema with bilateral pleural
effusions, new since the [**2174-12-15**] plain radiograph. 2.
Confluent opacity in the right mid-lung zone and base likely
represents alveolar edema, though pneumonic consolidation is a
consideration. 3. No supine evidence of pneumothorax.
.
Cardiac ([**2175-1-31**]): The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with mid to apical
anteroseptal/anterior hypokinesis. Overall left ventricular
systolic function is mildly depressed. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion.
No vegetation seen.
.
Abdominal U/S ([**2175-1-31**]): 1. Unremarkable liver and no biliary
dilatation. 2. Status post cholecystectomy. 3. Bilateral
pleural effusions, loculated on the right. 4. Atrophic kidneys.
.
TTE ([**2174-11-25**]): [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RV mildly dilated, EF 60-70%,
1+ MR, mild pulmonary HTN.
.
Micro:
Blood ([**1-30**]): Staph aureus coag +.
.
Endotracheal ([**2-1**]): Yeast. Staph aureus coag +.
.
Stool ([**1-31**], [**2-2**]): C. dificile negative.
.
Labs:
[**2175-2-8**]: WBC 8.1, Hgb 9.4, Hct 29.6, Plt 248, PT 15.6, PTT 33.5,
INR 1.4
[**2175-2-6**]: WBC 10.0, Hgb 9.6, Hct 29.8, Plt 235, PT 14.9, PTT
61.5, INR 1.3
[**2175-2-8**]: Na 139, K 4.3, Cl 106, HCO3 23, BUN 16, Cr 3.5, Glu 83
[**2175-2-6**]: Na 138, K 4.2, Cl 104, HCO3 23, BUN 25, Cr 4.1, Glu 100
[**2175-2-8**]: Ca 7.7, Mg 2.4, PO4 3.4
[**2175-2-6**]: Ca 8.0, Mg 2.6, PO4 3.4
[**2175-2-4**] 06:59AM BLOOD WBC-12.7* RBC-3.20* Hgb-9.7* Hct-30.7*
MCV-96 MCH-30.3 MCHC-31.6 RDW-18.8* Plt Ct-189
[**2175-2-2**] 05:30AM BLOOD WBC-11.5* RBC-3.13* Hgb-9.3* Hct-29.8*
MCV-95 MCH-29.9 MCHC-31.4 RDW-18.9* Plt Ct-126*
[**2175-1-30**] 06:39PM BLOOD WBC-15.3*# RBC-3.82*# Hgb-12.2# Hct-36.9#
MCV-97 MCH-31.9 MCHC-33.0 RDW-18.7* Plt Ct-229
[**2175-2-4**] 06:59AM BLOOD Plt Ct-189
[**2175-2-4**] 06:59AM BLOOD PT-13.9* PTT-31.4 INR(PT)-1.2*
[**2175-1-30**] 06:39PM BLOOD PT-13.6* PTT-26.8 INR(PT)-1.2*
[**2175-1-30**] 06:39PM BLOOD Plt Smr-NORMAL Plt Ct-229
[**2175-2-4**] 06:59AM BLOOD Glucose-225* UreaN-16 Creat-2.6* Na-141
K-3.9 Cl-104 HCO3-25 AnGap-16
[**2175-2-1**] 05:15AM BLOOD Glucose-89 UreaN-59* Creat-4.7*# Na-144
K-2.5* Cl-104 HCO3-22 AnGap-21*
[**2175-1-31**] 03:33AM BLOOD Glucose-294* UreaN-44* Creat-3.5*# Na-137
K-3.9 Cl-98 HCO3-19* AnGap-24*
[**2175-1-30**] 04:45PM BLOOD Glucose-206* UreaN-76* Creat-5.4*# Na-143
K-5.5* Cl-97 HCO3-19* AnGap-33*
[**2175-2-3**] 04:30AM BLOOD ALT-175* AST-37 AlkPhos-97 Amylase-66
TotBili-0.4
[**2175-1-30**] 05:10PM BLOOD ALT-355* AST-269* LD(LDH)-598*
CK(CPK)-143* AlkPhos-142* Amylase-356* TotBili-0.4
[**2175-2-3**] 04:30AM BLOOD Lipase-33
[**2175-1-30**] 05:10PM BLOOD Lipase-17
[**2175-2-2**] 09:02AM BLOOD CK-MB-NotDone cTropnT-0.67*
[**2175-1-31**] 06:34PM BLOOD CK-MB-9 cTropnT-0.83*
[**2175-1-31**] 02:08PM BLOOD CK-MB-8 cTropnT-0.81*
[**2175-1-31**] 03:33AM BLOOD CK-MB-11* MB Indx-8.7* cTropnT-0.60*
[**2175-1-30**] 05:10PM BLOOD CK-MB-8 cTropnT-0.59*
[**2175-2-4**] 06:59AM BLOOD Calcium-8.3* Phos-2.5* Mg-3.1*
[**2175-1-31**] 03:33AM BLOOD Albumin-3.2* Calcium-8.6 Phos-5.4*#
Mg-2.2
[**2175-2-3**] 04:30AM BLOOD Genta-3.6* Vanco-28.2*
[**2175-1-31**] 03:33AM BLOOD Genta-0.8* Vanco-16.1
[**2175-2-3**] 05:08PM BLOOD pO2-73* pCO2-37 pH-7.48* calTCO2-28 Base
XS-3
[**2175-1-30**] 07:50PM BLOOD pO2-183* pCO2-27* pH-7.46* calTCO2-20*
Base XS--2
[**2175-2-3**] 05:08PM BLOOD Lactate-1.4
Brief Hospital Course:
Hospital Course/Assessment/Plan:
Patient is an 82 year old female with a history of CAD status
post CABG, ESRD on hemodialysis, CVA with dementia who presents
with worsening mental status who was admitted to the ICU for
hypoxic respiratory failure.
.
.
1) Hypoxic respiratory failure:
On admission, most likely related to excess fluid, despite
stable hemodialysis schedule. Pleural effusions and pulmonary
edema on chest xray. No history of COPD. Appears to have
underlying PNA, as well.
- Continue hemodialysis for fluid removal. Blood culture on
[**1-30**] revealed staph aureus, coag positive blood. Initial
antibiotic was ceftazidime, but discontinued [**1-31**], as infection
thought to be related to HD line. Decision made to treat
through with vancomycin and gentamycin for potential line
sepsis. Flagyl continued for two weeks, despite stool that was
negative for C. difficile. Will be discharged on vancomycin and
flagyl.
By [**2-4**], patient maintaining 100% oxygen saturation on 2
liters nasal canula. On [**2-8**], patient oxygen saturation
95% on room air.
.
2) Fever and leukocytosis:
Multiple sources of infection. Sputum on [**2-1**] revealed some
yeast. Stool on [**2-2**] was C. dificile negative and negative for
salmonella, shigella, and campylobacter.
Treated presumed HD line infection with gentamicin and
vancomycin. AV fistulogram revealed AV fistula in left arm
functioning. Removed tunneled left catheter line on [**2175-2-9**], so
will continue only vancomycin for two weeks (until [**2175-2-24**]).
Dosing of antibiotics after hemodialysis sessions for vancomycin
trough less than 15. Will continue metronidazole for two weeks.
-On [**2-6**], left triple lumen (placed on [**2175-1-31**]) appeared
infected. Line removed.
.
3) Abnormal LFTs:
Most likely due to shock liver. Right upper quadrant ultrasound
did not reveal any obstructive picture.
.
4) Urinary Tract infection:
Patient had positive urine analysis on admission.
As above, treated with broad spectrum antibiotics.
.
5) Mental status changes:
Presented to hospital and unresponsive. Most likely due to
multiple conditions. Initially, had fluid overload and hypoxia.
In days prior to discharge, patient's mental status improved.
Much more lucid and requesting to eat on own. Consulted speech
and swallow to assist. Continued with thickened pureed liquids,
with aspiration precautions.
.
6) Diarrhea:
Patient presented with recent vomiting and diarrhea. Most
likely due to viral gastroenteritis. Rectal tube in place.
- C. dificile culture from [**2175-2-2**] negative. Despite this, will
continue on PO flagyl, as previous C. dificile infection and
patient has been hospitalized for extended period.
.
7) CAD status post CABG:
Elevated troponin compared with previous troponins with similar
degree of renal failure, but EKG shows no changes. Most likely
due to demand ischemia, in setting of hypoxia and respiratory
distress. factors.
- Continued aspirin. Initially held beta blocker and ACE I as
hypotensive. Trended cardiac enzymes. Did not start heparin.
.
8) Tight glycemic control:
Initiated for tight glycemic control in ICU setting. No history
of diabetes. Blood sugars remained in good control.
.
9) ESRD on HD:
Patient with right HD line, with L fistula not being used.
Initially, held nephrocaps and fosrenal as couldn't take PO
medications.
- Continued with HD on M,W,F schedule. Restarted nephro caps.
.
10) Dementia:
- Mild at baseline per son. Avoided ativan.
.
11) Depression:
Initially held effexor.
.
12) FEN/GI:
Initially NPO, with NGT placed secondary to altered mental
status.
-Consulted speech and swallow. With altered mental status,
concern for aspiration. Tolerated thickened liquids. NGT
removed, per patient on [**2-5**].
.
13) Prophylaxis:
Placed on SC heparin and PPI.
.
14) Access:
R tunneled line for HD pulled on [**2175-2-9**]. L subclavian triple
lumen catheter pulled on [**2-7**]. Right AV fistula with good flow.
.
15) Code:
DNR/DNI.
Ok to be intubated for a short period of time. Family said that
no heroic measures or long-term intubation or feeding tubes.
Would not want a trach, but ok to intubate if we project that it
would be a temporizing measure (for example, while we remove
fluid)
.
16) [**Name (NI) **] - son [**Name (NI) **] [**Name (NI) 7860**] is HCP - [**Telephone/Fax (1) 70582**]
Medications on Admission:
lisinopril 30mg daily
marinol 2.5mg daily
prednisone 7.5mg daily
prilosec 20mg daily
pravachol 20mg qHS
calcium carbonate 500mg [**Hospital1 **]
senna 1 tab qHS
lopressor 50mg tid
nephrocaps 1 tab qAM
asa 81mg daily
effexor 75mg daily
ativan 0.25mg daily, 0.5mg qPM prn
norvasc 10mg daily
fosrenal 500mg tid
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Continue for 2 weeks. Stop on [**2175-2-24**].
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous QHD (each hemodialysis): Give after dialysis
treatments, if trough<15.
Give until [**2175-2-24**].
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed: for fever>100.5.
12. Pravachol 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary:
-Hypoxic episode requiring intubation
-ESRD (dialysis treatments M,W,F)
.
Secondary:
-Status post right hip repair in [**2174-8-2**] which has prompted
prolonged nursing home stay
-Hypertension
-CABG x3 in [**2172**] at [**Hospital1 2025**] (found to have 3VD on cath)
-Arthritis
-Neuropathy
-Laparscopic cholecystectomy in summer [**2174**]
-Left temporal CVA [**11-7**]
-Pneumothorax after line placement in [**2174-12-2**] status post
chest tube
-Herpes zoster right t3/t4 in [**2174-11-2**]
Discharge Condition:
Stable.
Discharge Instructions:
-You were admitted for depressed oxygenation levels. Initially,
you needed to be intubated.
-You were found to have an infection in your blood. Several
antibiotics, vancomycin, gentamicin, and metronidazole, were
started.
One of these medications, vancomycin, can be administered after
dialysis sessions and should be administered for two more weeks,
until [**2175-2-24**].
-An AV fistulogram demonstrated patent flow. Your right
tunneled catheter line was pulled on [**2175-2-9**].
-If you experience any more increased shortness of breath, chest
pain, fever, or any other concerning symptoms, call your PCP or
come to the ED immediately.
Followup Instructions:
-You are scheduled to continue to receive vancomycin until
[**2175-2-24**]. This medication should be administered
following dialysis sessions. Dose for vancomycin troughs less
than 15.
-Your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) **]), will continue to
follow your progress.
ICD9 Codes: 486, 5990, 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6675
} | Medical Text: Admission Date: [**2124-1-14**] Discharge Date: [**2124-1-19**]
Date of Birth: [**2059-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
emergency cabg x4 on [**2124-1-14**] (LIMA to LAD, SVG to ramus, SVG to
OM, SVG to PDA
History of Present Illness:
64 year old male with history of chest pain intermittently since
last summer. It increases with exertion and is resolved with
rest. Had a + ETT on [**1-5**] and referred for cath today. He had a
dye reaction? in the cath lab and received solumedrol at that
time. He continued to have some chest pain in the cath lab and
was referred emergently to Dr. [**Last Name (STitle) **] for CABG. Cath showed LM
30%, LAD 80%, Ramus 90%, CX 70%, RCA 50%, EF 60%. Patient admits
to having taken 40 mg oral prednisone the evening prior to cath
for asthma flare.
Past Medical History:
asthma
GERD
hepatitis C at age 18
HTN
elev. chol
Social History:
married and lives with wife
businessman
one drink per day
quit smoking 15 years ago, 35 pk/yr history
Family History:
father died of MI at 52, mother with CABG
Physical Exam:
HR 94 165/77 RR 17 5'7" 179#
RRR S1 S2 no murmur
CTAB
soft, NT, ND
grossly nonfocal neuro exam
right fem art. line in place with 2+ bilat. fem pulses
+ DP/PT pulses
Pertinent Results:
[**2124-1-17**] 06:00AM BLOOD WBC-6.8 RBC-3.51* Hgb-10.5* Hct-27.9*
MCV-80* MCH-29.9 MCHC-37.5* RDW-14.6 Plt Ct-103*
[**2124-1-17**] 06:00AM BLOOD Plt Ct-103*
[**2124-1-17**] 06:00AM BLOOD Fibrino-638*#
[**2124-1-17**] 06:00AM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-133
K-4.0 Cl-98 HCO3-26 AnGap-13
[**2124-1-14**] 09:10AM BLOOD ALT-16 AST-15 AlkPhos-74 Amylase-76
TotBili-0.3
[**2124-1-14**] 09:10AM BLOOD WBC-10.6 RBC-3.31* Hgb-10.3* Hct-28.0*
MCV-85 MCH-31.2 MCHC-36.8* RDW-12.8 Plt Ct-233
[**2124-1-17**] 06:00AM BLOOD Calcium-8.2* Phos-2.1*
[**2124-1-14**] 09:10AM BLOOD VitB12-417
[**2124-1-14**] 09:10AM BLOOD Triglyc-27 HDL-46 CHOL/HD-2.7 LDLcalc-73
Brief Hospital Course:
Admitted for cath as above on [**1-14**] and taken to OR urgently for
CABG by Dr. [**Last Name (STitle) **]. Transferred to CSRU in stable condition on
titrated neo and propofol drips. Extubated in the early AM POD
#1. Chest tubes were removed and lasix diuresis started along
with beta blockade. Swan removed and transferred out to the
floor on POD #2. Began to ambulate on the floor and made rapid
progress. He went into afib briefly on [**1-17**], but converted to SR
on lopressor and amiodarone. Pacing wires were removed on POD
#4. Prelim. CXR on [**1-19**] shows left pleural effusion. Patient is
asymptomatic , no rales or wheezing, but has decreased BS at
left lung base. He remained in SR and was discharged to home
with VNA services on POD #5.
Medications on Admission:
adviar discus 500 mg/50 mg one puff [**Hospital1 **]
lisinopril 20 mg daily
[**Doctor First Name 130**] 180 mg daily
ASA 325 mg daily
plavix 75 mg daily ( had dose AM of admission)
lovastatin 20 mg daily
singulair 10 mg daily
toprol XL 25 mg daily
prevacid 30 mg daily
prednisone 20 mg po prn asthma flare ( had 40 mg last PM)
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
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. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days; then 400 mg daily for one week, then 200 mg
daily ongoing.
Disp:*80 Tablet(s)* Refills:*1*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] HOME CARE
Discharge Diagnosis:
CAD
s/p cabg x4
asthma
HTN
GERD
Hepatitis C
a fib
elev. chol.
Discharge Condition:
stable
Discharge Instructions:
may shower over wounds and pat dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, or wound drainage
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 2912**] in [**1-21**] weeks
follow up with Dr. [**Last Name (STitle) **] in 4 weeks
follow up with Dr. [**Last Name (STitle) **] in [**12-20**] weeks
Completed by:[**2124-1-19**]
ICD9 Codes: 9971, 4111, 2859, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6676
} | Medical Text: Admission Date: [**2145-12-15**] Discharge Date: [**2145-12-27**]
Date of Birth: [**2067-7-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percodan / Percocet / Codeine / Talwin / Demerol /
Valium / Aspirin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
Central Venous Catheter L subclavian
Also attempted RIJ.
History of Present Illness:
patient is a 78 yo female with MMP including RA, afib,
osteoporosis with compression fractures, AS and CHF presenting
with 3 days of LBP. Patient said that she woke up 3 days ago
with LBP that has worsening over the past couple of days. Denies
trauma, but admits that she sometimes "bounces on the bed" when
she comes back to bed from commode. Pain is [**10-20**] localized to
low back withour radiation to the legs. Denies numbness,
tingling, LE weaknes, bowel or bladder incontinence. She has not
had pain in this area before but has had pain in the areas of
her compression fractures in the past. Took some tylenol with
little effect, so came in ED.
.
In the ED T 97 Bp 92/60 HR 68 O2 sats91-95% on RA
She trasient dropped her SBPs of low 80s but went back up to low
100s after 1 liter NS. Received a total of 2 liters NS in ED.
Of, note she was started on lisinopril 10 mg Po QD on [**12-13**]. She
also receievd cipro 500 mg x1 for UTI, tylenol 1 g x1 and
morphine 2 mg x1.
.
Past Medical History:
# Aortic stenosis - valve area 1.1 on [**2144-4-3**]
# CHF (EF of 60%)
# atrial fibrillation - on warfarin
# s/p femur fx [**8-16**]
# s/p R BKD [**2144-10-28**]
# COPD
# Rheumatoid arthritis - on prednisone
# RA/SLE/positive [**Doctor First Name **] antibody - in remission
# osteoporosis
# venous stasis
# peripheral neuropathy
# h/o Clostridium difficile in the past
# spinal stenosis
Social History:
lives alone in home, able to do ADL's, has [**Name (NI) 269**], PT, home aid at
home. +tob hx, quit 40 years ago, no ETOH, no drugs
Family History:
arthritis, mother - liver cancer, father - CVA
Physical Exam:
Admission
T 96.7 BP 100/62 HR 72 RR 22 O2 sat 93% on RA 400 cc out foley
Gen - Elderly female sleeping in bed in NAD becoming very
uncomfortable with movement in bed
HEENT - MM dry, Op clear, EOMI
Neck: could not appreciate JVD, no thyroid nodules, no LAD
CV - irregularly irregular, nl S1, S2, 3/6 SEM at RUSB radiating
to carotids
Lungs - CTA with crackles at lung bases, L>R
Abd - obese, soft, NT/ND, NABS
Back - tenderness to palpation in lumbar spine and paraspinal
region, no CVAT
Rectal - normal rectal tone per ED and guaiac negative
Ext - s/p BKA on right, venous stasis changes on LLE with trace
edema, well healed scar over knee, negative SLR
Neuro - AAOx3, CN II-XII intact, strength in upper and LE
extremtities [**5-15**], sensation to light touch grossly intact
Skin - venous stasis changes on LLE, erythema under breast
bilaterally
.
Discharge
T 98.8 BP 130/90 HR 90 RR 2O O2 sat 91% on RA
Gen - NAD
HEENT - MMM
Neck: difficult to evaluate JVD, no LAD
CV - irregularly irregular, nl S1, S2, 3/6 SEM at RUSB radiating
to carotids
Lungs - CTA with crackles at lung bases increased from
yesterday, L>R
Abd - obese, soft, NT/ND, NABS
Back - point tenderness to palpation in lumbar spine and right
paraspinal region, no CVAT
Neuro - AAOx3, CN II-XII intact, strength in upper and LE
extremtities [**5-15**], sensation to light touch grossly intact
Skin - venous stasis changes on LLE, improving erythema under
breast bilaterally
Pertinent Results:
CT abd/ Pelvis:
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Bilateral small pleural
effusions have resolved in the interval. Chronic atelectasis and
bronchiectasis is noted at the left lung base.
Non-contrast evaluation of the liver is suboptimal, however
unremarkable. The patient is status post cholecystectomy. The
common bile duct is dilated, however, unchanged in appearance
compared to the prior study. Hypodense lesions within the head
of the pancreas noted on the prior study are not appreciated on
this limited non-contrast evaluation. Spleen and adrenal glands
are within normal limits. There is a large type 1 hiatal hernia,
with almost the entire stomach located in the thorax. This
appearance is stable from prior study of [**2144-10-11**] and
appears uncomplicated by obstruction. Several hypodensities are
noted in the renal parenchyma bilaterally, likely representing
simple cysts. There is no free air, no free fluid, and no
pathologically enlarged mesenteric or retroperitoneal lymph
nodes. There is scattered diverticulosis of the descending and
ascending colon without evidence of acute diverticulitis.
CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, urinary
bladder, uterus are unremarkable. The sigmoid is redundant.
There is no evidence of acute diverticulitis. There is no
retroperitoneal hematoma. There is right-sided femoral hernia,
containing small bowel loops without evidence of obstruction or
incarceration. The evaluation of the pelvis is somewhat limited
by large streak artifact produced by right-sided total hip
arthroplasty. No free pelvic fluid and no pathologically
enlarged pelvic or inguinal lymph nodes.
BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic
lesions. There are multiple compression fracture deformities in
the lumbar and thoracic spine, the degree of compression on T10
as well as inferior endplate of L1 has increased in the
interval.
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Interval increase in degree of compression of T10 and L1
vertebral bodies.
3. Type 1 hiatal hernia.
4. Stable right femoral hernia containing nonobstructed small
bowel loops.
5. Interval resolution of pleural effusions.
6. Coronary artery and aortic arch calcifications.
.
MRI T/L spine:
IMPRESSION:
1. Acute/subacute compression of inferior endplate of L1.
2. Chronic compressions of L2, L4 and L5 vertebrae.
3. Degenerative changes at multiple levels as described above
with moderate left subarticular recess narrowing and mild spinal
stenosis at L4-5 level.
6. Multiple chronic compressions in the thoracic region with
increased kyphosis. No spinal stenosis or extrinsic spinal cord
compression. No evidence of acute compression fracture in the
thoracic spine.
CT dated [**2145-12-15**].
FINDINGS: The right kidney measures 10.1 cm and the left 10.8
cm. The renal parenchymal thickness is normal without evidence
of calculi or hydronephrosis. Multiple renal cysts, the largest
one measuring 2.2 x 1.8 cm in the upper pole of the right
kidney.
IMPRESSION: No evidence of hydronephrosis.
.
CHEST (PORTABLE AP) [**2145-12-20**] 3:48 AM
Moderate left pleural effusion and mild pulmonary edema have
increased. Cardiomegaly is moderate and unchanged partially
obscured by the large intrathoracic stomach. No pneumothorax.
Pleural effusion is probably moderate on the left and small on
the right. No pneumothorax.
.
CHEST (PORTABLE AP) [**2145-12-22**] 4:04 AM
There is motion artifact and rotation of the patient. Allowing
for the technical limitations the left subclavian catheter tip
is in the SVC. moderate pulmonary edema, cardiomegaly and small
bilateral pleural effusions are stable. Left retrocardiac
opacity is due to a large intrathoracic stomach. There is no
pneumothorax.
.
ECHO:
Conclusions
The left atrium is elongated. The right atrium is markedly
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. There is
moderate to severe aortic valve stenosis (area 0.9 cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2144-12-28**],
the aortic valve area has further decreased (now moderate to
severe aortic stenosis, [**Location (un) 109**] 0.9 cm2).
Brief Hospital Course:
#)LBP: The patient was admitted with lower back pain located at
L5/S1 and somewhat latterally near the SI joint as well. There
was no clinical evidence for cauda equina syndrome or sciatica.
The patient received A CT abd/pelvis was performed in the ED,
which ruled out RP bleed and also found old T10/L1 compression
fracture. An MRI was performed which showed no cord compression,
chronic compressions of L2, L4 and L5 vertebrae and
Acute/subacute compression of inferior endplate of L1. This may
be the source of her pain although on physical exam her point
tenderness appears to be much lower. She should have a pelvic
MRI as an outpatient to evaluate the SI joint. The patient's
pain was not controlled on tylenol, lidocaine patch and small
doses of PRN Morphine. Calcitonin 200 units daily was added.
Oxycontin SR was added with continued [**2148-8-20**] pain. A pain
consult was obtained, and the patient was placed on Oxycotonin
SR TID 20mg-10mg-20mg and IV morphine breakthrough. Home dose of
neurontin was also increased. This combination prooved too
sedating. The patient became somnolent, and the oxycontin was
discontinued. She was subsequently controlled with neurontin,
tylenol and lidocaine patch. She was evaluated by PT who
recommended acute rehab which the patient refused. She will
receive home PT.
.
#Hypoxia: On admission, the patient's lasix was held due to
acute renal failure and low blood pressures. In the ED, she
initially received IVF. On the evening of [**12-19**], she began having
difficulty breathing. She was found to have SOB, wheezing as
well as crackels. O2 sats were low 80s on 2L NC and she was
placed on a 35% shovel mask. She received nebulizers. ABG was
7.32/54/87. EKG showed known atrial fibrillation. a CXR showed
now change. She received lasix 120mg IV with transient
improvement in O2 sats. Later on that evening, she was once
again hypoxic. Second ABG with 7.31/53/69 on 6L NC and 35%
shovel mask. Pt still only satting 94% on NRB. Patient was
transferred to MICU for BiPap. In the MICU, she received Bipap.
She also developed a fever, rigors and a leukocytosis to 22.
Hospital acquired pneumonia vs aspiration pneumonia was deemed
likely and she was started on Vanc/levo/flagyl. Although there
was no infiltrate seen on CXR, patient subsequently improved and
her leukocytosis trended down. She was also restarted her home
doses of lasix when her blood pressure improved. On [**12-23**], Vanc
was discontinued due to no evidence of MRSA on culture.
.
#)UTI: Pt was found to have UTI in the ED. Started on Bactrim.
ABx were switched to vanc/levo/flagyl while in the MICU for
pneumonia. However, Ucx grew 2,000 E.Coli resistant to Cipro.
Given the low organism count and negative UA, the patient was
not restarted on Bactrim. UA and Ucx were followed and showed no
subsequent infection.
.
#) Hypotension: On admission, the patient was hypovolemic on
exam with SBP 90-100. Lasix and Lisinopril were held in the
setting of hypotension and ARF. IVF hydration was given. Her
blood pressure improved while on the floor. However, after
transfer the the MICU, she became hypotensive and required
pressors likely secondary to PNA sepsis versus morphine. She was
briefly on dopamine then switched to levophed and quickly weaned
off. IV hydration was given. Her blood pressure remained stable
after that, and she was restarted on 80 mg Lasix ([**1-12**] home dose)
given pulmonary edema and hx CHF.
.
#) ARF: Pt was found to have a Cr of 1.8 on admission with a
baseline of 1.3. The is was thought to be due to recent addition
of Lisinopril and increase of Lasix causing pre-renal acute
renal failure. Creatinine peaked at 2.0 after transfer to MICU
and improved with IVF and BP control with pressors. The
creatinine returned to below baseline with good UOP. On [**12-23**],
she was restarted on [**1-12**] dose home lasix (80mg QD) with good UOP
and BPs tolerated. As her creatinine and blood pressure remained
stable, lasix was increased to her home dose 120 [**Hospital1 **] and her
lisinopril was also restarted. She will need outpatient labs
with Chem 7 to monitor her creatinine.
.
#)CHF: On admission, the patient appeared hypovolemic, so
lisinopril and lasix were held in the setting of ARF and
hypotension. The patient's acute hypoxia on the floor was
thought to be due to a pneumonia with some associated pulmonary
edema. She was treated in the ICU with Bipap and lasix as above.
Cardiac enzymes were negative. An echo was performed which
showed EF>55% without change in wall motion or systolic function
but continued worsening AS. She was restarted on lasix at 1/2
home dose and then titrated up as her blood pressure improved.
She had increased crackles at the bases on the morning of
discharge without worsening hypoxia. She received an additional
Lasix 20 IV with improvement prior to discharge. She was also
restarted on Lisinopril.
.
#)Afib: INR was closely monitored given that pt received cipro
in ED and was then given bactrim for UTI. INR was found to 3.1
on HD1 and 3.7 on HD2. Her warfarin was held. Patient
subsequently became subtherapeutic on INR. Coumadin was
restarted on [**12-22**]. On the day of discharge, her INR was low at
1.8 and she was given an elevated dose of coumadin 5mg. She
should have her INR drawn in two days prior to seeing her PCP [**Last Name (NamePattern4) **]
[**12-29**].
Medications on Admission:
Lisinopril 10 mg PO Qday just started on [**2145-12-13**]
Ascorbic Acid 500 mg PO once a day
Calcium-Cholecalciferol (D3) [Calcium 600 + D] 1 Tablet PO BID
COLACE 50MG PO BID
Dorzolamide 2 % Drops 1 gtt od twice a day glaucoma
Ergocalciferol (Vitamin D2) [Vitamin D] 400 unit PO QDAY
Furosemide 40 mg Tablet 3 Tablet(s) by mouth in am, 3 in pm
Gabapentin [Neurontin] 300 mg PO TID
Ibandronate 150 mg by mouth q mo for osteoporosis
Latanoprost 0.005 % Drops 1 ggt od ut dict
Metoprolol Succinate 50 mg PO QDAY
Multivitamin 1 Tablet(s) by mouth once a day
Protonis 40 mg by mouth once a day
Potassium Chloride 10 mEq by mouth once a day
Prednisone 10 mg by mouth once a day
Warfarin 3 mg Tablet [**1-12**] Tablet(s) by mouth once a day ut dict
afib
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic QDAY ().
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 30
days: Apply in the morning and take off at night.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily) for 3 days.
Disp:*qs * Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once
Daily at 16).
15. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day.
18. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
19. Ibandronate 150 mg Tablet Sig: One (1) Tablet PO once a
month.
20. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 10 doses.
Disp:*10 Tablet(s)* Refills:*0*
21. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days: Day 1 is [**12-20**].
Disp:*6 Tablet(s)* Refills:*0*
22. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days: Day 1 is [**12-20**].
Disp:*18 Tablet(s)* Refills:*0*
23. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
24. Outpatient Lab Work
INR checked x 30
- Please draw on the morning of [**12-29**]
- Fax results to Dr. [**Last Name (STitle) 7790**] [**Telephone/Fax (1) 11038**]
25. Outpatient Lab Work
Check creatinine x10
- please check on [**2145-12-29**]
- Fax results to Dr. [**Last Name (STitle) 7790**] [**Telephone/Fax (1) 11038**]
Discharge Disposition:
Home With Service
Facility:
All Care [**Telephone/Fax (1) 269**] of Greater [**Location (un) **]
Discharge Diagnosis:
Lumbar Compression Fracture
Pneumonia
Discharge Condition:
Improved
Discharge Instructions:
You were admitted for back pain which is most likely due to a
compression fracture. You will need to have another MRI of the
pelvis as an outpatient. You should use the lidocaine patch,
neurontin and tylenol for pain. You also developed Pneumonia.
You will need to finish a course of antibiotics for the
Pneumonia.
.
If you have any difficulty breathing or high fevers, please call
your doctor or go to the emergency room. If you have weakness in
your legs, trouble urinating or worsening back pain, call your
doctor or go to the emergency room.
.
For your heart failure:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Your coumadin on discharge was slightly low: INR 1.8. You were
given an increased dose of 5mg once prior to discharge. You
should have your INR check in the next 2-3 days.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]: [**12-29**] 1:50pm
.
Please obtain an outpatient MRI of your pelvis: [**Telephone/Fax (1) 327**]
Date/Time:[**2146-1-7**] 1:00
[**Hospital Ward Name 517**], basement level.
.
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2146-2-1**] 12:10
Provider: [**Name10 (NameIs) 2352**] ECHO Phone:[**Telephone/Fax (1) 15347**] Date/Time:[**2146-2-4**]
1:30
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2146-3-15**] 1:00
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 5849, 5990, 486, 4280, 4241, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6677
} | Medical Text: Admission Date: [**2131-4-5**] Discharge Date:
Date of Birth: [**2083-11-16**] Sex: F
Service: TRAUMA SURGERY
Of note, this discharge summary will encompass the time of
admission from [**2131-4-5**] to hospital day number 17, [**2131-4-21**]. The remainder of the discharge summary will be
dictated at a later time.
HISTORY OF PRESENT ILLNESS: This is a 47-year-old morbidly
obese woman who was transferred from an outside hospital for
multiple injuries after falling from her horse three days
prior. She was transferred to [**Hospital1 18**] on [**2131-4-5**]. Her
injury was sustained on [**2131-3-31**]. Apparently, this
patient landed on her right side. She was taken to a
hospital in [**Location (un) 8641**], [**Location (un) 3844**]. The extent of her
injuries there were as follows: 1. Hepatic contusion, grade
III. 2. Right renal contusion. 3. Right hemothorax. 4.
Right rib fractures, [**12-25**], posteriorly displaced. 5. Right
scapular fracture. 6. Left transverse process fracture,
L1-3. 7. Right thigh hematoma. On day number three of her
hospital stay at the outside hospital, she developed
abdominal pain and became hemodynamically unstable. She was
taken to the OR where she was found to have a biliary leak
with bile peritonitis. They were unable to close her abdomen
at the outside hospital and she was transferred to [**Hospital1 18**]
still intubated and sedated with an open abdomen and a right
chest tube for further management.
PAST MEDICAL HISTORY:
1. Morbid obesity with a BMI of 40.
2. Adult onset diabetes.
3. Asthma.
4. Hypertension.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. Total abdominal hysterectomy.
3. Umbilical hernia.
ADMISSION MEDICATIONS:
1. Glucophage.
2. Monopril.
3. Albuterol.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Upon presentation, the patient arrived
intubated and sedated with a temperature of 98.8. She had a
pulse of 98 and blood pressure of 100/42. She was saturating
100%. She was on SIMV 40% 02 and PEEP of 5. General: She
is an obese, pale woman who was intubated and sedated. She
had a normocephalic and atraumatic HEENT examination with
equal and reactive pupils, full extraocular movements. She
had distant heart sounds secondary to body habitus but
appeared to be in a regular rate and rhythm with no murmur
heard. Lungs: Her lung sounds were likewise distant with
decreased sounds at the right base. Abdomen: Her abdomen
was soft. There were no bowel sounds. It was obese. There
was an open wound with mesh dressing and serosanguinous
drainage from two JPs. She had 2+ pitting edema of her hands
bilaterally, trace edema of the arms and legs, with a wrist
brace on the right wrist. Neurologic: Unable to be assessed
secondary to sedation.
LABORATORY AND RADIOLOGIC DATA: The initial laboratories at
[**Hospital1 18**] showed a white blood cell count of 15.9, hematocrit
29.7, platelets 207,000. She had a Chem-7 with a sodium of
146, potassium 3.6, chloride 118, bicarbonate 21, BUN 22,
creatinine 0.9. She had glucose of 199. She had a PT of
13.8, PTT 24.5, and an INR of 1.3. Her fibrinogen was 872.
She had an ALT of 230, AST 117, and LDH of 590. Her alkaline
phosphatase was 88. Her amylase was 66, total bilirubin 3.0,
lipase 63, albumin 2.2, calcium 7.4, phosphate 1.4.
An ABG was performed and showed adequate oxygenation and
ventilation.
HOSPITAL COURSE: The patient remained in the ICU and was
transferred to the floor on hospital day number 15. The
remainder of the hospital course will be summarized by
system.
1. GASTROINTESTINAL: On the first day of admission, the
patient was taken to the OR for abdominal evaluation and
washout. She returned to the OR for washout on hospital day
number four and hospital day number 11. At each operative
intervention, she was given perioperative antibiotics. JP
drains were placed. Despite aggressive diuresis and repeated
OR visits, the abdomen was unable to be closed. The most
recent OR evaluation showed no signs of infection of the open
abdominal wound with slow healing by granulation tissue.
There is currently a mesh covering the abdominal wound.
Please see the operative notes for more detail.
At the time of this dictation, the plan is for the patient to
heal by secondary intention with granulation tissue.
Plastics has been consulted for future repair of the
abdominal wound with flap when deemed appropriate. She had
VAC dressing placement on hospital day number 17. It is
anticipated that she will be discharged to rehabilitation
with this VAC dressing in place and will follow-up with
plastics for further reevaluation of the healing process and
the appropriate timing for flap.
2. NEUROLOGIC: The patient arrived from the outside
hospital intubated and sedated. Sedation was weaned daily
and the patient was always responsive and moving all
extremities well. She was also able to follow commands.
After extubation on hospital day number 12, she was somewhat
confused and required frequent reorientation. By the time
she transferred to the floor, she was alert and oriented
times three.
3. RESPIRATORY: The patient was maintained on mechanical
assistance. She arrived intubated and sedated. She was
extubated successfully on hospital day number 12.
4. CARDIOVASCULAR: The patient was maintained on a Levophed
drip with a goal of mean arterial pressure under 65. This
was eventually discontinued on hospital day number 11 and she
was switched over to metoprolol 12.5 mg p.o. b.i.d. She was
diuresed aggressively with Lasix. Diamox was added as gases
indicated an alkalotic state. All diuretics were
discontinued by the time that the patient was transferred to
the floor. There were no events on the ICU telemetry.
Telemetry was continued 24 hours while she was on the floor
with no events and then discontinued.
5. HEMATOLOGY: The patient was admitted with a hematocrit
of 29. This decreased and remained stable at a hematocrit of
26. She received 2 units of packed red blood cells that were
transfused on [**2131-4-5**], hospital day number one, and
again 1 unit of packed red blood cells was transfused on
hospital day number eight. Her hematocrit has been stable at
approximately 26-28 since hospital day number eight.
6. GENITOURINARY: The patient has a Foley in place with
multiple urine cultures which have been negative.
7. ENDOCRINE: The patient was on insulin drip for glycemic
control while she was in the ICU. This was changed to a
regular insulin sliding scale when she was on the floor and
having a p.o. diet.
8. INFECTIOUS DISEASE: The patient was admitted and
promptly became febrile with elevated white count. She
intermittently spiked fevers since the time of her admission
to hospital day number three. She was initially started on
Zosyn and vancomycin but this was discontinued after
approximately four days of treatment. She was cultured
multiple times including surveillance cultures for MRSA which
were negative. All of the multiple cultures have been
negative except for blood cultures from hospital day number
seven. This revealed three out of four bottles positive for
Staphylococcus aereus. Sensitivities were not performed.
The patient was started on vancomycin on this day and is to
continue for a ten day course which will be complete on [**2131-4-23**].
During this time when she was febrile, central lines were
rewired and eventually resided even though catheter tips have
shown no growth. She currently has a right IJ which was
placed after documentation of positive blood cultures. At
the time of this dictation, hospital day number 17, the
patient has been afebrile for greater than 48 hours, the
longest period of time since her admission.
9. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
started on TPN when she initially arrived. Tube feeds were
initiated on hospital day number seven after bowel sounds
were noted and flatus was observed. An insulin drip was used
while the patient was in the ICU for glycemic control. Once
the patient was extubated, she was started on a clear diet on
hospital day number 14 and this has been slowly advanced to a
full diabetic diet. The patient has had some episodes of
loose stool on hospital 16 which has been sent for
Clostridium difficile. She remains on a regular insulin
sliding scale now that she is on the floor.
10. VASCULAR: A surveillance ultrasound of the lower
extremities was performed on hospital day number 12 and
revealed a thrombosis in the left greater saphenous vein.
The right leg was unremarkable. The presence of this clot
was close to the junction to enter the deep venous system,
although it is currently not in the deep venous system. The
ultrasound was repeated of the left leg two days later on
hospital day number 14 and was without change. Per Vascular
recommendations, the patient will continue on Lovenox at this
time and she will have a repeat ultrasound in one week which
will be hospital day number 21 which is [**2131-4-25**].
11. SPINE: A CT of the L spine was obtained and a consult
was also called for. The CT of the L spine showed left
transverse process fractures of L1 and L2 and a thoracic disk
protrusion at T11 and T12. There is also a right disk
osteophyte at L2 and L3. Final recommendations are pending
from the spine team at this time. She is to be fitted for a
TLSO brace when her abdominal issues are stable.
12. PROPHYLAXIS: The patient was placed on Lovenox on
hospital day number three. Prior to that, she had been on
subcutaneous heparin. Lovenox has been maintained throughout
her stay. She has received Prevacid during the times that
she was n.p.o. She has been on pneumatic boots bilaterally
which was changed to a pneumatic boot on the right side only
given the nature of her left thrombus.
13. FINAL SUMMARY: This is a 47-year-old woman who was
transferred from an outside hospital for management of her
biliary peritonitis. She also has multiple other injuries.
These other injuries are a hepatic contusion, grade III, a
right renal contusion, right hemothorax, right rib fractures,
I-12 posteriorly and displaced, a right scapular fracture,
and left transverse processes fractures of L1-3 and a right
thigh hematoma. She is currently status post four trips to
the OR and has an open abdominal wound that is unable to be
closed primarily. The plan for closure of this wound is to
allow granulation tissue to form and then to have a flap
placed by Plastics.
During the hospital stay here, the patient became bacteremic
and febrile. She is currently afebrile and will remain on a
ten day course of vancomycin, the last day of which is [**2131-4-23**]. She incidentally was found to have a thrombus of
her left greater saphenous vein close to the junction of the
deep venous vein system; however, it is not considered to be
a DVT. A repeat ultrasound for evaluation of this is to
occur on [**2131-4-25**]. She is currently on Lovenox. She is
being followed by Spine Surgery for management of her lumbar
transverse processes fractures. Specific recommendations are
pending.
At the time of this dictation, she is extubated successfully,
being cared for on the floor, alert and oriented times three,
taking solid foods, and has been afebrile for greater than 48
hours. Her activity is currently bed rest due to the open
abdominal wound and the risk of disrupting the site as well
as the unknown status of her transverse processes fractures.
It is anticipated that she will be able to go to
rehabilitation later this week to continue VAC dressing
changes and Physical Therapy evaluation. She will return per
Plastic Surgery recommendations for future grafting of her
abdominal wound site. The remainder of this discharge
summary will be dictated upon the patient's discharge from
the hospital.
This discharge summary encompasses the time from the
patient's admission from [**2131-4-5**] to hospital day
number 17, [**2131-4-21**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D.
[**MD Number(1) 10637**]
Dictated By:[**Last Name (NamePattern1) 37631**]
MEDQUIST36
D: [**2131-4-21**] 03:26
T: [**2131-4-21**] 16:17
JOB#: [**Job Number 56539**]
ICD9 Codes: 5185, 5849, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6678
} | Medical Text: Unit No: [**Numeric Identifier 67887**]
Admission Date: [**2173-6-18**]
Discharge Date: [**2173-7-28**]
Date of Birth: [**2173-6-18**]
Sex: M
Service: Neonatology
INTERIM HISTORY: Baby [**Name (NI) **] [**Known lastname 7568**] [**Known lastname **] is a 1370 gram male
boy who was born on [**2173-6-18**] at 31-4/7 weeks of
gestation. He has trisomy-21 and was admitted to the Neonatal
Intensive Care Unit for prematurity and respiratory distress.
Mother is a 29 year-old female, gravida I, para 0, I. Prenatal
screens were O positive, antibody negative, hepatitis B
negative, Rubella immune, RPR nonreactive and HSV negative.
Prenatal son[**Name (NI) 867**] did not show any structural heart
disease. Fetal ultrasounds did have indication for
echogenicities in the bowel that resolved on subsequent
ultrasounds. Mother received a full course of betamethasone
in mid-[**Month (only) 116**].
[**Known lastname 7568**] was delivered by cesarean section for worsening
uteroplacental insufficiency with absence of end diastolic
flow on the ultrasound. Rupture of membranes was at delivery
with clear fluid. Apgars were 7 and 9 at one and five minutes
respectively. He was vigorous, active with spontaneous
respirations at delivery.
Upon admission to the Neonatal Intensive Care Unit his weight
was 1370 grams (75%), length 41.5 cm (50%) and head
circumference 28 cm (50%). Vital signs: Heart rate 122,
temperature 97.9, respiratory rate 50s, blood pressure 77/43
and mean of 55. In general: Infant was a dysmorphic, premature
baby in mild respiratory distress. Anterior fontanelle open
and flat, wide set eyes, low -set ears and upslanting
palpebral fessures, flat occiput. CV: No murmurs. S1 and S2,
full femoral pulses. Pulmonary: he had retractions. No
flaring, grunting or tachypnea on room air. Coarse breath
sound decreased but equal bilaterally. Abdomen soft,
nondistended. Anus patent. Extremities warm, pink, well
perfused. Positive simian crease on upper extremities,
spacing between first and toes on lower extremities.
Genitourinary: Normal male genitalia, testes descended
bilaterally. Neurologic: Slightly decreased tone.
HOSPITAL COURSE BY SYSTEM:
Respiratory: He was placed initially on nasal CPAP with 21%
of FIO2 for 1 day and then was gradually weaned and changed
to room air. Initially he had some apnea, then bradycardia
especially with feeding but gradually resolved and currently
he is breathing room air and his respirations are between 40
to 60 breaths per minute. His last documented apnea or
bradycardia of prematurity was [**2173-7-17**].
Cardiology: Initially there was no murmur but during the
hospital stay he has had an intermittent soft systolic murmur
heard at the left sternal border. The femoral pulses are full
and positive bilaterally. His blood pressure is in the range
of 77/44 with a mean of 50 and his heart rate is between 140
to 150s. An electrocardiogram was done which showed slight
left axis deviation and an echocardiogram was revelaed a
small atrial septal defect versus patent foramen of ovale,
qualitatively normal left ventricular systolic function and
no pericardial effusion.
Fluids, Electrolytes and Nutrition: He was kept NPO for the
first day and given IV fluids. Feedings were gradually
started on the second day of life and IV fluids were weaned.
Currently, he is feeding Breast Milk at the breast or
expressed breast milk with 24 calories per ounce supplemented
with Similac Powder. He is also being sent home on Goldline
baby multivitamins. Discharge weight is 2555 grams.
During the hospital course he had hyperbilirubinemia and was
placed on phototherapy. The maximum bilirubin was 8.7 with a
direct of .3 on day of life 5. His last bilirubin was
7.0/0.3 on day of life 11 ([**2173-6-29**]).
Hematology: His last hematocrit was on [**2173-7-9**] which
revelaed a count of 42 with a reticulocyte count of 3.7. He
is being sent home on supplemental iron.
Infectious disease: He received oxacillin and gentamicin for 2
days. Blood culture were negative.
GI: He has a small umbilical hernia on exam.
Neurology: He had two head ultrasounds. The first on [**6-25**] did
not reveal any abnormlities. The second on [**7-19**] revealed a
small resolving subependymal bleed on the left.
Audiology: Hearing screen was performed on [**2173-7-27**] and
he passed in both ears.
Ophthalmology: The initial ophthalmology screen which was
done on [**2173-6-25**] revelaed immature retina to zone 3.
The repeat screen on [**2173-7-26**] showed mature retina.
Follow-up is recommended at 9 months of age.
Genetics: A chromosome study on [**6-22**] confirmed the diagnosis
of trisomy 21.
Social: The family was consulted by the [**Hospital1 190**] social worker. The social worker can be
reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Good.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 67888**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NNP
at the [**Location (un) 686**] House. (p) [**Telephone/Fax (1) 1260**] (f) [**Telephone/Fax (1) 67889**].
CARE/RECOMMENDATIONS:
1. Feeding: Breast Nilk and/or Similac 24 po ad lib.
2. Medications:
(a) Goldline baby multivitamins 1 ml po qday.
(b) Ferrous Sulfate (concentration 25 mg/ml) 0.4 ml po
qday.
3. Car seat position screen: Passed.
4. State newborn screening status: Samples sent [**7-2**] and [**7-28**].
No abnormal results have been reported.
5. Immunizations received: Hepatitis B vaccine on [**2173-7-18**].
Immunizations recommended:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3 criteria: 1) born at less than 32 weeks. 2)
born between 32 and 35 weeks with 2 of the following: Day
care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school
age siblings, or 3) with chronic lung disease.
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.
FOLLOW UP:
1. Pediatrician within 2 days of discharge.
2. Gentics/Down Syndrome Clinic at [**Hospital3 1810**]
([**Telephone/Fax (1) 47723**]).
3. Ophthamology at 9 months of age.
4. Bay Cove Early Intervention Program, [**Telephone/Fax (1) 43091**].
5. [**Location (un) 86**] VNA (f) [**Telephone/Fax (1) 37119**].
DISCHARGE DIAGNOSES:
1. Prematurity at 31 weeks of gestation.
2. Trisomy-21.
3. Transitional respiratory distress.
4. Hyperbilirubinemia.
5. Sepsis rule out.
6. Atrial Septal Defect versus Patent Foramen Ovale.
7. Small umbilical hernia.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 67890**]
MEDQUIST36
D: [**2173-7-26**] 14:18:42
T: [**2173-7-26**] 15:06:12
Job#: [**Job Number 67891**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6679
} | Medical Text: Admission Date: [**2106-8-19**] Discharge Date: [**2106-8-25**]
Date of Birth: [**2066-11-7**] Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending:[**First Name3 (LF) 16851**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain,
pulmonary, and hepatic mets. He underwent MRI this morning on
[**Hospital Ward Name 516**]. Shortly after receiving gadolinium contrast he
developed worsening RLQ abdominal pain, then developed shaking
of all 4 extremities. He reports that he was awake and alert
throughout the episode. He was noted to be alert and oriented x3
directly afterward. BP noted to be 70s/40s on machine and
manual recheck. He has had worsening RLQ pain for the last five
days.
Today he noticed his abdomen to be more distended than usual.
Approximately one week ago his oxycodone was increased. Last HD
session yesterday. Last round of chemotherapy was [**8-11**].
In ED, he received 2L NS but SBP still in 80s. Started
peripheral levophed at 0.09 with response to 100s-110s.
Initial VS in ED:
T 98.1 HR 105 BP: 104/68 RR 22 O2Sat 97 on 4L NC
In the ED, he started empiric vancomycin and cefepime for
broad-spectrum coverage. CT revealed significant progression of
his metastases (pulmonary, hepatic) but could not rule out
pneumonia. New ascites but no evidence of appendicitis or acute
abscess.
Initial VS in MICU:
T 98.5 HR 101 BP 105/72 RR 19 O2Sat 96% on 4L NC
Past Medical History:
Metastatic renal cell carcinoma:
-- [**2106-3-10**]: cough x 2 weeks
-- [**2106-4-15**]: Chest/Abd/Pelvis CT with pulm nodules, RUL mass,
mediastinal/hilar lymphadenopathy, retroperitoneal adenopathy
-- [**2106-5-3**]: Brain MRI with lesions in R choroid plexus, L
parieto-occipital junction, L frontal lobe
-- [**2106-5-5**]: VATS wedge resection of RUL mass; path confirmed
renal cell carcinoma with clear cell features as well as the
presence of a TFE3 gene fusion
-- [**2106-6-10**]: CyberKnife radiosurgery to brain met
-- [**2106-7-23**]: CyberKnife radiosurgery to brain met
ESRD - secondary to focal glomerulonephritis, on HD since [**2089**]
HTN
Anxiety
Past Surgical History:
-multiple AV fistula placements/repairs
-2 breast reduction procedures
-2 operations for undescented testes
-right orchiectomy
-kidney biopsy
-repair of a ruptured quadriceps tendon
Social History:
Mr. [**Known lastname **] is single. He is currently on disability. Smoked 1PPD
x 20yrs and quit approximately one month ago. Prior history of
alcohol dependence, but quit approximately four years ago. He
has been living with friends in [**Name (NI) 1110**].
Family History:
His mother is healthy at age 60. His father died at age 48 from
throat cancer (he consumed cigarettes and alcohol) and colon
cancer. His sister and brother are healthy but another brother
has the "gene" for colon cancer and gets yearly check ups
Physical Exam:
At [**Hospital Unit Name 153**] admission:
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. JVP flat.
Lungs: Shallow breathing with accessory muscle use. Distant
breath sounds, crackles at bilateral bases, no wheezes, rales,
ronchi. Posterior lung fields not examined due to patient's
pain attempting to sit up.
Abdomen: Distended, tense, diminished bowel sounds. Nontender
to palpation.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. AV fistula in RUE; scars of prior AV fistula in LUE. R
hand exquisitely tender to palpation.
Neuro: CNII-XII intact, 2+ reflexes bilaterally, gait deferred.
At discharge:
VS: 97.4 92/60 97% on 2L pain 3
GEN: nad, laying in bed
NECK: supple
HEENT: op clear, poor dentition
CHEST: faint wheezing anteriorly
CV: rrr no m/r/g
ABD: distended
EXT: feet tender (chronic) no edema
NEURO: AAOx3
PSYCH: appropriate, pleasant
Pertinent Results:
CT C/A/P on admission:
1. New enhancing hepatic mass and increased number and size of
pulmonary
nodules at the lung bases compatible with worsening metastatic
disease.
Several osseous metastatic lesions with soft tissue components
are not
significantly changed in the interval.
2. Worsening diffuse septal thickening, likely reflective of
worsening
pulmonary edema, though lymphangitic carcinomatosis is not
excluded. Small
bilateral pleural effusions, right larger than left.
3. New moderate volume ascites.
4. Atrophic kidneys with multiple cysts, likely related to
dialysis.
Dominant, peripherally calcified complex cystic lesion in the
right upper pole
of the kidney could reflect the patient's primary renal
carcinoma.
[**2106-8-24**] 09:36AM BLOOD WBC-4.3# RBC-3.18* Hgb-9.2* Hct-29.6*
MCV-93 MCH-29.0 MCHC-31.1 RDW-18.6* Plt Ct-204
[**2106-8-24**] 09:36AM BLOOD Glucose-95 UreaN-22* Creat-6.5*# Na-140
K-4.2 Cl-102 HCO3-26 AnGap-16
[**2106-8-24**] 09:36AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8
[**2106-8-20**] 10:53AM ASCITES WBC-2050* RBC-1475* Polys-80* Lymphs-3*
Monos-14* Atyps-0 Mesothe-3*
Brief Hospital Course:
Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain,
pulmonary, and hepatic mets admitted to the MICU with
hypotension after receiving gadolinium during MRI on day of
admission.
Active Issues:
---------------
# Septic shock: [**3-11**] SBP: He met SIRS criteria (HR, RR, WBC)on
admission and required levophed after 2L NS with most likely
etiology SBP. He was treated with ceftriaxone (see SBP for
further details). Hypersensitivity reaction to gadolinium has
been described but is rare, and he has previously received
gadolinium. He received HD to remove gadolinum once he was
hemodynamically stabilized. Adrenal insufficiency was ruled
out. His shock resolved and he was transferred to the general
medical floor without any further infectious issues.
# SBP: He completed a course of ceftriaxone and given albumin on
day 1 and day 3. He will continue on norfloxacin for
prophylaxis.
#New Onset Ascites: likely due to new hepatic mets and or
carcinomatosis. No portal or splenic vein thrombosis seen.
# ESRD: The patient received HD to remove gadolinum for MRI .
He then continued on a MWF HD schedule. He had difficulty
removing fluid during HD due to hypotension, which had been a
problem at his out patient facility as well and so he was
started on midorine.
# Pain: pt with groin, leg, feet, back and abdominal pain. Pain
regimen adjusted to increased home oxycontin dose, continued
home oxycodone, tramadol, started naproxen and tylenol around
the clock.
# HTN: pt remained normo-tensive with his baseline SBP in the
100s. He was not discharged on his previous anti-hypertensive,
nifedipine.
# Anemia: likely [**3-11**] chronic disease and chemo. No evidence of
bleeding.
- cont epo
# Metastatic renal cell CA: Pt had been followed by Dr. [**Last Name (STitle) 22658**] in
[**Location (un) 1110**]. Will establish care in [**Location (un) 86**] with Dr. [**Last Name (STitle) **]. His
records from Dr. [**Last Name (STitle) 22658**] were faxed to the new office on the day
of discharge. He was found to have progression of known brain
and pulmonary mets and new hepatic mets during admission.
Patient and mother are aware of this. Pt expressed wishes to be
resuscitated but not intubated. Explained that this was not
possible. Discussed his poor prognosis of weeks to months and
the likelyhood of suscessful resuscitation would be at most 5%.
Patient stated that he would remain full code for now and would
discuss it with his friends and mother.
Medications on Admission:
NIFEDIPINE 60 mg QSunday/Tues/Thurs
OXYCODONE-ACETAMINOPHEN PRN
TRAMADOL 50 mg TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Midodrine 5 mg PO TID
4. Naproxen 500 mg PO Q12H
5. Nephrocaps 1 CAP PO DAILY
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
hold for sedation
7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
hold for sedation or RR<10,
8. Polyethylene Glycol 17 g PO DAILY
Hold if patient having daily BMs.
9. Senna 1 TAB PO BID constipation
10. TraMADOL (Ultram) 50 mg PO TID
11. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
12. norfloxacin *NF* 400 mg Oral daily SBP prophylaxis
Discharge Disposition:
Expired
Facility:
[**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **] Center
Discharge Diagnosis:
spontaneous bacertial peritonitis
new hepatic metastasis of renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted due to an infection in your abdomen which has
been treated.You will require prophylactic antibiotics from now
on to prevent this infection from returning.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2106-8-31**] at 4:00 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 0389, 5856, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6680
} | Medical Text: Admission Date: [**2132-11-13**] Discharge Date: [**2132-11-18**]
Date of Birth: [**2070-10-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
anxiety attacks" associated with chest tightness
Major Surgical or Invasive Procedure:
[**2132-11-14**] Urgent coronary artery bypass graft x4: Left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to diagonal obtuse marginal and distal right
coronary arteries
[**2132-11-13**] Cardiac cath
History of Present Illness:
62 year old male has a history of hypertension, dyslipidemia,
type 2 diabetes and CAD s/p OM1 stenting in [**2122**]. Over the past
six months the patient has been having episodes of what he
describes as "anxiety attacks", associated with chest tightness.
Many of these episodes have correlated with exertion although
several months ago he did have some episodes that woke him from
sleep. Last evening while taking the dogs out into his back yard
he had additional chest tightness, unassociated with any other
symptoms. Stress testing in [**2132-9-15**] revealed new septal
hypokinesis with exercise. He was referred for left heart
catheterization. He was found to have three vessel diseae and is
now being referred to cardiac surgery for revascularization.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graft
Diabetes Mellitus type 2
Hyperlipidemia
Secondary diagnosis
Hypertension
Anemia
Fatty liver
Erectile dysfunction
Social History:
Race:Caucasian
Last Dental Exam:3 years ago
Lives with:Wife
Contact:[**Name (NI) 22678**] (wife) Phone #[**Telephone/Fax (1) 22679**]
Occupation:Chef
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: denies
Illicit drug use: denies
Family History:
Father with MI at age 62
Physical Exam:
Pulse:53 Resp:18 O2 sat:99/RA
B/P Right:127/62 Left:133/76
Height:5'7" Weight:185 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _no____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: cath site Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2132-11-13**] Cath: 1) Selective coronary angiography of this
right-dominant system demonstrated severe 3 vessel CAD. The
distal LMCA had 70-80% stenosis. The origin and proximal segment
of the LAD had diffuse 80% disease with good distal targets. The
mid LCX stents were subtotally occluded with probable good
targets distal to the stents. The RCA was totally occluded at
the origin with left-to-right collaterals. 2) Limited resting
hemodynamics revealed normal systemic arterial pressures with a
central aortic pressure of 111/61 with a mean of 73mmHg. 3)
Refer for CABG
[**2132-11-14**] Carotid U/S: Right ICA 80-99% stenosis. Left ICA 70-79%
stenosis.
[**2132-11-14**] Echo: PRE-BYPASS: 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 atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF=35 %). with normal free wall contractility.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. There
is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results before surgical
incision.
POST_BYPASS: Normal RV systolic function. Overall LVEF 40% to
45% Mild MR>
Intact thoracic aorta. Prebypass hypokinetic lateral wall seem
to be moving well.
[**2132-11-17**] 04:48AM BLOOD WBC-7.3 RBC-3.60* Hgb-10.8* Hct-30.7*
MCV-85 MCH-30.1 MCHC-35.2* RDW-13.8 Plt Ct-136*
[**2132-11-16**] 04:13AM BLOOD WBC-9.1 RBC-3.84* Hgb-11.5* Hct-31.3*
MCV-82 MCH-29.9 MCHC-36.7* RDW-14.3 Plt Ct-140*
[**2132-11-18**] 08:54AM BLOOD Glucose-352* UreaN-27* Creat-1.0 Na-139
K-4.6 Cl-97 HCO3-31 AnGap-16
[**2132-11-17**] 04:48AM BLOOD Glucose-115* UreaN-19 Creat-0.9 Na-138
K-3.5 Cl-97 HCO3-34* AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 17684**] was admitted following his cardiac cath which revealed
severe three vessel coronary artery disease. He underwent
pre-operative work-up and on [**11-14**] was brought to the operating
room where he underwent a coronary artery bypass graft x 4.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. He did show Right Upper Lobe collapse on
CXR, which resolved. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
Glyburide and Metformin were titrated for blood glucose
management. The patient will keep a blood glucose log on
discharge to present to his PCP. [**Name10 (NameIs) **] 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, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home with VNA
in good condition with appropriate follow up instructions.
Medications on Admission:
ATENOLOL 50 mg Daily
ATORVASTATIN80 mg Daily
COLCHICINE 0.6 mg Daily
FLUOXETINE 40 mg Daily
GLYBURIDE 5 mg [**Hospital1 **]
LISINOPRIL 40 mg Daily
METFORMIN 1000 mg [**Hospital1 **]
NAPROXEN 500 mg twice a day as needed for pain, take with food
NIFEDIPINE 90 mg Daily
NITROGLYCERIN 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually daily as needed for chest pain, may repeat in 5
minutes, call 911, proceed to Emergency
TADALAFIL [CIALIS] 20 mg [**2-17**] to one Tablet(s) by mouth daily as
needed; do not take ntg while taking cialis
ASPIRIN 325 mg Daily
MULTIVITAMIN Dosage uncertain
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*1*
5. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
10. glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*1*
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*1*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 1
weeks: to be reevaluated at wound check [**11-27**].
Disp:*7 Tablet(s)* Refills:*0*
13. Diabetes
Glucometer
Lancets
Test Strips
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft
Past medical history:
Hyperlipidemia
Hypertension
Diabetes Mellitus Type 2
Anemia
Fatty liver
Erectile dysfunction
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema no lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] [**2132-12-22**] 1:00 pm
Cardiologist: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] Date/Time:[**2132-11-28**] 2:40
Wound check with cardiac surgery [**Telephone/Fax (1) 170**] Date/Time:[**2132-11-27**]
10:30
at [**Hospital **] medical building
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**5-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2132-11-18**]
ICD9 Codes: 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6681
} | Medical Text: Admission Date: [**2115-4-30**] Discharge Date: [**2115-5-8**]
Date of Birth: [**2067-12-7**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Ceclor
Attending:[**First Name3 (LF) 16769**]
Chief Complaint:
ESRD on hemodialysis s/s SFSGS
Major Surgical or Invasive Procedure:
Living related kidney transplant [**2115-4-30**]
History of Present Illness:
Ms. [**Known lastname 2816**] is a 47year old female with ESRD secondary to FSGS.
She had 0nset of kidney disease at age 3 and started dialysis
two year later. She had initial dialysis by PD tolerated by
hemodialysis via neck catheter and right upper arm fistula.
Past Medical History:
ESRD secondary to FSGS
aortic endocarditis
ITP
PSH:
s/p AVR [**1-2**]
R knee '[**10**]
L elbow '[**11**]
splenectomy '[**83**]
Social History:
+tobacco
Physical Exam:
NAD
RRR
CTAB
s/nt/nd
no c/c/e
Pertinent Results:
[**5-1**] Renal u/s
"1) Renal artery outside of the parenchyma is very tortuous and
pulsatile which is probably the cause of turbulent color flow in
the renal hilum. There is no evidence of AV fistula. The peak
systolic velocities may be slightly increased. Although, these
findings could be artifactual due to tortuosity of this vessel,
if renal function deteriorates, recommend imaging wiht MRA, CTA,
or angiogram.
2) Normal intra-renal artery waveforms with RIs in expected
range. This is improved when compared to the study performed
yesterday."
[**2115-4-30**] 06:03PM PT-15.4* PTT-26.1 INR(PT)-1.6
[**2115-4-30**] 02:37PM GLUCOSE-115* UREA N-37* CREAT-6.6* SODIUM-138
POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-17
[**2115-4-30**] 02:37PM PHOSPHATE-4.1# MAGNESIUM-1.6
[**2115-4-30**] 02:37PM WBC-5.2 RBC-3.15* HGB-10.7* HCT-32.7*
MCV-104* MCH-34.1* MCHC-32.9 RDW-17.2*
[**2115-4-30**] 02:37PM PLT COUNT-278
[**2115-4-30**] 08:15AM PT-15.6* PTT-28.8 INR(PT)-1.6
TOXICOLOGY, SERUM AND OTHER DRUGS FK506
[**2115-5-7**] 06:15AM 12.71
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2115-5-8**] 05:42AM 3.4* 2.61* 8.9* 26.9* 103* 34.3* 33.2
17.2* 156
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2115-5-8**] 05:42AM 156
[**2115-5-8**] 05:42AM 20.7*1 37.8* 2.8
1 NOTE NEW NORMAL RANGE AS OF 12 AM [**2115-4-27**]
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2115-5-8**] 05:42AM 68* 87* 3.8* 140 5.6* 113* 19* 14
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2115-5-8**] 05:42AM 3.1* 8.1* 4.7*
TOXICOLOGY, SERUM AND OTHER DRUGS FK506
[**2115-5-8**] 05:42AM PND
Brief Hospital Course:
Ms. [**Known lastname 2816**] was taken to the OR on [**2115-4-30**]. Please see Dr. [**Name (NI) 16770**] Operative Note for detail. Intra-operatively, she was
noted to have minimal urine output. In the PACU, she continued
to have minimal urine output of only 8cc and 9cc for the first
two hours. She was given Lasix 80mg IV but with poor response,
again only putting out 9cc of urine. Ms. [**Known lastname 2816**] also had low
systolic blood pressures and was unable to maintain a systolic
blood pressure greater than 110mmHg with fluid boluses. She was
started on a Dopamine drip but she failed to respond
appropriately. She was then switched to a Neosynephrine drip
and her systolics increased to 120s-130s. Once these pressures
were achieved, Ms. [**Known lastname 2816**] began to have brisk urine output
300-500cc per hour.
On POD#1, because she still required a Neo drip, Ms. [**Known lastname 2816**] was
transferred to the SICU. She did well in the PACU, with
continued brisk urine output and weaned off the Neo drip. She
was transferred to the floor on POD #2. Her daily urine
creatine to protein ratios were followed by the renal team. She
was continued on a heparin drip given her AVR -- she was
transitioned to Coumadin, starting on POD #5, and by POD #6 had
a therpautic INR and her heparin drip was stopped.
On POD #7 her JP drain was pulled.
Throughout her hospital course she was on MMF and Tacrolimus,
with her FK levels appropriately adjusted by daily levels.
At the time of discharge, Ms. [**Known lastname 2816**] was voiding without
difficulty, had good pain control, a therapeutic INR, and
adquate FK levels. She was discharged home with explicit
follow-up instructions.
Medications on Admission:
Nephrocaps, Phoslo, Renagel, Xanax, Epogen,
Zestril, Lipitor, Lasix.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
4. Diphenhydramine HCl 25 mg Capsule Sig: [**12-30**] Capsules PO Q12H
OR QHS PRN () as needed for sleep.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QOD
().
7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day)
11. Epogen 10,000 unit/mL Solution Sig: One (1) Injection once
a week.
Disp:*5 * Refills:*2*
12. Warfarin Sodium (Coumadin)2mg tablet: take one tablet every
day
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD secondary to focal segmental glomerular sclerosis
Living related kidney transplant [**2115-4-30**]
s/p Aortic valve replacement [**2115-1-2**]
Discharge Condition:
stable. good
Discharge Instructions:
Call if fevers, chills, nausea, vomiting, inability to take
medications, increased drainage from JP drain, decreased urine
output or increased abdominal pain. [**Telephone/Fax (1) 697**]
Labs every Monday & Thursday for cbc, chem 7, calcium,
phosphorus, ast, t.bili, urinalysis, PT, PTT, INR, and trough
prograf level. Fax results immediately to transplant office
[**Telephone/Fax (1) 697**]
Collect 24 hour urine output starting 6am [**5-9**] after first
voiding. End collection Friday at 6 am. Bring 24 hour urine
collection to transplant office on Friday [**5-10**]
No driving while taking pain medication
no heavy lifting
may shower with soap & water.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-5-10**] 1:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-5-17**] 9:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-5-24**] 2:00
Completed by:[**2115-5-8**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6682
} | Medical Text: Admission Date: [**2180-4-22**] Discharge Date: [**2180-4-24**]
Date of Birth: [**2105-6-27**] Sex: F
Service: SURGERY
Allergies:
Aspirin / Ampicillin / Penicillins / Latex
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Increase in drainage at thyroidectomy and parathyroidectomy site
and shortness of breath.
Major Surgical or Invasive Procedure:
Drainage of seroma
Direct laryngoscopy
History of Present Illness:
74 yo female presented to the emergency department four days s/p
thyroidectomy and parathyroidectomy complaining of increased
drainage from the surgical site and shortness of breath. She
reported shortness of breath since her procedure and presented
with some new tightness in the throat.
Past Medical History:
PMH: Hepatitis C, DM, HTN, Erythema nodosum, Thyroid goiter,
urinary incontience, diabetic neuropathy, obesity
PSH: open CCY with IOC
Social History:
No alcohol or drug use. Lives alone, has involved family and
assistance from a home health aide.
Physical Exam:
On presentation:
99.7, HR 100, 123/104, 20, 97%
Constitutional: Mild difficulty breathing
HEENT: Anicteric
Thyroid incision intact with mild surrounding induration
and serosanguineous drainage from lateral aspect of wound.
Chest: Prominent upper airway sounds and mild stridor.
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Pelvic: Normal
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Pertinent Results:
[**2180-4-24**] 06:50AM BLOOD WBC-12.7*# RBC-4.45 Hgb-13.1 Hct-39.1
MCV-88 MCH-29.4 MCHC-33.4 RDW-12.8 Plt Ct-358
[**2180-4-23**] 04:57AM BLOOD WBC-6.3# RBC-4.20 Hgb-12.5 Hct-38.0
MCV-91 MCH-29.9 MCHC-33.0 RDW-13.1 Plt Ct-284
[**2180-4-22**] 12:20PM BLOOD Neuts-78.9* Lymphs-13.8* Monos-5.6
Eos-1.2 Baso-0.6
[**2180-4-23**] 04:57AM BLOOD Glucose-182* UreaN-25* Creat-0.7 Na-142
K-3.5 Cl-106 HCO3-23 AnGap-17
[**2180-4-22**] 12:20PM BLOOD Glucose-109* UreaN-22* Creat-0.9 Na-142
K-3.9 Cl-102 HCO3-25 AnGap-19
[**2180-4-24**] 06:50AM BLOOD Calcium-7.6* Phos-2.7 Mg-2.0
[**2180-4-23**] 04:57AM BLOOD Calcium-7.8* Phos-4.2# Mg-1.9
[**2180-4-22**] 12:29PM BLOOD pH-7.44 Comment-GREEN TOP
[**2180-4-22**] 12:29PM BLOOD Lactate-1.5 K-5.1
[**2180-4-22**] 12:29PM BLOOD freeCa-0.92*
Brief Hospital Course:
The patient was seen in the emergency department by ENT. Neck
films showed fluid or hematoma projecting into the airway. ENT
visualized airway by laryngoscope which revealed significant
soft tissue edema which was attributed to recent intubation. The
appearance of the patience neck without erythema or purulent
drainage indicated seroma as most likely diagnosis. The seroma
was drained in the emergency room and the patient received IV
Decadron and IV antibiotics, she was stabilized in the emergency
department and then transferred to the [**Hospital Unit Name 153**] for further
monitoring of the airway. Gram stain of the fluid of the seroma
showed leukocytes and no microorganisms. Preliminary culture of
the wound showed sparse growth of beta streptococcus group B.
The patients stay in the [**Hospital Unit Name 153**] was uneventful, wicks were placed
in the anterior neck wound and she was transferred to the
inpatient floor for further monitoring.
The patients stay on the inpatient floor was uneventful. The
wound was changed as ordered, and appeared stable. The patients
laboratory values were stable and she was discharged home
[**2180-4-24**] with appropriate discharge instruction.
Medications on Admission:
Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day.
Metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
Ursodiol 250 mg Tablet Sig: One (1) Tablet PO three times a day.
Discharge Medications:
1. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
7. Ursodiol 250 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO twice a day.
Disp:*180 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Seroma
Supraglottic edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for a fluid collection in the incision of your
thyroidectomy. This fluid collection as well as irritation to
your throat caused you to have some difficulty breathing. You
were admitted to the ICU for airway mointoring, and with some
medications and draining of the fluid collection you were able
to breath easily. You were found to have a fluid collection
known as a seroma. A seroma is a collection of fluid under the
skin that can develop after surgery. There is not an infection
in this fluid and you do not need antibiotics. This fluid
collection was drained, wicks were placed in the wound and you
are now stable to be discharged home. It is important that you
monitor the wound for signs of infeciton incliding: increasing
redness, increased pain not relieved with medication, or white,
green or light pink drainage. The wick will need to be chagned
twice daily and please apply sterile dry gauze to the wicked
area three times daily. You will be referred to visiting nurses
who will monitor the wound and assist you with the dressing.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] in one week. Call ([**Telephone/Fax (1) 9011**] to
make an appointment.
Completed by:[**2180-4-24**]
ICD9 Codes: 3572, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6683
} | Medical Text: Admission Date: [**2189-2-23**] Discharge Date: [**2189-3-2**]
Date of Birth: [**2136-8-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Patient admitted for weight reduction surgery.
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Bypass with umbilical hernia
repair with mesh. On [**2189-2-25**] patient taken back to operating
room for bleeding.
History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight of 317.9 lbs as
of
[**2188-11-24**] (his initial screen weight on [**2188-8-5**] was 309.9 lbs),
height of 71 inches and BMI of 44.3. His previous weight loss
efforts have included self-diets and monitoring. He has not done
any formal programs, taken prescription weight loss medications
or used over-the-counter ephedra-containing appetite
suppressants/herbal supplements. His weight at age 21 was 200
lbs
his lowest adult weight with his highest weight being his
current
weight of 317.9 lbs.
Past Medical History:
PMH: HTN, IDDM, severe OSA on CPAP (on 11), dyslipidemia, GERD,
ED [**2-2**]
testosterone deficiency, OA/joint pain (esp R knee), umbilical
hernia, acute pancreatitis (hospitalized [**2-/2187**]), trigger finger
release [**2185**], osteotomy [**2166**], ?ligament repair
Social History:
He used to smoke one pack per day cigarettes for 17 years quit
in [**2172**], no recreational drugs, has 4 bottles of beer weekly,
drinks 12- ounce cup of
coffee 3-4 times a day and has 12-ounce diet soda daily. He is
currently unemployed but occasionally does minimal home repairs.
He is married living with his wife age 50 a software engineer
and their 2 sons ages 24 and 27.
Family History:
Family history is noted for father deceased age 72 of heart
disease
(CHF); mother deceased age 38 of pneumonia and EtOH abuse; has 4
siblings with one sister age 53 living with obesity and another
with EtOH abuse.
Physical Exam:
His blood pressure was 146/76, pulse 78 and O2 saturation 97%
room air. On physical examination [**Known firstname **] was casually dressed in
no distress. His skin was warm, dry, few skin tags and acneiform
lesions, no rashes. Sclerae were anicteric, conjunctiva clear,
pupils were equal round and reactive to light, fundi normal with
sharp optic disks no retinal hemorrhages, mucous membranes were
moist, tongue pink and the oropharynx was without exudates or
hyperemia. Trachea was in the midline and the neck was supple
without adenopathy, thyromegaly or carotid bruits. Chest was
symmetric and the lungs clear to auscultation bilaterally with
good air movement. Cardiac exam was regular rate and rhythm with
normal S1 and S2, no murmurs, rubs or gallops. The abdomen was
obese but soft and non-tender, non-distended with normal bowel
sounds, no masses, there is 4 cm large reducible umbilical
hernia, no incision scars. There was no spinal tenderness or
flank pain. Lower extremities were noted for bilateral mild
venous insufficiency, trace edema and no clubbing. There was no
evidence of joint swelling or inflammation of the joints. There
were no focal neurological deficits and his gait noted light
limp.
Pertinent Results:
[**2189-2-24**] 07:05AM BLOOD WBC-12.3*# RBC-3.30*# Hgb-9.9*#
Hct-29.2*# MCV-88 MCH-29.9 MCHC-33.9 RDW-14.4 Plt Ct-386
[**2189-2-24**] 03:50PM BLOOD WBC-10.9 RBC-3.08* Hgb-9.3* Hct-27.0*
MCV-88 MCH-30.2 MCHC-34.5 RDW-14.5 Plt Ct-321
[**2189-2-25**] 06:00AM BLOOD WBC-11.4* RBC-2.50* Hgb-7.5* Hct-21.6*
MCV-87 MCH-30.0 MCHC-34.6 RDW-14.7 Plt Ct-277
[**2189-2-25**] 09:20AM BLOOD Hct-22.0*
[**2189-2-26**] 02:04AM BLOOD WBC-10.7 RBC-2.84* Hgb-8.6* Hct-24.9*
MCV-88 MCH-30.2 MCHC-34.5 RDW-15.1 Plt Ct-256
[**2189-2-27**] 05:45AM BLOOD WBC-10.5 RBC-2.83* Hgb-8.5* Hct-25.0*
MCV-88 MCH-30.1 MCHC-34.1 RDW-15.5 Plt Ct-249
[**2189-3-1**] 08:35AM BLOOD WBC-10.2 RBC-2.97* Hgb-8.8* Hct-25.8*
MCV-87 MCH-29.8 MCHC-34.2 RDW-15.1 Plt Ct-340
[**2189-2-28**] 06:05AM BLOOD Glucose-111* UreaN-19 Creat-0.5 Na-141
K-3.7 Cl-104 HCO3-28 AnGap-13
[**2189-2-24**] UGI [**2-24**]
IMPRESSION: Free passage of oral contrast from the gastric pouch
into the
non-dilated loops of jejunum, without evidence of anastomotic
leak at the
gastrojejunostomy.
UGI [**2189-2-26**]
Free passage of contrast into the gastric pouch without evidence
of leak. However, severe stenosis of the gastrojejunal
anastomosis with
minimal passage of contrast into the jejunum. Free reflux of the
gastric
pouch contents into the upper esophagus. The patient was kept in
a semi-
upright position for concern of aspiration.
KUB [**2189-2-27**]
No remaining contrast seen within the area of the gastric pouch.
Residual contrast seen within the colon to the level of the
rectum.
R Duplex [**2189-2-27**]
Duplex and color Doppler demonstrate no right upper extremity
DVT
either acute or chronic.
Brief Hospital Course:
Patient admitted and underwent a laparoscopic gastric bypass on
[**2189-2-23**]. He tolerated the procedure well, however his
postoperative course was complicated by a low urine output and a
falling hematocrit. His hct. dropped from 29.2 to 21.6 so it was
decided to take him back to the operating room for open
abdominal exploration
with clot evacuation and Gastrostomy tube procedure. He
recovered in the intensive care unit for approximately 24 hours
and then was transferred back to floor. His blood level remained
stable and he was progressed from a stage one to stage 3 diet
without problems.
We will discharge him to home with follow up with Dr. [**Last Name (STitle) **]
and the bariatric clinic. He will go home with a g-tube and
instruction has been given to him regarding this. He will also
go home with metformin and 25 units of glargine qHS [**First Name8 (NamePattern2) **] [**Last Name (un) **].
He will monitor his blood sugars and speak/visit with his
endocrinologist in one week.
Medications on Admission:
Lisinopril 40', Felodipine 10', Metoprolol 50'', HCTZ 25', NPH
15U qAM/15U qnoon/20U qPM, Lispro ISS, Metformin 1000''; Crestor
10', Omeprazole 20', ASA 81', Viagra 100''prn, MVI
Discharge Medications:
1. Roxicet 5-325 mg/5 mL Solution Sig: [**5-10**] ml PO every four (4)
hours as needed for pain.
Disp:*500 ml* Refills:*0*
2. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as
needed for constipation.
Disp:*500 ml* Refills:*0*
3. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day:
Please take for 6 months. You must open capsule and place in
drink.
Disp:*60 Capsule(s)* Refills:*5*
4. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day: Please
take for one month.
Disp:*600 ml* Refills:*0*
5. Diabetes Regimen
Please check your fingerstick blood sugars 4 times a day andn
log. Please hold your NPH insulin and follow up with your
primary care or endocrinologist in one week. You may continue
your metformin.
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day:
Please crush.
7. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day:
Please crush.
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Please crush.
10. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day:
Please crush.
11. HCTZ
Please hold and follow up with your primary care in one week to
assess need.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Obesity
Discharge Condition:
Stable.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. 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.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**10-15**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2189-3-12**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2189-3-12**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2189-4-24**] 9:00
Please follow up with your primary care provider [**Name Initial (PRE) **]/or
endocrinologist in one week.
Completed by:[**2189-3-2**]
ICD9 Codes: 2851, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6684
} | Medical Text: Admission Date: [**2131-4-2**] Discharge Date: [**2131-4-11**]
Date of Birth: [**2065-10-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Valium / Darvon / Latex
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest and left lateral back pain
Major Surgical or Invasive Procedure:
Asc Ao Aneurysm repair
[**Last Name (NamePattern4) 15255**] of Present Illness:
Mrs. [**Known lastname **] is a delightful 65 year old woman who back in
[**2130-12-27**] with a 6 month history of epigastric and left
lateral chest and back pain. A CT scan showed an enlarged aorta.
A cardiac catheterization was performed which showed no
significant coronary artery disease. She was subseqquently
referred to Dr. [**Last Name (Prefixes) **] for suirgical management. She is
admitted to day for preoperative testing and surgery.
Past Medical History:
Ascending aortic aneurysm
Hypertension
Hypercholesterolemia
Depression
Anxiety
Social History:
Smoked 1 pack per day for 47 years. SHe does not drink alcohol.
Lives with partner and has two daughters.
Family History:
Noncontributory
Physical Exam:
VITALS: 57 SB, BP: (L) 130/60, (R) 118/59 96% RA sat
NEURO: Alert, no focal deficits
CARDIAC: Regular rate and rhythm, No murmur
LUNGS: Clear
ABDOMEN: Soft, nontender, nondistened. Normoactive bowel sounds
EXTEMITIES: No edema, no varicosities
PULSES: 2+ femoral, 1+ dorsalis pedis and posterior tibial.
Pertinent Results:
[**2131-4-2**] 05:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM
[**2131-4-2**] 05:02PM URINE RBC-0 WBC-[**7-6**]* BACTERIA-FEW YEAST-NONE
EPI-0
[**2131-4-2**] 05:50PM PT-12.6 PTT-26.4 INR(PT)-1.0
[**2131-4-2**] 05:50PM WBC-5.8 RBC-3.98* HGB-12.2 HCT-35.0* MCV-88
MCH-30.6 MCHC-34.8 RDW-14.0
[**2131-4-2**] 05:50PM ALT(SGPT)-26 AST(SGOT)-37 ALK PHOS-85
AMYLASE-33 TOT BILI-0.4
[**2131-4-2**] 05:50PM GLUCOSE-99 UREA N-21* CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-31* ANION GAP-14
[**2131-4-2**] CXR
1. No acute cardiopulmonary disease.
2. Stable tortuosity of the thoracic aorta consistent with an
ascending aortic aneurysm.
[**2131-4-10**] CXR
Disappearance of tiny left apical pneumothorax. Persistent
enlargement of the heart shadow and left lower lobe densities
consistent with postoperative remaining pericardial effusion,
left lower lobe atelectasis and pleural densities. Further
followup to document embolization is recommended.
[**Last Name (NamePattern4) 4125**]ospital Course:
Ms. [**Known lastname **] was admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2131-4-2**] for surgical management of her aortic aneurysm.
She was worked-up in the usual preoperative manner. The
psychiatry service was consulted for her anxiety. It was
recommended that Ms. [**Known lastname **] continue her paxil and ativan as per
her at home doses. Levofloxacin and flagyl were started for a
urinary tract infection. The infectious disease service was
consulted and it was felt that her initial urinalysis was a
vaginal contaminant. Repeat urinalysis was performed and she was
cleared for surgery by the infectious disease service. On
[**2131-4-3**], Ms. [**Known lastname **] was taken to the operating room where she
underwent an ascending aorta replacement utilizing a 26 mm
gelweave graft. Postoperatively she was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, Ms. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. She was transfused with packed red blood cells for
postoperative anemia. On postoperative day two, she was
transferred to the cardiac surgical step down unit for further
recovery. Ms. [**Known lastname **] was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility. Her
pacing wires and drains were removed per protocol. Beta blockade
was titrated for optimal heart rate and blood pressure control.
Her diuretic was switched to hydrochlorothiazide for fluid
management. Ms. [**Known lastname **] developed wheezing with ambulation. A
chest x-ray showed a moderate left pleural effusion.
Thoracentesis was performed which drained 700 cc's of fluid with
good effect. Ms. [**Known lastname **] continued to make steady progress and
was discharged home on postoperative day eight. She will
follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist and her primary
care physician as an outpatient.
Medications on Admission:
Lipitor 20mg daily
Hydrochlorothiazide 50mg once daily
Multivitamin daily
Atenolol 50mg once daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
s/p Asc Aortic Aneurysm repair (#26 Gelweave graft)
PMH: HTN, ^chol, Depression, Anxiety
Discharge Condition:
good
Discharge Instructions:
keep wound clean and dry. OK to shower, no bathing or swimming.
take all medications as prescribed.
call for any fever, redness or drainage from wounds
Followup Instructions:
Dr [**Last Name (STitle) **] in [**3-30**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2131-4-11**]
ICD9 Codes: 2851, 5119, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6685
} | Medical Text: Admission Date: [**2185-9-11**] Discharge Date: [**2185-9-19**]
Date of Birth: [**2120-7-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65 yo male recently admitted to neurosurgery service at [**Hospital1 18**]
from [**Date range (1) 9154**] after sustaining an unexplained fall after
prolonged standing at work, who returned to [**Location **] today with
persistent nausea, vomiting, and vertigo. The patient had been
admitted for observation after a head CT showed a small
longitudinal mastoid fracture and a small traumatic SAH along
the lateral lining of the R. lower temporal bone. No surgical
intervention was deemed necessary. The pt was also evaluated by
ENT during that admission, noted to have fluid seen within the
left middle ear cavity, possibly representing blood, on CT of
temporal bones. Pt given Floxicin drops for 10 days with ENT
follow-up in two weeks.
.
In the ED the patient was found to be hypertensive to the 200's
systolic, improved with 20 mg IV labetalol. A CXR was thought to
be concerning for a new infiltrate, and he was given a dose of
levofloxacin. The patient underwent a repeat head CT which
showed interval resolution of small subarachnoid hemorrhage,
unchanged left temporal bone fracture. Neurosurgery was
consulted and felt no surgical intervention necessary at this
time. The patient was planned for admission to medicine for
syncope workup, however his blood pressure became difficult to
control and remained elevated despite 40 mg IV labetalol, 1 inch
of nitropaste, and SL nitro. The patient was then started on a
nitro drip with improvement of his blood pressure to 140's
systolic and was admitted to the [**Hospital Unit Name 153**] for close monitoring and
BP control.
.
On arrival to the floor patient states that he feels improved.
Denies headaches, changes in vision, chest pain or SOB. Denies
numbness or tingling in his extremities. No dysarthria. Denies
orthopnea, no LE edema, no recent change in exercise tolerance.
Has not had a history of syncope or falls in the past. Wife
notes that he has been unable to keep down his medications, also
notes "unsteady" on his feet, rises very slowly from sitting
position. Repeat head ct is negative. he was converted to po
anti-hypertensive medication and bp has been stable.
Past Medical History:
hypertension
SAH s/p fall/syncope after prolonged standing at work
Chronic gout- no flare for over a year
Leg weakness NOS
Pancreatic obstruction NOS 25 years ago, endoscopically released
Social History:
Lives with his wife, son, and daughter. [**Name (NI) 1403**] as a mechanic.
Quit smoking over 30 years ago, no ETOH for 20+ years. Denies
illicits.
Family History:
mother deceased age [**Age over 90 **], father died at age 55 of unknown cause,
heavy drinker
Physical Exam:
vitals: 96.7 bp 150/72 hr 62/min RR 17/min sats 97% on RA
GEN: comfortable at rest
HEENT: PERLAA, oropharynx clear
NECK: no LAD, no JVD, no carotid bruits
CV: RRR, no murmurs or rubs, PMI non-displaced,
LUNGS: CTA B/L w/ good inspiratory effort, no crackles or wheeze
ABDOMEN: soft, nt, nd, hypoactive BS
EXT: no [**Location (un) **], DP pulses palpable B/L
SKIN: dry, no rash
NEURO:CN II-XII grossly intact, A/O X3, normal finger-to-nose
and heel to shin testing, no nystagmus
Pertinent Results:
[**9-11**] Head CT: 1. Interval resolution of blood products in the
sulci of the anterior left temporal lobe, and occipital horns of
the lateral ventricles.
2. Left temporal bone fracture, with persistent fluid/blood in
that middle ear cavity, more completely evaluated and described
on temporal bone CT from [**2185-9-9**].
.
[**9-11**] CXR: FINDINGS: Two views are compared with the limited
bedside AP examination labeled "trauma" dated [**2185-9-7**]. There is
linear atelectasis at the left lung base with slight elevation
of that hemidiaphragm, new. However, no evidence of focal
consolidation is seen. The cardiomediastinal silhouette and
pulmonary vessels are within normal limits, with no evidence of
CHF. There are atherosclerotic changes involving the thoracic
aorta.
SEMI-UPRIGHT PORTABLE VIEW OF THE CHEST: Cardiac and mediastinal
contours are normal. Left lower lobe atelectasis has decreased.
There is interval development of pulmonary vascular engorgement
without interstitial or alveolar edema.
IMPRESSION:
1. New pulmonary vascular congestion without overt edema.
2. Interval improvement in left basilar atelectasis.
.
EKG: (not done in ED) sinus, Left bundle branch bloack, LAD,
borderline PR interval
.
TTE [**2185-9-12**]: Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right
atrial pressure is 0-5mmHg. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and regional/global systolic
function
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber
size and free wall motion are normal. The aortic root is
moderately dilated at
the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic
hypertension. There is no pericardial effusion.
.
Head CT [**2185-9-13**]: FINDINGS: At this time, it is extremely
difficult to identify any intracranial hemorrhage. There has
been no change in ventricular size since the prior examination
nor evidence for new brain abnormality, including an infarct.
There is re-demonstration of what is likely a 2-mm Virchow [**Doctor First Name **]
space or sublenticular cyst, left-sided in locale. As the
present examination is a head CT scan, the left temporal bone
fracture is not clearly delineated at this time, compared to the
high-resolution temporal bone study from [**9-9**].
CONCLUSION: No new intracranial pathology is defined
[**2185-9-16**] 07:30AM BLOOD WBC-8.4 RBC-4.03* Hgb-13.3* Hct-35.7*
MCV-89 MCH-33.1* MCHC-37.3* RDW-13.3 Plt Ct-216
[**2185-9-11**] 03:15PM BLOOD WBC-8.2 RBC-3.81* Hgb-12.7* Hct-33.6*
MCV-88 MCH-33.4* MCHC-37.8* RDW-13.1 Plt Ct-194
[**2185-9-11**] 03:15PM BLOOD Neuts-81.9* Lymphs-13.8* Monos-3.3
Eos-0.6 Baso-0.4
[**2185-9-13**] 04:11AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Spheroc-2+ Ovalocy-1+
Schisto-OCCASIONAL
[**2185-9-15**] 07:50AM BLOOD PT-12.1 PTT-30.0 INR(PT)-1.0
[**2185-9-19**] 07:40AM BLOOD UreaN-16 Creat-0.6 Na-130* K-3.9 Cl-96
HCO3-25 AnGap-13
[**2185-9-15**] 07:50AM BLOOD Glucose-113* UreaN-15 Creat-0.6 Na-125*
K-3.9 Cl-92* HCO3-23 AnGap-14
[**2185-9-11**] 03:15PM BLOOD Glucose-139* UreaN-9 Creat-0.6 Na-131*
K-3.5 Cl-96 HCO3-26 AnGap-13
[**2185-9-11**] 03:15PM BLOOD ALT-21 AST-21 LD(LDH)-177 CK(CPK)-34*
AlkPhos-60 Amylase-35 TotBili-0.6
[**2185-9-11**] 03:15PM BLOOD Lipase-19
[**2185-9-18**] 07:35AM BLOOD Mg-2.0 UricAcd-3.9
[**2185-9-16**] 07:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 Cholest-187
[**2185-9-12**] 04:36AM BLOOD %HbA1c-8.5*
[**2185-9-16**] 07:30AM BLOOD Triglyc-126 HDL-35 CHOL/HD-5.3
LDLcalc-127
[**2185-9-19**] 07:40AM BLOOD Osmolal-268*
[**2185-9-13**] 06:12PM BLOOD Osmolal-273*
[**2185-9-18**] 07:35AM BLOOD TSH-0.51
[**2185-9-18**] 07:35AM BLOOD Free T4-1.9*
[**2185-9-18**] 07:35AM BLOOD Cortsol-12.0
[**2185-9-11**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
[**2185-9-11**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-150 Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
[**2185-9-19**] 09:57AM URINE Osmolal-687
[**2185-9-13**] 02:20PM URINE Osmolal-717
[**2185-9-16**] 08:07PM URINE Osmolal-396
[**2185-9-18**] 05:22PM URINE Osmolal-617
[**2185-9-19**] 09:57AM URINE Hours-RANDOM UreaN-1205 Creat-124 Na-58
K-20
[**2185-9-13**] 02:20PM URINE Hours-RANDOM UreaN-605 Creat-93 Na-175
K-46 Cl-122 HCO3-LESS THAN
[**2185-9-11**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-150 Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
[**2185-9-11**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
Brief Hospital Course:
Hypertension- Initially controlled with IV labetolol and ntg in
the ICU, transitioned to oral medications on floor. Eventually
BP was fairly controlled on 40 mg lisinopril daily, 12.5 mg of
metoprolol [**Hospital1 **] and amlodipine 5 mg daily. These may need to be
further titrated with PCP. [**Name10 (NameIs) **] morning of discharge, he
accidentally got a dose of 25 mg metoprolol po x1 instead of
12.5 mg by the RN. He was asymptomatic at discharge. He denied
dizziness or any other symptoms. He was monitored for many hours
after this dose and was stable in terms of the vital signs.
Vitals at discharge were: T -98.8 BP - 136/76, P - 59, RR -18,
O2 sats 98% RA. He was advised to not take the metoprolol at
home for tonight i.e. day of discharge. However, he was advised
to start taking it on Tuesday [**2185-9-20**]. Nursing visits were set
up at home for BP monitoring.
SAH - repeat CT head did not show worsening of bleed. Cleared by
neurosurgery. Occasionally complained of headache, and was
treated with prn dosing of tylenol and oxycodone with good
control of symptoms.
Nausea/Vomiting- Had significant n/v initially and was not
tolerating PO's. Slowly improved to regular POs and
significant. Symptoms completely resolved at discharge and he
was tolerating po diet well. Continued with ear drops as
directed by ENT. ENT follow up arranged at discharge with Dr
[**Last Name (STitle) 3878**] (as recommended by the receptionist it Dr[**Name (NI) 18353**] office
- [**Doctor First Name 2411**])
SIADH, Hyponatremia was likely related to the intracranial
process. Renal was consulted as despite fluid restriction,
sodium remained low. Patient however, was asymptomatic. However,
without any other treatment other than fluid restriction to 1
lit / 24 hours, sodium improved to 130. An urgent care appt was
scheduled for this week at [**Company 191**] for rechecking Na levels and well
as BP check.
Anemia- hct stable, no signs of active bleeding seen. Will need
further evaluation by PCP as outpatient.
Impaired glucose tolerance - HbA1c was high but blood sugars
were not very high. Mainly < 150. Not started on treatment.
patient to discuss this with new PCP.
Syncope - in past. Etiology unclear. It is not known if the SAH
preceeded the syncope or was the cause of syncope. No
recurrence. No arrythmias noted. ECG at the prior admission
showed left bundle branch block. Repeat ECG this admit showed
same. Per Dr [**Last Name (STitle) **] who saw patient at admit to floor, no older
ECG at [**Hospital 1263**] hospital(where pt got prior care). Patient advised
to discuss this with new PCP for further [**Name9 (PRE) 8019**].
Chronic gout- stable on allopurinol .
PT consult given fall - initially tried to work with him on
medical floor, but BP increased with SBP greater than 200mm Hg
with any activity. With better BP control with oral meds, he was
able to walk with PT. An out-patient stres evaluation is
recommended. PT cleared patient for discharge home.
Should also get follow up F T4 (mildly high) in [**5-13**] weeks with
new PCP.
Medications on Admission:
1. Acetaminophen 325-650 mg PO Q6H:PRN
HydrALAzine 10 mg IV Q6H PRN SBP > 175
Allopurinol 200 mg PO DAILY
Insulin SC (per Insulin Flowsheet)Sliding Scale
Captopril 37.5 mg PO TID
Labetalol 0.5-2 mg/min IV DRIP TITRATE TO SBP < 160
Ciprofloxacin 0.3% Ophth Soln 3 DROP BOTH EARS TID
Metoprolol 12.5 mg PO BID
HYDROmorphone (Dilaudid) 0.5 mg SC Q4-6H:PRN
Pantoprazole 40 mg IV Q24H
Heparin 5000 UNIT SC TID
Prochlorperazine 10 mg PO/IV Q6H:PRN nausea
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Ciprofloxacin 0.3 % Drops Sig: Three (3) Drop Ophthalmic TID
(3 times a day) for 5 days: to both ears .
Disp:*1 bottle* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Start taking this medicine [**2185-9-20**].
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*90 Capsule(s)* Refills:*0*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*45 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
Sodium level. To be checked on [**2185-9-21**] by Dr [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 6401**] in
urgent care - [**Company 191**]. [**Telephone/Fax (1) 250**]
Discharge Disposition:
Home With Service
Facility:
Caregroup home Care
Discharge Diagnosis:
Subarachnoid hemorrhage and skull fracture
Hypertension
SIADH
Syncope
Left bundle branch block
Impaired glucose tolerance
Gout
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Your have requested a new primary care physician at our
hospital. An appointment has been made for you as below. Please
keep your appointments. Your new primary care doctor will be Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The appointment for this doctor is in [**Month (only) **]
[**2185**], but we have also made another appointment for this week
for a follow up on the blood test.
Call your doctor or return to the ED if you experience any:
Worsening headache
Lightheadedness
Dizziness, pass out
Nausea and vomiting
Visual changes (double vision, blurred vision)
Numbness or weakness of the arms or legs
Your sodium level has been low and it is recommended that you
follow up with the doctor on [**2185-9-21**] for monitoring blood tests
for sodium level.
You should also take less than 1 liter of fluids a day to
maintain the sodium levels in your blood.
Your blood sugars were ocassionally reported to be mildly high.
Please adhere to the diet the nurse has discussed with you. You
shoudl discuss these high blood sugars with your primary doctor,
Dr [**First Name (STitle) **]. Also, your ECG was abnormal and has a 'left bundle
branch block'. It is recommended that you discuss this with your
Dr [**First Name (STitle) **] as well. You may need a stress test for your heart.
This can arranged by your primary doctor.
Do not take the evening dose of metoprolol (a BP pill) today
i.e. [**2185-9-19**]. You should resume the prescribed dosing starting
[**2185-9-20**].
Followup Instructions:
[**Hospital1 18**], [**Location (un) 86**] - [**Hospital6 **] [**2185-10-25**] at 1330hrs,
[**Hospital Ward Name 23**] 6 with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your new primary care doctor.
The tel number to his clinic is [**Telephone/Fax (1) 250**].
It is also recommended that you go for a urgent care visit at
the [**Hospital6 **] ([**Hospital Ward Name 23**] 1) with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
on Tuesday [**2185-9-21**] at 1330hrs This is to check blood work for
sodium levels.
ENT - Dr. [**Last Name (STitle) 3878**] - [**2185-9-30**] at 3pm. ([**Location (un) **], [**Location (un) **], MA ([**Telephone/Fax (1) 7767**]
ICD9 Codes: 2859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6686
} | Medical Text: Admission Date: [**2146-12-1**] Discharge Date: [**2146-12-5**]
Date of Birth: [**2097-7-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 20128**]
Chief Complaint:
AMS, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49 year old male with history of HTN, Hep C, alcohol abuse,
epilepsy [**12-21**] TBI after motorcycle accident presents with AMS,
tachycardia, and auditory and visual hallucinations. Patient
had gone to a cognitive neurology clinic visit today, was noted
to be acting strange, complaining of progressive short term
memory loss for the last 6-8 weeks. His case worker accompanied
him, says that this is very different from his baseline mental
status. He was sectioned at cognitive neuro and sent to the ED.
Patient reports having auditory and visual hallucinations for
the last several months. Visual hallucinations are of bugs
flying around his head, also states that he has been hearing
voices; a few nights ago, felt that someone was hiding behind
his chair trying to hurt him. Denies active SI; when asked
about HI states "I feel like throttling someone". Endorses
history of depression and anxiety, but denies previous psych
hospitalizations or suicide attempts. Does not take psych meds
or follow with a therapist. Baseline ETOH abuse (several
"gallons" per day, beer and vodka), but states last drink 3 days
ago.
.
In the ED, his initial vitals were: 98.7, 134, 134/93, 20, 98%
RA. He was triggered for mental status and tachycardia. He got
3L of IV fluids, including a banana bag. Was treated with
ativan 2mg IV x2, valium 10 mg PO x1, and valium 5 mg IV x1.
His heart rate persisted in the 130's despite fluids and benzos.
His blood pressure and respiratory rate remained stable. EKG
was notable for sinus tachycardia. His neuro exam in the ED was
nonfocal. He was confused and appeared to be hallucinating.
Following the benzos, he was able to be aroused and have
conversations, but was sleepy. Labs notable for white count of
13 and creatinine of 2.5 (baseline 1.0). Vitals prior to
transfer were: 112/70, 130, 19, 99%.
.
In the MICU, patient was sleepy and occasionally fell asleep
during the interview but was easily arousable. He had somewhat
slowed speech and flat affect but did not appear to be actively
hallucinating. His mini mental status score was 20/30. Pt
[**Month/Day (2) 15797**] fever, chills, nausea, vomiting, abd pain, headache,
stiff neck, weight loss. Did endorse intermittent racing heart.
Tachycardia improved from 130 to 100 without further
intervention.
.
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, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. Obstructive sleep apnea.
2. History of gastric ulcer.
3. Status post appendectomy.
4. Hypertension.
5. Hepatitis C.
6. Alcohol dependence since the age of 15
7. Epilepsy [**12-21**] TBI
Social History:
Lives alone in apartment, unemployed and on disability. H/o
multiple arrests including A&B since adolescence and a charge of
attempted murder (beating his stepfather) which was eventually
dismissed. Reports biological father raped him multiple times
when patient was four years old to get back at patient's mother.
Lost custody of his children (multiple mothers) who are now in
[**Doctor Last Name **] care. IVDU, cocaine, MJ and crack; last drug use 3 months
ago (cocaine). Continues to drink heavily (as above). Denies
smoking.
Family History:
One sister with brain tumor. Substance abuse including alcohol
in multiple family members including siblings and father.
Physical Exam:
Vitals: BP: 124/83 P: 95 R: 18 O2: 99% RA
General: Alert, oriented x 2, drowsy but easily arousable, 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: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: strength 5/5, sensation intact, no dysmetria, no drift,
CN 2-12 intact.
Pertinent Results:
Admission Labs:
[**2146-12-1**] 05:30PM BLOOD WBC-13.4*# RBC-5.38 Hgb-15.8 Hct-46.0
MCV-86 MCH-29.3 MCHC-34.2 RDW-15.6* Plt Ct-180
[**2146-12-2**] 12:16AM BLOOD WBC-8.9 RBC-4.45* Hgb-13.4* Hct-38.0*
MCV-85 MCH-30.0 MCHC-35.1* RDW-15.4 Plt Ct-123*
[**2146-12-1**] 05:30PM BLOOD PT-13.6* PTT-23.2 INR(PT)-1.2*
[**2146-12-1**] 05:30PM BLOOD Glucose-76 UreaN-25* Creat-2.5*# Na-136
K-3.6 Cl-92* HCO3-26 AnGap-22*
[**2146-12-2**] 12:16AM BLOOD Glucose-107* UreaN-23* Creat-1.6* Na-136
K-3.2* Cl-99 HCO3-26 AnGap-14
[**2146-12-1**] 05:30PM BLOOD ALT-44* AST-60* AlkPhos-64 TotBili-1.9*
[**2146-12-2**] 12:16AM BLOOD ALT-35 AST-44* LD(LDH)-183 AlkPhos-50
TotBili-1.2
[**2146-12-1**] 05:30PM BLOOD Lipase-44
[**2146-12-2**] 12:16AM BLOOD Lipase-43
[**2146-12-2**] 12:16AM BLOOD cTropnT-<0.01
[**2146-12-1**] 05:30PM BLOOD Calcium-10.3 Phos-5.7*# Mg-2.0
[**2146-12-2**] 03:40PM BLOOD Albumin-4.0 Calcium-9.4 Phos-2.9 Mg-1.8
[**2146-12-2**] 12:16AM BLOOD VitB12-401 Folate-GREATER TH
[**2146-12-2**] 12:16AM BLOOD TSH-2.8
[**2146-12-1**] 05:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE CULTURE (Final [**2146-12-2**]): NO GROWTH.
RAPID PLASMA REAGIN TEST (Final [**2146-12-5**]):
NONREACTIVE.
Reference Range: Non-Reactive.
EKG [**12-1**]: Probable sinus tachycardia. Diffuse ST-T wave changes
which are non-specific. Compared to the previous tracing of
[**2145-10-7**] profound sinus tachycardia is new.
CXR: FINDINGS: The study is limited by body habitus and AP
portable technique. Please note the left lung base is difficult
to assess. Overall no focal consolidation is identified.
However, lung volumes are markedly diminished with resultant
bronchovascular crowding. No frank failure is identified. There
is mild prominence of the central pulmonary vasculature again in
part due to low lung volumes although mild element of vascular
congestion cannot be excluded. The mediastinum is distorted due
to low lung volumes. The cardiac silhouette size is exaggerated
by the same. No definite effusion or pneumothorax is seen.
IMPRESSION: Limited study due to factors above. No gross
consolidation or
failure noted.
CT Head: IMPRESSION:
1. No acute intracranial process.
2. Marked cerebral and cerebellar atrophy.
3. Left anterior temporal encephalomalacia.
Discharge Labs:
[**2146-12-3**] 06:50AM BLOOD WBC-5.4 RBC-4.43* Hgb-13.1* Hct-38.5*
MCV-87 MCH-29.6 MCHC-34.0 RDW-15.6* Plt Ct-124*
[**2146-12-3**] 06:50AM BLOOD PT-12.1 INR(PT)-1.0
[**2146-12-5**] 06:20AM BLOOD Glucose-86 UreaN-15 Creat-0.9 Na-139
K-3.7 Cl-101 HCO3-30 AnGap-12
[**2146-12-3**] 06:50AM BLOOD ALT-27 AST-29 AlkPhos-45
[**2146-12-3**] 06:50AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8
Brief Hospital Course:
49 year old male with history of alcohol withdrawal complicated
by seizures presents with sinus tachycardia, altered mental
status and auditory/visual hallucinations.
.
# Alcoholic withdrawal - Patient was monitored in ICU overnight
for withdrawal. Did not require any valium once on the floor.
No signs/symptoms of withdrawal. Was continued on thiamine,
folate, MVI.
.
# Mental status change - Unsure of the etiology. Seems chronic
in nature with several week history of auditory/visual
hallucinations. Psych and neurology saw patient and thought
problems were secondary to either alcohol withdrawal,
Korsokoff's, or traumatic brain injury. CT head negative for
acute intracranial pathology. Patient discharged with
instructions to follow up with cognitive neuro for testing.
.
# Acute renal failure - Pre-renal with creatinine of 2.5 on
admission. Improved to 1.0 with intravenous fluids.
.
# HTN - Patient was not controlled on home regimen. Metoprolol
and hydrochlorthiazide were uptitrated with better control.
Inactive Issues
- Cognitive neurology testing
- Oral surgeon follow-up for right tongue lesion
Medications on Admission:
1. multivitamin 1 tab daily
2. folic acid 1 mg daily
3. metoprolol succinate 25 mg daily
4. levetiracetam 1500 mg [**Hospital1 **]
5. hydrochlorothiazide 12.5 mg daily
Discharge Medications:
1. multivitamin Capsule Sig: One (1) Capsule PO once a day.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
4. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO twice a
day.
5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Altered Mental status, hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 732**],
It was a pleasure taking care of you during your
hospitalization. You were admitted because of altered mental
status noted at your cognitive neurology appointment. This was
thought to be secondary to withdrawal from alcohol as you had
recently stopped drinking. You were monitored in the Intensive
care unit for any signs of withdrawal and then were transferred
to the general medicine floor. You had no signs of withdrawal
while on the general medicine floor. You were seen by our
psychiatrists and neurologsits who thought that your memory
problems were either due to something called Korsakoff's
syndrome, which can be caused from too much drinking, or from
the trauma you suffered in your accident. You should not drink
any more alcohol as this will lead to more problems with your
thinking and memory. We noted your blood pressure to be
elevated so we increased the dosage of your blood pressure
medications.
We made the following changes to your medications.
INCREASED
metoprolol succinate to 50mg by mouth daily
hydrochlorthiazide (HCTZ) to 25mg by mouth daily
ADDED
Vitamin B12 250 mcg by mouth daily
Thiamine 100mg by mouth daily
Please follow-up with Dr. [**First Name (STitle) **] and your cognitive
neurologist.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in the next 1-2 weeks for an
appointment. His phone number is [**Telephone/Fax (1) 608**]. You will also
need to talk to him about seeing an Oral surgeon to follow-up
the swelling of your tongue. You need to reschedule your
appointment with Cognitive Neurology to be reassessed.
Department: RADIOLOGY
When: WEDNESDAY [**2147-2-1**] at 9:30 AM
With: ULTRASOUND [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: LIVER CENTER
When: WEDNESDAY [**2147-2-1**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 20129**]
Completed by:[**2146-12-6**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6687
} | Medical Text: Admission Date: [**2152-2-2**] Discharge Date: [**2152-2-23**]
Date of Birth: [**2152-2-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is an interim summary
covering the dates between [**2152-2-2**] and [**2152-2-23**]. This is a 21
day old male infant, with a corrected gestational age of 34
weeks. He was born at 30 weeks gestation to a 36 year old,
Gravida II, Para 0 to 2 woman. The pregnancy was complicated
by preterm labor and the mother received a course of
Betamethasone earlier in the pregnancy. She presented with a
second episode of preterm labor and was noted to have a
prolapsed cord. This infant was delivered via stat cesarean
section. Birth weight was 1,290 grams. Rupture of membranes
was unknown and clear fluid was noted at the time of
delivery. The infant emerged vigorous with good spontaneous
respiratory effort; however, he required bagged mask
ventilation for poor air entry and respiratory distress. He
was intubated in the delivery room. Apgars were 6 and 8. He
was brought to the Neonatal Intensive Care Unit for
prematurity and respiratory distress.
PHYSICAL EXAMINATION: General: Pink, active infant in mild
respiratory distress. HEAD, EYES, EARS, NOSE AND THROAT:
Narrow palpebral fissures. Palate examination deferred.
Orally intubated. Cardiovascular: Normal, regular rate and
rhythm, normal S1 and S2, no murmurs. Normal pulses in the
upper and lower extremities. Lungs: Good air entry; breath
sounds coarse bilaterally. Mild retractions. Abdomen: Soft,
nontender, nondistended, three vessel cord. Genitourinary:
Normal male external genitalia with testes palpable in canals
bilaterally. Neurologic: Tone appropriate for gestational
age; moving all extremities bilaterally. Immature reflexes.
HOSPITAL COURSE: 1.) Respiratory: The infant received one
dose of Surfactant replacement therapy and was extubated
shortly afterwards. He remained on C-Pap for one additional
day and since then, has been on room air. He did have apnea
of prematurity which was noted on day of life two. He has
been on caffeine since day of life five with minimal ongoing
apnea of prematurity.
2.) Cardiovascular: The infant has been hemodynamically
stable. He has no murmur.
3.) Fluids, electrolytes and nutrition: The infant was
advanced slowly on enteral feedings. During that time, he
did receive parenteral nutrition given his low birth weight.
He is currently on full enteral feedings, of which he is able
to take by mouth. He is receiving premature Enfamil 26
calories per ounce with ProMod. He has been growing well.
4. Gastrointestinal: Peak bilirubin was 7.2 on day of life
The infant was treated with single phototherapy until day of
life 11. He has no clinical jaundice.
6. Hematologic: The infant has not received any
transfusion. Most recent hematocrit was 44 on [**2-18**].
He has no signs or symptoms of anemia.
7. Infectious disease: The infant was initially started on
Ampicillin and Gentamycin, given his prematurity and
respiratory distress. His blood culture remained negative and
antibiotics were discontinued at 48 hours. He has no current
active infectious issues.
8. Neurologic: Head ultrasound on day of life 7 was
negative.
9. Sensory: The patient will require both audiologic
screening and ophthalmic examination prior to discharge.
10. Psychosocial: The [**Hospital1 69**]
social worker has been involved with the family.
CONDITION: Stable.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
IMMUNIZATIONS RECEIVED: None.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Respiratory distress syndrome.
3. Rule out sepsis.
4. Hyperbilirubinemia.
5. Breathing immaturity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 52805**]
MEDQUIST36
D: [**2152-2-23**] 01:55
T: [**2152-2-23**] 15:18
JOB#: [**Job Number 52979**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6688
} | Medical Text: Admission Date: [**2166-2-8**] Discharge Date: [**2166-2-13**]
Date of Birth: [**2121-12-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
stab to R neck
Major Surgical or Invasive Procedure:
s/p exploration of wound, R neck (at bedside)
History of Present Illness:
This is a 44 y/o gentleman who takes coumadin for a recent DVT,
who was Medflighted from [**Hospital3 **] with a self-inflicted
stab wounds to his right neck. Estimated blood loss was 500 mL.
He was intubated for airway protection at the OSH and
transferred to [**Hospital1 18**] in stable condition. He had already
received FFP and packed red cells upon arrival.
Past Medical History:
depression; severe schizophrenia; R leg DVT [**12-13**], on coumadin;
MI '[**62**]; hx of coumadin/lovenox/glyburide overdose
Social History:
Unknown.
Family History:
Unknown.
Physical Exam:
Upon arrival in the [**Hospital1 18**]:
Intubated, sedated.
HR 97, BP 120/p, 100% on ventilator
R neck: approximately 0.5 cm deep, 6 cm long laceration, active
bleeding.
L neck: superficical lac.
Cor reg.
Chest clear
Abd soft.
No obvious injury to any extremity.
Spine: No stepoffs or malalignment noted.
Pertinent Results:
[**2166-2-8**] 09:00PM WBC-18.4* RBC-2.42* HGB-6.7* HCT-20.1* MCV-83
MCH-27.8 MCHC-33.6 RDW-14.7
[**2166-2-8**] 09:00PM PLT COUNT-195
[**2166-2-8**] 01:15PM TYPE-ART TEMP-38.3 RATES-/25 TIDAL VOL-500
PEEP-5 O2-50 PO2-184* PCO2-38 PH-7.42 TOTAL CO2-25 BASE XS-0
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2166-2-8**] 01:15PM GLUCOSE-120* LACTATE-1.4
[**2166-2-8**] 01:15PM freeCa-1.15
[**2166-2-8**] 01:03PM GLUCOSE-111* UREA N-19 CREAT-1.4* SODIUM-141
POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2166-2-8**] 01:03PM CALCIUM-8.1* PHOSPHATE-3.1 MAGNESIUM-2.0
[**2166-2-8**] 12:12PM URINE COLOR-LtAmb APPEAR-SlCldy SP [**Last Name (un) 155**]-1.015
[**2166-2-8**] 12:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
[**2166-2-8**] 01:03PM PT-26.7* PTT-36.1* INR(PT)-2.7*
Brief Hospital Course:
Pt was admitted to the T-SICU after wound exploration in the
emergency room. An active bleeding vessel was tied off and
hemostasis was obtained. A CTA of the neck was performed which
was negative for any large vessel injury. The pt was begun on
levofloxacin because of a history of aspiration during a
self-extubation attempt at the OSH, and a chest xray revealed a
R upper lobe consolidation.
On HD 2 the pt was extubated without event and transferred to
the floor. Wound care was performed on his neck wound, which
improved in appearance. He was evaluated by ENT and thought to
have normal vocal cord function, and a barium swallow study
showed no leakage of contrast from the esophagus. His diet was
advanced and psychiatry was consulted for dispo planning and
follow-up. On HD 4 the pts coumadin was restarted. On the advice
of psychiatry the pt was maintained on IV Haldol. Serial EKG's
were checked with normal QTc intervals. On HD 6 he was
discharged to the Deaconass 4 psychiatric unit in stable
condition, with instructions for wound care, INR checks and to
continue levofloxacin for 6 days.
Medications on Admission:
Coumadin 5', Lamictal 25', Seroquel 200', Prevacid 30', Lipitor
40'; ToprolXL 50', glyburide 2.5", lisinopril 10'
Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
8. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) mL
Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Home with Service
Discharge Diagnosis:
s/p stab wound to R neck
Discharge Condition:
Good.
Discharge Instructions:
1) Resume all your home medications at their usual doses.
2) Have your INR checked twice a week and phone results to your
primary care doctor-- [**Doctor First Name **] Caticha, Phone ([**Telephone/Fax (1) 66479**].
3) Wet to dry dressings on your neck wound by nursing [**Hospital1 **].
Followup Instructions:
Trauma clinic in 2 weeks: call [**Telephone/Fax (1) 6439**] to schedule an
appointment.
Completed by:[**2166-2-13**]
ICD9 Codes: 5070, 311, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6689
} | Medical Text: Admission Date: [**2162-10-4**] Discharge Date: [**2162-10-11**]
Date of Birth: [**2091-11-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Latex / Lactose
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Fever, tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70yo with PMH significant for chronic afib on coumadin,
rate-controlled, and relatively recent soft tissue surgery with
fever, cough productive of brown sputum x 4 d, starting 1d after
receiving
DTaP and pnuemovax. + cough, shaking chills, + lethargy,
describes poor/minimal po intake. - dysuria, + loose stools x 2
months. No CP, SOB, n/v/diarrhea.
.
Went to [**Company 191**], where she was 101.5 in office, O2 sats 97%,
crackles at right base, with HR in the 180s. She was then sent
to ED for IV fluids, blood cultures, CXR, antibiotics. In ED,
initially, SBPs >100, but SBPs dropped to 70s upon standing for
CXR. Got IVFs, BP unresponsive, so sepsis line placed and
started on neosynephrine. Asymptomatic throughout. CXR showed
RLL PNA, so pt. was started on ceftriaxone/azithromycin.
Lactate 2.3-->1.8. Pt. got cardiology consult in ED, who
recommended not to start amio, and to treat infectious process.
Past Medical History:
atrial fibrillation, was on amio, but stopped [**1-1**]
achilles tendonitis
osteoarthritis
rectal prolapse
hyperlipidemia
osteopenia
Social History:
Worked as psychiatric social worker at [**Hospital1 18**] in past, currently
in private practice as a psychologisy Smoke until [**2126**], no
smoking since. + occasional ETOH.
Family History:
nc
Physical Exam:
On admission:
Vitals: 99.1, 123/87 on 1 mg/kg/min neo, 135 in Afib, 20/ 95% on
3L SvO2 75%, CVP 14-16
Gen: tired appearing, pleasant, cooperative, NAD
HEENT: PERRL, EOMI, MM slightly dry.
CV: tachy, irrefularly irregular, no MRGs noted
Pulm: decreased BS R base, + mild crackles and egophany in same
area. no wheezes
Abd: soft, non distended, nontender, +BS
Ext: lukewarm extremiteis, DP 2+ bilaterally
Neuro/Psych: Alert and oriented, CN III-XII individually tested
and intact
Pertinent Results:
[**2162-10-4**] 11:40AM BLOOD WBC-9.6 RBC-4.36 Hgb-14.1 Hct-42.3 MCV-97
MCH-32.3* MCHC-33.3 RDW-12.8 Plt Ct-237
[**2162-10-9**] 07:55AM BLOOD WBC-17.5* RBC-3.52* Hgb-11.6* Hct-34.0*
MCV-96 MCH-32.9* MCHC-34.1 RDW-14.3 Plt Ct-341
[**2162-10-11**] 10:00AM BLOOD WBC-10.9 RBC-3.59* Hgb-11.8* Hct-35.1*
MCV-98 MCH-32.9* MCHC-33.6 RDW-13.6 Plt Ct-473*
[**2162-10-4**] 09:35PM BLOOD Neuts-76.0* Bands-0 Lymphs-19.3 Monos-3.5
Eos-0.5 Baso-0.7
[**2162-10-11**] 10:00AM BLOOD Glucose-143* UreaN-19 Creat-1.1 Na-140
K-4.1 Cl-106 HCO3-30 AnGap-8
[**2162-10-4**] 11:40AM BLOOD Glucose-127* UreaN-18 Creat-1.0 Na-137
K-3.9 Cl-102 HCO3-23 AnGap-16
[**2162-10-11**] 10:00AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.2
[**2162-10-4**] 11:40AM BLOOD TSH-0.64
[**2162-10-7**] 05:15AM BLOOD VitB12-669 Folate-12.1
[**2162-10-4**] 11:40AM BLOOD T4-7.2
[**2162-10-5**] 05:06AM BLOOD Cortsol-34.6*
[**2162-10-4**] 11:34PM BLOOD Cortsol-12.5
[**2162-10-4**] 03:44PM BLOOD Lactate-2.3*
[**2162-10-5**] 02:08AM BLOOD Lactate-1.5
CXR [**10-4**]: 1. Right IJ CVL tip within the mid SVC. No evidence of
pneumothorax.
2. Developing right lower lobe pneumonia
CXR [**10-8**]:In comparison with the study of [**10-6**], there is again
an area of increased opacification at the right base medially
consistent with the clinical impression of pneumonia. This
appears to be less prominent than on the previous examination.
The right central catheter has been removed.
Brief Hospital Course:
70yo with chronic Afib with hypotension and afib with RVR,
likely pneumonial sepsis
.
# Afib with RVR: It was felt to be likely an exacerbation
secondary to infection. Her TSH was normal. Given her
hypotension, we initially avoided diltiazem and beta blockade.
She was digoxin loaded for rate control with good effect, and as
blood pressure increased, changed to beta blocade with
uptitration of metoprolol. Cardiology recommended against
amiodarone given thyroid toxicity. Upon transfer to the floor
her metoprolol was further uptitrated to the maximum dose of
450mg per day. While her blood pressure remained stable in the
100s/60s, her HR continued to be in the 120's with increases to
140-150 upon ambulation. She was again digoxin loaded and begun
on a standing dose of 0.125mg daily. This controlled her HR well
and allowed her metoprolol to be decreased to 100mg PO TID. She
restarted on her coumadin at 5mg but her INR became
supratherapeutic, likely in conjuction with the levofloxacin.
Her coumadin was held and her INR was allowed to drift to
therapeutic levels, after which she was started on 2mg daily
with stabilization of her INR betwen [**1-2**]. this will continue to
be monitored by her PCP and [**Hospital3 **].
.
# Sepsis. She was nitially treated with IV boluses to keep
CVP>8, maintaining SvO2 >70%, (no dobutamine given tachycardia,
and hct was above 30, and neo for MAPs>65. Given her infiltrate
on CXR and focal exam, pt. was thought to have
community-acquired pneumonial sepsis and changed from
CTX/Azithromycin to levofloxacin day 1 [**2162-10-4**]. She became HD
stable and was taken of the neosynephrine and the central line
was removed. She was then transfered to the floor. Blood
cultures and sputum cultures were NGTD at the time of discharge.
She became afebrile with stable blood pressures and breathing
comfortably on room air. She was discharged to complete a 14 day
course of levofloxacin with follow up from her PCP/
.
# GI: She developed diarrhea after starting levofloxacin.
C.diff was negative x 2 with resolution of her diarrhea after
several Percocet to control her chronic arthritis pain.
# hypothyroidism: Continued on her home levothyroxine with good
effect.
# hyperlipidemia: continued on her home atorvastatin with good
effect
# Arthritis: continued on home regimen of celebrex, percocet,
valium prn with minimal use and good effect.
# osteopenia: continued on alendronate, calcium, and vitamin D
Medications on Admission:
Amitriptyline HCl 25 mg qhs
CALCIUM 500 mg qdaily
CELEBREX 200 mg qdaily
Capsaicin 0.035%--apply to left wrist area, scar twice per day
DUCODYL 5 mg--2 (two) tablet(s) by mouth once a day
ESTRING 7.5 mcg/24 hour--one every 3 months
FOSAMAX 70MG - One q week
Fish Oil 1,000 mg--1 (one) cap qdaily
Glucosamine Chondroitin SMConc 750 mg-600 mg-55 mg-5 mg; 1
qdaily
LIPITOR 10MG qdaily
Levothyroxine 50 mcg qdaily, 75mcg on sundays.
MULTIVITAMIN qdaily
PERCOCET 5 mg-325 mg--[**12-1**] tabq4h PRN
TOPROL XL 75qdaily
VALIUM 5MG tidPRN
VITAMIN C 1,000 mg--[**Hospital1 **]
WARFARIN 2.5 mg m,w,f,sa,[**Doctor First Name **] 5 mg tu,th
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
2. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO qdaily ().
3. Flaxseed Oil Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO QSUN
(every Sunday).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO QDAILY
MONDAY THROUGH SATURDAY ().
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain , stiffness.
10. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*30 Tablet(s)* Refills:*2*
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*100 ML(s)* Refills:*0*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
17. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
18. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pneumonia of [**Last Name (un) 5487**] organism
Atrial fibrillation with rapid ventricular response
Secondary:
Osteoarthritis
Discharge Condition:
Afebrile. All vitals stable. HR well controlled with normal BP.
WBC in normal range. Ambulatory.
Discharge Instructions:
You were admitted for a pneumonia which also exacerbated your
atrial fibrillation causing a rapid heart rate. You were treated
with antibiotics and medications to slow your heart rate. You
should finish your course of antibiotics at home. We have also
adjusted your medications to control your heart rate. Please
take all your medications as prescribed.
Please call your doctor or return to the hospital if you
experience a temperature greater than 100.5, chills, shortness
of breath, chest pain, or any other symptoms that concern you.
Followup Instructions:
Please call Dr.[**Name (NI) 10427**] office at [**Telephone/Fax (1) 250**] to schedule a
follow up appointment in the next 1-2 weeks.
Provider: [**Name10 (NameIs) 13644**],NURSE [**First Name (Titles) 13644**] [**Last Name (Titles) **] Date/Time:[**2162-11-5**] 3:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2162-11-15**] 12:10
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2162-11-18**] 1:00
ICD9 Codes: 0389, 486, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6690
} | Medical Text: Admission Date: [**2183-1-22**] Discharge Date: [**2183-1-25**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MICU MEDICINE
MICU STAY/HISTORY OF PRESENT ILLNESS: The patient is a
34-year-old male, with poorly controlled hypertension of
unclear etiology, who was discharged yesterday after a 2-week
stay for the same presenting symptoms of nausea, vomiting,
abdominal pain and hypertension. The patient did well after
discharge and then after eating breakfast in the morning
developed his same nausea and vomiting. The patient was
unable to take any medications. The patient presented to the
Emergency Department with abdominal pain no different than
prior abdominal pain episodes. The patient had no bowel
movement changes, no fevers or chills, no hemoptysis, no
bright red blood per rectum, no headaches or vision changes.
In the Emergency Department, the patient was treated with a
Nitro drip and prn labetalol, as well as morphine and ativan.
When nausea and pain were under better control, the patient
still had increased blood pressure in the systolics of 200s.
The patient tolerated doses of blood pressure medication on
the floor. However, despite maximal Nitro drip and
labetalol, the patient's blood pressures remained in the
200s. The patient was, therefore, transferred to the MICU
for closer monitoring of his blood pressure.
PAST MEDICAL HISTORY:
1. Type 1 diabetes.
2. Gastroparesis.
3. Malignant hypertension.
4. Autonomic neuropathy.
5. CAD.
6. Chronic renal insufficiency, baseline 1.7-1.9.
7. History of [**Doctor First Name **]-[**Doctor Last Name **] tears.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Aspirin 81 qd.
2. Protonix 40 qd.
3. Clonidine patch.
4. Erythromycin.
5. Sertraline 50 qd.
6. Reglan 10 q 6 h.
7. Lopressor 150 [**Hospital1 **].
8. Lisinopril 10 [**Hospital1 **].
9. Glargine 5 q hs.
10.Ativan 2 prn.
11.Morphine prn.
12.Amlodipine.
SOCIAL HISTORY: The patient lives in [**Location 686**]. No
alcohol. No tobacco. Unemployed.
PHYSICAL EXAM: Afebrile, heart rate 97, blood pressure
140s-220s/100-130s, 100% on room air.
GENERAL: Fatigued, mildly ill-appearing, in no apparent
distress.
HEENT: Anicteric. OP clear.
NECK: Supple with no lymphadenopathy.
ABDOMEN: Positive bowel sounds, soft, nontender,
nondistended, no hepatosplenomegaly, no rebound tenderness.
CV: Regular rate, no murmurs.
CHEST: Clear to auscultation bilaterally.
EXTREMITIES: No clubbing, cyanosis or edema, 2+ pulses
bilaterally.
PERTINENT LABS ON ADMISSION: CBC - WBC count 8.5, crit 34.3.
Otherwise, his Chem-7 and CBC were unremarkable.
SUMMARY OF HOSPITAL COURSE - 1) UNCONTROLLED HYPERTENSION:
By [**2183-1-24**], the patient was taken off all of his IV
antihypertensives, including IV Nitro and labetalol. The
patient was transitioned to his home dose PO medications of
lisinopril, Lopressor, Norvasc and a clonidine patch.
Etiology of his malignant hypertension still remains a
mystery, and has been seen by multiple specialists in the
past. The diagnosis of pseudopheochromocytoma was
entertained, and urine studies were pending on discharge. On
discharge, the patient's blood pressure was maintained on his
home regimen of lisinopril, Lopressor, Norvasc, and a
clonidine patch with the blood pressures in the 120s-130s.
The patient additionally had no episodes of nausea or
vomiting approximately 12 hours before discharge.
2) GI: Nausea, vomiting and abdominal pain were controlled
with his home doses of Reglan, ativan, erythromycin, morphine
and Protonix.
3) DIABETES TYPE 1: The patient is on glargine 8 U q hs and
Humalog.
4) RENAL: The patient's creatinine was at baseline on
discharge.
5) ACCESS: The patient has a port-A-Cath in place.
6) CODE STATUS: The patient remained full code throughout
this admission.
CONDITION ON DISCHARGE: The patient was discharged to home
without any nausea or vomiting, and resolution of his
hypertensive episode. The patient was discharged on his
admission medication regimen for hypertension.
DISCHARGE STATUS: The patient was discharged in stable
condition to home.
DISCHARGE DIAGNOSES:
1. Malignant hypertension.
2. Type 1 diabetes.
3. Anemia of unknown etiology.
4. Chronic renal insufficiency.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg po qd.
2. Pantoprazole 40 mg po qd.
3. Clonidine 0.2 mg per 24 h patch q week.
4. Erythromycin 350 mg po q 6 h.
5. Sertraline 50 mg po qd.
6. Lisinopril 10 mg po bid.
7. Amlodipine 5 mg po qd.
8. Metoprolol 150 mg SR qd.
9. Reglan 5 mg/ml solution 1 injection q 6 h.
FOLLOW-UP PLANS: The patient is to follow-up with his PCP [**Last Name (NamePattern4) **]
[**2-14**] weeks on discharge.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 22260**]
MEDQUIST36
D: [**2183-3-4**] 13:50
T: [**2183-3-4**] 14:04
JOB#: [**Job Number 93221**]
ICD9 Codes: 2765, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6691
} | Medical Text: Admission Date: [**2126-1-5**] Discharge Date: [**2126-1-14**]
Date of Birth: [**2060-8-31**] Sex: M
Service: CARDIAC
ADMISSION DIAGNOSES: 1) Coronary artery disease. 2)
Myocardial infarction.
DISCHARGE DIAGNOSES: 1) Coronary artery disease. 2)
Myocardial infarction. 3) Status post coronary artery bypass
graft x 3.
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
male who was being transferred from [**Hospital3 **]. He
presented to that hospital while complaints of sudden onset
nausea and vomiting. EKG there demonstrated inferolateral ST
elevation MI with decreased ST anterior lead suggestive of
posterior involvement. The patient is transferred for urgent
cardiac catheterization. He received aspirin, heparin,
Aggrestat, prior to departure.
PAST MEDICAL HISTORY: 1) Hypercholesterolemia. 2)
Hypertension. 3) Angina.
MEDICATIONS: 1) lipitor, 2) Nitroglycerin prn.
PHYSICAL EXAMINATION: Vital signs - temperature 96.9, heart
rate 91, blood pressure 83-88/50-60, oxygen saturation 100%,
weight 89.4 kg. General - the patient is intubated and
sedated postcatheterization. Neck is supple, midline, with
no masses or lymphadenopathy. No bruit. Cardiovascular -
regular rate and rhythm. Patient currently has an
intra-aortic balloon pump. Chest clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended.
Extremities are warm, noncyanotic, no redness x 4. Palpable
distal pulses.
LABS ON ADMISSION: CBC - 7.8/38.8/162. INR 1.3, PTT 77.
Chemistries 140/3.5/104/26/20/0.9. First set of cardiac
enzymes - CK 120, MB 5, troponins negative, less than 0.3.
HOSPITAL COURSE: The patient was transferred via LifeFlight
for emergent cardiac catheterization. Cardiac
catheterization revealed a right dominant coronary
circulation with severe three-vessel coronary artery disease.
Left main had 20% distal tapering, LAD was totally occluded
proximally after the takeoff of a diffusely diseased diagonal
branch, moderate sized RI had 80% proximal lesion, left
circumflex is totally occluded, RCA was a large vessel with
40% lesion in the proximal aspect and a thrombotic occlusion
midvessel. An intra-aortic balloon was deployed after
stenting of the RCA because of the patient's hypotension and
requirement of a dopamine drip. Subsequent to
catheterization, the patient was transferred to the CCU for
support. He was continued on his dopamine drip.
On hospital day #1, the patient was seen to have a brief run
of NSVT. He was maintained on aspirin, heparin drip and
statin. Cardiothoracic surgery consultation was obtained who
agreed with urgent revascularization. The patient had
several further runs of what looked to be V-tach in the unit.
The patient was maintained on IABP. Dopamine was weaned off
on hospital day #3.
On [**2126-1-7**], the patient was taken to the operating room for
urgent coronary artery bypass graft x 3. The patient
tolerated the procedure well and was taken to the CSRU
postoperatively.
On postoperative day #1, the patient was extubated. He was
A-paced at a rate of 70s. The patient was on multiple drips
including amiodarone, insulin, neo, epi, at different times
through his CSRU course. They were all weaned appropriately.
On postoperative day #2, the balloon pump was discontinued.
Neo was also weaned off. The patient had a brief run of
atrial fibrillation. Once the patient began working with
physical therapy, it was seen that he had some difficulties
with abduction of both of his arms. He appeared
neurologically intact and without any other sensorimotor
deficits. The patient did have other episodes of rapid
atrial fibrillation, but ultimately converted back to a sinus
rhythm. He was begun on anticoagulation for this.
The patient was transferred to the floor on postoperative day
#3. OT consultation was also obtained who agreed with
transfer to rehab facility. The patient had ultimately an
unremarkable floor stay, and chest tubes and wires were
removed appropriately. The patient was ultimately discharged
to rehab facility for further work with movement of his arms,
as well as simple gait conditioning and activities of daily
living. He was discharged tolerating a regular diet, and
adequate pain control on PO pain meds, and having a
therapeutic INR. No more episodes of angina, or nausea or
vomiting.
PHYSICAL EXAMINATION ON DISCHARGE: An elderly man in no
acute distress. Vital signs were stable, afebrile. Chest
was clear to auscultation bilaterally. Cardiovascular was
regular rate and rhythm without murmurs, rubs or gallops.
There was no sternal click or sternal drainage. Abdomen was
soft, nontender, nondistended, no masses or organomegaly.
Extremities were warm, noncyanotic with 1+ pedal edema
bilaterally. Musculoskeletal - the patient had difficulty
with abduction of his arms and neural usage of his arms
particularly when trying to abduct them beyond a horizontal
level. Neuro grossly intact without specific sensory
deficits. Of note, the upper extremity movement was
bilateral in nature, but function was returning.
MEDICATIONS ON DISCHARGE: 1) lopressor 25 mg [**Hospital1 **], 2) lasix
20 mg qd x 10 days, 3) potassium chloride 20 mEq qd x 10
days, 4) amiodarone 400 mg [**Hospital1 **], 5) Lipitor 10 mg qd, 6)
percocet 5/325, [**12-6**] q 4 h prn, 7) aspirin 325 mg qd, 8)
ibuprofen 400 mg q 6 h, 9) colace 100 mg [**Hospital1 **], 10) coumadin to
be dosed appropriately to an INR between 1.5 and 2.0. On
discharge, the patient was taking coumadin in the 1 to 2 mg qd
range.
DISCHARGE CONDITION: Stable.
DISPOSITION: To rehab facility.
DIET: Cardiac.
INSTRUCTIONS: The patient should follow-up in one to two
weeks with his cardiologist. He should address the needs of
diuresis and/or adjustment of cardiac medications at that
time. The patient should follow-up with Dr. [**Last Name (STitle) **] in four
week's time. The patient is to continue aggressive physical
and occupational therapy to return to his activities of daily
living. INR checks should be done twice weekly and coumadin
dosing adjusted by either the rehab facility or his primary
care provider, [**Name10 (NameIs) **] alternatively the coumadin clinic.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**MD Number(1) 46561**]
MEDQUIST36
D: [**2126-1-14**] 12:42
T: [**2126-1-14**] 11:42
JOB#: [**Job Number 46562**]
ICD9 Codes: 4271, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6692
} | Medical Text: Admission Date: [**2155-12-9**] Discharge Date: [**2155-12-10**]
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Transferred from OSH with intracranial hemorrhage.
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
The pt is an 86 y/o F who presented to [**Hospital6 **] after
3 falls at home on [**2155-12-8**]. Details of the falls were related by
her grandson, [**Name (NI) 401**] [**Name (NI) 31469**]. He reports that the patient was unable
to walk because of weakness on the left side. She fell getting
out of bed on [**2155-12-8**], 45 minutes later in the bathroom, and
again at the breakfast table shortly thereafter. The grandson
noted that the patient couldn't use her walker at all secondary
to weakness after the third fall. Son arrived and picked patient
up off floor. Noted L sided weakness and called EMS. Left facial
droop
was noted but this was this is somewhat confounded by an old
bells palsy. At [**Hospital3 **], serial head CTs demonstrated
worsening R intraparenchymal bleed. She was sent here for
further care. She was admitted to the TSICU and was noted to be
increasingly drowsy and a CT head was done this morning which
showed worsening from previous CT.
Past Medical History:
HTN
DM - diet controlled
Bells palsy (30 yrs ago)
Asthma
Hypothyroidism
S/p hysterectomy
arthritis
Social History:
Lives with husband
Denies Alcohol, Smoking, and drugs
Family History:
NC
Physical Exam:
Vitals: T:98.8 P:70 R:14 BP:124/84 SaO2:96%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. pupils are surgical.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: With crackles at the right base.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: Patient has lesions over abdomen, previously diagnosed
with zoster.
Neurologic:
-Mental Status: keeps eyes closed. No spontaneous speech.
Patient responded to [**Last Name (un) **] name with opening her eyes and saying
"yes" after being aroused with sternal rub. When asked is she
was in pain, she said "yes". She did not elaborate further. Her
family and the ED team report that she asked for ice cream and
that she asked her daughter if she watched the football game
yesterday. This was not witnessed. Did not follow command.
Patient is
purposeful with right upper extremity, trying to move away the
noxious stimuli applied to contralateral limb.
-Cranial Nerves: Olfaction not tested. PERRL surgical
bilaterally. There is no ptosis bilaterally. Unable to perform
proper fundoscopic exam. Occulocephalic reflexes were intact.
Corneal intact on the right but not on the left. Nasal tickel
reflex intact. Flattened NLF on the left. Hearing intact to name
as above.
-Motor: Normal bulk, tone throughout. No adventitious movements
noted. She spontaneously moves the RUE and RLE. She has a
paucity of spontaneous movements on the left side. The LUE has
minimal movement to noxious stimuli. The LLE
has triple flexion.
-Sensory: Intact to noxious throughout.
-Coordination: Not tested.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was extensor bilaterally.
-Gait: Untested.
Pertinent Results:
[**2155-12-9**] 06:00AM BLOOD WBC-14.2* RBC-3.85* Hgb-13.1 Hct-37.1
MCV-97 MCH-34.0* MCHC-35.2* RDW-16.2* Plt Ct-158
[**2155-12-8**] 09:45PM BLOOD PT-15.7* PTT-39.4* INR(PT)-1.4*
[**2155-12-9**] 11:06AM BLOOD PT-15.0* PTT-37.4* INR(PT)-1.3*
[**2155-12-9**] 11:06AM BLOOD Glucose-146* UreaN-12 Creat-1.0 Na-140
K-2.9* Cl-101 HCO3-26 AnGap-16
[**2155-12-9**] 11:06AM BLOOD ALT-12 AST-18 CK(CPK)-53 AlkPhos-88
TotBili-0.5
[**2155-12-9**] 11:06AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-12-9**] 11:06AM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.4 Mg-2.0
Cholest-154
[**2155-12-9**] 11:06AM BLOOD Triglyc-113 HDL-70 CHOL/HD-2.2 LDLcalc-61
[**2155-12-9**] 11:06AM BLOOD Osmolal-304
[**2155-12-9**] 11:06AM BLOOD TSH-0.19*
[**2155-12-9**] 03:15PM BLOOD Type-ART Rates-16/ Tidal V-500 FiO2-50
pO2-126* pCO2-43 pH-7.40 calTCO2-28 Base XS-1 -ASSIST/CON
Intubat-INTUBATED
[**2155-12-9**] 03:15PM BLOOD Lactate-1.4
[**2155-12-9**] 03:15PM BLOOD freeCa-1.14
Head CT [**12-9**]:
1. Significantly limited study due to patient movement. Large
parenchymal hemorrhage in the posterior right parietal lobe with
local mass effect. Apparent effacement along the right
suprasellar cistern likely represents volume averaging due to
motion, however, evolving uncal herniation is not entirely
excluded. Attention to this finding on follow-up imaging is
recommended.
2. Diffuse white matter hypodensity throughout the bilateral
basal ganglia, likely sequela of severe chronic microvascular
ischemia, less likely infarction.
Repeat Head CT [**12-9**]:
1. Interval increase in size of intraparenchymal hemorrhage
within the right parietal lobe. Worsening of right lateral
ventricle mass effect.
2. No subfalcine or uncal herniation.
Brief Hospital Course:
Ms. [**Known lastname 31469**] was admitted to the ICU for further monitoring. She
was treated with mannitol and dilantin. Her systolic blood
pressure was maintained between 120-160 with a Map < 130. She
was also maintained normothermic and normoglycemic.
In the morning she was noted to be increasingly drowsy,
disproportionately to her initial lesion on CT. Her dilantin was
stopped and she was sent for a repeat CT. This showed new
bleeding extending into the ventricles and worsening edema. She
was started on mannitol. Neurosurgery was also consulted to
evaluate for possible interventions including a drain. They felt
that she was not a surgical candidate.
These finding were discussed at length with the family by both
neurology and the ICU service.
The family discussed their goals of care. The children wanted
their mother to be [**Name (NI) 3225**], however her husband wanted her to be
full code. Shortly after this discussion, she was noted to have
agonal breathing. She was therefore intubated.
After the intubation, the family and a further discussion
regarding their goals of care. Mr. [**Known lastname 31469**] decided to make his
wife [**Name (NI) 3225**]. She was extubated and started on morphine and
scopolamine for comfort. The patient expired ~12hrs later.
Medications on Admission:
Calcium 400mg [**Hospital1 **].
Actonel 35 qfri
Vit E dose uncertain.
Levothyroxine 175 qd
diazide 375/25
Singulair 10 qd
Protonix 40 qd
Combivent uncertain schedule.
advair 500/50 [**Hospital1 **]
Choline magnesium trisalycilate - 750 qd
Potassium dose uncertain
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Hemmorhagic Stroke
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6693
} | Medical Text: Admission Date: [**2117-1-12**] Discharge Date: [**2117-2-1**]
Date of Birth: [**2038-1-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Acute Hypoxemic Respiratory Failure
Major Surgical or Invasive Procedure:
thoracentesis and placement of pig-tail catheter in right thorax
History of Present Illness:
78M Myelofibrosis, Anemia requiring transfusions, Zenkers
Diverticulum, hx of aspiration PNA requiring intubation
([**5-1**])presenting with acute hypoxia in setting of large right
sided pleural effusions.
.
Of note the pt was recently admitted to [**Hospital 8**] Hospital on
[**2117-1-2**] following a fall at home during which he had a work-up
for head trauma and syncope. ECG at that time revealed RBBB and
LAFB. Hct of 20.7, CT Head without acute intracranial pathology.
CXR revealed right sided atelectasis vs PNA. The pt was treated
for a right facial laceration and admitted. The pt states he
received 2 blood transfusions ans was discharged home from the
OSH after approximately 2 days. No discharge summary currently
available.
.
The pt states that over the past few days he has noted worsening
right sided pain that radiates to his chest. Worse with
inspiration [**5-3**]. No palpitations. Denies fevers, but admits to
chills. No diaphroses. The pt has had stable 1 pillow orthopnea
and has DOE upon walking up one flight of stairs. The pt today
presented to his PCP where he was noted to have a BP of 80/P and
subsequently brought to the ED.
.
Upon arrival to the ED 97.9 93/37 70 19 94% (02 not listed). The
pt was continued to complain of [**5-3**] back pain. ED exam was
notabable for absent BS on right. CXR with low lung volumes on
right. CT chest revealed effusion on right with mild ascites. No
signs of acute bleed.
.
The pt received Vancomycin 1mg IV, Levofloxacin 750mg IV x1,
Azreonam 1gm IVx1 for suspected right sided PNA in setting of
question PCN allergy. A PIV 18g and 20g were placed. The pt
received 2L of NS and 1L of D5W with 3 amp of Bicarb. UOP of
250cc.
.
The pt was seen by interventional pulmonary that who performed a
bedside ultrasounded throacentesis during which 1200cc of
serosanginous fluid was drained. Initial pH 7.08, pleural LDH of
468 indicative of an exudative process thus a pigtail catheter
was placed. Follow-up CXRs without evidence of pneumothorax.
.
Vitals prior to transfer HR 70 122/58 16 100% on 12L NRB.
.
.
REVIEW OF SYSTEMS:
(+)ve: chills, chest pain, orthopnea, 1 episode of BRBPR 3 weeks
ago.
(-)ve: fever, night sweats, loss of appetite, fatigue,
palpitations, rhinorrhea, nasal congestion, cough, sputum
production, hemoptysis, dyspnea, paroxysmal nocturnal dyspnea,
nausea, vomiting, diarrhea, constipation, hematochezia, melena,
dysuria, urinary frequency, urinary urgency, focal numbness,
focal weakness, myalgias, arthralgias
Past Medical History:
# Myelofibrosis - Bone Marrow Bx [**2-/2115**], 20q deletion, JAK-2
mutation
# Chronic Anemia: Requiring Blood Transfusions [**1-26**] MF
# Aspiration PNA ([**4-/2116**]) with hypoxemic respiratory failure
requiring intubation (Unconfirmed Location - Per OSH Records)
# Zenker's Diverticulum - hx of aspiration events
# Significant macular degeneration and cataracts
# Depression
# Pruritis
# Mild symmetric LVH
# Moderate Pulmonary HTN ([**5-1**])
# ?BPH (Per OSH records)
Social History:
He does not smoke and denies any alcohol abuse. He lives alone,
independent of ADLs, although declining. He is a retired english
professor [**First Name (Titles) 767**] [**Last Name (Titles) 10358**] [**Location (un) 47997**]. Interest in [**Last Name (un) **].
Family History:
Mother deceased - [**Name2 (NI) **] CA
Physical Exam:
T=97.3 BP=120/44 HR=75 RR=18 98 6L
GENERAL: Pleasant, ill cachectic appearing M in NAD
HEENT: Right facial laceration. Right purulence from
conjunctiva. Mild conjunctival pallor. No icterus. Dry MM.
NECK: Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= flat
LUNGS: Clear on left anteriorly. Clear superiorly on right
anteriorly. Right pigtail catheter in place.
ABDOMEN: NABS. Soft, NT, mild distension, +Hepatosplenomegaly.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: No asterxis. A&Ox3. Appropriate. CN 2-12 grossly intact.
Preserved sensation throughout. 5/5 strength throughout. [**12-26**]+
reflexes, equal BL. Normal coordination. Gait assessment
deferred
PSYCH: Listens and responds to questions appropriately, pleasant
.
Exam as of [**2117-1-24**]
Vitals: 96.5 101/49 85 18 95%2Lnc
Pain: over sacrum and R chest wall
Access: PIV and LUE double lumen PICC
Gen: thin man, cachectic, weak
HEENT: mm dry
CV: RRR, no m
Chest: R chest tube site dry with dressing
Resp: +bibasilar crackles, no wheezing
Abd; soft, thin, nontender, +SM
Ext; R>L edema (new over past 2days)
Neuro: A&OX3, grossly nonfocal
Skin: sacral decub stage II with dressing, L 4th toe hyperemic
but good distal pulse, area of erythema with darker and
irregular border over R hip, pruritic for patient, not clear
cellulitis, ?fungal
psych: calm, pleasant
Pertinent Results:
Discharge Day Labs:
Other Pertinent Labs:
UA [**1-12**]: 6-10wbc, few bacteria, UCx neg
UA [**1-21**]: 21wbc, +casts, mod LE, few bac, neg nitrites, 18rbc,
UCx neg
.
[**1-21**]: Una 10, UCreat 98, Uurea 875
[**1-23**]: repeat urine lytes: FeNa 0.7
.
BC [**1-12**] NGTD X2
.
Pleural fluid Cx [**1-12**] NTD
Pleural fluid: wbc 2550 with 89%PMNs, LDH 468, pH 7.08
pleural fluid cytology: neg for malignancy
Sputum Cx upper flora
.
.
Imaging/results:
EKG: RBBB, LAFB
.
[**1-12**]: CXR
Large right pleural effusion, with consequent lower and middle
lobe collapse.
.
CXR [**1-16**]; Two views of the chest demonstrate a large right-sided
pleural effusion with atelectasis/consolidation of the right
lower lobe. Left lung is clear. A chest tube is present at the
right lung base. There is little interval change with prior
studies. Hila and mediastinum within normal limits
.
CXR [**1-22**] (post pigtail removal)
There is a small right lower lobe pneumothorax. Small bilateral
pleural effusions, left greater than right, are unchanged.
Bibasilar consolidations and right middle lobe opacities are
unchanged, as is faint right upper lobe opacity.
Cardiomediastinal contours are normal.
.
CT chest w and w/o contrast [**1-22**]
1. Marked decrease in size of now small complex loculated right
pleural effusion. The tip of the catheter remains within the
pleural cavity, but the formed pigtail is extrathoracic in
location with adjacent subcutaneous emphysema and soft tissue
swelling.
2. Slight increase of small simple left pleural effusion.
Persistent
pneumonia with component of coexisting atelectasis of both lower
lobes but improved aeration of the right upper and right middle
lobes. Nonspecific ground-glass opacities are noted within the
right middle and lower lung which may be related to infection or
reexpansion pulmonary edema.
3. Unchanged hypoattenuating hepatic and splenic lesions as
described. Many of the hepatic lesions are clearly simple cysts.
There is stable hepatosplenomegaly with sequelae of portal
hypertension.
4. Known Zenker's diverticulum.
.
CT chest noncontrast [**1-13**]
1. Decreased right pleural effusion, now moderate in size,
status post right pleural pigtail catheter placement. Small left
pleural effusion.
2. Multifocal pneumonia involving nearly the entire right lung,
and large portions of the left lower lobe.
3. Unchanged hepatosplenomegaly.
4. Unchanged appearance of probable Zenker's diverticulum.
.
CT c/a/p [**1-12**] c contrast:
1. Large right pleural effusion with resultant compressive
atelectasis or the right lung.
2. Hepatosplenomegaly.
3. Ascites.
4. Splenic hypodensity, not fully characterized, possible
hamartoma or hemangioma.
5. Nodularity of the left adrenal gland, but no distinct nodule.
This
finding should be correlated clinically and if indicated, with
serum
biochemical markers.
6. Collection of fluid and gas at the thoracic inlet in the
region of the esophagus, a finding which predisposes the patient
to possible aspiration and should be clinically correlated.
.
Renal US [**1-23**];
1. No hydronephrosis or nephrolithiasis.
2. Unchanged renal cysts and prostatic enlargement.
.
.
LABS:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2117-1-31**] 12:27PM 6.5 2.73* 8.6* 24.7* 91 31.6 34.9 17.5*
93*
Source: Line-PICC
[**2117-1-30**] 05:04AM 5.7 2.51* 7.9* 23.0* 92 31.5 34.4 17.4*
70*1
Source: Line-PICC
[**2117-1-29**] 08:00AM 4.9 2.51* 7.8* 22.8* 91 30.9 34.0 17.5*
68*2
Source: Line-left picc line
[**2117-1-28**] 06:45AM 5.1 2.48* 7.6* 22.7* 92 30.6 33.5 17.4*
66*1
Source: Line-left picc line
[**2117-1-27**] 04:06AM 5.1 2.25* 6.9* 21.5* 96 30.5 31.9 18.0*
59*3
Source: Line-PICC
[**2117-1-26**] 05:00AM 5.4 2.50* 7.4* 23.0* 92 29.6 32.2 17.8*
72*3
Source: Line-PICC
[**2117-1-25**] 08:47AM 5.4 2.59* 7.8* 24.1* 93 30.2 32.4 17.9*
107*1
Source: Line-picc line
[**2117-1-24**] 08:00AM 6.0 2.68* 8.1* 25.0* 93 30.0 32.2 17.8*
113*1
[**2117-1-23**] 05:50AM 6.9 2.68* 8.0* 24.9* 93 30.0 32.2 17.9*
132*3
[**2117-1-22**] 06:45AM 7.1 2.77* 8.4* 25.6* 92 30.2 32.7 18.0*
1511
[**2117-1-21**] 06:45AM 9.3 3.09* 9.4* 28.9* 93 30.3 32.5 18.1*
1711
[**2117-1-20**] 10:55AM 12.2*# 3.17* 9.3* 29.6* 93 29.4 31.6
18.2* 187
[**2117-1-19**] 06:10AM 7.3 2.65* 8.0* 24.2* 91 30.2 33.1 18.5*
1703
[**2117-1-18**] 01:00PM 10.9# 3.11*# 9.0*# 28.5*# 92 28.8 31.5
18.4* 203
[**2117-1-17**] 06:00AM 6.9 2.20* 6.5* 20.8* 95 29.6 31.2 18.5*
1753
[**2117-1-16**] 05:40AM 6.1 2.30* 6.8* 21.8* 95 29.7 31.3 18.8*
185
[**2117-1-15**] 05:55AM 7.4 2.35* 6.9* 22.1* 94 29.3 31.2 18.5*
205
[**2117-1-14**] 05:20AM 13.8*# 2.72* 8.1* 25.7* 95 29.9 31.6
18.7* 2081
[**2117-1-13**] 08:35AM 28.2*
[**2117-1-13**] 02:53AM 7.9 2.49* 7.4* 24.0* 97#4 29.8 30.9*
18.8* 1511
[**2117-1-12**] 11:16PM 8.5 2.92* 8.8* 30.2* 104*#4 30.3 29.2*
18.7* 1531
[**2117-1-12**] 02:00PM 12.8*#1 2.98*# 9.1*# 28.1*# 94 30.6 32.4
19.3* [**2007**]
VERIFIED BY SMEAR
LARGE FORMS PRESENT
VERIFIED
VERIFIED
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2117-1-28**] 06:45AM 80.7* 11.8* 4.8 2.6 0.1
Source: Line-left picc line
[**2117-1-25**] 08:47AM 82.8* 0 11.2* 4.7 1.2 0
Source: Line-picc line
[**2117-1-12**] 02:00PM 86* 3 4* 7 0 0 0 0 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Ovalocy
[**2117-1-12**] 02:00PM 3+ 2+ 2+ 1+ 1+ OCCASIONAL 2+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 11951**]
[**2117-1-31**] 12:27PM LOW1 93*
Source: Line-PICC
[**2117-1-30**] 05:04AM VERY LOW2 70*3 3+
Source: Line-PICC
[**2117-1-29**] 08:00AM VERY LOW4 68*5 3+
Source: Line-left picc line
[**2117-1-28**] 06:45AM 66*3
Source: Line-left picc line
[**2117-1-28**] 06:45AM 16.5* 37.3* 1.5*
Source: Line-left picc line
[**2117-1-27**] 04:06AM VERY LOW 59*6
Source: Line-PICC
[**2117-1-26**] 05:00AM VERY LOW 72*6
Source: Line-PICC
[**2117-1-25**] 08:47AM LOW7 107*3 2+
Source: Line-picc line
[**2117-1-24**] 08:00AM LOW8 113*3
[**2117-1-23**] 05:50AM LOW 132*6
[**2117-1-23**] 05:50AM 15.7* 1.4*
[**2117-1-22**] 06:45AM 1513
[**2117-1-21**] 06:45AM NORMAL 1713 2+
[**2117-1-20**] 10:55AM NORMAL9 187
[**2117-1-19**] 06:10AM NORMAL 1706
[**2117-1-18**] 01:00PM NORMAL10 203 1+
[**2117-1-18**] 01:00PM 15.9* 33.9 1.4*
[**2117-1-17**] 06:00AM NORMAL 1756 1+
[**2117-1-16**] 05:40AM 185
[**2117-1-15**] 05:55AM NORMAL11 205 1+
[**2117-1-14**] 05:20AM NORMAL 2083
[**2117-1-14**] 05:20AM 17.0* 39.8* 1.5*
[**2117-1-13**] 02:53AM 1513
[**2117-1-13**] 02:53AM 19.0* 39.2* 1.7*
[**2117-1-12**] 11:16PM NORMAL 1533 2+
[**2117-1-12**] 02:00PM 17.4* 35.8* 1.6*
[**2117-1-12**] 02:00PM NORMAL [**2009**]
LOW
FEW LARGE PLATELETS
VERY LOW
WITH LARGE FORMS
VERIFIED BY SMEAR
VERY LOW
LARGE FORMS PRESENT
LARGE FORMS PRESENT
VERIFIED
LOW
OCC LARGE FORMS
LOW
LARGE PLTS SEEN
NORMAL
OCC LARGE FORMS
NORMAL
MANY LARGE PLATELETS
NORMAL
MOD. LARGE PLTS
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2117-1-31**] 08:38AM 317*1 41* 0.8 137 4.7 105 26 11
Source: Line-PICC
[**2117-1-30**] 05:04AM 103*1 38* 0.7 138 4.0 105 27 10
Source: Line-PICC
[**2117-1-29**] 08:00AM 125*1 30* 0.8 138 3.7 106 28 8
Source: Line-left picc line
[**2117-1-28**] 06:45AM 126*1 29* 0.8 140 3.7 109* 28 7*
Source: Line-left picc line
[**2117-1-27**] 04:06AM 134*1 30* 0.9 137 3.4 106 23 11
Source: Line-PICC
[**2117-1-26**] 05:00AM 111*1 34* 0.9 137 4.3 110* 23 8
Source: Line-PICC
[**2117-1-25**] 08:47AM 111*1 35* 1.1 140 4.2 111* 25 8
Source: Line-picc line
[**2117-1-24**] 08:00AM 881 40* 1.3* 142 4.4 113* 24 9
[**2117-1-23**] 05:50AM 891 48* 1.4* 143 4.7 112* 25 11
[**2117-1-22**] 03:30PM 188*1 51* 1.7* 142 5.5* 112* 23 13
[**2117-1-22**] 06:45AM 971 56* 1.6* 142 5.8* 112* 23 13
[**2117-1-21**] 06:45AM 1001 44* 1.5* 143 5.7* 111* 28 10
[**2117-1-20**] 10:55AM 163*1 35* 1.2 140 5.0 109* 27 9
[**2117-1-19**] 06:10AM 891 28* 0.8 143 4.4 112* 28 7*
[**2117-1-18**] 01:00PM 129*1 29* 0.9 141 4.6 109* 26 11
[**2117-1-17**] 06:00AM 117*1 30* 0.9 140 4.0 110* 27 7*
[**2117-1-16**] 05:40AM 117*1 34* 0.8 138 3.6 107 28 7*
[**2117-1-15**] 05:55AM 1001 44* 1.1 141 3.9 108 25 12
[**2117-1-14**] 05:20AM 107*1 39* 1.2 139 4.2 106 27 10
ADDED B12 @ 08:08AM ON [**2117-1-14**]
[**2117-1-13**] 02:53AM 134*1 36* 1.2 142 4.3 108 27 11
[**2117-1-12**] 02:00PM 145*1 39* 1.5* 139 4.9 106 26 12
ADDED PON CPIS AT 1500
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2117-1-28**] 06:45AM Using this1
Source: Line-left picc line
[**2117-1-20**] 10:55AM Using this2
[**2117-1-12**] 02:00PM Using this3
ADDED PON CPIS AT 1500
Using this patient's age, gender, and serum creatinine value of
0.8,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
Using this patient's age, gender, and serum creatinine value of
1.2,
Estimated GFR = 59 if non African-American (mL/min/1.73 m2)
Estimated GFR = 71 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
Using this patient's age, gender, and serum creatinine value of
1.5,
Estimated GFR = 45 if non African-American (mL/min/1.73 m2)
Estimated GFR = 55 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2117-1-31**] 08:38AM 9 9 51 0.5
Source: Line-PICC
[**2117-1-17**] 03:00PM 9*1
[**2117-1-17**] 06:00AM 8*1
[**2117-1-12**] 02:00PM 7 6 54 0.7
ADDED PON CPIS AT 1500
VERIFIED BY REPLICATE ANALYSIS
NEW REFERENCE INTERVAL AS OF [**2116-12-28**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
OTHER ENZYMES & BILIRUBINS Lipase
[**2117-1-12**] 02:00PM 12
ADDED PON CPIS AT 1500
CPK ISOENZYMES CK-MB cTropnT
[**2117-1-17**] 03:00PM 2 <0.011
[**2117-1-17**] 06:00AM 2 <0.011
[**2117-1-12**] 02:00PM 0.012
ADDED ON TNT AT 1459
[**2117-1-12**] 02:00PM 2
ADDED PON CPIS AT 1500
<0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2117-1-31**] 08:38AM 7.7* 2.3
Source: Line-PICC
[**2117-1-29**] 08:00AM 7.6* 3.7 2.1
Source: Line-left picc line
[**2117-1-28**] 06:45AM 7.2* 3.5 2.1
Source: Line-left picc line
[**2117-1-27**] 04:06AM 7.1* 3.0 2.1
Source: Line-PICC
[**2117-1-26**] 05:00AM 7.3* 2.7 2.1
Source: Line-PICC
[**2117-1-25**] 08:47AM 7.6* 3.2 2.3
Source: Line-picc line
[**2117-1-24**] 08:00AM 7.6* 3.0 2.2
[**2117-1-23**] 05:50AM 2.3* 7.6* 3.9 2.3
[**2117-1-22**] 03:30PM 7.8* 4.7* 2.3
[**2117-1-22**] 06:45AM 7.8* 4.9* 2.3
[**2117-1-21**] 06:45AM 8.1* 4.6* 2.2
[**2117-1-20**] 10:55AM 7.8* 3.4 2.1
[**2117-1-19**] 06:10AM 8.0* 2.6* 2.1
[**2117-1-18**] 01:00PM 8.0* 2.6* 2.1
[**2117-1-16**] 05:40AM 2.5* 7.9* 2.4* 2.1
[**2117-1-15**] 05:55AM 8.1* 3.2
[**2117-1-14**] 05:20AM 8.0* 4.3 2.3
ADDED B12 @ 08:08AM ON [**2117-1-14**]
[**2117-1-13**] 02:53AM 2.8* 7.3* 3.7 2.1
HEMATOLOGIC VitB12
[**2117-1-14**] 05:20AM 672
ADDED B12 @ 08:08AM ON [**2117-1-14**]
LIPID/CHOLESTEROL Cholest Triglyc
[**2117-1-26**] 05:00AM 501
Source: Line-PICC
LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
ANTIBIOTICS Vanco
[**2117-1-16**] 05:30PM 26.2*
Random
.
.
Brief Hospital Course:
78 year old male (retired english professor) with h/o
myelofibrosis/anemia (transfusion dependent, dx [**2114**]),
longstanding zenker's diverticulum with chronic aspiration and
recurrent aspiration pneumonias admitted on [**1-12**] with the same.
.
1. Aspiration Pneumonia: Patient was initially admitted to the
[**Hospital Unit Name 153**] with significant RLL PNA with pleural effusion and
hypotension. Hypotension resolved with IVF and he was
transferred to floor. He underwent thoracentesis with resultant
exudative fluid, and a chest tube was placed with resultant
drainage of 3L of fluid and removal of the catheter on [**2117-1-22**].
He received a ten day course of Levofloxacin/Clindaymycin. At
the time of discharge he had normal oxygen saturations on room
air.
.
2. Chronic aspiration: Patient failed speech and swallow
evaluation several times. Dobhoff tube placement was
unsuccessful, a PICC was placed on [**2117-1-24**], and TPN was started.
The plan is for endoscopic repair of his Zenker's diverticulum
by Dr.[**Last Name (STitle) 1837**]. Dr[**Doctor Last Name **] office will call Rehab
to schedule a pre-operative visit.
.
3. Anemia [**1-26**] Myelofibrosis: Patient received intermittent
transfusions to maintain a Hct>22 (is also transfusion dependent
as an outpatient). Folate supplementation was continued. He is
followed for this issue by his hematologist, Dr.[**Last Name (STitle) 3638**].
.
4. Thrombocytopenia: Platelet count began to trend down during
the last week of hospitalization, thought to be [**1-26**] increased
splenic congestion in the setting of volume overload while on
TPN. There was also concern that his antibiotics were
contributing. After completing antibiotics and undergoing
diuresis with Lasix 20mg IV as needed, his platelet count began
to trend up, and on the day of discharge was 103.
.
5.Acute renal failure: Patient noted to have ARF on admission,
which improved with IVFs to Cr=0.8. However, he once again
developed ARF on [**1-21**] (peak creat 1.7) likely from volume
depletion as well, which again improved with hydration. Renal US
was within normal limits.
.
6. Sacral decubitus ulcer: Patient has a stage II sacral ulcer
and was getting wound care and turning frequently.
.
PCP: [**Last Name (NamePattern4) **].[**Last Name (STitle) 141**]
Hematologist: Dr.[**Last Name (STitle) 3638**]
ENT: Dr.[**Last Name (STitle) 97218**]
Medications on Admission:
Combivent
Folic Acid
Ferrous Sulfate
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Aspiration pneumonia c/b Parapneumonic pleural effusion
Zenker's diverticulum with chronic aspiration
moderate to severe malnutrition
sacral decub stage II
Myelodysplastic syndrome and Anemia, transfusion dependent
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 with a recurrent aspiration pneumonia and
pleural effusion which required drainage with a chest tube. You
were briefly in the ICU. You were treated with antibiotics with
improvement in your symptoms and completed these on [**2117-1-26**]. The
chest tube had some trouble draining but we were able to fix
this with TPA and it drained about 3L of fluid and your
breathing improved.
The cause of your pneumonia is due to recurrent aspiration, in
part due to your large zenker's diverticulum. Dr. [**Name (NI) 97219**] office will contact you to arrange a
pre-opertive visit to discuss repair of the diverticulum. A PICC
line was placed for TPN, which is IV nutrition. Our hope is that
this will make your nutrition status better so you can recover
from the surgery. You also required occasional blood
transfusions to keep your hematocrit above thirty. Your platelet
count dropped to a low of 59, but was increasing at the time of
discharge. This was thought to be due to splenic congestion due
to volume overload.
.
Please take all medications as prescribed. It is very important
to use your incentive spirometer and work with physical therapy
going forward.
Followup Instructions:
Please follow up closely with your PCP as soon as possible:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 142**]
.
You will be contact[**Name (NI) **] by Dr. [**Last Name (STitle) 97218**] to arranged for your
endoscopic surgery for Zenker's
ICD9 Codes: 5070, 5849, 5119, 4168, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6694
} | Medical Text: Admission Date: [**2177-5-11**] Discharge Date: [**2177-5-22**]
Date of Birth: [**2177-5-11**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **], twin number
two, is a 2,100 gram, 32 [**5-26**] week male born to a 32-year-old
G2, para 0 now 2 mother with serologies B positive, antibody
negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative, group B Streptococcus unknown. The
mother presented three days prior to admission with premature
rupture of membranes and in preterm labor treated with
magnesium sulfate. She was not treated with betamethasone
and unstoppable preterm labor proceeded to cesarean section.
The pregnancy is also notable for IVF twins.
The patient emerged and was vigorous. Apgar scores were
eight and nine.
PHYSICAL EXAMINATION: Weight: 2,100 grams (70th
percentile). Length: 45.5 cm (70th percentile), head
circumference 30 cm (30th percentile). Anterior fontanelle
was soft and flat, nondysmorphic. Palate intact. He had
some facial edema with bruising around his neck. Chest:
Symmetric. He had fair aeration with coarse breath sounds,
mild retractions, and grunting. Heart: Regular rate and
rhythm without a murmur. He had 2+ femoral pulses. Abdomen:
Soft, without hepatosplenomegaly. He had a three vessel
cord. Genitalia: He had normal male genitalia with both
testes descended into the scrotum. Hips: Stable without
clicks or clunks. He had no sacral dimples. His anus
appeared patent. Extremities: His extremities were all
intact. He had normal tone, appropriate for gestational age.
HOSPITAL COURSE:
RESPIRATORY: Due to grunting, flaring, and retractions, the
patient was initially placed on CPAP and a chest x-ray showed
moderate HMD. However, given the increased FI02 and
increased work of breathing, he was intubated and received
Surfactant times two. Chest x-ray at that time was also
notable for a moderate sized pneumomediastinum.
On day of life 8 the infant was able to be extubated from the
ventilator and transitioned to nasal cannula. On day of nine
he was transitioned off nasal cannula to room air, where he
remains.
He has not demonstrated any apnea and bradycardia of
prematurity. He has received any methylxanthines.
CARDIOVASCULAR: The patient was initially cardiovascularly
stable without a murmur and normal blood pressures for age.
However, on day of life four, he was noted to have slightly
widened pulse pressure and subsequently had blood via the ET
tube. He subsequently developed a blowing murmur at the left
sternal border. On day of life five, he was started on a
course of Indomethacin for presumed patent ductus arteriosus.
The murmur persisted and an echocardiogram was obtained on
[**5-18**] (results included) which showed a small to moderate PDA.
A second course of indocin was given with resolution of the
murmur. A follow-up echocardiogram has not been done to date.
This was planned to be done prior to discharge to home.
GI/FLUIDS, ELECTROLYTES, AND NUTRITION: The patient had a
peripheral IV placed, was n.p.o. on D10W at 80 cc per
kilogram per day. Enteral feedings were started on day of
life two and were advancing nicely; however, feeds were
discontinued on day of life four for initiation of Indocin.
After completion of the second course of Indocin, he has
slowly re-advanced on his enteral feedings. He is currently on
140 cc/k/day of PE20 at 90 cc/k/day with the remainder of
PN/IL.
His most recent electrolytes were 135, 5.1, 103, and
22 on [**5-19**].
GASTROINTESTINAL: The patient had serial bilirubins
followed. He was started on phototherapy on day of life
number three for a bilirubin of 10.2/0.3. His peak bilirubin
level was 12.5/0.3 on [**5-18**], day of life 7. Phototherapy was
discontinued on day of life number nine. His rebound
bilirubin level was 9.3/0.5 on [**2175-5-21**].
HEME: The patient's initial hematocrit was 50.5. He has
received no blood transfusions.
INFECTIOUS DISEASE: The initial white blood cell count was
10.9. There were 14 percent segs, 0 percent bands, with an
ANC of 1,526. A blood culture was drawn. He was treated
with ampicillin and gentamicin for 48 hours. Blood culture
was negative and antibiotics were discontinued.
INITIAL PKU: Sent on day of life number three.
SOCIAL: Parents live in [**Location (un) **], [**Location (un) 3844**]. Their
pediatrician will be Dr. [**Last Name (STitle) **] with [**Hospital 8117**] Pediatrics. They
will consider transfer to [**State 20192**]
Center at an appropriate interval.
Discharge diagnoses:
1. Prematurity
2. Respiratory distress syndrome, s/p surfactant x 2
3. Pneumomediastinum
4. Sepsis evaluation
5. Hyperbilrubinemia
6. Patent ductus arteriosus
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern4) 55464**]
MEDQUIST36
D: [**2177-5-16**] 17:23:34
T: [**2177-5-16**] 19:44:46
Job#: [**Job Number **]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6695
} | Medical Text: Admission Date: [**2197-11-3**] Discharge Date:[**2198-2-2**]
Date of Birth: [**2197-11-3**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 75392**], boy twin #1,
is the former 1.145 kg product of a twin 27-4/7 week
gestation pregnancy born to a 30-year-old, G1, P0, now 2
woman. Prenatal screens: Blood type O positive, antibody
negative, rubella unknown, RPR nonreactive, hepatitis B
surface antigen negative, group beta strep status unknown.
The pregnancy was known for in [**Last Name (un) 5153**] fertilization conception
with resulting dichorionic-diamniotic twins. There was an
echogenic cardiac focus noted on twin 1 on fetal ultrasounds;
otherwise, the fetal surveys were unremarkable. The mother
was admitted at 23-/57 weeks with preterm labor and vaginal
bleeding. A chronic placental abruption was eventually
diagnosed. She was treated with indomethacin and nifedipine.
She also received a complete course of betamethasone which
finished on [**2197-10-12**]. She had a spontaneous rupture of
membranes three days prior to delivery and was treated with
antibiotics. On the day of delivery, the mother experienced
increasing contractions, so the decision was made to deliver.
An elective C-section under spinal anesthesia was undertaken
for known breech position of the second twin. This twin #1
emerged with cry. He received facial CPAP and then was
intubated with a 3.0 endotracheal tube. The infant was
admitted to the neonatal intensive care unit for treatment of
prematurity. Apgars were 6 at one minute and 8 at five
minutes.
PHYSICAL EXAMINATION: Upon admission to the neonatal
intensive care unit, weight 1.45 kg, length 37 cm, head
circumference 27.5 cm all AGA.
HOSPITAL COURSE BY SYSTEMS AND PERTINENT LABORATORY DATA:
RESPIRATORY: This infant was treated with one dose of
surfactant. His peak inspiratory pressure was 18 and
positive end-expiratory pressure of 5, intermittent
mandatory respiratory rate of 20. He was extubated to
continuous positive airway pressure on day of life #1.
He continued on the continuous positive airway pressure
through day of life #8 when he transitioned to room air.
He subsequently required nasal cannula O2 and on day of
life #11 was placed back on continuous positive airway
pressure for increased work of breathing. He continued
on continuous positive airway pressure through day of
life 17 when he again transitioned to a nasal cannula.
On day of life #30, [**2197-12-3**], he transitioned to room
air. He was treated for apnea of prematurity
with caffeine citrate and this was d'cd on [**2197-12-20**]. At time
of discharge, he has been free of any apnea/bradycardia
for at least 5 days and is breathing comfortably in room
air with a respiratory rate of 40-70 breaths per minute.
CARDIOVASCULAR: This infant has maintained normal heart
rate and blood pressures. A soft intermittent murmur has
been heard but has not been present for the past few
weeks. His baseline heart rate is 150-170 beats per minute
with a recent blood pressure of 77/46 mm Hg, mean arterial
pressure 56 mHg.
FLUIDS, ELECTROLYTES AND NUTRITION: This infant was
initially fed nothing by mouth and maintained on
intravenous fluids. A double-lumen umbilical catheter was
placed for nutritional support. Enteral feedings were
started on day of life #2 and gradually advanced to full
volume. He had immature suck/swallow and breathing
coordination in the past,
He is taking 160-200 mL/kg/D of breast milk or
breastfeeding.
Weight at the time of discharge is 3070 g.
INFECTIOUS DISEASE: Due to his prematurity and severity
of illness and unknown group beta strep status of his
mother, this infant was evaluated for sepsis upon
admission to the neonatal intensive care unit. A
complete blood count and white blood cell differential
were sent and were within normal limits. A blood culture
was obtained prior to starting intravenous ampicillin
and gentamicin. Blood culture was no growth at 48 hours
and the antibiotics were discontinued. This infant has
not had any other infectious disease issues.
HEMATOLOGY: Hematocrit at birth was 45.7%. This infant
has not received any transfusions of blood products.
Most recent hematocrit was on [**1-23**], with hematocrit of 25.3
% and a reticulocyte count of 1.8%. He is on supplemental
iron.
GASTROINTESTINAL: This infant required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life #2, a total of
4.9 mg/dL. He was treated with phototherapy for
approximately one week. His most recent serum bilirubin
and final rebound was on [**2197-11-23**], on day of life 20,
with total 2.7 mg/dL.
NEUROLOGY: Head ultrasounds were performed on [**11-9**] and
[**2197-12-1**] with all results within normal limits. This
infant has maintained a normal neurological exam thus
far during admission.
SENSORY:
a. AUDIOLOGY: Hearing screening has been
performed and passed on [**1-26**].
b. OPHTHALMOLOGY: Initial screening eye exam for
retinopathy of prematurity was performed on [**2196-12-19**]
showing immature retinas zone 3 both eyes. A follow-
up on [**1-8**] was mature ou, no signs of retinopathy.
PSYCHOSOCIAL: Parents have been very involved since
birth. Mother is of Japanese and Brazilian descent. The
father is of Brazilian descent. They live in [**Location (un) 1468**],
[**State 350**].
ABDOMEN: [**Known lastname **] has a 1.5 cm umbilical hernia.
IMMUNIZATIONS: On [**1-5**] he received his 2 month immunizations,
which were Pediarix, Hemophilus B and Pneumoccocal vaccines.
Synagis was given on [**1-19**].
DISCHARGE DISPOSITION: Pedi at [**Hospital1 **] Medical Ass
is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47145**]. Mom to make appt
VNA to come to house day post discharge.
2. Medications: Ferrous Sulfate 4 mg/kg/day , TriViSol 1cc
daily.
3. Iron and vitamin D supplementation:
a. Iron supplementation is recommended for preterm
and low birthweight infants until 12 months corrected
age.
b. All infants fed predominantly breast milk should
received vitamin D supplementation at 200 international
units (may be provided as a multivitamin preparation)
daily until 12 months corrected age.
4. Car seat position screening passed.
5. State newborn screen was sent on [**2197-11-7**] with an
elevated phenylalanine level. Repeat specimen was sent
with no notification of abnormal results to date.
6. Immunizations: Hepatitis B vaccine was administered on
[**2197-12-4**].
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 4 criteria: 1) born at less than 32 weeks; 2)
born between 32 and 35-0/7 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities
or school-aged siblings; 3) chronic lungs disease; or
4) 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 and for the first 24 months of a
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 the
initial vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks but fewer than 12 weeks of
age.
DISCHARGE DIAGNOSES:
1. Prematurity at 27-4/7 weeks gestation.
2. Twin #1 of twin gestation.
3. Respiratory distress syndrome.
4. Apnea of prematurity.
5. Suspicion for sepsis ruled out.
6. Unconjugated hyperbilirubinemia.
7. Anemia of prematurity.
8. Umbilical hernia
9. S/PIntermittent cardiac murmur.
10.S/P Feeding immaturity.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2197-12-11**] 18:28:22
T: [**2197-12-11**] 19:14:48
Job#: [**Job Number **]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6696
} | Medical Text: Admission Date: [**2157-7-29**] Discharge Date: [**2157-8-4**]
Date of Birth: [**2106-10-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Self hanging
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 you male s/p self hanging attempt, ?5-10 minutes. GCS 8. He
was taken to a referring hospital where he was later transfered
to [**Hospital1 18**] with a C1 C2 subluxation.
Past Medical History:
HTN
GERD
Seasonal allergies
EtOH abuse
Depression
Social History:
+EtOH
Family History:
Noncontributory
Physical Exam:
GENERAL: The patient is sedated, in chemical coma.
HEENT: Normocephalic, atraumatic.
NECK: Has a hard cervical collar.
CARDIOVASCULAR: Tachycardic.
PULMONARY: Clear to auscultation.
ABDOMEN: Soft and nontender.
DERMATOLOGIC: Shows no rashes or lesions.
NEUROLOGICAL: He is in coma, chemically induced.
Pertinent Results:
[**2157-7-29**] 03:10AM GLUCOSE-119* UREA N-6 CREAT-0.5 SODIUM-136
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-13
[**2157-7-29**] 03:10AM WBC-6.3 RBC-3.52* HGB-13.0* HCT-37.5*
MCV-107* MCH-37.0* MCHC-34.7 RDW-15.3
[**2157-7-29**] 03:10AM PLT COUNT-112*
[**2157-7-29**] 03:10AM PT-16.0* PTT-30.8 INR(PT)-1.5*
[**2157-7-28**] 11:59PM ASA-NEG ETHANOL-121* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CT C-SPINE W/O CONTRAST
Reason: please eval for fx or malalignment
[**Hospital 93**] MEDICAL CONDITION:
50 year old man s/p hanging
REASON FOR THIS EXAMINATION:
please eval for fx or malalignment
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 50-year-old man status post hanging. Evaluate for
fracture or malalignment.
No prior comparison exams are available.
CT THE CERVICAL SPINE
TECHNIQUE: MDCT acquired axial images were obtained via cervical
spine without intravenous contrast. Coronal and sagittal
reformations were evaluated.
FINDINGS: Vertebral body height and alignment appear preserved.
Well corticated fragments noted anterior to the C4 through C6
vertebral bodies are likely small regions of anterior
longitudinal ligament ossificiation as no prevertebral soft
tissues identified, however in the setting of trauma,
ligamentous injury cannot be completely excluded. The coronal
view demonstrates mild asymmetry to the lateral masses of C1 on
C2 on the left side due to slght head rotation. Visualized
contents of the intrathecal sac appear unremarkable, however MRI
examination will be more sensitive for evaluation of spinal cord
injury. Retained oral secretions are noted within the nasal and
oropharynx.
IMPRESSION:
1. Maintained vertebral body height and alignment. Small well
corticated osseous fragments adjacent to the C4 through C6
vertebral bodies appear degenerative in nature as no
prevertebral soft tissue swelling is identified, however in
setting of hanging injury, ligamentous injury cannot be entirely
excluded.
2. Mild asymmetry to the lateral masses of C1 on C2 due to
rotation. These findings may be better evaluated with dedicated
MRI examination, if clinically indicated.
CHEST (PORTABLE AP)
Reason: please evaluate for ARDS/contusion s/p hanging
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with recent hanging
REASON FOR THIS EXAMINATION:
please evaluate for ARDS/contusion s/p hanging
UPRIGHT PORTABLE CHEST X-RAY PERFORMED ON [**2157-7-29**] AT 8:10 A.M.
COMPARISONS: None.
TECHNIQUE: Single portable chest x-ray, upright.
CLINICAL HISTORY: 50-year-old man with recent hanging, evaluate
for ARDS, contusion.
FINDINGS: An endotracheal tube is in place, with its tip
approximately 7 cm above the carina. The NG tube is seen
extending into the left upper quadrant. Lungs are clear
bilaterally. Cardiomediastinal silhouette is unremarkable. There
is no pneumothorax. No fractures are identified.
IMPRESSION:
ET tube and NG tube in good position.
No acute intrathoracic abnormality.
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery was
consulted given his cervical spine injury; no operative
intervention, he was placed in a hard cervical collar which will
need to remain in place for a total of 12 weeks.
Cardiology was consulted because of persistent tachycardia; he
was given beta blockers and placed on telemetry. His tachycardia
has resolved.
Behavioral Neurology was also consulted because of concerns over
anoxic brain injury related to the hanging attempt. It was
recommended to minimize sedation and to perform EEG to evaluate
for seizures if slow to awaken. He did wake up and has been
alert and oriented, cooperative with his care. He will require
outpatient follow up in [**Hospital **] clinic after discharge.
Psychiatry was also consulted given that this was a suicide
attempt and have recommended inpatient psychiatric admission.
He is being treated with a 7 day course Keflex for a right arm
cellulitis from an infiltrated IV site.
Medications on Admission:
pt denies
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): hold for HR <60; SBP <110.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Haloperidol 1 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for agitation.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
ML Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing: via nebulizer.
9. Sodium Chloride-Aloe [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37062**], Non-Aerosol Sig: [**1-25**]
Sprays Nasal TID (3 times a day) as needed for nasal dryness.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
s/p Self hanging
C1 C2 subluxation
Discharge Condition:
Stable
Discharge Instructions:
You must continue to wear your cervical (neck) collar for a
total of 12 weeks.
Return to the Emergency room if you develop any numbness,
weakness, loss of function in any of your extremities, shortness
of breath, chest pain and/or any other symptomsthat are
concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 23813**], Neurosurgery, in 4 weeks. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat CT scan of your cervical spine for this
appointment.
Completed by:[**2157-8-4**]
ICD9 Codes: 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6697
} | Medical Text: Admission Date: [**2105-11-13**] Discharge Date: [**2105-11-18**]
Date of Birth: [**2034-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Salicylates / Morphine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
Trach on vent.
History of Present Illness:
HPI: Pt is a 70 y/o F with a hx of COPD with a trach not
currently being vented, who presented from a NF to
[**Location (un) 745**]-Wellesly Hopsital with hypoxia and respiratory
difficulty. She is well known to [**Location (un) 745**]-Wellesly with numerous
previous admissions. Pt was not responsive to oxygen there and
per report the patient is at high risk for aspiration, since
peanuts and other food was found in her bedsheets. She is unable
to provide an accurate history. The patient was transferred to
[**Hospital6 **] CXR was suspicious for aspiration PNA
,R>L. In addition there was blood-tinged sputum from her trach.
Patient was treated with Vancomycin and Imipenem, and
transeferred to [**Hospital1 18**] as no ICU beds were available. Of note
patient was noted to have a potassium of 6.0, and was given
insulin, D50, and 1 amp of HCO3.
.
Of note, the patient was recently d/c'd from [**Location (un) 65053**]
Hospital [**2105-9-18**] after fevers and RML, RLL, and LLL PNA. There
was purelent material in the trach, and she was presumed to have
a recurrent PNA. She was treated at that time with Linezolid,
Aztreonam, and Tobramycin given her h/o PNA's with Proteus,
Psuedomonas, Serratia, and MRSA.
Past Medical History:
PMHx:
Morbid Obesity
COPD
CAD with old LBBB
CHF
Hypothroidism
Paroxysmal Atrial Fibrillation
Recurrent pancreatitis
s/p failed cholecystectomy for gallstones
h/o MRSA PNA, and MRSA bacteremia
h/o complicated PNA's with Pseudomonas, Proteus, and Serratia
h/o post-traumatic intubation w/ intubation requiring trach
CRF (unknown baseline, was 1.4 in [**10-17**])
Chronic foley, with h/o recurrent UTI's
h/o GIB
h/o pseudoseizures secondary to anxiety
h/o severe pustular psoriasis to certain antibiotics(amoxicillin
and levofloxacin)
h/o Anxeity and Depression
Type II DM
Catatracts
Social History:
Soc: Patient is resident of [**Hospital 745**] Healthcare Center; no current
Etoh or tobacco hx. Primary family are nephews.
Family History:
FMHx: Noncontributory (per OSH records)
Physical Exam:
VS(on admission): T=99.5, BP=135/59, HR=74, O2 sat 100%; vent
settings 500 x 18, PEEP 5, Rate 18 (breathing 20-26), FiO2 60%
GEN: Pt morbidly obese, in no acute distress
HEENT: nonicteric, mucosa moist; unable to assess JVP; erythema
diffuse over neck bilaterally
CHEST: transmitted vent sounds ant & lat
CV: RRR; difficult exam
ABD: obese, soft; prior surgical scars
EXT: [**12-14**]+ pitting LE edema
NEURO: pt alert, follows basic commands; tremor of left arm and
mild tremor of right arm; complete neuro exam difficult due poor
cooperation.
Pertinent Results:
[**2105-11-13**] 05:05PM GLUCOSE-98 UREA N-32* CREAT-1.3* SODIUM-141
POTASSIUM-5.5* CHLORIDE-110* TOTAL CO2-20* ANION GAP-17
[**2105-11-13**] 05:05PM ALT(SGPT)-14 AST(SGOT)-18 LD(LDH)-303* ALK
PHOS-306* TOT BILI-0.2
[**2105-11-13**] 05:05PM LIPASE-102*
[**2105-11-13**] 05:05PM ALBUMIN-3.4 CALCIUM-8.1* PHOSPHATE-3.3
MAGNESIUM-1.6
[**2105-11-13**] 05:05PM WBC-21.4* RBC-4.57 HGB-11.2* HCT-34.8*
MCV-76* MCH-24.5* MCHC-32.2 RDW-18.4*
[**2105-11-13**] 05:05PM TSH-1.0
[**2105-11-13**] 05:05PM NEUTS-93* BANDS-0 LYMPHS-1* MONOS-5 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2105-11-13**] 05:05PM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2105-11-13**] 05:05PM PLT COUNT-286
[**2105-11-13**] 05:05PM PT-15.0* PTT-21.7* INR(PT)-1.5
.
Labs from outside hospital:
ABG 7.28/41/162 on 50% FiO2
.
UA with 11,000 WBC's, 323 RBC's, many bact, +nitrite, 12 epis
.
Na 136, K 6.0(hemolyzed), bicarb 20, Chl 112, BUN 27, Cr 1.2,
Glu 192; Ca 7.8 (Alb 3.0), PO4 2.8, INR 1.4; negative cardiac
enzymes, BNP 76.5
.
WBC 24 (76N, no bands), Hct 44, Plt 326
.
CXR(OSH) - read as bilateral infiltrates, R>L
Brief Hospital Course:
Hospital Course:
70 year old nursing home resident with multiple medical problems
who presents with aspiration pneumonitis and UTI.
.
## Aspiration pneumonitis:
Patient was found to have a large right-sided consolidation that
resolved quickly within a day. Patient was satting 98-100%
trach on vent, then was taken off of the vent and continued to
sat >95% on 35% FiO2. She required suctioning Q6H, and was only
short of breath upon suctioning. She was maintained on
Imipenem/Cilastatin for an 8 day course (to be completed after
discharge) to cover for aspiration pneumonia. Sputum culture
grew out minimal yeast and oropharyngeal flora, but no bacterial
pathogen. She was placed on Vancomycin for 6 days to cover for
MRSA, but no MRSA grew from the sputum culture, and Vanco was
thus d/ced. Patient was not severely sick on admission, and
gradually improved until discharge. Vitals were stable at all
times.
.
Patient has a trach but is not vented, is not short of breath,
and eats and drinks at baseline. She is known to aspirate, but
"would rather die" than not be able to take food and drink by
mouth. She was maintained NPO until the day before discharge.
The patient is fully aware of the dangers of aspiration and
possible death, but she wishes to eat and drink by mouth. The
types of food that are least prone to aspiration were discussed
with the patient as being safer foods for her. Upon admission,
peanuts and potato chips were found in the patient's trach.
Code status was discussed with the patient because of likely
readmission to an ICU, and she would like to follow her nephew's
wishes, and her nephew wishes her to be full code.
.
## CHF:
There was a component of pulmonary edema due to CHF. Patient
was diuresed with a goal of -1 to -2 L per day, which was
achieved with Lasix 20 mg x1/day.
.
## Subglottic stenosis:
Communication between Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 65054**] (pulm fellow, [**Hospital1 18**]) and
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital3 1196**]. Patient does not
wish to remove her trach at this time, and she would not like
intervention or stent in her trachea.
.
## Paroxysmal AFIB:
Coumadin 4 QD (home regimen) had been held during admission, but
was restarted upon discharge. Patient was in normal sinus
rhythm during admission.
.
## Hyperkalemia:
Patient was hyperkalemic upon admission, and kayexylate was
administered 1x with decrease of K to 5.0. Patient was
asymptomatic. Patient was not hyperkalemic for the remainder of
admission, and EKG showed NSR without hyperkalemic morphology.
Cr was stable and wnl. Etiology of hyperkalemia was not
established.
.
## UTI:
Patient has a chronic foley catheter that was changed on
[**2105-11-16**]. UA showed 11,000 WBC, and urine culture was negative.
Patient was covered with Imipenem/Cilastatin.
.
## DM2:
BG were well controlled on insulin sliding scale.
.
## Pseudoseizures:
Patient has a history of pseudoseizures and has been maintained
on Dilantin. She was not able to take PO meds during admission,
but was restarted on Dilantin on the day before discharge. No
seizures were witnessed during admission.
.
## Depression:
Patient was discharged on Seroquel per home regimen.
.
## History of gallstone pancreatitis:
Right upper quadrant ultrasound was performed for RUQ pain, and
was found to be negative for cholelithiasis, with no gallbladder
wall thickness changes. LFTs and pancreatic enzymes were wnl.
.
## Chronic pain:
Patient has pain "all over" and in her right upper quadrant that
is intermittent. She was on a fentanyl patch with good pain
control.
.
## Access:
Patient has a mediport (placed on [**9-18**], clotted on [**9-24**]),
which now appears to be functioning. Site of port was clean.
.
## Code: FULL per nephew.
.
## Primary Communication: [**First Name9 (NamePattern2) 65055**] [**Known lastname **] @ ([**Telephone/Fax (1) 65056**],
([**Telephone/Fax (1) 65057**].
Medications on Admission:
Meds(at NH):
Pulmicort neb [**Hospital1 **]
Effexor XR 150mg QD
Fentanyl patch 50mcg q72 hours
Lasix 40mg QD
Norvasc 5mg QD
Prednisone 5mg QD
Protonix 40mg QD
Ursodiol 300mg QD
Colace 100mg QD
Oyster shell calcium w/ Vit D 500mg [**Hospital1 **]
Seroquel 75mg QD
Dilantin 100mg TID
Neurontin 300mg HS
Dilaudid 1mg QID prn pain
Ativan 1mg Q6 hours prn
Duoneb q4 hours prn
Tylenol prn
Coumadin 4mg QD
Realfin 100mg QD?
Metoprolol 75mg PO BID
Ambien prn
RISS
.
All: salicylates/ASA, amoxicllin, codeine,
floroquinolones/levaquin, morphine, sulfa, PCN(h/o severe rxn w/
sloughing of skin; per records never had a cephalosporin),
Metoclopromide
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
10. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
13. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Imipenem-Cilastatin 500 mg Recon Soln Sig: Five Hundred
(500) mg Intravenous Q8H (every 8 hours): Last date to give:
[**2105-11-20**].
18. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg
Intravenous Q8H (every 8 hours) as needed.
19. Warfarin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Home regimen, restarted [**2105-11-18**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1196**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary diagnosis: Aspiration pneumonia
Secondary diagnosis: UTI
Discharge Condition:
Good. Patient is eating and understands the associated dangers,
vitals stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 L
Followup Instructions:
1. Primary Care: Please make an appointment to see Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**], [**Telephone/Fax (1) 65058**].
2. Please follow up with a pulmonologist at [**Hospital1 16961**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] has seen this patient in the past.
Completed by:[**2105-11-18**]
ICD9 Codes: 5070, 5990, 4280, 496, 5849, 5859, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6698
} | Medical Text: Admission Date: [**2197-6-13**] Discharge Date: [**2197-6-23**]
Date of Birth: [**2142-8-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Weakness, Cough and SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 y/oM with HIV on HAART (viral load undetectable, last CD4 in
[**3-11**] 374), stage IV squamous lung CA s/p RUL s/p lobectomy,
chemo/XRT, local and distal recurrence, HCV who p/w worsening
fatigue, weakness, increasing dyspnea and new pleuritic chest
pain.
.
Pt. was in USOH (able to ambulate on flat ground ~ 1mi w/o DOE,
independent in majority of ADLs) until ~ 1wk ago when he
develped malaise and fatigue. Over the next few days he
developed a dry cough, which by 3 days PTA became productive of
yellow/green sputum. At the same time he developed left sided
pleuritic chest pain. He never had subjective fevers or chills,
no nightsweats, though had ~ 10-12lbs of wt loss over the past
month. By 2 days PTA, his dyspnea had worsened to the point that
he was unable to perform ADLs and required assisstance from his
mother. [**Name (NI) **] has had weakness in RUE and has had difficulty using
that arm, but this is unchanged from prior. Has not been exposed
to anyone with RFs for TB, no recent travel. Has not skipped any
of the [**Doctor Last Name **] meds. He had respiratory distress requiring
intubation for hypoxemic failure in [**2194**] after his right
thoracotomy and right upper lobectomy.
In the ED initial VS were 97.9 82 116/79 16 he desaturated to
88% on RA, increased to 93% with 2L NC. CTA showed a small LLL
PNA with no evidence of PE, and enlarging right apical tumor.
Blood cultures were drawn and was treated with zosyn, bactrim,
vancomycin. He was admitted to the floor and had a slowly
increasing O2 requirement to the point that this AM was satting
86% on 6L NC, requiring an NRB. He became more confused and
sleepy per nursing staff. MICU evaluation was initiated.
On evaluation, VS were 99.8F 106/72 88 26 93% on NRB, using
accessory muscles of respiration and nasal flaring and
tachypneic. STAT ABG was pH 7.40 pCO2 50 pO2 67, which was
essentially unchanged from the one prior. He c/o of SOB and
appeared slightly sleepy, though arousable to voice.
.
Review of systems:
(+) Per HPI, chronic weakness and tingling in right arm,
otherwise negative in detail.
Past Medical History:
- stage IV squamous cell lung cancer (Superior sulcus, T3, N0 at
presentation)
- dx [**2193**] with biopsy right lung apex squamous cell carcinoma.
- s/p right upper lobectomy in [**2195-8-14**]
- localized recurrence: Right lung apex in [**2196-6-1**] rx with CTX
and cyberknife [**2195**]-[**2196**]
- metastatic dx: T1-T2 neural foramina and nerve roots
- palliative CTX w/ gemcitabine d/ced [**3-11**] due to liver
dysfunction
other medical history
- Hx of Pulmonary Aspergillus fumigatus infection dx w/ BAL
[**2195-7-10**], tx w/ voriconazole, resolution in [**2195-11-19**].
- HIV on HAART, [**3-11**]: viral load undetectable; CD4 count 374
- HCV: genotype 1a, bx [**8-8**]
- pulmonary aspergillus dx on BAL [**7-9**] s/p voriconazole rx
- hx of + ppd s/p rx with INH
- hypotestosterone
- polysubstance abuse
- depressive d/o
- arthritis s/p R shoulder replacement .
Social History:
- unemployed, disabled. Living at home with his mother
- recovering addict (heroin, ETOH, other drugs)
- tobacco use: formerly smoked 1ppd, now [**4-10**] cigarettes daily
- not currently sexually active, partners have been female
Family History:
FH: [**Name (NI) 28142**] aunts w/lung cancer in 40s and 50s. father alive
w/o CA, mother w/ asthma and s/p removal of breast lesion.
Physical Exam:
General Appearance: Thin, cachectic, appeared fatigued
Eyes / Conjunctiva: Conjunctiva pale, R horners
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no
m/r/g
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: right apex and laterally, Rhonchorous: throughout),
no crackles appreciated
Abdominal: Soft, ND, no shifting dullness
Extremities: Clubbing, UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 28146**]; no edema, dry, warm
Musculoskeletal: Muscle wasting
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed, awakened eailsy to command and answered
questios appropriately, inquired about status. R horners, EOMi,
face symmeteric, intact to LT b/l, symmetric smile, tongue
midline, tremor. Shoulder shrig intact. Mild biceps and finger
flexion weakness. Otherwise full. LUE full. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 28147**]
weak, muscle wasting throughout. Toes down b/l. normal tone.
sensory exam deferred.
Pertinent Results:
[**2197-6-15**] 04:42AM BLOOD WBC-12.6* RBC-3.55* Hgb-13.4* Hct-40.1
MCV-113* MCH-37.8* MCHC-33.5 RDW-14.1 Plt Ct-148*
[**2197-6-16**] 01:45AM BLOOD WBC-12.0* RBC-3.29* Hgb-12.3* Hct-36.9*
MCV-112* MCH-37.3* MCHC-33.2 RDW-14.1 Plt Ct-129*
[**2197-6-16**] 04:23PM BLOOD WBC-11.6* RBC-3.38* Hgb-12.8* Hct-39.3*
MCV-116* MCH-38.0* MCHC-32.7 RDW-14.4 Plt Ct-132*
[**2197-6-13**] 03:54PM BLOOD Lactate-2.2*
[**2197-6-13**] 11:14PM BLOOD Lactate-1.2
[**2197-6-14**] 08:59AM BLOOD Lactate-1.5
[**2197-6-14**] 10:28AM BLOOD Lactate-1.4
[**2197-6-15**] 06:51AM BLOOD Lactate-1.2
[**2197-6-13**] CXR:
FINDINGS: Portable AP upright view of the chest is obtained.
Post-surgical
changes related to prior right upper thoracotomy and
reconstruction as well as
right upper lobectomy are again noted. There is subtle increased
nodular
opacity at the left lung base, which raises concern for
pneumonia. No large
pleural effusions are seen, though the right CP angle is
excluded.
Cardiomediastinal silhouette appears grossly stable. Left
humeral head
prosthesis is noted.
IMPRESSION: Findings concerning for left basilar pneumonia.
Brief Hospital Course:
Mr. [**Known lastname 28145**] was a 54 yo man with HIV on HAART (viral load
undetectable, last CD4 in [**3-11**] 374), stage IV squamous lung CA
s/p RUL s/p lobectomy, chemo/XRT, local and distal recurrence,
HCV who presented with worsening fatigue, weakness, increasing
dyspnea, new pleuritic chest pain, sputum production and
confusion.
.
# Stage IV lung CA: On presentation, Mr. [**Known lastname 28145**] had an apical
mass expanding, adrenal mass on CTA suspicious for metastasis
and radicular symptoms in right arm likely [**1-3**] nerve compression
but per Pain Clinic. On hospital day six, Mr. [**Known lastname 28145**] reported
significnt concern over a new foot drop on the right which
progressed to include right leg paralysis and numbness. An MRI
of the Spine revealed metastatic tumor cord compression at C7 to
T3 with significant stenosis at T2. Neuro-Surgery determined
that he was a poor surgical candidate because of the extensive
surgical debridment required or and high-risk nature of the
surgery. Radiation Oncology evaluated him and determined that
re-radiation was unlikely to improve his symptoms because of
poor tumor response in the past. Pain control was maintined and
he with his mother decided that inpatient hospice with a change
of code status to DNR/DNI would be best for Mr. [**Known lastname 28145**].
.
# HYPOXIC RESPIRATORY FAILURE, CHRONIC - He was found to have a
LLL consolodation consistent with a LLL pneumonia. The pneumonia
was believed to be aspiration vs. CAP and sputum culture failed
to identify a pathogen. He recieved 7 days of imperic antibotics
with azithromycin, ceftriaxone and flagyl which seemed to have
resolved the pneumonia, but he continued to [**Known lastname 28148**]
difficulty oxygenating. A PE was ruled out w/ CTA. And a Bubble
study and Echo did not further identifying cause of hypoxia. He
was aided by albuterol nebs Q2 hours and ipratropium nebs Q6H
PRN. In the setting of his lobectomy and recurrent lung cancer,
his new hypoxia was believed to represent a new baseline oxygen
need.
.
# ALTERED MENTAL STATUS ?????? Mr. [**Known lastname 28145**] [**Last Name (Titles) 28148**] several
paroxysmal episodes of profound agitation and combativeness that
responded best to zyprexa 5mg. These may have occured due to
metabolic derangement in setting of tumor burden or possibly
brain mets.
.
# HCV: unknown VL. Synthetic function at baseline. Bx in [**2193**]
-chronic viral hepatitis C with grade 2 inflammation and stage 2
fibrosis. No stigmata of acute liver failure or cirrhosis.
- HCV VL = 9,060,000
.
# HIV/AIDS on HAART: CD4 374 in [**3-11**] with undetectable VL. Has
had apthous ulcers recently. Had CD4 count resent.
- cont current antiretroviral medications
- f/u CD4 count.
- nystatin swish and swallow
.
# Code status: DNR/DNI comfort measures only
# Communication: Patient and mother [**Name (NI) 382**] [**Telephone/Fax (1) 28149**] [**Doctor First Name 1258**])
FYI: Pain medications over the last 24 hours, patient required a
total of morphine 52mg IV, morphine SR 60mg po, morphine IR
105mg po and a one-time dose of morphine SR 90mg at noon. Of
note, patient's home narcotic regimen prior to admission
included:
METHADONE [**Male First Name (un) **] 10MG/5ML 75 mg daily
MS CONTIN 200 MG XR12H-TAB (MORPHINE SULFATE) 1 tab po bid
HYDROMORPHONE HCL 8 MG TABS 1 tab po every 6 hours prn
Medications on Admission:
Methadone 75 mg PO/NG QAM
Albuterol 0.083% Neb Soln 1 NEB IH Q4H
Amitriptyline 25 mg PO/NG HS
Multivitamins 1 TAB PO/NG DAILY
CefePIME 2 g IV Q12H day 1 = [**6-13**]
Nystatin 500,000 UNIT PO/NG Q8H
Pregabalin 50 mg PO/NG [**Hospital1 **]
Clonazepam 0.5 mg PO/NG QAM:PRN anxiety
Sertraline 100 mg PO/NG DAILY
Docusate Sodium 100 mg PO BID
Senna 1 TAB PO/NG [**Hospital1 **]
Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
Fosamprenavir 1400 mg PO Q12H
Sulfameth/Trimethoprim DS 2 TAB PO/NG Q8H
HYDROmorphone (Dilaudid) 2-4 mg PO/NG Q6H:PRN pain
Vancomycin 1000 mg IV Q 12H day 1 = [**2197-6-13**]
Ipratropium Bromide Neb 1 NEB IH Q6H
ValACYclovir 1 gm PO BID
Lactulose 30 mL PO/NG Q8H:PRN constipation
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 656**] House
Discharge Diagnosis:
Pneumonia
Stage IV metastatic squamous cell lung cancer
Cervial Spine Metastasis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with fatigue, weakness and
difficulty breathing. You were treated for a pneumonia which
improved your breathing. You were found to have a spinal
metastatic cancer causing right leg weakness. You and your
mother considered available options and decided to pursue
hospice care. Please take all medications as prescribed.
Followup Instructions:
Please consult Dr. [**First Name (STitle) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] or Dr.
[**First Name (STitle) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] with questions about your
condition.
Completed by:[**2197-6-26**]
ICD9 Codes: 5070, 486, 2930, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6699
} | Medical Text: Admission Date: [**2155-7-12**] Discharge Date: [**2155-7-15**]
Date of Birth: [**2134-8-13**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5272**]
Chief Complaint:
Right Flank pain
Major Surgical or Invasive Procedure:
Right ureteral stent placement on [**2155-7-13**] with Dr. [**Last Name (STitle) 770**].
History of Present Illness:
Unsigned notes are not to be used for clinical decision making.
They are not final.
Date: [**2155-7-13**]
Signed by [**Name6 (MD) **] [**Name8 (MD) **], MD on [**2155-7-13**] at 7:40 am
Affiliation: [**Hospital1 18**]
NEEDS COSIGN
ATTENDING UROLOGIST: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] covering for Dr. [**First Name8 (NamePattern2) 1158**]
[**Last Name (NamePattern1) 770**]
UROLOGY CONSULT: Nausea, vomiting, and flank pain s/p
Extracorporeal Shockwave Lithotripsy (ESWL)
20F H/O bilateral nephrolithiasis presents to ER s/p ESWL 2 days
prior at [**Hospital6 2910**] with persistant N/V and
poor pain control. Denies Fever, chills, dysuria. Last UTI was
[**2-2**] treated with Cipro, diagnosed by lab, asymptomatic. Notes
increased frequencey since procedure but no passage of
fragments.
Denies gross hematuria. Last bowel movement 2 days prior.
PMH: hypothyroidism, nephrolithiasis in contest of >60 pound
weight loss, ADHD
PSH: ESWL x2
MEDS: levoxyl
ALL: NKDA
Physical Exam:
NAD
Soft, NT, ND
No CVAT
Pertinent Results:
[**2155-7-15**] WBC-7.0 Hgb-11.3* Hct-33.3* Plt Ct-248
[**2155-7-14**] Glucose-97 UreaN-6 Creat-1.1 Na-142 K-4.2 Cl-108
HCO3-26
Brief Hospital Course:
The patient was admitted to Dr.[**Name (NI) 825**] Urology service from
the [**Hospital1 18**] ED for overnight observation, pain control, and IV
fluids. A urine culture was obtained and antibiotics (Cipro)
were begun. She became febrile overnight and was taken urgently
to the OR for stent placement. Op Note is dictated separately.
She recieved Ancef pre-operatively in addition to the Cipro she
had been receiving. She became septic post-operatively and was
hypoxic requiring aggressive pulmonary toilet in the [**Hospital Unit Name 153**]
overnight. Her antibiotics were broadened to Ceftriaxone and
gentamycin. A CXR suggested volume overload and she received
Lasix in the PACU. With aggressive pulmonary toilet and diuresis
she improved and was transferred to the floor. Her cultures
returned only Gardnerella, for which she received 2 doses of
Flagyl. She was given fluconazole x1 given the broad coverage
antibiotics she received and issues with vaginal yeast
infections. She was D/C'd in stable condition with 14 days of
Cipro and instructions to follow up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 770**].
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) for 7 days: Can decrease frequency or stop if having loose
stools.
Disp:*28 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 20 days.
Disp:*40 Capsule(s)* Refills:*0*
4. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis with obstructing ureteral stone.
Discharge Condition:
Stable
Discharge Instructions:
-No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequecy over the next month. This is normal with a
stent in place.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain. Max
daily Tylenol dose is 4gm.
-Make sure you drink plenty of fluids to help keep yourself
hydrated and facilitate passage of stone fragments.
-You may shower as normal. No tub baths or submersion until
stone is removed.
-Do not drive or drink alcohol while taking narcotics
-Colace and Senna have been prescribed to avoid post surgical
constipation and constipation related to narcotic pain
medication, discontinue if loose stool or diarrhea develops.
-Resume all of your home medications, unless otherwise noted.
-Call Dr.[**Name (NI) 825**] office for follow-up AND if you have any
questions.
-If you have fevers > 101.5 F, vomiting, severe abdominal pain,
or inability to urinate, call your doctor or go to the nearest
emergency room.
Followup Instructions:
-Call Dr.[**Name (NI) 825**] office for follow-up AND if you have any
questions.
Completed by:[**2155-7-20**]
ICD9 Codes: 5849, 5990, 5180, 2449 |
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